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American Journal of Kidney Diseases

Favipiravir for COVID-19 in a Patient on Hemodialysis

Published:October 01, 2020DOI:https://doi.org/10.1053/j.ajkd.2020.09.007
      To the Editor:
      Favipiravir may be an effective option for treating infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), in maintenance dialysis.
      • Agrawal U.
      • Raju R.
      • Udwadia Z.F.
      Favipiravir: a new and emerging antiviral option in COVID-19.
      There have been few reports of favipiravir administration in hemodialysis patients. We administered favipiravir to a hemodialysis patient with COVID-19 and found that blood concentrations of favipiravir were similar to those seen in patients not receiving dialysis.
      A 72-year-old man presented with fever and cough at an outside hospital. After computed tomography of the chest showed left lower lobe consolidation, he was transferred to our hospital. Medical history included diabetes mellitus and kidney failure treated with hemodialysis since early 2016. A polymerase chain reaction test performed 1 week before hospitalization was negative but a test day 2 of hospitalization proved positive. Oxygenation worsened and he was intubated and ventilated. Favipiravir administration started on day 4. He continued receiving hemodialysis 2 or 3 days a week. Blood concentrations of favipiravir (determined as described in Item S1) are shown in Figure 1. On day 38, he experienced sudden clinical deterioration and died the next day.
      Figure thumbnail gr1
      Figure 1Blood concentrations of favipiravir. Hemodialysis was performed on days 3, 6, 11, 13, and 17. Abbreviation: PCR, polymerase chain reaction.
      The course of the decline in favipiravir blood concentrations that we observed was similar to that reported in patients not receiving hemodialysis.
      • Irie K.
      • Nakagawa A.
      • Fujita H.
      • et al.
      Pharmacokinetics of favipiravir in critically ill patients with COVID-19.
      ,
      • Nguyen T.H.
      • Guedj J.
      • Anglaret X.
      • et al.
      Favipiravir pharmacokinetics in Ebola-infected patients of the JIKI trial reveals concentrations lower than targeted.
      This was unexpected because the molecular weight of favipiravir is 157 Da, 53% to 54% is protein bound, and the volume of distribution is ~20 L, suggesting that dialysis would eliminate favipiravir.
      The half-maximal effective concentration of favipiravir against SARS-CoV-2 infection is 9.7 μg/mL, but blood concentrations after day 9 were all below this level.
      • Wang M.
      • Cao R.
      • Zhang L.
      • et al.
      Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro.
      Previous reports also indicated favipiravir that blood concentrations were lower than predicted and therapeutic drug monitoring may be necessary.
      • Irie K.
      • Nakagawa A.
      • Fujita H.
      • et al.
      Pharmacokinetics of favipiravir in critically ill patients with COVID-19.

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      Financial Disclosure

      The authors declare that they have no relevant financial interests.

      Peer Review

      Received September 10, 2020. Direct editorial input from a Deputy Editor. Accepted in revised form September 22, 2020.

      Supplementary Material

      References

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        Favipiravir pharmacokinetics in Ebola-infected patients of the JIKI trial reveals concentrations lower than targeted.
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