When to use Remdesivir, Favipiravir, Steroids and Tocilizumab drugs for covid 19 treatment: AIIMS doctor explains

• Remdesivir, steroids, plasma, Tocilizumab, and Favipiravir are some of the most widely used treatments for COVID-19.
• According to AIIMS’ director Randeep Guleria, the timing of using these drugs — depending on the condition of a COVID-19 patient — is critical in their effectiveness.
• Using them too early or too late could result in harmful side-effects.
• Here are the answers to some of the most frequently asked questions (FAQs) about COVID-19 drugs.

(Disclaimer: This should not be considered medical advice. The views and opinions expressed belong to Dr.Randeep Guleria, the director of AIIMS. Please check with your doctor before taking treatment.)

It’s been more than a year since the COVID-19 pandemic has been ravaging humanity. Despite predictions that the world would be out of the woods by now, the second wave of the virus is wreaking havoc in countries everywhere, including India.

As the number of cases has increased, so has the demand for the drugs that offer potential treatment. This includes everything from the overhyped Remdesivir to less known drugs like Tocilizumab and Favipiravir.

These drugs, however, are in short supply. Pharmacies across the country are reporting shortages. Moreover, this has led to a boom in blackmarket sales of these drugs.

According to Randeep Guleria, director of All India Institute of Medical Science (AIIMS), these drugs aren’t just something that you can take at home. And the timing of when they should be administered is critical in ensuring that a bad situation isn’t made worse.

In a press conference on April 19, Guleria answered some of the most frequently asked questions (FAQs) around COVID-19 and the drugs that fight it.

Here’s a quick look at his responses:

1. Is Remdesivir effective in the treatment of COVID-19?
   No study has conclusively been able to prove that Remdesivir is beneficial in the treatment of COVID-19. “It’s important to understand that Remdesivir is not a magic bullet and it’s not a drug that is reducing mortality,” said Guleria.
2. If there is not enough evidence to support the use of Remdesivir to treat COVID 19, why are doctors still prescribing it?
   “It [Remdesivir] does have a role,” Guleria explained. While everyone has been focused on coming up with a vaccine to fight off the pandemic, the same push has not been seen in the development of antivirals. So, in absence of a good drug that can treat COVID-19, doctors and patients are turning to Remdesivir in hopes of relief.
3. When should a patient of COVID 19 take Remdesivir?
   More important than the drug itself, is the timing of when it is administered. Taking it too early or too late, could do more harm than good.“Remdesivir has been shown to be useful only in those patients who were hospitalised, who showed oxygen saturation and had infiltrates on their chest X-ray or CT scan,” said Guleria. According to him, the optimal timing for Remdesivir is usually after five to seven days of having the virus. “It is of no use if given early to mild or asymptomatic patients,” he told the press. “It is of no use if it’s given very late because it would create a cytokine storm.” A cytokine storm is when the immune system goes into overdrive. The body starts to attack its own cells and tissues instead of just the virus.
4. Is Remdesivir something you can take at home?
   Remdesivir isn’t just a pill that you can down with a glass of water. It comes in a vial and has to be injected into the body. So, ideally, one should not be taking it at home.“It is for patients who are hospitalised and severe. Therefore it should not be given at home. It is for patients who need to be admitted and need hospital care,” said Guleria.
5. Are steroids effective in the treatment of COVID 19?
   Unlike Remdesivir, there is evidence to support the use of steroids in the treatment of COVID-19. The World Health Organisation’s (WHO) recovery trial showed that steroids do have a beneficial effect. “But again, the timing is critical. The recovery trial clearly showed that if we give steroids too early, before oxygen saturation, it showed a harmful effect. Those who got it early had higher mortality than those who did not,” warned Guleria.According to him, steroids are most effective during the later part of the disease, when there is more inflammation and oxygen saturation is falling. “Steroids are only useful for moderate or severe cases,” he said.
6. Is plasma a good way to fight off COVID-19?
   Plasma was popular when COVID-19 initially came around but studies in India, and around the world, have determined that it is not effective in the treatment. “Subsequently, other studies have been done and a large meta analysis as well which combines results of all the studies, have shown that plasma is not effective in treating COVID-19,” said Guleria.
7. Should a person with COVID-19 take Tocilizumab?
   Tocilizumab is a drug of last resort. According to Guleria, it should only be used when a COVID-19 infection in a patient is worsening despite steroids, Remdesivir, and other treatments like anticoagulants. “Tocilizumab is required in less than 2% of COVID 19 patients. Very few patients need this drug because it's only for treating a cytokine storm… And, therefore, it has a limited role,” he explained.
8. Is Favipiravir effective in treating COVID-19?
   Favipiravir is another antiviral that is being promoted for the treatment of COVID 19. It was initially doled out as a treatment of influenza after the H1N1 pandemic.“There is not enough evidence in robust studies to show that it is a good drug. In most countries, it is not being used. They’re not finding higher mortality,” said Guleria. And, since it’s not a proven treatment, India’s national guidelines also don’t recommend its use.
9. Is it possible to treat COVID-19 without any of the drugs mentioned above?
   According to Guleria, people with mild COVID-19 or those who are asymptomatic will improve with just symptomatic treatment.“Outside [in other countries] they treat COVID-19 with paracetamol, good hydration and multivitamins — all of them have recovered without any treatment,” he told reporters. “Giving treatment when it is not required, you may be doing more harm than good.”

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