Clinical trial NCT04357782
Conditions: COVID-19 Hypoxia
Keywords: Vitamin C Ascorbic Acid Hypoxia Sepsis Acute Lung Injury Acute Respiratory Distress Syndrome Severe acute respiratory syndrome (SARS)- Coronavirus (CoV)-2
Sponsor: Hunter Holmes Mcguire Veteran Affairs Medical Center
Start date: 2020-04-16; Completion date: 2020-10-13
Enrollment: 20 participants; Allocation: NON_RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
Previous research has shown that high dose intravenous vitamin C (HDIVC) may benefit patients with sepsis, acute lung injury (ALI), and the acute respiratory distress syndrome (ARDS). However, it is not known if early administration of HDIVC could prevent progression to ARDS.

We hypothesize that HDIVC is safe and tolerable in Coronavirus disease 2019 (COVID-19) subjects given early or late in the disease course and may reduce the risk of respiratory failure requiring mechanical ventilation and development of ARDS along with reductions in supplemental oxygen demand and inflammatory markers.

Detailed description:
The purpose of this study is to assess the safety, tolerability, potential efficacy of high dose intravenous vitamin C (HDIVC) therapy for patients with COVID-19 and decreased oxygenation. COVID-19 is a rapidly evolving pandemic with numerous prediction models suggesting potential shortages in ventilators, ICU beds, and high rates of hospital mortality. Case-series suggest sepsis and the acute respiratory distress syndrome (ARDS) are driving hospitalizations, morbidity (ICU beds, ventilator use, organ failures), and mortality. A therapy is urgently needed to be given early in the disease course in order to attenuate the infectious and inflammatory process, reduce risk of intubation, and reduce progression of organ failure and ARDS. By administering HDIVC at the first objective sign of worsening oxygenation, documented by change in peripheral capillary oxygen saturation (SpO2) to fraction of inspired oxygen (FIO2) ratio (S/F) or decreased SpO2 at baseline (mild hypoxia group), HDIVC may reduce the inflammatory process and development of respiratory failure requiring intubation. We will also enroll patients already in respiratory failure on ventilators (severe hypoxia group) and document safety and tolerability in both cohorts. By calculating ventilator and ICU-free days, we can potentially signal clinically relevant endpoints that could be used in larger trials needed to answer a crucial therapeutic question-can early administration of HDIVC in COVID-19 lead to faster recovery or improve outcomes? Moreover, we will document change in inflammatory markers that are elevated in COVID-19 (d-dimer, C reactive protein (CRP), lactate dehydrogenase (LDH), liver enzymes, and ferritin) to develop a mechanistic understanding and risk stratification of response to HDIVC infusion. Ultimately, if HDIVC is deemed safe and tolerable in hospitalized COVID-19 subjects, a larger clinical trial will be indicated. AVoCaDO will produce safety and tolerability data to test HDIVC in a multi-center, rapid, randomized, placebo-controlled trial of subjects with COVID-19.

Arms: arm 1: S/F ratio \>250 prior to Vitamin C infusion arm 2: S/F ratio ≤250 prior to Vitamin C infusion
Interventions: intervention 1: L-ascorbic acid
Intervention descriptions: intervention 1: 50 mg/kg L-ascorbic acid infusion given every 6 hours for 4 days (16 total doses)

Protocol documents:
Prot_SAP_000.pdf: 
 
 
Administration of Intravenous Vitamin C in Novel 
Coronavirus Infection and Decreased Oxygenation 
 
AVoCaDO 
 
Protocol Number: 001 
 
Principal Investigator:  
Brian C. Davis, MD 
 
Central Virginia VA Health System 
1201 Broad Rock Blvd 
Richmond, VA 23249 
 
Brian.Davis5@va.gov 
 
 
 
Version Number:  6.0 
 
07 July 2020 
 
 


  
 
ii 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ............................................................................................................................... 1 
1.1 
Synopsis ................................................................................................................................................ 1 
1.2 
Schema ................................................................................................................................................. 3 
1.3 
Schedule of Activities (SoA) ............................................................................................................... 7 
2 
INTRODUCTION ............................................................................................................................................ 8 
2.1 
Study Rationale .................................................................................................................................... 8 
2.2 
Background........................................................................................................................................... 8 
2.3 
Risk/Benefit Assessment .................................................................................................................. 12 
2.3.1 
Known Potential Risks ................................................................................................... 12 
2.3.2 
Known Potential Benefits .............................................................................................. 13 
2.3.3 
Assessment of Potential Risks and Benefits .............................................................. 13 
3 
OBJECTIVES AND ENDPOINTS .............................................................................................................. 13 
4 
STUDY DESIGN ........................................................................................................................................... 14 
4.1 
Overall Design .................................................................................................................................... 14 
4.2 
Scientific Rationale for Study Design.............................................................................................. 14 
4.3 
Justification for Dose ......................................................................................................................... 14 
4.4 
End of Study Definition ..................................................................................................................... 15 
5 
STUDY POPULATION ................................................................................................................................ 15 
5.1 
Inclusion Criteria ................................................................................................................................ 15 
5.2 
Exclusion Criteria ............................................................................................................................... 15 
5.3 
Lifestyle Considerations .................................................................................................................... 15 
5.4 
Screen Failures .................................................................................................................................. 15 
5.5 
Strategies for Recruitment and Retention ...................................................................................... 16 
6 
STUDY INTERVENTION ............................................................................................................................ 16 
6.1 
Study Intervention(s) Administration ............................................................................................... 16 
6.1.1 
Study Intervention Description ..................................................................................... 16 
6.1.2 
Dosing and Administration ............................................................................................ 16 
6.2 
Preparation/Handling/Storage/Accountability ................................................................................ 17 
6.2.1 
Acquisition and accountability ...................................................................................... 17 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ................................................ 17 
6.2.3 
Product Storage and Stability ....................................................................................... 17 
6.2.4 
Preparation ...................................................................................................................... 17 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 18 
6.4 
Study Intervention Compliance ........................................................................................................ 18 
6.5 
Concomitant Therapy ........................................................................................................................ 18 
6.5.1 
Rescue Medicine ............................................................................................................ 18 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .................................................................................................................... 18 
7.1 
Discontinuation of Study Intervention ............................................................................................. 18 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 19 
7.3 
Lost to Follow-Up ............................................................................................................................... 19 
8 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................................... 19 
8.1 
Efficacy Assessments ....................................................................................................................... 19 
8.2 
Safety and Other Assessments ....................................................................................................... 21 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 22 


  
 
iii 
8.3.1 
Definition of Adverse Events (AE) ............................................................................... 22 
8.3.2 
Definition of Serious Adverse Events (SAE) .............................................................. 22 
8.3.3 
Classification of an Adverse Event .............................................................................. 22 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 23 
8.3.5 
Adverse Event Reporting .............................................................................................. 24 
8.3.6 
Serious Adverse Event Reporting ............................................................................... 24 
8.4 
Unanticipated Problems .................................................................................................................... 24 
8.4.1 
Definition of Unanticipated Problems (UP) ................................................................. 24 
8.4.2 
Unanticipated Problem Reporting ................................................................................ 25 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 25 
9.1 
Statistical Hypotheses ....................................................................................................................... 25 
9.2 
Sample Size Determination .............................................................................................................. 25 
9.3 
Populations for Analyses .................................................................................................................. 26 
9.4 
Statistical Analyses............................................................................................................................ 26 
9.4.1 
General Approach .......................................................................................................... 26 
9.4.2 
Analysis of the Primary Efficacy Endpoint(s) ............................................................. 26 
9.4.3 
Safety Analyses .............................................................................................................. 26 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............................. 27 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 27 
10.1.1 
Informed Consent Process ........................................................................................... 27 
10.1.2 
Study Discontinuation and Closure ............................................................................. 29 
10.1.3 
Confidentiality and Privacy ........................................................................................... 29 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 30 
10.1.5 
Safety Oversight ............................................................................................................. 30 
10.1.6 
Clinical Monitoring .......................................................................................................... 30 
10.1.7 
Quality Assurance and Quality Control ....................................................................... 30 
10.1.8 
Data Handling and Record Keeping ............................................................................ 30 
10.1.9 
Protocol Deviations ........................................................................................................ 31 
10.1.10 
Publication and Data Sharing Policy ........................................................................... 31 
10.1.11 
Conflict of Interest Policy .............................................................................................. 31 
10.2 
Abbreviations ...................................................................................................................................... 32 
10.3 
Protocol Amendment History ........................................................................................................... 33 
11 
REFERENCES ............................................................................................................................................. 34 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
1 
STATEMENT OF COMPLIANCE 
The trial will be conducted in accordance with International Conference on Harmonisation Good Clinical 
Practice (ICH GCP) and applicable United States (US) Code of Federal Regulations (CFR). The Principal 
Investigator(s) will assure that no deviation from, or changes to the protocol will take place without 
documented approval from the Institutional Review Board (IRB), except where necessary to eliminate an 
immediate hazard(s) to the trial participants. All personnel involved in the conduct of this study have 
completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will be 
submitted to the IRB for review and approval.  Approval of both the protocol and the consent form must 
be obtained before any participant is enrolled.  Any amendment to the protocol will require review and 
approval by the IRB before the changes are implemented to the study.  All changes to the consent form 
will be IRB approved; a determination will be made regarding whether a new consent needs to be 
obtained from participants who provided consent, using a previously approved consent form. 
1 
 
PROTOCOL SUMMARY 
1.1 
SYNOPSIS  
Title: 
Administration of Intravenous Vitamin C in Novel Coronavirus Infection 
and Decreased Oxygenation (AVOCADO) 
 
Study Description: 
A novel coronavirus (SARS-CoV-2) has been recently identified to cause a 
new respiratory disease, Coronavirus disease-19 (COVID-19), and declared 
pandemic by the World Health Organization (WHO) on March 11, 2020.  
 
While the current mortality rates are unknown, a certain percentage of 
COVID-19 patients develop the Acute Respiratory Distress Syndrome 
(ARDS) leading to respiratory failure and death in high risk subjects such as 
elderly, and immunocompromised individuals.  
 
Previous research has shown that high dose intravenous vitamin C (HDIVC) 
may benefit in patients with acute lung injury (ALI) and ARDS. However, it 
is not known if early administration of HDIVC could prevent progression to 
ARDS. 
 
We hypothesize that intravenous administration of HDIVC is safe in COVID-
19 subjects given early or late in the disease course and may reduce the 
risk of respiratory failure requiring mechanical ventilation and 
development of ARDS. 
 
Objectives: 
 
To assess the safety, tolerability, and efficacy of a 96-hour intravenous 
vitamin C infusion protocol (50 mg/kg every 6 hours) in patients with 
COVID-19 and evidence of respiratory dysfunction.  
 
Endpoints: 
Primary Endpoint: Incidence of treatment related adverse events (TRAEs) 
during HDIVC infusion defined as 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
2 
• 
Acute kidney injury (increase in serum creatinine 3x baseline prior 
to initial HDIVC dose, hemolysis, iatrogenic hypoglycemia, pain at 
swelling site of infusion, crystalluria on urinalysis (UA) after last 
HDIVC dose 
• 
 
 
Secondary Endpoints:  
Biochemical Hepatic Safety (assessed days 1-4): 
• 
Change in liver enzymes (AST/ALT/ALP/TBILI)at baseline compared 
with value after last HDIVC dose 
 
Hematological and Coagulation Safety Profile (assessed days 1-4) 
• 
Change in White blood cell count, Hemoglobin, Hematocrit, 
Platelet count, INR, fibrinogen during HDIVC infusion 
 
Tolerability of HDIVC defined as: 
• 
Need for dose reduction, headache, dizziness, dry mouth, nausea, 
diarrhea, vomiting, flushing, rash, or hypotension during study 
infusion, assessed at hours 24, 48, and 96 
 
Efficacy indicators of HDIVC, stratified to subjects that receive HDIVC 
with mild hypoxemia (SFR >250) versus severe hypoxemia  (SFR <250 
• 
Ventilator-free days at day 28 
• 
ICU-free days at day 28  
• 
Hospital-free days at day 28 
• 
All-cause mortality at day 28 
• 
Oxygenation 
o Change in SpO2/FiO2 (S/F) ratio at baseline compared 
with value after last dose of HDIVC 
• 
Inflammation 
o Change in serum c-reactive protein (CRP), LDH, d-dimer, 
neutrophil/lymphocyte ratio, and ferritin at baseline 
compared with value after last dose of HDIVC 
 
Study Population: 
A total of up to 20 adult subjects with COVID-19 and documented 
evidence of decreased oxygenation will be enrolled in the study based on 
feasibility. All participants will be enrolled at the Central Virginia Veterans 
Administration Health System in Richmond, VA (RICVA). 
 
Phase: 
 
Phase 1 
 
Description of 
Sites/Facilities Enrolling 
Participants: 
 
Subjects will be recruited from the Emergency Department (ED), inpatient 
medicine unit, intensive care unit (ICU) admitted to the COVID-19 specific 
hospital floor or ICU. RICVA is a tertiary level medical center that serves 
more than 200,000 veterans annually in 52 cities and counties covering 
22,515 miles in central and southern Virginia and parts of North Carolina. 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
3 
Intervention: 
Participants will receive intravenous Vitamin C (50 mg/kg sterile L-ascorbic 
acid mixed in 5% dextrose in water) every 6 hours.  Active treatment will 
continue for 96 hours, discharge from study hospital, study withdrawal, or 
death, whichever comes first. 
 
Study Duration: 
28 days 
 
Participant Duration: 
28 days 
1.2 
SCHEMA 
Prior to  
Enrollment 
 
 
 
 
 
 
 
 
 
Hour 0 
 
 
 
 
Hour 6 
 
 
Hour 12 
 
Total N=20:  Screen potential participants by inclusion and exclusion criteria; document. 
Obtain informed consent. Document admission clinical data. 
Review medical record for baseline assessments 
Record baseline labs, EKG, UA, oxygenation status  
Administer first dose of Vitamin C 
Vitamin C 
Administer second dose of Vitamin C 
Enroll 
Administer third dose of Vitamin C 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
4 
 
 
Hour 18 
 
 
Hour 24 
 
 
Hour 30 
 
 
Hour 36 
 
 
Hour 42 
 
 
Hour 48 
 
 
 
Hour 54 
 
 
Hour 60 
 
 
Administer fourth dose of Vitamin C  
Administer fifth dose of Vitamin C. Assess for safety and tolerability 
Administer sixth dose of Vitamin C 
Administer seventh dose of Vitamin C 
Administer eighth dose of Vitamin C 
Assess for safety and tolerability. Record labs  
Administer ninth dose of Vitamin C 
Administer tenth dose of Vitamin C  
Administer eleventh dose of Vitamin C 
Administer twelfth dose of Vitamin C 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
5 
Hour 66 
 
 
Hour 72 
 
 
Hour 78 
 
 
Hour 84 
 
 
Hour 90 
 
 
Hour 96 
 
Hour 168 
 
 
 
Day 28 
 
 
 
 
                          END STUDY 
Calculate ICU-Free Days, Ventilator-
free days, Hospital-Free Days, All-
Cause Mortality 
Administer thirteenth dose of Vitamin C 
Administer fourteenth dose of Vitamin C 
Administer fifteenth dose of Vitamin C 
Administer sixteenth dose of Vitamin C 
Assess for safety and tolerability. Record lab, UA, EKG data  
Record labs via SOC  


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
6 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
7 
 
1.3 
SCHEDULE OF ACTIVITIES (SOA) 
 
Assessments 
Hour 
0 
Q 24 hrs 
1st 7 days 
or in ICU 
Hour 
48 
Hour 
96 
Hour 
168 
Day 
28 
VS: BP, HR, MAP, RR, Temp., O2 
sats, CVP, Glasgow Coma Scale, S/F 
ratio or P/F ratio if feasible 
R/S 
 
S 
S 
S 
 
Body Weight 
S 
 
 
 
I/Os Total and Urine and urinalysis 
for crystalluria 
R/S 
S 
S 
R/S 
 
 
Assessment of Renal Function with 
serum creatinine, urine output and 
Use of Dialysis 
R/S 
 
S 
S 
R/S 
 
 
Labs: 
Na+, K+, BUN, Cr, WBC, Hgb, Hct, 
Platelets, PT/INR, PTT, CRP, 
ferritin, procalcitonin, LDH, d-dimer 
R/S 
 
S 
S 
R/S 
R/S 
Bilirubin Total, AST, ALT, ALP, 
albumin 
R/S 
S 
S 
R/S 
 
All concomitant medications 
including: 
Corticosteroids, N-acetylcysteine, 
Antibiotics, Thiamine, Albumin, 
norepinephrine, vasopressin, other 
off-label or research COVID-19 
medications 
R 
 
R 
R 
R 
 
AE/SAE/Tolerability Assessments 
R 
R 
R 
R 
 
ICU/Hospital Free Days 
 
R 
Glucose Monitoring 
S 
S 
S 
S 
S 
 
EKG Monitoring 
R/S 
S 
S 
R/S 
 
 
All-Cause Mortality 
 
 
 
 
 
R 
 
 
S = standard of care (when feasible) R = research  
R/S = if not ordered as routine care, labs will be ordered/obtained for research by treating 
provider or study personnel  
 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
8 
 
2 
 
INTRODUCTION 
 
2.1 
STUDY RATIONALE  
 
The purpose of this study is to assess the safety, tolerability, efficacy of intravenously infused ascorbic 
acid (HDIVC) therapy for patients with COVID-19 and decreased oxygenation. COVID-19 is a rapidly 
evolving pandemic with numerous prediction models suggesting potential shortages in ventilators, ICU 
beds, and high rates of mortality if effective treatments are not developed quickly. A therapy is urgently 
needed to be given at disease onset in order to halt the infectious and inflammatory process, reduce risk 
of intubation, and development of ARDS. By administering the infusion at the first objective sign of 
worsening oxygenation, documented by change in S/F ratio or decreased pulse oximetry at baseline, 
HDIVC may reduce the inflammatory process and development of respiratory failure requiring 
intubation. We will also enroll patients already in respiratory failure on ventilators and document safety 
and tolerability, therapy demonstrating that HDIVC is safe in COVID-19 subjects early or late in the 
disease course. Due to the difficulty of running a study in a pandemic of highly infectious disease, we will 
use non-invasive measurements of deoxygenation, (i.e., Pulse Oximetry Saturation/Fraction of inspired 
oxygen, SFR) as opposed to obtaining an arterial blood gas to calculate PaO2/FiO2 ratio. The S/F ratio has 
been correlated with ARDS in previous studies. By measuring ventilator and ICU-free days, we can 
potentially signal efficacious endpoints that could be used in larger clinical trials needed to answer a 
crucial therapeutic question—can early administration of HDIVC in COVID-19 lead to faster recovery or 
improve outcomes? Moreover, we will document change in inflammatory markers that are elevated in 
COVID-19 (d-dimer, CRP, LDH, liver enzymes, and ferritin) to develop a mechanistic understanding and 
risk stratification of response to HDIVC infusion. Ultimately, if HDIVC is deemed safe in COVID-19 
subjects, a larger clinical trial will be urgently needed, and AVOCADO will provide the framework to 
quickly up-scale in the context of an unprecedented pandemic and strain on health systems.  
 
 
2.2 
BACKGROUND  
 
Brief Overview of COVID-19 Pandemic 
In December 2019, a cluster of pneumonia cases were 
reported in Wuhan, China, and a novel coronavirus, severe 
acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was 
identified.1 The World Health Organization (WHO) designated 
the respiratory disease as coronavirus disease (COVID-19) on 
February 12, 2020.2 Numerous reports have since 
characterized the COVID-19 clinical syndrome, ranging from 
asymptomatic/mild disease to severe disease leading to 
respiratory failure requiring mechanical ventilation, acute-
respiratory distress syndrome (ARDS), multi-organ failure, sepsis, and 
death.3–5 On March 12, 2020, WHO declared COVID-19 a pandemic as 
the virus had spread to 6 continents, with outbreaks in China, South 
Korea, Iran, Europe, and the United States (Figure 1).6,7 
Figure 1. Rapid spread of SARS-CoV-2 as of 
03/16/20. 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
9 
 
Figure 2. Clinical Measures in Critically Ill COVID-19 Patients in Washington State.8 
While only a small percentage of COVID-19 patients develop severe 
respiratory failure, the predicted surge in patient volume is causing concern 
about access to intensive-care unit (ICUs) and mechanical ventilators. Italy 
has already reached maximum capacity of ICU beds and early reports 
suggest rationing of ventilators in certain hospitals is occurring.9–11 
Guidelines have been developed to help physicians manage this crisis 
situation.12 Recent modeling based on data from China suggests the United 
States lacks the capacity to manage all COVID-19 patients due to lack of ICU 
beds and ventilators.13 Initial experiences with critically ill COVID-19 patients 
in the United States has recently been described, with most deaths due to 
ARDS (Figure 2). A safe, effective, and inexpensive therapy is urgently 
needed that can alter the natural history of the disease process and reduce 
strain on health systems. 
Preliminary Data To Support the Use of HDIVC in ARDS 
 
HDIVC prevents pulmonary neutrophil infiltration in a feces-induced peritonitis (FIP) model of 
sepsis/ARDS (Figure 3). 
 
HDIVC has been proposed to have a pleotropic effect in ARDS14 (Table), including acting as a stress 
hormone (required for synthesis of norepinephrine, dopamine, vasopressin)15, improves endothelial 
function by decreasing circulating thrombomodulin16, promotes lymphocyte maturation,17 and reduces 
cytokines driving inflammatory pathways in ARDS,18 including IL-6 in patients with pneumonia.19IL-6 is 
emerging as a key cytokine in COVID-19 pneumonia and ARDS and has been associated with increased 
morbidity and mortality.20 
 
 
Table: Potential Mechanisms of Vitamin C in ARDS (adopted from 
Kashiouris et al) 
 
Physiology/Mechanism 
Description 
Potential Mechanism in Covid-19 
FIP
FIP-AscA
Figure 2a: AscA (200 mg/kg) infused 30 min following onset of feces 
induced peritonitis (FIP) attenuates sepsis-mediated acute lung injury in 
wild type mice at 16 hours. (H&E stain, 40X magnification)
Figure 3a: AscA (200 mg/kg) infused 30 min following onset of feces
Induced peritonitis (FIP) attenuates sepsis-mediated acute lung 
injury in wild type mice at 16 hours. (H&E stain, 40X magnification)
FIP-AscA
Figure 2b: AscA (200 mg/kg) infused 30 min after of feces induced 
peritonitis significantly attenuated neutrophil sequestration in murine 
lung at 16 hours. (Anti-murine PMN monoclonal antibody, 40X Mag)
FIP
Figure 3b: AscA (200 mg/kg) infused 30 min after feces induced 
peritonitis significantly attenuated neutrophil sequestration in 
muring lung at 16 hours. (Anti-murine PMN monoclonal 
antibody, 40X Mag)


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
10 
 
 
Antioxidant 
Reverses oxidation of lipids by the 
neutrophil reactive oxygen species (ROS). 
May prevent oxidation of lipids, proteins, 
and DNA 
Attenuates ROS driving ARDS in 
Covid-19 
Stress Hormone Synthesis 
Essential co-factor in synthesis of 
norepinephrine from dopamine, 
increases adrenergic receptor activity, 
cofactor in hydroxylation of L-tyrosine to 
L-DOPA, cofactor in vasopressin 
synthesis, high concentration in brain 
and adrenal glands 
New reports suggest Covid-19 
patients in ICU have high 
vasopressor requirements (70%), 
HDIVC may lead to reduction in 
time on vasopressor due to 
increased endogenous synthesis 
Regulation of cellular gene 
expression in response to 
hypoxia and stress 
Needed to downregulate hypoxia 
induced factor 1alpha (HIF1a), which is a 
protein-transcription factor that 
regulates hundreds of genes in response 
to hypoxia and stress and is increased in 
sepsis, shock, and ARDS 
In intro study of SARS-CoV-1, the 
spike protein (also present in 
SARS-CoV-2) greatly enhanced 
expression of HIF1a 
Connective tissue 
maintenance 
Vital in wound healing and catalyzing 
formation of procollagen and elastin, 
stimulates production of new collagen, 
induces fibroblast collagen gene 
expression 
SARS-CoV-2 destruction of barrier 
function in lung tissue is key event 
leading to pneumonia/ARDS 
Carnitine biosynthesis 
Co-factor in synthesis of L-carnitine, 
which transports lipids into mitochondria 
and can down-regulate tumor necrosis 
factor-alpha (TNFa), a key driver of 
inflammation 
TNFa levels elevated in 
hospitalized Covid-19 subjects, 
and downregulation may reduce 
inflammatory process 
Phagocytic cell function 
Severe vitamin C deficiency (Scurvy) 
associated in impaired ability of 
neutrophil to phagocytose and generate 
reactive oxygen species, thereby 
decreasing microbiota destruction 
The spike protein may trigger 
dysfunction of immune cells based 
on in vitro data in SARS-CoV-1 
Immune cell clearance 
Promotes neutrophil apoptosis instead 
of necrosis via activation of caspase-3 
proteins; decreases circulating cell-free 
DNA, which can cause end-organ damage 
Inflammatory cells with necrosis 
described in early autopsy reports 
Lymphocytic function 
May promote lymphocytic proliferation, 
differentiation, and maturation. 
Decreased lymphocyte count is emerging 
as hallmark sign of COVID-19  
Increasing lymphocyte count may 
help with viral clearance 
Endothelial function 
HDIVC decreases plasma syndecan-1 
levels and glycocalyx shedding, which is a 
key mechanism in development of ARDS 
and fluid entering the alveoli space 
Covid-19 autopsy data shows 
severe damage to lung tissue with 
disruption of endothelial barrier 
similar in other ARDS etiologies 
 
HDIVC Increased Clearance of Bacteria from Circulation in a Preclinical Model of Sepsis/ARDS 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
11 
In the same murine model of sepsis, blood was obtained by cardiac 
puncture at the time of euthanasia using sterile technique varying 
time points after induction of feces induced peritonitis with or 
without associated HDIVC administration (Figure 4).  10 µl of blood 
was plated on agar plates and colonies counted after overnight 
incubation.  HDIVC treated mice had a highly significant decrease in 
colony counts compared to untreated mice (p< 0.01). Bronchoalveolar 
lavage in these mice also demonstrated an increased in alveolar 
protein content after induction of FIP and protection from HDIVC 
(data not shown). 
 
Human Data to Support the Safety and Efficacy of HDIVC in Humans with Sepsis/ARDS 
In the CITRIS-ALI study21, a multi-center, randomized, double 
blind placebo controlled trial, ARDS patients resulting from 
sepsis who received HDIVC (at 50 mg/kg every 6 hours for 4 
days, n=84) had higher ventilator-free days at day 28 than 
placebo though not significant (Figure 5). However, CITRIS-ALI 
showed that 
patients treated 
with HDIVC had 
significantly 
more ICU free days at day 28 
than placebo. (Figure 5) and 
hospital free days to day 60 
(Figure 6) found that 
patients receiving vitamin C 
had a higher number of ICU 
free days at day 28 and a higher show a statistically significant reduction in 
mortality and ICU-free days at 28 days in ARDS subjects receiving HDIVC 
compared to placebo. Further trials are currently in the planning and enrolling phase for HDIVC in sepsis 
and ARDS. A recent trial using the trio of lower dosage vitamin C plus thiamine and hydrocortisone 
(VITAMINS) did not show improvement in time alive or vasopressor free days in a multicenter, 
randomized, open-label trial. However, this trial gave a lower dose of HDIVC than CITRIS-ALI, was open-
label, and not in an ARDS-specific cohort.22 Furthermore, patients treated with HDIVC showed a 
significantly decreased organ failure as assessed by the sequential organ failure assessment score (SOFA) 
(Figure 7). Most importantly, the CITRIS-ALI trial found that patients treated with HDIVC had a 
significantly improved survival at days 28 (Figure 8). Thus with the clinical data in patients with acute 
lung injury (ARDS) we have justification to proceed with the application of HDIVC in COVID-19 positive 
patients. 
Figure 4: Blood cultures from septic mice after 
FIP onset. AscA treated mice (200 mg/kg) show 
significantly lower colony forming units per 10 µl 
of blood compared to untreated septic animals.
(30)
(39)
(n=84)
(n=82)
p=0.11
Ventilator Free Days
(33)
(42)
(n=84)
(n=82)
p=0.03
ICU Free Days
Fowler et al. JAMA. 2019 PMID: 31573637  
DAY 28
Figure 5
Figure 6 Hospital Free Days Day 60
(35)
(45)
(n=82)
(n=80)
P<0.05
Fowler et al. JAMA. 2019 PMID: 31573637  
Sequential Organ Failure Assessment Score
P<0.026 at 96 Hrs
10
10
9
10
8
6.5
Figure 7


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
12 
 Data for Use of High Dose Intravenous Vitamin C in Viral 
Respiratory Disease 
High dose vitamin C has also been given in a case of viral-
induced ARDS in a patient who developed severe respiratory 
failure that required mechanical ventilation and extracorporeal 
membrane oxygenation (ECMO). Rapid improvement in 
oxygenation was noted early after HDIVC, which was given for 
7 days total. The patient had no side effects from HDIVC or any 
long-term sequalae.23  
Vitamin C supplementation has been given in numerous trials for viral respiratory disease with mixed 
results. In one study with marine recruits (n=674), a randomized, double-blind study of oral vitamin C at 
2.0g/day reduced the reported pneumonia cases compared with placebo.24A randomized clinical trial is 
under way in Wuhan, China to administer 12g of intravenous vitamin C every 12 hours for 7 days 
compared with placebo (NCT04264533). 
 
2.3 
RISK/BENEFIT ASSESSMENT   
 
2.3.1 KNOWN POTENTIAL RISKS  
Potential Physical Risks of Ascorbic Acid Infusion: dry mouth, nausea, vomiting, dizziness, headache. 
pseudohyperglycemia (if checked with point of care glucose testing), crystalluria. 
 
Potential Psychological, Social, Legal Risks of Ascorbic Acid Infusion: No psychological, social or legal 
risks are identifiable from an extensive literature search.  
 
Risks of Blood Draws:  Not applicable to study as blood draws will be standard of care based on treating 
physician. 
 
Glucose Monitoring Plan: 
 
Guidance for blood glucose monitoring in patients enrolled in the AVOCADO Trial: 
 
Ascorbic acid is known to artefactually raise POC blood glucose readings by all POC devices except the 
StatStrip glucometer. However, it does not raise blood glucose readings from a basic metabolic panel or 
glucose results using the gas lab.  Thus, extreme care must be taken to assure an accurate blood glucose 
level from a metabolic laboratory (BMP) or arterial blood gas panel before initiating any insulin therapy, 
including sliding scale or scheduled insulin. 
 
Inpatient units not using the StatStrip POC glucometer should follow these guidelines: 
Guidance for blood glucose monitoring in patients enrolled this study: 
• 
Critical Care and Inpatient Unit Nursing and Treating Physician must be informed of vitamin C’s 
effect on point of care (glucometer) blood glucose and arterial blood gas glucose point of care 
values. The PI(s) will instruct the ordering providers about how to monitor blood glucose and 
insulin management in the study. 
CITRIS-ALI 28-Day Mortality
30%
46%
Gehan-Breslow-Wilcoxon, p= 0.01
HR = 0.55 (95% CI, 0.33 - 0.90)
Fowler et al. JAMA. PMID: 31573637  
Days Since Randomization
0
21
28
Figure 8


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
13 
• 
In-service training will be documented in the Study Training Log 
• 
Bold signage will be displayed on all study instructions, data collection forms, and at the 
patient’s head of bed, stating: 
❖ STOP! Do not use Accuchek or other Point of Care devices to measure glucose on this 
patient 
❖ Use only metabolic or gas lab glucose screening methods 
❖ This patient is enrolled in a study with Vitamin C, which artefactually increases POC glucose 
testing 
❖ Do Not Initiate or Utilize Sliding Scale, Scheduled Insulin, or Continuous Insulin Infusion 
Without Laboratory Confirmation of Blood Glucose 
• 
Those receiving insulin infusion or sliding scale insulin as a part of standard of care will have 
metabolic glucose screening on the schedule determined by the attending/ordering physician 
• 
Blood glucose monitoring for insulin administration guidance should only be by a metabolic or 
blood gas laboratory measured blood glucose results, whether or not the study patient is 
receiving insulin  
• 
Study personnel will follow each study patient closely to monitor insulin use to ensure that point 
of care glucose screening is suspended for the research subject. 
• 
Point of care glucose testing may resume 36 hours after the last infusion of study drug. 
 
 
2.3.2 KNOWN POTENTIAL BENEFITS  
Most observational studies suggest a mortality benefit in inpatient subjects given Vitamin C for serious 
infections and burns.  None of the observational trials have reported significant Vitamin C-related 
toxicity.  An animal model of acute lung injury with intravenous LPS and feces induced peritonitis 
demonstrate significantly less lung injury with Vitamin C, which may result in shortening the time 
patients require mechanical ventilation. 
 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS  
The identifiable risks arising from exposure to intravenous ascorbic acid infusion are low. Given the low 
risk associated with ascorbic acid infusion and the potential high likelihood of benefit we assess the 
risk/benefit ratio to be low (i.e., that benefit far outweighs risk). 
 
3 
OBJECTIVES AND ENDPOINTS 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR ENDPOINTS 
Primary 
 
 
 
Vitamin C infusion will be safe and 
tolerable in COVID-19 subjects 
Documented side effects and 
serious adverse events at hours 
24, 48, 96 (based on Ascor® 
package insert) 
HDIVC infusion may cause dry 
mouth, nausea, vomiting, dizziness, 
headache, flushing, rash, diarrhea. 
HDIVC can be excreted from kidney 
and lead to crystalluria, so will 
monitor urine pH via urinalysis.  
 
Secondary 
 
 
 
Efficacy of HDIVC in COVID-19 
Ventilator-free days 
ICU-free days 
Mortality at 28 days 
Previous research has suggested 
that HDIVC may reduce time on 
ventilator, therapy reducing ICU 
and mortality, which is critical in 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
14 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR ENDPOINTS 
setting of a pandemic caused by 
respiratory disease 
Secondary 
 
 
 
Efficacy of HDIVC in COVID-19 
Reduction in Inflammation 
Change in baseline CRP and 
ferritin compared with hour 
168 (day 7) 
Previous research has suggested 
that elevated CRP and ferritin at 
baseline are associated with 
increased risk of ARDS and 
mortality in COVID-19 
Secondary  
 
 
 
Efficacy of HDIVC in COVID-19 
Improvement in oxygenation 
Change in S/F ratio at baseline 
compared with hour 96 
 
 
Stabilization or improvement in the 
S/F ratio may be an indicator of 
early recovery and that subjects will 
not require mechanical ventilation 
 
 
4 
STUDY DESIGN  
 
4.1 
OVERALL DESIGN 
Up to 20 subjects with COVID-19 and decreased oxygenation will receive Vitamin C (sterile L-ascorbic 
acid for injection at 200 mg/kg per 24 hours with entire calculated 24-hour dose diluted in 200 ml of 5% 
dextrose in water). One fourth of the 24 hour calculated dosage will be administered in 30-minute 
intravenous infusions and occur every 6 hours for a total of 16 doses. Standard of care therapy will be 
followed and recorded when available. 
 
4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
The purpose of this study is to assess the safety, tolerability, efficacy of intravenously infused ascorbic 
acid therapy for patients with COVID19 and decreased oxygenation. By administering the infusion at the 
first objective sign of worsening oxygenation, documented by S/F ratio, decreased pulse oximetry at 
baseline, HDIVC may reduce the inflammatory process and development of respiratory failure requiring 
intubation, which is critical in a pandemic when ventilators, ICU beds, and medical staff may be in short 
supply. We will also enroll patients already in respiratory failure on ventilators and document ventilator-
free days, demonstrating proof of concept that COVID19 patients with ARDS may have similar recovery 
compared to sepsis-induced ARDS in other HDIVC clinical trials. 
 
4.3 
JUSTIFICATION FOR DOSE 
Dosing and bio-distribution data in humans show that pharmacological concentrations of vitamin C can 
only be attained following intravenous administration. Dosage selection for this trial was determined 
both from animal modeling, examining the biological effectiveness in a lung injury model system and 
from the recently conducted randomized double-blind phase I human sepsis safety trial.25 The 200 
mg/kg/24-hour IV dosing protocol was determined from quantification of plasma ascorbate levels and 
from assessing the impact on SOFA scores. Further, the dosage was selected following observation of 
the 200 mg/kg/24-hour regimen on biomarker levels. 
 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
15 
4.4 
END OF STUDY DEFINITION 
Active treatment will continue for 96 hours, discharge from study hospital, study withdrawal, or death, 
whichever comes first.  All subjects will be followed to day 28 for collection of outcomes data even 
though the study intervention will be completed by 96 hours from enrollment. 
 
5 
STUDY POPULATION 
 
5.1 
INCLUSION CRITERIA 
 
• 
Hospitalized with diagnosis of COVID-19 based on positive real-time polymerase chain reaction 
(RT-PCR) of nasal, oropharyngeal, or BAL specimen 
• 
Decrease in oxygenation: 
o Mild deoxygenation defined as S/F ratio decreased by 25% from baseline on admission, 
or SaO2 <95% breathing ambient air on admission (SFR ≥250 prior to study drug 
infusion) 
o Severe deoxygenation defined as respiratory failure requiring mechanical ventilation 
▪ 
SFR <250 prior to study drug infusion 
o 
Non-childbearing potential or childbearing potential with a negative pregnancy test at 
screening, and using a reliable method of contraception (i.e., abstinence, hormonal 
contraception, IUD, or vasectomized partner) 
 
5.2 
EXCLUSION CRITERIA 
 
1. 
Known allergy to Vitamin C 
2. 
Inability to obtain consent from patient or next of kin 
3. 
Chronic kidney disease, stage IV or above (eGFR <30) 
4. 
Presence of diabetic ketoacidosis, use of insulin infusion, or frequent need for point-of-care 
glucose monitoring (>6 times/24-hour period) as determined by treating physician 
5. 
History of glucose-6-phosphate dehydrogenase (G6PD) deficiency 
6. 
Admission ALT or AST greater than 10 times the upper limit of normal 
7. 
Active or history of kidney stone (nephrolithiasis or crystalluria) within the past 12 months 
8. 
Pregnancy 
9. 
Enrolled in another COVID-19 clinical trial that does not allow concomitant study drugs 
 
5.3 
LIFESTYLE CONSIDERATIONS 
Not applicable to this study. 
 
5.4 
SCREEN FAILURES 
Screen failures are defined as participants who consent to participate in the clinical trial but are not 
subsequently enrolled in the study intervention or entered in the study. A minimal set of screen failure 
information is required to ensure transparent reporting of screen failure participants, to meet the 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
16 
Consolidated Standards of Reporting Trials (CONSORT) publishing requirements and to respond to 
queries from regulatory authorities. Minimal information includes demography, screen failure details, 
eligibility criteria, and any serious adverse event (SAE). Subjects will be documented in the Study 
Screening Log when all Inclusion Criteria are met.   
 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of 
exclusion criteria such as failure to obtain consent, inability to locate the legally authorized 
representative (LAR), or delay in diagnosis may be rescreened. Rescreened participants should be 
assigned the same participant number as for the initial screening. 
 
5.5 
STRATEGIES FOR RECRUITMENT AND RETENTION 
Patients with COVID-19 will be recruited from the Emergency Department (ED), the medicine inpatient, 
and the intensive care units (ICU) at Central Virginia VA Health System in Richmond, Virginia (RICVA). 
RICVA is a large tertiary care medical center with a large referral base. Study personnel will review 
patients within the electronic medical record to identify potential candidates for enrollment. Permission 
to approach patients and/or their families will be requested from the attending physicians in charge of 
patient care in the ED, inpatient unit, or the ICU. All patients meeting the inclusion/exclusion criteria will 
be approached with a consent and will be entered into a screening log. If the patient is not enrolled, the 
screening log will include information explaining why enrollment did not occur (exclusion criteria, 
attending physician denial, patient refusal, etc.).  
 
For this study, we will not exclude subjects enrolled in other COVID-19 clinical trials as obtaining safety 
data of interactions with other medications has clinical merit. We will track all COVID-19 related 
medications given during this study, including a category for “other”. Subjects may be excluded from 
this study if other COVID-19 trials do not allow concomitant therapies or specifically exclude other 
COVID-19 treatments in protocol with or without washout phase. The IRB will be informed of initial 
enrollment and study investigators will follow IRB recommendations when multiple experimental 
studies are available to subjects. 
 
 
6 
STUDY INTERVENTION 
 
6.1 
STUDY INTERVENTION(S) ADMINISTRATION 
 
6.1.1 STUDY INTERVENTION DESCRIPTION 
 
All study drug doses will be administered via central or peripheral line infusion. Should no central or 
peripheral line be available at scheduled time of infusion, a call should be placed to pharmacy to 
determine if study drug may be piggybacked into the line that is infusing a different drug.  If 
administering study drug via piggyback is contraindicated, then study drug infusion may be delayed by a 
maximum of 6 hours. If clinical drug administration schedule is such that study drug will not have an 
available administration time beyond this delay, a dedicated new line (peripheral or central) could be 
inserted depending on judgment of attending physician. 
6.1.2 DOSING AND ADMINISTRATION 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
17 
1) First study drug dose (L-ascorbic acid) will be considered “Dose 1” and will be administered within 6 
hours of enrollment or the earliest available time post any clinically indicated procedure which 
requires the patient to be off the unit. All doses will be administered in the medicine inpatient unit 
or ICU.  Patients receiving vitamin C will receive 25% of the total daily calculated dosing 
(200mg/kg/24 hours) and will be infused over 30 minutes for this first dosing. 
2) Subsequent doses which represent 25% of the day’s total dose will be infused every six hours 
through 96 hours (+/- 6 hours).  
a) Timing of Dose 2 will be triggered by the provider order for every 6-hour administration and will 
therefore be listed on the bedside MAR.  As such, timing of Dose 2 may be out of the +/- 6 hour 
window and will not trigger a protocol deviation. 
b) If for any reason any other maintenance dose is not administered within window, the dose will 
be skipped and the next scheduled dose will be given and documented in the data collection 
tool.  
 
6.2 
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
VA Investigational Drug and/or VA Inpatient Pharmacy will coordinate acquisition of sterile L-ascorbic 
acid for infusion from the manufacturer.  
 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
ASCOR vials contain 25,000 mg/50mL of ascorbic acid and is supplied as pharmacy bulk packaging (PBP). 
The diluted ASCOR solution should appear colorless to pale yellow.  
 
6.2.3 PRODUCT STORAGE AND STABILITY 
ASCOR is light sensitive so light exposure should be minimized and stored per package insert 
instructions: 
 
Store under refrigeration (2°C to 8°C); protect from light with amber IV bag cover. Infusion solutions 
prepared by the IDS Pharmacy in the Pharmacy IV admixture suite will expire in 24 hours if refrigerated 
and light-protected.   
 
There is published data establishing the stability of admixtures of ascorbic acid to be at least 24 hours 
stored at room temperature or refrigerated. Also, Dr. Alpha Fowler has unpublished data that was 
obtained prior to an earlier IND trial (IND #113856) which demonstrates the stability of samples 
prepared in the same manner as described below. 
 
6.2.4 PREPARATION 
 Investigational Pharmacy will mix L-ascorbic acid once every 24 hours in four 50 ml hooded infusion 
bags and stored in the inpatient unit or ICU in the dark at 4ºC. The prepared IV bags will have the IV 
tubing attached and primed by the bedside nursing staff.  At designated infusion time, Nursing will 
infuse the contents of the light-shielded agent via infusion pump through tubing over 30 minutes. Prior 
studies performed have shown that L-ascorbic acid prepared for infusion in this way remains stable with 
no quantifiable oxidation. 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
18 
Study drug will be prepared in 50 ml D5W bags, USP, using aseptic technique according to USP 
797requirements.  All ASCOR pharmacy bulk package vials utilized will be discarded within 4 hours or 
sooner as per the ASCOR package insert. 
 
The volume of ascorbic acid to be added to the IV bag will be calculated. This same amount of fluid will 
be drawn out of the D5W 50 mL bag and discarded.  Then, the calculated volume of ascorbic acid will be 
added to the IV bag.  As much air as possible will be removed from the IV bag using an empty syringe 
with needle attached (in order to prevent oxidation).  The IV bag will be covered with a light-protective 
shroud.   
 
Microbiologic Controls:    
 
Investigational Pharmacy has an ISO Class 5 laminar airflow hood (Nuaire Class II Type A2 biological 
safety cabinet) in a segregated compounding area. This biological safety cabinet is recertified every 6 
months.  Compounding personnel must successfully complete media fill testing and gloved, finger-tip 
sampling as per USP 797 regulations. 
 
6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
Not applicable to this study. An amendment to the study protocol with randomization may be added if 
the safety endpoint is met and secondary endpoints suggest a clinical benefit. 
 
6.4 
STUDY INTERVENTION COMPLIANCE 
Adherence to the protocol will be assessed and verified using participant drug log, review of electronic 
medical records and review of the eCRF.   
 
6.5 
CONCOMITANT THERAPY 
Any concomitant medications as part of standard of care (particularly antibiotics, oxygen therapy, off-
label COVID-19 medications such as hydroxychloroquine, chloroquine, azithromycin, remdesivir, 
tocilizumab, lopinavir/ritonavir, mavrilimumab, convalescent serum, glucose infusion, insulin, albumin, 
corticosteroids, N-acetylcysteine, norepinephrine, vasopressin) provided will be recorded.  
 
6.5.1 RESCUE MEDICINE 
Not applicable.  
 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
 
7.1 
DISCONTINUATION OF STUDY INTERVENTION 
If subjects do not tolerate the drug due to side effects such as nausea, vomiting, flushing, rash, 
headache, diarrhea, develops crystalluria on urinalysis, or QTc prolongation >50% baseline, we will 
reduce the subsequent doses by 50%. If the QTc is greater than 600 msec at any time, the drug will be 
discontinued. 
 
Loss of indwelling venous/arterial catheter or peripheral intravenous access will also trigger the stopping 
of Vitamin C infusions but subjects will remain on study. Blood glucose monitoring will continue via the 
central laboratory for 36 hours after the last infusion via peripheral IV draws or peripheral sticks. 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
19 
Sampling via peripheral IV and/or peripheral stick is allowable as it occurs only 4 times throughout the 
study and likely only once (if at all) after the patient has been discharged and is without a central line. 
 
The study drug will be discontinued if a patient develops a metabolic acidosis unexplained by other 
etiologies (ie lactic acidosis secondary to septic shock). Determination of the presence of metabolic 
acidosis will be made by the clinical care team. Study drug will also be discontinued if primary care team 
or surrogate decision maker request withdrawal. The study drug will be discontinued if an allergic 
reaction during study infusion is documented, oxalate nephropathy is diagnosed (defined as rise in 
serum creatinine by 3 times baseline with oxalate crystals on urinalysis), an insulin drip is started, or 
hemolytic anemia develops (defined as drop in baseline serum hemoglobin >2 g/dL with laboratory 
evidence of hemolysis). Data collection will continue for these patients following withdrawal of study 
drug. 
 
 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
Participants are free to withdraw from participation in the study at any time upon request. 
 
7.3 
LOST TO FOLLOW-UP 
Not applicable to this study. 
 
8 
STUDY ASSESSMENTS AND PROCEDURES 
 
8.1 
EFFICACY ASSESSMENTS  
Screening 
Subjects will be evaluated for entry into the study according to stated inclusion and exclusion criteria. 
Individuals who are identified during screening as not eligible for the study need not complete all 
screening procedures. The reason for ineligible status will be documented on the Screen Failure Log. 
 
The following information will be obtained to evaluate each subject’s qualifications for participation in 
the study: 
• 
Demographic information including gender, date of birth, race, ethnicity 
• 
Medical and medication history over the past 30 days, including clinical data on admission 
• 
Collection of blood for chemistry, hematology, coagulation, microbiology, in female subjects of 
childbearing potential, a pregnancy test (urine pregnancy test or blood human chorionic 
gonadotropin (hCG) 
• 
Physical examination including height and weight (body mass index will be calculated based on 
these variables), and vital signs (systolic and diastolic blood pressure, pulse rate, respiratory 
rate, pulse oximetry, body temperature), respiratory exam (crackles yes/no, wheezing yes/no, 
increased work of breathing yes/no), abdominal exam (abdominal tenderness yes/no) 
neurological exam (Glasgow Coma Scale) 
• 
Chest imaging findings (CXR with bilateral infiltrate yes/no ground glass opacities yes/no; CT 
chest with bilateral ground glass opacities yes/no) based on radiological attending report 
• 
Mechanical ventilation (yes/no) 
• 
Use of supplemental oxygen (yes/no) 
• 
Review inclusion and exclusion criteria 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
20 
• 
Signed, written informed consent (may be done by telephone or telehealth/virtual if limited 
access to patient or surrogate due to hospital visitation policies) 
 
 
 
 
Assessments at Baseline (Hour 0): 
• 
Documentation of concomitant medications (if applicable); including oxygen therapy (to calculate 
S/F ratio), antibiotics, corticosteroids, albumin, thiamine, norepinephrine, vasopressin, and N-
acetylcysteine use, off-label or other study drugs for Covid-19 treatment 
• 
Documentation of blood for hematology, coagulation, clinical chemistries 
o COVID-19 biomarkers include Ferritin, CRP, LDH, lymphocyte count, d-dimer (primary 
provider or study personnel to order if not available) 
• 
Documentation of vital signs  
o Calculation of S/F ratio 
• 
Documentation of mechanical ventilation status (yes/no) 
• 
Documentation of EKG (study personnel to order if not available) 
• 
Documentation of negative urine or serum pregnancy testing for human chorionic gonadotropin 
(hCG) if female and of childbearing potential 
 
Treatment Day 1 (Hour 24): 
• 
Documentation of concomitant medications (if applicable) 
• 
Documentation monitoring of vital signs: blood pressure, temperature, heart rate, oxygen saturation 
o Calculate S/F ratio 
• 
Documentation of mechanical ventilation status (yes/no) 
• 
Documentation of blood test results for standard of care (SOC) hematology, coagulation, clinical 
chemistry  
• 
Document urinalysis  
• 
AE and tolerability review (phone interview may be conducted if feasible to reduce exposure of 
study personnel) 
 
Treatment Day 2 (Hour 48): 
• 
Documentation of concomitant medications (if applicable) 
• 
Documentation of vital signs: blood pressure, temperature, heart rate, oxygen saturation 
o Calculate S/F ratio 
• 
Documentation of mechanical ventilation status (yes/no) 
• 
Documentation of blood for hematology, coagulation, clinical chemistry via SOC  
• 
Document urinalysis  
• 
AE and tolerability review (phone interview may be conducted if feasible to reduce exposure of 
study personnel) 
 
Treatment Day 3 (Hour 72): 
• 
Documentation of concomitant medications (if applicable) 
• 
Documentation of vital signs: blood pressure, temperature, heart rate, oxygen saturation 
o Calculate S/F ratio 
• 
Documentation of mechanical ventilation status (yes/no) 
• 
Documentation of blood for hematology, coagulation, clinical chemistry via SOC  
• 
Document urinalysis  


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
21 
• 
AE and tolerability review (phone interview may be conducted if feasible to reduce exposure of 
study personnel) 
 
Treatment Day 4 (Hour 96, end of study infusion): 
• 
Documentation of concomitant medications (if applicable) 
• 
Documentation of vital signs: blood pressure, temperature, heart rate, oxygen saturation 
o Calculate S/F ratio 
• 
Documentation of mechanical ventilation status (yes/no) 
• 
Documentation of blood for hematology, coagulation, clinical chemistry via SOC (study team to 
order if not available) 
• 
Document urinalysis (primary provider or study personnel to order if not available) 
• 
Document EKG (primary provider or study personnel to order if  not available) 
• 
AE and tolerability review (phone interview may be conducted if feasible to reduce exposure of 
study personnel) 
 
Study Day 7 (Hour 168): 
• 
Documentation of mechanical ventilation status (yes/no) 
• 
Documentation of blood for SOC hematology, coagulation, clinical chemistry (if available) 
o COVID-19 markers include CRP, ferritin, LDH, lymphocyte count, d-dimer (order by study 
personnel if not already done) 
 
Study Day 28 
• 
Phone call or chart review to document ventilator-free days, ICU-free days, hospital-free days, 
mortality 
 
 
8.2 
SAFETY AND OTHER ASSESSMENTS 
 
Assessment of hepatic safety: We will follow the current guidance from FDA for assessment of liver 
safety in those with pre-existing hepatic impairment. Evaluation of Drug Induced Severe Hepatitis 
(eDISH): eDISH plots will be overlayed from drug treated arms at the end of the study to look for DILI 
signals. Those cases with bilirubin > 3x ULN and ALT > 8x ULN will be studied individually and adjudicated 
for DILI. These data will be provided for concordance to IRB. 
 
For individual cases, the following rules will be followed for drug discontinuation for DILI: 
 
If AST or ALT rise by > 50% from baseline but are less than 8 times the upper limit of normal and this is 
associated with less than 3 mg/dl rise in bilirubin, a hepatic panel will be repeated within 24 hours.  If 
the AST and ALT continue to rise >100 IU/L over 24 hours or bilirubin rises by >3 mg/dl, the study drug 
will be discontinued. 
 
If AST or ALT exceed 8 times the upper limit of normal at any time or bilirubin rises by 3 or more mg/dl 
from baseline within a 48-hour time frame, the study drug will be discontinued.   
 
Assessment of infusion safety: If the subject has clinically significant side effects based on the L-ascorbic 
acid package insert, the infusion will be stopped, the primary provider and PI will be notified.  
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
22 
An allergic reaction with symptoms such as hypotension, rash, flushing, hives, dyspnea, swelling of 
mouth or lips will lead to stopping of the study drug, notification of PI and primary provider, 
documentation of SAE, and the medical record will be amended with new allergy 
 
The most common adverse reactions are pain and swelling at the site of infusion. Nausea, vomiting, 
diarrhea, facial flushing, rash, headache, fatigue, or disturbed sleep can rarely occur. If clinically 
significant symptoms occur during the infusion, the infusion will be stopped, and subsequent doses 
reduced by 50% (100 mg/kg/day for 16 total doses). If symptoms continue at reduced dose, then the 
study drug will be discontinued.  
 
If development of severe acute kidney injury (increase in serum creatinine 3.0 times baseline) with 
urinalysis showing evidence of oxalate nephropathy (new onset proteinuria, hematuria, or oxalate 
crystals), or kidney biopsy with oxalate crystal deposition in tubules or interstitium, then the infusion 
will be discontinued, and treatment started for oxalate nephropathy. A recently published systemic 
review found 5 cases of oxalate nephropathy in 2,360 HDIVC subjects, and all occurred at 3 times higher 
doses (60 grams/day or higher)26 than described in protocol section 6.1.2. 
 
If hemolysis is suspected based on reduction in hemoglobin by >2 grams from baseline with laboratory 
evidence of hemolysis (increased reticulocyte count, elevated LDH, indirect bilirubin, reduced 
haptoglobin), the study drug will be discontinued, and treatment initiated as needed. 
 
If the patient is started on an insulin drip or it is deemed medically necessary to monitor blood glucose 
more than every 6 hours, then study infusion will be discontinued.  
 
These events will be documented in the SAE form, AE form and CRF form after grading by the PI for 
severity as described in section 8.3. 
 
8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 
Adverse event means any untoward medical occurrence associated with the use of an intervention in 
humans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
An adverse event (AE) or suspected adverse reaction is considered "serious" if, in the view of  the 
investigator(s), it results in any of the following outcomes: death, a life-threatening adverse event, 
prolongation of existing hospitalization, a persistent or significant incapacity or substantial disruption of 
the ability to conduct normal life functions, or a congenital anomaly/birth defect. Important medical 
events that may not result in death, or be life-threatening, may be considered serious when, based upon 
appropriate medical judgment, they may jeopardize the participant and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition.  
 
8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
The following subsections will include a discussion of how AEs will be classified. 
8.3.3.1 SEVERITY OF EVENT 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
23 
 
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s daily 
activities.  
• 
Moderate – Events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning. 
• 
Severe – Events interrupt a participant’s usual daily activity and may require systemic drug 
therapy or other treatment. Severe events are usually potentially life-threatening or 
incapacitating.  Of note, the term “severe” does not necessarily equate to “serious” 
 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
All adverse events (AEs) must have their relationship to study intervention assessed by the clinician who 
examines and evaluates the participant based on temporal relationship and his/her clinical judgment. 
The degree of certainty about causality will be graded using the categories below. In a clinical trial, the 
study product must always be suspect.  
 
• 
Related – The AE is known to occur with the study intervention, there is a reasonable possibility 
that the study intervention caused the AE, or there is a temporal relationship between the study 
intervention and event. Reasonable possibility means that there is evidence to suggest a causal 
relationship between the study intervention and the AE. 
• 
Not Related – There is not a reasonable possibility that the administration of the study 
intervention caused the event, there is no temporal relationship between the study intervention 
and event onset, or an alternate etiology has been established. 
 
8.3.3.3 EXPECTEDNESS  
 
The Principal and Sub-Investigators will be responsible for determining whether an adverse event (AE) is 
expected or unexpected.  An AE will be considered unexpected if the nature, severity, or frequency of 
the event is not consistent with the risk information previously described for the study intervention. 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the attention of 
study personnel during study visits and interviews of a study participant presenting for medical care, or 
upon review by a study monitor. 
 
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured on the 
appropriate case report form (CRF). Information to be collected includes event description, time of 
onset, clinician’s assessment of severity, relationship to study product (assessed only by those with the 
training and authority to make a diagnosis), and time of resolution/stabilization of the event. All AEs 
occurring while on study must be documented appropriately regardless of relationship. All AEs will be 
followed to adequate resolution. 
 
Any medical condition that is present at the time that the participant is screened will be considered as 
baseline and not reported as an AE.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the event 
at each level of severity to be performed. AEs characterized as intermittent require documentation of 
onset and duration of each episode. 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
24 
 
The study personnel will record all reportable events with start dates occurring any time after informed 
consent is obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study 
participation.  At each study visit, the investigator will inquire about the occurrence of AE/SAEs since the 
last visit.  Events will be followed for outcome information until resolution or stabilization. 
 
8.3.5 ADVERSE EVENT REPORTING  
 
Investigators will report all unanticipated problems that involve risk or harm to a research participant to 
the IRB in the required reporting time frame. The IRB will be notified within 5 business days of receiving 
notice of the unanticipated problem.   
Investigators will also determine if the serious adverse event is unexpected for Vitamin C.  Unexpected 
for Vitamin C is defined as any event not listed in the Vitamin C package insert. If the investigator 
determines that any serious and study-related adverse event is unexpected for Vitamin C, the FDA will 
be notified within 7 calendar days. Such events may also meet the definition of Unanticipated Problems 
as described below. 
 
Examples of untoward clinical occurrences, or disease-related events (DREs) that are expected in the 
course of COVID-19 include: 1) transient or worsening hypoxemia, 2) agitation, 3) delirium, 4) diarrhea, 
5) nosocomial infections, 6) skin breakdown, 7) acute hepatitis, 8) acute kidney injury that may require 
renal replacement therapy, 9) worsening of cardiopulmonary function that may require artificial 
cardiopulmonary support, 10) worsening hypotension that may require vasopressor support, and 11) 
acute thrombosis or coagulopathy. Such events, which are often the focus of prevention efforts as part 
of usual ICU care, will not be considered reportable adverse events unless the event is considered by the 
investigator to be associated with the study drug or procedures, or unexpectedly severe or frequent for 
an individual patient with sepsis and ARDS. Examples of unexpectedly frequent untoward clinical 
occurrences would be repeated episodes of unexplained hypoxemia. This would be in contrast to an 
isolated episode of transient hypoxemia (e.g., Sp02 ~85%), related to positioning or suctioning.  This 
latter event would not be considered unexpected by nature, severity or frequency. These events will be 
captured in the eCRF. 
 
8.3.6 SERIOUS ADVERSE EVENT REPORTING  
 
The study clinician will immediately report to the IRB any serious adverse event and must include an 
assessment of whether there is a reasonable possibility that the study intervention caused the event. 
Study endpoints that are serious adverse events (e.g., all-cause mortality) must be reported in 
accordance with the protocol unless there is evidence suggesting a causal relationship between the 
study intervention and the event (e.g., death from anaphylaxis). In that case, the investigator must 
immediately report the event to the IRB. 
 
All serious adverse events (SAEs) will be followed until satisfactory resolution or until the site 
investigator deems the event to be chronic or the participant is stable. 
 
 
8.4 
UNANTICIPATED PROBLEMS 
 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
25 
The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to 
participants or others to include, in general, any incident, experience, or outcome that meets all of the 
following criteria from the time of consent to through study hour 168 until resolved, withdrawn from 
the study, death, or lost to follow up: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the Institutional Review Board (IRB)-
approved research protocol and informed consent document; and (b) the characteristics of the 
participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
 
8.4.2  UNANTICIPATED PROBLEM REPORTING  
The investigator will report unanticipated problems (UPs) to the reviewing IRB. The UP report will 
include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 
• 
A detailed description of the event, incident, experience, or outcome;  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP;  
• 
A description of any changes to the protocol or other corrective actions that have been taken or 
are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:   
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB within 48 hours of the 
investigator becoming aware of the event.  
• 
Any other UP will be reported to the IRB within 5 business days of the investigator becoming 
aware of the problem.  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 
Human Research Protections (OHRP) within 5 business days of the IRB’s receipt of the report of 
the problem from the investigator. 
 
9 
STATISTICAL CONSIDERATIONS  
 
9.1 
STATISTICAL HYPOTHESES FOR PRIMARY ENDPOINT 
Not applicable to this study.  
 
9.2 
SAMPLE SIZE DETERMINATION 
We will aim to enroll 20 patients to establish safety data and consider an amendment to the protocol for 
additional enrollment based on COVID-19 cases and further evaluation of secondary endpoints. 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
26 
 
9.3 
POPULATIONS FOR ANALYSES 
We will stratify subjects for secondary analysis into subjects with mild decreased oxygenation, 
defined as SaO2 <95% on room air upon admission or requiring supplemental oxygenation and 
SFR ≥ 250. subjects with severe decreased oxygenation will be defined as SFR <250. 
 
9.4 
STATISTICAL ANALYSES 
 
9.4.1 GENERAL APPROACH 
 
Continuous variables will be compared across groups using Student’s T-test, ANOVA, or a Kruskal Wallis 
ANOVA depending on their distribution. Changes from baseline to time of measurement will be 
compared by analysis of covariance. Categorical variables will be measured by Fisher’s Exact test. 
Correlations will be assessed by Spearman’s coefficient. The Shapiro-Wilk test will be applied to 
determine normality. Parametric dependent means will be compared with paired Student’s T-test and 
non-parametric means will be analyzed using Wilcoxon signed-rank test. 95% confidence intervals will 
be calculated and a p value of <0.05 will be considered statistically significant. SPSS and Stata will be 
used to conduct analysis.  
 
9.4.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
 
The primary endpoint will be treatment related adverse events at end of study drug infusion, as defined 
in 9.4.3. Subjects will be stratified into two cohorts: mild deoxygenation and severe deoxygenation. 
Descriptive statistics will be applied.  
 
9.4.3 SAFETY ANALYSES 
Adverse Events 
Adverse events will be classified into standard terminology using the Medical Dictionary for Regulatory 
Activities (MedDRA). Adverse events will be listed by reported verbatim term and MedDRA-preferred 
term, start and stop date and time, study day, duration, severity, relationship to study drug, and 
seriousness. Additionally, data may be grouped for analysis by different levels of the MedDRA hierarchy. 
The incidence of AEs, the incidence of treatment- related AEs, and the severity of AEs will be tabulated 
by cohort (mild versus severe deoxygenation). The number and percentage of patients with SAEs and 
treatment-related SAEs and patients who withdraw due to an AE will be tabulated. 
 
Clinical Laboratory Testing 
Clinical laboratory test parameters will be listed for individual patients. Baseline for clinical laboratory 
parameters will be defined as the last evaluation before the start of the initial dosing with study drug. 
Summary statistics, including mean absolute change from baseline, will be calculated for each 
parameter and summarized. 
 
Vital Signs 
Vital signs results (systolic and diastolic blood pressure, pulse rate, pulse oximetry, and body 
temperature) will be listed for individual patients. Each vital sign measure will be tabulated by 
evaluation time point. Baseline for vital signs measurements will be defined as the last evaluation before 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
27 
the beginning of the first study drug. Summary statistics, including mean absolute change from baseline, 
will be determined and tabulated for each measure. 
 
Physical Exams 
Physical examination findings at baseline by attending physician will be documented based on chart 
review. Clinically significant changes will be recorded as AEs. Symptoms of interest previously reported 
with intravenous Vitamin C based on the package insert will be recorded daily, including dizziness, 
headache, nausea, vomiting, flushing, rash, or diarrhea. Physicians managing COVID-19 subjects will be 
listed as sub-investigators and amendments may be made to add investigators to protocol in order to 
limit research activities and conserve personal protective equipment (PPE).  
 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
10.1.1 INFORMED CONSENT PROCESS 
 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
Consent forms describing in detail the study intervention, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study intervention.   
 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the 
study and continues throughout the individual’s study participation. Consent forms will be Institutional 
Review Board (IRB)-approved and the participant will be asked to read and review the document. The 
investigator will explain the research study to the participant and answer any questions that may arise. 
A verbal explanation will be provided in terms suited to the participant’s comprehension of the 
purposes, procedures, and potential risks of the study and of their rights as research participants.  
Participants will have the opportunity to carefully review the written consent form and ask questions 
prior to signing. The participants should have the opportunity to discuss the study with their family or 
surrogates or think about it prior to agreeing to participate. The participant will sign the informed 
consent document prior to any procedures being done specifically for the study. Participants must be 
informed that participation is voluntary and that they may withdraw from the study at any time, without 
prejudice. A copy of the informed consent document will be given to the participants for their records. 
The informed consent process will be conducted and documented in the source document (including the 
date), and the form signed, before the participant undergoes any study-specific procedures. The rights 
and welfare of the participants will be protected by emphasizing to them that the quality of their 
medical care will not be adversely affected if they decline to participate in this study. 
 
Many of the patients approached for participation in this research protocol will have limitations of 
decision-making abilities due to their critical illness. Hence, most patients will not be able to provide 
informed consent.  Accordingly, informed consent will be sought from the potential subject’s legally 
authorized representative. 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
28 
Regarding proxy consent, the existing federal research regulations (‘the Common Rule’) state at 
45 CFR 46.116 that: “no investigator may involve a human being as a subject in research…unless the 
investigator has obtained the legally effective informed consent of the subject or the subject’s legally 
authorized representative”; and defines at 45 CFR 46 102 (c) a legally authorized representative (LAR) 
as: “an individual or judicial or other body authorized under applicable law to consent on behalf of a 
prospective subject to the subject’s participation in the procedures(s) involved in the research.”  OHRP 
defined examples of “applicable law” as being state statutes, regulations, case law, or formal opinion of 
a State Attorney General that addresses the issue of surrogate consent to medical procedures.  Such 
“applicable law” could then be considered as empowering the surrogate to provide consent for subject 
participation in the research.  
 
According to a previous President’s Bioethics Committee (National Bioethics Advisory Committee), an 
investigator should accept as an LAR…a relative or friend of the potential subject who is recognized as an 
LAR for purposes of clinical decision making under the law of the state where the research takes place. 
Finally, OHRP has opined in their determination letters that a surrogate could serve as a LAR for research 
decision making if such an individual is authorized under applicable state law to provide consent for the 
“procedures” involved in the research study. 
 
According to the Belmont Report, respect for persons incorporates at least two ethical convictions; first, 
that individuals should be treated as autonomous agents, and second, that persons with diminished 
autonomy are entitled to protection. One method that serves to protect subjects is restrictions on the 
participation of subjects in research that presents more than minimal risks. Commentators and Research 
Ethics Commission have held the view that it is permissible to include incapable subjects in research that 
involves more than minimal risk as long as there is the potential for beneficial effects and if the research 
presents a balance of risks and expected direct benefits similar to that available in the clinical setting.  
Several U.S. task forces have deemed it is permissible to include incapable subjects in research.  For 
example, the American College of Physicians’ document allows surrogates to consent to research 
involving incapable subjects only “if the net additional risks of participation are not substantially greater 
than the risks of standard treatment.”  Finally, the National Bioethics Advisory Committee (NBAC) stated 
“that an IRB may approve a protocol that presents greater than minimal risk but offers the prospect of 
direct medical benefits to the subject, provided that…the potential subject’s LAR gives permission…” 
 
Consistent with the above ethical sensibilities regarding the participation of decisionally incapable 
subjects in research and the previous assessment of risks and benefits in the previous section, the 
present trial presents a balance of risks and potential direct benefits that is similar to that available in 
the clinical setting, with the exception of the additional blood draws. 
 
In this study, consent will be obtained by the COVID-19 RICVA providers in order to limit risk of exposure 
to non-essential staff. The providers are listed as sub-investigators in the study and include experts in 
hospital medicine, infectious disease, and pulmonary/critical care. Providers will be educated on 
consent process and additional providers may be added to protocol via amendment process. The 
consent form itself will either kept in the subject’s room until discharge from the hospital and a digital 
photograph may be obtained in order to limit spread of COVID-19. Infectious disease and epidemiology 
will be consulted and provide protocols for handling consent paperwork, which may be updated by 
amendment to protocol. If informed consent is obtained via telephone or virtual meeting, then a 
witness not related to study team will be present to listen to conversation and sign ICF. All study 
participants who are consented via telephone or virtual meeting will be offered a physical consent form 
to be signed via fax or mail.  


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
29 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable 
cause.  Written notification, documenting the reason for study suspension or termination, will be 
provided by the suspending or terminating party to study participants and IRB. If the study is 
prematurely terminated or suspended, the Principal Investigator (PI) will promptly inform study 
participants, the Institutional Review Board (IRB), and will provide the reason(s) for the termination or 
suspension.  Study participants will be contacted, as applicable, and be informed of changes to study 
visit schedule. 
  
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping    
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination that the primary endpoint has been met 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, 
and satisfy the IRB and/or Food and Drug Administration (FDA). 
 
10.1.3 CONFIDENTIALITY AND PRIVACY  
Participant confidentiality and privacy is strictly held in trust by the participating investigators, their 
staff, and their interventions. This confidentiality is extended to cover testing of biological samples and 
genetic tests in addition to the clinical information relating to participants. Therefore, the study 
protocol, documentation, data, and all other information generated will be held in strict confidence. No 
information concerning the study or the data will be released to any unauthorized third party without 
prior written approval of the principal investigator(s).  
 
All research activities will be conducted in as private a setting as possible. 
 
Representatives of the Institutional Review Board (IRB), regulatory agencies or pharmaceutical company 
supplying study product may inspect all documents and records required to be maintained by the 
investigator, including but not limited to, medical records (office, clinic, or hospital) and pharmacy 
records for the participants in this study. The clinical study site will permit access to such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal use 
during the study. At the end of the study, all records will continue to be kept in a secure location for as 
long a period as dictated by the reviewing IRB, or Institutional policies. 
 
Study participant research data, which is for purposes of statistical analysis and scientific reporting, will 
be transmitted to and stored in a secure, electronic database. This will not include the participant’s 
contact or identifying information. Rather, individual participants and their research data will be 
identified by a unique study identification number. The study data entry and study management 
systems used by clinical sites and by research staff will be secured and password protected. At the end 
of the study, all study databases will be de-identified and archived. 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
30 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA  
Not applicable to study.  
 
10.1.5 SAFETY OVERSIGHT 
Safety oversight will monitored by the PI to ensure accurate recording of the data and reporting of any 
clinically significant AEs to the IRB or appropriate federal authorities.  
 
10.1.6 CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants are 
protected, that the reported trial data are accurate, complete, and verifiable, and that the conduct of 
the trial is in compliance with the currently approved protocol/amendment(s), with International 
Conference on Harmonisation Good Clinical Practice (ICH GCP), and with applicable regulatory 
requirement(s).  
 
• 
Monitoring for this study will be performed by an internal monitoring team, who may or may 
not be part of the study team.  
• 
On site monitoring will occur annually at the time of IRB continuing review and involve random 
review of certain data to assess for data accuracy, protocol compliance, and deviations. 
 
 
10.1.7 QUALITY ASSURANCE AND QUALITY CONTROL 
 
The investigational site will provide direct access to all trial related source data/documents, and reports 
for the purpose of monitoring and auditing by the IRB, and inspection by local and regulatory 
authorities. 
 
10.1.8 DATA HANDLING AND RECORD KEEPING  
 
A screening log will be created and stored in a password protected document on a secure network. Data 
will be entered into a password-protected software. 
 
10.1.8.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
Data collection is the responsibility of the clinical trial staff at VA under the supervision of the site 
investigators. The investigators are responsible for ensuring the accuracy, completeness, legibility, and 
timeliness of the data reported. 
 
All source documents should be completed in a neat, legible manner to ensure accurate interpretation 
of data.   
 
Hardcopies of the study visit worksheets will be provided for use as source document worksheets for 
recording data for each participant enrolled in the study.  Data recorded in the electronic case report 
form (eCRF) derived from source documents should be consistent with the data recorded on the source 
documents.  
 
Clinical data (including adverse events (AEs), concomitant medications, and expected adverse reactions 
data) and clinical laboratory data will be entered into secure data collection software with password 
protection (Microsoft Excel). Clinical data will be entered directly from the source documents. 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
31 
 
10.1.8.2 STUDY RECORDS RETENTION  
Study documents should be retained for a minimum of 1 year after study completion. 
 
10.1.9 PROTOCOL DEVIATIONS  
A protocol deviation is any noncompliance with the clinical trial protocol, International Conference on 
Harmonisation Good Clinical Practice (ICH GCP), or Manual of Procedures (MOP) requirements. The 
noncompliance may be either on the part of the participant, the investigator, or the study site staff. As a 
result of deviations, corrective actions are to be developed by the site and implemented promptly.  
 
These practices are consistent with ICH GCP:  
• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
5.1 Quality Assurance and Quality Control, section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
Protocol deviations must be sent to the reviewing Institutional Review Board (IRB) per their policies. The 
site investigator is responsible for knowing and adhering to the reviewing IRB requirements.  
 
10.1.10 
PUBLICATION AND DATA SHARING POLICY 
This study will be conducted in accordance with the following publication and data sharing policies and 
regulations: 
 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the 
published results of NIH funded research. It requires scientists to submit final peer-reviewed journal 
manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for 
publication. 
 
10.1.11 
CONFLICT OF INTEREST POLICY 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical 
industry, is critical.  Therefore, any actual conflict of interest of persons who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
persons who have a perceived conflict of interest will be required to have such conflicts managed in a 
way that is appropriate to their participation in the design and conduct of this trial.   
 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
32 
10.2 ABBREVIATIONS 
 
AE 
Adverse Event 
AKI 
Acute Kidney Injury 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
ARDS 
Acute respiratory distress syndrome 
AST 
Aspartate aminotransferase 
BMI 
Body mass index 
CFR 
Code of Federal Regulations 
CONSORT 
Consolidated Standards of Reporting Trials 
COVID-19 
Coronavirus disease 
CRF 
Case Report Form 
DILI 
Drug Induced Liver Injury 
DRE 
Disease-Related Event 
eCRF 
Electronic Case Report Forms 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
HIPAA 
Health Insurance Portability and Accountability Act  
HDIVC 
High dose intravenous vitamin C 
ICH 
International Conference on Harmonisation  
IDE 
Investigational Device Exemption 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
MedDRA 
Medical Dictionary for Regulatory Activities 
MOP 
Manual of Procedures 
NIH  
National Institutes of Health 
OHRP 
Office for Human Research Protections 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SOA 
Schedule of Activities 
SOC 
Standard of Care 
SOFA 
Sequential Organ Failure Assessment 
SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
US 
United States 
 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
33 
10.3 PROTOCOL AMENDMENT HISTORY 
 
Version 
Date 
Description of Change  
Brief Rationale 
2.0 
3/26/20 
Added background mechanism 
proposals, edited abbreviations, 
pregnancy added as inclusion, 
changed sub-investigators to 
research-certified 
Requested by IRB 
3.0 
4/2/20 
Edits to inclusion criteria, added 
study safety labs, adjusted PI/sub-I 
Requested by IRB 
4.0 
4/9/20 
Additional information to Exclusion 
#4 and Study Drug Discontinuation 
Clarification 
5.0 
5/21/20 
Amended kidney stone history 
exclusion to within past 12 months, 
further detailed clinical parameters 
for adverse event definitions and 
natural history of COVID-19 
Clarification 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
34 
 
 
 
 
 
 
 
 
11 REFERENCES  
 
1. Zhu, N. et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 382, 
727–733 (2020). 
2. World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. 
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-
the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it. 
3. Chen, N. et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus 
pneumonia in Wuhan, China: a descriptive study. The Lancet 395, 507–513 (2020). 
4. Huang, C. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 
The Lancet 395, 497–506 (2020). 
5. Wang, D. et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–
Infected Pneumonia in Wuhan, China. JAMA 323, 1061 (2020). 
6. Mahase, E. Covid-19: WHO declares pandemic because of “alarming levels” of spread, severity, and 
inaction. BMJ m1036 (2020) doi:10.1136/bmj.m1036. 
7. How is the coronavirus spreading around the world? https://www.nature.com/articles/d41586-020-
00758-2. 
8. Arentz, M. et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in 
Washington State. JAMA (2020) doi:10.1001/jama.2020.4326. 
9. Grasselli, G., Pesenti, A. & Cecconi, M. Critical Care Utilization for the COVID-19 Outbreak in 
Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA (2020) 
doi:10.1001/jama.2020.4031. 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
35 
10. Remuzzi, A. & Remuzzi, G. COVID-19 and Italy: what next? The Lancet S0140673620306279 (2020) 
doi:10.1016/S0140-6736(20)30627-9. 
11. ‘We are making difficult choices’: Italian doctor tells of struggle against coronavirus. 
https://www.independent.co.uk/news/health/coronavirus-italy-hospitals-doctor-lockdown-
quarantine-intensive-care-a9401186.html. 
12. The Extraordinary Decisions Facing Italian Doctors. 
https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/. 
13. Li, R. et al. The demand for inpatient and ICU beds for COVID-19 in the US: lessons from Chinese 
cities. http://medrxiv.org/lookup/doi/10.1101/2020.03.09.20033241 (2020) 
doi:10.1101/2020.03.09.20033241. 
14. Kashiouris, M. G. et al. The Emerging Role of Vitamin C as a Treatment for Sepsis. Nutrients 12, 292 
(2020). 
15. Eipper, B. A. & Mains, R. E. The role of ascorbate in the biosynthesis of neuroendocrine peptides. 
The American Journal of Clinical Nutrition 54, 1153S-1156S (1991). 
16. Huang, J., Fu, G., Yao, Q. & Cheng, G. Relation of thrombomodulin, TFPI and plasma antioxidants in 
healthy individuals and patients with coronary heart disease. Acta Cardiol 63, 341–346 (2008). 
17. Manning, J. et al. Vitamin C Promotes Maturation of T-Cells. Antioxidants & Redox Signaling 19, 
2054–2067 (2013). 
18. Carr, A. & Maggini, S. Vitamin C and Immune Function. Nutrients 9, 1211 (2017). 
19. Chen, Y. et al. Vitamin C Mitigates Oxidative Stress and Tumor Necrosis Factor-Alpha in Severe 
Community-Acquired Pneumonia and LPS-Induced Macrophages. Mediators of Inflammation 2014, 
1–11 (2014). 
20. Conti, P. Induction of pro-inflammatory cytokines (IL-1 and IL-6) and lung inflammation by COVID-
19: anti-inflammatory strategies. J Biol Regul Homeost Agents. 34, 1 (2020). 


AVoCaDO 
Version 6.0 
Protocol 001 
7 July 2020 
 
 
36 
21. Fowler, A. A. et al. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation 
and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI 
Randomized Clinical Trial. JAMA 322, 1261 (2019). 
22. Fujii, T. et al. Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time 
Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS 
Randomized Clinical Trial. JAMA 323, 423 (2020). 
23. Fowler III, A. A. et al. Intravenous vitamin C as adjunctive therapy for enterovirus/rhinovirus induced 
acute respiratory distress syndrome. WJCCM 6, 85 (2017). 
24. Pitt, H. A. & Costrini, A. M. Vitamin C prophylaxis in marine recruits. JAMA 241, 908–911 (1979). 
25. Medical Respiratory Intensive Care Unit Nursing et al. Phase I safety trial of intravenous ascorbic 
acid in patients with severe sepsis. J Transl Med 12, 32 (2014). 
26. Yanase, F. et al. Harm of IV High-Dose Vitamin C Therapy in Adult Patients: A Scoping Review. 
Critical Care Medicine 1 (2020) doi:10.1097/CCM.0000000000004396.