Remdesivir for COVID-19 Treatment: ACP Practice Points
- Qaseen A, Yost J, Etxeandia-Ikobaltzeta I, et al., on behalf of the Scientific Medical Policy Committee of the American College of Physicians.
- Should Remdesivir Be Used for the Treatment of Patients With COVID-19? Rapid, Living Practice Points From the American College of Physicians (Version 2). Ann Intern Med 2021;Feb 9:[Epub ahead of print].
This second version of a guidelines document by the Scientific Medical Policy Committee of the American College of Physicians (ACP) based on an updated systematic review provides evidence-based recommendations surrounding the use of remdesivir in the treatment of coronavirus disease 2019 (COVID-19). The following are 10 key points to remember summarizing the data and guidelines:
- There are five clinical trials assessing the effectiveness of remdesivir in the treatment of COVID-19, encompassing a total of 7,797 hospitalized patients.
- In this update, severity of disease is now defined by respiratory support requirements (no requirement, supplemental oxygen, or mechanical ventilation) rather than classifications such as “moderate or severe.”
- This second version incorporates findings from one new clinical trial published and the final findings of a prior study, both assessing the effectiveness of a 10-day remdesivir course compared to standard of care and placebo.
- The most recent data find little to no effect of a 10-day course of remdesivir on mortality or need for mechanical ventilation. Treatment with remdesivir remained associated with clinical improvement, length of stay, and a reduction in serious adverse events.
- There is insufficient evidence to advise against or for considering the use of remdesivir in patients who do not require supplemental oxygen at the time of drug initiation.
- Practice Point 1: A 5-day treatment of remdesivir in hospitalized patients with COVID-19 who do not require mechanical ventilation or extracorporeal membrane oxygenation (ECMO) should be considered; with no evidence of harm, and evidence for a slight reduction in mortality, moderate increase in recovery, and slight reduction in the need for mechanical ventilation.
- Practice Point 2: In post hoc analyses, treatment beyond 5 days in patients who progressed to requiring mechanical ventilation or ECMO was associated with lower mortality; thus, extending treatment to 10 days in patients who have not had adverse effects should be considered.
- Practice Point 3: Treatment with remdesivir should be avoided in patients with COVID-19 already on mechanical ventilation or ECMO, as a 10-day course of remdesivir in this patient population was associated with a modest increase in mortality.
- Significant evidence gaps remain regarding the optimal duration of treatment with remdesivir, the impact of disease severity, and duration of symptoms at the time of initiation of remdesivir.
- The ACP recommendations differ from the World Health Organization (WHO) guidelines, which advise against the use of remdesivir for the following reasons: they are based on different systematic reviews, the WHO guideline considered the effect of remdesivir regardless of its duration of use and did not make a recommendation based on disease severity, judging the credibility of the evidence to be insufficient to make a recommendation.
Keywords: Coronavirus, Coronavirus Infections, COVID-19, Extracorporeal Membrane Oxygenation, Iatrogenic Disease, Length of Stay, Primary Prevention, remdesivir, Respiration, Artificial, Respiratory Insufficiency, Severity of Illness Index, Standard of Care, Ventilation
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