Advances in Clinical and Medical Research Collation of Hydroxychloroquine Virological Clearance, Effectiveness, Safety in Covid-19 Patients with Control Group (Conventional Therapy) – a Systematic Review and Meta-Analysis

Objectives: Destitute of an effective treatment, several potential repurposed drugs have been tried in COVID-19. Despite unavailability of anecdotal evidence, several guidelines granted both Chloroquine (CQ) and Hydroxychloroquine (HCQ) in treatment. Clinical studies relating to those in COVID-19 disease has reported conflicting results. We sought to systematically evaluate the clinical effects contact, mainly in health workers [8]. On March 30, 2020 FDA issued an Emergency Use Authorization (EUA) in order to use both CQ and HCQ in the treatment of COVID-19. FDA issued EUA for the second time in the history. Formerly it was given for an investigational neuraminidase inhibitor, Peramivir during 2009-2010 to treat severely ill patients with H1N1 influenza [9]. The meta-analysis of 5 studies that reported rate of virological clearance or PCR negativity (n=312) found no benefit in HCQ arm. {OR, 1.863; 95% CI, 1.024 to 3.389; p=0.041} with a moderate heterogeneity (I 2 =70.3%, P=0.009). meta-analysis of 5 studies (n=1710) that reported about ADR outcomes found that, there exist an increased risk of ADRs in HCQ arm. {OR, 2.648; 95% CI, 2.068 to 7.717; p=0.000}, with no heterogeneity (I 2 = 0%, P=0.417). 6 studies (n=4,341) showed a significant increase in mortality in HCQ arm when compared with control arm {OR, 1.182; 95% CI, 0.981 to 1.425; p=0.079}, with substantial heterogeneity (I 2 = 82.0%, P=0.000). Conclusions: The systematic review and meta-analysis revealed a reduced antiviral efficacy in reducing mortality, ADR occurrence and has a decreased virological clearance in patients with COVID-19. in COVID-19 patients.

Studies which aim to evaluate the HCQ use in Covid-19 have many pitfalls like small sample size, heterogeneity, inconsistent reports, early cessation of trials etc. Hence it is obligatory to systematically review and critically appraise the available literatures, which might help policy makers, clinicians to stick onto a decision [10].

Objectives
To evaluate the safety, efficacy and virological clearance of Hydroxychloroquine in Covid-19 patients when compared to those patients receiving conventional therapy.

Methods
This study was carried out in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [11].
Criteria for considering relevant studies for the review were as follows:

Type of study
Inclusion Criteria: We included randomised/ non-randomised controlled trials, observational studies, case reports, case series, all studies conducted with Hydroxychloroquine in patients with Covid-19 that was compared to control arm.
Exclusion Criteria: We excluded experimental in vitro studies, editorials & expert opinions, case series without control group, review articles, articles with unavailable full text and non -English articles. The key term searched were "Hydroxychloroquine on Covid-19". Proper hand searching of cross-references of original articles, pre-prints was also performed to find out additional relevant articles ( Figure 1).

Results
Out of 12 studies included in the systematic review, a total of 2,834 patients enrolled. Of which 1326 patients received HCQ along with standard of care and 1508 patients received conventional standard of care. Non-HCQ arm was considered as Control arm ( Need of respiratory support and intubation on day5. Tang [20]  Benefit on virological clearance. Singh [22] et al Retrospective HCQ dosage regimen is not mentioned. However, 799 received azithromycin.
In 30 days, no much variation in mortality and need for mechanical ventilation when both arm was compared.

Safety Outcomes
Certain studies had reported occurrence of adverse events with HCQ. Seen adverse events include: nausea, vomiting, variations in LFT, diarrhoea, rashes, head ache, blurred vision and ECG abnormalities (Table 3).  [20]et al Higher incidence of adverse events was noted in HCQ arm (30%) whereas in control group it is 8.8%. The most common adverse event was diarrhoea in HCQ arm compared to control arm. Also one patient among HCQ arm had experienced blurred vision. Rosenberg [23] Higher incidence was on HCQ arm. A greater proportion of patients received HCQ + AZ experienced cardiac arrest (15.5%) and abnormal ECG findings (27.1%), whereas in HCQ alone is 13.7% and 27.3% respectively. In those with no HCQ and AZ, 6.8% and 14.0% respectively.

Cough period
Among these, a study by Chen [14] et al had reported about the outcome on duration of cough. Here, the number of cough days was markedly lesser in HCQ arm than in Control arm (Table 5).
Our systematic review and meta-analysis included 12 studies, with a total of 2,834 patients, HCQ n = 1326 & Std n = 1508. Non-HCQ arm was considered as Control arm. Meta-analysis of 5 studies did not exhibit a benefit on virological clearance. Moreover meta-analysis on other outcomes of interest like ADR occurrence, mortality was more on HCQ arm when compared to non-HCQ arm or conventional therapy. However our findings of lack of virological clearance efficacy, increased mortality, occurrence of ADR was consistent with various previously published articles which dealt with other viral diseases. CQ was ineffective in preventing and reducing influenza viral load in ferret models [24]. Also CQ did not prevent this infection (influenza) in a double-blinded placebo controlled human trial [25]. In a study, CQ shown to enhance Chikungunya viral load in various animal models [26].
Decreased efficacy of CQ/HCQ in COVID-19 can be of following reasons: 1. Most of the in vitro studies do pre-treatment protocols; here the cells are treated with the drug prior infecting with the tested virus. Whereas, in in vitro that compared pre treatment and post infection treatment shown CQ/HCQ have decreased antiviral efficacy if added after the infection. This may suggest that chronic prophylactic use of CQ/HCQ may be effective to prevent acquiring SARS-CoV-2 infection [27]. 2. Two studies that did pharmacokinetics study revealed that the mean HCQ level was 0.46 μg/mL, in those treated with 600 mg/day which is lower than lowest effective in vitro concentration of 0.72 μM [12]. A study by Balevic et al [28] showed that average pdc of HCQ was below the lowest antiviral concentration for SARS-CoV-2 of 0.48 μg/mL in most studies *28+.

Conclusion
This systematic review and meta-analysis revealed that HCQ has a reduced antiviral efficacy in reducing mortality, ADR occurrence and has a decreased virological clearance in patients with COVID-19. The drug should be used in patients with at most caution until there is positive results from RCTs with larger patient population.