Ivermectin for Severe COVID-19 Management

• ClinicalTrials.gov Identifier: NCT04646109
• Recruitment Status: Completed
• First Posted: November 27, 2020
• Results First Posted: January 27, 2021
• Last Update Posted: January 27, 2021
• Sponsor: Afyonkarahisar Health Sciences University
• Collaborator: NeuTec Pharma
• Information provided by (Responsible Party): Nurullah Okumuş, Afyonkarahisar Health Sciences University

Study Description

Brief Summary:

In this multicenter study; it was aimed to investigate the effectiveness and safety of ivermectin use in the treatment of patients with severe COVID-19 pneumonia that have no mutations which alter ivermectin metabolism and cause side effects.

Condition or disease	Intervention/treatment	Phase
COVID-19	Drug: Ivermectin	Phase 3

Detailed Description:

Patients with severe COVID-19 pneumonia were included in the study. Two groups, the study group and the control group, took part in the study.

Ivermectin 200 mcg/kg/day for five days (9 mg between 36-50 kg, 12 mg between 51-65 kg, 15 mg between 66-79 kg and 200 microgram/kg in > 80 kg) in the form of a solution prepared for enteral use added to the reference treatment protocol -hydroxychloroquine (2x400mg loading dose followed by 2x200mg, po, 5 days) + favipiravir (2x1600mg loading dose followed by 2x600mg maintenance dose, po, total 5 days) + azithromycin (first day 500mg followed by 4 days 250mg/day, po, total 5 days)- of patients included in the study group. Patients in the control group were given only reference treatment with 3 other drugs without ivermectin.

The mutations in 29 pairs of primers in mdr1/abcab1 gene by sequencing analysis using Sanger method, and the haplotypes and mutations of the CYP3A4 gene that cause the function losing were investigated among the patients who meet criteria and who were included in the study group according to randomization. Mutation screening was done when the first dose of the research drug ivermectin was given, ivermectin treatment was not continued in patients with mutations detected as a result of genetic examination and these patients were excluded from the study.

Patients were followed for 5 additional days after treatment. At the end of the treatment and follow-up period (At the end of 10th day), clinical response and changes in oxygenation and laboratory parameters were evaluated.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 66 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Intervention Model Description: Patients who were hospitalised with a pre-diagnosis of severe COVID-19 pneumonia and thereafter diagnosis of COVID-19 was also confirmed microbiologically with polymerase chain reaction (PCR) positivity in respiratory tract samples were included into the study. They were randomized to the study and control group, respectively. Single numbered patients were accepted as study group and double numbered patients as control group
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: The Effectiveness and Safety of Ivermectin as add-on Therapy in Severe COVID-19 Management
• Actual Study Start Date: May 11, 2020
• Actual Primary Completion Date: September 2, 2020
• Actual Study Completion Date: September 2, 2020

Arms and Interventions

Arm	Intervention/treatment
No Intervention: Control Group; Patients who were hospitalised with a pre-diagnosis of severe COVID-19 pneumonia and thereafter diagnosis of COVID-19 was also confirmed microbiologically with PCR positivity in respiratory tract samples were included into the study. They were randomized to the control and study group, respectively. Hydroxychloroquine, favipiravir and azithromycin (HFA) standard treatment protocol were given to the control group as recommended in the "COVID-19 (SARS-CoV-2 Infection) Guide" prepared by the Republic of Turkey Ministry of Health.
Experimental: Study Group; In addition to HFA treatment, ivermectin 200 micrograms/kg/day (9mg between 36-50 kg, 12mg between 51-65 kg, 15mg between 66-79 kg and 200 micrograms/kg in > 80 kg) in the form of a solution prepared for enteral use was added (HFA+I) to the treatment protocol of the study group's for five days. Blood sample was taken with the first dose of ivermectin and haplotype analysis was performed in ABCB1 and CYP3A4 genes in the whole study group.	Drug: Ivermectin; Ivermectin 5mg/5ml solution was manufactured by NEUTEC™ Pharmaceutical Company-Turkey, under "Good Manufacturing Practices" (GMP) certification conditions.; Other Name: Hydroxychloroquine, favipiravir and azithromycin

Outcome Measures

Primary Outcome Measures :

1. Gender Distribution of the Patients [ Time Frame: At the first day of the study ]
   The gender of patients (Male/female) in both groups were recorded at the time of inclusion.
2. Age Distribution of the Patients [ Time Frame: At the first day of the study ]
   The age of the patients (years) in both groups were recorded at the time of inclusion.
3. Percentage of Patients With Accompanying Diseases [ Time Frame: At the first day of the study ]

   At the beginning of the study, the patients were asked whether there were any of the following accompanying diseases and the percentage of patients with accompanying disease in both groups were recorded:

   • Diabetes mellitus
   • Hypertension
   • Coronary artery disease
   • Cardiac failure
   • Chronic obstructive pulmonary disease
   • Malignancy
   • Immunodeficiency
4. Percentage of Patients With Baseline Clinical Symptoms [ Time Frame: At the first day of the study ]

   At the beginning of the study, the patients were asked whether there were any of the following clinical symptoms and the percentage of patients with any of the clinical symptoms in both groups were recorded:

   • Fever
   • Cough
   • Sore throat
   • Dispnea
   • Headache
   • Weakness
   • Myalgia
   • Diarrhea
   • Nausea or vomiting
5. Body Temperature Means of the Patients [ Time Frame: At the first day of the study ]
   At the beginning of the study, the body temperatures (as degree celcius) of the patients were measured and the mean body temperature values of both groups were recorded.
6. Heart Rate Means of the Patients [ Time Frame: At the first day of the study ]
   At the beginning of the study, the heart rates (as per minute) of the patients were measured and the mean heart rate values of both groups were recorded.
7. Respiratory Rate Means of the Patients [ Time Frame: At the first day of the study ]
   At the beginning of the study, the respiratory rates (as per minute) of the patients were measured and the mean respiratory rate values of both groups were recorded.
8. Systolic and Diastolic Pressure Means of the Patients [ Time Frame: At the first day of the study ]
   At the beginning of the study, the systolic and diastolic pressures (as mmHg) of the patients were measured and the mean systolic and diastolic pressure values of both groups were recorded.
9. Number of Participants With Clinical Response [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
   The presence of at least two of the following criteria in patients at the end of 5th day were accepted as "clinical response": Extubation in mechanically ventilated patients, respiratory rate <26/min, SpO2 level in room air >90%, PaO2/FiO2 >300 in patients receiving oxygen, presence of at least two of the 2-point reduction criteria in "Sequential Organ Failure Assessment (SOFA)" score.
10. Changes in Oxygen Saturation (SpO2) Values [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
    Baseline SpO2 values of the patients were recorded in both groups. Then, their treatments were started and SpO2 values at the end of the 1st (TD1), 3rd (TD3) and 5th days (TD5) were also recorded. The end of the 5th day was accepted as the primary endpoint. While the change in SpO2 values on the 1st, 3rd and 5th days after the basal value calculated graphically, the change in the SpO2 value at the end of the 5th day (primary endpoint) with the baseline value was compared statistically (the results were given as p value).
11. Changes in the Ratio of Partial Pressure of Oxygen (PaO2) to Fraction of Inspired Oxygen (FiO2) (PaO2/FiO2) [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
    Baseline PaO2/FiO2 ratios of the patients were recorded in both groups. Then, their treatments were started and PaO2/FiO2 ratios at the end of the 1st (TD1), 3rd (TD3) and 5th days (TD5) were also recorded. The end of the 5th day was accepted as the primary endpoint. While the change in PaO2/FiO2 ratios on the 1st, 3rd and 5th days after the basal ratio was calculated graphically, the change in the PaO2/FiO2 ratio at the end of the 5th day (primary endpoint) with the baseline value was compared statistically (the results were given as p value).
12. Changes in Serum Lymphocyte Counts [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
    Baseline Serum Lymphocyte counts (cell/mm^3) of the patients were recorded in both groups. Then, their treatments were started and Serum Lymphocyte counts at the end of the 1st (TD1), 3rd (TD3) and 5th days (TD5) were also recorded. The end of the 5th day was accepted as the primary endpoint. While the change in Serum Lymphocyte counts on the 1st, 3rd and 5th days after the basal level was calculated graphically, the change in the Serum Lymphocyte count at the end of the 5th day (primary endpoint) with the baseline count was compared statistically (the results were given as p value).
13. Changes in the Ratio of Polymorphonuclear Leukocyte Count to Lymphocyte Count (PNL/L) [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
    Baseline PNL/L ratio of the patients were recorded in both groups. Then, their treatments were started and PNL/L ratios at the end of the 1st (TD1), 3rd (TD3) and 5th days (TD5) were also recorded. The end of the 5th day was accepted as the primary endpoint. While the change in PNL/L ratios on the 1st, 3rd and 5th days after the basal level was calculated graphically, the change in the PNL/L ratio at the end of the 5th day (primary endpoint) with the baseline ratio was compared statistically (the results were given as p value).
14. Changes in Serum Ferritin Levels [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
    Baseline serum ferritin levels (mg/dL) of the patients were recorded in both groups. Then, their treatments were started and serum ferritin levels at the end of the 1st (TD1), 3rd (TD3) and 5th days (TD5) were also recorded. The end of the 5th day was accepted as the primary endpoint. While the change in serum ferritin levels on the 1st, 3rd and 5th days after the basal level was calculated graphically, the change in the serum ferritin level at the end of the 5th day (primary endpoint) with the baseline level was compared statistically (the results were given as p value).
15. Changes in Serum D-dimer Levels [ Time Frame: From starting to the end of ivermectin therapy (0 to the end of 5th day) ]
    Baseline serum D-dimer levels (mg/L) of the patients were recorded in both groups. Then, their treatments were started and serum D-dimer levels at the end of the 1st (TD1), 3rd (TD3) and 5th days (TD5) were also recorded. The end of the 5th day was accepted as the primary endpoint. While the change in serum D-dimer levels on the 1st, 3rd and 5th days after the basal level was calculated graphically, the change in the serum D-dimer level at the end of the 5th day (primary endpoint) with the baseline level was compared statistically (the results were given as p value).
16. Genetic Examination of Haplotypes and Mutations That Cause Function Losing for Ivermectin Metabolism [ Time Frame: At the first day of ivermectin therapy (1st day) ]
    A blood sample was taken from the patients included in the study group, after taking or during the first dose of ivermectin. From the blood samples, haplotypes and mutations that cause the function losing were investigated by performing sequence analysis of multidrug resistance 1 (MDR1)/ABCB1 and CYP3A4 genes with Sanger method. In case of detection of mutation, the patient were excluded from the study and if observed, side effects of ivermectin were noted.
17. Treatment-Related Adverse Events as Assessed by CTCAE v4.0 [ Time Frame: At the first 5 days of study ]

    Adverse effects of ivermectin and drugs other than ivermectin (Hydroxychloroquine, favipiravir, azithromycin) were evaluated in the patients in the study group and and the number of participants were noted.

    Adverse effects of drugs other than ivermectin (Hydroxychloroquine, favipiravir, azithromycin) were evaluated in the patients in the control group and and the number of participants were noted.

Secondary Outcome Measures :

1. Number of Participants With Clinical Response [ Time Frame: 10 days (5 days ivermectin therapy plus 5 days follow-up) ]
   The presence of at least two of the following criteria in patients on the 10th day were accepted as "clinical response": Respiration rate between 22-24/min, SpO2 level in room air >95%, absence of oxygen requirement, observation of radiological improvement in control lung tomography and no need for intensive care.
2. Mortality [ Time Frame: Through study completion, an average of 3 months ]
   The number of died patients were evaluated in study and control groups
3. Changes in Oxygen Saturation (SpO2) Values [ Time Frame: From 6th to the end of 10th day ]
   In both groups, after the treatment period was completed (first 5 days, primary endpoint), patients were followed up for 5 more days (follow-up period). SpO2 values at the end of 6th (FD1), 8th (FD3) and 10th day (FD5) were also recorded. The end of the 10th day was accepted as the secondary endpoint. While the change in SpO2 values on the 6th, 8th and 10th days was calculated graphically, the change in the SpO2 value at the end of the 10th day (secondary endpoint) with the baseline value was compared statistically (the results were given as p value).
4. Changes in the Ratio of Partial Pressure of Oxygen (PaO2) to Fraction of Inspired Oxygen (FiO2) (PaO2/FiO2) [ Time Frame: From 6th to the end of 10th day ]
   In both groups, after the treatment period was completed (first 5 days, primary endpoint), patients were followed up for 5 more days (follow-up period). PaO2/FiO2 ratios at the end of 6th (FD1), 8th (FD3) and 10th day (FD5) were also recorded. The end of the 10th day was accepted as the secondary endpoint. While the change in PaO2/FiO2 ratios on the 6th, 8th and 10th days was calculated graphically, the change in the PaO2/FiO2 ratio at the end of the 10th day (secondary endpoint) with the baseline ratio was compared statistically (the results were given as p value).
5. Changes in Serum Lymphocyte Counts [ Time Frame: From 6th to the end of 10th day ]
   In both groups, after the treatment period was completed (first 5 days, primary endpoint), patients were followed up for 5 more days (follow-up period). Serum lymphocyte counts (cell/mm^3) at the end of 6th (FD1), 8th (FD3) and 10th day (FD5) were also recorded. The end of the 10th day was accepted as the secondary endpoint. While the change in serum lymphocyte counts on the 6th, 8th and 10th days was calculated graphically, the change in the serum lymphocyte count at the end of the 10th day (secondary endpoint) with the baseline value was compared statistically (the results were given as p value).
6. Changes in the Ratio of Polymorphonuclear Leukocyte Count to Lymphocyte Count (PNL/L) [ Time Frame: From 6th to the end of 10th day ]
   In both groups, after the treatment period was completed (first 5 days, primary endpoint), patients were followed up for 5 more days (follow-up period). PNL/L ratios at the end of 6th (FD1), 8th (FD3) and 10th day (FD5) were also recorded. The end of the 10th day was accepted as the secondary endpoint. While the change in PNL/L ratios on the 6th, 8th and 10th days was calculated graphically, the change in the PNL/L ratio at the end of the 10th day (secondary endpoint) with the baseline value was compared statistically (the results were given as p value).
7. Changes in Serum Ferritin Levels [ Time Frame: From 6th to the end of 10th day ]
   In both groups, after the treatment period was completed (first 5 days, primary endpoint), patients were followed up for 5 more days (follow-up period). Serum ferritin levels (mg/dL) at the end of 6th (FD1), 8th (FD3) and 10th day (FD5) were also recorded. The end of the 10th day was accepted as the secondary endpoint. While the change in serum ferritin levels on the 6th, 8th and 10th days was calculated graphically, the change in the serum ferritin level at the end of the 10th day (secondary endpoint) with the baseline value was compared statistically (the results were given as p value).
8. Changes in Serum D-dimer Levels [ Time Frame: From 6th to the end of 10th day ]
   In both groups, after the treatment period was completed (first 5 days, primary endpoint), patients were followed up for 5 more days (follow-up period). Serum D-dimer levels (mg/L) at the end of 6th (FD1), 8th (FD3) and 10th day (FD5) were also recorded. The end of the 10th day was accepted as the secondary endpoint. While the change in Serum D-dimer levels on the 6th, 8th and 10th days was calculated graphically, the change in the serum D-dimer level at the end of the 10th day (secondary endpoint) with the baseline value was compared statistically (the results were given as p value).
9. Rate of COVID-19 Polymerase Chain Reaction (PCR) Test Negativity [ Time Frame: At the end of 10th day ]
   At the end of the follow-up period (10th day), patients in the study and control group were investigated by PCR test for SARS-CoV-2 and the negative results were recorded as percentage for both groups.
10. Treatment-Related Adverse Events as Assessed by CTCAE v4.0 [ Time Frame: From the 6th day of study to the 10th day of study ]

    Adverse effects of ivermectin and drugs other than ivermectin (Hydroxychloroquine, favipiravir, azithromycin) were evaluated in the patients in the study group and and the number of participants were noted.

    Adverse effects of drugs other than ivermectin (Hydroxychloroquine, favipiravir, azithromycin) were evaluated in the patients in the control group and and the number of participants were noted.

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: Yes

Criteria

Inclusion Criteria:

• Patients who were hospitalised with a pre-diagnosis of "severe COVID-19 pneumonia" and thereafter diagnosis of COVID-19 was also confirmed microbiologically with PCR positivity in respiratory tract samples were included into the study. They were randomized to the study and control group, respectively.

Patients with at least one of the criteria below were accepted as patients with severe COVID-19 pneumonia;

1. Presence of tachypnea ≥ 30/minute, SpO2 level < 90% in room air, PaO2/FiO2 <300 in oxygen receiving patient
2. Presence of specific radiological finding for COVID-19 in lung tomography (bilateral lobular, peripherally located, diffuse patchy ground glass opacities)
3. Mechanical ventilation requirement
4. Acute organ dysfunction findings; patients with SOFA (sepsis-related organ failure assessment) score >2

Exclusion Criteria:

• Patients with the following characteristics were excluded from the study.

  1. Pediatric patients; <18 years of old
  2. Patients with chronic liver or kidney disease
  3. Pregnant women
  4. Patients with known ivermectin allergy

Contacts and Locations

Locations

Turkey

Afyonkarahisar Health Science University

Afyonkarahisar, Turkey

Gulhane Faculty of Medicine, University of Health Sciences

Ankara, Turkey

Yıldırım Beyazıt University, Ankara City Hospital

Ankara, Turkey

Haydarpasa Sultan Abdulhamid Han Training and Research Hospital

İstanbul, Turkey

Sponsors and Collaborators

Afyonkarahisar Health Sciences University

NeuTec Pharma

Investigators

• Study Chair: Nurullah Okumuş, Prof. Dr.; Afyonkarahisar Health Science University, Afyonkarahisar, Turkey
• Study Director: Neşe Demirtürk, A. Prof. Dr.; Afyonkarahisar Health Science University, Afyonkarahisar, Turkey
• Study Director: Rıza A. Çetinkaya, Prof. Dr.; Haydarpasa Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
• Study Director: Rahmet Güner, Prof. Dr.; Yıldırım Beyazıt University, Ankara City Hospital, Ankara, Turkey
• Study Director: İsmail Y. Avcı; Gulhane Faculty of Medicine, University of Health Sciences, Ankara, Turkey

  Study Documents (Full-Text)

Documents provided by Nurullah Okumuş, Afyonkarahisar Health Sciences University:

Study Protocol  [PDF] April 5, 2020

Informed Consent Form  [PDF] April 5, 2020

Statistical Analysis Plan  [PDF] April 5, 2020

More Information

Additional Information:

World Health Organization (WHO) Coronavirus Disease (COVID-19) Dashboard 

Publications:

Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS; China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Apr 30;382(18):1708-1720. doi: 10.1056/NEJMoa2002032. Epub 2020 Feb 28.

Jean SS, Lee PI, Hsueh PR. Treatment options for COVID-19: The reality and challenges. J Microbiol Immunol Infect. 2020 Jun;53(3):436-443. doi: 10.1016/j.jmii.2020.03.034. Epub 2020 Apr 4.

Croci R, Bottaro E, Chan KW, Watanabe S, Pezzullo M, Mastrangelo E, Nastruzzi C. Liposomal Systems as Nanocarriers for the Antiviral Agent Ivermectin. Int J Biomater. 2016;2016:8043983. doi: 10.1155/2016/8043983. Epub 2016 May 8.

Heidary F, Gharebaghi R. Ivermectin: a systematic review from antiviral effects to COVID-19 complementary regimen. J Antibiot (Tokyo). 2020 Sep;73(9):593-602. doi: 10.1038/s41429-020-0336-z. Epub 2020 Jun 12.

Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro. Antiviral Res. 2020 Jun;178:104787. doi: 10.1016/j.antiviral.2020.104787. Epub 2020 Apr 3.

• Responsible Party: Nurullah Okumuş, Prof. Dr., Afyonkarahisar Health Sciences University
• ClinicalTrials.gov Identifier: NCT04646109
• Other Study ID Numbers: IVMC_03
• First Posted: November 27, 2020
• Results First Posted: January 27, 2021
• Last Update Posted: January 27, 2021
• Last Verified: January 2021

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No
• Product Manufactured in and Exported from the U.S.: No

Keywords provided by Nurullah Okumuş, Afyonkarahisar Health Sciences University:

Ivermectin; SARS-CoV-2; Treatment

Additional relevant MeSH terms:

COVID-19; Pneumonia, Viral; Pneumonia; Respiratory Tract Infections; Infections; Virus Diseases; Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Lung Diseases; Respiratory Tract Diseases; Azithromycin; Hydroxychloroquine; Ivermectin; Favipiravir; Anti-Bacterial Agents; Anti-Infective Agents; Antimalarials; Antiprotozoal Agents; Antiparasitic Agents; Enzyme Inhibitors; Molecular Mechanisms of Pharmacological Action; Antirheumatic Agents; Antiviral Agents