Mei, 2020

LITERATURE REVIEW

Disusun Oleh :
Nama : Zerry Reza Syahrul
NIM : N 111 19 004

Pembimbing :
Ary Anggara, S.KM., M.Biomed

BAGIAN RISET PENYAKIT TROPIS DAN TRAUMATOLOGI

PROGRAM STUDI PROFESI DOKTER
FAKULTAS KEDOKTERAN
UNIVERSITAS TADULAKO
PALU
2020
 Review Jurnal

Judul Remdesivir in adults with severe COVID-19: a

randomised, double-blind, placebo-controlled, multicentre
trial
Jurnal The Lancet
Volume & Halaman -
Tahun 2020
Penulis Yeming Wang, Dingyu Zhang, Guanhua Du, Ronghui Du,
Jianping Zhao, Yang Jin, Shouzhi Fu, Ling Gao, Zhenshun
Cheng, Qiaofa Lu,
Yi Hu, Guangwei Luo, Ke Wang, Yang Lu, Huadong Li,
Shuzhen Wang, Shunan Ruan, Chengqing Yang, Chunlin
Mei, Yi Wang, Dan Ding, Feng Wu,
Xin Tang, Xianzhi Ye, Yingchun Ye, Bing Liu, Jie Yang,
Wen Yin, Aili Wang, Guohui Fan, Fei Zhou, Zhibo Liu,
Xiaoying Gu, Jiuyang Xu, Lianhan Shang,
Yi Zhang, Lianjun Cao, Tingting Guo, Yan Wan, Hong
Qin, Yushen Jiang, Thomas Jaki, Frederick G Hayden,
Peter W Horby, Bin Cao, Chen Wang
Reviewer Zerry Reza Syahrul (N 111 19 004)
Tanggal 06 Mei 2020

Latar Belakang Tidak ada obat antivirus spesifik yang terbukti efektif
Penelitian untuk pengobatan pasien dengan penyakit coronavirus
2019 (COVID-19). Remdesivir (GS-5734), prodrug analog
nukleosida, memiliki efek penghambatan terhadap patogen
Coronavirus pada hewan dan manusia, termasuk sindrom
pernapasan akut berat coronavirus 2 (SARS-CoV-2) in
vitro, dan menghambat sindrom pernapasan Timur
Tengah, SARS-CoV-1, dan replikasi SARS-CoV-2 pada
hewan model.
Tujuan Penelitian Tujuan utama dari penelitian ini adalah untuk mengetahui
apakah remdesivir dapat meningkatkan waktu
kesembuhan, mengurangi kematian, perbaikan klinis
dengan membandingkan dengan placebo pada pasien
COVID-19 derajat berat.
Subjek Penelitian Subjek penelitian ini adalah 158 orang yang diberikan
remdisivir dan 79 yang diberikan placebo. Dewasa (usia
≥18 tahun), pasien terkonfirmasi laboratorium infeksi
SARS-CoV-2, interval gejala – onset 12 hari atau kurang,
saturasi oksigen 94% atau kurang di udara kamar atau
rasio tekanan parsial oksigen arteri dengan oksigen yang
 diinspirasi fraksional 300 mm Hg atau kurang, dan
terkonfirmasi pneumonia pada pemeriksaan radiologi.
Metode Penelitian Metode yang digunakan dalam penelitian ini adalah
randomisasi secara investigator-initiated, individual
randomisasi, double-blind, placebo-controlled.
Variabel Dependen Variabel dependen dalam penelitian ini adalah pasien
infeksi novel coronavirus (COVID-19).
Variabel Independen Variabel independen dalam penelitian ini adalah
penggunaan terapi berupa placebo dan remdesivir
Cara Penilaian Perhitungan menggunakan Triangular boundaries dan rasio
alokasi 2:1 antara remdesivir dan placebo yang telah
diperhitungkan.

Hasil Penelitian Dari hasil penelitian didapatkan bahwa penggunan

remdesivir mengalami perbaikan klinis dibandingkan
placebo meskipun secara tidak signifikan.
Kekuatan Penelitian Kekuatan penelitian ini adalah data yang digunakan dalam
penelitian lebih banyak dibandingkan data yang digunakan
pada penelitian sebelumnya.
Kelemahan Keterbatasan penelitian kami mencakup ketidakkuatan
Penelitian untuk mendeteksi asumsi perbedaan dalam hasil klinis,
inisiasi pengobatan cukup terlambat pada COVID-19, dan
tidak adanya pengobatan data pemulihan virus menular
atau kemungkinan munculnya mengurangi kerentanan
terhadap remdesivir

1. Mencari sumber Literatur review dan studi pustaka

1.1. Remdesivir in adults with severe COVID-19: a randomised, double-blind,
placebo- controlled, multicentre trial

2. Mengevaluasi isi dari sumber-sumber yang di dapat

2.1 Isi dari sumber yang telah di dikutip oleh penulis telah memperlihatkan segala
hal-hal yang berkaitan dengan topik yang dibahas hingga penulis telah
memberikan penjelasan yang rinci terhadap jurnal yang dibuatnya,
sehingga pembacanya menemukan hal yang berkaitan dengan
pembahasan. Hal tersebut telah sesuai dengan apa yang telah ditetapkan.

3. Mencari summery terhadap sumber-sumber tersebut

3.1. Total sumber yang telah dikutip oleh penulis berjumlah 28, seluruh sumber
tersebut terdaftar dalam jurnal internasional. 5 sumber membahas tentang
COVID-19, 4 sumber yang membahas mengenai terapi COVID-19, 7
sumber membahas spesifik terhadap penggunaan remdesivir pada pasien
COVID-19 . Dari segala sumber tersebut telah saling melengkapi untuk
menjelaskan seluruh topic yang dibahas oleh penulis.

4. Mengutip tulisan yang dimasukkan di dalam literature

4.1. 1) The ongoing pandemic of severe acute respiratory syndrome coronavirus 2

Johns Hopkins University and Medicine. COVID-19 map. Johns Hopkins

Coronavirus Resource Centre. https://coronavirus.jhu.edu/map.html

2) Although most infections are self-limited, about 15% of infected adults

develop severe pneumonia that requires treatment with supplemental
oxygen and an additional 5% progress to critical illness with hypoxaemic
respiratory failure, acute respiratory distress syndrome, and multiorgan
failure that necessitates ventilatory support, often for several weeks.

Wu Z, McGoogan JM. Characteristics of and important lessons from the

coronavirus disease 2019 (COVID-19) outbreak in China: summary of a
report of 72 314 cases from the Chinese Center for Disease Control and
Prevention. JAMA 2020; published online Feb 24.
DOI:10.1001/jama.2020.2648.
 Chen N, Zhou M, Dong X, et al. Epidemiological and clinical
characteristics of 99 cases of 2019 novel coronavirus pneumonia in
Wuhan, China: a descriptive study. Lancet 2020; 395: 507–13.

Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of

adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort
study. Lancet 2020; 395: 1054–62.

3) At least half of patients with coronavirus disease 2019 (COVID-19)

requiring invasive mechanical ventilation have died in hospital

Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in critically ill

patients in the Seattle region–case series. N Engl J Med 2020; published
online March 30. DOI:10.1056/NEJMoa2004500.

4) Although several approved drugs and investigational agents have shown

antiviral activity against SARS-CoV-2 in vitro,

Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively

inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell
Res 2020; 30: 2–71.

Liu J, Cao R, Xu M, et al. Hydroxychloroquine, a less toxic derivative of

chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell
Discov 2020; 6: 16.

5) A multicentre, open-label, randomized controlled trial (RCT) of

hydroxychloroquine involving 150 adults admitted to hospital for COVID-
19 reported no significant effect of the drug on accelerating viral
clearance.

Tang W, Cao Zhu, Han M, et al. Hydroxychloroquine in patients with

COVID-19: an open-label, randomized, controlled trial. medRxiv 2020;
published online April 14. DOI:10.1101/2020.04.10.20060558 (preprint).

6) An RCT enrolling patients within 12 days of symptom onset found that

favipiravir

Chen C, Huang J, Cheng Z, et al. Favipiravir versus arbidol for COVID-

19: a randomized clinical trial. medRxiv 2020; published online April 15.
DOI:10.1101/2020.03.17.20037432 (preprint).

7) In severe illness, one uncontrolled study of five patients given

convalescent plasma suggested a possible benefit, although the patients
 already had detectable anti-SARS-CoV-2 neutralising antibodies before
receipt of the plasma.

Shen C, Wang Z, Zhao F, et al. Treatment of 5 critically ill patients with

COVID-19 with convalescent plasma. JAMA 2020; published online
March 27. DOI:10.1001/jama.2020.4783

8) An open-label RCT of oral lopinavir–ritonavir found no significant effect

on the primary outcome measure of time to clinical improvement and no
evidence of reduction in viral RNA titres compared to control

Cao B, Wang Y, Wen D, et al. A trial of lopinavir–ritonavir in adults

hospitalized with severe Covid-19. N Engl J Med 2020; published online
March 18. DOI:10.1056/NEJMoa2001282.

9) Remdesivir (also GS-5734) is a monophosphoramidate prodrug of an

adenosine analogue that has a broad antiviral spectrum including
filoviruses, paramyxoviruses, pneumoviruses, and coronaviruses

Lo MK, Jordan R, Arvey A, et al. GS-5734 and its parent nucleoside

analog inhibit filo-, pneumo-, and paramyxoviruses. Sci Rep 2017; 7:
43395.

Sheahan TP, Sims AC, Graham RL, et al. Broad-spectrum antiviral GS-
5734 inhibits both epidemic and zoonotic coronaviruses. Sci Transl Med
2017; 9: eaal3653.

10) In vitro, remdesivir inhibits all human and animal coronaviruses tested to
date, including SARS-CoV-2

Warren TK, Jordan R, Lo MK, et al. Therapeutic efficacy of the small

molecule GS-5734 against Ebola virus in rhesus monkeys. Nature 2016;
531: 381–85.

Brown AJ, Won JJ, Graham RL, et al. Broad spectrum antiviral remdesivir
inhibits human endemic and zoonotic deltacoronaviruses with a highly
divergent RNA dependent RNA polymerase. Antiviral Res 2019; 169:
104541.

11) and has shown antiviral and clinical effects in animal models of
SARS-CoV-1 and Middle East respiratory syndrome (MERS)-CoV
 infections.

Sheahan TP, Sims AC, Leist SR, et al. Comparative therapeutic efficacy of
remdesivir and combination lopinavir, ritonavir, and interferon beta
against MERS-CoV. Nat Commun 2020; 11: 222.

de Wit E, Feldmann F, Cronin J, et al. Prophylactic and therapeutic

remdesivir (GS-5734) treatment in the rhesus macaque model of MERS-
CoV infection. Proc Natl Acad Sci USA 2020; 117: 6771–76.

12) Remdesivir is a potent inhibitor of SARS-CoV-2 replication in human

nasal and bronchial airway epithelial cells.

Pizzorno A, Padey B, Julien T, et al. Characterization and treatment of

SARS-CoV-2 in nasal and bronchial human airway epithelia. bioRxiv
2020; published online April 2. DOI:10.1101/2020.03.31.017889
(preprint).

13) administration was shown to exert significant antiviral and clinical

effects (reduced pulmonary infiltrates and virus titres in bronchoalveolar
lavages vs vehicle only)

Williamson BN, Feldmann F, Schwarz B, et al. Clinical benefit of

remdesivir in rhesus macaques infected with SARS-CoV-2. bioRxiv 2020;
published online April 22. DOI:10.1101/2020.04.15.043166 (preprint).

14) Intravenous remdesivir was studied for treatment of Ebola virus disease,
in which it was adequately tolerated but less effective than several
monoclonal antibody therapeutics

Mulangu S, Dodd LE, Davey RT Jr, et al. A randomized, controlled trial

of Ebola virus disease therapeutics. N Engl J Med 2019; 381: 2293–303.

15) and has been used on the basis of individual compassionate use over the
past several months in patients with COVID-19 in some countries

Grein J, Ohmagari N, Shin D, et al. Compassionate use of remdesivir for

patients with severe Covid-19. N Engl J Med 2020; published online April
10. DOI:10.1056/NEJMoa2007016.

16) Case studies have reported benefit in severely ill patients with COVID-
19
 Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019 novel
coronavirus in the United States. N Engl J Med 2020; 382: 929–36.

Whitehead J, Stratton I. Group sequential clinical trials with triangular

continuation regions. Biometrics 1983; 39: 227–36.

17) Healthy adult volunteers receiving doses similar to our trial (200 mg on
day 1, 100 mg on days 2–4) had mean peak plasma concentrations of 5·4
μg/mL (percentage coefficient of variation 20·3) on day 1 and 2·6 μg/mL
(12·7) on day 5

Gilead Sciences. Investigator’s brochure of remdesivir, 5th edition. Feb

21, 2020.

18) Doses of 150 mg/day for 14 days have been adequately tolerated in
healthy adults, and a daily dose regimen of 150 mg for 3 days followed by
225 mg for 11 days appeared to be generally well tolerated in one patient
with Ebola meningoencephalitis

Jacobs M, Rodger A, Bell DJ, et al. Late Ebola virus relapse causing
meningoencephalitis: a case report. Lancet 2016; 388: 498–503.

19) Coronaviruses partially resistant to inhibition by remdesivir (about six-

times increased EC50) have been obtained after serial in vitro passage, but
these viruses remain susceptible to higher remdesivir concentrations and
show impaired fitness

Agostini ML, Andres EL, Sims AC, et al. Coronavirus susceptibility to the
antiviral remdesivir (GS-5734) is mediated by the viral polymerase and the
proofreading exoribonuclease. MBio 2018;

20). The frequent use of corticosteroids in our patient group might have
promoted viral replication, as observed in SARS and MERS

Lee N, Allen Chan KC, Hui DS, et al. Effects of early corticosteroid
treatment on plasma SARS-associated coronavirus RNA concentrations in
adult patients. J Clin Virol 2004; 31: 304–09.

Arabi YM, Mandourah Y, Al-Hameed F, et al. Corticosteroid therapy for

critically ill patients with Middle East respiratory syndrome. Am J Respir
Crit Care Med 2018; 197: 757–67.

5. Format citasi refrensi yang digunakan

5.1 Acuan kepustakaan pada bagian Pendahuluan dan Pembahasan ditulis dengan
penggunaan tipe Vancouver yaitu menuliskan angka pada akhir dari sitasi sebuah
kalimat.

Berdasarkan hasil evaluasi terhadap sumber kepustakaan yang diperoleh, telah

sesuai dengan syarat-syarat penulisan jurnal yang baik dan benar berdasarkan
penjelasan diatas.