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Sunday, October 4, 2020

Antiviral Drug Remdesivir Shows Promise For Treating Coronavirus In NIH Study

Since this initial post, April 30, 2020, the POTUS has been hospitalized and is reportedly receiving remdesivir antiviral therapy. Presumably, he may also be receiving dexamethasone which has also demonstrated outcomes benefit. How many do we have to treat with remdesivir to save one life? (Repost from April 30, 2020) Remdesivir (an anti-viral drug developed for Ebola treatment) demonstrated a 3% reduction in mortality rates (preliminary data, pending peer review, pending reproduction, pending publication from the NIH). That means in order to save one life with this drug we need to treat 33 patients. Or, to phrase it differently, for every 33 patients we treat with remdesivir, 32 will die and 1 will live. This is called the number needed to treat (NNT). The ideal NNT is 1, where everyone improves with treatment and no one improves with control. A higher NNT indicates that treatment is less effective. As a general rule of thumb, an NNT of 5 or under for treating a symptomatic condition is usually considered to be acceptable and in some cases even NNTs below 10. The NNT for remdesivir is 33. In the sickest of the sick, COVID-19 induces sepsis (an overwhelming infection and systemic failure of the body) with the damage largely due to the body's own immune response rather than to the virus itself. We know that with sepsis of other infectious causes, it's not what we do, it's when we do it. For instance, if we administer sepsis therapies within the initial 6 hours of the patient presenting to the ER, the NNT is 6 (we save one life out of every six). If we do the exact same management outside of that 6-hour window, we save no more lives and mortality remains at 20-30%. It's not what we do, it's when we do it. Take oseltamivir, an antiviral used to treat influenza infection. It's only effective if taken within the first 48 hours of symptom onset. Outside of that window, it's not effective and you just have to let the flu run its course. Likewise, it may be a timing issue with COVID-19 sepsis. We have to act sooner rather than later. From the New York City patient cohort of 5,700 COVID-infected patients, we know that the mortality rate for those age 65 and over who are intubated on mechanical ventilation is 97% (JAMA 2020). Since the mortality rate is high for this patient demographic, perhaps we should offer antiviral therapy sooner in the presentation.
from Rajesh Harrykissoon, MD

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