Favipiravir vs Hydroxychloroquine vs Control in COVID -19

October 25, 2021 updated by: Royal College of Surgeons in Ireland - Medical University of Bahrain

Treatment of Covid-19 With Favipiravir Versus Hydroxychloroquine: a Randomized Comparator Trial

Hydroxychloroquine is widely used to treat autoimmune diseases. Clinical investigation has found that a high concentration of cytokines were detected in the plasma of critically ill patients infected with SARS-CoV-2, therefore, hydroxychloroquine as anti-inflammatory agents may reduce this response in accord with their use in autoimmune disease where the cytokine response can be reduced.

Favipiravir is an antiviral drug developed in Japan that the data sheet notes that it is a pyrazinecarboxamide derivative with activity against influenza viruses, west nile virus, yellow fever virus, foot and mouth disease virus as well as against flaviviruses, arenaviruses, bunyaviruses and alphaviruses. In February the drug was used for COVID-19 disease in China and was declared effective in treatment, and a report published (in press) comparing Favipiravir with Lopinavir /ritonavir suggested that Favipiravir was superior for prevention of disease progression and viral clearance.

The objective of this pilot study is to compare three arms: hydroxychloroquine; favipiravir; standard care (no specific SARS-CoV-2 treatment) only, in symptomatic patients infected by SARS-CoV-2 in an open label randomized clinical trial. The difference between groups will allow an effect size to be determined for a definitive clinical trial.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/2019-nCoV) and has developed into a pandemic with serious global public health and economic sequelae. As of June 30, 2020 over 10,000,000 cases have been confirmed worldwide leading to over 500,000 deaths (https://coronavirus.jhu.edu/map.html). Currently no vaccine exists, however chloroquine and hydroxychloroquine have been documented as potentially having antiviral properties with efficacy against COVID-19 disease. Chloroquine is used in the treatment of malaria and amebiasis and is still used in the prophylaxis of malaria. Hydroxychloroquine sulfate is a derivative of Chloroquine that has been demonstrated to be much less (~40%) toxic than Chloroquine in animals. Hydroxychloroquine is widely used to treat autoimmune diseases, due to its immunomodulatory properties, such as systemic lupus erythematosus and rheumatoid arthritis, with an excellent safety profile. In vitro studies have suggested that their mode of action in COVID-19 disease is blockade of SARS-CoV-2 transport from endosomes to endolysosomes, which appears to be a requirement to release the viral genome. Clinical investigation has found that high concentrations of cytokines are detectable in the plasma of critically ill patients infected with SARS-CoV-2, suggesting that cytokine storm is associated with disease severity; therefore, Chloroquine/ hydroxychloroquine may reduce this response by acting as anti-inflammatory agents in accord with their use in autoimmune disease, where their reduction in cytokine response has been extensively researched and demonstrated.

Favipiravir is an antiviral drug developed in Japan (as noted in the data sheets) that it is a pyrazinecarboxamide derivative with activity against influenza viruses, west nile virus, yellow fever virus, foot and mouth disease virus as well as against flaviviruses (i.e. arenaviruses, bunyaviruses and alphaviruses). Its mode of action is through inhibition of viral RNA-dependent RNA polymerase. In February the drug was used for COVID-19 disease in China and was declared effective in treatment, and a report published (in press) comparing Favipiravir with Lopinavir /ritonavir suggested that Favipiravir was superior for prevention of disease progression and viral clearance.

"The Solidarity Trial" is a global pragmatic clinical trial being undertaken by WHO that aims to explore the efficacy of different treatment modalities for SARS-CoV-2. An application for Bahrain to join the study for collaboration has been made. In "The Solidarity Study" there will be four treatment modalities investigated, including chloroquine phosphate alone, remdesivir, lopinarvir with ritonavir or lopinarvir with ritonavir plus interferon. Favipiravir is not included, and therefore this study will not be replicating features of "The Solidarity Trial" but instead will provide additional and novel findings on favipiravir efficacy.

Study Type

Interventional

Enrollment (Actual)

150

Phase

  • Phase 2

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Bahrain
      • Manama, Bahrain
        • Royal College of Surgeons in Ireland - Bahrain

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

17 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Admitted COVID-19 patients being treated as an in-patient at a hospital facility.
  • COVID-19 diagnosis confirmed by PCR nasopharyngeal swab.
  • Study participants must be symptomatic with any COVID-19 symptoms defined by the Bahrain National Protocol
  • Onset of symptoms must be within 10 days prior to enrolment.
  • Study participants must have the ability to give informed consent.
  • Participants must be at minimum 21 years of age.
  • Mild to Moderate COVID-19 disease defined as saturation equals to or more than 93% on room air or PaO2:FiO2 ratio more than 300 on enrolment.

Exclusion Criteria:

  • Severe COVID-19 disease: defined as presence of SpO₂ less than 93% on room air or a PaO₂ to FiO₂ ratio of 300 or lower.
  • Patients on ventilatory support.

  • Cardiac dysfunction that would preclude treatment with hydroxychloroquine:

    1. Patients on medication known to prolong QT segment.
    2. Known history of LQT syndrome.
    3. Acquired QT prolongation at baseline >500ms.
    4. AV block.
    5. Bundle Branch Block.
    6. Known history of Cardiomyopathy, Pulmonary Hypertension, or Sick Sinus Syndrome.
    7. History of ventricular tachyarrhythmia.
    8. Patients with implantable cardioverter-defibrillator (ICD).
    9. Patients with a baseline bradycardia of less than 50 beats per minute.
  • Renal dysfunction (estimated glomerular filtration rate less than 30ml/min).

  • Hepatic dysfunction defined as:

    1. Transaminitis more than three times the upper limit of normal or
    2. Chronic liver disease of Child Pugh Class B or higher.
  • Gout or a history of gout
  • Patients that are pregnant or breastfeeding.
  • Patients with a known allergy to an intervention medication.
  • Patients who receive any of the study medications prior to randomization
  • Patient with G6PD
  • Readmission due to COVID19 disease.
  • Participants in any other COVID-19 disease trial.
  • Patients on immunosuppressants, HIV patients, cancer patients who received chemotherapy within the past 6 months, or who are on chronic oral steroids.
  • Patients unable to give informed consent.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Hydroxychloroquine
Hydroxychloroquine is widely used to treat autoimmune diseases, due to its immunomodulatory properties, such as systemic lupus erythematosus and rheumatoid arthritis, with an excellent safety profile. In vitro studies have suggested that their mode of action in COVID-19 disease is blockade of SARS-CoV-2 transport from endosomes to endolysosomes, which appears to be a requirement to release the viral genome.
Drug: Hydroxychloroquine

400mg BID PO day 1 then 200mg BID PO from day 2 to day 10.

In addition to Hydroxychloroquine all patients will receive the standard care (according to local Bahrain COVID19 guidelines). Any patient who is fit for discharge, can be discharged and medications will be stopped on discharge.

Other Names:
  • Plaquenil
  • Hydroxychloroquine sulfate
Other: Routine care for COVID-19 patients
Supportive care according to local guidelines
Other Names:
  • Standard clinical care
Experimental: Favipiravir
Favipiravir is an antiviral drug that it is a pyrazinecarboxamide derivative with activity against influenza viruses, west nile virus, yellow fever virus, foot and mouth disease virus as well as against flaviviruses (i.e. arenaviruses, bunyaviruses and alphaviruses).
Other: Routine care for COVID-19 patients
Supportive care according to local guidelines
Other Names:
  • Standard clinical care
Drug: Favipiravir

1600mg BID PO day 1600mg BID PO day 2 to day 10.

In addition to Favipiravir all patients will receive the standard care (according to local Bahrain COVID19 guidelines). Any patient who is fit for discharge, can be discharged and medications will be stopped on discharge.

Other Names:
  • T-705
  • Avigan
  • favipira
  • favilavir
Active Comparator: Standard clinical care
Supportive care according to local guidelines
Other: Routine care for COVID-19 patients
Supportive care according to local guidelines
Other Names:
  • Standard clinical care

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Primary outcome is the Medial clinical scale at end of study follow up
Time Frame: Until discharge, death or for a maximum of 30 days or readmission
Median clinical scale at end of study follow up (day 14 or on discharge/death, whichever is earlier)
Until discharge, death or for a maximum of 30 days or readmission

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Requirement of Escalation of Respiratory Support
Time Frame: Until discharge, death or for a maximum of 14 days or readmission
Implementation of escalation of Respiratory Support
Until discharge, death or for a maximum of 14 days or readmission
Adverse effects(cardiac, renal, hepatic, hypoglycaemia (defined as RBS <3.9 mmol/L))
Time Frame: Until discharge,death or for a maximum of 14 days or readmission
Monitor and document all adverse effects during therapy
Until discharge,death or for a maximum of 14 days or readmission
Requirement of ICU Admission
Time Frame: Until discharge, death or for a maximum of 14 days or readmission
Deterioration of clinical condition requiring ICU admission
Until discharge, death or for a maximum of 14 days or readmission
Mortality rate
Time Frame: Mortality will be collected up to 30 days
30 days Mortality rate due to COVID-19
Mortality will be collected up to 30 days
Readmission rate
Time Frame: Readmission will be collected up to 30 days from start of the study
30 days readmission rate will be captured
Readmission will be collected up to 30 days from start of the study
Daily National Early Warning (NEWS) 2 Score
Time Frame: Until discharge, death or for a maximum of 14 days
Daily NEWS 2 will be calculated which is a tool that improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes
Until discharge, death or for a maximum of 14 days
Daily Sequential Organ Failure Assessment (SOFA) score
Time Frame: Until discharge, death or for a maximum of 14 days
Daily SOFA score will be calculated which can identify the critical point at which patients exhibit the highest degree of organ dysfunction
Until discharge, death or for a maximum of 14 days
Change in Laboratory indices
Time Frame: Until discharge, death or for a maximum of 14 days
Determination of the change in D-dimer, ratio of Lymphocyte to Neutrophil, lactate before and after treatments as a measure of disease activity
Until discharge, death or for a maximum of 14 days
Discharge and Length of Hospital Stay
Time Frame: Until discharge, death or for a maximum of 14 days
Patients will be followed during their hospital stay until discharge
Until discharge, death or for a maximum of 14 days
QT prolongation
Time Frame: Until discharge, death or for a maximum of 14 days or readmission
Determination of the change in QT prolongation, before and after treatments as a measure of disease activity
Until discharge, death or for a maximum of 14 days or readmission
Cardiac arrythmia (fatal and non fatal)
Time Frame: Until discharge, death or for a maximum of 14 days or readmission
Detection of Cardiac arrythmia (fatal and non fatal), before and after treatments as a measure of disease activity
Until discharge, death or for a maximum of 14 days or readmission
Viral clearance
Time Frame: until discharge, death or for a maximum of 30 days
Viral clearance defined as a single negative SARS-CoV2 PCR nasopharyngeal swab
until discharge, death or for a maximum of 30 days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Royal College of Surgeons in Ireland - Medical University of Bahrain

Collaborators

Ebrahim Khalil Kanoo Community Medical Center
Hereditary blood Disorder Centre - Salmaniya Medical Complex
Mohammed Bin Khalifa Bin Sulman Al Khalifa Cardiac Centre, Awali
Jidhafs COVID-19 Centre
Sitra FICU
Salmaniya Medical Complex- 6th Floor
Salmaniya Medical Complex- Helipad

Investigators

  • Principal Investigator: Manaf Al Qahtani, Dr., Royal College of Surgeons in Ireland - Bahrain

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

August 11, 2020

Primary Completion (Actual)

March 6, 2021

Study Completion (Actual)

April 7, 2021

Study Registration Dates

First Submitted

May 9, 2020

First Submitted That Met QC Criteria

May 13, 2020

First Posted (Actual)

May 14, 2020

Study Record Updates

Last Update Posted (Actual)

October 26, 2021

Last Update Submitted That Met QC Criteria

October 25, 2021

Last Verified

August 1, 2021

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 40 / 07-May-2020

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

Yes

IPD Plan Description

Monitoring, audits, and REC review will be permitted and provide direct access to source data and documents. The Lead PI and the researchers assigned by him will have access to the stored data/specimens. Only the Lead PI and the researchers assigned working on this study will be eligible to obtain the data/specimens from the participants during data collection.

IPD Sharing Time Frame

Dr Manaf will act as the data custodian and is responsible for the storage, handling and quality of the study data.

Data will be collected in the case report form to allow for cross referencing to check validity.

Study documents (paper and electronic) will be retained in a secure (kept locked when not in use) location during and after the trial has finished. All essential documents including source documents will be retained for a period of 5 years after study completion (last patient, last study point). A label stating the date after which the documents can be destroyed will be placed on the inside front cover of the case notes of trial participants.

IPD Sharing Access Criteria

Study documents (paper and electronic) will be retained in a secure (kept locked when not in use) location during and after the trial has finished.

IPD Sharing Supporting Information Type

  • Study Protocol
  • Statistical Analysis Plan (SAP)
  • Clinical Study Report (CSR)
  • Analytic Code

Drug and device information, study documents

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

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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