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Antiviral — RNA Polymerase Inhibitor (COVID-19 / Hepatitis) Pregnancy: Use if clearly necessary — limited human data. MHRA and RCOG indicate remdesivir can be used in hospitalised pregnant women with COVID-19 requiring oxygen when benefit outweighs risk. Inform obstetric team.

Remdesivir

Brand names: Veklury

Adult dose

Dose: 200 mg IV loading dose on day 1, then 100 mg IV once daily on days 2–5 (hospitalised COVID-19, no mechanical ventilation). Day 2–10 if mechanically ventilated
Route: Intravenous (infuse over 30–120 minutes)
Frequency: Once daily
Max: 200 mg on day 1; 100 mg/day thereafter
COVID-19 in hospitalised adults requiring supplemental oxygen but NOT yet on mechanical ventilation: 5-day course. On mechanical ventilation: extend to 10 days. ACTT-1 trial showed 5-day benefit in time to recovery. Oral formulation under development. Source: BNF 90; NICE TA689; WHO Living Guidelines.

Paediatric dose

Dose: ≥28 kg: adult doses. <28 kg: 5 mg/kg IV loading, then 2.5 mg/kg daily mg/kg
Route: Intravenous
Frequency: Once daily
Max: 200 mg day 1; 100 mg/day thereafter
Licensed from 28 days (≥3 kg) for COVID-19 requiring hospitalisation. Weight-adjusted dosing for under 28 kg. Source: BNF for Children 2024; MHRA SPC Veklury.

Dose adjustments

Renal

eGFR ≥30 mL/min: no dose adjustment. eGFR <30 mL/min: use with caution (sulfobutylether-beta-cyclodextrin vehicle accumulates). If eGFR <30 — IV cyclodextrin exposure increases; weigh benefits vs risks. Oral remdesivir (when available) circumvents this issue.

Hepatic

ALT >5× ULN: consider withholding — hepatotoxicity monitoring essential.

Paediatric weight-based calculator

Licensed from 28 days (≥3 kg) for COVID-19 requiring hospitalisation. Weight-adjusted dosing for under 28 kg. Source: BNF for Children 2024; MHRA SPC Veklury.

Clinical pearls

  • ACTT-1 trial (NEJM 2020): remdesivir reduced time to recovery from 15 to 11 days in hospitalised COVID-19 patients (those on supplemental oxygen benefited most). Mortality reduction was non-significant in this trial. Subsequent data (ACTT-2, WHO SOLIDARITY): benefit primarily in oxygen-requiring patients not yet mechanically ventilated — consistent across trials.
  • Bradycardia — the infusion-related effect: clinically significant bradycardia occurs in a proportion of patients receiving IV remdesivir, particularly with rapid infusion. MHRA advises: monitor heart rate and blood pressure before infusion and periodically during; infuse over 30–120 minutes. Slow infusion rate if HR falls below 50 bpm during infusion.
  • WHO SOLIDARITY trial controversy: showed no significant reduction in mortality with remdesivir across all COVID-19 subgroups. This led to WHO 'conditional recommendation against' in non-ventilated patients — conflicting with FDA/EMA approval. The discrepancy relates to different patient populations and disease stage. NICE TA689 recommends based on ACTT-1 data (oxygen-requiring, pre-ventilated subgroup).
  • Hydroxychloroquine antagonism: in vitro and early trial data showed that combining hydroxychloroquine with remdesivir impairs remdesivir's intracellular activation (phosphorylation). Never combine with chloroquine or hydroxychloroquine.
  • Scope beyond COVID-19: remdesivir was originally developed for Ebola (limited efficacy) and later showed activity against SARS, MERS, and other RNA viruses. It is being explored for RSV and other emerging RNA viruses — broad-spectrum RNA polymerase inhibitor mechanism. Source: BNF 90; Beigel et al. NEJM 2020 (ACTT-1); Pan et al. NEJM 2021 (SOLIDARITY); NICE TA689; MHRA SPC Veklury.

Contraindications

  • Hypersensitivity to remdesivir
  • Concurrent use with chloroquine/hydroxychloroquine (antagonism demonstrated in vitro — avoid combination)

Side effects

  • Bradycardia (infusion-related — especially at higher infusion rates; infuse over minimum 30 minutes, preferably 120 minutes)
  • Hypotension, diaphoresis, shivering (infusion-related — usually rate-dependent)
  • Nausea
  • Elevated liver transaminases (ALT/AST) — monitor; hold if >10× ULN
  • Elevated INR (transient)
  • Cyclodextrin vehicle accumulation in severe renal impairment

Interactions

  • Chloroquine/hydroxychloroquine: antagonise remdesivir antiviral effect (reduce intracellular phosphorylation) — do not combine
  • Strong CYP3A4 inducers (rifampicin): reduce remdesivir active metabolite — avoid
  • P-gp inhibitors: may increase remdesivir exposure — monitor

Monitoring

  • Heart rate and blood pressure before and during each infusion (bradycardia monitoring)
  • Liver function tests (ALT, AST) before starting and every 2 days (hold if >5× ULN)
  • Renal function (eGFR) — cyclodextrin vehicle monitoring in low eGFR
  • INR (monitor if on anticoagulation)
  • Oxygen requirements (clinical response — should improve by day 3–5)

Reference: BNFc; BNF 90; BNF for Children 2024; Beigel et al. NEJM 2020 (ACTT-1); WHO SOLIDARITY trial 2021; NICE TA689; MHRA SPC Veklury. Verify against your local formulary and the latest BNF before prescribing.

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