Remdesivir

What is remdesivir?

Remdesivir is an antiviral medicine originally developed as a treatment for Ebola virus infection. The drug also demonstrates activity against Paramyxoviridae (the family of viruses responsible for measles and mumps), Pneumoviridae (respiratory syncytial virus), and others. But it was its activity against the Coronaviridae family of viruses that led to considerable interest in remdesivir as a potential treatment for COVID-19.¹ ²

Following its confirmation as an effective treatment for SARS-CoV-2 infection, a type of coronavirus, remdesivir is now approved for treating COVID-19. Essentially, remdesivir interrupts the production of coronavirus. As with many other viruses, SARS-CoV-2 replicates and spreads using its genetic information, in this case, ribonucleic acid (RNA). Viral RNA contains the instructions for replicating itself. The virus then uses the cell’s production line to create the building blocks of new viruses and assemble them. Remdesivir disrupts the creation of an enzyme the RNA uses to make copies of the viral genetic material, and the virus can no longer multiply.³ ⁴ ⁵ ⁶

What is remdesivir used to treat?

Remdesivir, also known by its brand name, Veklury,  is approved by the US Food and Drug Administration (FDA) for the treatment of COVID-19 infection. It helps prevent more severe symptoms and improves survival.⁷ ⁸

The specific indications defined by the US FDA for treatment with remdesivir are the following:⁹

• Adults, children, and infants ≥ 28 days of age and weighing a minimum of 3kg

• Hospitalized with COVID-19

• If not hospitalized, a patient must have mild-to-moderate COVID-19 and be at high risk for progressing into severe disease.

Patients should receive the medication as an intravenous (IV) infusion immediately after testing positive for COVID-19. Nonhospitalized patients should be treated within seven days of the symptoms starting. They can receive remdesivir at a local infusion center or hospital and are given daily doses for three days. However, patients are eligible for the drug only if they are in the following high-risk groups (according to the most updated National Institutes of Health (NIH) clinical treatment guidelines):¹⁰ ¹¹

• Over age 50, and even higher risk at 65 and above

• Immunocompromising medical condition

• Taking immunosuppressant medication

Other patients at increased risk include those with any of the following:

• Lapsed vaccination status or unvaccinated

• Chronic conditions like diabetes, obesity, and heart, lung, or kidney disease

• Poor access to therapy due to disparities in care

The recommendation for hospitalized patients is that they receive treatment as soon as the diagnosis is made. The drug should be continued for 5–10 days, depending on the patient’s need for ventilatory support, including mechanical ventilation and extracorporeal membrane oxygenation (ECMO).

Initial studies demonstrated the drug’s effectiveness in treating earlier forms of SARS-CoV-2, such as the ancestral, beta, and delta variants. Although more recent trials have confirmed remdesivir maintains activity against omicron and its newer subvariant forms.¹² ¹³

If you test positive for coronavirus and are eligible for the treatment, call your doctor for an assessment to see if the remdesivir is suitable in your case. If it is appropriate, your doctor will inform you where the treatment can be administered. 

Dosage forms and strengths

Remdesivir is available as a concentrated solution or a powder to be reconstituted with sterile water. Doses are given by IV infusion either in the hospital or an outpatient medical facility, so you would not be taking remdesivir at home. 

The available forms of remdesivir include the following:¹⁴

• Lyophilized powder for reconstitution: 100mg single-dose vial

• Concentrated solution: 100mg/20mL (5mg/mL) single-dose vial 

Dosing guidelines set by the US FDA are based on the patient’s age and weight, whether or not they are hospitalized, their need for ventilatory support, level of kidney function, and response to treatment.¹⁵

How do you take remdesivir?

Remdesivir is administered as an infusion into a vein. It is given in a medical setting by a healthcare professional per your doctor's prescription, and the dosing is based on the most recent prescribing guidelines. Administering the infusion takes between 30 minutes and two hours, and the duration of treatment depends on the severity of your condition and how you respond to the medication.¹⁶

Seeing results 

Remdesivir begins working quickly after you receive the infusion. But the drug is most effective if you receive it immediately after testing positive for COVID-19 and within a week of your symptoms starting. Patients differ in their experiences after treatment with remdesivir for COVID-19 infection, particularly if they have risk factors for severe illness. However, many who receive remdesivir will recover faster after receiving this drug, with a lower risk of progression to severe disease.¹⁷

Who should not take remdesivir?

Remdesivir is contraindicated for people with known hypersensitivity to any of the medication’s active or inactive ingredients. It’s also not recommended for people with kidney impairment who have an estimated glomerular filtration rate (eGFR) less than 30mL/min. The US FDA has not approved the drug for children younger than 28 days or weighing less than 3kg.¹⁸ ¹⁹

Additionally, people with liver disease or failure may need a dose adjustment or a different drug to treat their infection.

Potential side effects of remdesivir

Remdesivir can cause side effects in some patients. They do not always occur, but if they do, you may need medical attention, depending on their severity.²⁰

Below are the most common side effects of remdesivir:²¹

• Nausea and vomiting

• Diarrhea or constipation

• Insomnia

• Rash, itching

• Poor appetite

• Fever

• Bleeding or pain at the injection site

• Abnormal heart rhythm

• Low blood pressure

• Elevated blood sugar

• Elevated liver enzymes

• Reduced hemoglobin

• Reduced white blood cells

Less common and more severe adverse effects include the following:

• Anemia

• Hypersensitivity reaction

• Seizures

• Hepatitis

• Deep vein thrombosis (blood clot)

• Acute kidney injury

• Respiratory difficulty

• Heart attack

• Delirium

• Respiratory failure

Overdose 

Since remdesivir is administered in a medical setting by a healthcare professional, patients are protected from accidentally overdosing. Studies have shown little toxic effect when the drug is used as directed.²²

Allergy information

Remdesivir carries a risk for hypersensitivity reactions such as anaphylaxis, rash, hives, rapid heart rate, sweating, swelling of the lips or tongue, chills, vomiting, wheezing or difficulty breathing, and even loss of consciousness. Your care team will monitor for any signs of an allergic reaction during treatment.²³

Remdesivir and pregnancy

Pregnant individuals were excluded from participating in the clinical studies on the use of remdesivir in COVID-19. But more recent data from the compassionate use program did show a high recovery rate and improved obstetric outcomes. Nonclinical animal studies with remdesivir have not demonstrated any adverse effects on embryofetal development when given at significantly higher doses than those given to humans.²⁴ ²⁵ 

However, remdesivir has not been approved for use in people who are pregnant. It is important to note that having COVID-19 during pregnancy brings an increased risk of progressive disease and negative outcomes. Thus, remdesivir is recommended for use in pregnancy if the benefits outweigh the risk to the fetus and the mother.²⁶ ²⁷

Remdesivir and breastfeeding

There are no data on the effect of remdesivir in lactation. But animal studies have detected the medicine and its metabolites in nursing mothers. Recent research suggests that remdesivir is not transmitted in high doses via breastmilk, and there is no expectation of adverse effects. This should be a discussion between the patient and physician regarding the risks and benefits in individual cases.²⁸

Missed doses

Patients receiving a remdesivir injection in a clinical setting may sometimes miss a follow-up dose, which would likely impact the effectiveness of their COVID-19 treatment, leaving the patient vulnerable to a worsening infection.

Drug interactions

As with most other drugs, remdesivir may interact with other medications. Generally, remdesivir has an exceptionally low risk of interactions since it is metabolized quickly. The following are a few medications known to interact with remdesivir, and their use should be monitored carefully:²⁹

• Antibiotics, such as rifapentine (Priftin), rifabutin (Mycobutin), and rifampicin (Rifadin)

• Antimalarial drugs like chloroquine (Aralen) and hydroxychloroquine (Plaquenil)

• Anti-seizure medications like phenytoin (Dilantin) and carbamazepine (Tegretol)

• Bosentan (Tracleer)

• Steroids like dexamethasone (Decadron) and betamethasone 

• St. John’s wort 

• Ublituximab (Briumvi)

• Warfarin (Coumadin)

Give your doctor a list of all prescription and non-prescription drugs, herbs, or dietary supplements you use regularly or occasionally, to reduce the likelihood of a drug interaction. 

Can I drink alcohol while taking remdesivir? 

Some people taking remdesivir develop elevated liver enzymes, which may indicate liver inflammation. Because alcohol also affects the liver, combining the two may increase the risk of adverse effects and damage to the liver. Speak with your doctor about your alcohol use before starting remdesivir.³⁰ 

What to discuss with your doctor before taking remdesivir

Before taking remdesivir, speak with your doctor about your past and current health conditions and your lifestyle preferences. Be sure to include the following topics:³¹

• All current prescription and over-the-counter medications

• Any known allergies to other drugs or previous adverse reactions to an infusion

• Known complications with your liver or kidneys

• Your current and past alcohol or opiate use³²

• Diseases that compromise your immune health

• Plans to become pregnant (since remdesivir is not currently US FDA approved for use in pregnancy)

Informing your doctor about these health conditions, current medication or drug use, and previous experiences with medical treatment is essential and will help your doctor provide the best care for you. Providing this information can also help you anticipate and possibly avoid negative side effects or drug interactions.

Drug approval history

• May 2020: Remdesivir received an Emergency Use Authorization (EUA) from the US FDA³³

• October 2020: The US FDA issued a standard approval for use in adults and pediatric patients 12 and older³⁴

• April 2022: The US FDA revoked the EUA for remdesivir upon the expansion of the drug’s approval to include pediatric patients aged 28 days and older³⁵

Tips for taking remdesivir

Because remdesivir is administered intravenously, you will need to be under a doctor’s supervision to receive the drug. However, there are a few tips you can follow when taking remdesivir:

• Your infusion will take 30–120 minutes; bring something to do to pass the time during your session.³⁶

• Allot at least one additional hour to remain under the doctor’s supervision after your infusion for monitoring.³⁷

• Because remdesivir commonly causes nausea and vomiting, let your doctor know if you experience these symptoms and ask if an anti-nausea medication would be appropriate.

Frequently asked questions

Is remdesivir better than other COVID-19 treatments?

Remdesivir is one of the antiviral medicines used to treat COVID-19. Others include molnupiravir and Paxlovid (ritonavir and nirmatrelvir). A key difference is that remdesivir is administered through an IV infusion, and the others can be taken orally. Since all these drugs are relatively new, there is limited and variable information about which could be better. Your doctor will base the recommendation on several factors, including how long you have had symptoms, your age and health status, and your risk of progression to severe disease. Clinical trials are ongoing in examining the efficacy of these drugs. However, it is important to discuss your health information with your doctor, as some conditions might indicate the use of one drug over another.³⁸ ³⁹

Should I avoid some foods while on remdesivir?

There’s no need to change your diet unless advised otherwise by your healthcare professional. Drinking plenty of fluids will help you remain hydrated while your immune system fights the COVID-19 infection.⁴⁰