key: cord-0751262-p0jht22m authors: Tang, Wei; Cao, Zhujun; Han, Mingfeng; Wang, Zhengyan; Chen, Junwen; Sun, Wenjin; Wu, Yaojie; Xiao, Wei; Liu, Shengyong; Chen, Erzhen; Chen, Wei; Wang, Xiongbiao; Yang, Jiuyong; Lin, Jun; Zhao, Qingxia; Yan, Youqin; Xie, Zhibin; Li, Dan; Yang, Yaofeng; Liu, Leshan; Qu, Jieming; Ning, Guang; Shi, Guochao; Xie, Qing title: Hydroxychloroquine in patients with COVID-19: an open-label, randomized, controlled trial date: 2020-04-14 journal: nan DOI: 10.1101/2020.04.10.20060558 sha: 4b0e852d65a51f8e4c444048d870fca3db3214c2 doc_id: 751262 cord_uid: p0jht22m Abstract Objectives To assess the efficacy and safety of hydroxychloroquine (HCQ) plus standard-of-care (SOC) compared with SOC alone in adult patients with COVID-19. Design Multicenter, open-label, randomized controlled trial. Setting 16 government-designated COVID-19 treatment centers in China through 11 to 29 in February 2020. Participants 150 patients hospitalized with COVID-19. 75 patients were assigned to HCQ plus SOC and 75 were assigned to SOC alone (control group). Interventions HCQ was administrated with a loading dose of 1, 200 mg daily for three days followed by a maintained dose of 800 mg daily for the remaining days (total treatment duration: 2 or 3 weeks for mild/moderate or severe patients, respectively). Main outcome measures The primary endpoint was the 28-day negative conversion rate of SARS-CoV-2. The assessed secondary endpoints were negative conversion rate at day 4, 7, 10, 14 or 21, the improvement rate of clinical symptoms within 28-day, normalization of C-reactive protein and blood lymphocyte count within 28-day. Primary and secondary analysis was by intention to treat. Adverse events were assessed in the safety population. Results The overall 28-day negative conversion rate was not different between SOC plus HCQ and SOC group (Kaplan-Meier estimates 85.4% versus 81.3%, P=0.341). Negative conversion rate at day 4, 7, 10, 14 or 21 was also similar between the two groups. No different 28-day symptoms alleviation rate was observed between the two groups. A significant efficacy of HCQ on alleviating symptoms was observed when the confounding effects of anti-viral agents were removed in the post-hoc analysis (Hazard ratio, 8.83, 95%CI, 1.09 to 71.3). This was further supported by a significantly greater reduction of CRP (6.986 in SOC plus HCQ versus 2.723 in SOC, milligram/liter, P=0.045) conferred by the addition of HCQ, which also led to more rapid recovery of lymphopenia, albeit no statistical significance. Adverse events were found in 8.8% of SOC and 30% of HCQ recipients with two serious adverse events. The most common adverse event in the HCQ recipients was diarrhea (10%). Conclusions The administration of HCQ did not result in a higher negative conversion rate but more alleviation of clinical symptoms than SOC alone in patients hospitalized with COVID-19 without receiving antiviral treatment, possibly through anti-inflammatory effects. Adverse events were significantly increased in HCQ recipients but no apparently increase of serious adverse events. Trial registration ChiCTR2000029868. The potent in-vitro effects of hydroxychloroquine (HCQ) against SARS-CoV-2 has not convincingly been translated into clinical benefits in patients with COVID-19. A non-randomized trial showed significantly higher virus clearance rate at 6-day post inclusion in patients receiving 600mg hydroxychloroquine daily (N=20) than in patients with standard-of-care (N=16). In contrast, a randomized study of hydroxychloroquine published in Chinese showed no impact of hydroxychloroquine with a dose of 400mg hydroxychloroquine daily for 5 days on increasing virus negative conversion rate and alleviation of clinical symptoms in 30 patients with COVID-19. In our multicenter, parallel, open-label randomized trial that included 150 adult patients hospitalized for COVID-19, adding hydroxychloroquine to the current standard-of-care in patients with COVID-19 does not increase virus response but accelerate the alleviation of clinical symptoms, possibly through anti-inflammatory properties and recovery of lymphopenia. Clinicians might consider hydroxychloroquine treatment in symptomatic patients with elevated CRP and/or lymphopenia because hydroxychloroquine might prevent disease progression, particularly in patients at higher risk. Side effects of HCQ should be closely monitored, although no apparent safety concerns were observed in our trial using HCQ with a loading dose of 1, 200 mg daily for three days followed by a maintained dose of 800 mg daily for the remaining days (total treatment duration: 2 or 3 weeks for mild/moderate or severe patients, respectively). All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint The coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has swept into more than 200 countries, areas or territories within the four months. As of 5 April, more than 1 million infections and 60 thousands of deaths have been reported. 1 Several agents or drugs including, remdesivir, favipiravir, ribavirin, lopinavir-ritonavir (used in combination) and chloroquine (CQ) or hydroxychloroquine (HCQ), have been highlighted based on the promising in-vitro results and therapeutic experiences from another two coronavirus diseases including the severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS) 2 . However, none of these promising results has yet been translated into clinical benefits of patients with COVID-19, including lopinavir-ritonavir, reported from the most recently failed trial. 3 Another "wonder drug", CQ and its hydroxy-analogue HCQ, are glaring on the list of COVID-19 therapy, due to potent antiviral activity against SARS-CoV-2 from in-vitro studies, 4, 5 and promising results from news reports of some ongoing trials. 6 Despite their unclear benefits, CQ and HCQ are both recommended for off-label use in the treatment of COVID-19 by the Chinese National guideline 7 and recently authorized by the U.S. Food and Drug Administration for emergency uses. 8 HCQ was also recently recommended by the American president Donald Trump. Such a presidential endorsement stimulates an avalanche of demand for HCQ, which buried the dark-side of this drug. Deaths have been reported in Nigeria among people self-treating for apparent COVID-19 with CQ overdoses. 9 Retinopathy, gastrointestinal and cardiac side effects are well documented with the use of CQ or HCQ in the treatment of malarial and rheumatic diseases. 10 HCQ is preferred in clinical applications due to its lower toxicity, particularly retinal toxicity, 10 and three times the potency against SARS-CoV-2 infection comparing to CQ in the recent in-vitro study. 5 All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint 10 Currently, there is no convincing evidence from well-designed clinical trials to support the use of CQ/HCQ with good efficacy and safety for the treatment of COVID-19. Rapidly conduction of such trails with high-quality is challenging in the face of a dangerous coronavirus outbreak, in which, healthcare workers are under overwhelming work and highest risk of exposure to developing Having encountered numerous challenges, we conducted a multicenter, open-label, randomized, controlled trial to assess the efficacy and safety of HCQ sulfate in adult patients with COVID-19. A clearer verdict will come from such a trial for the use of HCQ in patients with COVID-19. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint The study was designed and initiated by the principal investigators after the protocol was approved by the institutional review board in Ruijin Hospital. It was conducted urgently during the outbreak of COVID-19 and in compliance with the Declaration of Helsinki, Good Clinical Practice guidelines, and local regulatory requirements. The Shanghai Pharmaceuticals Holding Co.,Ltd donated the investigated drug, HCQ, but was not involved in the study design, accrual, analyses of data, or preparation of the manuscript. A contract research organization (CRO), R&G PharmaStudies Co., Ltd., was hired to conduct the study, collect data and perform statistical analyses. Data were recorded by clinical research coordinators followed by query from clinical research associates. Confirmed data were then entered into the Web-based OpenClinica database for statistical analyses. An independent data and safety monitoring committee (IDMC) periodically reviewed the progress and oversight of the study. Hospitals with the capability of providing the current SOC for COVID-19 were invited to participate in the study by the principal investigators. Minimum requirements for the SOC included the provision of intravenous fluids, supplemental oxygen, regular laboratory testing, and SARS-CoV-2 test, hemodynamic monitoring and intensive care and the ability to deliver concomitant medications. The interim analysis was performed on March 14 and the results were presented to the IDMC for review. After data review, the IDMC concluded the trial after taking into consideration the good efficacy of HCQ in symptom alleviation and anti-inflammation reported from the interim analysis. Members from the IDMC and trial principal investigators all decided to report the trial results to promote the translation of these promising results into clinical benefits that could save lives in the All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint 12 emergently ongoing pandemic of COVID-19, particularly in overwhelming areas. The manuscript was drafted based on these results by the first and last authors with great input from all the co-authors. All authors vouch for the veracity of the data, analyses, and trial protocol and vouch that the trial was conducted and reported consistently with the protocol, which together with the statistical analysis plan, is available in the appendix. This study was a multicenter, randomized, parallel, open-label, trial of oral HCQ in hospitalized patients with COVID-19. No placebo was used and drugs were not masked. Patients meeting eligibility criteria were stratified according to the disease severity (mild/moderate or severe) and were then randomly assigned (in a 1:1 ratio) to receive either SOC or SOC plus HCQ. Patients were enrolled by the site investigator. The statistician performed the randomization; equal numbers of cards with each group assignment number randomly generated by computer were placed in sequentially numbered envelopes that were opened as the patients were enrolled. The patients were treated with SOC aligning with the indications from the updating National clinical practice guidelines for COVID-19 in China. Treatment of HCQ was begun within 24 hours after randomization and was administrated with a loading dose of 1, 200 mg daily for three days followed by a maintained dose of 800 mg daily for remaining days (total treatment duration: 2 weeks or 3 weeks for mild/moderate or severe patients, respectively). Dose for HCQ will be adjusted when adverse events are related to HCQ as judged by investigators. Details for dose adjustment were provided in the study protocol available online. Neither patients, nor investigators, nor statisticians were masked to treatment assignment. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint 13 Patients were enrolled at 16 government-designated COVID-19 treatment centers from three provinces in China (Hubei, Henan and Anhui province) between February 11, 2020 and February 29, 2020. All patients provided written informed consent. Eligible patients were at least 18 years of age, had ongoing SARS-CoV-2 infection confirmed with real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR). Patients who were willing to participate in this trial had to consent not to be enrolled by other clinical trials during the study period. A chest computed tomography examination result is needed for determining disease severity before randomization. Patients had to receive HCQ orally. Patients with known allergy to HCQ or existing conditions that could lead to severe adverse events during the trial period were excluded, particularly those with severe liver or renal diseases that could impair the ability to metabolize high doses of HCQ. Those unable to co-operate with investigators due to cognitive impairments or poor mental status were considered inappropriate for this trial. Female patients who were pregnant or during lactation period were excluded. Full eligibility criteria are provided in the protocol (appendix). Upper and/or lower respiratory tract specimens were obtained from each patient upon screening (Day -3~1), during treatment and post-treatment follow-up at scheduled visits on days 4, 7, 10, 14, 21 and 28. Collected specimens were tested to determine positive or negative results for SARS-CoV-2 at each site's local Center for Disease Control and Prevention according to the WHO recommendations. 12 Patients were assessed on each scheduled visit for vital signs, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), Tumor necrosis factor (TNF)-α, Interleukin-6 (IL-6), complete blood cells count with differential, blood chemistry, coagulation panel, pulse All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint 14 oximetry, and respiratory symptoms. Administration records of HCQ and adverse events were reviewed daily to ensure fidelity to the protocol and more importantly, patient safety. More details for data collection were provided in the protocol (appendix). The primary endpoint for this trial was the negative conversion of SARS-CoV-2 within 28-day. Key secondary endpoints included the alleviation of clinical symptoms, laboratory parameters, and chest radiology within 28-day. Definition for the alleviation of clinical symptoms was 1) resolving from fever to an axillary temperature of ≤ 36.6 and; 2) normalization of SpO2 (>94% on room air) and; 3) disappearance of respiratory symptoms including nasal congestion, cough, sore throat, sputum production and shortness of breath. Normalization of laboratory parameters were focused on CRP, ESR, IL-6 and TNF-α level. Other secondary outcomes for severe cases included all-cause mortality, clinical status as assessed with the six-category ordinal scale on days 7, 14, 21 and 28, days of mechanical ventilation, extracorporeal membrane oxygenation, supplemental oxygenation, and hospital stay for severe cases. Disease progression was assessed in mild/moderate cases. Safety outcomes included adverse events that occurred during the study period. Adverse events will be coded using the latest version of Medical Dictionary for Regulatory Activities coding dictionary and will be recorded in standard medical terminology and graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events. The overall negative conversion rate was estimated and compared by analyzing time to virus nucleic acid negativity using the Kaplan-Meier method on intention-to-treat population. The hazard ratio was estimated by the Cox model, which is the higher, the more rapid the conversion is. The same approach was applied to analyze other key secondary endpoints. Forest plot was used to All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint 15 display hazard ratios generated for each subgroup. The trial was designed to enroll approximately 360 subjects (180 per group) to assure a power of 80% and the family-wise type-I error ≤ 0.05. The sample size was calculated based on the alternative hypothesis of a 30% increase in the speed of virus nucleic acid negativity, therefore, a total of 248 events is needed with a Log-Rank test. An interim analysis was planned when around 150 patients were treated for at least 7 days. O'Brien-Fleming cumulative α -spending function by Lan-DeMets algorithm(Lan-Demets, 1983) was applied to control family-wise type-I error. Absolute changes from baseline of CRP and blood lymphocyte count by last assessment were compared between actual treatment groups using the Two-Sample T-test. Significance was claimed for other analyses than primary analysis if p-value <0.05. Data analyses were conducted on SAS version 9.4. This was a randomized controlled trial with no involvement of patients in the trial design, outcome measures, data analysis, results interpretation or manuscript writing. Personal health information used in this trial is not accessible to patients or the public. The study protocol is available online as a supplementary material with the publication of the paper. A preprint version of the study is publicly available on medRxiv. All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint A total of 191 patients admitted with COVID-19 from February 11, 2020 to February, 29 2020, were assessed for eligibility, of which 41 did not meet eligibility criteria. The remaining 150 patients underwent randomization; Among them, 75 patients were assigned to SOC and 75 patients to SOC plus HCQ group (Figure 1) . The mean age of the patients was 46 years and 55% were male. The mean day from disease onset to randomization was 16.6 and 89% of the patients had concomitant medication before randomization. The majority of the patients had mild to moderate COVID-19 (99%) and only 2 patients (1%) were severe upon screening. Baseline demographic, epidemiological and clinical characteristics of the patients between the two groups are shown in Table 1 . By 14 March 2020 (the cutoff date for data analysis) The median duration of follow-up was 21 days (range, 2 to 33) in the SOC group and 20 days (range, 3 to 31) in the SOC plus HCQ group. Of the 75 patients assigned to receive SOC plus HCQ, 6 patients did not receive any dose of HCQ; of them, 3 patients withdrew consent and 3 patients refuse to be administrated HCQ. Overall, the negative conversion rate of SARS-CoV-2 among patients who were assigned to receive SOC plus HCQ was 85.4% (95% confidence interval [CI], 73.8%, 93.8%), similar to that of the SOC group 81.3% (95%CI, 71.2% to 89.6%) within 28-day. Negative conversion rate at specific time-point, 4-, 7-, 10-, 14-or 21-day was also similar between the two groups. The negative conversion time did not differ between SOC plus HCQ and SOC group (median, 8 days vs. 7 days; hazard ratio, 0.846; 95%CI, 0.580 to 1.234; P=0.341) (Figure 2_panel A) . Post hoc analyses were performed in subgroups to explore any decrease of negative conversion All rights reserved. No reuse allowed without permission. author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint (which was not peer-reviewed) is the . https://doi.org/10.1101/2020.04. 10.20060558 doi: medRxiv preprint time by the addition of HCQ upon SOC. No such effects were observed in the analyzed subgroups according to age (≥45 years versus <45 years), BMI value (≥24 kg/m 2 versus <24 kg/m 2 ), presence or absence of existing conditions, days between disease onset and randomization (≥7 days versus <7 days), baseline CRP value (≥upper limit of normal versus