key: cord-0998319-95zrth5d
authors: Singh, Awadhesh Kumar; Singh, Akriti; Singh, Ritu; Misra, Anoop
title: “Hydroxychloroquine in patients with COVID-19: A Systematic Review and meta-analysis.”
date: 2020-05-12
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2020.05.017
sha: 022c679890eb8a7bd01ca1d195587fca65a8504e
doc_id: 998319
cord_uid: 95zrth5d

BACKGROUNDS AND AIMS: The role of hydroxychloroquine (HCQ) in the treatment of COVID-19 is not fully known. We studied the efficacy of HCQ compared to the control in COVID-19 subjects on a. viral clearance measured by reverse transcriptase polymerase chain reaction (RT-PCR) and, b. death due to all cause. METHODS: PubMed, Scopus, Cochrane and MedRxiv database were searched using the specific keywords up to April 30, 2020. Studies that met our objectives were assessed for the risk of bias applying various tools as indicated. Three studies each that reported the outcome of viral clearance by RT-PCR and death due to all cause, were meta-analyzed by applying inverse variance-weighted averages of logarithmic risk ratio (RR) using a random effects model. Heterogeneity and publication bias were assessed using the I(2) statistic and funnel plots, respectively. RESULTS: Meta-analysis of 3 studies (n = 210) on viral clearance assessed by RT-PCR showed no benefit (RR, 1.05; 95% CI, 0.79 to 1.38; p = 0.74), although with a moderate heterogeneity (I(2) = 61.7%, p = 0.07). While meta-analysis of 3 studies (n = 474) showed a significant increase in death with HCQ, compared to the control (RR, 2.17; 95% 1.32 to 3.57; p = 0.002), without any heterogeneity (I(2) = 0.0%, p = 0.43). CONCLUSIONS: No benefit on viral clearance but a significant increase in mortality was observed with HCQ compared to control in patients with COVID-19.

Scientist and physicians are working at heightened pace to research the treatment of coronavirus infection . Several potential candidate drugs have been tried in COVID-19. From these list of candidate drugs, two anti-malarial drugs came into limelight for following reasons. Initial studies found both chloroquine (CQ) and its derivative hydroxychloroquine (HCQ) inhibits SARS-CoV-2 effectively in vitro [1] [2] [3] . This led clinicians to believe that both drugs may have good potential in the treatment of COVID-19.

First report of human trial came from China. A commentary by Gao et al [4] referring to 15 Chinese trials (whose complete results are still not available), claimed benefit with CQ in inhibiting the exacerbation of pneumonia, improving lung imaging findings, promoting a virus-negative conversion, and shortening the disease in more than 100 patients. One study from these 15 Chinese trials, conducted by Chen et al [5] later showed data of 62 patients and found that HCQ significantly improved the clinical recovery (fever and cough) and pneumonia assessed by chest CT scan, compared to the control. However, a close look into this randomized control trial (RCT) found that the endpoints specified in the published protocol differed from those reported. First, the trial was originally supposed to report the results from two different dosage of HCQ on clinical and radiological outcome, although only the report of higher dose HCQ was reported finally. Second, the trial was stopped prematurely [6] . Another study from France, a non-randomized trial of HCQ (n=36) by Gautret et al [7] also reported a significant effect of HCQ and HCQ plus azithromycin (AZ) in lowering viral load and viral clearance compared to control as measured by reverse-transcriptase polymerase chain reaction (RT-PCR). However, this study was widely criticized due to the poor trial design, unreliable conclusions, no clinical endpoints, assessments made on day 6 despite a planned 10 days trial, different value of Cycle threshold for RT-PCR, and derivation of results after excluding six patients from the HCQ arm [8] . The publishing journal's society also subsequently declared that the trial by Gautret and Colleagues did "not meet the Society's expected standard" [9] .

Nevertheless, based on these limited observational and anecdotal evidence, several guidelines across the world allowed both these drugs in the treatment of COVID-19 [10] . Interestingly, Indian Council of Medical research hurriedly issued a guideline and additionally recommended the use of CQ and HCQ as a prophylactic agent in the close contacts including the health care workers [11] . Surprisingly, based on these emerging developments, US President while addressing the nation on pandemic claimed CQ and HCQ as a "game changer" in the treatment of COVID-19. The consequence of this announcement resulted in FDA issuing an Emergency Use Authorization (EUA) to use both the drugs in the treatment of COVID-19 on March 28, 2020. Historically, this new EUA represents the second time when FDA has ever used any emergency authority to permit use of a medication for an unapproved indication. Earlier, an investigational neuraminidase inhibitor, peramivir was given similar EUA by FDA during the 2009-2010 for severely ill patients with H1N1 influenza. Although later an RCT failed to show any benefit of peramivir in severely ill hospitalized patients with influenza, compared to the placebo. Nonetheless, peramivir is approved only for uncomplicated influenza since 2014.

Since several newer studies of HCQ on COVID-19 have recently become available, we aimed to study its effect on COVID-19 on two important objective outcomes. These two important outcomes include -a. viral clearance by RT-PCR negativity and, b. death due to all cause. In addition, we have also compiled the results from all the studies that have studied the efficacy and safety of HCQ in COVID-19, including non-controlled trials.

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [12] . However, this study has not been registered in the International Prospective Register of Systematic Reviews (PROSPERO).

Three authors (AKS, AS and RS) systematically searched the PubMed, Scopus, Cochrane library and MedRxiv data base up to April 30, 2020. The key terms searched were ''Hydroxychloroquine'' OR ''HCQ'' (All Fields) OR "viral clearance" OR "death" OR "clinical recovery" AND COVID-19 OR SARS-CoV-2. We retrieved all the studies conducted with hydroxychloroquine in patients with COVID-19 that was compared to control and explicitly reported at least one outcome of interest which include viral clearance by transcriptase polymerase chain reaction (RT-PCR) and or death due to all cause.

We excluded case reports, preclinical studies, studies that did not report outcomes with HCQ in COVID-19, and studies that did not compare the outcomes with HCQ compare to placebo or control. The studies that met our predefined inclusion criteria were screened by three authors (AKS, RS and AS), and the studies that entirely fulfilled our inclusion criteria were retrieved with their supplementary appendix for further review. Any ambiguity during study selection was resolved by mutual discussion and consensus. One study whose full text was available in Chinese (abstract in English) was translated to English by Google translator and one study was retrieved through hand search. A detailed PRISMA flow-diagram for the search strategy is included in figure 1.

Four reviewers (AKS, AS, RS and AM) independently assessed the studies for risk of bias ascertained through Jadad checklist, ROBINS-I tool and Newcastle-Ottawa scale for randomized, non-randomized and observational studies, wherever appropriate [13] [14] [15] and any disagreements were resolved through mutual discussion and consensus. Scoring of these studies on risk of bias tools have been outlined in supplementary table 1. A detailed PRISMA checklist has been appended in supplementary table 2.

Comprehensive meta-analysis (CMA) software Version 3, Biostat Inc. Englewood, NJ, USA was used to calculate all the statistical analyses. Seven studies were retrieved that reported any outcome with HCQ compared to the control in COVID- 19 . Three studies each reported for viral clearance measure by RT-PCR and the outcome of death due to any cause. We meta-analyzed the pooled data of primary outcomes of 3 trials that reported the rate of PCR negativity, and 3 trials that reported the difference in mortality between HCQ and control arm. Since one RCT by Chen et al reported resorption of pneumonia on chest computed tomography (CT) as a primary outcome but neither reported RT-PCR negativity, nor the mortality outcome, thus we did not include this study in the meta-analysis, however the outcome of this study shall be discussed.

Estimates from all the eligible studies have been combined by applying inverse variance-weighted averages of logarithmic risk ratio (RR), using random-effects analysis. Heterogeneity was measured using Higgins I² and Cochrane Q statistic [16] . Heterogeneity was considered as low (I 2 <25%) or moderate (25-50%) or high (>50%). All the p reported here are two-sided and a p value of < 0.05 is considered to be statistically significant. We also evaluated the potential publication bias by applying funnel plots using the "trim and fill" adjustment, rank correlation test and the Egger's test.

The overview of results including the risk of bias from all the 7 studies that compared HCQ to the control in COVID-19 have been summarized in table 1 [5, 7, [17] [18] [19] [20] [21] . The meta-data that was used in this metanalysis has been also represented in table 2. Table 3 summarizes the safety and efficacy of all the 10 trials conducted with HCQ in COVID-19, to date [5, 7, [17] [18] [19] [20] [21] [22] [23] [24] . One RCT by Chen et al [5] that is not included in this meta-analysis found "any improvement" in pneumonia were significantly higher in HCQ arm, compared to the control (80.6 vs. 54.8%, p=0.048). Moreover, significant improvement in chest CT (more than 50% absorption of pneumonia) was increasingly observed in HCQ arm, compared to the control (61.3 vs. 16 .1%, p=not reported).

Nevertheless, the meta-analysis of 3 studies (n=210) that reported the rate of PCR negativity (figure 2) found no benefit with HCQ, compared to the control (RR, 1.05; 95% CI, 0.79 to 1.38; p=0.74), although with a moderate heterogeneity (I 2 =61.7%, p=0.07). After the adjustment of publication bias, the Trim and Fill imputed the RR of 0.99 with 95% CI 0.69 to 1.42 (supplementary figure SF1) .

However, the meta-analysis of 3 trials (n=474) that reported the mortality outcome, showed a significant (2-fold) increase in death in HCQ arm (figure 3), compared to the control (RR, 2.17; 95% 1.32 to 3.57; p=0.002), without any heterogeneity

To our knowledge, this would be the most updated meta-analysis to report the effect of HCQ on viral clearance and mortality outcome, compared to the placebo that included 6 studies. Additionally, we have also analyzed the results from all the 10 studies available that have studied the efficacy and safety of HCQ in patients with COVID-19 (table 3) . on viral clearance and there was a 2-fold increase in death compared to the control arm, this could have been skewed by the one larger study that have shown a significant harm with HCQ, even when other smaller studies found no significant difference. For example, the study by Magagnoli et al (n=368) [21] found that there was no difference in the requirement of mechanical ventilator (MV) and death in patients who were on MV. However, the risk of death from any cause was higher in the HCQ group (adjusted hazard ratio 2.61, 1.10-6.17, p=0.03), compared to the control. Since this study contributed more than 84% of weight in this pooled meta-analysis of 3 studies, the signal of significant death appears to emerge. These findings underscores the safety of HCQ in the light of negligible benefit observed in some of these studies.

Despite several limitations of this meta-analysis, we feel this finding would instill some degree of skepticism and shall help in curbing the exuberant use of over enthusiastically claimed "magical" drug. Hopefully, large randomized controlled trial such as DISCOVERY (EudraCT 2020-000936-23) and RECOVERY (UK), that is currently studying the effect of HCQ in COVID-19 and comparing it with other anti-viral drugs will finally decide its fate. Meanwhile, we believe that any prudent clinician would follow a pragmatic approach and shall apply these drugs only after assessing the potential risk versus uncertain benefit.

While no benefit on viral clearance demonstrated by HCQ compared to the control in patients with COVID-19, a significant 2-fold increase in mortality with the HCQ warrants its use if at all, with an extreme caution, until the results from larger randomized controlled trials are available. 

Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro

In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus

Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro

Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies

Efficacy of hydroxychloroquine in patients with COVID-19: results of a randomized clinical trial

Therapeutic effect of hydroxychloroquine on novel coronavirus pneumonia (COVID-19)

Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial

Covid-19: US gives emergency approval to hydroxychloroquine despite lack of evidence

Chloroquine and hydroxychloroquine in the treatment of COVID-19 with or without diabetes: A systematic search and a narrative review with a special reference to India and other developing countries

Indian Council for Medical Research. Recommendation for empiric use of hydroxychloroquine for prophylaxis of SARS-CoV-2 infection

Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation

Assessing the quality of reports of randomized clinical trials: is blinding necessary?

ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions

Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses

Measuring inconsistency in meta-analyses

A pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (COVID-19)

Hydroxychloroquine in patients with COVID-19: an open-label, randomized, controlled trial

Clinical Outcomes of Hydroxychloroquine in Hospitalized Patients with COVID-19: A Quasi

No evidence of clinical efficacy of hydroxychloroquine in patients hospitalized for COVID-19 infection with oxygen requirement: results of a study using routinely collected data to emulate a target trial

Outcomes of hydroxychloroquine usage in United States veterans hospitalized with Covid-19

No evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe COVID-19 infection

Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: an observational study

fever (axillary temperature of ≤36.6 0 C), normalization of SpO2 (>94% on room air), disappearance of respiratory symptoms (nasal congestion, cough, sore throat, sputum production and shortness of breath), normalization of CRP, ESR, IL-6, TNF-α level and lymphocyte count within 28-days. In addition, PCR negativity at day 4, 7, 10, 14 or 21.1.234; p=0.341).ii. No difference in symptoms between two arms within 28-days. No difference in PCR negativity between two arms at day 4, 7, 10, 14 or 21.iii. A significantly greater reduction of CRP observed in HCQ arm compared to control (6.986 vs. 2.723 mg/l, p=0.045). A trend in more rapid recovery of lymphopenia also observed in HCQ arm compared to control. iv. Post-hoc analysis (confounding effects of anti-viral agents removed), found a significant improvement in symptoms in HCQ arm compared to control (HR 8.83, 1.09-71.3).The most common adverse event was diarrhea in HCQ arm compared to control (10 vs RT-PCR -reverse-transcriptase-polymerase-chain-reaction, ARDS-acute respiratory syndrome, HCQ-hydroxychloroquine, AZ-azithromycin, CIconfidence interval, ICU-intensive care unit, MV-mechanical ventilator, HR-hazard ratio, RR-relative risk, OR-odds ratio, nr-not reported, CT-computed tomography, ESR-erythrocyte sedimentation rate, CRP-c-reactive protein, IL-interleukin, TNF-tumor necrosis factor, O2-oxygen therapy, ID-infectious disease, ECG-electrocardiogram, AV-atrioventricular, LBBB-left bundle branch block

We hereby declare that we have no conflict of interest related to this article Awadhesh Kumar Singh Akriti Singh

Anoop Misra