Remdesivir treatment and clinical outcome in non-severe hospitalized COVID-19 patients: a propensity score matching multicenter Italian hospital experience

Real life experience on the use of Remdesivir in patients admitted to COVID-19 in two referral Italian hospital: a propensity score matched analysis

Remdesivir (RDV) was the first Food and Drug Administration (FDA)-approved medication for COVID-19, with discordant data on efficacy in reducing mortality risk and disease progression. In the context of a dynamic and rapidly changing pandemic landscape, the utilization of real-world evidence is of utmost importance. The objective of this study is to evaluate the impact of RDV on patients who have been admitted to two university referral hospitals in Italy due to COVID-19. All patients older than 18 years and hospitalized at two different universities (Bari and Palermo) were enrolled in this study. To minimize the effect of potential confounders, we used propensity score matching with one case (Remdesivir) and one control that never experienced this kind of intervention during hospitalization. Mortality was the primary outcome of our investigation, and it was recorded using death certificates and/or medical records. Severe COVID-19 was defined as admission to the intensive care unit or a qSOFAscore ≥ 2 or CURB65scores ≥ 3. After using propensity score matching, 365 patients taking Remdesivir and 365 controls were included. No significant differences emerged between the two groups in terms of mean age and percentage of females, while patients taking Remdesivir were less frequently active smokers (p < 0.0001). Moreover, the patients taking Remdesivir were less frequently vaccinated against COVID-19. All the other clinical, radiological, and pharmacological parameters were balanced between the two groups. The use of Remdesivir in our cohort was associated with a significantly lower risk of mortality during the follow-up period (HR 0.56; 95% CI 0.37-0.86; p = 0.007). Moreover, RDV was associated with a significantly lower incidence of non-invasive ventilation (OR 0.27; 95% CI 0.20-0.36). Furthermore, in the 365 patients taking Remdesivir, we observed two cases of mild renal failure requiring a reduction in the dosage of Remdesivir and two cases in which the physicians decided to interrupt Remdesivir for bradycardia and for QT elongation. Our study suggests that the use of Remdesivir in hospitalized COVID-19 patients is a safe therapy associated with improved clinical outcomes, including halving of mortality and with a reduction of around 75% of the risk of invasive ventilation. In a constantly changing COVID-19 scenario, ongoing research is necessary to tailor treatment decisions based on the latest scientific evidence and optimize patient outcomes.

Remdesivir-Induced Bradycardia and Mortality in SARS-CoV-2 Infection, Potential Risk Factors Assessment: A Systematic Review and Meta-Analysis

Background: The efficacy of remdesivir in reducing disease severity among COVID-19-infected patients has been established, but concerns have emerged regarding the potential side effects of bradycardia. The aim of this study was to investigate the association between remdesivir-induced bradycardia and mortality, while also identifying the related risk factors. Materials and methods: The PubMed/Medline, Cochrane Central and ClinicalTrials.gov databases were searched. Randomized controlled trials and prospective or retrospective cohort studies were included (through 14 July 2023). The random-effects model was implemented using Comprehensive Meta-Analysis software version 3.0 to examine the outcomes. Results: A total of 12 prospective or retrospective studies involving 7674 patients were analyzed. The primary outcomes revealed a significant association between remdesivir administration and bradycardia development (Odds ratio = 2.556, 95% CI = 2.049-3.188, p < 0.001). However, no statistically significant increase in the mortality rate was observed among patients with bradycardia during remdesivir treatment (Odds ratio = 0.872, 95% CI = 0.483-1.576, p = 0.651). The secondary outcome demonstrated a significant association between chronic kidney disease (CKD) and remdesivir-induced bradycardia (OR: 1.251, 95% CI: 1.003-1.561, p = 0.047). Moreover, patients with obesity (OR = 1.347, 95% CI = 1.098-1.652, p = 0.004) were more likely to experience remdesivir-induced bradycardia. Conclusions: Although a higher risk of bradycardia occurred during remdesivir treatment, the occurrence of remdesivir-induced bradycardia did not lead to higher mortality. Our study also identified patients with obesity and CKD as high-risk subgroups for experiencing bradycardia during remdesivir treatment.

Remdesivir: A Review in COVID-19

Remdesivir (Veklury®), a nucleotide analogue prodrug with broad-spectrum antiviral activity, is approved for the treatment of coronavirus disease 2019 (COVID-19), the illness caused by severe acute respiratory syndrome coronavirus 2 infection. Unlike some antivirals, remdesivir has a low potential for drug-drug interactions. In the pivotal ACTT-1 trial in hospitalized patients with COVID-19, daily intravenous infusions of remdesivir significantly reduced time to recovery relative to placebo. Subsequent trials provided additional support for the efficacy of remdesivir in hospitalized patients with moderate or severe COVID-19, with a greater benefit seen in patients with minimal oxygen requirements at baseline. Clinical trials also demonstrated the efficacy of remdesivir in other patient populations, including outpatients at high risk for progression to severe COVID-19, as well as hospitalized paediatric patients. In terms of mortality, results were equivocal. However, remdesivir appeared to have a small mortality benefit in hospitalized patients who were not already being ventilated at baseline. Remdesivir was generally well tolerated in clinical trials, but pharmacovigilance data found an increased risk of hepatic, renal and cardiovascular adverse drug reactions in the real-world setting. In conclusion, remdesivir represents a useful treatment option for patients with COVID-19, particularly those who require supplemental oxygen.