NIH updates: Remdesivir recommended for patients hospitalized for COVID-19
01 Dec 2023
Remdesivir is recommended for hospitalized patients with COVID-19, according to latest updates of the US National Institutes of Health (NIH) guidelines issued on 10th October 2023.
The updates offer recommendations on therapeutic management based on different levels of disease severity, including supplemental oxygen, high-flow nasal cannula (HFNC) oxygen or noninvasive ventilation (NIV) requirements at baseline. [NIH COVID-19 Treatment Guidelines, Therapeutic Management of Hospitalized Adults With COVID-19, 10 October 2023: https://www.covid19treatmentguidelines.nih.gov/management/clinical-management-of-adults/hospitalized-adults--therapeutic-management/]
The COVID-19 Treatment Guidelines panel recommends remdesivir for patients who do not require supplemental oxygen and are at high risk of progressing to severe disease. (Table) The grade of recommendation and level of evidence are BIII, as aggregate data showed that remdesivir was associated with a faster time to recovery in high-risk patients, but there was no clear evidence of survival benefit.
Notably, survival benefit was noted in a large retrospective cohort study in 28,338 immunocompromised patients hospitalized with COVID-19. Among them, 40 percent of patients did not require supplemental oxygen at baseline, and mortality was consistently reduced with remdesivir in this subgroup. Therefore, the panel recommends remdesivir for immunocompromised patients with a higher level of evidence (BIIb).
The panel recommends using remdesivir, without dexamethasone, for COVID-19 patients who require only minimal conventional oxygen. For those hospitalized with COVID-19 requiring conventional oxygen, the recommendation is to use dexamethasone plus remdesivir. These recommendations were both graded BIIa and based on the CANCO and SOLIDARITY trials, which showed that remdesivir significantly lowered rates of mortality or need for mechanical ventilation in this patient group.
For hospitalized patients with COVID-19 requiring HFNC oxygen or NIV, the panel recommends dexamethasone plus another immunomodulator, preferably baricitinib or tocilizumab. They also recommend adding remdesivir to the following groups of patients:
- Immunocompromised patients (BIIb);
- Patients with evidence of ongoing viral replication (eg, those with a low cycle threshold [Ct] value, or a positive rapid antigen test result) (BIII);
- Patients who are ≤10 days from symptom onset (CIIa).
Of note, for patients who progress to requiring mechanical ventilation or extracorporeal membrane oxygenation (ECMO) after remdesivir initiation, the panel suggests continuing remdesivir until completion of the treatment course.
