What is the recommended dosing regimen for Remdesivir (Veklury) in the treatment of COVID-19?

Remdesivir Dosing for COVID-19

For hospitalized adults and pediatric patients ≥40 kg, administer remdesivir 200 mg IV on day 1, followed by 100 mg IV daily for 5 days if not requiring mechanical ventilation/ECMO, or 10 days if requiring mechanical ventilation/ECMO. 1, 2, 3

Standard Adult Dosing Regimen

Loading and Maintenance Doses:

• Day 1: 200 mg IV infusion 1, 2, 3
• Day 2 onwards: 100 mg IV daily 1, 2, 3

Treatment Duration Based on Clinical Severity

Hospitalized patients NOT requiring mechanical ventilation/ECMO:

• 5-day course is the standard recommendation 1, 2, 3
• If clinical improvement is not demonstrated, treatment may be extended up to 5 additional days (total 10 days) 3

Hospitalized patients requiring mechanical ventilation/ECMO:

• 10-day course is recommended 1, 2, 3

Non-hospitalized high-risk patients:

• 3-day course (200 mg day 1, then 100 mg days 2-3) 2, 3
• Must be initiated within 7 days of symptom onset 2, 3

Pediatric Dosing (Weight-Based)

Pediatric patients weighing ≥40 kg:

• Use adult dosing: 200 mg day 1, then 100 mg daily 3

Pediatric patients 3 kg to <40 kg (≥28 days old):

• Day 1: 5 mg/kg IV 3
• Day 2 onwards: 2.5 mg/kg IV daily 3

Pediatric patients 1.5 kg to <3 kg (≥28 days old):

• Day 1: 5 mg/kg IV 3
• Day 2 onwards: 2.5 mg/kg IV daily 3

Term neonates <28 days old (≥1.5 kg):

• Day 1: 2.5 mg/kg IV 3
• Day 2 onwards: 1.25 mg/kg IV daily 3

Critical Timing Considerations

Initiate treatment as soon as possible after diagnosis of symptomatic COVID-19 2, 3

For outpatients, treatment must begin within 7 days of symptom onset 1, 2, 3

If patient worsens during 5-day course to require supplemental oxygen (but not mechanical ventilation), extending to 10 days should be based on clinical judgment 1, 2

If patient progresses to mechanical ventilation/ECMO during initial 5-day course, extend treatment to complete 10 days total 2

Absolute Contraindications

Do not use remdesivir in patients with:

• eGFR <30 mL/min/1.73 m² 1, 2, 3
• ALT ≥5 times upper limit of normal 2, 3
• History of clinically significant hypersensitivity to remdesivir 2, 3

Required Monitoring

Before initiating treatment, assess:

• Hepatic function (ALT/AST) 1, 3
• Renal function (eGFR) 1, 3
• Prothrombin time 3

During treatment, monitor:

• Hepatic function as clinically appropriate 3
• Discontinue if ALT increases to >10 times upper limit of normal or if accompanied by signs/symptoms of liver inflammation 1, 3
• Monitor for hypersensitivity reactions during and after infusion 3

Administration Details

Remdesivir must be administered by IV infusion only 3

Two formulations exist with different preparation requirements:

• Lyophilized powder (100 mg vial): requires reconstitution with Sterile Water for Injection, then dilution in 0.9% sodium chloride 3
• Solution (100 mg/20 mL): requires dilution in 250 mL of 0.9% sodium chloride 3

Infusion must occur in settings where healthcare providers have immediate access to medications for treating severe infusion/hypersensitivity reactions and ability to activate emergency medical services 3

Special Population Considerations

Patients on dialysis:

• No dosage adjustment required 3
• May be administered without regard to timing of dialysis 3

Pregnant or lactating patients:

• Guidelines do not specifically address this population as they were excluded from trials 1
• Decision should be made between patient and provider discussing potential benefits versus risks 1

Children <12 years or <40 kg:

• Use weight-based dosing as outlined above 3
• Only lyophilized powder formulation is approved for pediatric patients <40 kg 3

Clinical Context for Use

Remdesivir is NOT recommended for:

• Patients with non-severe COVID-19 at low risk of hospitalization (strong recommendation against) 1
• Patients already on mechanical ventilation/ECMO at baseline (evidence suggests potential for increased mortality) 2
• Patients hospitalized for conditions unrelated to COVID-19 who incidentally test positive 1

Greatest benefit observed in:

• Hospitalized patients requiring low-flow supplemental oxygen at baseline 2
• Patients with symptom duration ≤10 days 1