Veklury-Dexamethasone Combo Safely Treats COVID-19 in 3 MG Patients

Three patients with myasthenia gravis (MG) were safely treated for COVID-19 with a combination of the antiviral medication Veklury (remdesivir) and the anti-inflammatory dexamethasone, while having no apparent worsening of their MG symptoms.

Veklury was the first medication approved by the U.S. Food and Drug Administration (FDA) for the treatment of COVID-19.

“Considering the current practice of coadministering dexamethasone and remdesivir in COVID-19 patients requiring supplemental oxygen, we believe our findings suggest that remdesivir [Veklury] used in combination with dexamethasone is not associated with significant clinical worsening of MG,” the researchers wrote.

Their cases were described in a study titled “Use of Remdesivir in Myasthenia gravis and COVID‐19,” published in Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy.

Patients with MG are commonly treated with immunosuppressive medications, which may increase their risk of contracting COVID-19 or developing severe complications associated with the disease. Some antibiotics and antiviral treatments for COVID-19 have previously been linked to MG exacerbations, or sudden episodes of disease worsening.

The FDA approved Veklury in October 2020 for the treatment of COVID-19 requiring hospitalization. However, its use has not been investigated in patients with MG. 

In this case series, investigators described the cases of three individuals with MG who contracted COVID-19 and were safely managed with a combination of Veklury and dexamethasone.

The first patient was a 71-year-old man with type 2 diabetes, high cholesterol, high blood pressure, and a history of stroke, whose MG was being managed with mycophenolic acid. He was diagnosed with COVID-19 after being admitted with a fever, low oxygen, and a chest X-ray showing signs of COVID-19 pneumonia.

The man was treated with 200 mg of intravenous (IV, or into-the-vein) Veklury and 6 mg of IV dexamethasone before being transferred to intensive care due to respiratory failure. He received Veklury for a total of six days and dexamethasone for 10 days. The patient was enrolled in a clinical trial in which he received either the immunomodulator lenzilumab (600 mg) or a placebo every eight hours for three doses.

As his respiratory symptoms continued to worsen, the patient underwent a neurological examination, which ruled out MG exacerbation as a cause. He was diagnosed with an acute pulmonary embolism before his death.

The second patient was a 41-year-old woman with anxiety and obesity who had undergone a thymectomy (thymus removal surgery) and was receiving CellCept (mycophenolate mofetil), prednisone, and Mestinon (pyridostigmine) to control her MG. She was diagnosed with COVID-19 after being admitted to the hospital with shortness of breath, fever, delirium, and an abnormal chest X-ray.

The patient was transferred to intensive care with worsening respiratory symptoms and was treated to counteract her low blood oxygen levels. She received a single 200 mg dose of Veklury, followed by a daily dose of 100 mg in the next four days. Additionally, she was given 6 mg of dexamethasone every day for 10 days.

After completing dexamethasone treatment, the patient continued her MG treatment regimen. During this period of time, she showed no signs of MG exacerbations and was later discharged from the hospital, without ever requiring mechanical ventilation to assist her breathing.

A man, age 59, was the third patient treated with the combination in this case study. He had type 2 diabetes, sleep apnea, obesity, and asthma, and had been recently diagnosed with MG. One month before his hospital admission, he had an MG exacerbation caused by a change in treatment. 

The patient was diagnosed with COVID-19 after experiencing respiratory failure that required intubation and mechanical ventilation and showing signs of COVID-19 pneumonia in a chest X-ray. He was sedated and treated with a single 200 mg dose of Veklury, followed by a daily dose of 100 mg in the next four days, and a one-time 6 mg dose of dexamethasone. 

After completing the dexamethasone treatment, the patient continued his MG treatment of daily prednisone, twice-daily azathioprine, and Mestinon every eight hours. He was eventually discharged from the hospital with no signs of MG exacerbations.

“In these critically ill patients with MG and COVID-19 pneumonia, the use of the antiviral remdesivir in combination with dexamethasone did not precipitate a MG exacerbation or crisis,” the team concluded, adding that the evidence suggests that “remdesivir does not significantly worsen MG.”