key: cord-324553-qd8249w3 authors: Cadegiani, F. A.; Wambier, C. G.; Goren, A. title: An open-label prospective observational study of antiandrogen and non-antiandrogen early pharmacological approaches in females with mild-to-moderate COVID-19. The Pre-AndroCoV Female Trial. date: 2020-10-06 journal: nan DOI: 10.1101/2020.10.05.20206870 sha: doc_id: 324553 cord_uid: qd8249w3 Background: While COVID-19 remains largely unclear and mortality continues to raise, early effective approaches prior to complications lack, as well as researches for characterization and therapeutical potential options in actual early COVID-19. Although females seem to be less affected than females, hyperandrogenic (HA) phenotype, like polycystic ovary syndrome (PCOS), idiopathic hirsutism, congenital adrenal hyperplasia (CAH) female androgenetic alopecia (AGA), or idiopathic HA may be at higher risk due to its inherent enhanced androgenic activity. The present study aimed to evaluate the effects of any early pharmacological approach to females diagnosed with COVID-19 before seven days of symptoms, as well as investigate whether HA is an additional risk factor in this population. Materials and methods: Females with symptoms for less than seven days confirmed for COVID-19 through positive real-time polymerase chain reaction (rtPCR-SARS-CoV-2) were classified and divided as non-HA, HA, and HA using spironolactone (HA-spiro) groups. Patients were questioned for baseline characteristics, 23 different diseases, 44 drug classes and vaccines, 28 different symptoms, and eight different parameters to measure COVID-19 related clinical outcomes. Treatment was then provided, including azithromycin 500mg/day for five days in all cases, associated with hydroxychloroquine 400mg/day for five days, nitazoxanide 500mg twice a day for six days, or ivermectin 0.2mg/kg/day por three days, and optionally spironolactone 100mg twice a day until cure. Patients were assessed for COVID-19 clinical course, clinical and viral duration, and disease progression. Results: In total, 270 females were enrolled, including 195, 67, and eight in non-HA, HA, and HA-spiro groups, respectively. Prevailing symptoms were anosmia (71.1%), ageusia (67.0%), headache (48.1%), myalgia (37.4%), dry cough (36.3%), nasal congestion or rhinorrhea (34.1%), fatigue (33.3%), weakness (29.5%), hyporexia (27.8%), thoracic pain (24.8%), diarrhea (24.1%) and dizziness (21.5%). Earliest symptoms (days) were dizziness (1.0 +- 0.2 day), abdominal pain (1.1 +- 0.3); conjunctival hyperemia (1.1 +- 0.5), nasal congestion or rhinorrhea (1.2 +- 0.5), headache (1.2 +- 0.5), dry cough (1.2 +- 61617; 0.5), myalgia (1.2 +- 0.4), nauseas (1.3 +- 0.5) and weakness (1.3 +- 0.5). Time-to-treat, positive rtPCR, and duration of symptoms with and without anosmia and ageusia were significantly lower in HA-spiro than non-HA, HA, and overall non-users. Time-to-treat was similar while all duration of symptoms and positive rtPCR-SARS-CoV-2 were significantly shorter in non-HA than HA. Spironolactone users were more likely to be asymptomatic than non-users during COVID-19. Fewer non-HA than HA females were affected by anosmia, ageusia, dry cough, fatigue, weakness and hyporexia. Ageusia, weakness and myalgia lasted shorter in non-HA than HA. None of the patients needed hospitalization or any other COVID-19 complication. Conclusions: A sensitive, early detection of COVID-19 followed by a pharmaceutical approach with different drug combinations yielded irrefutable differences compared to sex-, age-, body mass index (BMI)-, and disease-matched non-treated controls in terms of clinical outcomes, ethically disallowing placebo-control randomized clinical trials in the early stage of COVID-19 due to the marked improvements. HA females presented more severe and prolonged clinical manifestations, although none progressed to worse outcomes. Spironolactone mitigated the additional risks due to HA. the early stage of COVID-19 due to the marked improvements. HA females presented more severe and prolonged clinical manifestations, although none progressed to worse outcomes. Spironolactone mitigated the additional risks due to HA. COVID-19 is a multi-systemic and multi-factorial syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Its exact mechanisms of action are still largely unclear, and despite the massive number of infections and deaths, effective approaches before it becomes severe lack (1) (2) (3) (4) . One of the most likely reasons to explain why we have failed to detect effective approaches is that while we are searching for molecules with antiviral activity, we are detecting COVID-19 too late, when viral infectivity no longer plays a key role in the pathophysiology at that stage, which will naturally lead to lack of efficacy from these antiviral approaches. While we have focused the vast majority of the researches on patients after they acute lung injury and hospitalized patients, a relative shortage of researches in actual earlier stages of COVID-19, in comparison to the relevance of trying to discover effective approaches for secondary prevention, i.e., preventions of COVID-19 complications after its detection. Meanwhile. number of researches that allege to have researched in mild patients actually included hospitalized patients only, which is inherently contradictory Because of the large pre-symptomatic period, asymptomatic infected subjects, prolonged incubation and viral shedding period, and unrevealed means of transmission, viral spreading remains, despite all unprecedented public policies. (since anosmia and ageusia tend to appear after three a five days only), highly heterogeneous clinical presentation, and lack of good predictors of those who will further develop acute lung injury are still challenges to detect COVID-19 during the period when therapies focusing on antiviral activity may still be effective (6) (7) (8) (9) . An additional challenge to be overcome it the persistence of policies focusing on the sine-quo-non presence of fever or shortness of breath to perform the diagnostic realtime Polymerase Chain Reaction (rtPCR) for SARS-CoV-2 (10,11). While these two symptoms should not be considered as signs for the presence of COVID-19, but for severe COVID-19 instead, we will fail to diagnose COVID-19 when complications are potentially avoidable. The reports on the literature claiming that fever is present in the majority of patients with COVID-19 are based on data collected from registers that require fever to diagnose COVID-19, which is per se a limitation for a more accurate description of COVID-19 manifestations. Reports based on diagnostic tools for COVID-19 that do not require fever show that fever may be present in as low as 10% of infected patients only (12) (13) (14) . Several different molecules demonstrated in vitro antiviral activity against SARS-CoV-2 and have been proposed as promising therapies for COVID-19 (13) , among which the most attempted drug combinations included azithromycin in the majority of the cases, in association with hydroxychloroquine, ivermectin or nitazoxanide (13, 14) . However, since detection of COVID-19 is predominantly delayed due the mandatory presence of fever for its suspect, antiviral approaches will be less effective, since at this stage of the disease viral infectivity becomes less central. Accordingly, randomized clinical trials (RCT) on alleged early COVID-19 yielded conflicting results, although the majority have been exclusively performed in hospitalized patients (10-14). We have concluded that pharmacological therapies for truly early and mild COVID-19 has not been investigated thoroughly, which precludes from conclusive findings regarding the efficacy of antiviral approaches at this stage. To evaluate potential antiviral therapies, it is critical to detect COVID-19 during the first days after its appearance, which is only feasible with more sensitive approaches its diagnosis. Although underreported, risks for acute lung injury, thrombosis and other clinical complications in COVID-19 are also related to increased exposure, enhanced activity, and/or hypersensitivity to androgens (15) (16) (17) (18) (19) (20) (21) (22) (23) . Overrepresentation of males in terms of complications related to COVID-19 are not fully justified by differences in age, body mass index (BMI), prevalence of comorbidities, i.e., there is an inherent risk related to male sex (15) (16) (17) (18) . This is likely explained, at least partially, by the transmembrane serine protease 2 (TMPRSS-2), a critical protein for the SARS-CoV-2 entry into the cells, that are largely and solely regulated by androgens. Among males, androgenetic alopecia (AGA) as an independent predictor of complications related to COVID-19, possibly due to a resultant of overexpression of androgen receptors (AR), due to enhanced dihydrotestosterone (DHT) levels, activity, response, or a combination between these factors, that discloses AGA as a clinical phenotype expression. While females are underrepresented among severe COVID-19 patients, risk factors including menopause, aging, uncompensated type 2 diabetes mellitus (T2DM), hypertension and obesity seem to enhance the risk of severe COVID-19 in females more than in males. In addition, in an analogically similar manner than AGA males, females with any expression of hyperandrogenism (HA), including polycystic ovary syndrome (PCOS), idiopathic hirsutism, congenital adrenal hyperplasia (CAH) due to 21alphahydroxylase or 11beta-hydroxylase deficiency, female AGA, or idiopathic HA, have sufficient mechanistical plausibility to support the hypothesis that this population may be at higher risk compared to non-HA females. In this regard, the use of antiandrogens has demonstrated promising results, as already observed for both males and females, at least when used chronically (19) (20) (21) (22) . This reinforces the role of the role of antiandrogen approaches as an additional path to improve outcomes in COVID-19. Nonetheless, similarly to the use of antiviral therapies, antiandrogens should be tested during the first stage, as it affects viral infectivity. There were sufficient theoretical, mechanistical, observational and epidemiological observations to intuitively hypothesize that if the lack of sensitivity is to detectCOVID-19 is addressed and therefore diagnosed during the first stage, preferably before seven days of symptoms, antiviral pharmacological attempts could be then effective. At this point, it is uncertain whether this approach would be affective, which is our objective. Together, the evaluation of sex differences, as well as differences between phenotypes within each sex, would also disclose additional information for promising approaches for specific populations. The objectives of the present study are to perform a thorough and comprehensive clinical characterization of patients with COVID-19 detected through a highly sensitive case-detection basis, and to explore the clinical responses and outcomes to a variety of drug combinations. In addition, we aimed to detect sex-specific and androgenic phenotype-specific clinical manifestations and outcomes. This is an open-label prospective observational study performed alongside with our currently ongoing RCT This specific study is an open label prospective observational study of the characterization and clinical outcomes of females with COVID-19 in response to specific therapeutic combinations. In order to detect cases during the earliest stages of COVID-19, we employed a highly sensitive case-detection criteria for suspect for COVID-19. We changed from the mandatory presence of severity or specific signs (shortness of breath, fever, anosmia, ageusia) to the occurrence of absolutely any atypical symptom or changes in patters of chronic symptoms, even when not supposedly related to COVID-19. Suspected females underwent rtPCR-SARS-CoV-2 (Abbott RealTime SARS-CoV-2 . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint 4. GI infection-like clinical presentation: at least two of diarrhea, nauseas, vomiting, or abdominal pain; 5. Mixed between clusters: when there are symptoms to fill criteria for at least two clusters 6. Unspecific presentation: when there are only unspecific or insufficient symptoms to fill criteria for any cluster; or 7. Asymptomatic. After characterization, drug combination including azithromycin 500mg/day for five days, with hydroxychloroquine 400mg/day for five days, nitazoxanide 500mg twice a day for six days, or ivermectin 0.2mg/kg/day for three days was then provided. The choice between hydroxychloroquine, nitazoxanide, and/or ivermectin was based on an almost-random manner, i.e., randomly, except when clinical judgement considered otherwise. In addition, spironolactone, vitamin D, vitamin C, zinc, apibaxan, rivaroxaban, enoxaparin, and glucocorticoids could have been prescribed, also according to medical judgement. Patients were then evaluated for: 1. Time-to-appearance and duration of each symptom (number of days); 2. Time until full remission of symptoms, not including anosmia and ageusia (number of days); 3. Time until full remission of symptoms, including anosmia and ageusia (number of days); 4. Duration of positive rtPCR-SARS-CoV-2 (in number of days, where rtPCR was performed every seven days); 5. Level of clinical improvement in Days -7 to -4, -3 to -1, 0, 1, 2, 3, 7, 14, 21, 30 and 60 days, where 0 corresponds to the worst day of symptoms (scored according to the number and severity of symptoms) and 100 means asymptomatic or entirely recovered; 6. Ability to perform everyday activities in Days 0, 3, 7, 14 and 30 (0 = no loss of capacity and 100 = complete inability to perform any self-care or everyday activity); 7. WHO COVID Ordinal Outcomes Scale; 8. Brescia COVID-19 score; 9. Disease progression outcomes, including hospitalization, mechanical ventilation, and death. Full raw data is available at a data repository (https://osf.io/cm4f8/). . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. Hypnotics (zolpidem, zopiclone, eszopiclone, ramelteon) Selective serotonin reuptaker inhibitors (SSRIs) (fluoxetine, (des)venlafaxine, sertraline, (es)citalopram, vortioxetine, fluvoxamine) Other antidepressants and humor stabilizers (bupropion, topiramate, trazodone, ami-ou nortriptiline, topiramate, oxcarbamazepine) Benzodiazepines (Lora-, broma-, dia-, clonazepam; alpra-, midazolam) Atypical antipsychotics (olanzapine, quetiapine, risperidone, clozapine, aripiprazole) Central nervous system (CNS) stimulants (methylfenidate, lisdexamfetamine, modafinil) Omega-3 (> 3g/day) Vitamina D (> 1,000iu/day) Zinc (> 15mg/day) Vitamin C (> 500mg/day) . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint Tables 6 to 15 detail characteristics and parameters of overall females and for each group (non-HA, HA and HA-spiro), and overall and pairwise comparisons. Tables 2 to 5 depict baseline and medical characteristics, Tables 6 to 8 describe COVID-19 presentation, Tables 9 and 10 show the proposed pharmacological interventions for COVID-19, and Tables 11 to 15 depict COVID-19 clinical outcomes. In total, 270 females confirmed for COVID-19 were included. Of these, 195, 67, and eight were from the non-HA, HA, and HA-spiro groups. The dropout rate for clinical characterization and disease outcomes was zero. Baseline characteristics are described in Table 2 . HA females were significantly younger, shorter, and heavier than non-HA. The major and prevailing diseases were present in similarly present in all groups (Table 3) , while chronic kidney disease (CKD) was present in one patient, and liver fibrosis and cirrhosis, and current cancer were absent. Although HA had greater BMI than non-HA females, prevalence of obesity was similar between groups. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint BCG, influenza and pneumococcal were similar between groups, as well as practice of regular physical (Table 5) . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint Table 6 describes COVID-19 clusters of clinical presentation. URTI-like syndrome was statistically more prevalent in HA than non-HA, while anosmia-ageusia predominance, dengue fever-like, GI infection-like, mixed and unspecific symptomatology were similar between groups. Spironolactone users were more likely to be asymptomatic than non-users during COVID-19. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint present in fewer than 20% of patients include "sore throat" (15.9%), pre-orbital pain (12.6%), arthralgia (10.4%), conjunctival hyperemia (8.1%), nauseas (8.1%), abdominal pain (7.8%), upper back pain (7.7%), "sinusitis" (6.7%), shortness of breath (5.9%), lower back pain (5.2%), and pre-orbital pain (3.5%), dry eyes (2.2%) and dry mouth (1.1%). COVID-19 has shown the following sequence of symptoms, in a chronological order: 1. Earlier symptoms (< 2.0 days from the first symptom; in days): 4.7 ± 2.5), hyporexia (4.8 ± 2.8), and conjunctival hyperemia (4.9 ± 2.6); and those with prolonged duration (> 5 days), including dry cough (5.4 ± 3.5) "sore throat" (5.5 ± 1.9), headache (5.7 ± 3.5), "sinusitis" (6.0 ± 2.6), dry eyes (6.2 ± 2.1), ageusia (7.0 ± 5.7), dry mouth (7.0 ± 0.0), fatigue (7.2 ± 4.9) and anosmia (7.9 ± 6.2). Similar time-to-appearance and duration: fever, "feverish", nasal congestion or rhinorrhea, headache, shortness of breath, "sinusitis", "sore throat", dizziness, thoracic pain, lower back pain, diarrhea, nauseas, abdominal pain, pre-orbital pain, and dry eyes and mouth. Although conjunctival hyperemia was almost five times more present in HA than non-HA females (in terms of percentage), it did not reach statistical significance. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint Anosmia and ageusia were almost absent in spironolactone users. Fewer non-HA than HA females were affected by anosmia, ageusia, dry cough, fatigue, weakness and hyporexia. Ageusia, weakness and myalgia lasted shorter in non-HA than HA. Time-to-appearance was shorter in non-HA for upper back pain. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. 7.0 ± 0.0 n/a HA = hyperandrogenic; n/s = non-significant n/a = non-applicable As shown in Table 8 , among proposed therapeutical options for COVID-19, besides azithromycin, which was given to all patients, nitazoxanide, hydroxychloroquine and ivermectin were prescribed in statistically equal proportions. There were also no differences between the percentage of additional drugs prescribed between groups (Table 9 ). is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint Table 10 shows the average time-to-treat and the clinical and biochemical duration of COVID-19 manifestations. Time-to-treat, positive rtPCR, and duration of symptoms with and without anosmia and ageusia were all significantly lower in HA-spiro when compared to non-HA, HA, and overall non-users, even when only HA-spiro females with symptoms were included for the analysis. Conversely, while time-to-treat was similar, all other three outcomes were significantly shorter in non-HA compared to HA. Table 11 details the clinical course of COVID-19. Although the peak of symptoms is apparently higher in the HA group, it did not reach statistical significance when compared to non-HA due to the wide variability. Conversely, the recovery process seems to be slower in this group, as evidenced by the largest differences between HA and non-HA, and between HA and HA-spiro in Days 2 to 7, which coincides with the early response to proposed pharmacological treatments. HA-spiro group had fewer symptoms than non-spironolactone users in Days -3 to -1 and Day 7, as well as than HA females in Days -3 to -1 and Days 2 to 7. . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint HA = hyperandrogenic; n/s = non-significant; n/a = non-applicable 1.0 (n/s) HA = hyperandrogenic; n/s = non-significant; n/a = non-applicable; CI = confidence interval As in Table 12 , which depicts the World Health Organization (WHO) COVID Ordinal Outcomes in the present population, HA females had significantly higher scores than non-HA and HA-spiro groups in Days 0 and 7, and became similar after Day 14. None of the patients presents as Scores 3 to 5 throughout the disease. The loss of capacity to perform everyday activities is described in Table 13 . None of the spironolactone users had any level of loss of everyday activities. Conversely, HA were significantly more compromised when compared to non-HA and HA-spiro females (p = 0.004 and 0.028, respectively), by the time that proposed treatments started (Day 0). This was mitigated in the following days (Days 3, 7, 14 and 30) . Except for spiro-HA (not affected at any time), Day 3 had significant improvement compared to Day 0. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. 1.0 (n/s) HA = hyperandrogenic; n/s = non-significant; CI = confidence interval Table 14 is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint that they do not believe to be due to COVID-19. The majority of patients had at least one complain that would not be reported if not actively questioned. Researches have largely focused approaches for stages two and three, while assumed that none of proposed therapies for earlier stages would be effective ('wait and see'). Culturally, unlike bacterial infections, specific antiviral treatments tend to be avoided. Except for chronic and relapsing viruses, antivirals have been studied at an irregular basis, and their clinical use have long been avoided. Moreover, drugs for other diseases that might disclose direct or indirect antiviral activity have been underestimated. More important than the culture of non-viral treatment that surrounds the medical field, is that the lack of specific symptoms and the usual presence of uncommon clinical presentations, that likely precluded the majority of the patients from an actual early diagnosis. The change in the paradigm for detection of COVID-19 towards more sensitive and active search for COVID-19 may have driven the better outcomes observed in the present study. We consider imperative that policies for COVID-19 diagnosis change The patient with COVID-19: characterization of the patients and the disease Baseline characteristics were significantly different between non-HA and HA probably because HA females tend to be shorter and present higher BMI. The differences between age is understandable when one considers that the phenotypical expression of HA tends to occur earlier in lifetime. Furthermore, recognition of female HA (except for dramatic cases, as beard females) has only occurred in the last decades, and was underdiagnosed until short time ago. Differences in BMI between HA and non-HA was relatively lower than differences in age, and obesity was similarly present between groups. Conversely, even being significantly younger, HA females presented more severe manifestations of COVID-19 than non-HA . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint While none of the prevailing chronic diseases presented any difference between groups, metformin and oral contraceptives were more used in HA than non-HA females, possibly due to the fact the PCOS is the most common underlying condition that leads to HA. In a similar manner of what has been observed in males, symptoms in females could be easily clustered (23-26). At least two symptoms of each cluster were together within a same patient in more than 80% of patients. The clusters of anosmia-ageusia predominance, dengue fever-like, URTI-like, and GI infection-like clinical presentation have been detected, in addition to those with unspecific symptoms, or with more than one cluster. The remarkable URTI-like clinical symptoms among HA females may be due to enhanced infectivity that has been shown to occur under hyperandrogenic states. The similar number of patients treated with hydroxychloroquine, nitazoxanide and ivermectin and the lack of major differences at least in terms of COVID-19 complications shows that the choice for a specific medication to be added to azithromycin is not imperative. Also, although preliminary hypotheses and data demonstrating the important role of azithromycin as an adjuvant therapy against SARS-CoV-2, whether this drug plays an add-on benefit effect is uncertain, and remains unanswered, since we did not compare with versus without its use. Correspondingly, additional drugs and supplements were given according to an individualized clinical evaluation, and were used in similar percentages between groups. The use of anticoagulant, specially Xa factor inhibitors and enoxaparin, were based on the risk for thrombosis and development of other complications, since COVID-19 is a pro-thrombotic state per se. Vitamin D, and at slightly lesser extent, zinc and vitamin C, were prescribed to the majority of treated patients. Hence, whether these additional prescriptions helped to improve outcomes cannot be concluded from the present study. All early COVID-19 related outcomes, including duration of positive rtPCR-SAR-CoV-2 and symptoms with or without anosmia and ageusia were markedly lower in HA-spiro when compared to non-HA, HA, and overall non-users. However, time-to-. CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint treatment was equally lower in HA-spiro females. Hence, whether the shorter and milder clinical presentation in COVID-19 among spironolactone users is due to earlier beginning of treatment is unknown, although COVID-19 disease course remained better in the HAspiro group after adjustments for non-asymptomatic patients only. Unlike HA-spiro, since time-to-treat and treatment options were similar between non-HA and HA females, obesity prevalence was similar, and HA were younger than non-HA, prolonged clinical and viral duration among HA females may only be explained by the hyperandrogenism. Although spironolactone users had more asymptomatic presentation than other groups, when HA-spiro patients presented symptoms, these symptoms presented similar time-to-appearance and duration than non-HA females. The great majority of the symptoms occurred in similar percentages and presented similar durations for all groups. Increased fatigue, dry cough and anosmia, and increased and prolonged weakness, myalgia and ageusia found in HA females should also be explained by hyperandrogenism, in an analogical manner than male AGA (5, 6, 14, 16, 17) , due to enhanced expression of TMPRSS-2. Differences in disease course were more evident between Days 0 and 7 in HA females, as this population presented slower speed of improvement compared to other groups, as evidenced by three methods to quantify this speed (Tables 11 to 13 ), which means that HA females were shown to improve, but took longer than other groups. Despite the slower symptom regression in HA, all groups showed increased recovery rate after initiation of any of the proposed therapies. The importance of measuring loss of capacity to perform everyday activities lays on the fact that infected patients remain isolated for approximately 14 days, and needs to be able to perform the basic hygiene and self-care activities during this period. Although HA females were more compromised than non-HA and HA-spiro females, even this group was only slightly affected, and lasted for less than three days. Unlike rapid clinical recovery, radiology did not show any improvement during the first 30 days after treatment initiation. However, there is a major bias that those that . CC-BY-ND 4.0 International license It is made available under a perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint underwent more than one chest CT were those that persisted with complains or were already compromised. Hence, radiological improvement may be less prolonged that what has been shown in the present study. Criteria employed to measure COVID-19 severity, ilike WHO COVID Scale and Brescia Respiratory Scale, revealed to be inaccurate in the present analysis, since none of the patients progressed to respiratory complications, hospitalization, and other outcomes. Instead, more sensitive scales were better to detect differences. Oppositely to non-spironolactone HA females, HA that use spironolactone had markedly better clinical outcomes related to COVID-19. Additionally, the small number of patients with COVID-19 taking spironolactone may reflect its potential preventive effect, despite the lack of any other data to support this hypothesis. Spironolactone has been proposed to exert multiple beneficial roles in COVID-19, including increase of circulating-to-attached angiotensin converting enzyme 2 (ACE2) ratio, increased angiotensin receptor (AT) 2-to-AT1 ratio, decreased TMPRSS2 activity, as well as antiviral and anti-inflammatory activities (20) (21) (22) , and its promising roles have been reinforced by the present analysis. The importance of unveiling potential effective treatments for COVID-19 not only lays on preventing hospitalization, mechanical ventilation, and death, but also preventing long-term, post-cure persisting symptoms, termed as "post-COVID syndrome", that has shown to be present in at least 20 to 30% of patients, and includes autoimmune, mental, psychiatric, muscular, respiratory and gastrointestinal disorders, and persisted fatigue, resembling chronic fatigue syndrome (CFS), unrelated to any specific biochemical marker to date (27, 28) . Hence, whenever a pharmacological intervention study is conducted, researchers should not only consider acute, but also chronic complications as targets to evaluate efficacy. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . https://doi.org/10.1101/2020.10.05.20206870 doi: medRxiv preprint When duration and severity of clinical symptoms, disease duration, and related complications are compared with the extensive reports on the literature, differences are undisputable, particularly for clinical outcomes (10-12). At least in the present population of females, differences were sufficiently overwhelming to justify the lack of need for placebo-control trials, from an ethical perspective. However, open label RCTs and other prospective observational studies are mandatory to confirm the clear findings of the present study, when compared to the expected outcomes for COVID-19 in females. As a prospective observational study conducted prior to a double-blind placebocontrol RCT, aiming to better determine the selection process and parameters to be evaluated, as well as define the most plausible pharmacological approach between hydroxychloroquine, nitazoxanide, ivermectin, or none. As per the study deisgn, the lack of a placebo group initially hampers from conclusive findings. However, this has been overcome by the evident differences when compared to the well-established COVID-19 course and outcomes, which disallows us from performing the RCT as a full placebocontrol. The replication of a highly sensitive case-detection guidance that include the occurrence of absolutely any symptom as being suspected for COVID-19 may find barriers that may preclude from a successful approach, including: 1. Lack of general and medical education regarding the unspecific pattern of COVID-19 clinical presentation; 2. Self-judgement of not being affected by COVID-19; 3. Inability to correlate non-obvious symptoms with COVID-19, losing the window of opportunity; and 4. Cultural focus on the severe patient, neglecting those are possibly preventable from COVID-19 complication. Although this may not necessarily occur with all patients, the larger number of patients treated early, the better clinical outcomes should be. is the author/funder, who has granted medRxiv a license to display the preprint in (which was not certified by peer review) preprint The copyright holder for this this version posted October 6, 2020. . Since COVID-19 is an extensive, diffuse, and largely unclarified disease, a thorough medical evaluation that encompasses questions for all organs and systems should be performed at a regular basis, in clinical practice, not only restricted to researching purposes. The early detection associated with any drug combination among azithromycin, hydroxychloroquine, nitazoxanide and ivermectin yielded notable improvements in terms of course of COVID-19, when compared to literature. Among females, presenting HA may be an additional risk for COVID-19 severity, as they presented to be slightly more affected and had a prolonged recovery process when compared to non-HA and spironolactone users. The chronic use of spironolactone in a daily dose 100mg or more in HA females not only seemed to mitigate, but also reduce risks to below those found in non-HA. This has shown to have similar relative risks when compared to the presence of AGA and use of dutasteride among males, respectively. A sensitive, early detection of COVID-19 followed by a pharmaceutical approach with a drug combination between azithromycin in all cases, associated with hydroxychloroquine, nitazoxanide or ivermectin demonstrated unequivocal differences when compared to the extensively described natural disease course when pharmacological treatments potentially effective for COVID-19 is not provided, particularly if detected until three days after the beginning of symptoms. 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Otolaryngol Head Neck Surg Post COVID-19 syndrome associated with orthostatic cerebral hypoperfusion syndrome, small fiber neuropathy and benefit of immunotherapy: a case report. eNeurologicalSci Considering the potential for an increase in chronic pain after the COVID-19 pandemic The funding of present study was fully supported by Corpometria Institute (Brasilia, DF, Brazil) and Applied Biology Inc (Irvine, CA, USA). Authors declare no conflict of interest with any of the pharmacological interventions proposed by the present study.