What is the recommended dosing of ivermectin for COVID-19 treatment?

Ivermectin Is Not Recommended for COVID-19 Treatment at Any Dosage

The Infectious Diseases Society of America (IDSA) strongly recommends against using ivermectin for COVID-19 treatment in both hospitalized and ambulatory patients, regardless of dosage. 1, 2

Evidence Against Ivermectin Use

• Multiple high-quality clinical trials have demonstrated that ivermectin provides no benefit for COVID-19 treatment, regardless of dosage 1, 3
• Despite ivermectin's in vitro activity against SARS-CoV-2, the concentrations required for antiviral effects are considerably higher than those achievable in human plasma and lung tissue at standard dosing 2
• The IDSA makes a conditional recommendation against ivermectin for hospitalized patients (very low certainty evidence) and a strong recommendation against its use for ambulatory patients (moderate certainty evidence) 1

Clinical Outcomes with Ivermectin

• Mortality: Ivermectin does not reduce mortality in COVID-19 patients (RR: 0.83; 95% CI: 0.50,1.37) 2, 3
• Hospitalization: Ivermectin fails to demonstrate beneficial effects on hospitalization (RR: 0.85; 95% CI: 0.65,1.11) 1, 2
• Mechanical ventilation: No beneficial effect demonstrated (RR: 0.40; 95% CI: 0.13,1.27) 2
• Viral clearance: No significant effect on viral clearance at day seven in either hospitalized patients or outpatients 1, 2
• Recent large-scale trials: A 2024 multi-regional study in Japan and Thailand with 1,030 participants found no statistically significant difference between ivermectin and placebo for improvement of clinical symptoms 4

Safety Concerns

• While ivermectin is generally well-tolerated at doses used for parasitic infections, potential serious adverse events cannot be excluded in COVID-19 patients 1
• The risk of serious adverse events in hospitalized patients treated with ivermectin showed a concerning trend (RR: 3.10; 95% CI: 0.54,17.89) 1, 2
• Administering ivermectin for COVID-19 exposes patients to potential harm without demonstrated benefit 1, 3

Dosing Information (Not Recommended)

• Various doses have been studied in clinical trials (100-400 mcg/kg/day) for durations ranging from one to seven days 1
• Despite testing multiple dosing regimens, no clinical benefit has been demonstrated at any dose 1, 3
• The most recent high-quality trial used 0.3-0.4 mg/kg daily for three days and found no efficacy compared to placebo 4

Clinical Decision Algorithm

1. For patients with COVID-19 requesting ivermectin:

   • Explain that high-quality evidence shows no benefit for mortality, hospitalization, or viral clearance 2, 3
   • Recommend evidence-based treatments according to current guidelines 1, 2

2. For patients with concurrent parasitic infections who also have COVID-19:

   • Treat the parasitic infection according to standard guidelines 1
   • Clarify that ivermectin will not provide additional benefit for COVID-19 symptoms 2, 5

Common Pitfalls to Avoid

• Do not be influenced by early, low-quality studies suggesting benefit; more recent, larger, and higher-quality trials have consistently shown no benefit 3, 4, 5
• Avoid being misled by in vitro studies showing antiviral activity, as the required concentrations cannot be safely achieved in humans 1, 2
• Do not use ivermectin in combination with other unproven therapies for COVID-19, as this may increase risk without benefit 5
• Be aware that some patients may seek ivermectin based on misinformation; provide clear education about the lack of evidence for its use 2, 3