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No benefit to ivermectin for the treatment of COVID-19 in regions where strongyloidiasis is not endemic
Clinical Question
Is the purported benefit of ivermectin in the treatment of COVID-19 confounded by inadvertently treating disseminated strongyloidiasis?
Bottom line
This systematic review of all available ivermectin trials in the treatment of COVID-19 found a benefit only in those trials performed in areas of high strongyloidiasis prevalence. No independent benefit of ivermectin in the treatment of COVID-19 occurred in areas of low prevalence of strongyloidiasis. 1a
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Self-funded or unfunded
Setting: Various (meta-analysis)
Synopsis
The purported benefit of ivermectin for the treatment of COVID-19 continues to be controversial. Corticosteroid therapy is commonly used for severe COVID-19 infection and is also a risk factor for precipitating disseminated strongyloidiasis and a subsequent high risk of mortality. These investigators thoroughly searched recent systematic reviews and additional references in a dedicated ivermectin trial database from January 2019 to November 2021. Two investigators independently performed the search with an additional investigator assessing the risk of bias of each trial. A total of 12 trials (N = 3901 patients) were included in the analysis. The global mean prevalence of strongyloidiasis is 8.1%. Of the 12 included trials, 4 trials occurred in areas of high strongyloidiasis prevalence (> 8.1% prevalence) with 8 trials occurring in areas of low strongyloidiasis prevalence (< 8.1%). Ivermectin trials that occurred in areas of low strongyloidiasis prevalence were not associated with a significant decreased risk of mortality (relative risk [RR] = 0.84; 95% CI 0.60 - 1.18). However, those trials that took place in areas of high regional strongyloidiasis prevalence were significantly associated with a decreased risk of mortality (RR = 0.25; 0.09 - 0.70). On further analysis, the relative risk of mortality significantly decreased with ivermectin treatment in proportion to increasing strongyloidiasis prevalence. The overall risk of bias of the individual trials was low to moderate, and no evidence of significant publication bias was detected.
Reviewer
David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC
Comments
Ivermectin & Strongyloidiasis
There needs to be more precision in the report: - 'areas with prevalence' is not the same as patients diagnosed with strongyloidiasis.
ivermectin and strongyloides
This is a highly problematic report for a bunch of reasons
1. how is prevalence defined? "high" and "low" actually just mean above and below the mean; given the worldwide purported prevalence, we should have seen a lot more positive studies, not equivocal ones.
2. how sick was the study population? if they weren't given steroids there shouldn't have been much of a tx benefit. the RR is suspiciously dramatic
3. an RR of 0.25 is a dramatic effect, and a dramatic benefit if this is truly the case (I am not convinced); if this were actually true, the title should have been shouting the benefits - this is highly suspicious of bias either way
Role of ivermectin in reducing mortality in high prevalence
Sampling was really good
There was attempt to eleminate bias.both high low prevalence areas for strongyloides studied. And advocacy of ivermectin reduced mortality in high prevalence areas.But the inference of this study might induce a sidelining tendency towards ivermectin amongst physicians . Low prevalence area doesn't mean disease free area. So the conclusion must have an anecdote in this regard. Better not to defer use of ivermectin in Covid since there is every chance that a patient from low prevalence area might have an infestation and this should be borne in mind when prescribing