Prophylaxis against covid-19: living systematic review and network meta-analysis
Authors: Jessica J Bartoszko, Reed AC Siemieniuk, Elena Kum, Anila Qasim, Dena Zeraatkar, Juan Pablo Diaz Martinez, Maria Azab, Sara Ibrahim, Ariel Izcovich, Gonzalo Bravo Soto, Yetiani Roldan, Arnav Agarwal, Thomas Agoritsas, Derek K Chu, Rachel Couban, Tahira Devji, Farid Foroutan, Maryam Ghadimi, Kimia Honarmand, Assem Khamis, Francois Lamontagne, Mark Loeb, Shelley L McLeod, Sharhzad Motaghi, Srinivas Murthy, Reem A Mustafa, Bram Rochwerg, Charlotte Switzer, Lehana Thabane, Per O Vandvik, Robin WM Vernooij, Ying Wang, Liang Yao, Gordon H Guyatt, Romina Brignardello-Petersen
Journal: BMJ (2021)

Abstract Updates This is the second version (first update) of the living systematic review, replacing the previous version (available as a data supplement). When citing this paper please consider adding the version number and date of access for clarity. Objective To determine and compare the effects of drug prophylaxis on severe acute respiratory syndrome coronavirus virus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (covid-19). Design Living systematic review and network meta-analysis (NMA). Data sources WHO covid-19 database, a comprehensive multilingual source of global covid-19 literature to 4 March 2022. Study selection Randomised trials in which people at risk of covid-19 were allocated to prophylaxis or no prophylaxis (standard care or placebo). Pairs of reviewers independently screened potentially eligible articles. Methods After duplicate data abstraction, we conducted random-effects bayesian network meta-analysis. We assessed risk of bias of the included studies using a modification of the Cochrane risk of bias 2.0 tool and assessed the certainty of the evidence using the grading of recommendations assessment, development and evaluation (GRADE) approach. Results The second iteration of this living NMA includes 32 randomised trials which enrolled 25 147 participants and addressed 21 different prophylactic drugs; adding 21 trials (66%), 18 162 participants (75%) and 16 (76%) prophylactic drugs. Of the 16 prophylactic drugs analysed, none provided convincing evidence of a reduction in the risk of laboratory confirmed SARS-CoV-2 infection. For admission to hospital and mortality outcomes, no prophylactic drug proved different than standard care or placebo. Hydroxychloroquine and vitamin C combined with zinc probably increase the risk of adverse effects leading to drug discontinuation—risk difference for hydroxychloroquine (RD) 6 more per 1000 (95% credible interval (CrI) 2 more to 10 more); for vitamin C combined with zinc, RD 69 more per 1000 (47 more to 90 more), moderate certainty evidence. Conclusion Much of the evidence remains very low certainty and we therefore anticipate future studies evaluating drugs for prophylaxis may change the results for SARS-CoV-2 infection, admission to hospital and mortality outcomes. Both hydroxychloroquine and vitamin C combined with zinc probably increase adverse effects. Systematic review registration This review was not registered. The protocol established a priori is included as a supplement. Funding This study was supported by the Canadian Institutes of Health Research (grant CIHR-IRSC:0579001321).