An open letter, signed by >100 physicians, concluding this
study is fatally flawed can be found at [jamaletter.com]
This is a phone survey based RCT with low risk patients, 200
ivermectin and 198 control, showing lower mortality, lower disease
progression, lower treatment escalation, and faster resolution of symptoms
with treatment, without reaching statistical significance. Authors find the
results of this trial alone do not support the use of ivermectin. However the
effects are all positive, especially for serious outcomes which are unable to
reach statistical significance with the very small number of events in the
low risk population.
With the low risk patient population, there is little room for
improvement with an effective treatment - 59/57% (IVM/control) recovered
within the first 2 days to either "no symptoms" or "not hospitalized and no
limitation of activities"; 73/69% within 5 days. Less than 3% of all patients
The primary outcome was changed mid-trial, it was originally
clinical deterioration, which is more meaningful, and shows greater benefit.
The new outcome of resolution of symptoms includes "not hospitalized and no
limitation of activities" as a negative outcome and is not very meaningful in
terms of assessing how much treatment reduces serious outcomes. Using this
measure could completely invalidate results - for example a treatment that
eliminates all COVID-19 symptoms but has a temporary minor adverse event
could be seen as worse.
Authors state that "preliminary reports of other randomized
trials of ivermectin as treatment for COVID-19 with positive results have not
yet been published in peer-reviewed journals", however there were 8
peer-reviewed RCTs with positive effects published prior to this paper(and 19
total peer-reviewed studies with positive effects).
Authors advised taking ivermectin on an empty stomach, reducing
lung tissue concentration by ~2.5x [Guzzo]
76 patients were excluded due to control patients receiving
ivermectin. However, there was a similar percentage of adverse events like
diarrhea, nausea, and abdominal pain in both treatment and control groups.
These are potential non-serious side effects of treatment and suggest that it
is possible that many more control patients received some kind of
Ivermectin was widely used in the population and available OTC
at the time of the study. The study protocol only excluded patients with
previous ivermectin use within 5 days, however other trials often monitor
effects 10+ days after the last dose [osf.io]
This study reportedly has an ethical issue whereby participants
were told the study drug was "D11AX22"
The editor-in-chief of JAMA initially offered to help with this issue, but
later indicated that "JAMA does not review consent forms", however the lead
author reportedly confirmed the issue [francesoir.fr, trialsitenews.com, trialsitenews.com (B)]
The study protocol specifically allows "the use of other
treatments outside of clinical trials". The paper provides no information on
what other treatments were used, but other treatments were commonly used at
the time. Additionally, the control group did about 5x better than
anticipated for deterioration, also suggesting that the control patients used
some kind of treatment. Patients that enroll in such a study may be more
likely to learn about and use other treatments, especially since they do not
know if they are receiving the study medication.
The study protocol was amended 4 times. Amendments 2-4 are
provided but amendment 1 is missing. Amendment 2 increased the inclusion
criteria to within 7 days of onset, including more later stage patients and
reducing the expected effectiveness. The trial protocol lists “the duration
of supplemental oxygen” as an outcome but the results for this outcome are
Grants and/or personal fees, including in some cases during the
conduct of the study, were provided by Sanofi Pasteur, GlaxoSmithKline,
Janssen, Merck, and Gilead. For more details see [trialsitenews.com (C)]
For other confounding issues see [osf.io (B)]
issues can be found in the comments of the article [jamanetwork.com]
Most data was collected via surveys, without physical
examination. 87% medication adherence. NCT04405843
López-Medina et al., 3/4/2021, Double Blind Randomized Controlled Trial, Colombia, South America, peer-reviewed, median age 37.0, 19 authors, dosage 300μg/kg days 1-5.
risk of death, 66.8% lower, RR 0.33, p = 0.50, treatment 0 of 200 (0.0%), control 1 of 198 (0.5%), continuity correction due to zero event (with reciprocal of the contrasting arm).
risk of escalation of care, 60.8% lower, RR 0.39, p = 0.10, treatment 4 of 200 (2.0%), control 10 of 198 (5.1%), odds ratio converted to relative risk.
risk of escalation of care with post-hoc <12h exclusion, 34.3% lower, RR 0.66, p = 0.51, treatment 4 of 200 (2.0%), control 6 of 198 (3.0%), odds ratio converted to relative risk.
risk of deterioration by >= 2 points on an 8-point scale, 43.1% lower, RR 0.57, p = 0.35, treatment 4 of 200 (2.0%), control 7 of 198 (3.5%), odds ratio converted to relative risk.
risk of fever post randomization, 24.8% lower, RR 0.75, p = 0.33, treatment 16 of 200 (8.0%), control 21 of 198 (10.6%), odds ratio converted to relative risk.
risk of unresolved symptoms at day 21, 15.3% lower, RR 0.85, p = 0.53, treatment 36 of 200 (18.0%), control 42 of 198 (21.2%), odds ratio converted to relative risk, Cox proportional-hazard model.
hazard ratio for lack of resolution of symptoms, 6.5% lower, RR 0.93, p = 0.53, treatment 200, control 198.
relative median time to resolution of symptoms, 16.7% lower, relative time 0.83, treatment 200, control 198.
This study is excluded in meta analysis: strong evidence of patients in the control group self-medicating, ivermectin widely used in the population at that time, and the study drug identity was concealed by using the name D11AX22.
Effect extraction follows pre-specified rules
prioritizing more serious outcomes. For an individual study the most serious
outcome may have a smaller number of events and lower statistical signficance,
however this provides the strongest evidence for the most serious outcomes
when combining the results of many trials.