Intended for healthcare professionals

Practice Rapid Recommendations

Remdesivir for severe covid-19: a clinical practice guideline

BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2924 (Published 30 July 2020) Cite this as: BMJ 2020;370:m2924

Visual summary of recommendation

Population Does not apply to: Disease severity Mild Moderate Severe Applies to people withat least one of: Patients with mild or moderate covid-19 Pediatric patients Respiratory rate >30 Respiratory distress SpO 2 <94% on room air Requires intensivecare admission This recommendation applies onlyto people with these characteristics: Adults withconfirmed covid-19
Recommendation 1 We suggest remdesivir rather than no remdesivir in patients with severe covid-19 Usual supportive care Remdesivir or 100 mg intravenously daily for 5-10 days No remdesivir Strong All or nearly all informed people would likely want usual supportive care. Benefits would outweigh harms for almost everyone Weak Most people would likely want usual supportive care. Benefits would outweigh harms for the majority, but not for everyone Weak Most people would likely want Remdesivir. Benefits would outweigh harms for the majority, but not for everyone Strong All or nearly all informed people would likely want remdesivir. Benefits would outweigh harms for almost everyone Resource limited settings Remdesivir is a new drug with uncertain benefits and undetermined cost-effectiveness, not yet approved for marketing or reimbursed for use in many countries. The significant opportunity costs and potential to exacerbate existing health inequities in resource-limited settings may well justify policy decisions not to offer remdesivir to patients until more conclusive evidence is available.
Recommendation 2 Randomised controlled trials examining remdesivir in patients with covid-19 should continue pending further data Further information is required to identify subgroups of covid-19 patients that are more or less likely to benefit from therapy Further information is necessary to raise the quality of evidence for all outcomes Need for further evidence We place a high value on ensuring that, ultimately, high quality evidence will be available regarding the impact of remdesivir on all critical outcomes. This is necessary to ensure that we will be able to make wise decisions regarding the relative merits of emerging treatments. For example, establishing the magnitude of impact (if any) of remdesivir on mortality will be crucial

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Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Bram Rochwerg, methods chair, critical care physician1 2,
  2. Arnav Agarwal, methodologist, internist1 3,
  3. Linan Zeng, methodologist1 4,
  4. Yee-Sin Leo, clinical chair, infectious disease specialist5,
  5. John Adabie Appiah, pediatric critical care physician6,
  6. Thomas Agoritsas, methodologist, internist1 7,
  7. Jessica Bartoszko, methodologist1 *,
  8. Romina Brignardello-Petersen, methodologist1 *,
  9. Begum Ergan, critical care physician8,
  10. Long Ge, methodologist1 9 10 *,
  11. Heike Geduld, emergency physician11,
  12. Hayley B Gershengorn, critical care physician12 13,
  13. Hela Manai, emergency physician14,
  14. Minhua Huang, patient partner15,
  15. François Lamontagne, methodologist, critical care physician16,
  16. Seema Kanda, patient partner17,
  17. Leticia Kawano-Dourado, respiratory medicine physician18 19,
  18. Linda Kurian, internist20,
  19. Arthur Kwizera, critical care physician21,
  20. Srinivas Murthy, methodologist, paediatric critical care physician22 ,
  21. Nida Qadir, critical care physician23,
  22. Reed Siemieniuk, methodologist, internist1,
  23. Maria Asuncion Silvestre, maternal and child health specialist24 25,
  24. Per Olav Vandvik, methodologist, internist26,
  25. Zhikang Ye, methodologist, pharmacist1,
  26. Dena Zeraatkar, methodologist1 *,
  27. Gordon Guyatt, methodologist, internist1 12
  1. 1Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
  2. 2Department of Medicine, McMaster University, Hamilton, Ontario Canada
  3. 3Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Pharmacy Department-Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
  5. 5National Center for Infectious Diseases, Singapore
  6. 6Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
  7. 7Division of General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
  8. 8Department of Pulmonary and Critical Care, Dokuz Eylul University, School of Medicine, Izmir, Turkey
  9. 9Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, China
  10. 10Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, China
  11. 11Division of Emergency Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
  12. 12Division of Pulmonary, Critical Care and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
  13. 13Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
  14. 14Emergency Medical Services, Faculty of Medicine, Tunis, Tunisia
  15. 15Guangdong Kuaiwen Information Technology Co. LTD, Guangzhou, Guangdong, China
  16. 16Department of Medicine, Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
  17. 17McMaster University (alumnus)
  18. 18Pulmonary Division, Heart Institute (InCor)- HCFMUSP, Medical School, University of Sao Paulo, São Paulo, Brazil
  19. 19Research Institute, Hospital do Coração (HCor), São Paulo, Brazil
  20. 20Division of Hospital Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
  21. 21Department of Anaesthesia and Critical Care, College of Health Sciences, Makerere University, Kampala, Uganda
  22. 22Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  23. 23Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
  24. 24Kalusugan ng Mag-Ina (Health of Mother and Child), Inc., Quezon City, Philippines
  25. 25Asia-Pacific Center for Evidence-Based Healthcare, Manila, Philippines
  26. 26Department of Health Economics and Health Management, Institute for Health and Society, University of Oslo, Oslo, Norway
  27. *Not panel member, systematic review team and resource for guideline panel
  28. Not panel member, resource for methodology and content support
  1. Correspondence: B Rochwerg, 711 Concession St, Hamilton, Ontario, Canada L8V 1C3 rochwerg{at}mcmaster.ca

Abstract

Clinical question What is the role of remdesivir in the treatment of severe covid-19? This guideline was triggered by the ACTT-1 trial published in the New England Journal of Medicine on 22 May 2020.

Current practice Remdesivir has received worldwide attention as a potentially effective treatment for severe covid-19. After rapid market approval in the US, remdesivir is already being used in clinical practice.

Recommendations The guideline panel makes a weak recommendation for the use of remdesivir in severe covid-19 while recommending continuation of active enrolment of patients into ongoing randomised controlled trials examining remdesivir.

How this guideline was created An international panel of patients, clinicians, and methodologists produced these recommendations in adherence with standards for trustworthy guidelines using the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. The panel considered an individual patient perspective and allowed contextual factors (such as resources) to be taken into account for countries and healthcare systems.

The evidence The linked systematic review (published 31 Jul 2020) identified two randomised trials with 1300 participants, showing low certainty evidence that remdesivir may be effective in reducing time to clinical improvement and may decrease mortality in patients with severe covid-19. Remdesivir probably has no important effect on need for invasive mechanical ventilation. Remdesivir may have little or no effect on hospital length of stay.

Understanding the recommendation Most patients with severe covid-19 would likely choose treatment with remdesivir given the potential reduction in time to clinical improvement. However, given the low certainty evidence for critical outcomes and the fact that different perspectives, values, and preferences may alter decisions regarding remdesivir, the panel issued a weak recommendation with strong support for continued recruitment in randomised trials.

Footnotes

  • Research, doi: 10.1136/bmj.m2980
  • This BMJ Rapid Recommendation article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (http://magicproject.org/) and The BMJ. A summary is offered here and the full version including decision aids is on the MAGICapp (https://app.magicapp.org), for all devices in multilayered formats. Those reading and using these recommendations should consider individual patient circumstances, and their values and preferences and may want to use consultation decision aids in MAGICapp to facilitate shared decision making with patients. We encourage adaptation and contextualisation of our recommendations to local or other contexts. Those considering use or adaptation of content may go to MAGICapp to link or extract its content or contact The BMJ for permission to reuse content in this article.

  • Contributors: All panel members participated in the teleconferences or email discussions and met all authorship criteria. Non-panel members: J Bartoszko, R Brignardello-Petersen, L Ge, and D Zeraatkar provided systematic review team and resource for the guideline panel; S Murthy and G Guyatt, provided resource for methodology and content support.

  • Competing interests: All authors have completed the BMJ Rapid Recommendations interests disclosure form, and a detailed description of all disclosures is reported in appendix 3 on bmj.com. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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