Hydroxychloroquine and Ivermectin for the Treatment of COVID-19 Infection
Condition: COVID-19
MeSH terms: COVID-19
Study type: Interventional
Phase: Phase 3

Summary: 
      Background: In December 2019, patients with pneumonia secondary to a new subtype of
      Coronavirus (COVID-19) were identified in China. In a few weeks the virus spread and cases
      started practically all over the world. In February 2020, the WHO declared a pandemic. Severe
      symptoms have been found in patients mainly with comorbidities and over 50 years of age. At
      this time there is no proven therapeutic alternative. In vitro studies and observational
      experiences showed that antimalarial drugs (Chloroquine and hydroxychloroquine) had antiviral
      activity and increased viral clearance. Ivermectin, on the other hand, has been shown in
      vitro to reduce viral replication and in an observational cohort, greater viral clearance
      with promising clinical results. So far there is no standard of treatment and clinical trials
      are needed to find effective treatment alternatives. Objective: To evaluate the safety and
      efficacy of treatment with hydroxychloroquine and ivermectin for serious COVID-19 infections
      in no critical hospitalized patients. Material and methods: Randomized controlled trial of
      patients diagnosed with respiratory infection by COVID-19, who present criteria for
      hospitalization. Randomization will be performed to receive hydroxychloroquine at a dose of
      400 mg every 12 hours for one day and then 200 mg every 12 hours, to complete a 5-day
      treatment schedule. Group 2: Ivermectin 12 mg every 24 hours for one day (less than 80 kg) or
      Ivermectin 18 mg every 24 hours for one day (greater than 80 kg) + placebo until the fifth
      day. Group 3: Placebo. Prior to randomization, the risk of cardiovascular complications
      determined by corrected QT interval, related to hydroxychloroquine intake will be assessed.
      If the patient is at high risk, the allocation will be to ivermectin only or to placebo in an
      independent randomization, if the risk is low, any of the three groups could be assigned.
      Outcomes: The primary outcome will be discharge from hospital for improvement. The safety
      outcomes will be requirement of mechanical intubation, septic shock or death. Viral clearance
      will also be evaluated by means of PCR, which will be taken on the 5th day after admission,
      day 14 and 21.
    

Detailed description: 
      Background In late December 2019, the health authorities of the People's Republic of China
      reported several cases of pneumonia of unknown origin in Wuhan City, Hubei Province, China.
      On December 31, 2019, the Chinese Center for Disease Control and Prevention began etiological
      and epidemiological research on this disease. Three samples of bronchoalveolar lavage were
      taken from patients from the Jinyintan hospital in Wuhan and through various processes they
      came to identify a new coronavirus that they initially called on January 7, 2020 as:
      2019-nCoV. On January 2020, the World Health Organization (WHO) made the first
      recommendations on the epidemiological surveillance of this new coronavirus.

      On January 22, 2020, the first session of the Emergencies Committee was convened by WHO in
      Geneva, Switzerland and on January 30 Public Health Emergency of International Importance
      (ESPII) was declared to the 2019 outbreak.

      On February 11, the International Committee on Virus Taxonomy made up of experts, based on
      the biology, species and type of virus isolated, names this new coronavirus as SARS-CoV-2 and
      responds to "Severe Acute Respiratory Syndrome Coronavirus 2 "(Severe Acute Respiratory
      Syndrome CoronaVirus 2 for its acronym in English), the WHO proposes that same day to call
      the disease caused by SARS-CoV-2 as COVID-19.

      The first case reported in Latin America was in Brazil on February 26 and on the 28th of the
      same month, Mexico communicates its first confirmed case of the new coronavirus in a
      35-year-old patient from a trip to Italy. Given the alarming levels of spread and severity of
      COVID-19, at a press conference on March 11, 2020, WHO Director-General Tedros Adhanom
      Ghebreyesus declares the SARS-CoV-2.5 outbreak as a pandemic.

      IVERMECTIN The SARS-CoV-2 viral genome was rapidly sequenced to allow for a diagnostic test,
      epidemiological follow-up, and the development of preventive and therapeutic strategies,
      however, to date there is no evidence from clinical trials for any therapy that improves the
      evolution of patients suspected or confirmed with COVID-19.

      New potential candidates for the treatment of this disease have emerged. A preclinical study
      showed that ivermectin, an FDA-approved antiparasitic drug, reduces the viral load of
      SARS-CoV-2 in vitro.

      Ivermectin is a broad-spectrum antiparasitic that has shown antiviral activity against a
      broad group of viruses in recent years. It has been shown to inhibit the import of HIV viral
      integrase into the nucleus of human cells and also replication of the virus. It does
      something similar with other proteins of the SV40 virus and the dengue virus. It has also
      been shown to limit the infection of RNA viruses such as dengue, West Nile virus, Venezuelan
      equine encephalitis virus, and influenza virus. It has also been shown to be effective
      against DNA viruses such as pseudorabies of the mice. On the other hand, it has not been
      shown to be effective against the zika virus in mice, although this should be re-evaluated.

      Studies on the SARS-CoV-1 coronavirus have revealed that the alpha/beta1 importin of the
      virus plays a role in infection in relation to intracellular signals of the capsid protein,
      which may have an impact on the division of host cells. Studies in cultures of infected cells
      show that ivermectin has a potent antiviral effect against SARS-CoV-2 and opens up hopeful
      expectations for using this antiparasitic in the early treatment of COVID-19 which is likely
      to help reduce the viral load, prevent progression to severe phase and limit person-to-person
      transmission. Therefore, the development of clinical protocols comparing it with other
      antivirals with alternate mechanisms of action is important and should be established as soon
      as possible.

      In the study by Patel et al., Ivermectin was evaluated in a cohort of patients requiring
      invasive mechanical ventilation. In the ivermectin group, they were admitted to a dose of
      150mcg/kg once they were intubated and observed a significant reduction in mortality, as well
      as significant reductions in the length of hospitalization and days in the intensive care
      unit.

      Hydroxychloroquine Antimalarial drugs such as chloroquine (CQ) and hydroxychloroquine (HCQ)
      have been used for more than a century. They have been used not only for malaria but also in
      rheumatic conditions due to their anti-inflammatory properties and good safety profile. That
      is why, in the midst of a pandemic, the question of the use of antimalarials in the treatment
      and prophylaxis of covid-19 has been raised.

      Kayaerts et al. demonstrated the inhibition of SARS-CoV by chloroquine in Vero E6 cells at
      different post-infection times. Vincent et al. demonstrated the dose-dependent inhibition
      effect of the virus on Vero E6 cells immediately after viral absorption and also 3 to 5 hours
      later. They also demonstrated that the cells pre-treated with CQ were refractory to the virus
      in addition to improving terminal glycosylation of the ACE2 receptor, decreasing the viral
      affinity for the receptor and also reducing the onset of infection. The above illustrates the
      possibility of using HCQ for prophylaxis or treatment against SARS-CoV. Due to the
      similarities of SARS-CoV-2 with the SARS virus, several studies have proposed the use of HCQ
      and CQ for management of the current pandemic.

      Wang et al. tested the in vitro effect of several antivirals approved by the Food and Drug
      Administration (FDA) of the United States of America. Remdesivir showed blocking of viral
      infection after virus entry with an Effective Concentration of 50% (EC50) of 0.77 μM and a
      cytotoxic concentration of 50% (CC50) greater than 100μM. Chloroquine had an EC50 = 1.13μM,
      and a CC50 greater than 100μM and an EC90 of 6.9μM. Chloroquine was effective at the viral
      entry and post-entry level, while remdesivir was only effective at the post-entry level. The
      above suggests a possible use of CQ as a prophylactic for SARS-CoV-2.19 infection.

      Yao et al. Also tested the effect of HCQ and CQ in vitro. They tested the pharmacological
      activity of chloroquine and hydroxychloroquine using Vero cells infected with SARS-CoV-2.
      Physiology-based pharmacokinetic models (PBPK) were implemented for both drugs separately
      integrating their in vitro data. Using PBPK models, hydroxychloroquine concentrations in the
      lung fluid were simulated under 5 different dosing regimens to explore the most effective
      regimen while considering the safety profile of the drug. In this study, it was found that
      HCQ (EC50 = 0.72 μM) is more potent than chloroquine (EC50 = 5.47 μM) in vitro. Based on the
      results of the PBPK models, a loading dose of 400 mg twice daily of orally administered
      hydroxychloroquine sulfate is recommended, followed by a maintenance dose of 200 mg twice
      daily for 4 days for infection by SARS-CoV-2, since it reached three times the potency of CQ
      phosphate when administered 500 mg twice a day 5 days in advance.

      Gao et al. demonstrated the superiority of CQ over control treatment in more than 100
      patients with respect to inhibition of exacerbation of pneumonia, improvement in lung imaging
      findings, promoting negative virus conversion and shortening the course of disease in more
      than 10 hospitals in China. Gautret et al. treated 20 patients with hydroxychloroquine and
      compared the results with 16 controls in France. They used PCR to measure viral load on days
      3, 4, 5, and 6 post-inclusion. The treatment group had a higher mean age, but no gender
      difference was made between the two groups. Asymptomatic patients and patients with upper and
      lower respiratory tract infections were treated. They concluded that HCQ was effective in
      reducing viral load. The results on day 3 indicated that 50% of the patients treated with HCQ
      had a reduction in viral load (p = 0.005), on day 4 it showed a 60% reduction (p = 0.04) on
      day 5, a 65% reduction (p= 0.006) and on day 6, 70% of the patients showed a reduction in the
      viral load (p= 0.001). Furthermore, they described the synergistic effect of azithromycin
      when used in conjunction with HCQ to decrease viral load. Dual treatment showed a 100%
      decrease in viral load (p <0.001) for day 6, while hydroxychloroquine alone showed a 70%
      decrease.

      In the recently published recommendations of the American Society for Infectious Diseases
      (IDSA) on April 11, 2020, it is established that in hospitalized patients with COVID-19, the
      use of HCQ / CQ should only be given in the context of a clinical trial.

      The best evidence currently available has failed to demonstrate or exclude a beneficial
      effect of HCQ on the clinical progression of COVID-19, as inferred by radiological findings,
      or on viral clearance by means of PCR tests, although a somewhat higher proportion in the HCQ
      group experienced clinical improvement (RR: 1.47; 95% CI 1.02 - 2.11, p=0.04). However, the
      certainty in the evidence was rated as very low mainly due to small sample sizes,
      co-interventions, and risk of bias due to methodological limitations. Furthermore, the
      selected results should be considered indirect, since significant patient outcomes (eg,
      mortality, rate of progression to ARDS, and need for mechanical ventilation) were not
      available.

      Studies evaluating the addition of azithromycin (AZ) to HCQ provided indirect comparisons of
      failure of virological clearance with historical controls. The observed risk of mortality
      among patients who received HCQ + AZ during the hospitalization was 3.4% (6/175 patients).
      However, an estimated mortality rate in an untreated cohort was not provided in the
      manuscript. Compared to the lack of viral clearance in historical controls (100% virological
      failure), 12 symptomatic patients were compared on day 5 or 6 of a separate hospital in
      France. Patients who received HCQ + AZ treatment experienced numerically fewer cases of
      virologic failure (43% combined virologic failure; 29/71 patients). There is very low
      certainty in this comparison of treatment effect, mainly due to very high risk selection
      bias, making any claims of effectiveness highly uncertain. Furthermore, relying on
      intermediate outcomes, such as viral clearance to determine important outcomes for the
      patient (including a reduction in the development of pneumonia, hospital or ICU admission, or
      the need for intubation) adds another layer of imprecision.

      Finally, Barbosa et al conducted a comparative study of hospitalized adults with viral
      pneumonia secondary to SARS-CoV-2 during the last two weeks of March 2020. A group receiving
      HCQ and support measures against another group that only received support measures. The
      primary endpoints were the effect of hydroxychloroquine use on the need to increase
      respiratory support, change in lymphocyte count, and change in neutrophil-lymphocyte ratio.
      In this study, of 63 included patients, 32 were assigned to the HCQ arm. The administration
      of HCQ was associated with the need to increase the degree of ventilatory support compared to
      those who did not receive HCQ for 5 days (p = 0.013). The change in total lymphocytes in the
      HCQ group was not different from that in the group that only received support measures. These
      authors concluded that the use of HCQ tends to worsen the neutrophil / lymphocyte ratio
      compared to the group that only received supportive measures, in addition to the fact that
      the use of HCQ was found to increase the risk that the patient required ventilatory
      management with intubation.

      Definition of the problem

      Due to the high rate of spread of COVID-19 infection, associated with a high rate of
      hospitalization due to respiratory failure, empirical treatment of active agents in vitro has
      become a common practice.

      Hydroxychloroquine and ivermectin have demonstrated viral inhibition in vitro and
      observational experiences have proposed them as potentially safe alternatives with clinical
      efficacy.

      The proposed treatments have an adequate margin of safety, in addition to the fact that we
      have extensive clinical experience because they were previously used in humans to treat
      malaria, rheumatologic diseases, or parasitosis. Due to this, in conjunction with the urgent
      need to seek therapeutic alternatives, controlled studies are required without assuming
      efficacy.

      Justification COVID-19 infection has collapsed health systems in industrialized countries due
      to the large number of patients requiring respiratory assistance. There is no standard
      treatment for the management of this infection and the focus has been on the already known
      life support and management of Adult Respiratory Failure Syndrome in critically ill patients.
      The treatments used empirically have an adequate safety profile due to the experience in
      other clinical settings. The use of these empirical alternatives should be based on clinical
      trials since efficacy and safety should not be assumed in the group of patients with
      COVID-19. The Miguel Hidalgo Centennial Hospital has been assigned as a hospitalization
      center for COVID-19 patients in Aguascalientes Mexico.

      Hypothesis

      Treatment with hydroxychloroquine or Ivermectin will be superior to placebo, with a shorter
      hospital stay and a lower rate of complications (intubation, septic shock, or death).
    

Intervention name(s): Hydroxychloroquine; Ivermectin; Placebo
Intervention type(s): Drug; Drug; Drug
Intervention description(s): Hydroxychloroquine: 400 mg PO every 12 hours for one day. Subsequently 200 mg every 12 hours per 4 more days.; Ivermectin 12 mg PO every 24 hours for one day (in case of weight less than 80 kg) or 18 mg PO every 24 hours for one day (in case of weight over 80 kg) Subsequently this group will take two tablets of placebo 12 hrs after ivermectin ingestion and then one tablet of placebo each 12 hrs per 4 more days.; Two tablets of placebo PO every 12 hours for one day. Subsequently one tablet of placebo every 12 hours per 4 more days.
Intervention MeSH terms: Hydroxychloroquine; Ivermectin
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Treatment