Clincosm LogoSign in Get a demo

REMED: Effect of Two Different Doses of Dexamethasone in Patients With ARDS and COVID-19

Sponsor
Brno University Hospital (Other)
Overall Status
Recruiting
CT.gov ID
NCT04663555
Collaborator
Masaryk University (Other), Vascular surgery, University hospital Královské Vinohrady, Prague (Other), General University Hospital in Prague (Other), University Hospital Ostrava (Other), St. Anne's University Hospital Brno (Other), University Hospital Motol Prague (Other), University Hospital Olomouc (Other), University Hospital Plzeň (Other), Tomáš Baťa Regional Hospital (Other), Military University Hospital Praha (Other)
300
Enrollment
1
Location
2
Arms
26.8
Anticipated Duration (Months)
11.2
Patients Per Site Per Month

Study Details

Study Description

Brief Summary

REMED is a prospective, phase II, open-label, randomised controlled trial testing superiority of dexamethasone 20 mg vs 6 mg. The trial aims to be pragmatic, i.e. designed to evaluate the effectiveness of the intervention in conditions that are close to real-life routine clinical practice. The study is multi-centre and will be conducted in the intensive care units (ICUs) of ten university hospitals in the Czech Republic. This is an open-label trial in which the participants and the study staff will be aware of the allocated intervention. Blinded pre-planned statistical analysis will be performed.

Condition or Disease Intervention/Treatment Phase
Phase 4

Detailed Description

Since December 2019, Covid-19 virus has infected millions of people worldwide. A significant number of patients develop hyperinflammatory state affecting lungs, which may lead to the need of oxygen therapy. In most severe cases, acute respiratory distress syndrome (ARDS) develops and high flow oxygen therapy or invasive mechanical ventilation is necessary (Wu et al., 2020). Therapeutic options in Covid-19 associated ARDS patients remain limited and mortality is still excessive. Systemic corticosteroids have potential to limit hyperinflammatory response by modulating immune system. This effect is mediated mainly by binding to glucocorticosteroid receptor α (GRα)(Meduri et al., 2020). Their effectiveness was proved in heterogeneous ARDS patients recently (Villar et al., 2020). In patients with Covid-19 pneumonia in need for oxygen therapy or mechanical ventilation, dexamethasone 6 mg per day is currently recommended. This therapy is mandated by the results of RECOVERY trial (Horby et al., 2020). After this trial was published, three randomised trials comparing hydrocortisone (Angus et al., 2020; Dequin et al., 2020) or dexamethasone (Tomazini et al., 2020) against placebo were stopped prematurely. All these studies were included in the subsequent IPD metaanalysis (Sterne et al., 2020). However, dose of 6 mg of dexamethasone is currently being reappraised. The aforementioned study in non Covid-19 ARDS patients (Villar et al., 2020) used 20 mg of dexamethasone per day, which is roughly equivalent to the methylprednisolone regimen (1mg/kg/day) studied in early severe ARDS patients (Meduri et al., 2007). Only these moderate doses (80-100 mg of methylprednisolone, equivalent to 15-19 mg of dexamethasone) have full potential to modulate immune response by saturating GRα receptors (Meduri et al., 2020). Importantly, prematurely stopped CoDEX trial (Tomazini et al., 2020) comparing dexamethasone against placebo in Covid-ARDS patients, used initial daily dose of 20 mg of dexamethasone versus placebo.

In the light of these facts, 6 mg of dexamethasone given to COVID-19 patients with different severity of illness (WHO classification group 5-10) may miss important therapeutic potential or may prevent a potential deleterious effects of a full dose therapeutic corticosteroid. Authors hypothesize that the patients with moderate to severe ARDS undergoing mechanical ventilation may benefit from higher doses of dexamethasone (Villar et al., 2020; Tomazini et al., 2020; Meduri et al., 2007).

The primary objective of this study is to test the hypothesis that administration of dexamethasone 20 mg is superior over 6 mg in adult patients with moderate or severe ARDS due to confirmed COVID-19.

Primary endpoint: Number of ventilator-free days (VFDs) at 28 days after randomisation, defined as being alive and free from mechanical ventilation (more than 48 hours).

Secondary endpoints:

  1. Mortality from any cause at 60 days after randomization;

  2. Dynamics of inflammatory marker (CRP) change from Day 1 to Day 14;

  3. WHO Clinical Progression Scale at Day 14 (range 0-10; 0 = no illness, 1-9 = increasing level of care, and 10 = death);

  4. Adverse events related to corticosteroids (new infections, new thrombotic complications) until Day 28 or hospital discharge;

  5. Independence at 90 days after randomization assessed by Barthel Index The long-term outcomes of this study are to assess long-term consequences on mortality and quality of life at 180 and 360 days through telephone structured interview using Barthel Index.

Study Design

Study Type:
Interventional
Anticipated Enrollment :
300 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Intervention Model Description:
REMED is a prospective phase II open-label randomized controlled trial testing superiority of dexamethasone 20 mg vs 6 mg. The study is multi-centre and will be conducted in intensive care units (ICUs) of university hospitals in the Czech Republic. The trial aims to be pragmatic, i.e. designed to evaluate the effectiveness of the intervention in conditions that are very close to the real-life routine clinical practice. Dexamethasone will be administered once daily intravenously for 10 days. 300 participants will be enrolled and followed up for 360 days after randomization. Following stratification factors will be applied: Age < 65 and ≥ 65 (12); Charlson Comorbidity index (CCI; APPENDIX B Assessment tools, scores, and scales, Chapter 14.2) < 3 and ≥ 3; CRP < 150 mg/L and ≥ 150 mg/L Trial centre. Patients will be randomized in 1 : 1 ratio in one of the two treatment arms. Randomization through eCRF will be available 24 hours every day.REMED is a prospective phase II open-label randomized controlled trial testing superiority of dexamethasone 20 mg vs 6 mg. The study is multi-centre and will be conducted in intensive care units (ICUs) of university hospitals in the Czech Republic. The trial aims to be pragmatic, i.e. designed to evaluate the effectiveness of the intervention in conditions that are very close to the real-life routine clinical practice. Dexamethasone will be administered once daily intravenously for 10 days. 300 participants will be enrolled and followed up for 360 days after randomization.Following stratification factors will be applied:Age < 65 and ≥ 65 (12); Charlson Comorbidity index (CCI; APPENDIX B Assessment tools, scores, and scales, Chapter 14.2) < 3 and ≥ 3; CRP < 150 mg/L and ≥ 150 mg/L Trial centre. Patients will be randomized in 1 : 1 ratio in one of the two treatment arms. Randomization through eCRF will be available 24 hours every day.
Masking:
None (Open Label)
Primary Purpose:
Treatment
Official Title:
Effect of Dexamethasone in Patients With ARDS and COVID-19 - Prospective, Multi-centre, Open-label, Parallel-group, Randomized Controlled Trial (REMED Trial)
Actual Study Start Date :
Feb 2, 2021
Anticipated Primary Completion Date :
Apr 30, 2022
Anticipated Study Completion Date :
Apr 30, 2023

Arms and Interventions

Arm Intervention/Treatment
Experimental: DEX 20 mg

Patients in the intervention group after randomization will receive dexamethasone 20 mg intravenously once daily on day 1-5, followed by dexamethasone 10 mg intravenously once daily on day 6-10.

Drug: Dexamethasone
Patients in the intervention group after randomization will receive dexamethasone 20 mg intravenously once daily on day 1-5, followed by dexamethasone 10 mg intravenously once daily on day 6-10. If successful extubation occurs before day 10, treatment with dexamethasone is withdrawn.
Active Comparator: DEX 6 mg

Patients in the control group after randomization will receive dexamethasone 6 mg day 1-10.

Drug: Dexamethasone
Patients in the intervention group after randomization will receive dexamethasone 20 mg intravenously once daily on day 1-5, followed by dexamethasone 10 mg intravenously once daily on day 6-10. If successful extubation occurs before day 10, treatment with dexamethasone is withdrawn.

Outcome Measures

Primary Outcome Measures

  1. Number of ventilator-free days (VFDs) at 28 days after randomization [28 days]

    Number of ventilator-free days (VFDs) at 28 days after randomisation, defined as being alive and free from mechanical ventilation (more than 48 hours)

Secondary Outcome Measures

  1. Mortality from any cause at 60 days after randomization [60 days]

  2. WHO clinical progression scale at day 14 [14 days]

    WHO clinical progression scale (range, 0-10, where 0 = no illness, 1-9 = increasing level of care, and 10 = death) (WHO Working Group on the Clinical Characterisation and Management of COVID-19 infection, 2020) assessed at day 14

  3. Dynamics of inflammatory marker [14 days]

    Dynamics of inflammatory marker (CRP) change from Day 1 to Day 14

  4. Adverse events related to corticosteroids [28 days]

    new infections, new thrombotic complications

  5. Functional independence [90 days]

    Independence at 90 days after randomization assessed by Barthel Index

Other Outcome Measures

  1. Long-term outcome regarding mortality [180 and 360 days]

    Death from any cause at 180 and 360 days

  2. Long-term outcome regarding functional independence [180 and 360 days]

    Functional independence at 180 and 360 days assesed through telephone structured interview using Barthel Index.

Eligibility Criteria

Criteria

Ages Eligible for Study:
18 Years and Older
Sexes Eligible for Study:
All
Accepts Healthy Volunteers:
No
Inclusion criteria:
Subjects will be eligible for the trial if they meet all of the following criteria:

  1. Adult (≥ 18 years of age) at time of enrolment;

  2. Present COVID-19 (infection confirmed by RT-PCR or antigen testing);

  3. Intubation/mechanical ventilation or ongoing high-flow nasal cannula (HFNC) oxygen therapy;

  4. Moderate or severe ARDS according to Berlin criteria:

  • Moderate - PaO2/FiO2 100-200 mmHg;

  • Severe - PaO2/FiO2 < 100 mmHg;

  1. Admission to ICU in the last 24 hours.
Exclusion criteria:
Subjects will not be eligible for the trial if they meet any of the following criteria:

  1. Known allergy/hypersensitivity to dexamethasone or excipients of the investigational medicinal product (e.g. parabens, benzyl alcohol);

  2. Fulfilled criteria for ARDS for ≥ 14 days at enrolment;

  3. Pregnancy or breastfeeding;

  4. Unwillingness to comply with contraception measurements from the enrolment to at least 1 week after the last dose of dexamethasone (sexual abstinence is considered as the adequate contraception method);

  5. End-of-life decision or patient is expected to die within next 24 hours;

  6. Decision not to intubate or ceilings of treatment in place;

  7. Immunosuppression and/or immunosuppressive drugs in medical history:

  8. Systemic immunosuppressive drugs or chemotherapy in the past 30 days;

  9. Systemic corticosteroids use before hospitalization;

  10. Any dose of dexamethasone during the present hospital stay for COVID-19 for more than (≥) last 5 days before enrolment;

  11. Systemic corticosteroids during present hospital stay for other conditions than COVID-19 (e.g. septic shock);

  12. Present haematological or generalized solid malignancy;

  13. Any of contraindications of corticosteroids, e.g.

  • intractable hyperglycaemia;

  • active gastrointestinal bleeding;

  • adrenal gland disorders;

  • a presence of superinfection diagnosed with locally established clinical and laboratory criteria without adequate antimicrobial treatment;

  1. Cardiac arrest before ICU admission;

  2. Participation in another interventional trial in the last 30 days.

Contacts and Locations

Locations

Site City State Country Postal Code
1 University Hospital Brno Brno Czechia 62500

Sponsors and Collaborators

  • Brno University Hospital
  • Masaryk University
  • Vascular surgery, University hospital Královské Vinohrady, Prague
  • General University Hospital in Prague
  • University Hospital Ostrava
  • St. Anne's University Hospital Brno
  • University Hospital Motol Prague
  • University Hospital Olomouc
  • University Hospital Plzeň
  • Tomáš Baťa Regional Hospital
  • Military University Hospital Praha

Investigators

None specified.

Study Documents (Full-Text)

More Information

Publications

Responsible Party:
Jan Malaska, MD. Ph.D. EDIC, Brno University Hospital
ClinicalTrials.gov Identifier:
NCT04663555
Other Study ID Numbers:
  • CZECRIN No. 2020/47
  • 2020-005887-70
First Posted:
Dec 11, 2020
Last Update Posted:
Mar 3, 2022
Last Verified:
Mar 1, 2022
Individual Participant Data (IPD) Sharing Statement:
Yes
Plan to Share IPD:
Yes
Studies a U.S. FDA-regulated Drug Product:
No
Studies a U.S. FDA-regulated Device Product:
No
Keywords provided by Jan Malaska, MD. Ph.D. EDIC, Brno University Hospital
Covid19
ARDS
dexamethasone
Additional relevant MeSH terms:
COVID-19
Dexamethasone

Study Results

No Results Posted as of Mar 3, 2022