Azithromycin with nitazoxanide, hydroxychloroquine or ivermectin, with or without dutasteride, for early stage COVID-19: an open-label prospective observational study in males with mild-to-moderate COVID-19 (The Pre-AndroCoV Male Trial).
Authors: Cadegiani Flavio A , Goren Andy , Wambier Carlos G , McCoy John 
Published: October 2020

Abstract
Background: COVID-19 is a multisystemic disorder caused by SARS-CoV-2 that has led to more than 1,000,000 deaths until the end of September 2020. Besides aging, obesity, and metabolic diseases, males, in particular those affected by androgenetic alopecia (AGA), are at higher risk to develop complications. While policies for diagnosis of COVID-19 still focus on the presence of fever or shortness of breath, these symptoms tend to appear only in later and more severe stages of the disease, when viral infectivity is already, hampering potential antiviral approaches. In addition, clinical characterization of early COVID-19 stages still lacks. The objective of the present observational study was to characterize prospectively clinical features and predictors in males during early COVID-19, and to evaluate whether the combination of more sensitive case-detection, early diagnosis and early pharmacological approaches would lead to improved clinical outcomes. Material and methods: Males confirmed for COVID-19 through positive real-time polymerase chain reaction (rtPCR) for SARS-CoV-2 with less than seven days of symptoms and three days of COVID-19 confirmation were divided into non-AGA, AGA not using dutasteride (AGA no-5ARi), and AGA using dutasteride (AGA-5ARi) groups. Patients were actively characterized for baseline and lifestyle characteristics, 22 different diseases, 42 drug classes and vaccines, 26 different symptoms, and 10 different parameters to measure COVID-19 related clinical outcomes. Azithromycin plus hydroxychloroquine, nitazoxanide 500mg or ivermectin, with or without dutasteride or spironolactone were used. Patients were then evaluated for COVID-19 clinical course, duration and progression.Results: A total of 305 males were enrolled, including 192 non-AGA, 71 AGA non-ARi and 52 AGA-5ARi. The prevailing symptoms were anosmia (68.9%), ageusia (61.2%), headache (37.5%), hyporexia (37.5%), fatigue (35.2%), dry cough (35.2%), fever or “feverish” (33.9%), thoracic pain (32.4%), conjunctival hyperemia (29.5%), weakness (29.5%), nasal congestion or rhinorrhea (28.6% and myalgia (26.3%). ARi users remained asymptomatic throughout COVID-19 treatment in 82.7% (43 of 52 males), and the only symptoms present in more than two patients were anosmia and ageusia. Thoracic, upper back, lower back pain, arthralgia affected a higher percentage of AGA no-5ARi than non-AGA males (all p < 0.01), but had similar durations (p = n/s). Anosmia, ageusia, headache, fatigue, myalgia and conjunctival hyperemia were more commonly present and lasted for longer periods in AGA no 5ARi patients (all p < 0.01). Self-reported perception of “sinusitis” and “sore throat”, dry cough and weakness were equally present (p = n/s) but had longer duration in AGA no-5ARi males (all p < 0.01).The different drug were equally distributed. AGA males were more severely affected than non-AGA in terms of duration of clinical manifestations (9.4 ± 6.0 vs 14.2 ± 7.3 days, p < 0.0001) and viral shedding (14.0 ± 5.2 vs 17.8 ± 6.2 days; p < 0.0001), which has been fully mitigated by the chronic use of dutasteride (p < 0.0001 and < 0.0001 vs non-AGA and AGA no-5ARi, respectively, for both clinical manifestations and viral shedding duration. Non-AGA, AGA no-5ARi and AGA-5ARi achieved 95% clinical recovery in seven, 14, and two days, respectively. In regards functional capacity, AGA no -5ARi males at Days 30, 14, 7, and 3 after treatment initiation were similar than non-AGA at Days 14, 7, 3, and 0, respectively (all p > 0.9). None of the patients required hospitalization and mechanical ventilation, or progressed to more severe states. Conclusion: The combination of more sensitive and earlier diagnosis of COVID-19 with a variety of drug combinations with preliminary demonstration of direct or indirect antiviral activity against SARS-CoV-2 demonstrated indisputable improved COVID-19 related clinical outcomes compared to the extensively described COVID-19 clinical course, and avoided the progression to more severe state in all patients included in the present analysis, independently of risk factors, demonstrating that any additional risk factor can be completely mitigated by the combination of more sensitive clinical suspect with early pharmacological approaches.The overwhelming differences indicate that full placebo control RCTs for early COVID-19 may be ethically questionable. Instead, double blind therapies with different options, or mixed open label placebo control for COVID-19 should be considered.