Evaluation of Sovodak (Sofosbuvir/Daclatasvir) Treatment Outcome in COVID-19 Patient's Compared with Kaletra (Lopinavir/ritonavir): a Randomized Clinical Trial

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection and treatment are signicant health organizations' concerns worldwide. Although there is no proven drug license against the virus, a variety of components have under investigation. In this regard, the present study was intended to evaluate the consequences of Sovodak (Sofosbuvir/Daclatasvir) treatment in COVID-19 patients compared with Kaletra (Lopinavir/ritonavir). Methods: This study was conducted as a randomized trial using 120 COVID19 conrmed cases between August 19th and September 19th, 2020, in which subjects were classied into two treatment groups, 58 (Sovodak group) and 54 (Kaletra group). Related statistical operations calculated signicant outcomes such as survival rate and hazard ratio via SPSS v.16. Sovodak was composed of Sofosbuvir 400mg and Daclatasvir 60mg, and Kaletra included Lopinavir 400 mg and ritonavir 100 mg. Results: We observed that there was no signicant difference concerning the comorbidities, death, ICU admission, remission. Besides, Kaletra had a higher rate of discharge versus Sovodak (HR=1.551 (95% CI=1.008-2.386), P-value=0.046), and a better outcome was observed in patients receiving Conclusion: Sovodak compared to Kaletra by Hazard plot. Sovodak (Sofosbuvir/Daclatasvir) therapy in COVID19 cases was accompanied by a signicantly higher survival rate and better outcome than Kaletra (Lopinavir/ritonavir).


Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) was rst identi ed in China and then spread to the rest of other countries. World Health Organization (WHO) announced a global alarm called COVID-19 for the disease [1]. The recent Situation Report (14 Dec 2020) of a total of 71,051,805 con rmed cases, 1,608,648 have died, and there are 574,969 new cases per day and 8,726 new deaths.
Iran reported 1,108,269 con rmed cases and 52,196 deaths with daily new cases of 7,451 and deaths of 247 people in which it is ranked the 14th among all countries [2]. Currently, there are no licensed drug available acts against SARS-CoV2. However, there are different candidate components and drugs under clinical trials such as Atazanavir, Lopinavir/ritonavir, Remdesivir, Sofosbuvir, Favipiravir, Arbidol, Chloroquine, and Hydroxychloroquine, Immunomodulators, TNF antagonist, Anti-IL6 antibody, Intravenous immunoglobulin, Corticosteroids, Cyclosporine, Tacrolimus [3,4]. Lopinavir/ritonavir (LPV/RTV) or Kaletra are antiretroviral protease inhibitors that have been used in the treatment of human immunode ciency virus (HIV) since 2000 [5]. Kaletra is composed of Lopinavir/ritonavir (LPV/RTV) (400 mg and 100 mg, respectively). RTV is conjugated to LPV to increase its half-life [6]. LPV acts against the viral 3-chymotrypsin-like protease, and it has been used against SARS-CoV-1 and MERS-CoV viruses previously [7][8][9]. There have been some Kaletra administration records for COVID-19 [10] operation, and according to guidelines, it is used for severe patients [11]. Several investigations have focused on its e cacy in COVID19 patients [12,13]. Sofosbuvir is a clinically approved anti-hepatitis C virus (HCV) drug [14] [14]. Sofosbuvir is a nucleotide analog that has been approved against HCV polymerase. This drug is also able to suppress positive-strand RNA viruses [15]. SARS-CoV-2 has RNA-dependent RNA polymerase (RdRp), which could inhibit by sofosbuvir [16]. Some studies have suggested that sofosbuvir may bind strongly to the enzyme SARS-CoV-2 RdRp and inhibit its function [17,18]. Sofosbuvir is a safe drug and has fewer side effects. It can be tolerated at a dose of 400 mg daily over a 24-week course of treatment [19]. in Iran, Sofosbuvir is available in combination with daclatasvir (Sovodak commercial name) (doses of 400 and 60 mg, respectively) [20]. It has been used for COVID19 patients, and then trials run to evaluate its effects.
Given the COVID 19 pandemic and the absence of proven treatment, as well as the high cost of Kaletra combination therapy and its scarcity, evaluating the e cacy of drugs such as second-generation oral antivirals in the treatment of COVID 19 can be valuable. Therefore, we decided to conduct a bicentric randomized clinical trial to compare the two treatment regimens Kaletra (LPV/RTV) and the combination therapy Sovodak (Sof/Dac).

Patients and setting
In this parallel 2-arm controlled-randomized, single-center study, a total of 120 patients referred to Firoozgar hospitals a liated to Iran University of Medical Sciences, Tehran, Iran, were taken from August 19th to September 19th, 2020. Ethics approved by the Ethical Committee of Iran University of Medical Sciences, Tehran, Iran (code: IR.IUMS.FMD.REC.1399.407).
All patients with mild to moderate disease admitted to Firoozgar hospital, Tehran, Iran, were recruited based on inclusion criteria included age more than 18, hospitalized patients with respiratory symptom and sao2 >90 and diagnostic chest CT scan (mild to moderate scores), with or without Tempreture>38, Excluded patients were patients have hypersensitivity to the drug, pregnant or breastfeeding, using other COVID-19 related drugs, heart rate<60/min, having organ failure, eGFR< 50 mL/min, decreased level of consciousness, blood pressure less than 90/60 mm Hg, hypoxia, blood oxygen saturation less than 90%, allergies to study drugs, prior COVID-19 treatment, organ failure and patients requiring mechanical ventilation at the time of hospitalization or patients with adverse reaction drugs. All medical history of patients obtained from hospital data repositories and routine visits.
Sovodak was composed of Sofosbuvir 400 mg and Daclatasvir 60mg. Kaletra was included Lopinavir 400 mg and ritonavir 100 mg. Two study groups set in a randomized manner by using the ABAB block was used for the patients. Patients in block A used Sovodak (SOF/DAC 400/60) (Sovodak, Fanavaran Rojan Mohaghegh Daru Co, Tehran, Iran) one tablet every 24 hours. A group was obtained hydroxychloroquine 400 mg every 12 hours for the rst day, then 200 mg every 12 hours for 5 to 7 days. Group B used Kaletra (LPV/RTV 400/100) 2 tablets every 12 hours for seven days and took hydroxychloroquine 400 mg for the rst day every 12 hours. The clinical recovery analyzed the main outcome in 5 to 7 days by normalization of fever (≤37.2 °C), respiratory rate (≤24/minute), and oxygen saturation (≥94%). All study medication was discontinued at discharge. If the hospitalized patient's condition deteriorated, drop saturation, increased respiratory rate, we change the drug or admit the patient to ICU, we de ne them as the failure of treatment. Abnormal lung CT scan was de ned as ground glass, air bronchogram, and consolidation ndings.

Outcomes and laboratory monitoring
White blood cell count (WBC), and erythrocyte sedimentation rate (ESR) was determined at baseline, at the end of the study, and during the study, if needed. Clinical recovery was de ned as normalization of body temperature (<37.2°C), respiratory rate (<24/min), and oxygen saturation≥93% without supplementary oxygen therapy at room temperature. The relative improvement of radiological evidence, lesion progression, and no need for new treatment and invasive mechanical ventilation methods were also considered responses to the treatment regimens studied.
Statistical analysis SPSS v.16 was used for statistical analysis. Variables normality was determined using the K-S test. The better outcome de ned as a lower hospitalization period and no need for re-health care. Fisher's exact test for categorical outcomes. The Cox Proportional Hazard analysis was carried out for adjustment of baseline characteristics. We used the Student t-test or Mann-Whitney test to compare means and medians. Values less than 0.05 were considered as statistically signi cant.

Clinical trial Registry
The present study approved by Iranian Registry of Clinical Trials (IRCT) (https://www.irct.ir/) at 12/10/2020 by the code IRCT20200328046885N1. All guidelines and protocols submitted and approved by IRCT.

Results
Among all COVID-19 admitted patients, 120 patients followed up to 14 days, 112 were included in the analysis ( gure 1). The rest of the study group was excluded from the analysis due to avoid length-bias and other reasons. Of them, 54 patients (48.2%) were in the Kaletra group, and 58 patients (51.8%) were in the Sovodak group. Demographic characteristics of admitted patients in each group are listed in table 1.
Underlying disease was found in 88 (78.57%) of all patients included in two groups. No statistically signi cant difference was detected between the two groups regarding the evaluated characteristics. Table  2 shows comorbidity and other variables of statistical analysis. Table 3 shows the status of the outcome in patients who obtained Sovodak and Kaletra separately. No, any signi cant difference was detected between the two groups concerning the evaluated outcomes. Further details were obtained in table 3. Table 4 showed the COX hazard proportional model results in which the length stay of hospitalization was considered the outcome, and the type of treatment predictor. Our results showed the patients who used Kaletra had a higher rate of discharge according to the time of hospitalization (HR=1.551 (95% CI=1.008-2.386), P-value=0.046). The survival function plot was displayed in gure 2.
The hazard function plot was also drawn up, and it demonstrated that the Kaletra Hazard line is above of Sovodak hazard line. This result could de ne the better outcome of using Sovodak compared to Kaletra in both patients with underlying disease and without ( gure 3).
Recent articles have claimed that combination therapy of hydroxychloroquine and Kaletra is unlikely to have any bene cial effects against COVID-19 and might even be harmful to the patients, so alternative treatments must be explored and used [22][23][24]. According to the studies [14,16,25,26], there are no speci c side effects in people using Sofosbuvir, so this drug can be used as a suitable alternative for treating patients with COVID-19.
In this regard, by the present study, we have set up a randomized trial on 112 con rmed COVID19 patients (54 were in the Kaletra group and 58 were in the Sovodak group) in a referral hospital in Tehran, Iran. We found that there was no signi cant difference regarding the comorbidities, death, ICU admission, remission. Additionally, Kaletra had a higher rate of discharge versus Sovodak (HR=1.551 (95% CI=1.008-2.386), P-value=0.046), and a better outcome was observed in patients using Sovodak compared to Kaletra by Hazard plot.
Clinical trials in Iran have been performing on Sofosbuvir's e cacy alone or in combination with daclatasvir or other antivirals such as ledipasvir and velpatasvir for the treatment of COVID-19 patients (https://www.irct.ir/). Among these studies, we can name the study of Sadeghi et al. [26], which was performed on two groups of patients; a treatment arm receiving sofosbuvir and daclatasvir plus standard care, and a control arm receiving standard care alone. This study showed that the addition of sofosbuvir and daclatasvir to standard care signi cantly reduced the hospitalization duration and mortality rate compared with standard care alone. This study provides timely evidence of the e cacy of Sovodak in the treatment of COVID-19 patients during its rapid pandemic. One of this study's strengths was that all patients were treated with standard medication, and the study was not placebo-controlled. In this case, it became possible to compare patients based on the type of treatment of choice, in addition to treatment with hydroxychloroquine. Performing a placebo-controlled trial during a pandemic is a challenge. Also, due to the higher mortality probability of the present disease, a placebo-controlled trial is not recommended if left untreated.
In the study of Sadeghi et al. [13] on 66 COVID19 patients (33 in Kaletra and 33 in Sovodak groups), they have not found any increase in Kaletra's survival rate compared with Sovodak group. Interestingly, we have found signi cant differences in the two groups' survival rate, and Sovodak had a better outcome than Kaletra in both patients with underlying disease and without. This differences may re ect the limitation of Sadeghi et al. [13] by the sample size in which our study enrolled more than three times larger sample size versus that study. Additionally, Sadeghi et al. [13] reported Sovodak combination with standard care could reduce the hospitalization duration; in the current study, we have found that the Kaletra group had lower ICU admission, disease severity, and hospitalization duration compared with the Sovodak group; however, the better outcome was seen in Sovodak group based on Hazard function plot.
Some undesirable events, such as loss of follow-up due to Iran heath policy encourage people to stay at home to follow the treatment until severe symptoms emergence [13] and death, may impact our results. Our study follow-up duration mean was 14 days but some of the cases followed 20 or fewer days. Cao et al.
[27] followed 14 days for more than 85% of participants.
In a study, Kaletra (lopinavir-ritonavir) treatment in COVID19 patients had no associations with acceleration in clinical improvement, reducing mortality, and viral load depression [27]. Some studies have shown the worse effect of Kaletra + hydroxychloroquine combination therapy in COVID19 patients [27,28]. Compared to our study, we have found more death in the Kaletra group, although it was not signi cant. Moreover, a worsen outcome was shown in our studied Kaletra group compared with the Sovodak group. However, ICU admission, disease severity, and hospitalization duration were lower than those of the Sovodak group due to follow-up loss or death.

Study of Abbaspour Kasgari et al.
[29] on 48 COVID19 patients divided into two groups: 24 intervention group (by the administration of 400 mg sofosbuvir, 60 mg daclatasvir, and 1200 mg ribavirin) and 24 control group (standard care). They did not nd hospitalization stay differences, ICU admission, and death rate between the two groups. However, they reported a signi cantly higher recovery rate in the sofosbuvir/daclatasvir/ribavirin arm (Gray's P= 0.033). Compared to our study, the differences may due to the larger sample size, our center setting, and enrollment of patients from different provinces referred to the capital of Iran, not just local residents.
Our study had some limitations. Viral load quantitation and its follow-up during treatment to calculate the viral shedding period are very important to estimating treatment e ciency; however, total recovery, ICU admission, and laboratory tests could illustrate it as well; however, their association was not clearly understood [27,30]. The serum concentration of each drug could help nd both drugs' antiviral effect, which contains two components. In this regard, we have failed to calculate their levels due to the high costs of analysis and limited budget. Also, we have not a long-term follow-up after treatment for the participants to estimate the complete drug e ciency. Other limitations include different participant numbers and the difference in CT scan involvement ndings at the baseline divided into two groups. Additionally, there was a shortage of SARS-CoV-2 PCR tests not to obtain follow-up PCR on the patients.

Conclusion
In conclusion, this large scale study proves Sovodak administration's priority by little or no side effects versus Kaletra. Sovodak might be useful in reducing the hospitalization duration and mortality rate and increasing patients' remission. These results justify the integration of sofosbuvir/daclatasvir into largescale trials leading to approval for treatment of coronavirus infection. In this regard, we have found that the overall survival rate and outcome by the Sovodak group were better than those in the Kaletra group.
However, our limitations, such as viral load quantitation and long term follow-ups, need to be considered in further multi-center studies.

Declarations Ethical Approval and Consent to Participate
All methods were carried out in accordance with the Declaration of Helsinki and informed consent was obtained from each patient. Written consent signed by each participant. This study approved by the Ethical Committee of Iran University of Medical Sciences, Tehran, Iran with ethical code IR.IUMS.FMD.REC.1399.407.

Availability of data and materials
The present study datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Con ict of interest
All authors declare that they have no con ict of interest.