Remdesivir (Veklury®)

• Remdesivir is an expensive treatment, and the principle of cost-effective prescribing should be followed.
• The decision to initiate treatment with remdesivir should be made by the admitting care consultant. The decision to treat with remdesivir is not an emergency and should be made judiciously after assessment and in a timely manner.
• Remdesivir should not be initiated in patients who present to hospital and are unlikely to survive (determined by clinical judgement).
• Remdesivir should generally not be initiated in patients who present to hospital more than 10 days after symptom onset. Where use is considered beyond 10 days of symptoms onset (e.g. in heavily immunocompromised patients) this should be discussed with the infectious diseases consultant on-call.
• Where the only eligibility criteria from TA878 are either BMI>30, diabetes mellitus, or hypertension approval from the infectious diseases consultant on-call is required.

The treatment course for high-risk patients not on oxygen is 3 days.

For patients on oxygen for COVID-19 pneumonitis the course is 5 days. Any extension of these durations needs approval by the infectious diseases consultant on-call.

Significantly immunocompromised patients may be eligible for an extended course of remdesivir (up to 10 days), but only if agreed and approved by the ID consultant on-call.

The use of remdesivir should be reassessed daily. Consider stopping remdesivir if:

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

• The recommended dosage is a single loading dose of remdesivir 200mg intravenously on day 1, followed by a once daily maintenance dose of remdesivir 100mg for the remainder of the treatment course. For duration of treatment see above.

• Given via IV infusion over 30 – 120 minutes
• Flush with at least 30mL 0.9% sodium chloride after infusion complete

For full list please SmPC and BNF for remdesivir.

Manufacturer advises caution — treatment should not be started if ALT is 5 times the upper limit of normal. If ALT increases during treatment, remdesivir may need to be withheld, consult product literature for further information.

Manufacturer advises avoid if eGFR less than 30 mL/minute/1.73 m² (except in patients with end-stage renal disease on haemodialysis).

Remdesivir should be avoided in pregnancy unless the clinician believes the benefits of treatment outweigh the risks to the individual. The care and treatment of pregnant women with COVID-19 should be discussed with a senior obstetrician.

Renal and liver function should be monitored carefully during treatment with remdesivir as clinically appropriate.

Remdesivir may prolong the QT interval, and a patient risk-assessment should be undertaken prior to initiation of treatment.  A baseline ECG should be performed, with monitoring of QTc interval from days 1 to 3 in patients at increased risk, eg who are prescribed additional QT prolonging medication. Seek advice from cardiology as necessary.

• The consultant / team in charge of the patient should:
• • Check the patient meets the remdesivir eligibility criteria as detailed above.
  • Document remdesivir prescription in the patient’s TRAK notes using the short code \remd .
  • Discuss with infectious diseases consultant on-call if using out with above listed criteria and indications or using when elevated BMI, diabetes or hypertension are the sole eligibility criteria.
• Nursing staff should order the remdesivir on a pharmacy order form from pharmacy; include the patient’s name and CHI number on the order.
• When ordering supply, the full course of remdesivir should be requested and transferred with the patient.
• With the exception of critical care areas, remdesivir will only be supplied by pharmacy 9am to 4pm (Mon to Fri) and during pharmacy opening-hours at weekends, which vary across the acute hospitals. Out of hours requests from non-critical care areas will not be processed until the following morning unless an urgent supply is requested by the ID consultant on call.

Remdesivir should be discontinued in patients who develop any of the following:

• ALT ≥5 times the upper limit of normal during treatment with remdesivir (remdesivir may be restarted when ALT is <5 times the upper limit of normal)
• ALT elevation accompanied by signs or symptoms of liver inflammation or increasing conjugated bilirubin, alkaline phosphatase, or international normalised ratio (INR)
• eGFR <30 mL/min (except in patients with end-stage renal disease on haemodialysis).

\REMD
This is the Trak short code to be used to document the use of remdesivir.