0% found this document useful (0 votes)
35 views15 pages

Ivermectin Protocols

The document summarizes key clinical trials that evaluated the use of ivermectin (IVM) for the treatment of COVID-19. The ACTIV-6 trial found that among outpatients with COVID-19, IVM 600 μg/kg daily for 6 days or IVM 400 μg/kg daily for 3 days did not reduce time to recovery or hospitalization and death compared to placebo. The TOGETHER trial also found that in outpatients with recent SARS-CoV-2 infection, IVM did not reduce the need for emergency department visits or hospitalization compared to placebo. Overall, the major clinical trials showed that IVM did not significantly improve clinical outcomes for patients with COVID-19.

Uploaded by

Paulinho Cts
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
0% found this document useful (0 votes)
35 views15 pages

Ivermectin Protocols

The document summarizes key clinical trials that evaluated the use of ivermectin (IVM) for the treatment of COVID-19. The ACTIV-6 trial found that among outpatients with COVID-19, IVM 600 μg/kg daily for 6 days or IVM 400 μg/kg daily for 3 days did not reduce time to recovery or hospitalization and death compared to placebo. The TOGETHER trial also found that in outpatients with recent SARS-CoV-2 infection, IVM did not reduce the need for emergency department visits or hospitalization compared to placebo. Overall, the major clinical trials showed that IVM did not significantly improve clinical outcomes for patients with COVID-19.

Uploaded by

Paulinho Cts
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 15

Table 7b.

Ivermectin: Selected Clinical Trial Data


Last Updated: December 20, 2023

The clinical trials described in this table are the RCTs that had the greatest impact on the Panel’s recommendation. The Panel reviewed other
clinical studies that evaluated the use of IVM for the treatment of COVID-19.1-26 However, those studies have limitations that make them less
definitive and informative than the studies summarized in this table.

Methods Results Limitations and Interpretation

ACTIV-6: Double-Blind RCT of Ivermectin 600 μg/kg in Outpatients With Mild to Moderate COVID-19 in the United States27
Key Inclusion Criteria Participant Characteristics Key Limitation
• Aged ≥30 years • Median age 48 years; 59.1% women • The low number of events limited
• Not hospitalized • 38.1% with BMI >30; 9.2% with DM; 26.8% with HTN the power to determine an effect on
hospitalization and death.
• Positive SARS-CoV-2 test result within past 10 days • 83.6% received ≥2 COVID-19 vaccine doses.
• ≥2 COVID-19 symptoms for ≤7 days • Median of 5 days from symptom onset to receipt of Interpretation
study drug • Among outpatients with COVID-19, IVM
Key Exclusion Criteria 600 μg/kg PO once daily for 6 days did
• End-stage kidney disease Primary Outcome not shorten time to sustained recovery
• Liver failure or decompensated cirrhosis • Median time to sustained recovery: 11 days in IVM arm or reduce incidence of hospitalization or
vs. 11 days in placebo arm (HR 1.02; 95% CrI, 0.92– death.
Interventions 1.13)
• IVM 600 μg/kg PO once daily for 6 days (n = 602) Secondary Outcome
• Placebo (n = 604) • Hospitalization or death by Day 28: 5 (0.8%) in IVM arm
Primary Endpoint vs. 2 (0.3%) in placebo arm
• Time to sustained recovery (i.e., ≥3 consecutive days Safety Outcomes
without symptoms) • Occurrence of AEs: 52 of 566 patients (9.2%) in IVM arm
Key Secondary Endpoint vs. 41 of 576 patients (7.1%) in placebo arm
• Hospitalization or death by Day 28 • Occurrence of SAEs: 5 of 566 patients (0.9%) in IVM arm
vs. 3 of 576 patients (0.5%) in placebo arm
Safety Endpoint
• Occurrence of AEs and SAEs

COVID-19 Treatment Guidelines 367

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

ACTIV-6: Double-Blind RCT of Ivermectin 400 μg/kg Once Daily in Outpatients With Mild to Moderate COVID-19 in the United States28
Key Inclusion Criteria Participant Characteristics Key Limitation
• Aged ≥30 years • Mean age 48 years; 59% women • The low number of events limited
• Not hospitalized • 41% with BMI >30; 11.5% with DM; 26% with HTN the power to determine an effect on
hospitalization and death.
• Positive SARS-CoV-2 test result within past 10 days • 47% received ≥2 COVID-19 vaccine doses.
• ≥2 COVID-19 symptoms for ≤7 days • Median of 6 days from symptom onset to receipt of study Interpretation
drug • Among outpatients with COVID-19, IVM
Key Exclusion Criteria 400 μg/kg PO once daily for 3 days did
• End-stage kidney disease Primary Outcome not shorten time to sustained recovery
• Liver failure or decompensated cirrhosis • Median time to sustained recovery: 12 days in IVM arm or reduce incidence of hospitalization or
vs. 13 days in placebo arm (HR 1.07; 95% CrI, 0.96– death.
Interventions 1.17)
• IVM 400 μg/kg PO once daily for 3 days (n = 817) Secondary Outcome
• Placebo (n = 774) • Hospitalization or death by Day 28: 10 (1.2%) in IVM arm
Primary Endpoint vs. 9 (1.2%) in placebo arm
• Time to sustained recovery (i.e., ≥3 consecutive days Safety Outcomes
without symptoms) • Occurrence of AEs: 24 of 766 patients (3.1%) in IVM arm
Key Secondary Endpoint vs. 27 of 724 patients (3.7%) in placebo arm
• Hospitalization or death by Day 28 • Occurrence of SAEs: 9 of 766 patients (1.2%) in IVM arm
vs. 9 of 724 patients (1.2%) in placebo arm
Safety Endpoint
• Occurrence of AEs and SAEs

COVID-19 Treatment Guidelines 368

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

TOGETHER: Double-Blind, Adaptive RCT of Ivermectin in Nonhospitalized Patients With COVID-19 in Brazil29
Key Inclusion Criteria Participant Characteristics Key Limitations
• Positive SARS-CoV-2 antigen test result • Median age 49 years; 46% aged ≥50 years; 58% • Health care facility capacity may have
• Within 7 days of symptom onset women; 95% self-identified as mixed race influenced the number and duration of
• Most prevalent risk factor: 50% with obesity ED visits and hospitalizations.
• ≥1 high-risk factor for disease progression (e.g., aged
>50 years, comorbidities, immunosuppression) • 44% within 3 days of symptom onset at enrollment • No details on safety outcomes (e.g., type
of treatment-emergent AEs) other than
Interventions Primary Outcome grading were reported.
• IVM 400 μg/kg PO once daily for 3 days (n = 679) • Composite of ED observation >6 hours or hospitalization Interpretation
• Placebo (n = 679; not all patients received IVM placebo) for COVID-19 by Day 28 (ITT): 100 (14.7%) in IVM arm vs.
111 (16.4%) in placebo arm (relative risk 0.90; 95% CrI, • In outpatients with recent SARS-CoV-2
Primary Endpoint 0.70–1.16) infection, IVM did not reduce the need
• Composite of ED observation >6 hours or hospitalization for ED visits or hospitalization when
• 171 (81%) of events were hospitalizations (ITT) compared with placebo.
for COVID-19 by Day 28
Secondary Outcomes
Key Secondary Endpoints
• No difference between IVM arm and placebo arm in:
• Viral clearance at Day 7
• Viral clearance at Day 7 (relative risk 1.00; 95% CrI,
• All-cause mortality 0.68–1.46)
• Occurrence of AEs • All-cause mortality: 21 (3.1%) vs. 24 (3.5%) (relative
risk 0.88; CrI, 0.49–1.55)
• Occurrence of AEs

COVID-19 Treatment Guidelines 369

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

COVID-OUT: RCT of Metformin, Ivermectin, and Fluvoxamine in Nonhospitalized Adults With COVID-19 in the United States30
Key Inclusion Criteria Participant Characteristics Key Limitations
• Aged 30–85 years • Median age 46 years; 56% women; 82% White • Study included SpO2 measurements
• BMI ≥25 or ≥23 if Asian or Latinx • Median BMI 30 using home pulse oximeters as 1 of
the composite measures of the primary
• Laboratory-confirmed SARS-CoV-2 infection within 3 days • 27% with CVD endpoint. However, the FDA has issued
of randomization • 52% received primary COVID-19 vaccination series. a statement concerning the accuracy
• ≤7 days of COVID-19 symptoms • Mean of 4.8 days of symptoms of these home pulse oximeters, making
Key Exclusion Criteria this study endpoint less reliable.
• Approximately 68% enrolled while Delta was the
• Immunocompromised dominant variant; approximately 29% enrolled while • SpO2 data were incomplete or missing
Omicron was dominant. for 30% of the patients.
• Hepatic impairment
Primary Outcomes • The low number of events limited
• Stage 4–5 chronic kidney disease or eGFR <45 mL/ the power to determine the effect on
min/1.73 m² • Composite of hypoxemia, ED visit, hospitalization, or hospitalization and death.
death by Day 14: 105 (25.8%) in IVM arm vs. 96 (24.6%)
Interventions Interpretations
in control arm (aOR 1.05; 95% CI, 0.76–1.45, P = 0.78)
• IVM 390–470 ug/kg PO once daily for 3 days (n = 410) in • IVM did not prevent the composite
• No difference between IVM alone arm and placebo alone
the following arms: endpoint of hypoxemia, ED visit,
arm in occurrence of primary endpoint (aOR 1.06; 95%
• IVM alone (n = 206) CI, 0.67–1.67) hospitalization, or death.
• Metformin plus IVM (n = 204) • ED visit, hospitalization, or death by Day 14 in a • No primary, secondary, or subgroup
• IVM control (n = 398), which included the following arms: prespecified secondary analysis: 23 (5.7%) in IVM arm analysis demonstrated a benefit for the
vs. 16 (4.1%) in control arm (aOR 1.39; 95% CI, 0.72– use of IVM over placebo.
• Placebo alone (n = 203)
2.69)
• Metformin alone (n = 195)
• Hospitalization or death by Day 14 in a prespecified
Primary Endpoints secondary analysis: 4 (1.0%) in IVM arm vs. 5 (1.3%) in
• Composite of hypoxemia (SpO2 ≤93%, as measured by a control arm (aOR 0.73; 95% CI, 0.19–2.77); 1 death in
home pulse oximeter), ED visit, hospitalization, or death IVM arm vs. 0 deaths in control arm
by Day 14 Secondary Outcomes
• A prespecified secondary analysis evaluated the • No difference between arms in total symptom severity
occurrence of ED visits, hospitalization, or death by Day score by Day 14
14.
• Drug discontinuation or interruption: 20% in IVM arm vs.
Key Secondary Endpoints 25% in placebo alone arm
• Total symptom severity score by Day 14, as measured by
a symptom severity scale
• Drug discontinuation or interruption

COVID-19 Treatment Guidelines 370

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

IVERCOR-COVID19: Double-Blind, Placebo-Controlled, Randomized Trial of Ivermectin in Nonhospitalized Patients With COVID-19 in Argentina31
Key Inclusion Criterion Participant Characteristics Key Limitation
• Positive SARS-CoV-2 RT-PCR result within 48 hours of • Mean age 42 years; 8% aged ≥65 years; 47% women • Study enrolled a young population with
screening • 24% with HTN; 10% with DM; 58% with ≥1 comorbidity few of the comorbidities that predict
disease progression.
Key Exclusion Criteria • Median of 4 days from symptom onset
• Required supplemental oxygen or hospitalization Interpretation
Primary Outcome
• Concomitant use of CQ or HCQ • Among patients who had recently
• Hospitalization for any reason: 5.6% in IVM arm vs. 8.3% acquired SARS-CoV-2 infection, there
Interventions in placebo arm (OR 0.65; 95% CI, 0.32–1.31; P = 0.23) was no evidence that IVM provided any
• Weight-based dose of IVM PO at enrollment and 24 Secondary Outcomes clinical benefit.
hours later for a maximum total dose of 48 mg (n = • Need for MV: 2% in IVM arm vs. 1% in placebo arm (P =
250) 0.7)
• Placebo (n = 251) • All-cause mortality: 2% in IVM arm vs. 1% in placebo
Primary Endpoint arm (P = 0.7)
• Hospitalization for any reason • Occurrence of AEs: 18% in IVM arm vs. 21% in placebo
arm (P = 0.6)
Key Secondary Endpoints
• Need for MV
• All-cause mortality
• Occurrence of AEs

COVID-19 Treatment Guidelines 371

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

Double-Blind, Placebo-Controlled, Randomized Trial of Ivermectin in Patients With Mild COVID-19 in Colombia32
Key Inclusion Criteria Participant Characteristics Key Limitations
• Positive SARS-CoV-2 RT-PCR or antigen test result • Median age 37 years; 4% aged ≥65 years in IVM arm, 8% • Due to low event rates, the primary
• ≤7 days of COVID-19 symptoms in placebo arm; 39% men in IVM arm, 45% in placebo endpoint changed from the proportion of
arm patients with clinical deterioration to the
• Mild disease time to symptom resolution during the
• 79% with no known comorbidities
Key Exclusion Criteria trial.
• Median of 5 days from symptom onset to randomization
• Asymptomatic disease • The study enrolled younger, healthier
Primary Outcome patients, a population that does not
• Severe pneumonia
• Median time to symptom resolution: 10 days in IVM arm typically develop severe COVID-19.
• Hepatic dysfunction vs. 12 days in placebo arm (HR 1.07; P = 0.53) Interpretation
Interventions • Symptoms resolved by Day 21: 82% in IVM arm vs. • In patients with mild COVID-19, IVM
• IVM 300 μg/kg PO once daily for 5 days (n = 200) 79% in placebo arm 300 μg/kg once daily for 5 days did not
• Placebo PO (n = 198) Secondary Outcomes improve the time to symptom resolution.
Primary Endpoint • No difference between arms in proportion of patients who
• Time to symptom resolution within 21 days showed clinical deterioration or required escalation of
care
Key Secondary Endpoints • Occurrence of AEs:
• Clinical deterioration • Discontinued treatment due to AEs: 8% in IVM arm vs.
• Escalation of care 3% in placebo arm
• Occurrence of AEs • No SAEs related to intervention

COVID-19 Treatment Guidelines 372

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

I-TECH: Open-Label RCT of Ivermectin in Patients With Mild to Moderate COVID-19 in Malaysia33
Key Inclusion Criteria Participant Characteristics Key Limitation
• Positive SARS-CoV-2 RT-PCR or antigen test result • Mean age 63 years; 55% women • Open-label study
within 7 days of symptom onset • 68% received ≥1 COVID-19 vaccine dose; 52% received Interpretation
• Aged ≥50 years 2 doses.
• In patients with mild to moderate
• ≥1 comorbidities • Most common comorbidities: 75% with HTN; 54% with COVID-19, there was no evidence
DM; 24% with dyslipidemia that IVM provided any clinical benefit,
Key Exclusion Criteria
• Mean of 5 days symptom duration including no evidence that IVM reduced
• Required supplemental oxygen the risk of progression to severe disease.
• Severe hepatic impairment (ALT >10 times the ULN) Primary Outcome
• Progression to severe COVID-19 (mITT): 52 (21.6%)
Interventions
in IVM plus SOC arm vs. 43 (17.3%) in SOC alone arm
• IVM 400 μg/kg PO once daily for 5 days plus SOC (n = (relative risk 1.25; 95% CI, 0.87–1.80; P = 0.25)
241)
Secondary Outcomes
• SOC (n = 249)
• No difference between IVM plus SOC arm and SOC alone
Primary Endpoint arm in:
• Progression to severe COVID-19 (i.e., hypoxemia • In-hospital, all-cause mortality by Day 28: 3 (1.2%) vs.
requiring supplemental oxygen to maintain SpO2 ≥95%) 10 (4.0%) (relative risk 0.31; 95% CI, 0.09–1.11; P =
Key Secondary Endpoints 0.09)
• In-hospital, all-cause mortality by Day 28 • MV: 4 (1.7%) vs. 10 (4.0%) (relative risk 0.41; 95% CI,
0.13–1.30; P = 0.17)
• MV or ICU admission
• ICU admission: 6 (2.5%) vs. 8 (3.2%) (relative risk 0.78;
• Occurrence of AEs 95% CI, 0.27–2.20; P = 0.79)
• Occurrence of AEs: 33 (13.7%) in IVM plus SOC arm vs.
11 (4.4%) in SOC alone arm; most with diarrhea (14 vs. 4)

COVID-19 Treatment Guidelines 373

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

COVER: Phase 2, Double-Blind RCT of Ivermectin in Nonhospitalized Patients With COVID-19 in Italy34
Key Inclusion Criteria Participant Characteristics Key Limitations
• Asymptomatic or oligosymptomatic disease • Median age 47 years; 58% men • Small, Phase 2 study
• SARS-CoV-2 infection confirmed by RT-PCR result • 86% with COVID-19 symptoms • 90% of subjects screened were not
• Not hospitalized or receiving supplemental oxygen • 2.2% received a COVID-19 vaccine. enrolled for various reasons.
• Recruitment stopped early because of a
Key Exclusion Criteria Primary Outcomes
decline in the number of COVID-19 cases.
• CNS disease • No SAEs related to intervention
Interpretations
• Receiving dialysis • Mean log10 reduction in VL at Day 7: 2.9 in IVM 1,200 μg/
kg arm vs. 2.5 in IVM 600 μg/kg arm vs. 2.0 in placebo • A high dose of IVM (1,200 μg/kg) appears
• Severe medical condition with <6 months survival to be safe but not well tolerated; 34% of
prognosis arm (IVM 1,200 μg/kg vs. placebo, P = 0.099; IVM 600
μg/kg vs. placebo, P = 0.122) patients discontinued therapy due to AEs.
• Use of warfarin, antiviral agents, CQ, or HCQ • There was no significant difference in
Other Outcomes
Interventions reduction of VL between IVM and placebo
• 14 (15.1%) discontinued treatment: 11 (34.4%) in IVM arms.
• IVM 1,200 μg/kg PO once daily for 5 days (n = 32) 1,200 μg/kg arm vs. 2 (6.9%) in IVM 600 μg/kg arm vs. 1
• IVM 600 μg/kg plus placebo PO once daily for 5 days (n (3.1%) in placebo arm
= 29) • All discontinuations in IVM 1,200 μg/kg arm were due to
• Placebo PO (n = 32) tolerability
Primary Endpoints
• Number of SAEs
• Change in VL at Day 7
Other Endpoint
• Drug discontinuation or interruption

COVID-19 Treatment Guidelines 374

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

Open-Label RCT of Ivermectin in Hospitalized Patients With COVID-19 in Egypt35


Key Inclusion Criteria Participant Characteristics Key Limitation
• RT-PCR-confirmed SARS-CoV-2 infection by pharyngeal • Mean age 42 years for IVM arm, 39 years for SOC arm; • Small, open-label study
swab 50% men
Interpretation
• Hospitalized with mild to moderate COVID-19 • 49% with ≥1 comorbidities
• The use of IVM did not reduce all-cause
Key Exclusion Criterion Primary Outcome mortality, hospital LOS, or the need
• Cardiac problems • All-cause mortality by 28 days: 3 (3.7%) in IVM arm vs. 4 for MV among patients with mild to
(4.9%) in SOC arm (P = 1.00) moderate COVID-19.
Interventions
• IVM 12 mg PO once daily for 3 days (n = 82) Secondary Outcomes
• SOC (n = 82) • Mean hospital LOS: 9 days in IVM arm vs. 11 days in SOC
arm (P = 0.085)
Primary Endpoint
• Need for MV: 3 (3.7%) in each arm (P = 1.00)
• All-cause mortality by 28 days
Key Secondary Endpoints
• Hospital LOS
• Need for MV

COVID-19 Treatment Guidelines 375

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

Double-Blind, Placebo-Controlled, Randomized Trial of Ivermectin in Patients With Mild to Moderate COVID-19 in India36
Key Inclusion Criteria Participant Characteristics Key Limitations
• Positive SARS-CoV-2 RT-PCR or antigen test result • Mean age 53 years; 28% women • Although the primary endpoint was a
• Hospitalized with mild to moderate COVID-19 • 35% with HTN; 36% with DM negative SARS-CoV-2 RT-PCR result
on Day 6, no RT-PCR result or an
Interventions • 79% with mild COVID-19 inconclusive RT-PCR result was reported
• IVM 12 mg PO once daily for 2 days (n = 55) • Mean of 6.9 days from symptom onset for 42% of patients in the IVM arm and
• Placebo PO (n = 57) • 100% received HCQ, steroids, and antibiotics; 21% 23% in the placebo arm.
received RDV; 6% received tocilizumab. • The time to discharge was not reported,
Primary Endpoint and outcomes after discharge were not
Primary Outcome
• Negative SARS-CoV-2 RT-PCR result on Day 6 evaluated.
• Negative SARS-CoV-2 RT-PCR result on Day 6: 24% in
Key Secondary Endpoints IVM arm vs. 32% in placebo arm (rate ratio 0.8; P = Interpretation
• Symptom resolution by Day 6 0.348) • IVM provided no significant virologic or
• Discharge by Day 10 Secondary Outcomes clinical benefit for patients with mild to
moderate COVID-19.
• Need for ICU admission or MV • Symptom resolution by Day 6: 84% in IVM arm vs. 90% in
• In-hospital mortality placebo arm (rate ratio 0.9; P = 0.36)
• Discharge by Day 10: 80% in IVM arm vs. 74% in placebo
arm (rate ratio 1.1; P = 0.43)
• No difference between arms in need for ICU admission or
MV
• In-hospital mortality: 0 in IVM arm (0%) vs. 4 in placebo
arm (7%)

COVID-19 Treatment Guidelines 376

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

RIVET-COV: Double-Blind, Placebo-Controlled, Randomized Trial of Ivermectin in Patients With Mild to Moderate COVID-19 in India37
Key Inclusion Criteria Participant Characteristics Key Limitation
• Positive SARS-CoV-2 RT-PCR or antigen test result • Mean age 35 years; 89% men • Small sample size
• Nonsevere COVID-19 • 60% to 68% with mild COVID-19 (including asymptomatic Interpretation
patients); 33% to 40% with moderate COVID-19
Key Exclusion Criteria • The use of IVM did not affect the
• Median of 4–5 days symptom duration; similar across proportion of patients with negative
• CrCl <30 mL/min
arms SARS-CoV-2 RT-PCR results at Day 5 or
• Transaminases >5 times ULN the clinical outcomes.
• 10% in each arm received concurrent antivirals (RDV,
• MI, heart failure, QTc interval prolongation favipiravir, or HCQ).
• Severe comorbidity Primary Outcomes
Interventions • Negative SARS-CoV-2 RT-PCR result at Day 5: 48% in
• Single dose of IVM 24 mg PO (n = 51) IVM 24 mg arm vs. 35% in IVM 12 mg arm vs. 31% in
• Single dose of IVM 12 mg PO (n = 49) placebo arm (P = 0.30)
• Placebo (n = 52) • No significant difference between arms in decline of VL at
Day 5
Primary Endpoints
Secondary Outcomes
• Negative SARS-CoV-2 RT-PCR result at Day 5
• No difference between arms in time to symptom
• Decline of VL at Day 5 resolution
Key Secondary Endpoints • Clinical worsening at Day 14: 8% in IVM 24 mg arm vs.
• Time to symptom resolution 5% in IVM 12 mg arm vs. 11% in placebo arm (P = 0.65)
• Clinical worsening at Day 14 • No difference between arms in number of hospital-free
days at Day 28
• Number of hospital-free days at Day 28
• No difference between arms in frequency of AEs; no SAEs
• Frequency of AEs
were reported

COVID-19 Treatment Guidelines 377

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


Methods Results Limitations and Interpretation

Double-Blind RCT of Ivermectin, Chloroquine, or Hydroxychloroquine in Hospitalized Adults With Severe COVID-19 in Brazil38
Key Inclusion Criteria Participant Characteristics Key Limitations
• Hospitalized with laboratory-confirmed SARS-CoV-2 • Mean age 53 years; 58% men • Small sample size
infection • Most common comorbidities: 43% with HTN; 28% with • No clearly defined primary endpoint
• ≥1 of the following severity criteria: DM; 38% with BMI >30
Interpretation
• Dyspnea • 76% with respiratory failure on admission
• Compared to CQ or HCQ, IVM did not
• Tachypnea (>30 breaths/min) Outcomes reduce the proportion of hospitalized
• SpO2 <93% • No difference between IVM, CQ, and HCQ arms in: patients with severe COVID-19 who died
• PaO2/FiO2 <300 mm Hg or who required supplemental oxygen,
• Need for supplemental oxygen: 88% vs. 89% vs. 90% ICU admission, or MV
• Involvement of >50% of lungs confirmed by CXR or • Need for MV: 24% vs. 21% vs. 21%
CT scan
• ICU admission: 28% vs. 22% vs. 21%
Key Exclusion Criterion • Mortality: 23% vs. 21% vs. 22%
• Cardiac arrhythmia • Mean number of days of supplemental oxygen: 8 days
Interventions in each arm
• IVM 14 mg once daily for 3 days (n = 53) • No difference between arms in occurrence of AEs
• CQ 450 mg twice daily on Day 0, then once daily for 4 • Baseline characteristics significantly associated with
days (n = 61) mortality:
• HCQ 400 mg twice daily on Day 0, then once daily for 4 • Aged >60 years (HR 2.4)
days (n = 54) • DM (HR 1.9)
Endpoints • BMI >33 (HR 2.0)
• Need for supplemental oxygen, MV, or ICU admission • SpO2 <90% (HR 5.8)
• Occurrence of AEs
• Mortality
Key: AE = adverse event; ALT = alanine transaminase; BMI = body mass index; CNS = central nervous system; CQ = chloroquine; CrCl = creatinine clearance; CT =
computed tomography; CVD = cardiovascular disease; CXR = chest X-ray; DM = diabetes mellitus; ED = emergency department; eGFR = estimated glomerular filtration
rate; FDA = Food and Drug Administration; HCQ = hydroxychloroquine; HTN = hypertension; ICU = intensive care unit; ITT = intention-to-treat; IVM = ivermectin; LOS
= length of stay; MI = myocardial infarction; mITT = modified intention-to-treat; MV = mechanical ventilation; the Panel = the COVID-19 Treatment Guidelines Panel;
PaO2/FiO2 = ratio of arterial partial pressure of oxygen to fraction of inspired oxygen; PO = oral; RCT = randomized controlled trial; RDV = remdesivir; RT-PCR = reverse
transcriptase polymerase chain reaction; SAE = severe adverse event; SOC = standard of care; SpO2 = oxygen saturation; ULN = upper limit of normal; VL = viral load

COVID-19 Treatment Guidelines 378

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


References
1. Spoorthi V, Sasank S. Utility of ivermectin and doxycycline combination for the treatment of SARS-CoV-2. Int Arch Integrated Med. 2020;7(10):117-
182. Available at: https://iaimjournal.com/wp-content/uploads/2020/10/iaim_2020_0710_23.pdf.
2. Camprubí D, Almuedo-Riera A, Martí-Soler H, et al. Lack of efficacy of standard doses of ivermectin in severe COVID-19 patients. PLoS One.
2020;15(11):e0242184. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33175880.
3. Bhattacharya R, Ray I, Mukherjee R, et al. Observational study on clinical features, treatment and outcome of COVID-19 in a tertiary
care centre in India—a retrospective case series. Int J Sci Res. 2020;9(10):69-71. Available at: https://www.worldwidejournals.com/
international-journal-of-scientific-research-(IJSR)/article/observational-study-on-clinical-features-treatment-and-outcome-of-covid-19-in-a-tertiary-
care-centre-in-india-andndash-a-retrospective-case-series/MzI0NTg=/?is=1&b1=141&k=36.
4. Morgenstern J, Redondo JN, De León A, et al. The use of compassionate ivermectin in the management of symptomatic outpatients and hospitalized
patients with clinical diagnosis of COVID-19 at the Medical Center Bournigal and the Medical Center Punta Cana, Rescue Group, Dominican
Republic, from May 1 to August 10, 2020. medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.10.29.20222505v1.
5. Cadegiani FA, Goren A, Wambier CG, McCoy J. Early COVID-19 therapy with azithromycin plus nitazoxanide, ivermectin or hydroxychloroquine
in outpatient settings significantly improved COVID-19 outcomes compared to known outcomes in untreated patients. New Microbes New Infect.
2021;43:100915. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34249367.
6. Carvallo H, Roberto H, Eugenia FM. Safety and efficacy of the combined use of ivermectin, dexamethasone, enoxaparin and aspirin against COVID
19. medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.09.10.20191619v1.
7. Bukhari KHS, Asghar A, Perveen N, et al. Efficacy of ivermectin in COVID-19 patients with mild to moderate disease. medRxiv. 2021;Preprint.
Available at: https://www.medrxiv.org/content/10.1101/2021.02.02.21250840v1.
8. Elalfy H, Besheer T, El-Mesery A, et al. Effect of a combination of nitazoxanide, ribavirin, and ivermectin plus zinc supplement (MANS.NRIZ study)
on the clearance of mild COVID-19. J Med Virol. 2021;93(5):3176-3183. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33590901.
9. Chahla RE, Ruiz LM, Mena T, et al. Cluster randomised trials—ivermectin repurposing for COVID-19 treatment of outpatients with mild disease in
primary health care centers. Research Square. 2021;Preprint. Available at: https://www.researchsquare.com/article/rs-495945/v1.
10. Tanioka H, Tanioka S, Kaga K. Why COVID-19 is not so spread in Africa: how does ivermectin affect it? medRxiv. 2021;Preprint. Available at:
https://www.medrxiv.org/content/10.1101/2021.03.26.21254377v1.
11. Roy S, Samajdar SS, Tripathi SK, Mukherjee S, Bhattacharjee K. Outcome of different therapeutic interventions in mild COVID-19 patients in a single
OPD clinic of West Bengal: a retrospective study. medRxiv. 2021;Preprint. Available at:
https://www.medrxiv.org/content/10.1101/2021.03.08.21252883v2.
12. Shahbaznejad L, Davoudi A, Eslami G, et al. Effects of ivermectin in patients with COVID-19: a multicenter, double-blind, randomized, controlled
clinical trial. Clin Ther. 2021;43(6):1007-1019. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34052007.
13. Roman YM, Burela PA, Pasupuleti V, et al. Ivermectin for the treatment of coronavirus disease 2019: a systematic review and meta-analysis of
randomized controlled trials. Clin Infect Dis. 2022;74(6):1022-1029. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34181716.
14. Ahmed S, Karim MM, Ross AG, et al. A five-day course of ivermectin for the treatment of COVID-19 may reduce the duration of illness. Int J Infect
Dis. 2021;103:214-216. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33278625.
COVID-19 Treatment Guidelines 379

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


15. Chaccour C, Casellas A, Blanco-Di Matteo A, et al. The effect of early treatment with ivermectin on viral load, symptoms and humoral response
in patients with non-severe COVID-19: a pilot, double-blind, placebo-controlled, randomized clinical trial. EClinicalMedicine. 2021;32:100720.
Available at: https://www.ncbi.nlm.nih.gov/pubmed/33495752.
16. Chachar AZK, Khan KA, Asif M, et al. Effectiveness of ivermectin in SARS-COV-2/COVID-19 patients. Int J Sci. 2020;9:31-35. Available at:
https://www.ijsciences.com/pub/article/2378.
17. Gonzalez JLB, Gámez MG, Enciso EAM, et al. Efficacy and safety of ivermectin and hydroxychloroquine in patients with severe COVID-19: a
randomized controlled trial. Infect Dis Rep. 2022;14(2):160-168. Available at: https://www.mdpi.com/2036-7449/14/2/20.
18. Hashim HA, Maulood MF, Ali CL, et al. Controlled randomized clinical trial on using ivermectin with doxycycline for treating COVID-19 patients in
Baghdad, Iraq. Iraqi J Med Sci. 2021;29(1):107-115. Available at: https://www.iraqijms.net/index.php?do=view&type=article&id=779.
19. Khan MSI, Debnath CR, Nath PN, et al. Ivermectin treatment may improve the prognosis of patients with COVID-19. Arch Bronconeumol (Engl Ed).
2020;56(12):828-830. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33293006.
20. Krolewiecki A, Lifschitz A, Moragas M, et al. Antiviral effect of high-dose ivermectin in adults with COVID-19: a proof-of-concept randomized trial.
EClinicalMedicine. 2021;37:100959. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34189446.
21. Okumuş N, Demirtürk N, Çetinkaya RA, et al. Evaluation of the effectiveness and safety of adding ivermectin to treatment in severe COVID-19
patients. BMC Infect Dis. 2021;21(1):411. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33947344.
22. Podder CS, Chowdhury N, Sina MI, Mohosin Ul Haque WM. Outcome of ivermectin treated mild to moderate COVID-19 cases: a single-centre,
open-label, randomised controlled study. IMC J Med Sci. 2021;14(2). Available at: https://doi.org/10.3329/imcjms.v14i2.52826.
23. Soto-Becerra P, Culquichicón C, Hurtado-Roca Y, Araujo-Castillo RV. Real-world effectiveness of hydroxychloroquine, azithromycin, and ivermectin
among hospitalized COVID-19 patients: results of a target trial emulation using observational data from a nationwide healthcare system in Peru.
medRxiv. 2020;Preprint. Available at: https://www.medrxiv.org/content/10.1101/2020.10.06.20208066v3.
24. Rajter JC, Sherman MS, Fatteh N, et al. Use of ivermectin is associated with lower mortality in hospitalized patients with coronavirus disease 2019: the
ivermectin in COVID nineteen study. Chest. 2021;159(1):85-92. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33065103.
25. Chowdhury ATMM, Shahbaz M, Karim MR, et al. A comparative study on ivermectin-doxycycline and hydroxychloroquine-azithromycin therapy on
COVID-19 patients. EJMO. 2021;5(1):63-70. Available at: https://www.ejmo.org/10.14744/ejmo.2021.16263/.
26. Niaee MS, Namdar P, Allami A, et al. Ivermectin as an adjunct treatment for hospitalized adult COVID-19 patients: a randomized multi-center clinical
trial. Asian Pac J Trop Med. 2021;14(6):266-273. Available at:
https://journals.lww.com/aptm/Fulltext/2021/14060/Ivermectin_as_an_adjunct_treatment_for.3.aspx.
27. Naggie S, Boulware DR, Lindsell CJ, et al. Effect of higher-dose ivermectin for 6 days vs placebo on time to sustained recovery in outpatients with
COVID-19: a randomized clinical trial. JAMA. 2023;329(11):888-897. Available at: https://pubmed.ncbi.nlm.nih.gov/36807465.
28. Naggie S, Boulware DR, Lindsell CJ, et al. Effect of ivermectin vs placebo on time to sustained recovery in outpatients with mild to moderate
COVID-19: a randomized clinical trial. JAMA. 2022;328(16):1595-1603. Available at: https://pubmed.ncbi.nlm.nih.gov/36269852.
29. TOGETHER Investigators. Effect of early treatment with ivermectin among patients with COVID-19. N Engl J Med. 2022;386(18):1721-1731.
Available at: https://www.ncbi.nlm.nih.gov/pubmed/35353979.

COVID-19 Treatment Guidelines 380

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024


30. Bramante CT, Huling JD, Tignanelli CJ, et al. Randomized trial of metformin, ivermectin, and fluvoxamine for COVID-19. N Engl J Med.
2022;387(7):599-610. Available at: https://www.ncbi.nlm.nih.gov/pubmed/36070710.
31. Vallejos J, Zoni R, Bangher M, et al. Ivermectin to prevent hospitalizations in patients with COVID-19 (IVERCOR-COVID19) a randomized, double-
blind, placebo-controlled trial. BMC Infect Dis. 2021;21(1):635. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34215210.
32. López-Medina E, López P, Hurtado IC, et al. Effect of ivermectin on time to resolution of symptoms among adults with mild COVID-19: a randomized
clinical trial. JAMA. 2021;325(14):1426-1435. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33662102.
33. Lim SCL, Hor CP, Tay KH, et al. Efficacy of ivermectin treatment on disease progression among adults with mild to moderate COVID-19 and
comorbidities: the I-TECH randomized clinical trial. JAMA Intern Med. 2022;182(4):426-435. Available at:
https://www.ncbi.nlm.nih.gov/pubmed/35179551.
34. Buonfrate D, Chesini F, Martini D, et al. High-dose ivermectin for early treatment of COVID-19 (COVER study): a randomised, double-blind,
multicentre, phase II, dose-finding, proof-of-concept clinical trial. Int J Antimicrob Agents. 2022;59(2):106516. Available at:
https://www.ncbi.nlm.nih.gov/pubmed/34999239.
35. Abd-Elsalam S, Noor RA, Badawi R, et al. Clinical study evaluating the efficacy of ivermectin in COVID-19 treatment: a randomized controlled study.
J Med Virol. 2021;93(10):5833-5838. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34076901.
36. Ravikirti, Roy R, Pattadar C, et al. Evaluation of ivermectin as a potential treatment for mild to moderate COVID-19: a double-blind randomized
placebo controlled trial in Eastern India. J Pharm Pharm Sci. 2021;24:343-350. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34265236.
37. Mohan A, Tiwari P, Suri TM, et al. Single-dose oral ivermectin in mild and moderate COVID-19 (RIVET-COV): a single-centre randomized, placebo-
controlled trial. J Infect Chemother. 2021;27(12):1743-1749. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34483029.
38. Bermejo Galan LE, Dos Santos NM, Asato MS, et al. Phase 2 randomized study on chloroquine, hydroxychloroquine or ivermectin in hospitalized
patients with severe manifestations of SARS-CoV-2 infection. Pathog Glob Health. 2021;115(4):235-242. Available at: https://www.ncbi.nlm.nih.gov/
pubmed/33682640.

COVID-19 Treatment Guidelines 381

Downloaded from https://www.covid19treatmentguidelines.nih.gov/ on 1/11/2024

You might also like