key: cord-1053091-3tio10sx
authors: Sarma, Phulen; Kaur, Hardeep; Kumar, Harish; Mahendru, Dhruv; Avti, Pramod; Bhattacharyya, Anusuya; Prajapat, Manisha; Shekhar, Nishant; Kumar, Subodh; Singh, Rahul; Singh, Ashutosh; Dhibar, Deba Prasad; Prakash, Ajay; Medhi, Bikash
title: Virological and clinical cure in COVID‐19 patients treated with hydroxychloroquine: A systematic review and meta‐analysis
date: 2020-05-03
journal: J Med Virol
DOI: 10.1002/jmv.25898
sha: 166e8feb0fdf70d2c21b7d7555d074ec917310b1
doc_id: 1053091
cord_uid: 3tio10sx

Following the demonstration of the efficacy of hydroxychloroquine against severe acute respiratory syndrome coronavirus 2 in vitro, many trials started to evaluate its efficacy in clinical settings. However, no systematic review and meta‐analysis have addressed the issue of the safety and efficacy of hydroxychloroquine (HCQ) in coronavirus disease 2019. We conducted a systematic review and meta‐analysis with the objectives of evaluation of safety and efficacy of HCQ alone or in combination in terms of “time to clinical cure,” “virological cure,” “death or clinical worsening of disease,” “radiological progression,” and safety. RevMan was used for meta‐analysis. We searched 16 literature databases out of which seven studies (n = 1358) were included in the systematic review. In terms of clinical cure, two studies reported possible benefit in “time to body temperature normalization” and one study reported less “cough days” in the HCQ arm. Treatment with HCQ resulted in less number of cases showing the radiological progression of lung disease (odds ratio [OR], 0.31, 95% confidence interval [CI], 0.11‐0.9). No difference was observed in virological cure (OR, 2.37, 95% CI, 0.13‐44.53), death or clinical worsening of disease (OR, 1.37, 95% CI, 1.37‐21.97), and safety (OR, 2.19, 95% CI, 0.59‐8.18), when compared with the control/conventional treatment. Five studies reported either the safety or efficacy of HCQ + azithromycin. Although seems safe and effective, more data are required for a definitive conclusion. HCQ seems to be promising in terms of less number of cases with radiological progression with a comparable safety profile to control/conventional treatment. We need more data to come to a definite conclusion.

Coronavirus disease 2019 (COVID-19) has been declared a global pandemic by WHO. 1,2 However, we have limited therapeutic options. 2, 3 With the rising toll of infected populations and rising number of deaths, the preferential global concern is the development of safe and effective therapeutics against COVID-19. Although lopinavir/ritonavir was initially a first-line agent in the management of the disease, a study conducted by Cao et al 4 compared lopinavir-ritonavir with the standard of care and no benefit was observed in the primary endpoint.

However, at the same time chloroquine (CQ) emerged as a potent inhibitor of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) in vitro. 5 In SARS-CoV-2 infected Vero-E6 cell lines, low-micro molar concentration of CQ inhibited virus infection (EC 50 = 1.13 μM) with high selectivity index (SI > 88.50). 5 CQ increases endosomal pH and also alters glycosylation of angiotensin-converting enzyme 2 receptors, thus altering the pathogenesis in vitro. [6] [7] [8] Besides, CQ also has immunomodulatory activity 5 and enhances the activity of regulatory T cells. 9 Beneficial effect of CQ came to light in recent clinical studies also.

In a randomized clinical trial, CQ (n = 10 patients) performed better than lopinavir-ritonavir (n = 12) combination 10 any may represent an effective and in-expensive option. However, CQ is one of the major treatment options against malaria and overuse may lead to resistance. Again the toxicity profile of CQ is also a major concern. 11 Hydroxychloroquine (HCQ), being a less toxic derivative, came to the limelight soon. 12 One group found CQ to be more potent than HCQ, 12 however, another research group found HCQ to be more potent. 13 In the study by Yao et al, 13 the EC 50 to inhibit the virus in SARS-CoV infected Vero cells was 0.72 µM 13 and using a physiologically based pharmacokinetic modelling model, they established that this concentration can be attained by a loading dose of HCQ 400 mg BD on the first day, followed by 200 mg BD for SARS-CoV-2. 13 Following these findings many clinical trial started worldwide, comparing HCQ to other treatment regimes, however, until now the results of only seven studies are reported. In this regard, we have conducted the first systematic review and meta-analysis to evaluate the efficacy and safety of HCQ in clinical settings. Time to clinical recovery is calculated in terms of time to normalization of body temperature and total no of cough days. 16 The clinical cure parameters are important as one of the patient, who became polymerase chain reaction (PCR) negative following therapy, still died of the disease in the study by Gautret 

After a search of databases and removal of duplicates, two authors (HK and HRDK) independently screened the titles/abstracts using the selection criteria. For relevant articles, full texts were obtained for further evaluation. In case of any discrepancy PS and BM were consulted and the issue was resolved.

Data extraction was done separately by two authors (PS and HRDK) using pretested data extraction forms following the template provided by the Cochrane data extraction form. In articles published in a language other than English, Google translate was used to identify relevant data.

For RCTs, we used the Cochrane risk of bias tool for randomized controlled studies. 14 In the case of nonrandomized interventional studies, we used ROBINS-I tool. 19 In the case of observational studies, Newcastle

Ottawa Scale was used. 20 Three investigators (DM, HRDK, and PS) separately evaluated the possibility of bias using these tools. Publication bias was not evaluated by funnel plot as there was only three studies which were included in the meta-analysis part of the study. 21 

Statistical heterogeneity was evaluated by χ 2 test and I 2 statistics. 14 An I 2 value of 0 < 40% is not considered as significant, 30% to 60% is taken as moderate heterogeneity, 50% to 90% considered as substantial heterogeneity, and 75% to 100% is considered as significant heterogeneity.

As all the data were dichotomous data, we used either odds ratio (OR) or risk ratio (RR) as appropriate for estimating the point estimate along with 95% confidence interval (CI). In the absence of significant clinical heterogeneity, we have performed the metaanalysis using the Mantel Hazel method or inverse variance method for dichotomous data and continuous data respectively. When statistical heterogeneity was low to moderate, we used a fixed-effect model for pooling of data otherwise, the random-effects model was applied. 14 

We screened a total of 16 literature databases and identified 278 nonduplicate articles, which were evaluated for possible inclusion using title and abstract. Out of these, 25 articles were selected for full-text screening and finally, seven articles (total participants = 1358) were included in the systematic review and three articles were included in the meta-analysis. About 18 articles were excluded following full-text screening (reasons: editorial = 3, review = 5, expert consensus/recommendation = 3, chloroquine = 3, in vitro = 2, in-silico = 1, and kinetic study = 1). The PRISMA chart for the included studies is showed in Figure 1 . The details of the included studies are shown in Table 1 

We used Cochrane risk of bias tool for RCTs for evaluation of risk of bias in case of two RCTS. 16, 25 Data showed in Figure S1 . Risk of bias assessment of the study by Gautret et al 24 was done by using ROBINS-I scale 19 and it was ranked as low, moderate, serious, or critical risk of bias 27 (Data shown in Table S2 ). The study by Molina et al, 26 Chorin at al, 22 the second study of Gautret et al, 24 Figure 5 ).

As there is a huge criticism 28 about the first study on HCQ by Gautret et al, 17 Coming to safety, there was no difference seen between the conventional/standard treatment/control arm and the HCQ arm.

Regarding recurrence of the disease during therapy, in the study by Gautret et al, 17 one patient had a recurrence of the disease (being PCR negative initially, followed by a return of PCR positivity, while still on treatment with HCQ and Azi). 17 So, the development of resistance to the drugs during therapy may be a possibility, which we need to be monitored closely.

As the study by Gautret et al, 17 showed a high risk of bias, we conducted a sensitivity analysis and reanalyzed the same endpoints while excluding the data of Gautret et al. 17 However, the final conclusions remained the same despite the exclusion of the study.

Details of the sensitivity analysis can be found in Figure S2 to S4.

To address the issue of combining HCQ with other drugs, the two studies by Gautret et al, 17, 24 and another study by the same group 23 showed benefit in terms of efficacy of a combination of HCQ + Azi in COVID-19. In the first study, 17 treatment with the combination resulted in 100% virological cure on day 6 post inclusion in the combination arm (n = 6), compared with 57.1% virological cure in the HCQ alone arm (n = 14) and 12.5% virological cure in the control arm (n = 16). In the second study also, 24 they found virological clearance (total sample size = 80) in 83% of patients on day 7.

Treatment with HCQ resulted in a shorter duration of hospital stay. 24 However the six patients in the first study were also included in the second study. In the third study by the same group, 23 26 Chorin et al, 2020 found that around 11% of the population on the combination therapy showed evidence of significant QTc prolongation (> 500 ms) and development of acute renal failure was an important predictor of extreme QTc prolongation. 22 The key limitations of our study were a limited number of clinical studies with a limited number of participants and three studies being reported from the same group.

Another major limitation was the lack of control/conventional/ standard group. In case of Jun et al, 25 the control group was treated with conventional treatment. However, it is unknown what was basically given to treat the control arm. Many of the blogs claim that the control arm was treated with Kelatra (lopinavir-ritonavir combination) and arbidol. All the patients in both the arms were also treated with interferon-alpha. 29 But the authenticity of this blog is unknown though. In the study by Gautret et al, 17 patients who met exclusion criteria or who are not given hydroxychloroquine were treated as controls. However, how these controls were treated is unknown. In the study by Chen Z et al, 2020 also, details of treatment of the control/conventional treatment group is not available. 16 Another concern is the return of PCR positivity in a patient who was turned PCR negative by treatment with HCQ + Azi. This highlights the possibility of occurrence of resistance to this regime.

However this needs further validation. 

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The authors acknowledge PGIMER, Chandigarh Library for their kind support during this period of lockdown.

All the authors declared that there are no conflict of interests.