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Adhikari NKJ, Hashmi M, Tirupakuzhi Vijayaraghavan BK, Haniffa R, Beane A, Webb SA, Angus DC, Gordon AC, Cook DJ, Guyatt GH, Berry LR, Lorenzi E, Mouncey PR, Au C, Pinto R, Ménard J, Sprague S, Masse MH, Huang DT, Heyland DK, Nichol AD, McArthur CJ, de Man A, Al-Beidh F, Annane D, Anstey M, Arabi YM, Battista MC, Berry S, Bhimani Z, Bonten MJM, Bradbury CA, Brant EB, Brunkhorst FM, Burrell A, Buxton M, Cecconi M, Cheng AC, Cohen D, Cove ME, Day AG, Derde LPG, Detry MA, Estcourt LJ, Fagbodun EO, Fitzgerald M, Goossens H, Green C, Higgins AM, Hills TE, Horvat C, Ichihara N, Jayakumar D, Kanji S, Khoso MN, Lawler PR, Lewis RJ, Litton E, Marshall JC, McAuley DF, McGlothlin A, McGuinness SP, McQuilten ZK, McVerry BJ, Murthy S, Parke RL, Parker JC, Reyes LF, Rowan KM, Saito H, Salahuddin N, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Tolppa T, Trapani T, Turgeon AF, Turner AM, Udy AA, van de Veerdonk FL, Zarychanski R, Lamontagne F. Intravenous Vitamin C for Patients Hospitalized With COVID-19: Two Harmonized Randomized Clinical Trials. JAMA 2023; 330:1745-1759. [PMID: 37877585 PMCID: PMC10600726 DOI: 10.1001/jama.2023.21407] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
Importance The efficacy of vitamin C for hospitalized patients with COVID-19 is uncertain. Objective To determine whether vitamin C improves outcomes for patients with COVID-19. Design, Setting, and Participants Two prospectively harmonized randomized clinical trials enrolled critically ill patients receiving organ support in intensive care units (90 sites) and patients who were not critically ill (40 sites) between July 23, 2020, and July 15, 2022, on 4 continents. Interventions Patients were randomized to receive vitamin C administered intravenously or control (placebo or no vitamin C) every 6 hours for 96 hours (maximum of 16 doses). Main Outcomes and Measures The primary outcome was a composite of organ support-free days defined as days alive and free of respiratory and cardiovascular organ support in the intensive care unit up to day 21 and survival to hospital discharge. Values ranged from -1 organ support-free days for patients experiencing in-hospital death to 22 organ support-free days for those who survived without needing organ support. The primary analysis used a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented efficacy (improved survival, more organ support-free days, or both), an OR less than 1 represented harm, and an OR less than 1.2 represented futility. Results Enrollment was terminated after statistical triggers for harm and futility were met. The trials had primary outcome data for 1568 critically ill patients (1037 in the vitamin C group and 531 in the control group; median age, 60 years [IQR, 50-70 years]; 35.9% were female) and 1022 patients who were not critically ill (456 in the vitamin C group and 566 in the control group; median age, 62 years [IQR, 51-72 years]; 39.6% were female). Among critically ill patients, the median number of organ support-free days was 7 (IQR, -1 to 17 days) for the vitamin C group vs 10 (IQR, -1 to 17 days) for the control group (adjusted proportional OR, 0.88 [95% credible interval {CrI}, 0.73 to 1.06]) and the posterior probabilities were 8.6% (efficacy), 91.4% (harm), and 99.9% (futility). Among patients who were not critically ill, the median number of organ support-free days was 22 (IQR, 18 to 22 days) for the vitamin C group vs 22 (IQR, 21 to 22 days) for the control group (adjusted proportional OR, 0.80 [95% CrI, 0.60 to 1.01]) and the posterior probabilities were 2.9% (efficacy), 97.1% (harm), and greater than 99.9% (futility). Among critically ill patients, survival to hospital discharge was 61.9% (642/1037) for the vitamin C group vs 64.6% (343/531) for the control group (adjusted OR, 0.92 [95% CrI, 0.73 to 1.17]) and the posterior probability was 24.0% for efficacy. Among patients who were not critically ill, survival to hospital discharge was 85.1% (388/456) for the vitamin C group vs 86.6% (490/566) for the control group (adjusted OR, 0.86 [95% CrI, 0.61 to 1.17]) and the posterior probability was 17.8% for efficacy. Conclusions and Relevance In hospitalized patients with COVID-19, vitamin C had low probability of improving the primary composite outcome of organ support-free days and hospital survival. Trial Registration ClinicalTrials.gov Identifiers: NCT04401150 (LOVIT-COVID) and NCT02735707 (REMAP-CAP).
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Affiliation(s)
- Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | | | - Rashan Haniffa
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Abi Beane
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Health Care, Perth, Australia
| | - Derek C Angus
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, England
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, England
| | - Carly Au
- Intensive Care National Audit and Research Centre, London, England
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Ménard
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Sheila Sprague
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Hélène Masse
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David T Huang
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
- University College Dublin, Dublin, Ireland
- Alfred Health, Melbourne, Australia
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Angelique de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Djillali Annane
- UVSQ University Paris Saclay, Institut-Hospitalo Universitaire Prometheus, Paris, France
- Médecine Intensive-Réanimation, Hôpital Raymond-Poincaré, Garches, France
| | - Matthew Anstey
- Sir Charles Gairdner Hospital, Nedlands, Australia
- University of Western Australia, Perth
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marie-Claude Battista
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Zahra Bhimani
- St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
| | | | - Emily B Brant
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frank M Brunkhorst
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Aidan Burrell
- Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Allen C Cheng
- Monash Infectious Disease, Monash Health and School of Clinical Sciences, Monash University, Clayton, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dian Cohen
- Bishop's University, Sherbrooke, Quebec, Canada
- Massawippi Valley Foundation, Ayer's Cliff, Quebec, Canada
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew G Day
- Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Lennie P G Derde
- European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
- Intensive Care Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Lise J Estcourt
- Department of Haematology, NHS Blood and Transplant, Bristol, England
- Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | | | | | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Christopher Horvat
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nao Ichihara
- Department of Cardiovascular Surgery, School of Medicine, Jikei University, Tokyo, Japan
| | | | - Salmaan Kanji
- Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Patrick R Lawler
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Edward Litton
- Fiona Stanley Hospital, Department of Intensive Care Unit, University of Western Australia, Perth
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Queen's University of Belfast, Belfast, Northern Ireland
- Centre for Infection and Immunity, Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Medical Research Institute of New Zealand, Wellington
- Auckland City Hospital, Cardiothoracic and Vascular Intensive Care Unit, Auckland, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | | | - Bryan J McVerry
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Rachael L Parke
- Medical Research Institute of New Zealand, Wellington
- Auckland City Hospital, Cardiothoracic and Vascular Intensive Care Unit, Auckland, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Luis Felipe Reyes
- Department of Infectious Diseases, Universidad de La Sabana, Chia, Colombia
- Department of Critical Care Medicine, Clinica Universidad de La Sabana, Chia, Colombia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Nawal Salahuddin
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Marlene S Santos
- Department of Critical Care, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher W Seymour
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manu Shankar-Hari
- Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, Scotland
| | - Timo Tolppa
- National Intensive Care Surveillance, Colombo, Sri Lanka
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care, Université Laval, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Departments of Traumatology, Emergency Medicine, and Critical Care Medicine, Université Laval Research Center, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia
| | | | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - François Lamontagne
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Griffee MJ, Bozza PT, Reyes LF, Eddington DP, Rosenberger D, Merson L, Citarella BW, Fanning JP, Alexander PM, Fraser J, Dalton H, Cho SM. Thrombotic and hemorrhagic complications of COVID-19 in adults hospitalized in high-income countries compared with those in adults hospitalized in low- and middle-income countries in an international registry. Res Pract Thromb Haemost 2023; 7:102142. [PMID: 37601011 PMCID: PMC10439444 DOI: 10.1016/j.rpth.2023.102142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 08/22/2023] Open
Abstract
Background COVID-19 has been associated with a broad range of thromboembolic, ischemic, and hemorrhagic complications (coagulopathy complications). Most studies have focused on patients with severe disease from high-income countries (HICs). Objectives The main aims were to compare the frequency of coagulopathy complications in developing countries (low- and middle-income countries [LMICs]) with those in HICs, delineate the frequency across a range of treatment levels, and determine associations with in-hospital mortality. Methods Adult patients enrolled in an observational, multinational registry, the International Severe Acute Respiratory and Emerging Infections COVID-19 study, between January 1, 2020, and September 15, 2021, met inclusion criteria, including admission to a hospital for laboratory-confirmed, acute COVID-19 and data on complications and survival. The advanced-treatment cohort received care, such as admission to the intensive care unit, mechanical ventilation, or inotropes or vasopressors; the basic-treatment cohort did not receive any of these interventions. Results The study population included 495,682 patients from 52 countries, with 63% from LMICs and 85% in the basic treatment cohort. The frequency of coagulopathy complications was higher in HICs (0.76%-3.4%) than in LMICs (0.09%-1.22%). Complications were more frequent in the advanced-treatment cohort than in the basic-treatment cohort. Coagulopathy complications were associated with increased in-hospital mortality (odds ratio, 1.58; 95% CI, 1.52-1.64). The increased mortality associated with these complications was higher in LMICs (58.5%) than in HICs (35.4%). After controlling for coagulopathy complications, treatment intensity, and multiple other factors, the mortality was higher among patients in LMICs than among patients in HICs (odds ratio, 1.45; 95% CI, 1.39-1.51). Conclusion In a large, international registry of patients hospitalized for COVID-19, coagulopathy complications were more frequent in HICs than in LMICs (developing countries). Increased mortality associated with coagulopathy complications was of a greater magnitude among patients in LMICs. Additional research is needed regarding timely diagnosis of and intervention for coagulation derangements associated with COVID-19, particularly for limited-resource settings.
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Affiliation(s)
- Matthew J. Griffee
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
- ISARIC, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Patricia T. Bozza
- Laboratory of Immunopharmacology, Institutio Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Luis Felipe Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chia, Colombia
| | - Devin P. Eddington
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Laura Merson
- ISARIC, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | | | | | - Peta M.A. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, Australia
| | - Heidi Dalton
- Pediatric Critical Care Medicine, Heart and Vascular Institute, Inova Fairfax Hospital, Annandale, Virginia, USA
| | - Sung-Min Cho
- Divisions of Neuroscience Critical Care and Cardiac Surgery, Departments of Neurology, Surgery, Anesthesia and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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8
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Blette BS, Granholm A, Li F, Shankar-Hari M, Lange T, Munch MW, Møller MH, Perner A, Harhay MO. Causal Bayesian machine learning to assess treatment effect heterogeneity by dexamethasone dose for patients with COVID-19 and severe hypoxemia. Sci Rep 2023; 13:6570. [PMID: 37085591 PMCID: PMC10120498 DOI: 10.1038/s41598-023-33425-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023] Open
Abstract
The currently recommended dose of dexamethasone for patients with severe or critical COVID-19 is 6 mg per day (mg/d) regardless of patient features and variation. However, patients with severe or critical COVID-19 are heterogenous in many ways (e.g., age, weight, comorbidities, disease severity, and immune features). Thus, it is conceivable that a standardized dosing protocol may not be optimal. We assessed treatment effect heterogeneity in the COVID STEROID 2 trial, which compared 6 mg/d to 12 mg/d, using a causal inference framework with Bayesian Additive Regression Trees, a flexible modeling method that detects interactive effects and nonlinear relationships among multiple patient characteristics simultaneously. We found that 12 mg/d of dexamethasone, relative to 6 mg/d, was probably associated with better long-term outcomes (days alive without life support and mortality after 90 days) among the entire trial population (i.e., no signals of harm), and probably more beneficial among those without diabetes mellitus, that were older, were not using IL-6 inhibitors at baseline, weighed less, or had higher level respiratory support at baseline. This adds more evidence supporting the use of 12 mg/d in practice for most patients not receiving other immunosuppressants and that additional study of dosing could potentially optimize clinical outcomes.
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Affiliation(s)
- Bryan S Blette
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University School of Public Health, New Haven, CT, USA
| | - Manu Shankar-Hari
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 304 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA.
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