From 16 April 2020 through 5 August 2020, 1800 study participants seen by clinicians in 7 countries and 23 study sites who tested positive for SARS-CoV-2 by PCR were enrolled for evaluation and treatment of SARS-CoV-2 and the ITR to the virus as shown in Table 3. Tables 3 and 4 show the demographics of these individuals including 70.1 % men and 29.9 % women with an average age of 59 + 19 years.
Outpatient Outcomes: As patients entered the study, Figure 2 shows that they were initially seen as outpatients and divided into two groups. The first group of 847 (47 %) people included those whose clinicians did not think they required treatment. Of these 504 (59.5 %) were determined to be recovering on follow up evaluation 3-5 days later. Three hundred and forty-three (40.5 %) showed clinical deterioration requiring admission to hospital for treatment. Of these 301 were enrolled in Phase I of the study accounting for 88.5 % of Phase I patients, with 42 enrolled in Phase II of the study accounting for 26.1 % of the Phase II participants. Tables 3 and 4 show the demographics of these patients along with the severity of their admission measurements (FMTVDM, Ferritin, IL-6) of SARS-CoV-2.
The second group of people included those who received one-of-four outpatient treatment regimens by their clinicians after initial evaluation. These 953 patients represented 53 % of the study participants. Of these 953, 795 (83.4 %) were determined to have responded to outpatient treatment and were not admitted as shown in Tables 5 and 6. Analysis of these four different outpatient treatment regimens showed different response rates depending upon the combination of drugs used independent of supplemental zinc provided which as noted in the methods section included a minimum of 200 mg of elemental zinc. The reported successful treatment response ranged from 74.2-100 % depending upon the regimen. With the exception of Treatment 4, which included a one-time dose of 200 mg of Primaquine, the success rate as shown in Table 6 was 74.2 to 97.9 %. Among patients successfully treated as outpatients, Figure 2 shows the percentages following each of the four treatment groups that were deemed to have successfully responded to aminoquinoline outpatient treatment, including 28.3 % of cases with Treatment 1; 21.4 % with Treatment 2; 23.8 % with Treatment 3; and 26.5 % with Treatment 4 including Primaquine.
Upon re-evaluation 3-5 days later, 158 (16.6 %) of those who received outpatient aminoquinoline treatment were subsequently admitted to hospital with 39 enrolled in Phase I, and 119 in Phase II. The outpatient failures represented 11.5 % of the Phase I patients and 73.9 % of those in Phase II.
Table 4 shows the severity of SARS-CoV-2 upon admission for patients who did and did not receive outpatient therapy. There were no statistical differences those who were admitted and failed aminoquinoline treatment and those who received no pre-hospital treatment. The results of the two groups are pooled together in Table 7. Outpatients did not undergo diagnostic measurement of FMTVDM, Ferritin or IL-6 to quantitatively measure treatment results. Their physicians subjectively determined their outcomes.
Phase I Outcomes – Analysis of Sequential Single Drug Treatments Added in Queue.
Of the 501 patients admitted to hospital, 340 (67.9 %) were enrolled in Phase I looking at the effect of sequentially adding single drug treatments to the single drug treatment started upon admission following diagnostic evaluation including FMTVDM, Ferritin, IL-6, 12-lead electrocardiograms, and additional blood work already noted. The measurement of QTc in all treatment groups including both Phase I and II did not compromise treatment algorithms and there were no reported cases of Torsades de pointes TdP) or other ventricular dysrhythmias reported. Similarly Phase I, and II Treatments, were not altered due to glucose; liver and renal function tests, or QTc, and they consequently not be discussed further here.
Patients Who Failed Outpatient Aminoquinoline Treatment: As shown in Figure 2 and Table 8, of the 340 patients enrolled in Phase I, 39 (11.5 %) of these were patients who failed outpatient aminoquinoline treatment. Roughly half (51.3 %) had received Treatment 1, 43.6% had received Treatment 2, and 5.1 % had received Treatment 3. None of the outpatients who received Treatment 4 containing Primaquine failed outpatient treatment.
Of these 39 patients, 8 (20.5 %) received Treatment 6 (Remdesivir) as shown in Figure 2 and Table 8. Five of the 8 (62.5 %) responded successfully to treatment as defined by changes in FMTVDM, Ferritin and IL-6 levels. Of the three (37.5 %) that did not respond, the addition of Interferon a-2b (Treatment 9) in 1 case, and Convalescent Plasma (Treatment 11) in two other cases produced successful treatment results in all three (100 %) cases.
Ten (25.6 %) of the 39 received Treatment 7 (Tocilizumab) as a first line treatment following aminoquinoline failure, with 10 (100 %) of these patients responding favorably. Eleven (28.2 %) were successfully treated with Methylprednisolone (Treatment 8) without further treatment change. Of the remaining 10 (25.6 %) who were received Treatment 9 (Interferon a-2b), 90 % (9) responded to treatment, with 1 (10%) responding to the addition of Methylprednisolone (Treatment 8).
Of those admitted for further evaluation and treatment after failing outpatient aminoquinolines, 35 (89.7 %) responded to first line treatment including Remdesivir, Tocilizumab, Methylprednisolone and Interferon a-2b. Of the four (10.2 %) that required an additional line of treatment, 3 (75 %) of these were being treated with Remdesivir and 1 (25 %) with Interferon a-2b.
Patients Who Received No Outpatient Treatment: Figure 2, 3 and Table 8 show the flow and treatment results of patients who were enrolled in Phase I of the study after failing to improve as outpatients without treatment.
As shown in Figure 2, 301 (88.5 %) of the Phase I patients were individuals who had received no outpatient treatment and were admitted to hospital for further evaluation and treatment. This group of patients is further detailed in Figure 3 and Table 8.
Patients enrolled without prior outpatient treatment were randomly assigned to one of nine first line treatments, and one of ten when more than one treatment was added to the treatment regimen. This tenth treatment was defined as Treatment 11 (Convalescent Plasma). The original tenth treatment (Losartan) noted in Table 1 was thought to have a potential benefit based upon animal models but was excluded by the IRB given concerns about the potential increase in ACE2 receptors and lack of further potential information when the study was initiated.
Of the 301 patients in this part of Phase I, 38 (12.6 %) were randomly assigned to Treatment 1 (Hydroxychloroquine, Azithromycin). None of the patients showed a measureable treatment response. Of these 38, 5 (13.2 %) received Remdesivir (Treatment 6) as a second line drug, with none of the patients responding to the addition of Remdesivir. These same 5 patients then went on to receive a third drug, including 2 who responded to Treatment 7 (Tocilizumab) and 3 who responded to Treatment 8 (Methylprednisolone).
Eleven (28.9 %) of the 38 patients who failed first line treatment with Treatment 1, where given Tocilizumab (Treatment 7) as their second drug. Of these 11 patients, 8 (72.7 %) responded and three required the addition of a third drug; including two who received Treatment 8 (Methylprednisolone) and one who received Convalescent Plasma (Treatment 11). All three of these patients responded to treatment.
Methylprednisolone (Treatment 8) was given to 10 (26.3 %) of those who failed to respond to Treatment 1. Eight (80 %) of these patients responded to Methylprednisolone leaving only 2 to require a third drug including one who received Treatment 7 (Tocilizumab) and one who received Treatment 9 (Interferon a-2b) – both patients responded to this third drug treatment.
Seven (18.4 %) of these patients received Interferon a-2b (Treatment 9) as their second drug with 6 (85.7 %) of them responding. The remaining patient responded with Convalescent Plasma (Treatment 11). The five (13.2 %) of these patients received Convalescent Plasma (Treatment 11) as their second drug – all five (100 %) favorably responded to treatment.
Of the 38 patients, no one responded to the initial treatment with Treatment 1 (Hydroxychloroquine, Azithromycin). Twenty-seven (71 %) responded to the addition of a second drug and the remaining 11 people successfully responded to addition of a third drug.
Twenty-nine (9.6 %) of the 301 patients admitted without prior outpatient treatment were first given Treatment 2 (Hydroxychloroquine, Doxycycline). None of these 29 patients responded to this as the initial drug treatment. Of these 29 patients, 3 (10.3 %) were randomly assigned to receive Remdesivir. None of the three patients responded; however, all three responded to the addition of a third drug including two who responded to Treatment 8 (Methylprednisolone) and one who responded to Convalescent Plasma (Treatment 11).
Four (13.8 %) of the 29 patients received Treatment 7 (Tocilizumab) as the second drug with a 50 % response rate. The two patients who did not respond to the combination of Treatment 2 and 7, both responded to Treatment 9 (Interferon a-2b).
Ten (34.5 %) of the patients received Methylprednisolone (Treatment 8) as their second drug with 7 (70 %) responding to treatment. Of the three remaining, one received Tocilizumab (Treatment 7), one Interferon a-2b (Treatment 9), and one Convalescent Plasma (Treatment 11). All three responded to the addition of the third drug.
Interferon a-2b (Treatment 9) was administered as the second drug in 11 (37.9 %) of the 29 patients. Nine (81.8 %) of these patients responded to treatment with two others requiring a third drug including one who received Tocilizumab (Treatment 7) and one who received Methylprednisolone (Treatment 8). Both of these patients responded to the addition of the third drug. The final (3.4 %) patient who failed Treatment 2 received Convalescent Plasma (Treatment 11) and responded to treatment.
Of the 29 patients who failed to respond to Treatment 2 as their initial treatment, 19 (65.5 %) responded to the addition of a second drug. The remaining ten (34.5 %) patients responded to the addition of a third drug.
Treatment 3 (Hydroxychloroquine, Clindamycin) was the initial drug Treatment assigned to 25 (8.3 %) of the 301 patients who received no outpatient treatment prior to admission. Of these patients none were randomly assigned to receive Remdesivir (Treatment 6), or Convalescent Plasma (Treatment 11) as a second line drug.
Ten (40 %) of these 25 patients were randomly assigned to receive Tocilizumab (Treatment 7) as their second drug added to Treatment 3. Of these 8 (80 %) responded to treatment and two required the addition of a third drug, including one who received Treatment 8 (Methylprednisolone) and one who received Treatment 11 (Convalescent Plasma), to achieve treatment success.
Six (24 %) of the 25 were randomly assigned to receive Methylprednisolone (Treatment 8) treatment in addition to Treatment 3. All 6 (100 %) responded to treatment requiring no additional treatment. The nine (36 %) remaining patients received Interferon a-2b (Treatment 9). Eight (88.9 %) responded to this as the second drug with one remaining patient requiring the addition of Methylprednisolone (Treatment 8) to achieve successful treatment.
Of the 25 patient who began with Treatment 3 (Hydroxychloroquine, Clindamycin) as their initial hospital treatment, 22 (88 %) responded to the addition of a second drug and only 3 (12 %) required the inclusion of a third drug for successful treatment.
The fourth treatment (HCQ, Clindamycin, Primaquine) randomly selected among those who received no outpatient treatment was given to 21 (7 %) people. None of the patients responded to this initial treatment. During selection of the second line drug treatment to be added to Treatment 4, none of the patients were randomly assigned to either Treatment 6 (Remdesivir) or Treatment 11 (Convalescent Plasma).
Four (19 %) patients received Tocilizumab (Treatment 7) as their second drug and all four (100 %) of these patients responded to treatment. An additional 8 (38.1 %) received Methylprednisolone (Treatment 8), and 9 (42.8 %) received Interferon a-2b (Treatment 9) as their second drug. In all 21 (100 %) of these cases, patients responded to the addition of Methylprednisolone, Tocilizumab or Interferon a-2b. Collectively none of the patients responded to first line treatment with Treatment 4; however, they all responded to the addition of either Methylprednisolone, Tocilizumab or Interferon a-2b after initially receiving Treatment 4 including Primaquine in addition to the Hydroxychloroquine, Clindamycin found in Treatment 3.
Twenty-five (8.3 %) of the 301 patients who were admitted to Phase I after being admitted without receiving outpatient treatment were placed on Treatment 5 (Primaquine, Clindamycin); the only aminoquinoline treatment regimen that did not contain Hydroxychloroquine and the only drug which did not have an intravenous or nebulizer option for patients thereby eliminating it from evaluation and use in intubated patients. Of these 25 individuals none responded to Treatment 5 as first line therapy. However all 25 (100 %), including 9 (36 %) receiving Tocilizumab (Treatment 7), 8 (32 %) receiving Methylprednisolone (Treatment 8), and 8 (32 %) receiving Interferon a-2b (Treatment 9) responded to the addition of these second drug Treatments and did not require the addition of a third drug for treatment.
Of the 301 patients in this part of Phase I, 39 (13 %) were initially started on Remdesivir (Treatment 6). Of these 11 (28.2 %) responded to Remdesivir as the first line drug treatment leaving 28 (71.8 %) requiring a second drug to be added to Remdesivir. Of the 11 who did respond, 6 (54.5 %) were from Belgium.
Of the 28 people who did not respond to Remdesivir, 7 received Tocilizumab (Treatment 7) as a second drug. Four (57.1 %) of these seven people responded, with 3 others requiring the addition of a third drug Interferon a-2b (Treatment 9) to achieve treatment success.
Six of those who failed to respond to Remdesivir received Methylprednisolone (Treatment 8) as their second drug, with 5 (83.3 %) responding. Only 1 required a third drug, Interferon a-2b (Treatment 9), for treatment success.
Of the remaining 14 people who failed to respond to Remdesivir, 6 received Interferon a-2b (Treatment 9) with an 83.3 % response rate. The remaining individual received and responded to Tocilizumab (Treatment 7). The remaining 8 patients received Convalescent Plasma (Treatment 11) with 100 % response.
When Remdesivir (Treatment 6) had Treatment 7 (Tocilizumab) added as a second drug following Remdesivir there was no significant (p = NS) improvement in treatment effect. There was one death (2.6 %) following treatment with Remdesivir among patients who received no pre-hospital treatment. This patient died on day 4 while on ventilator as shown in Table 9.
As shown in Table 8 when taken collectively, including patients who received aminoquinoline treatment as an outpatient and those who received no pre-hospital treatment, there were 47 people who received Remdesivir (Treatment 6) as their first in hospital treatment and of these 16 (34 %) responded with 1 death (2.1 %). Thirty individuals went on to receive a second drug with 25 (83.3 %) responding, leading to 5 individuals receiving a third drug with 100 % treatment response.
Treatment 7 (Tocilizumab) was provided as first line treatment to 39 (13 %) of the patients enrolled in Phase I who had received no outpatient aminoquinoline treatment. Fourteen (35.9 %) of the patients responded to Tocilizumab. One death occurred in a ventilator patient on day 3 as shown in Table 8. Of the 24 remaining patients initially started on Tocilizumab, all 24 (100 %) responded to the addition of a second drug, including 3 who received Remdesivir (Treatment 6), 2 who received Methylprednisolone (Treatment 8), 8 who received Interferon a-2b (Treatment 9), and 11 who received Convalescent Plasma (Treatment 11).
Collectively of the patients who received no outpatient treatment, or received an aminoquinoline, almost half (49 %) responded to Tocilizumab (Treatment 7) alone, with the remaining patients responding to the addition of either Remdesivir (Treatment 6), Methylprednisolone (Treatment 8), Interferon a-2b (Treatment 9), or Convalescent Plasma (Treatment 11).
Forty (13.3 %) of the patients in Phase I who had not received outpatient treatment received Methylprednisolone (Treatment 8) as their first drug treatment when admitted. Of these, 22 (55 %) responded to treatment. The remaining 18 (45 %) responded to second line treatment including 3 who received Remdesivir (Treatment 6), 6 who received Tocilizumab (Treatment 7), 5 that received Interferon a-2b (Treatment 9), and 4 who received Convalescent Plasma (Treatment 11).
Including patients who received no outpatient treatment and those who received outpatient aminoquinoline treatment, 33 (64.7 %) responded to Methylprednisolone (Treatment 8) as their first line drug. The remaining 18 (35.3 %) responded to the addition of either Tocilizumab (Treatment 7), Interferon a-2b (Treatment 9), or Convalescent Plasma (Treatment 11).
The remaining 45 (15 %) patients enrolled in Phase I were treated with Interferon a-2b (Treatment 9). Of these 32 (71.1 %) individuals responded to Interferon a-2b with the remaining 13 (28.9 %) responding to the addition of a second drug; including 1 given Remdesivir (Treatment 6), 5 given Tocilizumab (Treatment 7), 5 given Methylprednisolone (Treatment 8) and 4 receiving Convalescent Plasma (Treatment 11).
Combining patients who received outpatient aminoquinoline treatment with those who did not, Interferon a-2b successfully treated patients as a single drug treatment almost three-quarters of the time; 90 % of the time when patients had received outpatient aminoquinoline treatment.
Phase II Outcomes – Analysis of Combined Drug Treatments Targeting the Immune ITR to SARS-CoV-2.
As shown in Figure 2, of the 501 patients treated in hospital, 161 (32.1 %) were enrolled in Phase II of the study. Of these 161 patients, 119 (73.9 %) had received outpatient aminoquinoline treatment and 42 (26.1 %) received no prior treatment. Figure 4 and Table 10 shows the details of Phase II.
Patients Who Failed Outpatient Aminoquinoline Treatment: One hundred nineteen patients who had received Treatments 1 (Hydroxychloroquine, Azithromycin), 2 (Hydroxychloroquine, Doxycycline), or 3(Hydroxychloroquine, Clindamycin – No Primaquine) as outpatients and were now admitted to hospital were randomly assigned to receive one of three treatments focusing on the immune ITR associated with SARS-CoV-2. These three treatments consisted were (1) Treatment 8 (Methylprednisolone), (2) a combination treatment of Treatments 7 (Tocilizumab) and 9 (Interferon a-2b), or (3) a combination of Treatments 5 (Primaquine, Clindamycin – No Hydroxychloroquine), 7 (Tocilizumab) and 9 (Interferon a-2b).
As shown in Figure 4 and Table 10, 35 (29.4 %) of these patients received Methylprednisolone (Treatment 8) as their first treatment with a 100 % effective treatment response. Forty-three (36.1 %) patients were started on the Combination Treatment of 7 (Tocilizumab) and 9 (Interferon a-2b). Forty-two (97.7 %) of the patients were successfully treated. One (2.3 %) patient died on day 5 (Table 9) while on the ventilator after failing treatment and receiving additional treatment with Convalescent Plasma (Treatment 11).
Forty-one (34.4 %) of the 119 were started on Combination Treatment 5 (Primaquine, Clindamycin – No Hydroxychloroquine), 7 (Tocilizumab) and 9 (Interferon a-2b). All 41 (100 %) patients were successfully treated.
Of the 119 patients who received an aminoquinoline treatment as an outpatient and then received a treatment regimen focusing on the immune ITR response to SARS-CoV-2 immediately upon admission, 118 (99.2 %) successfully responded to treatment. One (0.8 %) died on the 5th hospital day on the ventilator after receiving Convalescent Plasma (Treatment 11).
Patients Who Received No Outpatient Treatment: Phase II also included 42 patients who had not received an aminoquinoline as an outpatient as shown in Figures 2 and 4, and Table 10. In addition to the three treatments focusing on the immune ITR response to SARS-CoV-2, these patients were also randomized to potentially receive one of two aminoquinoline treatments as first line treatment. These two aminoquinoline treatments were Treatment 4 (Hydroxychloroquine, Clindamycin, Primaquine), and Treatment 5 (Primaquine, Clindamycin – No Hydroxychloroquine).
Nine (21.4 %) of these 42 patients received Treatment 4 (Hydroxychloroquine, Clindamycin, Primaquine) as their first treatment. None of the patients showed a successful response. Four (44.4 %) of the nine (in red) then received Treatment 8 (Methylprednisolone) and 5 (55.5 %) received (in red) the combination treatment of 7 (Tocilizumab) and 9 (Interferon a-2b). All 9 (100 %) showed successful treatment.
Seven (16.7 %) of the 42 received Treatment 5 (Primaquine, Clindamycin – No Hydroxychloroquine) as first line treatment without success. Of these 7, 3 (42.8 %) had Treatment 8 (Methylprednisolone) added (in red) to the regimen and 4 (57.1 %) had the combination of Treatments 7 (Tocilizumab) and 9 (Interferon a-2b) added (in red) to the regimen. In all 7 (100 %) of the cases, patients were successfully treated.
Nine (21.4 %) of the 42 patients who received no treatment as outpatients, received Treatment 8 (Methylprednisolone) as their first line in hospital drug treatment. All 9 (100 %) responded to treatment. In total there were 51 patients who received Treatment 8 (Methylprednisolone) during Phase II. Of these 35 had failed outpatient aminoquinoline treatment, 9 had received no outpatient treatment, and 7 others had received either Treatment 4 (Hydroxychloroquine, Clindamycin, Primaquine) or 5 (Primaquine, Clindamycin – No Hydroxychloroquine) before receiving Methylprednisolone as a second drug. In all 51 (100 %) cases patients were successfully treated with the addition of Methylprednisolone (Treatment 8).
Of the 42 patients who received no outpatient treatment, 11 (26.2 %) received 7 (Tocilizumab) and 9 (Interferon a-2b) as their first line treatment. All 11 (100 %) of these patients responded to treatment. In total 63 patients were treated with a combination of Treatments 7 (Tocilizumab) and 9 (Interferon a-2b) during Phase II. Of these, 62 (98.4 %) responded to treatment, with 1 (1.6 %) failing to successfully respond. This patient died as previously noted on Day 5 while on ventilator and after receiving Convalescent Plasma (Table 9).
The final 6 (14.3 %) patients received the ITR treatment combination, Treatments 5 (Primaquine, Clindamycin), 7 (Tocilizumab) & 9 (Interferon a-2b) with all 6 (100 %) patients responding. When added to the 41 patients who also received this treatment combination, 47 patients were successfully treated with the combination of Treatments 5 (Primaquine, Clindamycin), 7 (Tocilizumab) & 9 (Interferon a-2b).
Collectively Looking at Phase I and II to Evaluate the Statistical Significance of the 52-Treatment Regimens.
The cumulative 52 Treatment regimens resulting from the 10 individual Treatments applied in Phases I and II provided the measureable outcomes of the various drug treatments and treatment combinations that were then statistically compared as shown in Table 11. Following the protocol established for determining when a treatment should be abandoned due to worsening of the patient as defined by an increase in FMTVDM of greater than 25 units, no treatments were abandoned. While some treatments provided no definable measureable benefit, their absence of detriment was defined as a possible stabilization of the patient to which additional treatment was then added per protocol.
Comparing The 52-Treatment Combinations to Find SARS-CoV-2 Treatment(s): The results of the sequential addition of treatment to prior treatment(s) resulted in 52-treatment combinations from the 10 Treatment Arms that were then statistically analyzed to determine treatment outcomes. Given an absence of statistical differences (p=NS) several treatments were combined for further statistical analysis as “Triple Drug Treatment.” These combinations included (a) Treatment 1 (Hydroxychloroquine, Azithromycin) to which two of the following Treatments 6-9 and 11 were added sequentially, (b) Treatment 2 (Hydroxychloroquine, Doxycycline) to which two of the following Treatments 7-9, 11 were added sequentially, (c) Treatment 3 (Hydroxychloroquine, Clindamycin – No Primaquine) to which two of the following Treatments 7-9, 11 were added sequentially, and finally (d) Treatment 6 (Remdesivir) to which two of the following Treatments 7-9 were added sequentially.
When multiple ANOVA was applied to FMTVDM, Ferritin and IL-6, the absolute and measured changes in response to treatments were statistically significant at p < 0.0001.
As shown in Table 11, when Treatment 1 (Hydroxychloroquine, Azithromycin) was given to patients there was no statistical demonstrable improvement with p > 0.9999. When Treatment 6 (Remdesivir) was added, there was no change (p > 0.9999); however, when Treatments 7 (Tocilizumab), 8 (Methylprednisolone), 9 (Interferon a-2b) or 11 (Convalescent Plasma) were added to Treatment 1, the improvement in FMTVDM was statistically significant at p < 0.0001. The same improvement (p < 0.0001) was noted when two or more Treatments (6-9, 11) were added to Treatment 1.
Patients who received Treatment 2 (Hydroxychloroquine, Doxycycline) either alone or with the addition of Treatment 6 (Remdesivir) noted no FMTVDM improvement with p > 0.9999. When patients receiving Treatment 2 were additionally given Treatment 7 (Tocilizumab) there was minimal change with p = 0.8061, although they did statistically improve (p < 0.0001) when Treatment 8 (Methylprednisolone) or Treatment 9 (Interferon a-2b) was added. However, when Treatment 11 (Convalescent Plasma - P) was added to Treatment 2, there was no improvement (p = 0.9976). Finally when Triple Drug Treatment was used with Treatment 2, the outcome was significant (p < 0.0001).
The Third aminoquinoline Treatment arm 3 (Hydroxychloroquine, Clindamycin) showed no improvement (p > 0.9999) when given alone; but when given with Remdesivir, Methylprednisolone, or Interferon a-2b; there was a statistically significant improvement with p < 0.0001. A similar improvement was seen when Treatment 3 was combined with two of the following treatments; Tocilizumab, Methylprednisolone, Interferon a-2b, and Convalescent Plasma (p < 0.0001).
When Treatment 4 consisting of Hydroxychloroquine, Clindamycin, and Primaquine was given to patients upon admission to hospital there was no measureable tissue effect (p > 0.9999) on FMTVDM. When Tocilizumab, Methylprednisolone, and Interferon a-2b were added there was a statistically significant improvement with p < 0.0001. This same level of significance (p < 0.0001) was seen when the drug combination of Tocilizumab, and Interferon a-2b were added to Treatment arm 4.
The fifth and final Treatment Arm 5 including an aminoquinoline included Primaquine and Clindamycin absent the Hydroxychloroquine present in Treatment Arm 4. Like the first four Treatments including an aminoquinoline in patients who had not received an aminoquinoline as an outpatient, patients treated with Treatment 5 failed to show a significant benefit with p > 0.9999. The addition of Tocilizumab, Methylprednisolone, and Interferon a-2b resulted in a statistically significant (p < 0.0001) benefit. The same improvement (p < 0.0001) was seen when the combination of Tocilizumab, and Interferon a-2b were added to Treatment 5.
When Remdesivir (Treatment 6) was given to patients there was a significant improvement when given by itself (p < 0.0001); however when combined with Treatment 7 (Tocilizumab) there was less but still significant benefit noted with p = 0.0058. This treatment benefit was not lost when Methylprednisolone, Interferon a-2b or Convalescent Plasma were added to Remdesivir Treatment (p < 0.0001). The same improvements (p < 0.0001) were noted when Remdesivir was used in conjunction with a combination of two or more of the following three treatments, viz. Tocilizumab, Methylprednisolone and Interferon a-2b.
When patients were initially treated with Treatment 7 (Tocilizumab) there was a significant improvement with a p value of < 0.0001; however when Remdesivir (Treatment 6) was added to Tocilizumab the improvement was blunted (< 0.0071) compared with adding either Treatment 9 (Interferon a-2b) or Treatment 11 (Convalescent Plasma); both of which produced a better treatment outcome (p < 0.0001). However, when Methylprednisolone (Treatment 8) was added to Tocilizumab, the combination failed to show any improvement; p = 0.9448.
The initiation of Methylprednisolone (Treatment 8) by itself produced the most significant initial treatment response with a reduction of FMTVDM from 198 + 24 to 139 + 34, with a p value of < 0.0001. Adding Treatment 7 (Tocilizumab) or Treatment 9 (Interferon a-2b) to Methylprednisolone produced a significant additional benefit (p < 0.0001). However, when Treatment 6 (Remdesivir) was added to Methylprednisolone the treatment effect was less pronounced (p = 0.0079), as was the combination of Methylprednisolone and Convalescent Plasma (Treatment 11) with an effect of p = 0.0009.
Initiating treatment with Interferon a-2b (Treatment 9) produced a significant improvement (p < 0.0001); however in the one case where Interferon a-2b was combined with Remdesivir (Treatment 6) the combination effect was not significant with p = 0.9999. The combination of Methylprednisolone (Treatment 8) with Interferon a-2b did not produce an added benefit (p = 0.4400), while the combination of Interferon a-2b with either Tocilizumab (Treatment 7) or Convalescent Plasma (Treatment 11) did produced an additional beneficial effect (p < 0.0001).
When initial treatment was provided using combination drug therapy as was done during Phase II of the study, the combination of Treatment 7 (Tocilizumab) and Treatment 9 (Interferon a-2b) produced a greater treatment effect (p < 0.0001) than any single initial drug treatment with FMTVDM going from 198 + 24 to 132 + 29. The use of triple drug therapy using Treatments 5 (Primaquine, Clindamycin), Treatment 7 (Tocilizumab), and Treatment 9 (Interferon a-2b) produced a slightly greater treatment benefit with FMTVDM improving from 198 + 24 to 124 + 19 (p < 0.0001).
The difference between the initial treatment of SARS-CoV-2 patients using Triple Drug Treatment combining Treatments 5 (Primaquine, Clindamycin), Treatment 7 (Tocilizumab), and Treatment 9 (Interferon a-2b) was not statistically different from the Dual Drug Treatment of Treatment 7 (Tocilizumab) and Treatment 9 (Interferon a-2b) with a p value of 0.6654. While Dual Treatment with Tocilizumab and Interferon a-2b were better than Methylprednisolone, the difference was not statistically significant (p = 0.9200), in contrast to Triple Drug Treatment where a statistically significant difference of p = 0.0294 was seen.
Table 11 also shows the statistical significance of changes in Ferritin levels with treatment. The changes track the treatment response measured at the tissue level although as shown in Table 7 and Figures 7 and 8 there was is an initial delay in Ferritin response with greater variability. This lag time is shown by the slowed statistical response denoted by blue font in Table 9.
Quantitatively Find SARS-CoV-2 Treatment Response: The measured changes in IL-6 over the course of treatment for the various combinations of treatments are shown in Table 9. Differences between IL-6 and FMTVDM are displayed in red. Like Ferritin, the changes in IL-6 lag behind those measured with FMTVDM although the lag is less pronounced than that of Ferritin.
Each of the three (FMTVDM, Ferritin and IL-6) measured changes correlated inversely with hospitalization indicating improvement with successful treatment. Changes in Ferritin (r = - 0.544) and IL-6 (r = - 0.602) levels lagged behind measured changes in FMTVDM (r = - 0.633) tissue response to treatment effectiveness. Figure 7 shows the relationship between IL-6 and FMTVDM tissue measurements with a correlation of 0.718. The correlation between Ferritin and FMTVDM was 0.673.
Descriptive statistics comparing the quantitative measurements used for determination of CVP severity and treatment response are shown in Table 7 and Figure 8. Changes in FMTVDM, Ferritin and IL-6 showed statistically significant reductions (improvements with treatment) of p < 0.0001 for each of the serial quantitative measures following treatment from admission through day 10 or until the desired treatment outcomes as defined was achieved, with the following exceptions.
The difference between admission and day 4 FMTVDM measurements was p = 0.04 (p < 0.05) while the difference between admission and day 10 was p = 0.0181 (p < 0.05). While serial reductions in FMTVDM were measureable over the course of treatment, serial reductions in IL-6 were not statistically significant (p=NS) until day 7 when p < 0.0063. While Ferritin levels showed persistent reductions with treatment (p < 0.001), there was greater variability in Ferritin levels than FMTVDM or IL-6 as shown in Figure 6 and Table 6 where variability is standard deviation squared.
Differences in Discharge and Extubation by Treatment: Following determination of the effectiveness of patient outpatient and inpatient treatments, patient outcomes were also defined by measuring the period of time patients were hospitalized for treatment and if intubated the amount of time patients remained on the ventilator. Based upon each of the patients outpatient and inpatient treatment groups Tables 9 and 12 show the number of patients who were intubated at each site and during what Phase of the study. Beyond intubation and placement on ventilator support there were no additional differences noted in the method of oxygenation that significantly influenced outcomes, treatment response or discharge dates.
As Tables 9 and 12 show there were 52 intubations during Phase I of the study representing 15.3 % (52 of 340) of the patients. Two (3.8 %) of these patients died during the first 5 days of admission. Only 5 patients were intubated during Phase II of the study representing 3.1 % of the 161 patients enrolled in Phase II. One of these patients died on day 5. Of the 57 intubated patients, 3 (5.3 %) died – all within the first 5 days of admission. Each of the three deaths occurred on different treatments.
When patient outcomes were initially analyzed to determine if there was a specific treatment – either outpatient or inpatient – that was associated with a difference in time to extubation or time to discharge, patients were evaluated looking at both outpatient and inpatient treatment regimens. As shown in Tables 11 and 12 there were obvious differences associated with specific treatments that were statistically significant at p < 0.0001.
The results were then clustered together based upon common factors as shown in Table 12 with a p value of < 0.0001. These results of these clustered groups are displayed in bold font.
When patients were given sequential single drug treatments, successively building upon prior treatments to find the treatment combination that worked for any given patient based upon measured changes in FMTVDM, Ferritin and IL-6; patients who had received outpatient Treatments 1, 2 or 3 – all with hydroxychloroquine – and required admission to the hospital and were then started on a single drug regimen from Treatments 6-9 had an average hospital stay of 14 + 3 days (range 9 – 22 days). Of these 31 (79.5 %) were intubated and successfully extubated in 4 + 2 days.
In contrast, patients who had not received an aminoquinoline as an outpatient and who received single drug sequential treatments had a range of hospitalization from 18 – 44 days. Upon further examination these patients clustered based upon initial inpatient treatment. Those who were admitted and were given an aminoquinoline treatment without Primaquine first (Treatments 1-3) were hospitalized for an average of 38 + 4 days with a range of 30 – 44 days. Of these 8 (8.7 %) of the 92 required intubation. These patients were extubated on average within 9 + 2 days.
Two specialized groups of patients who had not received outpatient aminoquinoline treatment, received Treatment 4 or 5 containing Primaquine as their first line treatment. These patients were admitted for an average of 27 + 6 days. Only 2 (4.3 %) of these 46 patients were intubated and they were extubated in 8 + 1 days.
Patients who were given Remdesivir (Treatment 6) as their first single drug treatment and who had not received outpatient treatment with an aminoquinoline had an average hospital stay of 23 + 1 days (21 – 25 days). One (2.6 %) of these patients required intubated and died on day 4 of hospitalization.
The remaining patients who were enrolled in Phase I who did not received aminoquinoline (Treatments 1-3) as an outpatient were started either on Tocilizumab (Treatment 7), Methylprednisolone (Treatment 8), or Interferon a-2b (Treatment 9) as a single drug treatment. These single agent drugs focusing on treating InflammoThrombotic Responses (ITR) were associated with an average hospital stay of 22 + 3 days, ranging from 18 – 25 days. Seven (5.6 %) of these 124 patients required intubation, resulting in one death on day 3 of admission. The remaining six patients were extubated on an average of 6 + 1 days.
When the initial hospital drug treatment consisted of using either Methylprednisolone (Treatment 8) or a combination of drugs (Treatment 7 - Tocilizumab, Treatment 9 - Interferon a-2b) focusing on earlier treatment the ITR, and the possible inclusion of Primaquine [6,7] to further inhibit viral replication and decrease the ITR, patients who had received outpatient treatment with one of the regimens containing Hydroxychloroquine without Primaquine (Treatments 1-3), and who were initiated on these treatment regimens had an average hospital stay of 8 + 1 day, ranging from 6 – 13 days. Of these 119 patients, 5 (4.2 %) were intubated with one death on day 5 of the admission.
Patients who received no outpatient aminoquinoline treatment (Treatments 1-3) and who received either Treatment 4 (Hydroxychloroquine, Clindamycin, Primaquine) or 5 (Primaquine, Clindamycin) as their first line treatment in hospital had an average hospital stay of 29 + 2 days, ranging from 27 – 32 day. None of these patients required intubation and there were no deaths.
Finally, patients who received Methylprednisolone (Treatment 8) or a combination of drugs (Treatment 7 -Tocilizumab, Treatment 9 - Interferon a-2b with or without Treatments 4 or 5 containing Primaquine ) and had not received outpatient aminoquinoline treatment had an average hospital stay of 17 + 2 days, ranging from 13 – 19 days. None of these patients required intubation and there were no deaths.
The shortest hospital stay of slightly more than a week (8 + 1 days) was seen in patients who had received hydroxychloroquine (Treatment 1-3) as an outpatient, even though it had failed to prevent admission, and then received as first line hospital treatment either Treatment 8 (Methylprednisolone), or combination Treatment 5 (Primaquine, Clindamycin) and 7 (Tocilizumab); or Treatments 5 (Primaquine, Clindamycin), 7 (Tocilizumab) and 9 (Interferon a-2b); or Treatments 7 (Tocilizumab) and 9 (Interferon a-2b); all targeting the immune ITR, and who were not intubated.
The second shortest hospital stays also occurred among patients who had received outpatient HCQ treatments and then received as their first single drug sequential treatment either Treatment 6 (Remdesivir), Treatment 7 (Tocilizumab), Treatment 8 (Methylprednisolone), or Treatment 9 (Interferon a-2b). This regimen resulted in an average hospital stay of 2 (14 + 3 days) weeks.
By contrast the two longest hospital stays were associated with patients who had not received outpatient HCQ treatment and either received (1) a combination of Hydroxychloroquine, Clindamycin and Primaquine (Treatment 4), or Primaquine and Clindamycin without the Hydroxychloroquine (Treatment 5), with an average hospital stay of 29 + 2 days; or (2) were initially started on Treatment 1-3 containing Hydroxychloroquine. The difference between these groups with the shortest and longest stays is statistically significant at p < 0.0001.
The treatment combination that resulted in the fastest recovery time and the shortest hospital stay was for patients who upon admission were immediately started on either Treatment 8 (Methylprednisolone); or combination of Treatments including (1) 5 (Primaquine, Clindamycin) & 7 (Tocilizumab), (2) 5 (Primaquine, Clindamycin), 7 (Tocilizumab) & 9 (Interferon a-2b), or (3) Treatments 7 (Tocilizumab) & 9 (Interferon a-2b).
As shown in Table 12 for patients who had received prior aminoquinoline treatment as an outpatient, the time for recovery and discharge from hospital was approximately one week, and slightly more than two weeks for those who had not received outpatient treatment. There was no statistically significant difference (p = 0.5216) between the four treatments groups targeting the immune ITR associated with SARS-CoV-2, with each resulting in successful treatment and discharge on an average of 7-8 days.