Conditions: Covid19
Keywords: Estradiol Progesterone Covid19 Estrogen Hormones Progestogens Depo-Estradiol Prometrium Micronized Progesterone
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 10
Healthy volunteers: no

Brief summary:
The purpose of this study is to determine to what extent a short systemic steroid therapy with estradiol and progesterone, administered early to hospitalized and confirmed COVID-19 positive patients of both sexes in addition to standard of care (SOC) can reduce the severity of symptoms and outcomes compared to SOC alone.

Detailed description:
Severe Acute Respiratory Syndrome Associated Corona Virus (SARS-CoV-2), causing COVID-19, has killed over 2.8 million people globally, including 550,000 in the US as of March 2021. Although, the vaccination campaign is ramping up, vaccination hesitancy in the United States represents up to 25-30% of the population, and hospitalizations and deaths are still at the level of 2020. Apart from corticosteroids, most available therapeutic options are at best marginally efficient in reducing disease severity and mortality and extremely expensive. Therefore, the systematic investigation of clinically approved drugs is a priority in order to determine what does improve the disease and invest resources to go to full-scale production. Our current understanding of the disease is that COVID-19 deaths result from an inappropriate immune response with outpouring of pro-inflammatory chemokines leading to lung infiltration and hyperactivation of monocytes and macrophages producing pro-inflammatory cytokines (cytokine storm), resulting in lung edema, reduced gas exchange, and ultimately leading to acute respiratory distress syndrome and multiorgan failure. Men with COVID-19 have a uniformly more severe outcome than women. In series from China, Europe and the U.S., COVID-19 mortality was consistently 1.5 to 2-fold higher in men than in women, suggesting that female biological sex is protecting women from COVID-19 mortality. It is established that women exhibit heightened immune responses to viral infections compared to men, which is at least partially due to the genetic benefit of gene dosage in X-linked immune-response genes. Ovarian steroids, however, also play a protective role. In New York City, among 5700 hospitalized patients, the female protection from COVID-19 mortality was observed at all ages, but was more pronounced in subjects under 50 years of age (18% mortality in women) compared to patients \> 50 years of age (40.5% mortality in women), suggesting that ovarian steroids are involved in mitigating COVID-19 mortality in pre-menopausal women. Further, the analysis of electronic health records of over 68,000 COVID-19 patients revealed that estrogen therapy is associated with more than 50% reduction in mortality. The main female steroids, 17β-estradiol and progesterone exhibit potent immuno-modulatory and anti-inflammatory actions via estrogen and progesterone receptors expressed in all immune cells, including epithelial cells, macrophages, dendritic cells, cluster of differentiation 4 (CD4+) and cluster of differentiation 8 (CD8+) lymphocytes, and B cells. Progesterone also acts partially via the glucocorticoid receptor. Together estradiol and progesterone produce a state of decreased innate immune cells production of proinflammatory cytokines, enhanced T cells anti-inflammatory responses and immune tolerance, and enhanced B-cell-mediated antibody production. The National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel recommends the use of dexamethasone 6 mg per day for up to 10 days or until hospital Discharge (whichever comes first) as standard of care (SOC) for the treatment of hospitalized COVID-19 patients who require supplemental oxygen but who are not mechanically ventilated and for the treatment of hospitalized patients who are mechanically ventilated. Remdesivir is SOC at Tulane for COVID-19 patients who require supplemental oxygen but who are not mechanically ventilated. We believe that in hospitalized COVID-19 patients, a short treatment with the combination estradiol and progesterone, administered early and as a prevention in addition to SOC, will prevent or mitigate the cytokine storm while increasing antibody production and prevent severe outcomes, without side effects. Therefore, it will provide steroid immunomodulation without immunosuppression. The advantage of repurposing estradiol and progesterone compounds is the depth of knowledge regarding their clinical efficacy and toxicity that has accumulated from decades of clinical and basic studies. Estradiol and progesterone are widely available in hospitals, inexpensive, manufacturable to scale, and can be prescribed immediately.

Arms:
arm 1: Standard of Care along with Estradiol Cypionate 5mg intramuscular injection at admission and Progesterone 200mg by mouth daily for 5 days starting at admission. arm 2: Standard of Care along with placebo injection and placebo pill

Standard of Care consistent with the National Institutes of Health (NIH) COVID-19 Treatment Guidelines

Interventions: intervention 1: Placebo injection and placebo pill intervention 2: Estradiol Cypionate 5 mg/ml intervention 3: Progesterone 200 mg Oral Capsule
Intervention descriptions: intervention 1: Standard of Care consistent with the National Institutes of Health (NIH) COVID-19 Treatment Guidelines intervention 2: Standard of Care along with Estradiol Cypionate 5mg intramuscular injection at admission. intervention 3: Standard of Care along with Progesterone 200mg by mouth daily for 5 days starting at admission.

Protocol document:
Prot_SAP_000.pdf: 
 
 
 
 
Acute Estradiol and Progesterone 
Therapy in Hospitalized Adults to 
Reduce COVID-19 Severity: A 
Randomized Control Trial 
 
 
 
NCT Number: NCT04865029 
 
 
Protocol Date: 8/25/2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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Study Title:  Acute Estradiol and Progesterone Therapy in Hospitalized Adults to Reduce COVID-19 
Severity: A Randomized Control Trial  
 
 
1. Study aim, background, and design 
Coronavirus SARS-CoV-2, causing COVID-19, has infected over 20 million people and killed over 
700,000 as of August 2020. Although, the vaccination campaign is ramping up, vaccination hesitancy in 
the United States represents up to 25-30% of the population (1), and hospitalizations and deaths are 
still at the level of 2020. Apart from corticosteroids (2), most available therapeutic options are at best 
marginally efficient in reducing disease severity and mortality and extremely expensive (3-5). Therefore, 
the systematic investigation of clinically approved drugs is a priority in order to determine what does 
improve the disease and invest resources to go to full-scale production. Our current understanding of 
the disease is that COVID-19 deaths result from an inappropriate immune response with outpouring of 
pro-inflammatory chemokines leading to lung infiltration and hyperactivation of monocytes and 
macrophages producing pro-inflammatory cytokines (cytokine storm), resulting in lung edema, reduced 
gas exchange, and ultimately leading to acute respiratory distress syndrome and multiorgan failure (1-
8). Men with COVID-19 have a uniformly more severe outcome than women. In series from China, 
Europe and the U.S., COVID-19 mortality was consistently 1.5 to 2-fold higher in men than in women, 
suggesting that female biological sex is protecting women from COVID-19 mortality (9-13). It is 
established that women exhibit heightened immune responses to viral infections compared to men (14), 
which is at least partially due to the genetic benefit of gene dosage in X-linked immune-response 
genes. Ovarian steroids, however, also play a protective role. In New York City, among 5700 
hospitalized patients, the female protection from COVID-19 mortality was observed at all ages, but was 
more pronounced in subjects under 50 years of age (18% mortality in women) compared to patients > 
50 years of age (40.5% mortality in women) (13), suggesting that ovarian steroids are involved in 
mitigating COVID-19 mortality in pre-menopausal women.  Further, the analysis of electronic health 
records of over 68,000 COVID-19 patients revealed that estrogen therapy is associated with more than 
50% reduction in mortality (15). The main female steroids, 17β-estradiol and progesterone exhibit 
potent immuno-modulatory and anti-inflammatory actions via estrogen and progesterone receptors 
expressed in all immune cells, including epithelial cells, macrophages, dendritic cells, CD4+ and CD8+ 
lymphocytes, and B cells (14,16). Progesterone also acts partially via the glucocorticoid receptor. 
Together estradiol and progesterone produce a state of decreased innate immune cells production of 
proinflammatory cytokines, enhanced T cells anti-inflammatory responses and immune tolerance, and 
enhanced B-cell-mediated antibody production (14,17,18). The National Institutes of Health (NIH) 
COVID-19 Treatment Guidelines Panel recommends the use of dexamethasone 6 mg per day for up to 
10 days or until hospital Discharge (whichever comes first) as standard of care (SOC) for the treatment 
of hospitalized COVID-19 patients who require supplemental oxygen but who are not mechanically 
ventilated and for the treatment of hospitalized patients who are mechanically ventilated. Remdesivir is 
SOC at Tulane for COVID-19 patients who require supplemental oxygen but who are not mechanically 
ventilated. We believe that in hospitalized COVID-19 patients, a short treatment with the combination 
estradiol and progesterone, administered early and as a prevention in addition to SOC, will prevent or 
mitigate the cytokine storm while increasing antibody production and prevent severe outcomes, without 
side effects (18). Therefore, it will provide steroid immunomodulation without immunosuppression. The 
advantage of repurposing estradiol and progesterone compounds is the depth of knowledge regarding 
their clinical efficacy and toxicity that has accumulated from decades of clinical and basic studies. 
Estradiol and progesterone are widely available in hospitals, inexpensive, manufacturable to scale, and 
can be prescribed immediately. Please note there is no increased risk of blood clot following acute and 
systemic administration of natural hormones. The risk exists following chronic and orally administered 
synthetic hormones (as discussed below).  
 


 
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Study Objectives 
The purpose of this study is to determine to what extent a short and preventive systemic steroid therapy 
with estradiol and progesterone, administered early to hospitalized and confirmed COVID-19 positive 
patients of both sexes in addition to standard of care (SOC) can reduce the severity of symptoms and 
outcomes compared to SOC alone. Note that premenopausal women will be included as acute illness 
can alter the function of the hypothalamo-pituitary gonadal axis, creating a functional hypogonadism 
leading to low estrogen levels. 
 
This study has two study arms. One arm will receive standard of care (SOC) with administration of 
placebo-equivalent with similar frequency, volume and method of administration as for the drug below. 
The other arm will receive SOC along with the study drugs, a single IM injection of long-acting estradiol 
cypionate (Depo-Estradiol) 5mg upon admission and a daily oral administration of progesterone 200mg 
(Progesterone generic 200mg) for 5 days. Clinical status will be assessed at day 14 and day 28 and 60 
days. 
 
 
Study Design 
Study Type: 
Interventional (Clinical Trial)  
Estimated Enrollment: 
120 participants 
Allocation: 
Randomized, placebo-equivalent controlled 
Masking: 
Double-blinded 
Primary Purpose: 
Treatment 
Setting:  
 
     Inpatient hospitalization 
 
 
 
2. Subject population 
Up to 120 participants hospitalized in the Department of General Internal Medicine and Geriatrics at the 
Medical Center with mild to severe COVID-19 (WHO ordinal scale score 3-5, Fig.2) confirmed by 
SARS-CoV-2 PCR test will be recruited for this study. Participants will be recruited at admission by the 
medical staff of the Department of General Internal Medicine and Geriatrics under the leadership of Dr. 
Bateman (Co-I) who will identify participants that meet study eligibility criteria from their admission list. 
 
2.1. Sample Size Considerations 
Sample size calculations are based on 80% Power, using a two-sided Pearson’s Chi-square Test for 
Proportion Differences at the 5% significance level. It is estimated that between 60% and 70% of 
hospitalized patients with mild or severe disease will improve clinically and become ambulatory after 
standard treatment (WHO ordinal scale score 1-2  Fig.2)). Table 1 presents the sample sizes that are 
required in each treatment group to detect a significant difference in the percent of hospitalized patient 
leading to an ambulatory disease (shift from category 5-8 to category1-2  in 20%, 25%, 30% or 35% of 
hospitalized patients after treatment with estradiol (E2) and progesterone (P4)).  Efforts will be made to 
recruit 60 patients in each treatment group in order to stratify by disease severity, age and gender. 
 


 
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Table 1. 
 
Treatment 
Percent leading 
to a scale 1-2 
Sample Size 
SOC 
60% 
32 
SOC + E2 + P4 
90% 
32 
 
 
 
SOC 
60% 
22 
SOC + E2 + P4 
95% 
22 
 
 
 
SOC 
70% 
62 
SOC + E2 + P4 
90% 
62 
 
 
 
SOC 
70% 
36 
SOC + E2 + P4 
95% 
36 
 
 
An interim analysis will be performed at 50% enrollment to determine to what extent a strong treatment 
efficacy warrants stopping the trial early. Table 2 presents interim sample sizes and required Z test statistics 
for comparing two proportions at each of stage of a O’Brien-Fleming alpha-spending sequential design (24). 
Based on 80% power and an overall 5% significance level, if the interim analysis for the first 60 enrolled 
patients results in differences that are more than 2.96 standard deviations from 0, the trial will end, and 
treatment efficacy will be concluded. Otherwise, the trial will enroll the total 120 patients.  
 
Table 2. 
 
 
 
Treatment 
Sample Size 
Standardized Z test 
Statistic  
Stage 1 
SOC 
30 
2.96 
 
SOC + E2 + P4 
30 
 
 
 
 
 
Stage 2 
SOC 
60 
1.96 
 
SOC + E2 + P4 
60 
 
 
 
 
 
 
2.2 Inclusion Criteria: 
 
1. Hospitalization at the Medical Center in the Department of General Internal Medicine and 
Geriatrics with COVID-19 (WHO Ordinal scale score 3-5, Fig.2) and confirmed by SARS-CoV-2 
PCR.  
2. Respiratory symptoms (fever, shortness of breath or cough) or abnormal lung exam or chest 
imaging characteristic of mild to severe COVID-19 pneumonia*. 
3. Patient and/or legally authorized representative (LAR) agrees to comply with study procedures 
and the collection of blood samples per protocol 
4. Patient and/or LAR agrees to be placed on prophylactic dose of anticoagulation for prevention 
of deep venous thrombosis (DVT) (if necessary). 


 
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5. Patient or legally authorized representative has signed informed consent 
6. Women of childbearing age with a negative pregnancy test on admission 
 
*Severity of COVID-19 defined by FDA guidance document “COVID-19: Developing Drugs and 
Biological Products for Treatment or Prevention Guidance for Industry” 
(https://www.fda.gov/media/137926/download). 
 
2.3 Exclusion Criteria: 
 
1. Patient under 18 years of age 
2. Critical COVID-19 (respiratory failure requiring intubation and mechanical ventilation, shock, 
multi-organ failure) 
3. Pregnant women confirmed by pregnancy test 
4. Women who are within six weeks of postpartum 
5. Patient is not hospitalized at the Medical Center with confirmed COVID-19 
6. Patient included in another COVID-19 trial (excluding hydroxychloroquine and dexamethasone) 
7. Women already treated by estrogen and or progestogen therapy two weeks prior to admission 
8. Men already treated by testosterone therapy prior to admission 
9. History of breast or endometrial cancer 
10. Abnormal genital bleeding 
11. Active or recent (e.g., within the past year) stroke or myocardial infarction 
12. History of blood clots including deep vein thrombosis related to clotting disease, or pulmonary 
emboli (prior to hospitalization). 
13. History of liver dysfunction or disease. 
14. Patients with end-stage renal disease 
15. Patients taking inhibitors of CYP3A4 such as erythromycin, clarithromycin, ketoconazole, 
itraconazole, and ritonavir.  
16. Patients taking St. John’s Wort preparations (Hypericum perforatum), phenobarbital, 
carbamazepine, and rifampin. 
17. Patients within 6 weeks of major orthopedic surgery 
 
 
 
 
3. Procedure 
The study will begin after the study team obtains IND from the FDA and IRB approval from Tulane 
University Biomedical IRB. The study will utilize the  Medical Center Research Pharmacy for 
randomization, the accountability, storage, dispensing, handling, and disposal of drugs. The Clinical 
Translational Unit (CTU) will also participate in the implementation of the study. We estimate that the 
study will be complete within 12 months.  
 
3.1 Collection of blood samples 
 
The collection of routine blood samples and patient monitoring will be conducted as part of the standard 
of care procedures that are utilized at the hospital for COVID-19 patients. The collection of blood 
samples (CBC with differential, blood chemistry, inflammation markers) is to monitor disease severity 
and is independent from this protocol, but we will use the data in our analysis as explained in section 
3.5. Women of childbearing age will have a pregnancy test on admission 
 
 


 
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An additional blood sample will be collected for our study at admission and after 5 days of treatment. 
We will collect about 1-5 teaspoons of blood at these two time points. This blood sample will be stored 
in Dr. Mauvais-Jarvis lab for 1) isolation of peripheral blood mononuclear cells (PBMC) to assess the 
effect of treatment on immune cells populations by flow cytometry and PBMC gene expression by RNA-
Seq  2) and metabolomics profiling to determine metabolic and molecular signatures of the efficacy of 
treatment. De-identified serum and PBMC frozen samples will be transferred to the University of 
Michigan Metabolomics Core to perform untargeted metabolomic analyses. University of Michigan will 
not receive identifiable information nor a link to identifiers related to the samples.  
 
Additionally, we propose to use the serum and PBMC from our collected blood samples to perform 
multi-dimensional analysis in the Center for Translational Research in Infection and Inflammation 
(Collaboration with Dr. Jay Kolls), and the laboratories of Dr. James McLachlan and Dr. Mauvais-Jarvis 
at Tulane University School of Medicine. Blood samples will be stored for up to 3 years.  
 
 
3.2 Treatment arms and interventions 
Treatment Arm: Standard of Care* along with Estradiol Cypionate 5mg intramuscular injection at 
admission and Progesterone 200mg by mouth daily for 5 days starting at admission. 
Control Arm: Standard of Care along with placebo-equivalent injection  of normal saline at admission 
and placebo-equivalent pill folic acid 400 mg pill daily for 5 days starting at admission. The dose of folic 
acid (400 mg daily for 5 days) is safe. Participants will be able to take additional folic acid (e.g., over the 
counter vitamins, or through food) should they choose, as there is no safety concern for overdose over 
5 day period of folic acid. Folic acid is not expected to have a treatment or preventive effect for SARS-
CoV-19 and is considered a placebo-equivalent product for this study. 
 
*Standard of Care at the Medical Center is consistent with the National Institutes of Health (NIH) 
COVID-19 Treatment Guidelines Panel and consists of dexamethasone 6 mg per day for up to 10 days 
or until hospital Discharge (whichever comes first) for the treatment of hospitalized COVID-19 patients 
who require supplemental oxygen but who are not mechanically ventilated and in hospitalized patients 
who are mechanically ventilated. Remdesivir is SOC at Tulane for COVID-19 patients who require 
supplemental oxygen but who are not mechanically ventilated.  
 
Blinding: 
This is a blinded study. However, the medications are not identical-appearing. The dosing is also 
different for the oral study drug and placebo (folic acid) so blinding will operate in different ways across 
those involved in the study to preserve blinding for the participants, those who directly interact with 
them, and measurement of the study endpoints: 
• 
Participants will be blinded. The injection syringe for Estradiol Cypionate or normal saline will be 
covered with blinding tape to mask the difference in color. The bottles of oral medications will 
not identify the treatment allocation. Medication bottles will be labeled to say “Progesterone 
200mg or folic acid 400 mg). 
• 
Treating clinicians and study team will be blinded 
• 
Study pharmacy staff will be unblinded, as they will prepare and blind the study medications. 
 
 
 


 
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Dosing Instructions: 
Estradiol cypionate 5 mg (1mL) or normal saline (1 mL) will be administered intramuscularly. One pill of 
oral progesterone 200 mg or Folic acid 400 mg will be administered orally at bedtime with a glass of 
water. 
 
Hazardous Drugs Handling Considerations 
Estradiol Cypioante and progesterone are hazardous agents (NIOSH 2016 [group 2]). NIOSH 
recommends single gloving for administration of intact tablets or capsules. For IM preparation, NIOSH 
recommends double gloving, a protective gown, and ventilated engineering controls (a class II 
biological safety cabinet or a compounding aseptic containment isolator). Double gloving and a gown 
are required during IM administration. 
 
 
3.3 Outcome Measures 
For all randomized patients according to section 2.2, demographic and clinical variables, including sex, 
age, race/ethnicity, BMI, symptoms, vital signs blood pressure, respiratory rate, temperature, oxygen 
saturation), chronic comorbidities through diagnosis codes, medications, clinical course during 
hospitalization (described in primary outcome below) will be reviewed in the patients’ medical charts. 
Laboratory measurements including when available CBC, blood chemistry, liver function test, 
creatinine, BUN, lactate, troponin, ferritin, CRP, procalcitinin, Brain-type natriuretic peptide, D-dimer, 
interleukin-6, G6PD. We will review the participants' medical records for up to 6 months after hospital 
discharge. 
 
Primary outcome: 
For all randomized patients with baseline inclusion criteria, WHO ordinal scale score 3-5, the primary 
efficacy end point will  be the proportion of patients who achieve scores 1 or 2 on the 9-point World 
Health Organization (WHO) ordinal scale (Fig. 2) through day 28. 
 
Secondary outcomes: 
For all randomized patients, the following secondary end points will be assessed at day 14, 28 and 60 
1. Length of hospital stay 
2. Duration of mechanical ventilation 
3. Cause of death and number of days death occurred after admission 
4. Readmission 
5. Change in biological markers below between admission and occurrence of primary endpoint (2 
values at least 2 days apart) 
6. Grade 3 and 4 adverse events  
7. Serious adverse events  
Biological markers 
Obtained from Standard Of Care: Inflammation: neutrophil:lymphocyte ratio, C-reactive protein, ferritin, 
procalcitonin. 
Hypercoagulability: D-dimers, fibrinogen 
Tissue injury: troponin, ALAT, ASAT, LDH 
 
Metabolome, Proteome, PBMC 


 
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Safety measures and monitoring. 
This study is considered greater than minimal risks. In all randomized patients according to section 2.2, 
we will monitor adverse events described in section 4 on a daily basis (Fig.1). Thus, we will perform 
daily examination of injection sites with documentation and measurement of any erythema, swelling, 
tenderness or induration; legs will be examined daily for evidence of deep vein thrombosis. Note that 
daily monitoring of clinical status (including symptoms, examination, laboratory assessments, oxygen 
saturation) is already part of COVID-19 SOC. We will carefully monitor patients with renal impairment 
for potential fluid retention. 
 
We have formed an independent Data Safety and Monitoring Board (DSMB) to monitor study safety. 
The DSMB will consists of four board members who are MDs clinicians and researchers with the 
experience necessary to interpret the data and ensure patient safety. Specifically, the board members 
are knowledgeable about COVID-19 and the treatment involved in this study. The DSMB includes, an 
Infectious disease specialist, an endocrinologist, hematologists-oncologists, women’s health specialist 
and a biostatistician. The initial DSMB meeting occured before the start of the trial to discuss the 
protocol and guidelines for monitoring the study. At this meeting, guidelines were defined for stopping 
the study for safety concerns (Study stopping rules) and where relevant, for efficacy based on plans 
specified in the protocol. The DSMB will meet on a quarterly basis. It will provide the Principal 
Investigator a letter after each meeting with the results of their review and their recommendations for 
the continuation of the study. The DSMB includes the following 5 members outside of the Tulane 
University School of Medicine faculty who were identified by Dr Mauvais-Jarvis prior to the start of the 
study:  
1. 
Frank Greenway, MD, Chair of DSMB (Endocrinology) - The Pennington Biomedical 
Research Center 
2. 
Erin Brewer, MD, MPH (Women’s Health) - Southeast Louisiana Veterans Health Care 
System (SLVHCS) 
3. 
Phillip Yeon, MD, MPHTM (Infectious Diseases)- SLVHCS  
4. 
Nancy Vander Velde, MD (Hematology and Oncology)- SLVHCS  
5. 
Donald E. Mercante, PhD (Biostatistics)- Louisiana State University 
No member of the DSMB will have direct involvement in the conduct of the study. The DSMB will 
review and evaluate the accumulated study data for participant safety, adverse events, study conduct, 
progress, adherence to the protocol and efficacy. The DSMB will consider study-specific data as well as 
relevant background knowledge about COVID-19, estrogen and progesterone therapy, and the patient 
population under study. The data will remain blinded. The frequency of DSMB meetings will depend on 
the rate of enrollment but will roughly occur quarterly. The DSMB meetings will be private and closed 
meetings. Dr. Mauvais-Jarvis will be responsible for convening meetings by conference calls or Zoom 
videoconferences or as face-to-face meetings, and coordinating the distribution of meeting materials to 
DSMB members. The written open session reports from DSMB meetings will be submitted to the 
Tulane IRB. 
We will implement a group sequential trial framework with the option for stopping for safety or harm with 
an early interim look once 30 patients finish the Day 28 assessment. This will allow the DSMB to evaluate 
trial safety data. A decision about study continuation will be made based on the independent DSMB 
recommendations. The DSMB will convene if study participants experience a higher rate than the 
background rate of thromboembolic disease. The DSMB will also convene when ≥ Grade 3 AE are 
observed and considered related to drug or not.  
 
We will follow-up in person or by telephone for all subjects in your trial for any adverse events/serious 
adverse events (AEs/SAEs) and mortality at Day 60. 
 


 
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Adverse events will be graded according to Common Terminology Criteria for Adverse Events (CTCAE) 
Version5 and taken care with the corresponding specialized clinical management of the SAE. 
Grade 1 adverse events (asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated) or Grade 2 adverse events (moderate; minimal, local or noninvasive 
intervention indicated; limiting age-appropriate instrumental activity of daily living): such as breast 
tenderness, nausea, vomiting, bloating, stomach cramps, headaches, vaginal itching, abnormal uterine 
bleeding will not require discontinuation of treatment. 
Grade 3 (severe) like DVT and 4 (life-threatening) serious adverse events such as MI, stroke, POME, 
anaphylaxis will be managed by treatment discontinuation (except SOC) and appropriate specialized 
clinical management of the SAE. 
 
A schedule of risk assessment is shown on Fig.1 
 
 
3.4 Statistical Analysis 
For all randomized patients according to section 2.2, clinical outcomes and demographic characteristics 
will be summarized and presented separately for the treatment group and the control group, as well as 
overall for all patients.  Categorical variables such as the primary outcome, readmission, as well as 
race and sex will be summarized with counts and percentages. Quantitative outcomes, such as length 
of stay, change in biological markers, age and BMI will be summarized with means, medians, standard 
deviations, and interquartile ranges.  Univariate analyses will be performed as the primary method to 
assess the unadjusted effect of treatment on the primary outcome and on readmission rate using the 
Pearson Chi-square test. Differences in average length of stay and in change in biological markers will 
be assessed with either a two-sample t test or the Mann-Whitney nonparametric test. Multivariate 
analyses will be performed to compare treatment to control responses while adjusting for various co-
factors. Multiple logistic regression will be used as supportive method to test for significant differences 
in the proportion with the primary outcome, between the active treatment and placebo-equivalent 
groups, while adjusting for age, race, sex, bmi and other potential co-factors. For the secondary 
outcomes. multiple logistic regression will also be used to test for significant differences in the 
proportion readmits, between the active treatment and placebo-equivalent groups, and multiple linear 
regression will be used to test for significant differences in average length of stay and changes in 
biological markers, between the treatment and SOC groups, while adjusting for potential influencing co 
factors.    
 
3.5 Data Storage 
All data and research files will be de-identified and stored using the secure web application Research 
Electronic Data Capture (REDCap). REDCap is protected by a login as well as encryption. There is 
also an audit trail, which tracks all logins and activities in the database.  All data for this study will be 
electronic; there will be no paper records. Enrolled subjects will be assigned a sequential study ID (i.e. 
001, 002, etc) that is linked to their medical record number.  A link between the study ID numbers and 
medical record number will be kept in a separate file from the de-identified database and stored 
securely in REDCap.  Only the IRB-approved study investigators will have access to the data and link.  
The password-protected study log will be destroyed three years after the study is complete. 
 
 
4. Risks 
 
This is a greater than minimal risk study due to the new investigational use of an FDA-approved drug in 
this study. IM injection may cause some swelling and tenderness at the injection site. The side effects 
of estradiol includes breast tenderness. The side effects of progesterone include vaginal bleeding. In 


 
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addition, drawing blood from a vein may cause local pain, bruising, occasional lightheadedness, 
dizziness, fainting, and very rarely, infection at the site of the blood draw. To reduce risk of anxiety or 
pain related to the blood draw, experienced nurses or phlebotomists will draw blood. 
 
The risk of deep vein thrombosis (DVT) or pulmonary embolism associated with estradiol and 
progesterone treatment exists but is minimal.  First, the risk of DVT is associated with chronic hormone 
therapy, over months, not acute hormone therapy of several days. Most importantly, the risk is minimal 
because of parenteral estradiol administration, which does not alter clotting factors. DVT risk occurs 
mainly following orally administered estrogens and synthetic progestin because of first-pass liver 
metabolism leading to high liver exposures to hormones that increase hepatic production of clotting and 
inflammatory factors (19). Additionally, the DVT risks are usually associated with the use of conjugated 
equine estrogens (Premarin) alone or associated with a synthetic progestin like medroxyprogesterone 
acetate (Prempro) (19). There is no documented risk with natural hormones estradiol given systemically 
(IM, SC) and no documented risk with the use of progesterone. Additionally, most COVID-19 patients 
are at risk of DVT and will be placed on prophylactic anticoagulants at admission as Tulane SOC.  
 
There is a risk of breach of confidentiality.  In order to minimize this risk, all data will be de-identified 
and minimal PHI will be gathered (i.e., medical record number). Maintaining a link between the study ID 
number and medical record number is important to prevent a given chart being entered twice in the 
database. PHI will be stored securely in REDCap and separately from the study dataset.  
 
A schedule of risk assessment is shown on Fig.1 
 
Subjects withdrawal criteria 
- 
when a subject’s safety may be compromised such as when a subject is experiencing related 
adverse events requiring discontinuation of treatment,  
- 
when the study is being closed by the PI related to increased risk to participants  
- 
when the subject is non-compliant with required study regimens or procedures  
- 
when the subject desires to voluntary withdraw for the study 
 
 
5. Benefits 
There is immediate benefit for individual subjects in this study as we expect the hormonal treatment to 
prevent mortality and to decrease the severity of COVID-19 disease. Additionally, the knowledge gained 
by this study may provide important insights into the pathogenesis of the disease. Overall this study will 
benefit society as it will address the question of whether hormones partially explain the female protection 
from COVID-19 and if we can use hormone therapy for life saving off-label therapeutic applications. 
 
6. Remuneration 
Subjects will be compensated for participation in this research study. Compensation will be in form of 
clin card which is a specially designed debit card for clinical research onto which your funds will be 
loaded as appropriate. As each scheduled visit is completed, funds will be approved and added to your 
card. The funds will be available within 1 business day and often times immediately after being loaded 
and can be used at your discretion. You will be issued one card for the duration of your participation in 
the study. If your card is lost or stolen, ask a study team member for a replacement ClinCard .Subjects 
will be given $25 for each completed visit 1-6 (screening visit  and each day of treatment (maximum of 
5 days)) and $50 for the end of study visit 7 (via telephone). 
 
 


 
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7. Academic or Extra Credit 
NA 
 
8. Costs 
Patient and/or their insurance will be responsible for the entire standard of care costs associated with 
hospitalization. The patient will not need to pay for anything related to the study drugs. 
 
9. Alternatives 
NA 
 
 
10. Consent process and documentation 
The consent process will be administered to the patient (or legally authorized representative (LAR) in 
the case that the patient is unable to consent) using the Adobe Sign feature on an iPad or smartphone 
in order to minimize the safety concerns for study personnel conducting the consent procedures. Adobe 
Sign minimizes the exposure of research team members to the COVID-19 virus by minimizing the need 
for them to go into the room to obtain the signature from the patient. Adobe Sign also protects patient 
privacy by signing the informed consent form securely and electronically. Adobe Sign also provides a 
secure way for the LAR to sign the informed consent form in situations where they cannot be physically 
present in the hospital due to Stay at Home Order or for being out of state. The patient or LAR have the 
option to keep the password-protected signed electronic copy of the informed consent form by entering 
their Email address and choosing a password while signing through Adobe Sign. That way, the patient 
or LAR do not face the risk of losing the written informed consent form after the patient is discharged. 
 
The consent interview will take place in a private setting. If the patient does not have a personal 
smartphone device that they would like to use for the consent process, the study team member will 
hand an iPad which can be encased in a plastic case to the clinical care team member, who will go into 
the patient’s room when they have to for clinical care and hand out the iPad to the patient. The study 
team member will go over and discuss the informed consent with the patient over the phone and 
answer any questions the patient might have. Patients who wish to proceed with consenting will be 
provided with time to ask questions and discuss the consent and the study to demonstrate that they 
have a clear understanding of the study.  Only then will the consent process be finalized with signatures 
and initials as appropriate and described below, using a pen, stylus, or finger. 
 
To complete the informed consent form, the patient will log into Adobe Sign for TUMG and follow the 
instructions given to them over the phone from the research team member to sign the informed consent 
document. There will be two signature requirements: 1) the patient or LAR, and 2) the witness/clinical 
care team member obtaining the signature. The patient/LAR and witness/clinical care team member will 
enter their email address and get an electronic copy of the informed consent signature page where they 
will sign. After the patient/LAR sign the informed consent, an Email will be sent to the witness/clinical 
care team member to sign as well. Then, an email from Adobe Sign will be sent to the patient and the 
research team member to have an electronic copy of the signed informed consent. There is a password 
option available for the patient or LAR to use so the electronic copy sent to their email can be locked 
and seen only by them using the password. If the patient/LAR used the iPad (not personal smartphone 
device) for this process, then the clinical care team will bring out the iPad from the patient’s room and 
give it back to the research team member, where either the plastic case can be disposed of or the iPad 
can be disinfected. For the LAR who couldn’t be present physically (e.g., out of state, Stay at Home 
Order, etc), the research team member will send an electronic copy of the informed consent to the 
LAR’s email to read. They will talk over the phone with the LAR to explain and discuss the informed 
consent in detail. The LAR and another witness from LAR’s side will sign the informed consent using 


 
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the same steps mentioned above using Adobe Sign on their mobile or tablet devices by using the link 
sent from the research team member to the LAR’s email after the informed consent was discussed. The 
LAR and research team member will receive an electronic copy of the signed informed consent sent to 
their emails.  
 
The HIPAA authorization form will also be signed using AdobeSign, as detailed above. The HIPAA 
authorization form will thus be documented using an electronic signature. 
 
11. Qualifications of the investigators 
PI: Franck Mauvais-Jarvis, MD, PhD, Professor of Medicine, Division of Endocrinology 
Dr. Mauvais-Jarvis is a physician-scientist and Endocrinologist and expert in diabetes and obesity and 
the role of sex hormones in biology and disease. Dr. Mauvais-Jarvis has extensive experience in 
investigator-initiated clinical trials 
 
Co-I:  Dragana Lovre, MD, Assistant Professor, Section of Endocrinology Dept of Medicine.  
Dr. Lovre is an attending physician in the Section of Endocrinology and has several years of experience 
in conducting clinical trials at Tulane University.  
She will lead all of the clinical trial activities along with Dr. Mauvais-Jarvis and Dr. Bateman. 
Dr. Lovre will also be involved in data management, statistical analysis, visualization and publication of 
data. 
 
Co-I:  Kristin Bateman, MD, Assistant Professor, Section of General Internal Medicine and Geriatrics  
 Associate Program Director, Internal Medicine. Dr. Bateman is an attending physician in the Section of 
General Internal Medicine and Geriatrics and will be the primary physician involve in recruiting patients.  
 
Co-I: Manika Bhondeley, PhD, Staff scientist. Dr. Bhondeley has experience in handling and 
processing blood samples, cellular and molecular biology techniques, cell culture techniques, and 
Bioinformatics tools. She will be responsible for the processing of blood samples and isolation of 
PBMC. 
 
Co-I: Vivian Fonseca, MD, Department of Medicine - Section of Endocrinology and Metabolism. Dr. 
Fonseca is the Assistant Dean for Clinical Research at Tulane University School of Medicine. He is also 
a Professor of Medicine, the Tullis–Tulane Alumni Chair in Diabetes, and Chief of the Section of 
Endocrinology.  
 
Co-I: John Lefante, PhD, Biostatistics and Data Science. Dr. Lefante is a Professor and Chair in 
Biostatistics and Data Science in the Tulane University School of Public Health and Tropical Medicine. 
He received his PhD from University of Alabama in Birmingham, and his MS and BA from University of 
New Orleans. Dr. Lefante will be the statistician for this study. 
 
Co-I: James McLachlan, PhD, Department of Microbiology and Immunology. Dr. McLachlan is an 
Associate Professor in Microbiology and Immunology in the Tulane University School of Medicine.  
 
Co-I: Jay Kolls, MD, Medicine & Pediatrics. Dr. Kolls is a Professor of Medicine & Pediatrics and the 
John W. Deming Endowed Chair in Internal Medicine in the Tulane University School of Medicine.  
 
 
 
 
 


 
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12. References 
 
 
1. 
Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID-19: consider 
cytokine storm syndromes and immunosuppression. The Lancet. 2020;395(10229):1033-1034. 
2. 
Chen G, Wu D, Guo W, Cao Y, Huang D, Wang H, Wang T, Zhang X, Chen H, Yu H, Zhang X, Zhang 
M, Wu S, Song J, Chen T, Han M, Li S, Luo X, Zhao J, Ning Q. Clinical and immunological features 
of severe and moderate coronavirus disease 2019. The Journal of clinical investigation. 
2020;130(5). 
3. 
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, 
Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang 
J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The 
Lancet. 2020;395(10223):497-506. 
4. 
Blanco-Melo D, Nilsson-Payant BE, Liu W-C, Uhl S, Hoagland D, Møller R, Jordan TX, Oishi K, 
Panis M, Sachs D, Wang TT, Schwartz RE, Lim JK, Albrecht RA, tenOever BR. Imbalanced Host 
Response to SARS-CoV-2 Drives Development of COVID-19. Cell. 
5. 
Chousterman BG, Swirski FK, Weber GF. Cytokine storm and sepsis disease pathogenesis. 
Seminars in Immunopathology. 2017;39(5):517-528. 
6. 
Ye Q, Wang B, Mao J. The pathogenesis and treatment of the `Cytokine Storm' in COVID-19. J 
Infect. 2020. 
7. 
Tanaka T, Narazaki M, Kishimoto T. Immunotherapeutic implications of IL-6 blockade for 
cytokine storm. Immunotherapy. 2016;8(8):959-970. 
8. 
McGonagle D, Sharif K, O'Regan A, Bridgewood C. The Role of Cytokines including Interleukin-6 
in COVID-19 induced Pneumonia and Macrophage Activation Syndrome-Like Disease. 
Autoimmunity Reviews. 2020:102537. 
9. 
Guan W-j, Ni Z-y, Hu Y, Liang W-h, Ou C-q, He J-x, Liu L, Shan H, Lei C-l, Hui DSC, Du B, Li L-j, 
Zeng G, Yuen K-Y, Chen R-c, Tang C-l, Wang T, Chen P-y, Xiang J, Li S-y, Wang J-l, Liang Z-j, Peng 
Y-x, Wei L, Liu Y, Hu Y-h, Peng P, Wang J-m, Liu J-y, Chen Z, Li G, Zheng Z-j, Qiu S-q, Luo J, Ye C-j, 
Zhu S-y, Zhong N-s. Clinical Characteristics of Coronavirus Disease 2019 in China. New England 
Journal of Medicine. 2020;382(18):1708-1720. 
10. 
Klein SL, Dhakal S, Ursin RL, Deshpande S, Sandberg K, Mauvais-Jarvis F. Biological sex impacts 
COVID-19 outcomes. PLoS Pathog. 2020;16(6):e1008570. 
11. 
Mauvais-Jarvis F. Aging, Male Sex, Obesity, and Metabolic Inflammation Create the Perfect 
Storm for COVID-19. Diabetes. 2020. 
12. 
Mauvais-Jarvis F, Bairey Merz N, Barnes PJ, Brinton RD, Carrero JJ, DeMeo DL, De Vries GJ, 
Epperson CN, Govindan R, Klein SL, Lonardo A, Maki PM, McCullough LD, Regitz-Zagrosek V, 
Regensteiner JG, Rubin JB, Sandberg K, Suzuki A. Sex and gender: modifiers of health, disease, 
and medicine. Lancet. 2020;396(10250):565-582. 
13. 
Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, Consortium 
atNC-R. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients 
Hospitalized With COVID-19 in the New York City Area. Jama. 2020;323(20):2052-2059. 
14. 
Klein SL, Flanagan KL. Sex differences in immune responses. Nature Reviews Immunology. 
2016;16(10):626-638. 


 
Version Date: 8-25-21 
Version Number: 1.1 
Page 14 of 14 
15. 
Seeland U, Coluzzi F, Simmaco M, Mura C, Bourne PE, Heiland M, Preissner R, Preissner S. 
Evidence for treatment with estradiol for women with SARS-CoV-2 infection. medRxiv. 
2020:2020.2008.2021.20179671. 
16. 
Phiel KL, Henderson RA, Adelman SJ, Elloso MM. Differential estrogen receptor gene expression 
in human peripheral blood mononuclear cell populations. Immunology Letters. 2005;97(1):107-
113. 
17. 
Straub RH. The Complex Role of Estrogens in Inflammation. Endocrine reviews. 2007;28(5):521-
574. 
18. 
Mauvais-Jarvis F, Klein SL, Levin ER. Estradiol, progesterone, immunomodulation and COVID-19 
outcomes. Endocrinology. 2020. 
19. 
Mauvais-Jarvis F, Manson JE, Stevenson JC, Fonseca VA. Menopausal hormone therapy and 
type 2 diabetes prevention: Evidence, mechanisms and clinical implications. Endocr Rev. 2017. 
 
 
 
 
 
 
 
 
 


 
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Figure 2. Adapted from WHO R&D Blueprint Feb 18, 2020, Geneva, Switzerland