Should statins be held in patients with severe viral infections, such as COVID-19, who are being treated with remdesivir, particularly those with a history of liver disease or kidney disease?

Do Not Hold Statins When Using Remdesivir

Statins should be continued in patients receiving remdesivir for COVID-19, as abnormal liver function tests are not a contraindication to using either medication, and both can be safely administered together with appropriate monitoring. 1

Key Guideline Recommendation

The Clinical and Molecular Hepatology guidelines explicitly state that abnormality in liver function tests is not a contraindication in the use of experimental or off-label treatments for COVID-19 including remdesivir, chloroquine, hydroxychloroquine, tocilizumab, and statins. 1 This is the most direct evidence addressing your question and comes from established hepatology guidelines.

Rationale for Continuing Statins

Liver Safety Profile

• Both remdesivir and statins may cause liver enzyme elevations, but these are generally transient and do not require discontinuation 1
• In randomized controlled trials, remdesivir caused bilirubin elevation in approximately 10% of patients (not significantly different from placebo at 9%) and AST elevation in 5% (versus 12% in placebo) 1
• Hepatic dysfunction in COVID-19 patients is generally transient and does not require special treatment 1
• LFT abnormalities are more commonly related to COVID-19 severity itself rather than the medications used 1

Required Monitoring Approach

Regular monitoring of liver function tests is necessary when using these medications together, regardless of baseline liver function test results. 1 Specifically:

• The FDA recommends assessing kidney and hepatic function at baseline and during remdesivir treatment 1
• Discontinue remdesivir only if ALT levels increase to ≥5 times the upper limit of normal OR if any ALT elevation is accompanied by signs/symptoms of liver inflammation, increasing conjugated bilirubin, alkaline phosphatase, or INR 1
• This threshold is high and rarely reached with statin co-administration

Special Populations

Patients with Pre-existing Liver Disease

• Even in patients with baseline liver disease, statins and remdesivir can be used together 1
• The guideline emphasizes that abnormal baseline LFTs should not prevent treatment 1
• Monitor more frequently but do not automatically discontinue either medication

Patients with Renal Impairment

• While remdesivir has theoretical concerns in severe renal impairment (eGFR <30 mL/min), recent evidence suggests it can be used safely with monitoring 2, 3, 4, 5
• Statins should be continued as they may provide cardiovascular protection in critically ill patients
• No specific drug-drug interaction between statins and remdesivir necessitates holding either medication

Clinical Pitfalls to Avoid

Do not reflexively discontinue statins when starting remdesivir. The most common error is assuming additive hepatotoxicity requires prophylactic discontinuation, but the evidence does not support this approach 1

If liver enzymes rise during treatment, consider alternative causes first: 1

• COVID-19 complications (myositis, especially when AST exceeds ALT)
• Ischemia
• Cytokine release syndrome
• Other drug-induced liver injury from concurrent medications

Only discontinue medications if specific FDA thresholds are met (ALT ≥5x ULN or accompanied by clinical signs of hepatic inflammation) 1