Thread by @FranciscoMarty_

#Remdesivir begins distribution in the #USA today via #EUA.

I thought would write down some practical #tips based on my #qualitative anecdotal experience after personally treating close to 200 patients with #COVID19.

For quantitative results, wait for the papers¬—thread

“this juice works, doc!” When you hear similar expressions 1-2 days after starting #remdesivir multiple times, you start to wonder. Don't recall a similar proportion of patients smile after feeling so sick 1-2 days earlier with #COVID19. x/n? Wait for the papers.

Like #treatment for any severe infectious disease (meningitis, Gram-negative bacteremia, influenza pneumonia, etc), earlier is always better. #COVID19 is no different. #Remdesivir stops #SARS-CoV2 replication, but won’t heal the lung injury.

And the lung injury in #COVID19 is nasty and slow to heal, slower that any pneumonic process I ever recall in 25 years in medicine. Patients feel great, appetite comes back, all pains and fevers are gone, but the lung heals slowly.

So my preference on when to use #remdesivir? Use it early in severe #COVID19 disease, anyone with an abnormal chest X-ray that drops to SpO2 <94%: limit the lung injury, get patients home in 2-4 days, not 2 to 4 weeks.

And I would not play number games in terms of age, comorbidities, immunosuppression. If they are sick enough to be in the hospital with #COVID19, sick enough to treat. We see responses in all patient groups, young & old, cancer & transplant, earlier is better.

Patients who end up in the #ICU on mechanical ventilation with #COVID19 likely benefit too given the #ACTT DSMB disclosed info to investigators, but the lung damage is already advanced and takes time to heal, no different that other #lung infections

And yes, several patients who we treated early in their severe #COVID19 disease were able to go home without completing 5 days of #remdesivir. No one has come back yet with recrudescent disease. You can use those vials for others, more beds.

The risk of #hepatotoxicity with #remdesivir is real, 3% of patients needing discontinuation for Hy’s law criteria quoted in the #NIAID press release. Lots of #COVID19 patients come with high ALT/AST though. If <5xULN, treat them, enzymes go down.

The risk for acute #kidney injury is due to the #cyclodextrine used to solubilize #remdesivir. So follow your experience with IV #voriconazole, other drugs in assessing risk/benefit, and consider dosing below GFR <50.

#Cyclodextrine is dialyzable. Although excluded from the study protocols, I would use #remdesivir without qualms in patients on #hemodialysis or #CVVH with severe #COVID19. The #EUA is silent on renal function, risk/benefit.

If patients in the #ICU on #remdesivir treatment defervesce, but then start having fevers again a few days later, please don’t invoke #cytokine storms. Do the basics: look for #VAP, bacteremias, thromboembolic disease, nosocomial stuff.

Pandemic times—we get to use #remdesivir before all the data is out.
#COVID19 is not the #flu & #remdesivir is not #oseltamivir, I think is much better.
We must continue public health measures, get effective #vaccines. This is a first tool delivered to all today, full data soon.