Remdesivir for in-patients

Remdesivir is an adenosine nucleotide prodrug which is metabolised intracellularly to the active substrate remdesivir triphosphate.

Discharge letters to primary care should explicitly record the treatment that has been given, together with the dose and date of administration.

Restricted: Formulary. In-line with NICE TA971 or recommendation by Micro/ID.

NICE TA971 states that remdesivir is recommended as an option for treating COVID‑19 in hospitals in:

• adults, only if they have a high risk of serious illness (risk factors as defined in section 5 of NICE's TA 878 ‘guidance on nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19’)

The groups of clinical conditions are as below and details of the risk factors for progression to severe COVID-19 in adults can be found HERE.

• Down's syndrome and other genetic disorders
• Solid cancer
• Haematological diseases and recipients of haematological stem cell transplant (HSCT)
• Renal disease 
• Liver diseases 
• Solid organ transplant recipients
• Immune-mediated inflammatory disorders (diseases in which autoimmune or autoinflammation-based pathways are implicated in disease, for example, inflammatory arthritis, connective tissue diseases, inflammatory skin diseases, inflammatory gastrointestinal disease)
• Respiratory
• Immune deficiencies
• HIV/AIDS
• Neurological disorders

Day 1: 200mg remdesivir as a single dose iv

Day 2 onwards: 100mg remdesivir iv OD 

Renal impairment 

No dose adjustment. Patient should be monitored for side effects.

Hepatic impairment

No dose adjustment is required.

Monitor LFTs closely. For patients with pre-exisitng liver impairment Remdesivir should be discontinued if during its use, alanine aminotransferase (ALT) becomes 5 or more times the patient's baseline.

Interactions

All interactions should be checked using The Liverpool COVID-19 Drug Interaction Checker and Summary of Product Characteristics.

Duration for treatment of COVID-19 with pneumonia requiring supplemental oxygen:

The usual total duration of treatment is 5 days, but it may be extended up to 10 days for severely immunocompromised patients (MDT decision only).

Consider stopping remdesivir if:- 

• Patient clinically improves and no longer requires supplemental oxygen 72 hours after commencement of treatment; 
• Patient continues to deteriorate despite 48 hours of sustained mechanical ventilation.

• Pregnancy: Discuss patient with Micro/ID AND obstetrics. Consent for use of remdesivir must be documented.
• Breastfeeding: See BNF, Summary of Product Characteristics (SPC) for remdesivir or speak to pharmacy. Consent for use of remdesivir must be documented

• Monitoring: the use of remdesivir should be reassessed daily. Daily LFTs and U&Es should be performed.
• Discontinuation: Remdesivir should be discontinued in patients who develop:
  • ALT 5 times or more the upper limit of normal during treatment with remdesivir, or, ALT elevation accompanied by signs or symptoms of liver inflammation or increasing conjugated bilirubin, alkaline phosphatase or INR
  • Bradycardia
  • Adverse reactions thought to be hypersensitivity
  • Other adverse reactions thought to be due to remdesivir (complete yellow card, found here).

1. National Institute for Health and Care Excellence. Technology appraisal guidance 971. Remdesivir and tixagevimab plus cilgavimab for treating COVID-19. Last updated 8^th May 2024. Accessed via: www.nice.org.uk. [Accessed 18/9/24]
2. National Institute for Health and Care Excellence. Technology appraisal guidance 878. Nirmatrelvir plus ritonavir, sotrovimab and tocilizumab for treating COVID-19 Last updated: 13^th March 2024. Accessed via: www.nice.org.uk. [Accessed 18/9/24]
3. Gilead Sciences Ltd. Summary pf Product Characteristics, Veklury 100 mg powder for concentrate for solution for infusion [online]. Last revision of the text: 19/8/24. Accessed via https://www.medicines.org.uk/emc/product/11597/smpc [Accessed 18/9/24]
4. The Renal Drug Database. Remdesivir - last updated:11/8/23. Accessed via: https://renaldrugdatabase.com [Accessed 12/8/24].