COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

Treatment Rochwerg B, Agarwal A, Zeng L, et al. Remdesivir for severe covid-19: a clinical practice guideline. BMJ. 2020 Jul 30;370:m2924. doi: 10.1136/bmj.m2924.

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.

Discipline / Specialty Area Score
Hospital Doctor/Hospitalists
Internal Medicine
Infectious Disease
Intensivist/Critical Care
Comments from MORE raters

Hospital Doctor/Hospitalists rater

This guideline is very practical and useful. It's a very useful tool for this pandemia.

Infectious Disease rater

This is a review of the existing studies on remdesivir and supports the weak recommendation for remdesivir. The data support a decrease in length of stay and propensity for mechanical ventilation with the use of remdesivir. Given the absence of other robust antiviral agents that directly act on SARS CoV2, this is better than nothing and so while studies are ongoing, it is useful to remember that it might still be useful as a treatment consideration.

Intensivist/Critical Care rater

This is s good initiative to formulate such live updated guideline based on emerging evidence on COVID-19 where evidences and options are changing every day. Due rapidly changing pathophysiology, daily emergence of new features and new treatment modality makes us hard to follow one especially when the recommendation based on some study changing day by day and many are not possibly correctly reviewed or analysed and hastily published creating huge confusion and disbeliefs. Strength: A good, speciality-based committed formed to analyse evidence and do the meta-analysis based updated recommendation. Weakness: Many recommendation are possibly biased and influenced by big journal's RCT than looking into the fallacies and loopholes of those studied. Even weak level of evidence have been stressed as recommendation which may mislead clinicians. When evidence on remdesivir is not so strong, and can even be harmful, recommending it even in severe most cases is debatable.

Respirology/Pulmonology rater

Our institution uses limited supplies of open label Remdesivir in cases of severe COVID-19. Its use is guided by shared decision-making with the infected individuals. The living network meta-analysis approach described in this article demonstrates that as more information is gathered and more knowledge emerges, clinicians and patients will be able to make better informed decisions on the use of remdesivir.