Can Remdesivir (remdesivir) cause hyperkalemia?

From the Guidelines

Remdesivir can potentially cause hyperkalemia, although it is not a commonly reported side effect. According to the evidence from the Annals of Internal Medicine 1, remdesivir is associated with various adverse events, including renal toxicity, which may increase the risk of hyperkalemia. The FDA recommends assessing kidney function at baseline and during treatment with remdesivir, and discontinuing its use if alanine aminotransferase levels increase to >10 times the upper limit of normal or if alanine aminotransferase elevation is accompanied by signs or symptoms of liver inflammation 1.

Key Points to Consider

• Remdesivir's impact on renal function may contribute to the development of hyperkalemia, particularly in patients with pre-existing kidney disease.
• Healthcare providers should monitor electrolyte levels, including potassium, during remdesivir treatment, especially in patients with risk factors for electrolyte disturbances.
• Symptoms such as muscle weakness, fatigue, irregular heartbeat, or numbness and tingling may indicate hyperkalemia and should prompt immediate medical evaluation.
• Regular laboratory monitoring of potassium levels during treatment is crucial, particularly for those with underlying kidney disease or those taking other medications that may affect potassium levels.

Adverse Events Associated with Remdesivir

• The evidence from the Annals of Internal Medicine 1 reports various adverse events associated with remdesivir, including acute kidney injury, increased alanine aminotransferase level, and increased serum potassium level.
• However, the certainty of evidence for these adverse events is low, and the true effect of remdesivir on hyperkalemia may be substantially different from the estimated effect.

Clinical Implications

• Remdesivir should be used with caution in patients with pre-existing kidney disease or those at risk of electrolyte disturbances.
• Healthcare providers should carefully monitor patients receiving remdesivir for signs and symptoms of hyperkalemia and adjust treatment accordingly.
• The benefits and harms of remdesivir treatment should be carefully weighed, particularly in patients with underlying medical conditions that may increase the risk of adverse events.

From the Research

Remdesivir and Hyperkalemia

• There is no direct evidence in the provided studies that remdesivir causes hyperkalemia 2, 3.
• A study on the effect of remdesivir on adverse kidney outcomes in hospitalized patients with COVID-19 and impaired kidney function found no statistically significant differences in peak creatinine during hospitalization, incidence of doubling of creatinine, and rate of kidney replacement therapy initiation in remdesivir-treated patients versus matched untreated historical comparators 2.
• Another study evaluated the use of remdesivir in patients with severe renal impairment and found that the incidence of possible adverse events, including hepatotoxicity and nephrotoxicity, was not significantly different between patients with and without severe renal impairment 3.
• Hyperkalemia is a condition where a serum potassium level is >5.5 mmol/l, and it can be caused by certain medical conditions, such as chronic kidney disease (CKD), diabetes mellitus, and others 4, 5.
• The treatment of hyperkalemia includes glucose and insulin, bicarbonate, calcium gluconate, beta-2 agonists, hyperventilation, and dialysis, as well as medications such as sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer 4, 6, 5.

Kidney Function and Hyperkalemia

• Remdesivir use in patients with impaired kidney function (eGFR between 15 - 60 mL/min/1.73m2) who present to the hospital with COVID-19 is not associated with increased risk of adverse kidney outcomes 2.
• Patients with severe renal impairment who received remdesivir had a higher incidence of serum creatinine elevations, but this was not attributed to remdesivir 3.
• The management of hyperkalemia in patients with chronic kidney disease (CKD) is complex and requires consideration of the benefits and risks of different treatment strategies, including potassium binders such as SPS, CPS, patiromer, and SZC 5.