Remdesivir shows no clear benefit in children with severe COVID-19

The antiviral remdesivir offers no clear benefit in the treatment of children with severe COVID-19, falling short of reducing the time spent in high dependency or intensive care unit (HD/ICU), according to a study from Singapore.

Data from 15 children (median age 2.5 years, 60 percent boys) with SARS‐CoV‐2 infection admitted to KK Women's and Children's Hospital showed no significant difference in the cumulative proportion of children de-escalated from day 5 of HD/ICU care. This outcome occurred in five of seven children who received remdesivir and in seven of eight children who did not receive the antiviral (control group; 70 percent vs 87.5 percent; p=0.57). [Health Sci Rep 2023;6:e1698]

All of the children were eventually de-escalated from HD/ICU care by day 10, with the remdesivir and control groups having similar outcomes such as days to fever <38°C (1 vs 2 days; p=0.35) and length of hospital stay (6 vs 4.5 days; p=0.07).

These findings, according to the investigators, were likely confounded by selection bias in terms of severity, as children in the remdesivir group required more respiratory and hemodynamic support.

Compared with the control group, the remdesivir group had higher World Health Organization (WHO) Ordinal Scale scores (median, 6 vs 5; p=0.03), higher procalcitonin levels (median, 4.31 vs 0.12 ug/L; p=0.02), and longer HD/ICU care duration (median, 5 vs 1 day; p=0.01).

“Even though we could not discern a clear benefit in terms of reducing HD/ICU duration in our limited cohort, we could not rule out the possibility of a longer duration of higher acuity care and hospitalization if they did not receive early initiation of remdesivir therapy,” the investigators said.

As for safety, remdesivir was reasonably safe in the cohort, they added. There were no cases of renal, cardiac, or liver events directly related to remdesivir therapy. Also, none of the children died from COVID‐19 infection.

To date, remdesivir has not been evaluated in large, controlled studies of children with COVID-19. Observational studies in this population were either missing comparison groups or focused on mild cases, other treatments, or just safety. [Pediatrics 2021;147:e2020047803; Eur J Pediatr 2021;180:1317-1322; Biol Pharm Bull 2022;45:1853-1856; Pediatr Infect Dis J 2023;42:310-314]

Additionally, the timing of remdesivir initiation varied widely among the said studies, whereas the present study initiating treatment within a narrow timeframe of 1–2 days after admission.

“It was interesting that our [control] group had good outcomes despite the presence of comorbidities and requirement for oxygen support. They had lower WHO severity scale scores and lower procalcitonin levels,” the investigators said.

“Larger studies are needed to evaluate the predictive value of these factors in guiding necessity of remdesivir therapy in this cohort,” they added.