Potential to save lives: An intensive care doctor argues for ‘compassionate use’ of ivermectin for Covid-19

We know that Maverick Citizen respects and protects the crucial role of the South Africa Health Products Regulatory Authority (SAHPRA) in ensuring efficacy and safety of medicines. However, where the need is urgent and immediate, we also think that public debate of the evidence on which its decisions are based is also important. The use of Ivermectin is a case in point. 

Here, a frontline intensive care doctor explains why he thinks there are strong medical grounds to make ivermectin available for compassionate use.

Between 21 December 2020 and 9 January 2021 South Africa recorded a further 8,100 deaths from Covid-19 and a total of 292,260 new cases. This means we have had: an average of 13,917 new cases daily and an average of 386 deaths per day.

I have chosen 21 December because that is when the Rapid Review by the National Essential Medicines List Committee (NEMLC) Covid-19 subcommittee recommended we wait for more large randomised controlled trials (RCTs) to be published to decide whether ivermectin is appropriate for South Africa. 

The scientists who put this review together need to be commended for producing it in a short period; that document became the basis for continued objection to the immediate granting of permission for ivermectin use for patients with Covid-19. Their document is at least slightly better than the initial from SAHPRA, released on 22 December, and whose improved 6 January statement is here.

But, in my view the Rapid Review was inadequate. It is also unacceptable, considering that since its publication there has been enough outcry and enough information has been shared on what it missed. More than three weeks later they have not reviewed their recommendation, which the Department of Health (DoH) continues to use to refuse the authorisation of this potentially life-saving medication.

It is interesting that the DoH, through its Ministerial Advisory Committee (MAC), released a follow-up memo, dated 7 January 2021. This memo acknowledges that the “unregulated use of ivermectin is evident in South Africa and increasing” and that, “at a community level it appears that ivermectin is being widely promoted for the treatment and/or prevention of Covid-19. There are numerous anecdotal reports from general practitioners and pharmacists of the widespread prescribing and sale of ivermectin for these purposes.” 

Although this memo is a step in the right direction, it is too timid and less pragmatic about maximising on saving patients’ lives. It reaches the same conclusion that “until more robust evidence is available, the routine use of ivermectin for either the prevention or treatment of Covid-19 is not justified” while recognising that “emerging evidence must be actively sought and carefully reviewed”.

(Photo: trialsitenews.com/Wikipedia)

• At the end of November 2020 our admitted cases doubled from between six and eight to more than 20 in a week;


• That number increased to more than 40 by the next week and to more than 80 by 21 December. On this day we began mobilising all surgical departments to free their beds to accommodate a projected unmanageable surge;


• The patients we were seeing with this resurgence were, worryingly, younger (40s) and sicker than our first surge;


• By 28 December we had 110 admitted patients, and 133 by 4 January 2021 (a 17-fold increase in fewer than 30 days);


• We were losing an average of four patients a day, including persons under investigation (PUI) with results unknown and Covid-19 patients (more than two per day);


• The number of patients requiring oxygen grew exponentially compared with the first surge.


• Our mortality for Covid and PUI patients has gone up 40-fold.

• Faster viral clearance – an obvious marker of drug effect;


• Shorter hospital stay – a measure more relevant in resource-constrained environments;


• 48% higher rates of clinical recovery;


• An 83% increase in survival rates – the goal of most therapeutic interventions; and


• The drug was effective in all the clinical stages of the disease – prevention/prophylaxis->out-of-hospital treatment – and treatment of severe disease.

• “It makes treating Covid-19 patients fun again.” I dare you to find any South African doctor in the frontline who can say this about treating these patients;


• “Patients with very low oxygen saturations around 60-80% are discharged within a day of admission, off oxygen.” This is in a country poorer than South Africa, with an even worse challenge of resources.

• Steroids, which are advocated by everyone, have a very narrow window of effectiveness, with a modest 25% mortality reduction. The benefit of steroids is that they are cheap and readily available;


• The antiretroviral combination of Lopinavir/Ritonavir has been declared ineffective. With our high HIV/Aids population, this was a reasonable drug to study if it was to be effective since it is readily available with a known side-effect profile;


• Tocilizumab has been found ineffective in the large multicentre, randomised control trial by Solidarity, with a narrow window of purported benefit. The UK has authorised it for licensure and prescription in Covid-19, based on the results of the single REMAP-CAP trial. This is a drug that costs R55,000 ($3,600) for a patient course of treatment, with a modest benefit of 8.5% mortality reduction;


• Hydroxychloroquine had to be quickly withdrawn due to side-effects and no benefit on mortality; it also had a narrow window of effectiveness;


• Remdesivir is the last drug being studied by the Solidarity Trial, and is slowly also showing a lack of statistically significant effect on mortality, with a limited window of effectiveness. It also has a discouraging price tag, especially for low-income countries, of R10,000 per patient.

• Staff shortages – either endemic or from current illness with Covid-19;


• Staff deaths from Covid-19;


• High-risk staff who cannot work during a surge;


• Fear that prevents staff from coming into work.

• Prophylaxis using the I-Mask Protocol (shared here) to limit frontline staff infections – this can be extended to all frontline workers, including food industry staff, police, teachers, public transport drivers and hospitality industry workers. That way we can have a reasonable continuation of essential services.


• It can be used to reduce or limit the need for hospital admissions and for early outpatient treatment protocols like this one. We are already overburdened, and ivermectin holds clear evidence of benefit for out-of-hospital treatment;


• It can be used to reduce hospital stay in very sick patients and improve mortality overall using protocols like the MATH+ Protocol – which gives the opportunity to discharge patients earlier and for clinicians to focus on the more severe cases with less therapeutic response.