Research Protocol

Version-2

A Randomized, Double-Blind Placebo Controlled

Clinical Trial of Ivermectin plus Doxycycline for the
Treatment of Confirmed Covid -19 Infection

Principal Investigator

Dr. Reaz Mahmud

FCPS (Medicine), MD (Neurology)
Assistant Professor
Department of Neurology
Dhaka Medical College, Dhaka

Trial Registration: ClinicalTrials.gov Identifier: NCT04523831.

Document date: 26.08.20

1
Amendment Approval

2
 Part A
Project Title: A Randomized, Double-Blind Placebo Controlled Clinical Trial of Ivermectin
plus Doxycycline for the Treatment of Confirmed Covid -19 Infection

1. Principal Investigator:

Name Designations & place of posting

Dr. Reaz Mahmud Assistant Professor, Department of
Neurology, Dhaka Medical College

2. Co-Principal investigators:
Name Designations & place of posting
Professor Mujibur Rahman Professor and Head, Department of Medicine,
Dhaka Medical College
Dr. Iftikher Alam Assistant Professor, Department of
Neurology, Dhaka Medical College
Dr. Kazi Gias Uddin Ahmed Associate Professor and Head, Department of
Neurology, Dhaka Medical College
Dr. AKM. Humayon Kabir Associate Professor, Department of
Medicine, Dhaka Medical College

3. Co-investigators:
Name Designations& place of posting
Dr. S. K Jakaria Been Sayeed Indoor Medical Officer, Department of
Medicine, Dhaka Medical College.
Dr. Mahfuzul Haque Assistant Professor, Department of Medicine,
Dhaka Medical College
Dr.MD. Shahidul Islam Junior Consultant, Medecine, Sarkari
Karmachari Hospital, Dhaka.
DR. Mohammed Monirul Islam Assistant Surgeon, MoHFW

Dr. Mohammad Aftab Russel Medical officer, OSD, MD Thesis part

student, Department of Neurology, Dhaka
Medical College
Dr. Anindta Barshan Indoor Medical Officer, Department of
Medicine, Dhaka Medical College
Dr. Farhana Binte Monayem Medical Officer, Sarkari Karmachari
Hospital,Dhaka.
Dr. Mohammad Zaid Hossain Associate Professor, Department of
Medicine, Dhaka Medical College
Dr. Mohammad Abdullah Yusuf Assistant Professor, Department of
Microbiology, National Institute of
Neurosciences and Hospital.

3
4. Place of the study/Institution(s):
Covid-19 Dedicated Unit, Dhaka Medical College Hospital.
5. Sponsoring/Collaborating Agencies:
None
6. Duration:
03 months (June 2020 to August 2020).
7. Date of Commencement:
01, June 2020
8. Date of Completion:
25, August 2020
9. Total Cost: Not estimated

10. Other Support for Proposed Research:

(1) Is this research project being No

supported by any other source?

(2) Has an application for funding of No

this project been submitted to any

other organization(s)?

11. Date of Submission : 16-06-2020

4
 :

PART – B

PRINCIPAL INVESTIGATOR(S) INFORMATION SHEET

1. (i) Name :Dr. Reaz Mahmud

(ii) Designation: Assistant Professor, Neurology

(iii) Official Address with telephone: Dhaka Medical College Hospital, Dhaka.

Phone: 01912270803

(iv) Present Residential Address with telephone: Road # 07, House # 13

Abdullah bagh, Uttar Badda, Badda Dhaka.

4. Academic Background:

Degree University Field Year

MBBS Dhaka University May,2003
FCPS BCPS Medicine January,2013
MD Dhaka University Neurology June,2015

5. Field of Specialty:

Medicine & Neurology

5
 6. (a) Research Experience :

1. Association between Hypertensive retinopathy and Done for FCPS Dissertation

Lacunar stroke.

2. Risk Factors and Morphological Differences of Done for MD thesis

Ruptured Saccular Aneurysm in different sites of Anterior

Circulation in Patients presenting with Subarachnoid

Haemorrhage

3. Recent sensitivity Pattern of Salmonella Typhi in a Done for Research

private hospital.

(b) Other Experience:

Teaching:

1. Assistant Registrar cardiology NICVD, 03-08-09 to 21-06-10

2. Assistant Registrar Medicine, Faridpur Medical college Hospital, Faridpur 23-06-10 to
31-06-12

Administration:

Work as a Departmental Head, Critical Care Medicine, Sarkari Karmachari Hospital from
01-11-2016 to 04-12-2019

Others:

6
5. Number of Scientific Publications:

Sl No National/ Original/ Authorship Reference

International review
1 National Original Co-author Ali M Y, Mahmud R. A case report on
Lepra Reaction Type II. Faridpur Medical
college journal 2012; 2 : 93-97
2 National Original Author Mahmud R, Ali MY, Islam MS, Shanewaz
S, Rabbani G, Manayem FB. Association
Between Hypertensive Retinopathy and
Lacunar Infarct- A Study in Faridpur
Medical College Hospital. DCIMC J 2016;
3(2):27-33

3 National Original Co-author Saha R, Mahmud R, Hossain MZ,Sarker

PK. Families with Neurocutaneous
Syndrome:Report of two cases.Dhaka Med
Coll J 2013; 22(1): 102-107.

4 National Original Author Mahmud R, Habib M, Uddin S,Risk Factors

and Morphological Differences of Ruptured
Saccular Aneurysm in Different Sites of
Anterior Circulation in Patients Presenting
with Subarachnoid Haemorrhage. Journal of
National Institute of Neurosciences
Bangladesh. January 2017; 3(1):21-28.

5 National Original Author Islam K, Mahmud R. Recent sensitivity

Pattern of Salmonell Typhi in a private
hospital.J Medicine 2018; 19: 15-17
6 National Original Author Mahmud R, Habib M. Huntington's Disease
with Retinitis Pigmentosa- a Case Report.
Faridpur Med. Coll. J 2017;12(1):50-52.
7 National Original Co-Author Ghose, S., Ahmed, K. G., Chowdhury, A.,
Hasan, A., Saha, K., Mahmud, R., Joy, N.,
Biswas, R., Sarkar, M. S., Rahman, M. M.,
Sina, H., Arifuzzaman, M., Alam, I.,
Hossain, M. M., Karim, A., & Habib, M.
(2018). Assessment of Initial Stroke
Severity by National Institute Health Stroke
Scale (NIHSS) Score at Admission. Journal
of Dhaka Medical College, 26(2), 90-93.
https://doi.org/10.3329/jdmc.v26i2.38765

7
 PART - C

Project Title: A Randomized, Double-Blind Placebo Controlled Clinical Trial of

Ivermectin plus Doxycycline for the Treatment of Confirmed Covid -19 Infection.

1. Summary:
On 31 December 2019, the World Health Organization (WHO) was formally notified about a
cluster of cases of pneumonia in Wuhan City, China. On 7 January the responsible virus was
isolated and its genome sequence was shared on 12 January. It was named as COVID-19, a
novel Coronavirus, SARS-CoV-2. It is a member of the Corona virus family which is RNA
enveloped viruses.
Very rapidly the virus emerged as pandemic. Now it is dominating the lives of every people
of this universe. Till date 75,53,182 confirmed cases of COVID-19, including
4,23,349 deaths, reported to WHO. In Bangladesh cases as well as the death tolls are also
increasing exponentially (84,379 cases and 1,139 death).
Management of the COVID-19 relies on mainly supportive care and oxygen supplementation
via non-invasive or mechanical ventilation in critical cases. Patients who are critically ill may
also require vasopressor support and antibiotics for secondary bacterial infections.
There is no vaccine or highly effective antiviral drugs for COVID-19. Currently there is a
tremendous effort around the world to develop effective preventive and therapeutic treatment
for this disease.
World Health Organization has launched a non-blinded clinical trial (SOLIDARITY) to
evaluate four candidate treatments (remdesivir, lopinavir/ritonavir, lopinavir/ritonavir/
interferon beta-1a, and chloroquine or hydroxychloroquine) versus standard of care in 18
countries worldwide. RECOVERY trial one of the largest trials to see the efficacy and safety
of hydroxychloroquine revealed that they are no clear cut clinical benefit for COVID-19.
Other drugs in the SOLIDARTY trial are quite expansive for resource limited countries like
Bangladesh.
Study Published in the American Journal of Tropical Medicine advocates further research
into Ivermectin for COVID-19 Treatment. The spotlight on Ivermectin was brought by
Australian researchers from Monash University who demonstrated its efficacy against the
SARS-CoV-2 coronavirus in vitro studies.
In a recent international, multicenter, propensity-score matched case- controlled study using
prospectively collected data on patients diagnosed with COVID 19 by Patel et al, observed
substantial benefit using Ivermectin over standard care.

8
In different study Doxycycline also showed promising results in treatment of COVID 19
infection. It is highly lipophilic antibiotics that are known to chelate zinc component of
matrix metalloprotienases (MMP). Corona viruses are known to rely heavily of MMPs for
survival, cell infiltration and replication. It also has an anti-inflammatory effect which might
be effective in combating cytokine storm of Covid-19 infection.
So it have been planned to conduct an experimental clinical trial using combination of
ivermectin and doxycycline for treatment of COVID 19 along with the other standard care. It
would be a randomized double blind placebo controlled Trial. The study would be conducted
on 200 confirmed cases of Covid- 19. Another 200 patients will receive placebo.
The primary outcome would be the Days required for the Clinical improvement of the
patients from the day of randomization.

Data will be analyzed using SPSS 20. Unpaired t-test would be used for testing quantitative
data and for testing qualitative data two sample z- test would be used. For the comparison
between two groups Hazard ratio, Kaplan-Meire curve, binary logistic regression would be
used to see the outcome. Result of the study and statistical analysis will be presented by
tables, figures, graphs, diagrams, charts and photographs. All these will have own legends
(i.e. title) and will be serially numbered. Discussion will be done on the basis of result
obtained from the study and comparing with similar studies done at home and abroad.
Summarization will be drawn after discussion. Conclusion will be drawn depending upon the
results and discussion.

9
 PART - D

INTRODUCTION
On 31 December 2019, the World Health Organization (WHO) was formally notified
about a cluster of cases of pneumonia in Wuhan City1. On 7 January the causative virus
was isolated and its genome sequence was shared on 12 January. The cause of the severe
acute respiratory syndrome that became known as COVID-19 was a novel corona virus,
SARS-CoV-22. The virus Spread quickly through out the universe in quick succession.
The World Health Organization (WHO) on March 11, 2020, has declared the novel
Corona virus (COVID-19) outbreak a global pandemic3.

Phylogenetic analysis suggests that SARS-CoV-2 originated in animals, probably bats,

and was transmitted to other animals before crossing into humans at the Huanan wet
market in Wuhan City4-5. It was the year 1918, when a new flu pandemic launched
worldwide The pandemic infected 3% to 5% percent of the world's population
including remote Pacific islands and the Arctic. The Life expectancy dropped by about
12 years6. The fatal casualties of the diseased had reached the number of the fifty million
victims7.

That dreadful experience might be compared with the recent ongoing pandemic. By 13
june 2020, there have been 75,53,182 confirmed cases of COVID-19, including
4,23,349 deaths, reported to WHO8. Most of the countries of the word are in strict
lockdown state. Now it is dominating the lives of every people of this universe. The
Economy of the world also constricted. In Bangladesh cases as well as the death tolls are
also increasing exponentially. Our Economy is also shrinking day by day.

While the clinical presentation of COVID-19 ranges from asymptomatic to fulminant and
fatal, severe cases of infection can develop pneumonia, acute respiratory distress
syndrome, sepsis and/or multiple organ failure which are not unique to coronavirus 9.

Death is due to pneumonia and possibly hyper-inflammation associated with cytokine

storm syndrome10.

Management of the COVID-19 relies on mainly supportive care. Approximately 14% of

the Covid-19 patients develop severe disease that requires hospitalization and oxygen
support, and 5% require admission to an intensive care unit 11.
There is no vaccine or specific antiviral drug for COVID-19 for which the people of the
world are craving.
Worldwide the scientific community has focused on developing and/or repurposing
medicines that can target SARS-Cov 2 and help control the pandemic of COVID-19.

10
Repurposing currently available medicines against COVID-19 has led to the development
of hundreds of trials worldwide. Therapeutics under investigation includes various
antiviral and immunomodulatory medicines12.

Table: 1 All drugs used for COVID-19 in vitro lab and in vivo (clinical) human
studies published from January 202013.

Name of the Drug Name of the Drug Name of the drug

Meplazumab(monoclona Darunavir(antiviral) Umifenovir/arbidol(
l antibody) antiviral).
Ivermectin Nelfinavir(antiviral) Lopinavir/ritonavir(
LPV/r)protease
inhibitor
Siltuximab(monoclonal Remdesivir(antiviral) Interferon-alphaα
antibody).
Danoprevir(antiviral) Corticosteroids . Interferon-beta β.
Tocilizumab/IL- Chloroquine/hydroxychloroquine Heparin
6(monoclonal antibody).
Favipiravir(antiviral) Convalescent Plasma α-Lipoic acid

Many studies carried out independently in small group of people but there is a risk that
the trials will lack statistical strength.
World Health Organization has launched a nonblinded clinical trial (SOLIDARITY) to
evaluate four candidate treatments (remdesivir, lopinavir/ritonavir, lopinavir/ritonavir/
interferon beta-1a, and chloroquine or hydroxychloroquine) versus standard of care in 18
countries worldwide14.
Recently a publication in lancet journal claimed that they were unable to confirm a
benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on
in-hospital outcomes for COVID-19. Each of these drug regimens was associated with
decreased in-hospital survival and an increased frequency of ventricular arrhythmias
when used for treatment of COVID-19. The Findings were controversial.
Other drugs in the SOLIDARTY trial are quite expansive as well as toxic for resource
limited countries like ours. Study Published in the American Journal of Tropical
Medicine advocates further research into Ivermectin for COVID-19 Treatment. It could
emerge as a good drug candidate. It is cheap and less toxic. Dosing regimen is also
simple.
The spotlight on Ivermectin was brought by Australian researchers from Monash
University who demonstrated its efficacy against the SARS-CoV-2 coronavirus in vitro
studies16.
Ivermectin has a broad spectrum antiviral activity. Recently it is found to be effective to

11
combat infections of RNA viruses like human immunodeficiency virus (HIV)-1,
influenza, west nile virus , Zika virus and dengue virus(DENV)17.

Caly L etal demenostrate ivermectin has antiviral action against the SARS-CoV-2
clinical isolate in vitro, with a single dose able to control viral replication within 24–48 h
in their system16.
Importin (IMP) α/β1 30 is a heterodimer that binds to the SARS-CoV-2 cargo protein and
moves it into the nucleus which reduces the host cell antiviral response. Ivermectin
destabilizes the Impα/β1 heterodimer, prevents it from viral protein binding and thus
from entering the nucleus.16, 17.
Ivermectin has an established safety profile for human use although there is not enough
evidence to make conclusions about the safety profile in pregnancy18.
However, the in vivo antiviral potential of ivermectin has only been reported against the
pseudorabies virus 19 and parvoviruses 20.
Considering the promising result of the in vitro study, the clinical benefit of ivermectin
therapy was evaluated in an observational registry-based study involving critically ill
SARS-CoV-2-infected patients. Treatment with ivermectin at a dose of 150 μg/kg was
found to be associated with a lower mortality rate and reduced healthcare resource use 21
The clinical efficacy and utility of ivermectin in SARS-CoV-2-infected patients are
unpredictable at this stage, as we are dealing with a completely novel virus.
The exact mechanism behind ivermectin is still under investigation but studies have
found that a single treatment of ivermectin in a COVID-19 patient can cause the effect of
a ~5000-fold reduction in viral RNA at 48 hours16.22. Due to an immensely significant
decrease in viral load with just one dose, ivermectin holds a significant amount of
promise and thus, warrants further investigation in humans.
In a recent international, multicenter, propensity-score matched case- controlled study
using prospectively collected data on patients diagnosed with COVID 19 by Patel et al,
observed substantial benefit using Ivermectin over standard care16. They found that fewer
patients died in the ivermectin group ( 7.3 versus 21.3 percent) and overall death rates
were lower with ivermectin ( 1.4 versus 8.4 percent).

Tetracyclines are antibiotics that are generally well-tolerated and widely available. They
are generally used as broad spectrum antibiotics to treat different bacterial diseases as
well as some atypical infection23.

However, several authors have suggested they may be effective against different viruses
as well. In a recent article, Mohit Sochi and Mahiyar Etminan , have suggested that they
may be effective against COVID 1924.

Tetracyclines are highly lipophilic antibiotics that are known to chelate zinc component
of matrix metalloprotienases(MMP)25. Corona viruses are known to rely heavily of

12
MMPs for survival,cell infiltration and replication, many of which have zinc as part of
their MMP complex26. It may be possible that zinc chelating properties of tetracyclines
may aid in inhibition of COVID 19 infection in humans. Some in vitro studies also
suggested that tetracyclines may inhibit RNA replication on positive sense single
stranded RNA viruses, like COVID 19.

Second, teracyclines have well known anti-inflammatory effects. The anti-inflammatory

mechanism of tetracyclines is complexe and not fully understood. However, it probably
involves inactivation of MMPs, serine proteases and decrease production of
inflammatory cytokines such as TNF-alpha, interleukin beta and IL-627. It has been
suggested that cytokines play an important role in the pathogenesis of COVID 19
including exacerbation of lung damage28,29. Several authors have suggested that
tetracyclines may be used to treat inflammatory disorders including those caused by
Corona viruses.

Third, as they are highly lipophilic drugs, tetracycline has good tissue penetration in the
lungs .This, along with their anti- inflammatory properties, might allow them to inhibit
viral replication in the lung and reduce lung damage. The recommendation of using
tetracyclines as treatment for Corona virus was previously suggested given that
chemically modified tetracycline can prevent septic shock induced by ARDS30.

Based on the evidences, Mohit Sodhi et Al strongly urged international research groups
to consider investigating the potential therapeutic efficacy of tetracycline in treating
COVID 19.

Compared with the original tetracycline, the synthetics, including minocycline and
doxycycline, show a better pharmacokinetic profile than the first-generation tetracyclines
when used orally, being rapidly and completely absorbed, even in elderly populations,
with a longer half-life and excellent tissue penetration, with almost complete
bioavailability31
The rationale of using combination of ivermectin and doxycycline for treatment of
COVID 19 is based on their antiviral and anti-inflammatory properties. Since the two
drugs have different mode of action, their synergistic effect would be of value to contain
the viral infection by targeting different sites of the pathogenesis of the disease.

13
2. OBJECTIVES:

General objectives:
To observe the benefit (clinical and microbiological) of Ivermectin and Doxycycline in
Confirmed Covid 19 cases.
Specific objectives:
1. To observe the clinical outcome in trial group and the placebo group.
2. To observe the duration require for the recovery in the trial and placebo group
3. To compare the outcome between the two groups.

3. RATIONALE:
Covid-19 is an emergent pandemic, threatens the life of millions of the people throughout
the globe. There is increasing effort of the scientist to unveil a remedy of covid-19. Still it
is unsuccessful. At present there is no other alternative other than experimenting the
existent drug against the virus. There are several trials going throughout the globe.
Among them Ivermectin showed good efficacy in vitro trial. Some clinical trial also
proved it beneficial. The Doxycycline also has some anti-viral role with its prominent
anti-inflammatory role. Synergistic action of the two drugs might be proved some benefit
in clinical trial. As both drugs are cheap and less toxic, if it does, it would be the blessing
for the poor people of the globe.

4. METHODOLOGY:

Study type: Interventional Clinical trial

Estimated enrollment: 200 participants per group

For superior trial, the formula is:

N=size per group; p=the response rate of standard treatment group; p 0= the response rate
of new drug treatment group; zx= the standard normal deviate for a one or two sided x; d=

14
the real difference between two treatment effect; δ 0= a clinically acceptable margin; S2=
Polled standard deviation of both comparison groups.
All parameters were assumed as follows: p =0.40; p0=0.58; α=0.05;β=0.20; δ=0.18;
δ0=0.10.

However, we are assuming that lost to follow up or refuse to include in trial will be 20%,
that means 24. So at least 150 patients will be allocated randomly and power of this study
will be 80%.
Allocation:
Randomized: Block randomization (Computer generated randomization code)
Intervention model: Parallel assignment

Intervention model description: Patient will be randomized 1:1 to placaebo with

standard care and combined doxycycline and ivermectin with standard care.
Blinding: Double blind (The participant and the clinicians/data collectors will be
unaware of the treatment the participant receives)
Primary purpose: Treatment
Official title: A phase III trial to promote recovery from covid 19 with combined
Doxycycline and Ivermectin along standard care.

Provider of placebo and active ingredients: Popular pharmaceutical limited

Dosage of the drugs: Ivermactin 6 mg 2 tab stat, cap Doxycycline 100 mg 1 cap BD 5
days

15
Content of the placebo:

Placebo description of Ivermectin: Attached with Annexure 1

16
 Placebo Description of Doxycycline: Attached with Annexure II

Estimated study date: 01 June, 2020

Estimated primary completion date, 25 August 2020
Estimated study completion date: September, 2020

Inclusion Criteria:
 At least 18 years of age
 COVID-19 infection, confirmed by polymerase chain reaction (PCR) test within 3 days
from enrollment
 Only mild and moderate COVID-19 infected cases
 Able to provide informed consent

Exclusion Criteria:
 Unable to take oral medication
 Pregnant or breast feeding lady
 Patients with severe COVID symptoms or admission in ICU/HDU

17
  Alanine Aminotransferase (ALT) or aspartate aminotransferase (AST) > 5 X upper limit
of normal (ULN)
 On non-invasive positive pressure ventilation or mechanical ventilation at time of study
entry
 Known hypersensitivity to Doxycycline or ivermectin or its components.

Research instruments:

1. Informed consent form.

2. Case record form

Primary Outcome Measure:

The number of days required for clinical improvement

1. Early Clinical improvement of the patients

How many days it requires to become the patient completely symptoms free
[Time Frame: 7 days]
2. Late clinical recovery
How many days the symptoms persist
[Time Frame: 12 days]
Secondary Outcome Measure:
1. Percentage of patients having clinical deterioration.
Patients deteriorating to next level of severity, like moderate, severe and death
[Time Frame: 1 month]
2. Persistently positive for RT-PCR.
Percentage of Covid-19 Patients repeatedly become positive for RT-PCR for
Covid-19
[Time Frame: 14 days]
Data collection technique:
Data will be collected by assigned. trained data collectors (Physician).
Patient will be enrolled according to defined inclusion and exclusion criteria in the
current research. Informed written consent will be obtained from the patient or their
relatives. Each patient participating in the trial will be uniquely identified, and
information such as his name, address is recorded in the trial 'subject number list'. Only
the principle investigator will be aware about the allocation of the drugs. The patients

18
and the data collectors will be unaware about the group allocation of the drugs. The Data
will be reviewed by the co-investigators. It will be managed by principle and co-principle
investigators in designated computer.
Clinical assessment (fever, cough, Anorexia, Temperature, pulse, blood pressure,
respiratory rate, oxygen saturation) will be done every day. Routine investigation (CBC,
ESR, CRP, Creatinine, RBS, SGPT, chest x-ray, D- Dimer) will be done at admission and
at day 3, 5, 7, 10 and 14 day. In case of the clinical deterioration it would done according
to necessity. RT-PCR will be done at day-0, Day 5, day 7 and day 14.

Standard care: both the experimental and placebo will receive the available standard of
care, like-
 Paracetamol, Antihistamine, Cough suppressant, Vitamins
 Oxygen therapy according to indication and need
 Low molecular weight heparin according to indication
 Appropriate other broad spectrum antibiotics
 Other drugs for associated co- morbid condition

Management of the adverse events:

Drugs adverse effect will be monitored by a defined committee. The patient experiencing
adverse effect of the drugs will be discontinued from the study. It will be managed with
priority to the highest possible level by the hospital authority as well as the investigators.

If the patient progresses from mild to moderate or severe disease, the study will be
continued and available management of the appropriate severity will be immediately
started. The patient will be monitored closely.

Data analysis:
Data will be analyzed by computer with the help of SPSS (Statistical Package for Social
Sciences) version 20. To compare mean of the two group chi square will be used. Comparing
drug outcome in between two group survival analysis by Kaplan-Meier curve will be done for the
duration of recovery. Odds ratio will be formulated from linear logistic regression for early and
late clinical recovery. Hazard ratio will be formulated from the cox regression analysis for
severity conversion and persistence of the positivity. Crude odds ratio will be adjusted in cox
proportional hazard ratio model. Each Ivermectin-Doxycycline plus standard of care group will
be compared with the placebo plus standard care group using the log-rank test, hazard ratio and
95% CI. Participants who were lost to follow up, died, discontinue drugs due to adverse effect
will censored on the last study day. All P values will be two-sided and will be shown without

19
adjustment for multiple testing. All analyses will be performed according to the intention to treat
principle.

Dropout management: Intention to treat measure will be taken

Observation and Results:

Result of the study and statistical analysis will be presented by tables, figures, graphs,
diagrams, charts and photographs. All these would have own legends (i.e. title) and will
be serially numbered.

Discussion:
Discussion will be done on the basis of result obtained from the study and comparing
with similar studies done at home and abroad.

Summary:
Summarization will be drawn after discussion.

Conclusion:
Conclusion would be drawn depending upon the results and discussion

Conflict of interest:
Popular pharmaceutical will only provide drugs and the placebo.
None of the investigators will receive remuneration from the pharmaceutical company.
They will not get any access to data profile.

Operational definition:
(According to WHO guideline)

Confirmed Covid-19:

Cases with positive RT-PCR for Covid 19 irrespective of symptoms.

Uncomplicated (mild) Illness

These patients usually present with symptoms of an upper respiratory tract viral infection,
including mild fever, cough (dry), sore throat, nasal congestion, malaise, headache,
muscle pain, or malaise. Signs and symptoms of a more serious disease, such as dyspnea,
are not present.

20
Moderate Pneumonia

Respiratory symptoms such as cough and shortness of breath (or tachypnea in children)
are present without signs of severe pneumonia.

Severe Pneumonia

Fever is associated with severe dyspnea, respiratory distress, tachypnea (> 30

breaths/min), and hypoxia (SpO2 < 90% on room air). However, the fever symptom must
be interpreted carefully as even in severe forms of the disease, it can be moderate or even
absent. Cyanosis can occur in children. In this definition, the diagnosis is clinical, and
radiologic imaging is used for excluding complications.

Acute Respiratory Distress Syndrome (ARDS)

The diagnosis requires clinical and ventilatory criteria. This syndrome is suggestive of a
serious new-onset respiratory failure or for worsening of an already identified respiratory
picture. Different forms of ARDS are distinguished based on the degree of hypoxia. The
reference parameter is the PaO2/FiO2:

 Mild ARDS: 200 mmHg < PaO2/FiO2 ≤ 300 mmHg. In not-ventilated patients or
in those managed through non-invasive ventilation (NIV) by using positive end-
expiratorypressure (PEEP) or a continuous positive airway pressure (CPAP) ≥ 5
cmH2O.

 Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg.

 Severe ARDS: PaO2/FiO2 ≤ 100 mmHg.

When PaO2 is not available, a ratio SpO2/FiO2 ≤ 315 is suggestive of ARDS.

Chest imaging utilized includes chest radiograph, CT scan, or lung ultrasound

demonstrating bilateral opacities (lung infiltrates > 50%), not fully explained by
effusions, lobar, or lung collapse.

Clinical improvement Criteria

1. Body temperature remains normal for at least 3 days (ear temperature is lower than
37.5 °C).

21
2. Respiratory symptoms are significantly improved.
3. Lung imaging shows obvious improvement in lesions.
4. There is no co-morbidities or complications which require hospitalization.
5. SpO2, >93% without assisted oxygen inhalation.

22
 8. FLOW CHART of Study workup:

Sl Activities
No 1st 2nd 3rd 4th 5th, 6 th, 7 th 8th

1 Recruitment
and training
of the field
staff

2 Pretesting
and
finalization
of the
questionnaire

3 Consultative
meeting

4 Data
collection

5 Data entry
and editing

6 Data analysis
and draft
report
writing

7 Disseminatio
n of Results

23
9. ETHICAL IMPLICATIONS

The following points will be considered during the study:

1. Patients (subjects) and key relatives were clearly informed about the scope and
limitation of the study.

2. Written consent will be obtained from the patients (subjects) or from parents if patient
(subject) is unable to give reliable information.

3. Confidentiality of the patients (subjects) about personal information was strictly

maintained.

4. The study will not be causing any environmental hazard.

24
10. REFERENCES:

1. World Health Organization. GCM teleconference – Note for the Records. 10 January
2020. Subject: Pneumonia in Wuhan, China. Available from: https: // www. who. int/
blueprint / 10-01-2020-nfr-gcm.pdf?ua=.
2. World Health Organization. Novel coronavirus (2019-nCoV). Situation Report – 1. 21
January 2020. Available from: https://www.who.int/docs/default-source /coronaviruse
/situation-reports/20200121-sitrep-1-2019-ncov.pdf?sfvrsn=20a99c10_4.
3. WHO Director-General's opening remarks at the media briefing on COVID-19 - 11
March 2020, available from:https://www.who.int/dg/speeches/detail/who-director-
general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
4. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H et al. Genomic characterisation and
epidemiology of 2019 novel coronavirus: implications for virus origins and receptor
binding. Lancet 2020; 395:565–74.
5. Andersen KG, Rambaut A, W. Ian Lipkin WI, Holmes EC, Garry RF. The proximal
origin of SARS-CoV-2. Nature Med2020; 17 March. DOI: https://doi.org /10.1038/
s41591 -020-0820-9.
6. Tsoucalas G, Kousoulis A, Sgantzos M. The 1918 Spanish Flu Pandemic, the Origins of
the H1N1-virus Strain, a Glance in History. European Journal of Clinical and Biomedical
Sciences. Vol. 2, No. 4, 2016, pp. 23-28. doi: 10.11648/j.ejcbs.20160204.11)
7. Wilton P. Spanish flu outdid WWI in number of lives claimed. CMAJ. 1993; 148(11):
2036-2037
8. WHO Corona virus (Covid-19) Dashboard available fromhttps://extranet. who.int/ public
emergency.
9. Rodriguez-Morales AJ, Cardona-Ospina JA, Gutie´rrez-Ocampo E, Villamizar-Pen˜a R,
Holguin-Rivera Y, Escalera-Antezana JP, et al. Clinical, laboratory and imaging features
of COVID-19: a systematic review and meta-analysis. Travel Med Infect Dis. 2020;
34:101623.
10. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID-19:
consider cytokine storm syndromes and immunosuppression. Lancet 2020;395
(10229):1033–4.

25
11. Team NCPERE. Vital surveillances: the epidemiological characteristics of an outbreak of
2019 novel coronavirus diseases (COVID-19) – China. China CDC Weekly.
2020;2(8):113-22.
12. World Health Organization.International Clinical Trial Registry Platform. COVID19
trials. Available at:https://www.who.int/ictrp/en/
13. PAHO, Ongoing Living Update of Potential COVID-19 Therapeutics: summary of rapid
systematic reviews. Availble at https://www.paho.org/en/documents/ongoing-living-
update-potential-covid-19-therapeutics-summary-rapid-systematic-reviews
14. UN health chief announces global 'solidarity trial' to jumpstart search for COVID-19
treatment". United Nations, World Health Organization. 18 March 2020. Retrieved 2
April2020
15. Mehra RM. Desai SS. Ruschitzka F. Patel AN. Hydroxychloroquine or chloroquine with
or without a macrolide for treatment of COVID-19: a multinational registry analysis.
www.thelancet.com Published online May 22, 2020 https://doi.org/10.1016/S0140-
6736(20)31180-6.
16. Caly L, Druce JD, Catton MG, Jans DA, Wagstaff KM, The FDA approved Drug
Ivermectin inhibits the replication of SARS-CoV-2 in vitro, Antiviral Research, https://
doi.org/10.1016/j.antiviral.2020.104787.
17. Sundy N Y Y, Sarah C A, Chunxiao W, Alexander L, Marie A B, Natalie A B, David A
J. The Broad Spectrum Antiviral Ivermectin Targets the Host Nuclear Transport Importin
α/β1Heterodimer. j.antiviral May 2020;177:104760.doi: 10.1016
18. Canga AG, Prieto AMS, Liébana MJD, Martínez NF. The pharmacokinetics and
interactions of ivermectin in humans--a mini-review. AAPS J 2008; 10 (1) : 42-46.
19. Lv C, Liu W, Wang B, Dang R, Qiu L, Ren J, Yan C, Yang Z, Wang X. Ivermectin
inhibits DNA polymerase UL42 of pseudorabies virus entrance into the nucleus and
proliferation of the virus in vitro and vivo. Antiviral Res. 2018;159:55–62.
https://doi.org/10.1016/j.antiviral.2018.09.010.
20. Nguyen KY, Sakuna K, Kinobe R, Owens L. Ivermectin blocks the nuclear location
signal of parvoviruses in crayfish, Cherax quadricarinatus. Aquaculture. 2014;420–
421:288–94. https://doi.org/10.1016/j.aquaculture.2013.11.022.

26
21. . Patel A, Desai S. Ivermectin in COVID-19 Related critical illness. SSRN. 2020.
https://doi.org/10.2139/ssrn.3570270.
22. Yavuz SS, Ünal S: Antiviral treatment of COVID-19. Turk J Med Sci. 2020, 50:611-619.
10.3906/sag-2004-145
23. Frieman, M., Yount, B., Heise, M., Kopecky-Bromberg, S.A., Palese, P., Baric, R.S.,
Severe acute respiratory syndrome coronavirus ORF6 antagonizes STAT1 function by
sequestering nuclear import factors on the rough endoplasmic reticulum/Golgi
membrane, J Virol, 81 (18) (2007), pp. 9812-9824.
24. M. O. Griffin, E. Fricovsky, G. Ceballos, and F. Villarreal, “Tetra-cyclines: a pleitropic
family of compounds with promisingtherapeutic properties. Review of the literature,”The
AmericanJournal of Physiology—Cell Physiology,vol.299,no.3,pp.C539–C548, 2010
25. Sodhi M, Etminan M Theraputic potential for tetracycline in the treatment of Covid-19
Pharmacotherapy 2020 May;40(5):487-488.doi: 10.1002/phar.2395. Epub 2020 May 4.
26. Zakeri B, Wright GD. Chemical biology of tetracycline antibiotics. Biochem Cell
Biol2008;86(2):124–36.
27. Phillips JM, Gallagher T, Weiss SR. Neurovirulent murine coronavirus JHM.SD uses
cellular zinc metalloproteases for virus entry and cell‐cell fusion. J Virol2017;
91(8):e01564‐16.
28. Henehan M, Montuno M, De Benedetto A. Doxycycline as an anti‐inflammatory agent:
updates in dermatology. J Eur Acad Dermatol Venereol2017;31(11):1800–8.
29. Kritas SK, Ronconi G, Caraffa A, Gallenga CE, Ross R, Conti P. Mast cells contribute to
coronavirus‐induced inflammation: new anti‐inflammatory strategy [published online
ahead of print, 2020 Feb 4]. J Biol Regul Homeost Agents2020;34(1).
30. Griffin MO, Fricovsky E, Ceballos G, Villarreal F. Tetracyclines: a pleitropic family of
compounds with promising therapeutic properties. Review of the literature. Am J Physiol
Cell Physiol2010;299(3):C539–48.
31. J. J. Leyden, K. Kaidbey, and E. H. Gans, “The antimicrobial effects in vivo of
minocycline, doxycycline and tetracycline inhumans,”Journal of Dermatological
Treatment, vol.7,no.4,pp.223–225, 1996.

27
 Patient Information Sheet
(For the patients/respondents)

(Please read the handout in front of patient/respondent and explain in local language and
understandable way).
The objective of this handout is to give you necessary information that will help you to take
decision whether you will participate in this research work or not.

1. About the study:

To assess the differences in clinical and microbiologic outcome difference between the patients
receiving ivermectin and doxycycline and the patient not having these. This research work will
be conducted by the Department of Medicine, Dhaka Medical College, Dhaka. We want to
include you as a study participant after receiving a written consent from you. I will explain you
in a moment what are the components and your role in the study.

2. Purpose of the study:

Find out the differences in clinical and microbiologic outcome difference between the patients
receiving ivermectin and doxycycline and the patient not having these.

3. Confidentiality:
The information that we will collect from this research project will be kept confidential unless
permitted by you. Information that will be collected from this study will only be used for
research purpose. Your personal information will not be disclosed to anyone other than the
investigators.

4. Right to refuse or withdraw:

You have all the right to refuse to participate in this study if you do not wish to do so. Refusing
to participate will not affect your treatment in any way. You may stop participating in this study
at any time you wish.

5. Incentives:

28
You will not be provided any incentives to take part in this research. You will be given honorium
and conveyance expenditure if you are to come for this research work.

6. Risks and discomforts:

There is a slight risk that you may share some personal and confidential information by chance
or that you may feel uncomfortable about some of the topics. However, we do not wish this to
happen. You may refuse to give answer to any question or any portion of it if you need to do so.

7. Benefits:
You might not get direct benefit from this study. You will get appropriate treatment in this
hospital after the diagnosis of your disease. Your participation is likely to help us to acquire
more knowledge about this disease which may be of benefit to other patients of our country.

8. Procedure of research:
If you agree, we will enroll you as a study participant and will adopt the following procedures for
your participation-

i. We will take signature/thumb impression in the attached consent form in

duplicate and a copy will be returned to you.
ii. We will ask you some questions to fill in a printed Case Record Form.
iii. You will be examined physically for the sake of this study.

If you agree to participate in this study, please sign the attached consent form.

29
 INFORMED CONSENT FORM

I, Mr/Mrs/Miss ……………………………………………., hereby giving informed consent

willingly to participate in the study to be done by Dr. Reaz Mahmud. I agree to participate in the

study voluntarily without any prejudice. I am fully convinced that during study I will not suffer

from any serious physical or psychological problems. I am also informed that this study was

carried out in the developed countries safely and my participation will bring fruitful result that

will be beneficial for most patients in our country. I have right to withdraw myself from this

study at any time. I shall not receive any financial benefit. I have understood that my personal

information, medical records & laboratory tests will be kept strictly confidential & will be used

for research purpose only.

Signature/Thumb impression of participant/Guardian:………………………….

Date: ………………………………

Name: …………………………………………………

Address: ………………………………………………

………………………………………………………….

………………………………………………………….

Signature of witness Signature of Researcher

Date: Date:

Name of witness:

30
 Project Title: A Randomized, Double-Blind Placebo Controlled Clinical Trial of
Ivermectin plus doxycycline for the Treatment of Confirmed Covid -19 Infection
Case Record Form

Patient ID: ……………

Demography

1. Name: 2. Age: 3. Sex: M / F

4. Address:
5. Epidemiological link: Y / N
5. Mobile No:
6. Residency: Urban / Rural
7. Smoker: Y / N
8. Marital Status: Married / Single
9. Education: Literate / Illiterate
Date of starting symptoms
Date of becoming Covid positive
Hospital Admission Date
Clinical Feature

Trait Follow-up
Yes-1, No-2
On Enrollment D D3 D4 D-5 D-6 D-7 D-8 D-9 D- D- D- D- D-
2 10 11 12 13 14
Fever Yes No
Cough Yes No
Running nose Yes No
Sputum Yes No
Respiratory Yes No
distress
Sore throat Yes No
Hoarseness of Yes No
voice
Chest pain Yes No
Diarrhoea Yes No
Vomiting Yes No
Anosmia Yes No
Anorexia Yes No
Headache Yes No
Confusion Yes No

31
 Obsrvation

Trait Follow-up
Yes-1, No-2
On Enrollment D D3 D4 D-5 D-6 D-7 D-8 D-9 D- D- D- D- D-
2 10 11 12 13 14
Temperature
Pulse rate
BP
Respiratory Rate
Oxygen
saturation
Co- Morbidity DM/HTN/ IHD/ HF/ CKD/CLD/Asthma/COPD/Malignancy/ CTD

Investigations Profile

Trait Value
Admission D-3 D-5 D-7 D-10 D-14
Hb
WBC
Neutrophil
Lymphocyte
Platelet
ESR
CRP
RBS
Creatinine
SGPT
D-Dimer
Na
K
ECG
Covid-19
RT-PCR

Radio-Imaging
Trait Findings
Chest X-Ray Normal/ Consolidation ( unilateral or bilateral) / Patchy opacity
CT Chest Consolidation/ Ground Glass Opacity/nodule/ multifocal

Principal Investigators: ……………….. Date:

32
Annexure-1

33
Annexure II:

34
DSM Board Minutes

35
36