{'fraction_non_alphanumeric': 0.04061752307166458, 'fraction_numerical': 0.027230260909194486, 'mean_word_length': 4.8948959032907995, 'pattern_counts': {'":': 0, '<': 1, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 1, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A Comparative Study on Ivermectin-Doxycycline and Hydroxychloroquine-Azithromycin Therapy on COVID-19 Patients

DOI: 10.14744/ejmo.2021.16263 EJMO 2021;5(1):63–70

treatment's current considerations include lopinavir/ritonavir, favipiravir, and remdesivir. These are currently in use in moderate to severe COVID-19 patients. Treatments for patients in the early stage of the disease with mild to moderate symptoms have not been well established. Studies have shown that Chloroquine and Hydroxychloroquine (HCQ) are not beneficial in moderate to severe COVID19 disease. However, they have become the current standard for mild to moderate and early disease states. Chloroquine has been shown as a potential suppressor of SARS-CoV-2 in an in vitro study. [1] Though many trials have established a good outcome in mild to moderate cases, unfortunately, chloroquine toxicity is a paramount concern. [2] HCQ, a less toxic derivative, has also been found to be effective. [3] Recently, an anti-parasitic drug Ivermectin has been described as highly effective in an in vitro study against SARS-CoV-2. [4] HCQ-Azithromycin combination therapy has also been shown to be a possibly effective combination therapy in the treatment of SARS-CoV-2. [5,6] These two studies reported 100% and 83% recovery in the sixth and seventh day with a reduced hospital stay. Alam MT et al. [31] recently described an encouraging result in a case series of COVID19 patients with a combination of Ivermectin and Doxycycline. Till now, there has not been a randomized study of Ivermectin in patients with mild to moderate COVID19. Ivermectin is well-tolerated, less toxic, and has fewer adverse effects than HCQ. HCQ-Azithromycin combination therapy has also been mentioned in the "National guideline for COVID management 4.0" of Bangladesh as an initial therapy against COVID19. Due to drug complications and discouraging statements about HCQ treatment made by WHO, it is crucial to find an effective, economical alternative to HCQ. Therefore, we decided to investigate the efficacy of Ivermectin-Doxycycline combination therapy and compare it to the standard HCQ-Azithromycin treatment according to the "National guideline for COVID management 4.0" among the mild to moderate cases of COVID19 patients.

Ethical Consideration and Approval, Informed Consent
This study was approved by the Ethical committee of Chakoria Upazilla Health Complex, Chittagong, Bangladesh. UHC/Chakoria/Ethical Approval/2020/01 (15-04-20). The purpose of the research was explained to participants. Once verbal consent was understood and agreed upon, a written form was given. This was done to get informed consent and legal identification. The individuals who gave consent were enrolled in this study.

Study Population and Data Collection
Patients (16 years to 80 years of age) tested positive for SARS-CoV-2 infection by Real-time polymerase chain reaction (RT-PCR) at Chakoria Upazilla Health Complex, Cox's Bazar, Bangladesh, from second may to the fifth June 2020, were initially included in this study, including those with and without the symptoms. The PCR analysis of the collected samples was performed in Cox's Bazar Medical College. All patients received a full evaluation, including a history of current illness, comorbid condition, and associated complaints. Patients with unstable comorbid conditions like bronchial asthma, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD), uncontrolled diabetes mellitus (DM), advanced renal and hepatic disease, carcinoma, hospitalized, and immuno-compromised patients were excluded. Patients were examined for oxygen saturation and only those with oxygen saturation of 95% or above who fit the outpatient treatment protocol for COVID19 were included. Patients with respiratory symptoms received chest radiographs. Those with normal or near-normal chest radiographs (up to 10% involvement) were included.

Randomization and Treatment Intervention
Randomization was done using an odd-even methodology and applied to registration numbers, consecutively in a 1:1 ratio, by the hospital registration office. Treatment was given, and the final enrolment was done by the attending physician (investigator). All the patients enrolled in this study were treated as outpatient department (OPD) patients.
For the study, patients were divided into two groups, as follows: • Group A (n=60): Ivermectin 200µgm/kg single dose + Doxycycline 100mg BID for ten days.
• Group B (n=56): Hydroxychloroquine 400mg for the first day, then 200mg BID for nine days + Azithromycin 500mg daily for five days (considered as the control group).
Ivermectin dosing was determined by the case series performed by Alam MT et al., and HCQ dosing was decided as per "National guideline for COVID management 4.0".
All the subjects were provided with symptomatic treatment such as fever, headache, cough, and myalgia. Drug interactions and contraindications for each individual were considered carefully. The schedule of medication intake was adequately explained to each patient. Group A's instructions included that Ivermectin tablet (200µg/ kg) single dose to be taken on an empty stomach an hour before a meal on the first day. Doxycycline 100 mg cap-sule be taken twice daily after meal for ten days starting from day one. Group B's instructions included Hydroxychloroquine 400mg (two tablets of 200mg each) to be taken on the first day, then 200mg (one tablet) twice daily after meal for nine days. Azithromycin 500mg (one tablet of 500mg) to be taken once daily after meal for five days starting from day one. Patients were advised to self-isolate, take proper nutrition, hydration, and maintain a sanitary environment.

Repeat Nasopharyngeal and Throat Swab PCR
All subjects underwent repeat nasopharyngeal and throat swab PCR for SARS-CoV2 every other day until their PCR was negative. These repeat PCR tests began on the fifth day after taking the medication for subjects who began the study and remained symptom-free. The PCR repeat testing began on the second symptom-free day onward for subjects who began the study with symptoms or developed symptoms. The investigators had telephone contact with all the subjects every three days throughout the study to determine any therapy's adverse effects. A re-evaluation PCR was performed after seven days following the first negative PCR.
Endpoints were a negative PCR and resolution of symptoms. The duration from the first day of drug intake to the negative PCR was counted as the recovery period. The duration from the first day of drug intake to the disappearance of symptoms was counted as the period to symptomatic recovery. "Adverse effects" were determined by the existence of the pharmacological side effects of the particular drug during treatment. A detailed history of adverse effects (other than previous disease symptoms) experienced by each participant was collected during the follow-up sample collection. An asymptomatic participant presented with no symptom of COVID-19 and remained the same until the negative PCR.

Data Analysis and Statistics
Data were presented as mean±standard deviation, and statistical analysis was done by Graph pad Prism software. Column analysis was done to find the mean with the standard deviation in each group. T-test was done to see the significance between the values where needed. P<0.05 was considered statistically significant.

Results
This study was completed in a pre-determined period from May second to June fifth, 2020, and 181 patients tested positive for SARS-CoV-2 infection in that period. 42 patients had comorbid conditions (some required hospitalization) that might have affected the recovery time, and 14 patients were unwilling to participate in the study. Nonetheless, 9 patients did not show-up (3 from group A and 6 from group B) for the follow-up sample collection, so these were excluded, and 116 patients were finally included in the analysis (Fig. 3).

Demographic Characteristics of the Study Subjects
As shown in Table 1

Recovery Rate and Mean Recovery Duration Between Groups
In group A, recovery to negative PCR rate was 100% (60/60). The mean recovery duration to negative PCR was 8.93 days (8 to 13 days). 41 (63.3%) of patients had no new complaints other than their presenting symptoms. New symptoms that may have been attributed to adverse drug effects included 14 (25) lethargy in 14 (23.3%), nausea in 11 (18.3%), and occasional vertigo in 7 (11.66%) of patients (Fig. 1c).
In group B, out of 56 patients, two male patients were re-ferred to a tertiary hospital. They did not recover to a negative PCR as part of the study. Therefore, the recovery rate to negative PCR was 96.36% (54/56). The mean duration of recovery to negative PCR was 9.33 days (5 to 15 days). 30 (53.57%) of the patients had no new complaints other than their presenting symptoms. Fresh symptoms that were recognized as an adverse effect of HCQ included 13(23.21%) with mild blurred vision and headache; 22 (39.2%) with increased lethargy and dizziness, 10 (17.85%) with occasional, mild palpitation, and 9 (16.07%) with nausea and vomiting (Fig. 1e).

Difference in Recovery to Negative PCR between Groups
The difference between group A and group B recovery to negative PCR duration was not statistically significant in unpaired t-test, p=0.2314 (Fig. 1c) (Fig. 1f ).

Mean Duration of Time to Negative PCR between Groups
In the secondary analysis of subjects who began the study with symptoms, the mean duration of time to negative PCR was 9.061 days in group A and 9.738 days in group B. This was not statistically significant in the unpaired t-test, p=0.0714. The mean duration of time to becoming negative PCR of patients without symptoms was 8.364 days in group A and 7.917 days in group B, which was not statistically significant in unpaired t-test, p=0.443 (Fig. 2b). Further analysis showed the highest recovery was achieved on the eighth day among group A patients in case of both asymptomatic (n=11) and symptomatic (n=49) patients,  (Fig. 2 c, d). This recovery was relatively slower in group B. On the sixth day 3 (7.5%), seventh day 1 (2.5%), eighth day 9 (22.5%), ninth and tenth day 8 (20%) each, eleventh and twelfth day 4 (10%) each, thirteenth day 1 (2.5%), and fourteenth day 2 (5%) in group B patients with symptoms (n=40). Among asymptomatic patients (n=14), this was 1 (7.5%) on the fifth day, 2 (14.2%) individually on the sixth, sev-enth, eighth, tenth day, 4 (28.57%) on the ninth day, and 1 (7.1%) on the eleventh day (Fig. 2 c, d). No significant difference in the recovery duration was found in the subgroup analysis of the recovery duration according to the study groups' age. 61 to 70 years in group A had the longest recovery duration, 9.5±2.12, and 71 to 80 years was the shortest 8days. In group B, this was 11.71±2.48 days in the 41 to 50 years and 8.37±2.44 days in the 10 to 20 years age group (Fig. 2 e).

Discussion
The COVID-19 pandemic in Bangladesh is part of the coronavirus worldwide pandemic disease caused by a newly discovered coronavirus. It was initially called novel coronavirus and later named SARS-CoV-2 due to its similar characteristics with SARS-CoV-1. [7][8][9] The treatment methods for COVID-19 are emerging and rapidly evolving because of ongoing research being done worldwide by a record number of investigators. Due to each medical and research facility's uniqueness, the approach to patient care with COVID-19 varies from institution to institution in Bangladesh. Many patients with mild to moderate disease were treated with HCQ and Azithromycin. New concerns about HCQ has led us to seek alternatives with shorter recovery time and better tolerability. Thus, we have undertaken a comparative therapeutic analysis, comparing these standard drugs with Ivermectin and Doxycycline.
In this randomized treatment study of groups A and B, the presenting symptoms of the COVID19 patients were fever, cough, sore throat, weakness, chest discomfort, breath- ing difficulty, diarrhea, myalgia, and abdominal pain. To avoid the recovery duration's influence, we solely selected the cases devoid of severe comorbidities. The difference in recovery to negative PCR duration was not significant (p=0.231) among the two groups. The mean recovery duration is shorter, 8.933 days in group A than in group B, 9.33 days (Fig. 1 c). Also, group A had a better outcome ratio of 100% (60/60) recovery to negative PCR compared to that of group B 96.36% (54/56).
HCQ has decades of treatment use as an immunomodulator. [10] At present, it has been the topic of discussion concerning its potential use to treat patients with COVID-19. [11] It is thought that the effect of HCQ results in the selective killing of the infected cells. Therefore, it may accelerate viral clearance in COVID-19. [13] Some studies showed that severe deterioration in some patients with COVID-19 had been closely associated with dysregulated and excessive cytokine release termed "cytokine storm." [14,15] HCQ was found to inhibit SARS-CoV-2 infection in vitro and significantly decrease cytokine production, especially the pro-inflammatory cytokines. [16] Correspondingly, Azithromycin is a macrolide group of antibiotics. It has been studied as part of possible treatment of COVID-19 combined with HCQ and has been reported to add benefit. [17,18] However, a recent report failed to establish whether it has any antiviral activity or any synergistic activity with HCQ in the treatment of COVID-19. [19] Therefore, a further comparative study can enhance the significance of HCQ-Azithromycincombination therapy.
On the other hand, Ivermectin is a relatively safe and well-tolerated anti-parasitic drug that can inhibit nuclear transport activity. [20] Recently, in-vitro studies have shown its function against SARS-CoV-2. [21,22] A recent report suggested that Ivermectin reduces mortality rates in hospitalized patients with COVID-19. [23] However, it is unknown if antiviral levels are attainable while using known dosing regimens of Ivermectin therapy in patients with COVID-19. [24,25] Thus, it is vital to investigate Ivermectin's dose regimens for COVID-19 treatment or to determine if there is appropriate synergism using combination therapy with another drug. Also, Doxycycline is a tetracycline class of antibiotics with a long history of clinical use. [26] The efficacy and tolerability of Ivermectin and Doxycycline were established in combination with an earlier study to treat onchocerciasis. [27] Several recent studies have suggested a therapeutic role of Doxycycline against COVID-19. [28,29] In our study, the difference in recovery to become symptom-free was not statistically significant (Fig. 1c). Nevertheless, the Ivermectin group showed better symptomatic recovery than the HCQ group (Fig. 2 a-d). According to the age among study groups, the difference was not statistically significant (Fig. 2 e). Ivermectin-Doxycycline combination expressed an earlier and faster relief of COVID features (Fig. 1 g) and viral clearance than the HCQ-Azithromycin combination. However, the mean recovery duration is not statistically significant (Fig. 1c). In the Ivermectin-Doxycycline group a greater number of patients gained faster symptomatic recovery than that of the HCQ group (Fig. 1h] This suggests Ivermectin-Doxycycline may have better efficacy in reducing the COVID-19 symptoms than HCQ-Azithromycin therapy. The Ivermectin-Doxycycline group had better patient compliance and fewer adverse effects compared to the HCQ-Azithromycin group (Fig. 1 d, e). The adverse effects of HCQ in our study are similar to others. [30,31] The sex difference was also examined, but there were no significant differences between males and females in this study ( Fig. 1 f ). According to this study, the Ivermectin-Doxycycline treatment regimen was well tolerated, and effective treatment for mild to moderate degrees of SARS-CoV-2 infection. Not only concerning the time to become symptom-free and the viral clearance, but also in terms of safety, side-effect profile, and compliance the Ivermectin-Doxycycline combination is superior to HCQ-Azithromycin therapy for mild to moderate degrees of COVID-19 patients. We strongly believe that increasing the dose and the duration of Ivermectin treatment will further benefit in reducing the recovery period of COVID19 infection beyond that which was seen in our study. This will also prevent disease progression and morbidity in COVID-19 patients.
Our study has limitations, and these include relatively small sample size, the dose of Ivermectin, and case selection. The outcome may be biased by factors like disease severity, lack of cooperation of some participants, and unknown comorbidity.

Conclusion
Researchers have suggested different drug combination therapies for COVID19. According to our study, the Ivermectin-Doxycycline combination therapy has better symptomatic relief, shortened recovery duration, fewer adverse effects, and superior patient compliance compared to the Hydroxychloroquine-Azithromycin combination. Based on this study's outcomes, the Ivermectin-Doxycycline combination is a superior choice for treating patients with mild to moderate COVID-19 disease. Despite this study's limitation, we tried to select our study group patients without any major or unstable comorbid condition as far as possible to avoid differences in treatment outcomes among the groups. Further study is required on a larger scale with an increase in Ivermectin treatment duration.