Acetylcysteine for the Treatment of Suspected Remdesivir‐Associated Acute Liver Failure in COVID‐19: A Case Series

Abstract

Remdesivir is a direct-acting nucleoside RNA polymerase inhibitor with activity against the novel severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) virus used in the treatment of coronavirus disease 2019 (COVID-19) pneumonia. Here, we present two cases of suspected remdesivir-associated acute liver failure (ALF) in which the liver failure improved after continuous infusion acetylcysteine and withdrawal of remdesivir. Both patients had significant increases in transaminases between day 3 and day 10 of remdesivir therapy accompanied by coagulopathy and encephalopathy. After initiation of continuous infusion acetylcysteine, the transaminases of both patients rapidly improved. Ultimately, one patient fully recovered while the other died of suspected septic shock. Due to its novel nature and only recent widespread use, there are very little data on the risk of ALF from remdesivir. Additionally, the data for the use of acetylcysteine to manage non-acetaminophen-induced ALF are limited. It is important to consider the risk of remdesivir-associated ALF when weighing the risk versus benefits of use, and acetylcysteine may have a role in its management.

Liver injury in the era of COVID-19

“…Data on a potential relationship between remdesivir and acute liver injury in the COVID-19 population are limited, but worth further exploration[ 50 ].…”

Remdesivir for patients with COVID-19

“…Patients with elevated levels of liver enzymes or a glomerular filtration rate less than 30 mL/min were excluded from the published trials. 1,2,4,5 Drug-induced liver injuries have been reported, 6 and anaphylaxis and infusion-related reactions can occur. 1 PRACTICE | FIVE THINGS TO KNOW ABOUT ...…”

“…Peter E. Wu MD MSc, Andrew M. Morris MD SM n Cite as: CMAJ 2021. doi: 10.1503/cmaj.202505; early-released January 6,2021…”

Le remdésivir chez les patients atteints de la COVID-19

“…Les patients ayant d'importants taux d'enzymes hépatiques ou un débit de filtration glomérulaire de moins de 30 mL/ min ont été exclus des essais publiés 1,2,4,5 . Des lésions du foie causées par le médicament ont été signalées 6 , et des réactions anaphy lactiques ou liées à la perfusion peuvent se produire 1 .…”