Oral Fluvoxamine With Inhaled Budesonide for Treatment of Early-Onset COVID-19 : A Randomized Platform Trial

Abstract

Background: Previous trials have demonstrated the effects of fluvoxamine alone and inhaled budesonide alone for prevention of disease progression among outpatients with COVID-19.

Objective: To determine whether the combination of fluvoxamine and inhaled budesonide would increase treatment effects in a highly vaccinated population.

Design: Randomized, placebo-controlled, adaptive platform trial. (ClinicalTrials.gov: NCT04727424).

Setting: 12 clinical sites in Brazil.

Participants: Symptomatic adults with confirmed SARS-CoV-2 infection and a known risk factor for progression to severe disease.

Intervention: Patients were randomly assigned to either fluvoxamine (100 mg twice daily for 10 days) plus inhaled budesonide (800 mcg twice daily for 10 days) or matching placebos.

Measurements: The primary outcome was a composite of emergency setting retention for COVID-19 for more than 6 hours, hospitalization, and/or suspected complications due to clinical progression of COVID-19 within 28 days of randomization. Secondary outcomes included health care attendance (defined as hospitalization for any cause or emergency department visit lasting >6 hours), time to hospitalization, mortality, patient-reported outcomes, and adverse drug reactions.

Results: Randomization occurred from 15 January to 6 July 2022. A total of 738 participants were allocated to oral fluvoxamine plus inhaled budesonide, and 738 received placebo. The proportion of patients observed in an emergency setting for COVID-19 for more than 6 hours or hospitalized due to COVID-19 was lower in the treatment group than the placebo group (1.8% [95% credible interval {CrI}, 1.1% to 3.0%] vs. 3.7% [95% CrI, 2.5% to 5.3%]; relative risk, 0.50 [95% CrI, 0.25 to 0.92]), with a probability of superiority of 98.7%. No relative effects were found between groups for any of the secondary outcomes. More adverse events occurred in the intervention group than the placebo group, but no important differences between the groups were detected.

Limitation: Low event rate overall, consistent with contemporary trials in vaccinated populations.

Conclusion: Treatment with oral fluvoxamine plus inhaled budesonide among high-risk outpatients with early COVID-19 reduced the incidence of severe disease requiring advanced care.

Primary funding source: Latona Foundation, FastGrants, and Rainwater Charitable Foundation.

Visual Abstract.. Oral Fluvoxamine With Inhaled Budesonide for Treatment of Early-Onset COVID-19

Previous trials have shown the effects of fluvoxamine alone and inhaled budesonide alone for prevention of disease progression among outpatients with COVID-19. This placebo-controlled, randomized trial, conducted at 12 clinical sites in Brazil, sought to determine whether the combined effect of both drugs would increase treatment effects.

Figure 1.. Participant flow chart.

Figure 2.. Subgroup analyses comparing fluvoxamine–budesonide versus matched placebo.

In the prespecified subgroup analyses, we found consistent evidence of treatment benefits with fluvoxamine–budesonide compared with matched placebo. BMI = body mass index; CrI = credible interval; ITT = intention-to-treat.