Clinical trial NCT03680274: Lessening Organ Dysfunction With VITamin C
Official title: Lessening Organ Dysfunction With VITamin C (LOVIT)
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: PHASE3
Conditions: Sepsis
Vitamin C
Intensive Care Unit
COVID-19
Pandemic
Coronavirus
Lead sponsor: Université de Sherbrooke
Sponsor class: OTHER
Collaborators: name: Lotte & John Hecht Memorial Foundation
First posted: 2018-09-21
Enrollment: 872
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: LOVIT is a multicentre concealed-allocation parallel-group blinded randomized controlled trial to ascertain the effect of high-dose intravenous vitamin C compared to placebo on mortality or persistent organ dysfunction at 28 days in septic intensive care unit patients. Patients with COVID-19 are considered eligible for this study.

Detailed description: Background. The burden of sepsis is increasing worldwide. It is the cause of 8 million global deaths each year. Currently, treatment options are limited to antimicrobials and supportive care such as intravenous fluids, vasopressors, mechanical ventilation, and renal replacement therapy. In the absence of effective therapies specifically targeting the dysregulated immune response, prolonged use of these life-sustaining therapies can be debilitating. A growing body of evidence suggesting that vitamin C, an inexpensive and readily available intervention, is potentially lifesaving in sepsis. Intravenous vitamin C may be the first therapy to mitigate the dysregulated cascade of events that leads to sepsis. If proven effective, vitamin C could be used worldwide and drastically change outcomes in high- and low-income settings alike.

Objectives. To determine whether intravenous vitamin C, compared to placebo, reduces mortality and morbidity in sepsis (induced by bacterial and viral pathogens (as COVID-19)), and compare clinical and biochemical measures of organ dysfunction, and health-related quality of life (HRQoL) at 6 months. To ascertain the volume of distribution, clearance, and plasma concentration over a course of 96 hours of intravenous vitamin C 50 mg/kg of weight every 6 hours or matching placebo (pharmacokinetic (PK) substudy).

Methods. Patients will be randomly assigned to vitamin C (intravenous, 50 mg/kg every 6h) or placebo (0.9% NaCl or dextrose 5% in water) for 96 hours. Study personnel at the clinical sites will document the composite of death or persistent organ dysfunction at day 28. Daily assessments will occur for organ function, on days 1, 3, 7 for inflammation, infection, and endothelial injury biomarkers, at baseline for vitamin C level, and at 6 months for mortality and HRQoL. The LOVIT Trial will be conducted in adult general Canadian and international intensive care units. For the PK substudy: Blood samples will be drawn around the 8th dose at time 0 and then after administration at times 1h, 2h, 4h and 6h (the 6h level will be immediately prior to the next dose). The PK substudy will be conducted with 100 participants in 3 of the 25 participating centers.

Relevance. In the context of increasing off-label use of vitamin C for sepsis and ongoing trials of vitamin C bundled with other pharmacological interventions, the LOVIT Trial will constitute a rigorous assessment of the effect of vitamin C monotherapy on patient-important outcomes.

Eligibility criteria: Inclusion Criteria:

1. Admitted to the intensive care unit with proven or suspected infection as the main diagnosis;
2. Currently treated with a continuous IV infusion of vasopressors (norepinephrine, epinephrine, vasopressin, dopamine, phenylephrine).

Exclusion Criteria:

1. \> 24 hours of intensive care unit admission;
2. Known Glucose-6-phosphate dehydrogenase (G6PD) deficiency;
3. Pregnancy;
4. Known allergy to vitamin C;
5. Known kidney stones within the past 1 year;
6. Received any intravenous vitamin C during this hospitalization unless incorporated in parenteral nutrition;
7. Expected death or withdrawal of life-sustaining treatments within 48 hours;
8. Previously enrolled in this study;
9. Previously enrolled in a trial with which co-enrolment is not allowed.

The LOVIT trial has broad eligibility criteria and includes patients with a primary diagnosis of sepsis of any cause (including sepsis caused by viral pathogens as COVID-19).

Primary outcomes:
measure: Number of deceased participants or with persistent organ dysfunction
timeFrame: Both assessed at 28 days
Secondary outcomes:
measure: Number of participants with persistent organ dysfunction-free days in intensive care unit
timeFrame: Up to day 28
measure: Number of participants deceased at 6 months
timeFrame: 6 months
measure: Score of health related quality of life in 6-month survivors
timeFrame: 6 months
measure: Global tissue dysoxia
timeFrame: Days 1, 3, 7
measure: Organ function (including renal function)
timeFrame: Days 1, 2, 3, 4, 7, 10, 14, 28
measure: Rate of inflammation
timeFrame: Days 1, 3, 7
measure: Rate of infection
timeFrame: Days 1, 3, 7
measure: Rate of endothelial injury
timeFrame: Days 1, 3, 7
measure: Occurrence of stage 3 acute kidney injury
timeFrame: Up to day 28
measure: Acute hemolysis
timeFrame: Up to day 28
measure: Hypoglycemia
timeFrame: During the time participants receive the 16 doses of the investigational product and the 7 days following the last dose
measure: Vitamin C volume of distribution
timeFrame: 8th dose of vitamin C at time 0 (immediately prior to the dose) and then after administration at times 1 hour, 2 hours, 4 hours and 6 hours (Pharmacokynetic substudy)
measure: Vitamin C clearance
timeFrame: 8th dose of vitamin C at time 0 (immediately prior to the dose) and then after administration at times 1 hour, 2 hours, 4 hours and 6 hours (Pharmacokynetic substudy)
measure: Vitamin C plasma concentration
timeFrame: 8th dose of vitamin C at time 0 (immediately prior to the dose) and then after administration at times 1 hour, 2 hours, 4 hours and 6 hours (Pharmacokynetic substudy)
Other outcomes:
Locations:
city: Sherbrooke
country: Canada
facility: Research Center of the CHUS
state: Quebec
Study officials:
affiliation: Université de Sherbrooke and CIUSSS de l'Estrie - CHUS
name: François Lamontagne, MD FRCPC MSc
role: PRINCIPAL_INVESTIGATOR
affiliation: Sunnybrook Health Sciences Centre, University of Toronto
name: Neill Adhikari, MDCM FRCPC MSc
role: PRINCIPAL_INVESTIGATOR
References:
citation: Lamontagne F, Masse MH, Menard J, Sprague S, Pinto R, Heyland DK, Cook DJ, Battista MC, Day AG, Guyatt GH, Kanji S, Parke R, McGuinness SP, Tirupakuzhi Vijayaraghavan BK, Annane D, Cohen D, Arabi YM, Bolduc B, Marinoff N, Rochwerg B, Millen T, Meade MO, Hand L, Watpool I, Porteous R, Young PJ, D'Aragon F, Belley-Cote EP, Carbonneau E, Clarke F, Maslove DM, Hunt M, Chasse M, Lebrasseur M, Lauzier F, Mehta S, Quiroz-Martinez H, Rewa OG, Charbonney E, Seely AJE, Kutsogiannis DJ, LeBlanc R, Mekontso-Dessap A, Mele TS, Turgeon AF, Wood G, Kohli SS, Shahin J, Twardowski P, Adhikari NKJ; LOVIT Investigators and the Canadian Critical Care Trials Group. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit. N Engl J Med. 2022 Jun 23;386(25):2387-2398. doi: 10.1056/NEJMoa2200644. Epub 2022 Jun 15.
citation: Lachance O, Goyer F, Adhikari NKJ, Masse MH, Bilodeau JF, Lamontagne F, Leclair MA. High-dose vitamin-C induced prolonged factitious hyperglycemia in a peritoneal dialysis patient: a case report. J Med Case Rep. 2021 May 21;15(1):297. doi: 10.1186/s13256-021-02869-4.
citation: Masse MH, Menard J, Sprague S, Battista MC, Cook DJ, Guyatt GH, Heyland DK, Kanji S, Pinto R, Day AG, Cohen D, Annane D, McGuinness S, Parke R, Carr A, Arabi Y, Vijayaraghavan BKT, D'Aragon F, Carbonneau E, Maslove D, Hunt M, Rochwerg B, Millen T, Chasse M, Lebrasseur M, Archambault P, Deblois E, Drouin C, Lellouche F, Lizotte P, Watpool I, Porteous R, Clarke F, Marinoff N, Belley-Cote E, Bolduc B, Walker S, Iazzetta J, Adhikari NKJ, Lamontagne F; Canadian Critical Care Trials Group. Lessening Organ dysfunction with VITamin C (LOVIT): protocol for a randomized controlled trial. Trials. 2020 Jan 8;21(1):42. doi: 10.1186/s13063-019-3834-1.