key: cord-1017544-xnrb0byz authors: Biber, A.; Mandelboim, M.; Harmelin, G.; Lev, D.; Ram, L.; Shaham, A.; Nemet, I.; Kliker, L.; Erster, O.; Schwartz, E. title: Favorable outcome on viral load and culture viability using Ivermectin in early treatment of non-hospitalized patients with mild COVID-19, A double-blind, randomized placebo-controlled trial. date: 2021-05-31 journal: nan DOI: 10.1101/2021.05.31.21258081 sha: 5031d7b1b5516381c20272422041162adc7bd064 doc_id: 1017544 cord_uid: xnrb0byz Background: Ivermectin, an antiparasitic agent, also has antiviral properties. Our aim was to assess whether ivermectin can shorten the viral shedding in patients at an early stage of COVID19 infection. Methods: The double blinded trial compared patients receiving ivermectin 0.2 mg/kg for 3 days vs. placebo in non-hospitalized COVID19 patients. RT-PCR from a nasopharyngeal swab was obtained at recruitment and then every two days. Primary endpoint was reduction of viral-load on the 6th day (third day after termination of treatment) as reflected by Ct level>30 (non-infectious level). The primary outcome was supported by determination of viral culture viability. Results: Eighty nine patients were eligible (47 in ivermectin and 42 in placebo arm). Their median age was 35 years. Females accounted for 21.6%, and 16.8% were asymptomatic at recruitment. Median time from symptom onset was 4 days. There were no statistical differences in these parameters between the two groups. On day 6, 34 out of 47 (72%) patients in the ivermectin arm reached the endpoint, compared to 21/ 42 (50%) in the placebo arm (OR 2.62; 95% CI: 1.09 to 6.31). In a multivariable logistic regression model, the odds of a negative test at day 6 was 2.62 time higher in the ivermectin group (95% CI: 1.06 to 6.45). Cultures at days 2 to 6 were positive in 3/23 (13.0%) of ivermectin samples vs. 14/29 (48.2%) in the placebo group (p=0.008). Conclusions: There were significantly lower viral loads and viable cultures in the ivermectin group, which could lead to shortening isolation time in these patients. Ivermectin is an FDA-approved broad spectrum anti-parasitic agent, which was initially approved in humans in 42 1987 to treat onchocerciasis, awarding the discoverers the Nobel prize of Medicine in 2015. Its main activity was 43 known for therapy against infections caused by roundworm parasites. Over the years, the spectrum was extended 44 and included also parasitic skin infections such as scabies among others. In addition, ivermectin has anti-inflammatory properties. [9] Since the excessive inflammatory response to SARS-51 CoV-2 is thought to be a major cause of disease severity and death in patients with COVID-19, [10] ivermectin may 52 have further value in addition to its anti-viral properties. With its high safety profile, ivermectin is a potential treatment against COVID-19 in its different stages. Some Patients were eligible for enrollment in the study if they were 18 years of age or older; not pregnant; with molecular 72 confirmation of COVID-19 by RT-PCR; and with the intention to receive results within the first three days from 73 symptoms onset. However due to the delay (three to four days) in getting results in the community, we extended the 74 time up to seven days from symptoms onset. Since our main outcome was the change in viral shedding (as reflected 75 by Ct value), asymptomatic cases were also included within 5 days from molecular diagnosis. Patients were excluded if they weighed below 40kg, were with known allergy to the drugs, unable to take oral 77 medication, participating in another RCT for treatment of COVID-19. In addition, patients who had RT-PCR results with Ct (cycle threshold) value >35 in first two consecutive were excluded. Patients with comorbidities of 79 cardiovascular disease, diabetes, chronic respiratory disease (excluding mild intermittent asthma), hypertension, and 80 or cancer were defined as high-risk patients. Randomization in a 1:1 ratio was done by computer-generated program using randomization.com 83 (http://www.jerrydallal.com/random/randomize.htm) by Clinical Research Coordinator (CRC), blinded to the rest of 84 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Patients assigned to the intervention arm received ivermectin in a dosage regimen according to body weight; patients 87 weighing between 40-69 kg received four tablets (=12mg) daily and patients weighing ≥70kg received five tablets 88 (=15mg) daily, all for three days. Patients assigned to the placebo arm received the same number and same 89 appearance of pills per weight daily, for three days. They were guided to take the pills one hour before a meal. The Patients were followed up daily by telephone until their discharge. Patients were asked whether they took the pills as 104 guided, if they noticed any adverse effect following treatment and whether there were any follow up of symptoms. Unexpectedly some patients who were isolated in the hotels as verified positive patients were found to be borderline 106 or negative upon our RT-PCR test (Figure 1 ). Therefore, Patients with missing data along the follow up were carried over from the last data available 108 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The primary clinical endpoint was viral clearance following a diagnostic swab taken on the sixth day (third day after 110 termination of treatment), in the intervention group compared to placebo. Although negative PCR is defined in Israel 111 with Ct>40, reaching this level may take a few weeks, and there is significant evidence that a non-infectious state is 112 usually achieved at Ct level>30.[14-16] Therefore we defined a negative test at a non-infectious level as measured CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint Sample size: Based on published data from the Ministry of Health at the time of study initiation, we expected less 133 than 10% of patients at day six show a negative RT-PCR test. With the interventional drug we expected a reduction 134 of at least 25% in the proportion of positive cases. Hence, considering a potential decrease from 90% to 67·5% (25% 135 decrease), with a power (1-β) of 80% at a significance level of 5% (α= 0·05), a minimal sample size of 96 136 participants in total, was required to detect a statistically significant difference. Therefore, 48 patients were needed 137 in each study arm. To account for a loss to follow-up of 10% after 14 day, we aimed to recruit a total of 105 138 participants. Continuous variables are presented as mean ± standard deviation or as median and interquartile range. Categorical 142 variables are presented as N (%). Differences between ivermectin and placebo groups were assessed using a Chi-143 square test and t-test, for categorical and continuous data respectively. Where cross tabulation frequencies were less 144 than 5, the Fisher exact test was used. A multivariate logistic regression model was used to determine the impact of 145 ivermectin while controlling for age, sex, weight, and being symptomatic or not on reduction of viral load on day 6 th 146 as reflected by Ct level>30. Results include adjusted odds ratios (OR), and 95% confidence intervals (CI). Kaplan- Meier curves were drawn, and survival analysis conducted with log-rank test using for time to negative RT-PCR (Ct CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint From May 15 th , 2020 through end of January 2021, a total of 116 patients underwent randomization, and 89 were 156 eligible for analysis (Figure 1 ). The baseline study population characteristics are detailed in Table 1 . The median age of the patients was 35 years 158 (range, 20 to 71), 22·4% equal or older than 50 years and 7·8% equal or older than 60 years. A majority of the 159 patients were males (78·4%). Twelve (13·5%) patients had comorbidities associated with risk for severe disease [17]; 17% and 9·5% among the ivermectin and placebo groups respectively, p=0·53. Among the study population 83% were symptomatic. The most common symptoms, fatigue, fever, cough, headache, 163 and myalgia were prevalent in approximately half of the study population. (symptoms detailed in Table S1 -164 supplement). None of these variables were statistically different between the two study arms. 166 Viral load during the study period is depicted in Figure 2 . Viral load of the ivermectin group decreased faster in 167 comparison to the placebo group at the early stage of the intervention, during days two to six. As spontaneous 168 recovery takes place also in the placebo group the viral load is decreasing, having similar viral load since day eight. As mentioned above, our calculations were based on negative results reflected in Ct >30. The rate of negative RT-170 PCR for SARS-CoV-2 at day four (one day after termination of treatment) through day ten was higher in patients 171 receiving ivermectin but was statistically significant on days six to eight (Table 2) . In the multivariable logistic regression model, the adjusted odds ratio of negative SARS-CoV-2 RT-PCR negative 173 test (Ct>30) at day six and eight for the ivermectin group were 2·62 (95% CI: 1·06-6·45, P=0·04) and 3·87 group 174 (95% CI: 1·36-11·04, P=0·01) fold higher than for the placebo group, respectively. (Table 3) 175 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. During the study period four patients were referred to hospitals, with three of them being in the placebo arm. The 179 first placebo-treated patient was hospitalized for 11 days with prolonged respiratory symptoms and needed oxygen 180 even after his discharge from hospital. The second was hospitalized for one day due to respiratory complaints. The 181 third one was referred to hospital due to headache and dizziness and was diagnosed with sinusitis after evaluation 182 (brain CT and MRI). In addition, one asymptomatic patient became symptomatic, which occurred in the placebo 183 group. In the ivermectin arm, one patient was referred to hospital due to shortness of breath at the day of In a composite calculation, taking into account Ct values >30 together with non-viable culture, the negative results of the ivermectin group reached significance even at day four (one day after ending the treatment) with 86% 193 negative patients compared to 59% in the placebo group (P=0·04) (see Table 2b ). Among the 116 intention to treat participants, 3 patients reported having diarrhea following the treatment, two 196 (3·5%) in the ivermectin group and one (1·7%) in the placebo group. In all cases the diarrhea resolved in two days. Two patients in the placebo arm reported rash during the treatment course which subsided within one to two days. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The anti-viral activity was also reflected in the Kaplan-Meier curve where the effect of the drug was seen after the 209 second day of treatment (Figure 3 ). To further explore the anti-viral activity, we observed the culture viability in both placebo and ivermectin groups. The broad-spectrum antiviral activity of ivermectin is related to its ability to target the host importin (IMP) α/β1 215 nuclear transport proteins responsible for nuclear entry of cargoes of viral proteins, which in turns block the host 216 anti-viral activity. In some viruses the viral protein (such as integrase and NS5) has been identified while in SARS- Our study has several limitations. First, the sample size was relatively small, and was designed to look for 241 differences in viral load, but not for clinical deterioration and prevention of hospitalization. The second limitation 242 was that drug therapy was not physically observed by investigators. Finally, our study was conducted among mild-243 non-hospitalized patients and therefore the results cannot be applied to a more severe or immune-suppressed 244 populations. The strength of our study was its double-blind structure with more substantial outcomes such as Ct values and 246 culture viability where the laboratory personnel did not have any information concerning the patients' assignment. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint In conclusion, our study strongly supports the notion that ivermectin has anti-SARS-CoV-2 activity. If used at the 248 early stage of disease onset, it may shorten the isolation time and reduce transmission. Further studies are needed to 249 test its ability to prevent clinical deterioration for high-risk groups and to examine its potential as a prophylactic 250 drug. Vaccines are now starting to become available, but it will take years before they are distributed worldwide. As 251 this drug may also reduce mortality, urgent intervention with further well-designed studies are needed. Access to data 265 All data supporting the results will be provided by the corresponding author upon publication. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint 20 . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint COVID-19: consider 304 cytokine storm syndromes and immunosuppression Ivermectin as a potential drug for 306 treatment of COVID-19: an in-sync review with clinical and computational attributes Comparison and correlation of commercial SARS-CoV-2 real-time-PCR 309 assays SARS-CoV-2 RNA identification in nasopharyngeal swabs: issues in pre-312 analytics Predicting Infectious Severe Acute Respiratory Syndrome Coronavirus 2 From Diagnostic Samples Virological assessment of hospitalized patients with COVID-2019 Snapshot PCR Surveillance for SARS-CoV-2 in Hospital 323 Staff in England Characteristics of and Important Lessons From the Coronavirus Disease 325 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center Disease Control and Prevention The broad 328 spectrum antiviral ivermectin targets the host nuclear transport importin alpha/beta1 heterodimer Ivermectin as a Broad-Spectrum Host-Directed Antiviral: The Real Deal? Prioritization of Anti-SARS-Cov-2 Drug Repurposing Opportunities Based on Plasma and Target Site Concentrations Derived from their Established Human 336 Identification of the metabolites of ivermectin in humans Ivermectin in Combination With Dihydroartemisinin-Piperaquine and Primaquine in Healthy Adult Thai 344 Effect of Ivermectin on Time to Resolution of Symptoms Among Adults With Mild COVID-19: A Randomized Clinical Trial The effect of early treatment with 353 ivermectin on viral load, symptoms and humoral response in patients with non-severe COVID-19: A pilot, 354 double-blind, placebo-controlled, randomized clinical trial A five-day course of 357 ivermectin for the treatment of COVID-19 may reduce the duration of illness CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted May 31, 2021. ; https://doi.org/10.1101/2021.05.31.21258081 doi: medRxiv preprint