Understand Roles of Remdesivir and Dexamethasone for COVID-19

Posted November 10, 2020: Article in Progress. We’re releasing this article ahead of our December 2020 issue to quickly provide information to our readers. The information contained in this version is based on the best evidence available to us as of the date of posting. The final version may include revised recommendations.

Remdesivir (Veklury) is now FDA approved for all hospitalized COVID-19 patients who are at least 12 years old and weigh 40 kg.

But this doesn’t mean it should be used more. Remdesivir can shorten recovery time in some cases...but isn’t yet shown to reduce mortality. Plus it costs over $3,000 for a 5-day course.

On the other hand, dexamethasone reduces mortality in COVID-19 patients requiring supplemental oxygen...and costs under $1/day.

Be ready to explain specific roles for each med.

No supplemental oxygen. Generally skip remdesivir in this case...since there’s no compelling evidence for benefit. And don’t use dexamethasone. Benefits don’t seem to outweigh potential risks.

Low-flow oxygen. Continue to start dexamethasone.

Consider adding remdesivir in patients needing low-flow oxygen, such as up to 6 L/min by nasal cannula. Explain that remdesivir shortens recovery by a few days versus placebo in these patients.

The theory with combining is that remdesivir may decrease viral shedding while dexamethasone targets inflammation. But clarify there’s no current evidence that the combo is better than dexamethasone alone.

Consider limiting remdesivir to patients who are within 10 days of symptom onset. It’s too soon to say whether there’s benefit starting it later in the course of illness.

Typically stop remdesivir after 5 days in patients on low-flow oxygen... 10 days isn’t better. And there aren’t data for extending to 10 days in nonresponders.

Higher oxygen needs. Also use dexamethasone in patients requiring mechanical ventilation or extracorporeal membrane oxygenation (ECMO)...or on high-flow oxygen devices, such as high-flow nasal cannula or BiPAP.

But generally don’t add remdesivir. There isn’t good evidence that it improves outcomes in these sicker patients.

Renal insufficiency. Labeling doesn’t recommend remdesivir if eGFR is less than 30 mL/min...due to concerns for accumulation of a cyclodextrin excipient, which may cause renal or liver toxicity.

But don’t automatically rule out remdesivir in renal dysfunction. Risks are theoretical. Plus IV voriconazole has a similar warning and amount of cyclodextrin...but short courses seem well tolerated.

Get our chart, Treatments of Interest for COVID-19, for the latest on other therapies, including famotidine and tocilizumab.

References

  1. N Engl J Med. 2020 Oct 8; doi:10.1056/NEJMoa2007764
  2. N Engl J Med 2020 Jul 17; doi:10.1056/NEJMoa2021436
  3. N Engl J Med. 2020 May 27: doi: 10.1056/NEJMoa2015301
  4. www.covid19treatmentguidelines.nih.gov/
  5. J Am Soc Nephrol. 2020 Jul;31(7):1384-1386