Maharashtra is on a massive treasure hunt. The treasure? Remdesivir! Typically 5 to 8 vials of the antiviral injection are needed to treat moderate to severe cases of Covid. Heartrending messages like these are circulating on Whatsapp groups everyday, “My friends dad needs Remdesivir urgently he’s on a ventilator – can you try your political contacts”. But even politicians, social workers and doctors, with all their clout are finding it difficult to procure.
According to one pharma major, in January they virtually stopped making the antiviral, as sales dropped with covid numbers falling and there was no off-take of the drug. Now some of the 7 major companies manufacturing Remdesivir have responded by doubling production from the last covid wave.
Speaking to a senior FDA commissioner in Maharashtra, he partly attributed the acute shortage to the alleged rampant prescription of the drug In private hospitals. He said, ‘currently the requirement of the state is 80000- 100000 vials a day. Official requirement should not be more than 10 percent of the cases per day. In private hospitals Remdesivir is prescribed in an unregulated and uncontrolled manner and that’s why the demand is very high. Manufacturers can supply about 40k to 45k vials per day’. He went on to say that high-ranking state officials have been assured by manufacturers that 50 percent of their Remdesivir stock will be supplied to Maharashtra and it will come to the market after 20th April.
However private doctors feel that the drug is not being prescribed irresponsibly. In the absence of an alternative so far, doctors in India do rely on it. Speaking to Dr Hemant Thakkar back in November 2020, he had said, ‘amongst all the drugs that have been tried if there is one drug that comes back to the prescribing pen it’s Remdesivir, amongst the antivirals. By the time the patient comes to my table he’s on the 5th day, if the indications are relentless fever, accompanied by bad lab parameters and a CT scan showing more that 30 percent lung involvement I would not wait. I will start Remdesivir. If you start early you prevent the patient from going into complications, which is seen on the 7th or 8th day’.
A lack of planning for a second wave has led to this grim situation. BMC corporator, Mumbai A ward, Harshita Narwekar says, ‘remdesivir shortage is because of bad planning. Even Jumbo centers were shut in Maharashtra. Seeing the trends abroad and warnings of virologists we should have anticipated this. We are not ready for this’. She confirmed that former Maharashtra CM Devendra Fadnavis has spoken to pharma majors and asked them not to export any Remdesivir even if there are current orders.
A pharma industry insider expressed that the government should have stockpiled Remdesivir 2 or 3 months ago. ‘They should have placed orders with the manufacturers. The American govt always does that. At the time of anthrax scare they stockpiled ciprofloxacin, at the time of bird flu, they stockpiled oseltamavir. The govt has to work hand in hand with the industry’, he said.
At this point however, rather than looking back at the things we could have and should have done, it would be more helpful to take a look at new research and trials being conducted on existing medicines that could be taken at the onset of the virus to reduce lung inflammation and possibly reduce the need for Remdesivir. One such trial conducted by Oxford university researchers recently and reported in the UK press in April, finds that an affordable asthma drug – Budesonide –in the form of inhalers, can reduce swelling in the lungs and also slow down coronavirus. This is sold in India under the brands Budecort, Bubate, Budvent forte, foracort, etc.
Dr Yusuf Hamied | Photo: University of Cambridge website
Interestingly last year in March 2020, Dr Yusuf Hamied, Chairman of Cipla, had spoken about cortico steroids and their role in treating Covid, ‘Corona is a respiratory disease and some of the anti-asthmatic drugs we make will benefit in coronavirus. It’s up to the doctors to prescribe them’.
A year later the oxford research reinforces this.
The dosage of the steroids in Budesonide and cyclosenide inhalers is extremely low compared to a tablet or an injection because it is going straight into the lungs. It is very effective because it is a targeted dose. I even suggest taking budecort or cyclesonide as a prophylactic in advance for a week or 10 daysDr Yusuf Hamied, Chairman of Cipla
According to an article by the health editor of Mailonline published on 12th April, Budesonide inhalers will be the first treatment specifically for Covid patients to take at home – all other medical breakthroughs so far have been for hospital use.
Thirty-two per cent of over-50s who tested positive and were given large doses of the steroid inhalers recovered within two weeks. Experts say the drug could work with a dual effect. Stopping swelling in the airways to make it easier to breathe and also damaging the virus so it can’t spread as well.
Professor Mona Bafadhel, a respiratory physician on the Oxford team, said budesonide dampens down the excessive immune response in some patients, while reducing the activity of their Ace- 2 receptors, which are the entry point for Sars-Cov-2 virus into human cells.
These findings may be more significant now with a new strain of the virus in India, where the change in the spike protein makes it bind more strongly with the ACE2 receptors, which are abundantly found in the lungs. In other words doctors say that the new variant is often times not found in the nasopharyngeal region and directly affects the lungs, which means the window period is shortened. And it’s possible it goes undetected in the RTPCR test.
Speaking to Dr Hamied, he reiterated again, ‘The dosage of the steroids in Budesonide and cyclosenide inhalers is extremely low compared to a tablet or an injection because it is going straight into the lungs. It is very effective because it is a targeted dose. I even suggest taking budecort or cyclesonide as a prophylactic in advance for a week or 10 days. It is such a minute dose’.
Medical doctor Subhash Hira who specializes in infectious diseases and is on several global scientist panels of WHO on covid prevention also finds merit in this research, ‘budesonide nasal inhaler is a good product to reduce inflammation in upper respiratory tract and lung tissue. It is surface acting steroid that is better than using high systemic doses of steroids I.e. methylprednisolone or betamethsone in moderate to severe COVID patients. Early use of budesonide in respiratory congestion will prevent progression to severe respiratory symptoms and could prevent you from reaching a stage where you need prolonged use of remdesivir’.
Budesonide nasal inhaler is a good product to reduce inflammation in upper respiratory tract and lung tissue. It is surface acting steroid that is better than using high systemic doses of steroids
Dr Subhash Hira, who specializes in infectious diseases
Remdesivir will hit the market in a few days, but at the rampant rate this new strain is spreading and the acute shortage of hospital beds and oxygen it would be worthwhile to pay heed to the above scientific findings after consulting one’s physician.
Professor Richard Hobbs, one of the experts running the Oxford study, called the discovery a 'significant milestone for this pandemic'.