Publication Skipper CP, Ann Intern Med, 2020
Dates: 2020-03-22 to 2020-06-05
Funding: Private ()
Multicenter / USA, Canada |
Follow-up duration (days): 14
|Inclusion criteria||Registry and Protocol Inclusion Criteria:
● Provision of informed consent
● Exposure to a COVID19 case within 4 days as either a household contact or occupational exposure, OR Symptomatic COVID19 case with confirmed diagnosis within 4 days of symptom onset OR symptomatic high risk exposure with known COVID19 contact and within 4 days of symptom onset
Report Inclusion Criteria:
We enrolled nonhospitalized adults who were required to have 4 or fewer days of symptoms and either PCR-confirmed SARS-CoV-2 infection or compatible symptoms after a high-risk exposure to a person with PCR-confirmed COVID-19 within the past 14 days.
High-risk exposure was defined as an immediate household contact or a close occupational exposure to someone with COVID-19 (for example, health care worker or first responder).
Health care workers who had COVID-19–compatible symptoms and high-risk exposure but whose contact had PCR results pending were enrolled after symptom review by an infectious diseases physician.
All of these participants met the COVID-19 case definition of the U.S. Council of State and Territorial Epidemiologists (Supplement) (10).
Participants in a third group had a high-risk exposure and were asymptomatic at the time of consent for a companion postexposure prophylaxis trial, which had the same inclusion and exclusion criteria (11); however, these participants became symptomatic before starting their study medicine on day 1 and were analyzed as part of this trial.
|Exclusion criteria||Supplemental Methods 2: Additional Exclusion Criteria
The full list of exclusion criteria, included:
● Symptoms >4 days (per inclusion criteria)
● Age <18 years old
● Current hospitalization
● Hydroxychloroquine allergy
● Retinal eye disease
● Known glucose-6 phosphate dehydrogenase deficiency
● Known chronic kidney disease (stage 4 or 5 or receiving dialysis)
● Known porphyria
● Weight less than 40 kg
● Receiving chemotherapy
● Current use of hydroxychloroquine, chloroquine
● Current use of cardiac arrhythmia medicines of: flecainide; amiodarone; digoxin; procainamide; or sotalol.
● In Canada, additional exclusions mandated by regulatory authorities were: pregnancy, breastfeeding; severe diarrhea or vomiting; known cirrhosis with encephalopathy or ascites; known prolonged cardiac QT interval, ventricular arrhythmia, or history of sudden cardiac death; or QT-prolonging medicines (as below) (3)
● On April 20, 2020, additional U.S. exclusions were added for weight less than 50kg, structural or ischemic heart disease, personal or family history of cardiac QT prolongation, and QT-prolonging medications (as below).
Concomitant QT prolonging medications included current use of:
● QT prolonging medicines of:
○ Antimicrobials: azithromycin clarithromycin, erythromycin, ciprofloxacin, levofloxacin, moxifloxacin, ketoconazole, itraconazole, or mefloquine
○ Antidepressants: amitriptyline, citalopram, desipramine, escitalopram, imipramine, doxepin, fluoxetine, wellbutrin, or venlafaxine
○ Antipsychotic or mood stabilizers: haloperidol, droperidol, lithium, quetiapine, thioridazine, ziprasidone
○ Sumatriptan, zolmitriptan
The prohibition of azithromycin and other QT prolonging medicines was at the express direction of the U.S. FDA as potentially unsafe in an outpatient clinical trial.
Hydroxychloroquine (800 mg once, then 600 mg )
Duration : 5 days
Placebo ([folic acid 400mcg / lactose])
Duration : 5 days
738 participants (n1=247 / n2= 491)
|Characteristics of participants|
Mean age : NR
Severity : Mild: n=423 / Moderate: n=0/ Severe: n=0 Critical: n=0
|In the register|
|In the report|
The initial primary outcome was an ordinal outcome by day 14 of not hospitalized, hospitalized, or intensive care unit stay or death.
Yes. In English
|Risk of bias
The overall risk of bias reported in the table corresponds to the highest risk of bias for the outcomes assessed for the systematic review
|General comment||"In addition to the published report and supplementary file, the study registry, protocol and SAP were used in data extraction and risk of bias assessment. 100 participants that were randomized in a prevention trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2016638?query=TOC) but became symptomatic by D1 were included in this trial. There is no change from the trial registration in the intervention and control treatments. All outcomes specified in the protocol/registry are reported in the paper. The primary outcome was modified while still blinded due to the pooled event rate of the initial primary outcome (ordinal outcome by day 14 of not hospitalized, hospitalized, or intensive care unit stay or death) being substantially lower than the initial 10% expectation (original sample size calculations as described in Statistical Analysis section). The target sample size was thus modified and reduced following the change in outcome and the decision to stop recruitment was made by the DSMB."|