Lessening Organ Dysfunction With VITamin C - COVID-19 (LOVIT-COVID)

Lessening Organ Dysfunction With VITamin C - COVID

LOVIT-COVID is a multicentre concealed-allocation parallel-group blinded randomized controlled trial to ascertain the effect of high-dose intravenous vitamin C compared to placebo on mortality or persistent organ dysfunction at 28 days in hospitalized COVID-19 patients.

Study Overview

• Status: Completed
• Conditions: COVID-19; Vitamin C; Hospitalized Patients
• Intervention / Treatment: Drug: Vitamin C; Drug: Control

Detailed Description

Background. Research suggests that vitamin C is potentially lifesaving in the intense inflammatory cascade such as that associated with COVID-19. Inflammation and oxidative stress are among the main mechanisms underlying COVID-19-associated acute hypoxemic respiratory failure. Previous evidence had also already established that a dysregulated inflammatory cascade may distinguish patients who transition from a relatively mild viral pneumonitis to acute respiratory distress syndrome and multiorgan failure. As such, adjunct immune modulation therapies may improve outcomes of COVID-19 patients who are hospitalized. Numerous preclinical studies have shown that, in addition to direct scavenging of oxygen radicals, vitamin C limits their production and restores endothelial function.

As the majority of hospitalized patients with COVID-19 are not critically ill, avoiding clinical deterioration and subsequent intensive care unit admission is a high priority. Participation in research should be offered before patients become critically ill, at which time many perceive that treatment may be too late. It is important to ensure that as many COVID-19 patients as possible are offered the opportunity to participate to research since that is generally the only means to access investigational therapies. The proposed trial will address this gap, by evaluating the efficacy of intravenous vitamin C in hospitalized patients with confirmed COVID-19.

Objectives. The overarching objective, which is identical to the objective of the parent LOVIT trial (NCT 03680274), is to determine whether intravenous vitamin C, compared to placebo, reduces morbidity and mortality in patients hospitalized with COVID-19. To ascertain the volume of distribution, clearance, and plasma concentration over a course of 96 hours of intravenous vitamin C 50 mg/kg of weight every 6 hours or matching placebo (pharmacokinetic (PK) substudy).

Methods. Patients will be randomly assigned to vitamin C (intravenous, 50 mg/kg every 6h) or placebo (0.9% NaCl or dextrose 5% in water) for 96 hours. Study personnel at the clinical sites will document the composite of death or persistent organ dysfunction at day 28. Daily assessments will occur for organ function, on days 1, 3, 7 for inflammation, infection, and endothelial injury biomarkers, at baseline for vitamin C level, and at 6 months for mortality and HRQoL. The LOVIT-COVID Trial will be conducted in Canadian and possibly international sites. For the PK substudy: Blood samples will be drawn around the 8th dose at time 0 and then after administration at times 1h, 2h, 4h and 6h (the 6h level will be immediately prior to the next dose). The PK substudy will be conducted with 100 participants in some of the participating centers.

Relevance. A growing body of evidence suggests that vitamin C, an inexpensive and readily available intervention, is potentially lifesaving in sepsis and may also be beneficial in COVID-19. LOVIT-COVID will constitute rigorous assessments of the effect of vitamin C monotherapy on patient-important outcomes. If proven effective, vitamin C could be used worldwide and drastically change outcomes in high- and low-income settings alike.

• Study Type: Interventional
• Enrollment (Actual): 392
• Phase: Phase 3

Contacts and Locations

Study Locations

• Canada
  • Quebec
    • Sherbrooke, Quebec, Canada, J1H 5N4
      • Research Center of the CHUS
    • Sherbrooke, Quebec, Canada, J1H 5N4
      • Research Centre of the CHUS

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Confirmed diagnosis of COVID-19;
• Admitted to hospital (ward or intensive care unit).

Exclusion Criteria:

• Receiving or has received vasopressors during the current hospitalization;
• More than 24 hours has elapsed since receipt of non-invasive ventilatory support (high-flow nasal cannula or continuous positive airway pressure or non-invasive ventilation) or invasive mechanical ventilation;
• Patient is expected to be discharged from the hospital in the next 24 hours;
• More than 14 days have elapsed since the commencement of hospital admission with respiratory illness;
• Known glucose-6-phosphate dehydrogenase (G6PD) deficiency;
• Known sickle cell anemia
• Pregnancy or breastfeeding;
• Known allergy to vitamin C;
• Known kidney stones within the past 1 year;
• Received any intravenous vitamin C during this hospitalization unless incorporated in parenteral nutrition;
• Expected death or withdrawal of life-sustaining treatments within 48 hours;
• Previously enrolled in this study;
• Previously enrolled in a trial for which co-enrolment is not allowed (co- enrolment to be determined case by case).

The trial has broad eligibility criteria and includes all COVID-19 patients admitted to the hospital (e.g. hospital ward or the intensive care unit) who are not receiving vasopressors.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Vitamin C; Vitamin C: 50 mg/kg of weight administered intravenously every 6 hours for 96 hours (16 doses).	Drug: Vitamin C; Intravenous vitamin C administered in bolus doses of 50 mg/kg mixed in a 50-ml solution of either normal saline (0.9% NaCl) or dextrose 5% in water (D5W) during 30 to 60 minutes, every 6 hours for 96 hours (i.e. 200 mg/kg/day and 16 doses in total).; Other Names: Ascorbic acid
Placebo Comparator: Control; Normal saline (0.9% NaCl) or dextrose 5% in water (D5W) in a volume to match the vitamin C.	Drug: Control; Dextrose 5% in water of normal saline (0.9% NaCL) in a volume to match vitamin C.; Other Names: Placebo

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Death or persistent organ dysfunction	Number of deceased participants or with persistant organ dysfunction (dependency on mechanical ventilation, new renal replacement therapy, or vasopressors).	Both assessed at 28 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of intensive care unit-free days	Number of whole and part study days for which the patient is alive and not admitted to an intensive care unit	Assessed at 21 days
Persistent organ dysfunction-free days in ICU	Number of study days in ICU without persistant organ dysfunction	Assessed at 28 days
Number of patients deceased at 6 months	Mortality at 6 months	6 months
Health related quality of life in 6-month survivors	Assessed by the EQ-5D-5L EuroQol questionnaire (EQ-5D-5L). The EQ-5D-5L essentially consists of 2 pages: the EQ-5D descriptive system and the EQ-5D visual analog scale (EQ VAS). The descriptive system comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems, and extreme problems. The patient is asked to indicate her/his health state by ticking the box next to the most appropriate statement in each of the 5 dimension. This decision results in a 1-digit number that expresses the level selected for that dimension. The digits for the 5 dimensions can be combined into a 5-digit number that describes the patient's health state. The EQ-VAS records the patient's self-rated health on a vertical visual analog scale, where the endpoints are labelled 'The best health you can imagine' and 'The worst health you can imagine'.	6 months
Organ function	Assessed by the Sequential Organ Failure Assessment (SOFA) score. Used to track a person's status during the stay in an intensive care unit to determine the extent of a person's organ function or rate of failure. The score is based on six different sub-scores, one each for the respiratory (PaO2/fraction of inspired oxygen FiO2) mmHg), cardiovascular (mean arterial pressure OR administration of vasopressors required), hepatic (liver bilirubin mg/dl [µmol/L]), coagulation (platelets x 103/µl), renal (kidneys creatinine (mg/dl) [µmol/L] (or urine output)), and neurological (Glasgow coma scale). The sub-score of each system ranges from 0 (best) to +4 (worst).	Days 1, 2, 3, 4, 7, 10, 14, 28
Global tissue dysoxia	Assessed by serum lactate concentration	Days 1, 3, 7
Rate of inflammation	Assessed by interleukin-1 beta (IL-1ß), tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP).	Days 1, 3, 7
Rate of infection	Assessed by procalcitonin (PCT).	Days 1, 3, 7
Rate of endothelial injury	Assessed by thrombomodulin (TM) and angiopoietin-2 (ANG-2).	Days 1, 3, 7
Occurrence of stage 3 acute kidney injury	Assessed by Kidney Disease: Improving Global Outcomes (KDIGO) criteria	Up to day 28
Acute hemolysis	clinician judgment of hemolysis, as recorded in the chart, OR; hemoglobin drop of at least 25 g/L within 24 hours of a dose of investigational product plus 2 of the following:reticulocyte count >2 times upper limit of normal at clinical site lab;haptoglobin <lower limit of normal at clinical site lab;indirect (unconjugated) bilirubin >2 times upper limit of normal at clinical site lab;lactate dehydrogenase (LDH) >2 times upper limit of normal at clinical site lab. Severe hemolysis: o hemoglobin <75 g/L AND at least 2 of the above criteria AND requires 2 units of packed red blood cells.	Up to day 28
Hypoglycemia	Core lab-validated glucose level <3.8 mmol/L	During the time participants receive the 16 doses of the investigational product and the 7 days following the last dose.
Vitamin C volume of distribution	Assessed by chromatography-tandem mass spectrometry	8th dose of vitamin C at time 0 (immediately prior to the dose) and then after administration at times 1 hour, 2 hours, 4 hours and 6 hours (Pharmacokynetic substudy).
Vitamin C clearance	Assessed by chromatography-tandem mass spectrometry	8th dose of vitamin C at time 0 (immediately prior to the dose) and then after administration at times 1 hour, 2 hours, 4 hours and 6 hours (Pharmacokynetic substudy).
Vitamin C plasma concentration	Assessed by chromatography-tandem mass spectrometry	8th dose of vitamin C at time 0 (immediately prior to the dose) and then after administration at times 1 hour, 2 hours, 4 hours and 6 hours (Pharmacokynetic substudy).

Collaborators and Investigators

• Sponsor: Université de Sherbrooke
• Collaborators: Lotte & John Hecht Memorial Foundation
• Investigators: Principal Investigator: François Lamontagne, MD, FRCPC, MSc, Université de Sherbrooke and CIUSSS de l'Estrie - CHUS; Principal Investigator: Neill K Adhikari, MDCM, FRCPC, MSc, Sunnybrook Health Sciences Centre, University of Toronto

Study record dates

Study Major Dates

• Study Start (Actual): August 14, 2020
• Primary Completion (Actual): July 15, 2022
• Study Completion (Actual): December 6, 2022

Study Registration Dates

• First Submitted: May 21, 2020
• First Submitted That Met QC Criteria: May 21, 2020
• First Posted (Actual): May 26, 2020

Study Record Updates

• Last Update Posted (Actual): April 21, 2023
• Last Update Submitted That Met QC Criteria: April 20, 2023
• Last Verified: April 1, 2023

More Information

Terms related to this study

• Keywords: Coronavirus; COVID-19; Vitamin C; Pandemic; Hospitalized patients
• Additional Relevant MeSH Terms: Coronavirus Infections; Coronaviridae Infections; Nidovirales Infections; RNA Virus Infections; Virus Diseases; Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Pneumonia, Viral; Pneumonia; Lung Diseases; COVID-19; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Protective Agents; Micronutrients; Vitamins; Antioxidants; Ascorbic Acid
• Other Study ID Numbers: MP-31-2021-3741

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No