Is Ivermectin (antiparasitic medication) recommended for the treatment or prevention of Coronavirus Disease 2019 (COVID-19)?

Ivermectin Should Not Be Used for COVID-19

Ivermectin is not recommended for the treatment or prevention of COVID-19 in any setting—hospitalized, ambulatory, or prophylactic—based on strong guideline recommendations and lack of clinical efficacy despite adequate plasma concentrations being unattainable. 1

Guideline Recommendations by Clinical Setting

For Ambulatory (Outpatient) COVID-19 Patients

• The Infectious Diseases Society of America (IDSA) issues a strong recommendation against ivermectin use (moderate certainty of evidence). 1
• This strong recommendation indicates that nearly all informed patients should decline this treatment, as undesirable effects outweigh any potential benefits. 1

For Hospitalized COVID-19 Patients

• The IDSA conditionally recommends against ivermectin (very low certainty of evidence). 1
• While uncertainty exists in this population, the guideline panel concluded that harms outweigh benefits even in severe disease. 1

For Prevention (Prophylaxis)

• The World Health Organization recommends against ivermectin for COVID-19 prevention, noting it diverts resources from proven effective treatments like nirmatrelvir/ritonavir, remdesivir, and molnupiravir. 2

Why Ivermectin Fails as COVID-19 Treatment

Pharmacological Impossibility

• Ivermectin's in vitro antiviral activity against SARS-CoV-2 requires concentrations 50-100 times higher than what is achievable in human plasma and lung tissue. 1, 2
• The IC50 concentrations demonstrated in laboratory studies cannot be safely reached in living patients without significant toxicity. 2, 3
• While ivermectin shows anti-inflammatory effects in laboratory settings, these hypothesized mechanisms have not translated to clinical benefit. 1

Clinical Trial Evidence

• A 2024 Phase III randomized, double-blind, placebo-controlled trial (IVERMILCO Study) with 1,030 patients in Japan and Thailand found no efficacy: time to symptom improvement was approximately 96 hours (4 days) in both ivermectin and placebo groups (p=0.61). 4
• This represents the highest quality, most recent evidence—a large, well-designed RCT showing definitively that ivermectin at doses of 0.3-0.4 mg/kg for 3 days provides no benefit. 4
• A 2021 Cochrane systematic review found very low to low certainty evidence, concluding uncertainty about both efficacy and safety, with no support for use outside clinical trials. 5
• Meta-analyses of peer-reviewed RCTs show ivermectin does not reduce mortality (RR 0.60,95% CI 0.14-2.51), need for mechanical ventilation, duration of hospitalization, or viral clearance. 5

Methodological Problems in Early Studies

• Multiple early RCTs had high risk of bias, including inadequate randomization methods such as allocation by odd/even days and non-random assignment of critically ill patients. 2
• Many positive early reports came from pre-print articles that were not peer-reviewed or were later retracted. 1
• Studies comparing ivermectin to hydroxychloroquine (a treatment with evidence of harm) were excluded from guideline analyses. 1

Safety Concerns

Adverse Effects at Higher Doses

• Higher doses potentially needed for antiviral effects cause significant adverse events: dizziness, nausea, fever, headache, muscle/joint pain, and skin reactions. 2, 6
• Ivermectin bioavailability increases 2.5-fold when taken with high-fat food, potentially leading to unintended toxicity. 6

High-Risk Populations

• Patients with severe liver disease face substantially higher toxicity risk and require close monitoring if ivermectin is used for any FDA-approved indication. 2, 6

Resource Allocation Concerns

• Using ivermectin for COVID-19 diverts attention and resources from evidence-based treatments that have proven mortality benefits. 2
• The dramatic increase in off-label prescribing (from 3,589 to 39,102 prescriptions per week in the U.S.) represents misallocation of healthcare resources. 7

Common Pitfalls to Avoid

• Do not be swayed by in vitro data: laboratory antiviral activity does not translate to clinical efficacy when therapeutic concentrations cannot be achieved safely. 1, 2
• Reject early meta-analyses that included pre-print or low-quality studies: these analyses are now superseded by higher quality evidence showing no benefit. 5, 4
• Ivermectin is FDA-approved only for parasitic infections (onchocerciasis, strongyloidiasis); it has no proven therapeutic utility for viral or inflammatory conditions. 1, 6, 3

What to Tell Patients

• Reassure patients that if sufficient evidence emerges, regulatory authorities would approve ivermectin for COVID-19—but current evidence definitively shows no benefit. 7
• Direct patients toward proven effective treatments based on their risk category and disease severity. 2
• Explain that the most recent, highest quality trial (2024, n=1,030) showed ivermectin performs identically to placebo. 4