Administrative information
Title {1} | Effect of dexamethasone in patients with ARDS and COVID-19 (REMED trial)—study protocol for a prospective, multi-centre, open-label, parallel-group, randomized controlled trial |
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Trial registration {2a and 2b}. | EudraCT No.:2020-005887-70 and ClinicalTrials.gov Identifier: NCT04663555 on December 11, 2020, on ClinicalTrials.gov |
Protocol version {3} | 1.2 | 22.03.2021 |
Funding {4} | REMED is an investigator-initiated clinical trial. Funding will be granted from the project research infrastructure Czech Clinical Research Infrastructure Network CZECRIN (LM 2018128) and University Hospital Brno. |
Author details {5a} | Jan Maláska1*, Jan Stašek1, František Duška2, Martin Balík3, Jan Máca4, Jan Hruda5, Tomáš Vymazal6, Olga Klementová7, Jan Zatloukal8, Tomáš Gabrhelík9, Pavel Novotný10, Regina Demlová11, Jana Kubátová11, Jana Vinklerová11, Adam Svobodník11, Milan Kratochvíl12, Jozef Klučka12, Roman Gál1, Mervyn Singer13 on behalf of the REMED Study Group. 1Department of Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Masaryk University, Faculty of Medicine, Jihlavská 20, 625 00 Brno, Czech Republic, Jan Maláska: malaska.jan@fnbrno.cz, Jan Stašek: stasek.jan@fnbrno.cz, Roman Gál: gal.roman@fnbrno.cz 2Department of Anaesthesia and Intensive Care, University Hospital Královské Vinohrady and Charles University, 3rd Faculty of Medicine, Šrobárova 1150 100 34 Praha, Czech Republic, frantisek.duska@lf3.cuni.cz 3Department of Anaesthesia and Intensive Care, General University Hospital in Prague and Charles University, 1st Faculty of Medicine, U Nemocnice 499/2 128 08 Praha, Czech Republic, martin.balik@vfn.cz 4Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ostrava and University Ostrava, Faculty of Medicine, 17. listopadu 1790, 708 52 Ostrava-Poruba, Czech Republic, jan.maca@fno.cz 5Department of Anaesthesiology and Intensive Care Medicine, St. Anne’s University Hospital and Masaryk University, Faculty of Medicine, Pekařská 664/53, 656 91 Brno, Czech Republic, jan.hruda@fnusa.cz 6Department of Anaesthesiology and Intensive Care Medicine, University Hospital Motol and Charles University, 2nd Faculty of Medicine, V Úvalu 84/1, 150 06 Praha 5, Czech Republic, tomas.vymazal@fnmotol.cz 7Department of Anaesthesiology and Intensive Care Medicine, University Hospital Olomouc and Palacky University, Faculty of Medicine, I. P. Pavlova 185/6, 779 00 Olomouc, Czech Republic, Olga.Klementova@fnol.cz 8Department of Anaesthesiology and Intensive Care Medicine, University Hospital Plzeň and Charles University, Faculty of Medicine in Pilsen, alej Svobody 80, 304 60 Plzeň-Lochotín, Czech Republic, ZATLOUKALJ@fnplzen.cz 9Department of Anaesthesiology and Intensive Care Medicine, Tomáš Baťa Regional Hospital, Havlíčkovo nábřeží 600, 762 75 Zlín, Czech Republic, Tomas.Gabrhelik@bnzlin.cz 10Department of Anaesthesiology and Intensive Care, Military University Hospital Praha and Charles University, 1st Faculty of Medicine, U Vojenské nemocnice 1200, 169 02 Praha, Czech Republic, Pavel.Novotny@uvn.cz 11Department of Pharmacology/CZECRIN, Masaryk University, Faculty of Medicine, Kamenice 5, Brno, 62500 Czech Republic, Regina Demlová: demlova@med.muni.cz, Jana Kubátová: jana.kubatova@med.muni.cz, Jana Vinklerová: jvinkler@med.muni.cz, Adam Svobodník: svobodnika@gmail.com 12Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Masaryk University, Faculty of Medicine, Jihlavská 20, 625 00 Brno, Czech Republic, Milan Kratochvíl: kratochvil.milan@fnbrno.cz, Jozef Klučka: klucka.jozef@fnbrno.cz 13Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Gower Street, London, WC1E 6BT, United Kingdom, m.singer@ucl.ac.uk *corresponding author |
Name and contact information for the trial sponsor {5b} | University Hospital Brno Jihlavská 20 625 00 Brno, Czech Republic |
Role of sponsor {5c} | Trial funders have no role in the study design, collection, analysis and interpretation of the data. Investigators declare no financial or non-financial competing interest regarding the focus of this trial. |
Clinical trial background
Introduction
Rationale and up-to-date evidence
Anticipated risks and benefits
Trial objectives and endpoints
Primary objective(s) and endpoint(s)
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Day 0 is the day of randomization.
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The time frame is 28 days.
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Free from mechanical ventilation means extubation for > 48 h without reintubation in a 28-day survivor or disconnection from the ventilator in patients with tracheostomy (irrespective of PEEP valve) for > 48 h without reconnection to the ventilator in a 28-day survivor.
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VFDs are counted from the last successful extubation or disconnection from the ventilator.
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If death occurs before day 28, VFD = 0 (to penalize non-survival, regardless of intubation status).
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If death occurs after day 28, 28-day ventilation and survival status is used for calculating VFDs (censor after 28 days).
Secondary objective(s) and endpoint(s)
Exploratory objective(s) and endpoint(s)
Trial design
Trial population
Inclusion criteria
Exclusion criteria
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Intractable hyperglycaemia
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Active gastrointestinal bleeding
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Adrenal gland disorders
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The presence of superinfection diagnosed with locally established clinical and laboratory criteria without adequate antimicrobial treatment
Randomization and stratification
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Age < 65 and ≥ 65 [12]
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Charlson Comorbidity Index (CCI) < 3 and ≥ 3
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CRP < 150 mg/L and ≥ 150 mg/L
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Trial centre
Blinding
Enrolment stopping rules
Premature termination of participation in the trial
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Withdrawal of informed consent (subject’s decision to withdraw for any reason)
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Important deviation in the process of informed consent
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Life-threatening adverse reaction to dexamethasone at the discretion of the investigator
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Newly emerged pregnancy of a participant after the enrolment
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Instruct the participant about the right on early termination of participation
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Assure him/her that the end of participation will not affect the attitude of the physician or further treatment and its quality
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Ask for discussing this decision with the investigator in advance
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Make a note in the patient’s medical records and eCRF about the date of early termination of participation
Study treatment
Dexamethasone (ATC code: H02AB02)
All authorized medicinal products containing dexamethasone in the form of solution for i.v. injection/infusion can be used. |
Qualitative and quantitative composition
Pharmaceutical form and route of administration
Other information
Packaging and labelling
Delivery and storage
Dosing schedule
Dose modification and delays
Permitted concomitant medication
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Remdesivir (at the discretion of the investigator)
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Prevention of thromboembolic disease (anticoagulants)
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Gastric ulcer prophylaxis for patients on dexamethasone
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Nutrition, hydration, electrolytes, vitamins and glucose administration
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Antipyretics (paracetamol, metamizole)
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Antibiotics
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Bronchodilators
Restricted concomitant medication
Potent inhibitors of CYP3A include, e.g., systemic azole antimycotics, clarithromycin, erythromycin, telithromycin, diltiazem and verapamil. |
Potent inducers of CYP3A include, e.g., phenytoin, rifampicin, phenobarbital and carbamazepine. |
Course of the trial
Screening of eligible patients
Overview of medical care about the study participant
Clinical examinations and assessments
Study procedures
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Eligibility screen—inclusion and exclusion criteria
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Informed consent procedure
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Pregnancy testing (hCG) in women with childbearing potential—preferentially from a blood sample, if statim hCG is not available at the time of enrolment and urine pregnancy testing is necessary
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Demographic data (age, sex, race or ethnic group, BMI)
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Medical history (allergies, comorbidities and CCI, chronic medication)
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Vital signs (temperature, blood pressure, heart rate, respiratory rate)Day 1:
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Vital signs (temperature, blood pressure, heart rate, respiratory rate)
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Administration of dexamethasone according to the allocation to treatment arms
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Blood count and routine biochemistry [RBC, WBC, haematocrit, lymphocyte count, platelets, coagulation profile, renal and liver functions (BUN, creatinine, AST, ALT, bilirubin), d-dimer, LDH, troponin, pH, blood gases, sodium, potassium, chloride, glycaemia]
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Inflammatory markers (CRP; other markers, e.g. procalcitonine, presepsin, interleukin-6 at the discretion of each centre)
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COV-HI assessment—based on day 1 CRP or ferritin level
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APACHE II score counted using the worst values in the first 24 h of ICU stay (the score is determined based on specific parameters from medical history, vital signs, blood count and biochemistry, and other examinations)Day 2:
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Administration of dexamethasone according to the allocation to treatment arms
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Inflammatory markers (CRP; other markers, e.g. procalcitonine, presepsin, interleukin-6 at the discretion of each centre)
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COV-HI assessment—based on day 2 CRP levelDay 3 to day 10:
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Administration of dexamethasone according to the allocation to treatment arms
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Inflammatory markers (CRP; other markers, e.g. procalcitonine, presepsin, interleukin-6 at the discretion of each centre)Day 14:
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World Health Organization Clinical Progression Scale
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Inflammatory markers (CRP; other markers, e.g. procalcitonine, presepsin, interleukin-6 at the discretion of each centre)Day 1 to day 28/ICU discharge (whichever comes first):
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Checking adverse events and adverse reactions (with a special interest in newly emerged infections and new thrombotic complications)
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Ventilatory status, i.e. use of a mechanical ventilator or other ventilation/oxygen support
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Vital status
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Discharge from ICU and hospitalDays 60, 90, 180 and 360:
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Out-patient visits (if possible) or structured phone call interviews led by study nurse with the patient or his/her family member or caregiver
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Vital status
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Quality of life by the assessment of daily life activities and functional independence (Barthel Index)
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Checking adverse events and reactions
Biological samples
Assessment tools, scores and scales
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APACHE II
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Barthel Index
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Charlson Comorbidity Index
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COV-HI
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Glasgow Coma Scale
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Spontaneous breathing trial
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WHO CPS
Safety assessments
Definitions (according to the Directive 2001/20/EG)
Adverse event | AE | Any untoward medical occurrence in a patient or clinical trial subject administered a medicinal product and which does not necessarily have a causal relationship with this treatment |
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Adverse drug reaction | ADR | All untoward and unintended responses to an investigational medicinal product related to any dose administered |
Serious adverse event | SAE | A serious adverse event/reaction is any untoward medical occurrence or effect that at any dose: • Results in death • Is life-threatening • Requires hospitalization or extension of existing hospitalization • Results in persistent or significant disability or incapacity • Is a congenital anomaly or birth defect |
Serious adverse reaction | SADR | |
Unexpected adverse reaction | UADR | Adverse reaction, the nature, severity or outcome of which is not consistent with the product information (SmPC) |
Suspected unexpected serious adverse reaction | SUSAR | Any suspected adverse reaction related to the study treatment that is both serious and unexpected |
AE surveillance, recording and documentation
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Seriousness
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Severity
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Causality, i.e. relation to the study medication
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Duration (start and end dates or whether it continues)
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Action taken (no action taken, study medication discontinued, prolongation of the ongoing hospitalization, administration of a drug, etc.)AE needs to be followed until its resolution, i.e. until it subsides, stabilizes and becomes chronic or the subject dies.If AE fulfils the criteria of SAE, a separate form must be completed besides the standard eCRF record.AEs will be recorded according to the Medical Dictionary for Regulatory Activities (MedDRA). The most recent MedDRA version at the start of the study will be used.
Treatment of AE
Assessment of seriousness
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SAE which occurs after enrolment (i.e. after giving informed consent), but before the study medication was initiated
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Hospitalization(s) planned before the enrolment
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Death not related to the dexamethasone use1
Assessment of intensity (severity)
Grade 1 | AE is asymptomatic or mildly symptomatic and requires only observation, no medical intervention. |
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Grade 2 | AE with medium intensity, requires local, non-invasive or small-scale treatment. |
Grade 3 | AE is medically significant and requires hospitalization or extension of ongoing hospitalization, but it is not directly life-threatening. |
Grade 4 | AE is life-threatening and requires urgent significant medical intervention. |
Grade 5 | AE leads to death. |
Assessments of causality
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Related—The event is known to occur with the study medication, there is a reasonable possibility that the study medication caused the AE, or there is a temporal relationship between the study medication and AE. Reasonable possibility means that there is evidence to suggest a causal relationship between the study medication and the AE.
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Not related—There is no reasonable possibility that the administration of the study medication caused the AE, there is no temporal relationship between the study medication and AE onset, or an alternate aetiology has been established.The investigator is obliged to report any SAE within 24 h after he/she learns about it to the sponsor using serious adverse event form (SAE form). The blank forms are stored in the investigator’s site file. The announcement will be done by e-mail: farmakovigilance@med.muni.cz
Reporting of SAE and SUSAR
Follow-up
Reporting of SUSAR
Pregnancy
The investigator should report the pregnancy to the sponsor within 24 h of learning of its occurrence using pregnancy form. This announcement will be done by e mail: farmakovigilance@med.muni.cz. |
Statistics
Sample size determination
Analysis of efficacy
Subgroup analysis
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Age
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Sex
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BMI
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Comorbidities
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P/F ratio
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Length of dexamethasone treatment before enrolment
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ECMO procedure
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Other corticosteroids than study medication administered (from day 11 to day 28)
Analysis of safety
Planned interim analysis
Missing data
Data management and quality assurance
eCRF database
Trial documents and medical records
Monitoring and auditing
Deviations and violations
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Other corticosteroid than dexamethasone administered (from day 1 to day 10)
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Discrepancy in the informed consent procedure
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Assessment of inclusion/exclusion criteria ex post
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Different single dose of dexamethasone administered (from day 1 to day 10)
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Administration of dexamethasone shorter than 10 days (this does not apply for discharging the subject from hospital due to clinical improvement)
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Prolongation of dexamethasone treatment (i.e. number of days on treatment in both arms)
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Administration of other corticosteroids than study medication (from day 11 to day 28)