ACP reviews evidence on remdesivir for inpatients, updates practice points

ACP has updated its systematic review and Practice Points on the use of remdesivir for hospitalized patients with COVID-19.

The review, published by Annals of Internal Medicine on March 1, found one new randomized controlled trial (RCT) and one new subtrial comparing a 10-day course of remdesivir with placebo or standard care, making a total of five RCTs and two subtrials for consideration. The update confirmed that a 10-day course of remdesivir probably results in little to no mortality reduction but probably results in a moderate increase in the proportion of patients recovered by day 29 and may reduce time to clinical improvement and hospital length of stay. The new data led to an updated conclusion that remdesivir probably results in a small reduction in the proportion of patients receiving ventilation or extracorporeal membrane oxygenation (ECMO) at specific follow-up times and that the drug may lead to a small reduction in serious adverse events but a small increase in risk of any adverse event.

Based on the updated review, the ACP Practice Points on this topic were unchanged, but their rationales were updated or reaffirmed. The three points are as follows:

• Consider remdesivir for five days to treat hospitalized patients with COVID-19 who do not require invasive ventilation or ECMO.
• Consider extending the use of remdesivir to 10 days to treat hospitalized patients with COVID-19 who develop the need for invasive ventilation or ECMO within a five-day course.
• Avoid initiating remdesivir to treat hospitalized patients with COVID-19 who are already on invasive ventilation or ECMO.

The update also noted that College's Scientific Medical Policy Committee, which develops the Practice Points, has decided to retire this topic from living status, considering that surveillance was originally planned through December 2021 and the last three updates did not result in important changes to the conclusions.

In other COVID-19 news, two recent studies looked at long-term outcomes in COVID-19 patients who underwent tracheostomy and mechanical ventilation. An analysis of patients discharged to long-term acute care hospitals after respiratory failure, published by CHEST on Feb. 24, compared 37 with COVID-19 to 128 with another diagnosis. It found that the COVID-19 patients had a higher adjusted ventilator liberation rate (91.4% vs. 56.0%) as well as greater improvement in functional status and shorter length of stay. “We believe that COVID patients represent a unique population in the post-acute care settings. Allowing time for rehabilitation and ventilator liberation attempts can help them to achieve a recovery beyond what is seen in the general [long-term acute care hospital] population,” the authors said. The other study, published by Critical Care Medicine on Feb. 21, followed 81 COVID-19 patients with tracheostomy and percutaneous endoscopic gastrostomy (PEG) placement for 90 days, finding that 9.9% had died, 2.7% still had the tracheostomy, 32.9% still had the PEG, and 58.9% were at home.