Transient liver enzyme derangement following Remdesivir use: a case series

Remdesivir, a nucleotide analog RNA polymerase inhibitor, which was originally evaluated in clinical trials to thwart the Ebola outbreak in 2014, has shown in vitro efficacy against SARS-CoV-2. Experience on its efficacy and safety in COVID-19 is accumulating. In COVID-19, Remdesivir therapy is given intravenously for 5 to 10 days and is frequently accompanied by transient, reversible mild-to-moderate elevations in serum aminotransferase levels but has been only rarely linked to instances of clinically apparent liver injury as a drug-induced liver injury (DILI). It may be caused by direct toxicity possibly due to inhibition of mitochondrial RNA polymerase. Here, we have discussed two cases where liver enzyme levels increased dramatically on the day next after initiating Remdesivir. Case one and two showed grade 4 and grade 3 hepatotoxicity respectively. In both cases, a positive de-challenge was observed and concomitant drugs were not considered to be confounders.  Hence, Remdesivir has a causal relationship with the occurrence of this adverse drug reaction.