Evaluation of the Effect of Combination Therapy on Treatment of COVID-19: A Cohort Study

and biological abnormalities, as well as the radiological and pathological patterns of the disease have been described so far. Moreover, many studies have addressed different therapeutic strategies for the management of the disease.

The proposed medicines for the treatment of COVID-19 included Kaletra (lopinavir–ritonavir), remdesivir, oseltamivir, ribavirin, sofosbuvir (2-5), immunomodulators, such as chlorine and hydroxychloride (6-7) as well as  anti-inflammatory medications, such as corticosteroids (8-10) or their combination (11).

The main COVID-19 management strategy has its focus on antiviral treatments with Kaletra (lopinavir–ritonavir), remdesivir, oseltamivir, ribavirin, sofosbuvir (2-5), immunomodulators, such as chlorine and hydroxychloride (6,7) and anti-inflammatory therapies, such as corticosteroids (8-10) or their combination, owing to the two-phase pathogenesis of the disease (11).

Antiviral therapies are effective in the treatment of such diseases as Middle East respiratory syndrome coronavirus, severe acute respiratory syndrome coronavirus, and influenza. However, the effectiveness of these medications in the treatment of COVID-19 has not been widely approved, even though evidence indicates the decreasing pattern of viral load over time. The other management strategies are focused on anti-inflammatory therapies, such as the use of corticosteroids, particularly in patients with organizing pneumonia patterns (8,9).

In general, the administration of corticosteroids has been recommended for critically ill patients suffering from COVID-19 (10). A combination of antiviral drugs with corticosteroids has also been suggested which may effectively decrease viral load and treat inflammation in the patients.

Due to the importance of COVID-19 treatment, the present study aimed to investigate the combination therapy on the treatment of this disease.

This cohort study included 175 confirmed COVID-19 patients in the age range of 25-95 years who were hospitalized at two medical centers designated for the treatment of COVID-19 in Qom and Qazvin, Iran, from March 17 to April 29, 2020. All the COVID-19 patients in this study were diagnosed according to the WHO interim guidelines. The medical records of all patients were obtained from the hospital data and the death of any patient was recorded as an outcome. The study was approved by the Medical Ethics Committee of Baqiyatallah University of Medical Sciences (IR.BMSU.REC.1399.001).

According to the data obtained from the hospitals, each patient received one of the four combination therapy regimens and was consequently assigned to one of the four groups of 1, 2, 3, and 4. Medicines applied on patients in Group1 included azithromycin (250 mg daily), prednisolone (25 mg/daily), and naproxen (250 mg BD). Medication in Group 2 included lopinavir/ritonavir  (200/50 mg tablets two times/12 h), azithromycin (250 mg daily), naproxen (250 mg BD), and prednisolone (25 mg daily). Patients in Group 3 took hydroxychloroquine (250 mg tablets two times/12 h), azithromycin (250 mg daily), naproxen (250 mg BD), and prednisolone (25 mg daily). Medicine regimen in Group 4 consisted of meropenem (1gr/8h), levofloxacin (500 mg/day), vancomycin (1gr/12h), hydroxychloroquine (200 mg/12 h), and oseltamivir (75 mg/12 h).

Inclusion criteria in this study included 1) Diagnosis of COVID-19 based on approved diagnostic tools, such as real-time RT-PCR (throat-swab specimens) or chest CT scan according to the WHO interim guidelines which included symptoms of typical coronavirus pneumonia (i.e., patchy infiltration and focal unilateral to ground-glass opacity, ill-defined margins, smooth or irregular interlobular septal thickening, air bronchogram, crazy-paving pattern, and thickening of the adjacent pleura) (23-14), 2) Oxygen saturation (SPO2) ≤93, 3-16≤Age≤100, 3) Patients with controlled diabetic status, no history of gastrointestinal bleeding, non-pregnant and non-lactating mothers, 4) Patients with no history of immunosuppressive therapy or chemotherapy in the past month. However, patients with high missing data in the medical records were excluded from the study.

In this study, the patients’ demographic data, history of past diseases, and laboratory findings (i.e., white blood cell count (WBC), neutrophil, lymphocyte, hemoglobin, platelet count (Plate), C- reactive protein (CRP),  creatinine) were obtained. Moreover, the vital signs of the patients were monitored which included temperature, respiratory rate (RR), pulse rate (PR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and resting stable oxygen saturation (5 min after disconnecting). Eventually, symptoms, such as cough, fever, dyspnea, weakness and lethargy, headache, dizziness, anorexia, and body pains were extracted from the medical records of hospitalized patients.

3.1. Statistical Analysis

The data were analyzed using R software (version 3.2 for Windows) based on non-missing values through the Kruskal-Wallis Test, analysis of variance (ANOVA), analysis of covariance (ANCOVA), and Chi-square test (for comparing demographic and baseline variables among the four combination regimens). Qualitative and quantitative variables were reported in percentages and mean±SD, respectively. A p-value less than 0.05 (P≤0.05) was considered statistically significant.

The COVID-19 pandemic has had a notable impact on the death rate of the health system and inflicted huge socio-economic costs on numerous countries around the world over the past year (15). The lack of a clear, reliable, and proven standard therapy for COVID-19 is one of the serious public health problems. Therefore, the current research aimed to evaluate the effect of combination therapy on the treatment of COVID-19 disease. Based on the obtained result in this study, the combination of azithromycin, prednisolone, and naproxen led to better clinical results, compared to the other three combination therapy regimens. This result can be attributed to the concurrent use of azithromycin and prednisolone. Moreover, an early upper respiratory tract shedding of the virus has been confirmed in asymptomatic and pauci symptomatic patients at the early emergence of the symptoms (16). Therefore, antiviral regimens and handling of virus load lost effect in symptomatic patients over time, considering the fact that patients in this study were not in the early phase of the disease. Moreover, anti-inflammatory drugs have been recommended for the treatment of pulmonary lesions and improvement of clinical outcomes in some patients due to their effectiveness in controlling cytokine storms (17).

The results of a study conducted by Russell indicated that low-dose prednisolone could have beneficial effects on the treatment of COVID-19 (18). Another study performed by Arshad et al. showed that the application of azithromycin was associated with a reduction in mortality rate associated with COVID-19 (19). In addition,  a review study conducted by Jean et al. reported the excellent clinical efficacy of hydroxychloroquine along with azithromycin on COVID-19 patients (20). The pharmacological mechanism of azithromycin and prednisolone in the treatment of COVID-19 is presented in the studies conducted by Sultana et al. (21) and Caruso et al., respectively (22). Based on the results of a study conducted by Vahedi et al. low-dose prednisolone in combination with azithromycin, naproxen, and lopinavir/ritonavir led to a reduction in COVID-19 hospital stay (11). Based on the results of a  meta-analysis conducted by Sarma et al. (23) no significant improvement was observed in the status of COVID-19 patients treated with hydroxychloroquine. In addition, the results of a  review study by Yousefi et al. indicated that neuraminidase inhibitors, such as oseltamivir, peramivir, and zanamivir were not recommended for the treatment of COVID-19 disease (24).

The results of another study showed that laboratory variables, such as WBC, lymphocyte, CRP, as well as SPO2 were associated with a hospital mortality rate (25).

Regarding the limitations of the present study, one can refer to the lack of certain clinical recording and laboratory results, which was due to inadequate patient profiles in the hospitals’ electronic medical reports. Consequently, the recommendations in this study were made based on the available data.

Based on the obtained result in this study, the combination of azithromycin, prednisolone, and naproxen was a more effective treatment regimen, compared to the other three combination therapy regimens.

The authors gratefully acknowledge financial support from Baqiyatallah University of Medical Sciences and would like to thank all the personnel, especially the staff of Baqiyatallah Hospital, for their cooperation throughout the study.

Authors’ contribution: Amir Hosein Ghazale, Ali Ghazviniand Mostafa Ghanei conducted the study design. Data collection was performed by Ensieh Vahedi,  Shideh Omidian, Abolfazl Mozafari, Mohammad Rezapour,  Nafiseh Rastgoo, Fatemeh Movaseghi, Fateme Mansouri, Mohammad Ali Zohal, Maryam Gheraati,  Hassan Goodarzi, Amir Mohammad Dehghan Banadkooki, Amir Mohammad Dehghan Banadkooki, Shahrzad Saloo, and Hesamodin Salou. Data analysis was carried out by Mohammad Gholami Fesharaki. Eventually, Mohammad Gholami Fesharaki, Mostafa Ghanei, and Amir Hosein Ghazale wrote the manuscript.

Ethical Approval: The cohort study was approved by the Medical Ethics Committee of Baqiyatallah University of Medical Sciences (IR.BMSU.REC. 1399.001) and was conducted in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Conflict of interests: The authors declare that he has no conflicts of interest regarding the publication of the present study.

Funding/Support: This study was funded by Baqiyatallah University of Medical Sciences.

Informed consent: Informed consent was not required to conduct this study.