Early remdesivir shields transplant recipients against life-threatening COVID-19

In solid organ transplant (SOT) recipients with moderate symptoms of SARS-CoV-2 infection, early administration of a 3-day remdesivir course appears to effectively prevent COVID-19-related hospitalization as well as the clinical worsening of those who are hospitalized, according to a study.

“Treatment with early remdesivir significantly reduced hospital admission at 28 days from the first positive nasopharyngeal RT-PCR swab for SARS-CoV-2,” the investigators said.

A multivariable Cox proportional-hazard regression model that accounted for gender, age, comorbidities count, and positivity of IgG anti-spike SARS-CoV2 showed that remdesivir treatment was associated with a 95-percent reduction in the risk of hospitalization and progression of COVID-19 (adjusted hazard ratio [aHR], 0.05, 95 percent confidence interval [CI], 0.00–0.65; p=0.01). [Int J Infect Dis 2022;doi:10.1016/j.ijid.2022.05.001]

There were no differences seen in the median duration of viral clearance, defined as testing negative on the nasopharyngeal SARS-CoV-2 RT-PCR swab, between the two groups (p=0.86).

“Although having no impact on COVID-19 patients’ survival, remdesivir [has been shown to confer] a benefit when treatment was initiated in the early stage of SARS-CoV-2 infection,” the investigators pointed out. [BMJ 2020;370:m2980; New Engl J Med 2022;386:385-387; Ann Intern Med 2021;174:209-220]

The findings of the present study provide some evidence that the efficacy of an early 3-day course of remdesivir in preventing COVID-19-related hospitalization and progression among outpatients with mild-to-moderate COVID-19 extends to SOT recipients, “who need special consideration and effective early treatments owing to their scarce immune response to COVID-19 vaccination,” they added. [New Engl J Med 2022;386:305-315]

The study comprised 24 SOT patients in Italy, of whom seven (29.1 percent) received pre-emptive remdesivir and 17 (70.9 percent) did not. In the group of patients who did not receive remdesivir, five had chronic kidney disease (estimated glomerular filtration rate [eGFR] <30 ml/min, but none was in chronic dialysis replacement) while 12 were asymptomatic at the time of COVID-19 diagnosis.

Eight patients were already hospitalized for non-COVID-19‒related reasons, and only one of them who was treated with the 3-days remdesivir course showed no clinical worsening. None of the patients required mechanical ventilation, and only a single patient died.

“Due to the possible adaptive mutations of variants in the spike protein which might result in escape phenomena to monoclonal antibodies, antiviral agents remain a more valuable choice [for SOT patients with COVID-19],” according to the investigators.

Despite the limitations of the study, including its small sample size and retrospective nature, the investigators expressed their satisfaction with their data on early remdesivir use in SOT patients who “were, are, and possibly will be one of the most affected by SARS-CoV-2.”