What is the recommended dose of Remdesivir (Veklury) for COVID-19 treatment?

Remdesivir Dosing for COVID-19

For hospitalized adults and pediatric patients ≥40 kg, administer remdesivir 200 mg IV loading dose on day 1, followed by 100 mg IV daily, with treatment duration of 5 days for those not requiring mechanical ventilation/ECMO, 10 days for those requiring mechanical ventilation/ECMO, and 3 days for non-hospitalized high-risk patients. 1, 2

Adult and Pediatric Patients ≥40 kg Dosing

Loading and Maintenance Doses:

• Day 1: 200 mg IV loading dose 1, 2
• Day 2 onwards: 100 mg IV once daily 1, 2

Treatment Duration by Clinical Setting:

Hospitalized Patients NOT on Mechanical Ventilation/ECMO

• Standard duration: 5 days (total of 5 doses) 1, 2
• If clinical worsening occurs during the 5-day course requiring supplemental oxygen (but not mechanical ventilation), extending treatment beyond 5 days should be based on clinical judgment 1
• May extend up to 10 days total if patient does not demonstrate clinical improvement 2

Hospitalized Patients on Mechanical Ventilation/ECMO

• Duration: 10 days 1, 2
• If a patient progresses to requiring mechanical ventilation or ECMO during the initial 5-day course, extend treatment to 10 days 1

Non-Hospitalized High-Risk Patients

• Duration: 3 days 1, 2
• Must initiate within 7 days of symptom onset 1, 2
• Indicated for patients with mild-to-moderate COVID-19 and at least one risk factor for progression to severe disease (immunosuppression, malignancy, hematological malignancies) 1

Pediatric Dosing (<40 kg)

For pediatric patients weighing 1.5 kg to <40 kg: 2

• Term neonates <28 days old and ≥1.5 kg:

  • Loading dose: 2.5 mg/kg IV on day 1
  • Maintenance: 1.25 mg/kg IV once daily from day 2 2

• Patients ≥28 days old weighing 1.5 kg to <3 kg:

  • Loading dose: 2.5 mg/kg IV on day 1
  • Maintenance: 1.25 mg/kg IV once daily from day 2 2

• Patients ≥28 days old weighing 3 kg to <40 kg:

  • Loading dose: 5 mg/kg IV on day 1
  • Maintenance: 2.5 mg/kg IV once daily from day 2 2

Critical Timing Considerations

Initiate treatment as soon as possible after diagnosis of symptomatic COVID-19 1, 2

• Greatest mortality benefit occurs in patients requiring low-flow oxygen at baseline, with mortality reduction risk ratios of 0.21-0.24 1
• Early initiation within 1-4 days from symptom onset is more effective than days 5-7 for preventing oxygen desaturation 3

Absolute Contraindications

Do not use remdesivir in patients with: 1

• eGFR <30 mL/min/1.73 m² 1, 2
• ALT ≥5 times the upper limit of normal 1
• History of clinically significant hypersensitivity to remdesivir 1

When NOT to Initiate Remdesivir

Do not start remdesivir in patients already on mechanical ventilation or ECMO at baseline, as evidence shows potential for increased mortality in this population 1

Required Monitoring

Before starting treatment: 1, 2

• Assess hepatic function (ALT/AST) 1, 2
• Assess renal function (eGFR) 1, 2
• Check prothrombin time 1, 2

During treatment: 1

• Discontinue if ALT increases to >10 times the upper limit of normal 1
• Discontinue if ALT elevation is accompanied by signs or symptoms of liver inflammation 1

Renal Impairment Adjustments

No dosage adjustment required for any degree of renal impairment, including patients on dialysis 2

• Remdesivir may be administered without regard to timing of dialysis 2
• However, do not initiate if eGFR <30 mL/min/1.73 m² 1

Administration Requirements

• Route: Intravenous infusion only 2
• Setting: Must be administered where healthcare providers have immediate access to medications for treating severe infusion/hypersensitivity reactions and ability to activate emergency medical system 2
• Preparation: Must be diluted prior to IV infusion; two formulations exist (lyophilized powder and solution) with different preparation requirements 2

Common Adverse Events

• Metabolic: hyperglycemia 1
• Hepatic: increased ALT/AST 1
• Renal events 1
• Nausea (9-10% vs 3% standard care) 4
• Hypokalemia (6% vs 2% standard care) 4
• Headache (5% vs 3% standard care) 4