Analysis 1.2: Condition improvement Data for ‘mild to moderate COVID-19’ and ‘severe’ COVID-19’ subgroups were not pooled for this outcome because the statistical test for subgroup differences indicates that the effect size is not the same for these subgroups. Moderate certainty evidence suggests that ivermectin probably increases the likelihood of people with mild to moderate COVID-19 improving by about 34% (22% to 48%) (5 studies, 743 participants; RR 1.34, 95% CI 1.22 to 1.48; evidence certainty downgraded for study design limitations) compared with no ivermectin treatment. For those with severe COVID-19 infection, low certainty evidence suggests that it may increase the likelihood of improvement by a greater extent than for mild to moderate infections (1 study, 200 participants, RR 1.88, 95% CI 1.54 to 2.30). This evidence was downgraded to low certainty because of study design limitations and because it was derived from a single small study
Analysis 1.3: Condition deterioration Moderate certainty evidence suggests that ivermectin probably reduces the risk of a person’s condition deteriorating by about 53% (95% CI 23% to 71%) compared with no ivermectin treatment (5 studies, 1175 participants; RR 0.47, 95% CI 0.29 to 0.77).
Analysis 1.4: Recovery time (clinical), as measured by study authors
For the subgroup of studies evaluating ivermectin as an outpatient treatment for COVID-19 infection, low certainty evidence suggests that ivermectin may reduce recovery time compared with no ivermectin treatment by about a day (2 studies, 176 participants; MD - 1.06, 95% CI -1.63 to -0.49). Although the effect is consistent across the two studies in this subgroup, the evidence was downgraded for imprecision1 and study design limitations. Evidence on the effect of ivermectin on recovery time among people treated in hospital (subgroup analysis 1.4.2 and 1.4.3 in the forest plot below) similarly require more data to improve the certainty of this evidence.
Analysis 1.5: Recovery time to a negative PCR test Low certainty evidence from two studies among outpatients suggests that ivermectin may reduce the time to a negative PCR test by about two days compared with no ivermectin treatment (2 studies, 186 participants; MD -1.88, 95% CI -3.62 to -0.15). The evidence was downgraded for imprecision and study design limitations.
Analysis 1.6: Length of hospital stay
The evidence presented here is based on a sensitivity analysis whereby study data at high risk of bias (Elgazzar 2020) were excluded pending author query. The resulting low certainty evidence suggests that ivermectin may reduce the length of hospital stay by about a day in people with mild to moderate COVID-19 infection (2 studies, participants; MD -1.03, 95% CI -1.82 to -0.23; downgraded for study design limitations and imprecision)
Outcome 1.7: Admission to hospital (for treated outpatients) There were no data for this outcome.
Outcome 1.8. Admission to ICU or requiring ventilation
Low certainty evidence from a single OCT suggests that ivermectin may lead to potentially large reductions in the number of people with COVID-19 infections requiring ICU admission (248 participants; RR 0.11, 95% CI 0.01 to 0.80). The evidence for this outcome was downgraded due to design limitations and imprecision.
Outcome 1.9: Severe adverse events
These findings are of very low certainty. It is not possible to determine whether the two adverse events in the Mahmud 2020 study were due to ivermectin or doxycycline; however, esophagitis (the adverse event reported) is a known adverse effect associated with doxycycline. Non-severe adverse events were reported in a few studies but these data were not extracted.
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