Steroid Dosing by bioMARker Guided Titration in Critically Ill Patients With Pneumonia

Study Overview
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Brief Summary
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This research study is being done to determine the appropriate dose of steroids and the appropriate duration for steroid use to reduce inflammation in severe pneumonia needing a form of breathing support. This study seeks to compare usual care to a unique (individualized) dosing strategy. A marker of inflammation in the body will be measured in blood samples. This marker of inflammation is called C- reactive protein. The overall goal is to identify patients that will benefit most from steroid use and decrease use of steroids. The information collected from this study may provide information that may improve management of patients with severe pneumonia requiring a form of breathing support.

Detailed Description
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This is a two-arm single-center pilot phase II clinical trial. Patients will be screened at the time of hospital admission and will be required to be enrolled within the clinical trial within 48 hours of hospital admission. In the individualized, biomarker-concordant arm, all patients will receive steroids once at the time of admission, then a daily morning dose. In order to account for varying turnaround time at different laboratories, C-Reactive Protein (CRP) levels will be drawn with early morning labs, and used to determine the steroid dosing for the day. Patients will receive daily CRP measurements for the first 5 days of the hospitalization, or until hospital discharge. CRP measurements will be discontinued once the CRP is less than 50mmol/L. Steroid administration will be facilitated using standardized computerized physician order entry. The patients, treating physicians and outcome assessors will be blinded to the group assignment. Steroid order sets will include 6 hourly point of care glucose monitoring, and an insulin sliding scale for glucose levels to facilitate glucose management. The need for insulin drip will be determined by the treating physician. Additional testing including serum and urine ketones will be informed by the glucose level, serum anion gap and bicarbonate levels in routine basic metabolic panels and determined by the treating physician. In the usual care arm, patients will receive daily CRP measurements for the first 5 days of the hospitalization, or until hospital discharge.

Official Title
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SMART Trial: Steroid Dosing by bioMARker Guided Titration in Critically Ill Patients With Pneumonia

Conditions
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Pneumonia

Intervention / Treatment
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* Drug: Methylprednisolone
* Other: Usual Care


Participation Criteria
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Eligibility Criteria
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For the Pneumonia arm of the study: Inclusion Criteria: Patients admitted to hospital with community acquired pneumonia. Acute respiratory failure SpO2/FiO2 < 315 (SpO2<90% on room air or <97% on 2L NC). Exclusion Criteria: Contraindications or unwilling to use steroids by patient or provider Refractory septic shock defined as a requirement of norepinephrine dose or equivalent above >0.1 microgram/kilogram/minute or 2 or more vasopressors Pre-admission chronic use of steroids or other immunosuppressive medications Adrenal insufficiency Comfort care Leukopenia <1000/mm or neutropenia <500/mm (except if attributable to pneumonia) and HIV positive with a CD4 count <100 Recent or past history of bone marrow or solid organ transplantation Hospital admission in the previous 30 days Suspected flare of Interstitial lung disease (infectious and non-infectious) Positive influenza testing or high suspicion for influenza For the COVID-19 arm of the study: Inclusion Criteria: Patients admitted to hospital with COVID-19 pneumonia (high suspicion or confirmed by positive SARS CoV-2 testing). Acute respiratory failure SpO2/FiO2 < 315 (SpO2<90% on room air or <97% on 2L NC). Exclusion Criteria: Contraindications or unwilling to use steroids by patient or provider Refractory septic shock defined as a requirement of norepinephrine dose or equivalent above >0.1 microgram/kilogram/minute or 2 or more vasopressors Pre-admission chronic use of steroids or other immunosuppressive medications Adrenal insufficiency Comfort care Leukopenia <1000/mm or neutropenia <500/mm (except if attributable to pneumonia) and HIV positive with a CD4 count <100 Recent or past history of bone marrow or solid organ transplantation Suspected flare of Interstitial lung disease (infectious and non-infectious) Positive influenza testing or high suspicion for influenza

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Usual Care<br>Usual care as determined by the patient's primary team. | Other: Usual Care<br>* Usual care as determined by the patients treatment team.<br>|
| Experimental: Biomarker-adjusted Steroid Dosing<br>Individualized, biomarker concordant steroid use: dosing, titration and duration according to CRP level. This is a predetermined dosing table that adjusts dose of steroid by CRP level. Specifically: if CRP < 50 mmol/L: discontinue steroid; if CRP is between 51-100 mmol/L: 0.5 mg methylprednisolone (or dose equivalent of oral prednisone); if CRP is between 101-150 mmol/L: 0.75 mg/kg methylprednisolone (or dose equivalent of oral prednisone); if CRP level is between 151-200 mmol/L: 1 mg/kg methylprednisolone (or dose equivalent of oral prednisone); if CRP level > 200 mmol/L: 1.5 mg/kg methylprednisolone (or dose equivalent of oral prednisone). | Drug: Methylprednisolone<br>* Methylprednisolone will be administered based on CRP-guided protocol outlined under 'Biomarker-adjusted steroid dosing'.<br>* Other names: Biomarker guided steroid dosing;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Timely Initiation of Corticosteroids and Implementation of Biomarker-titrated Corticosteroid Dosing | Number of eligible subjects to adhered to the timely initiation and daily corticosteroid treatment according to ESICM/Society of Critical Care Medicine SCCM clinical practice guideline (control group) or biomarker concordance (intervention group) | Within 30 days of enrollment in study. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mortality | Number of subject deaths | 90 days | 
| Need for High Flow Nasal Cannula Oxygen | Number of subjects to need high flow nasal cannula oxygen | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 
| Need for Noninvasive Mechanical Ventilation | Assessed by the number of participants that required noninvasive mechanical ventilation. | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 
| Need for Invasive Mechanical Ventilation | Assessed by the number of participants that required invasive mechanical ventilation. | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 
| Organ Failure | Organ failures measured by Sequential Organ Failure Assessment (SOFA). The overall score is based on 6 sub-scores respiratory system, neurologic system, cardiovascular system, hepatic system, coagulation, and renal system using an overall scale of 0-24, which 0=no organ failure, 24=complete organ failure. | Measured daily for approximately 5 days | 
| New Onset Cardiac Arrhythmias | Number of participants who develop arrhythmias identified by electrocardiogram or echocardiogram. | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 
| Myocardial Injury | Number of participants with evidence of myocardial injury determined by daily troponin peak and /or new diagnosis of Left Ventricular (LV) dysfunction (LVEF <40%) or new diagnosis of cor pulmonale | Up to day +14 following study enrollment. | 
| Cardiovascular Dysfunction | Number of subjects with new and/or worsening right ventricle (RV)/left ventricle (LV) dysfunction | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 
| Occurrence of Hyperglycemia | Number of participants who have hyperglycemia while receiving corticosteroids. Hyperglycemia is defined as a consistently elevated blood sugar level requiring insulin administration. | Up to day +5 following study enrollment. | 
| Occurrence of Delirium | Number of participants who develop delirium while receiving corticosteroids. Delirium will be assessed by Confusion Assessment Method for the ICU (CAM-ICU) measurement tool. The CAM-ICU is a binary (yes/no) scale for assessing the presence of delirium. | Up to day +5 following study enrollment. | 
| Occurrence of Secondary Infection | Number of participants who develop secondary infections during and after steroid therapy. A secondary infection is defined as a new infection that develops after initiation of corticosteroid therapy, until 5 days after steroids are discontinued. | Up to day +14 following study enrollment. | 
| ICU Admission | Number of subjects admitted to the ICU | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 
| Oxygen-free Days | Number of days subjects did not require oxygen assistance. | Within hospitalization or 30 days of study enrollment (whichever is sooner) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Pneumonia, steroid, COVID-19, SARS CoV-2