Methylprednisolone Pulses in Hospitalized COVID-19 Patients Without Respiratory Failure: A Randomized Controlled Trial

Background Corticosteroids are the cornerstone of the treatment of patients with COVID-19 admitted to hospital. However, whether corticosteroids can prevent respiratory worsening in hospitalized COVID-19 patients without oxygen requirements is currently unknown. Aims To assess the efficacy of methylprednisolone pulses (MPP) in hospitalized COVID-19 patients with increased levels of inflammatory markers not requiring oxygen at baseline. Methods Multicenter, parallel, randomized, double-blind, placebo-controlled trial conducted in Spain. Patients admitted for confirmed SARS-CoV-2 pneumonia with raised inflammatory markers (C-reactive protein >60 mg/L, interleukin-6 >40 pg/ml, or ferritin >1,000 μg/L) but without respiratory failure after the first week of symptom onset were randomized to receive a 3-day course of intravenous MPP (120 mg/day) or placebo. The primary outcome was treatment failure at 14 days, a composite variable including mortality, the need for ICU admission or mechanical ventilation, and clinical worsening, this last parameter defined as a PaO2/FiO2 ratio below 300; or a 15% decrease in the PaO2 from baseline, together with an increase in inflammatory markers or radiological progression. If clinical worsening occurred, patients received tocilizumab and unmasked corticosteroids. The secondary outcomes were 28-day mortality, adverse events, need for ICU admission or high-flow oxygen, length of hospital stay, SARS-CoV-2 clearance, and changes in laboratory parameters. Results A total of 72 patients were randomized and 71 patients were analyzed (34 in the MPP group and 37 in the placebo group). Twenty patients presented with treatment failure (29.4 in the MPP group vs. 27.0% in the placebo group, p = 0.82), with no differences regarding the time to treatment failure between groups. There were no cases of death or mechanical ventilation requirements at 14 days post-randomization. The secondary outcomes were similar in MPP and placebo groups. Conclusions A 3-day course of MPP after the first week of disease onset did not prevent respiratory deterioration in hospitalized COVID-19 patients with an inflammatory phenotype who did not require oxygen.

The focus in the search for new treatments for COVID-19 has been on antiviral drugs and vaccines. Current data suggest that the disease has three stages: an early infection phase related to the viral response (stage I), lasting 5 to 7 days; a pulmonary phase (stage II), up to 10 to 12 days after the onset of symptoms; and finally, in a subgroup of patients, a hyperinflammation phase (stage III), consisting of cytokine release syndrome that tends to lead to acute respiratory distress syndrome (ARDS), invasive mechanical ventilation almost always being required to keep the patient alive, as well as to other complications such as hemophagocytic and antiphospholipid antibody syndromes (2,3).
The main cause of death in COVID-19 is acute respiratory failure secondary to ARDS, triggered by the viral infection in the hyperinflammation phase (4). It is known that both the innate and adaptive immune systems are involved in this response, leading to T-cell activation and differentiation and the release of type 1 interferons and pro-inflammatory cytokines (IL-1, IL-6, IL-8, IL-21, TNF-β and MCP-1), among other immune mediators (5).
During the previous pandemics caused by coronaviruses (severe acute respiratory

syndrome [SARS] and the Middle East respiratory syndrome [MERS]), glucocorticoids
were not among the recommended evidence-based treatments, as it seemed that they could be associated with a poorer course of the disease (6). In line with this, the World Health Organisation (WHO) advised against the use of glucocorticoids in the treatment of SARS-CoV-2, given that some studies found these drugs to be associated with a delayed viral clearance, psychosis, complications related to diabetes mellitus, avascular necrosis and even a higher risk of mortality (7).
Despite this recommendation by the WHO, given the poor response to antiviral drugs and growing data on the cytokine release syndrome in COVID-19, the medical Version 7.0 24th April 2020 3 community has started to prescribe glucocorticoids empirically in the early inflammatory stage of the disease. Their use in real clinical practice has been supported by more recent publications suggesting that glucocorticoids do benefit patients without significant adverse effects or delayed viral clearance (8,9), and in Spain, by the inclusion of these drugs in the majority of hospital protocols for COVID-19. Nonetheless, the level of evidence available leaves many questions unanswered, that are difficult to address outside of a comparative clinical trial.
From the molecular point of view, pulsed glucocorticoids over 3 to 5 days at high doses (from 100 mg/day of prednisone or equivalent) work through dual (genomic and nongenomic) mechanisms of action with a low risk of toxicity. That is, as well as strong genomic effects following the complete saturation of the cytosolic glucocorticoid receptors (GRs) and their subsequent translocation into the cell nucleus, high doses lead to non-genomic effects mediated by selective membrane receptors (10). These additional non-genomic effects are associated with strong clinical response that is rapid, as it does not depend on the process of nuclear translocation of the glucocorticoid-GR complex and modulation of gene expression. On the other hand, the majority of adverse events related to glucocorticoids, including infections, are dose-and time-dependent, and hence tend to be associated with long-term maintenance treatments at doses under 100 mg/day of prednisone or equivalent that only activate the genomic pathway.
Given all this, the objective of this study was to assess the safety and efficacy of pulsed glucocorticoids in the inflammation phase (stage II) of COVID-19 for modifying the clinical course of the disease, need for mechanical ventilation, intensive care unit (ICU) admission and mortality.

RATIONALE
Currently, there is a compelling need for drugs with evidence-based efficacy and safety in patients with COVID-19. The need is particularly acute in patients with severe pneumonia in which cytokine release syndrome is triggered, as their prognosis is poor if there is a delay in starting treatment. In the context of health services being overwhelmed by excessive demand for intensive care and a limited availability of interleukin inhibitors, glucocorticoids are seen as a promising treatment option, and moreover, they are familiar to most practicing physicians. The aim of this study was to assess the safety and efficacy of glucocorticoids in COVID-19 pneumonia in the inflammation phase, specifically seeking to reduce ICU admissions, the need for mechanical ventilation and mortality.

2.-HYPOTHESIS
In patients with COVID-19 pneumonia in the inflammation phase (stage II), treatment with pulsed glucocorticoids is able to reduce the rate of treatment failure and other complications compared to the standard treatment.

PRIMARY OBJECTIVE
To assess the efficacy of pulsed glucocorticoids during the inflammation phase of the pneumonia caused by the SARS-CoV-2 virus.

SECONDARY OBJECTIVES
To compare

STUDY DESIGN
This is to be a phase 3 double-blind parallel-group randomised clinical trial: 1. Experimental group: standard of care + pulsed glucocorticoids versus 2. Control group: standard of care The standard of care will consist of the treatment provided following the standard protocol at the time in the hospital. This may be updated during the course of the study.

CONTEXT AND DURATION OF THE STUDY
For this study, we will invite consecutive patients with a diagnosis of pneumonia caused by SARS-CoV-2 (COVID-19) to participate, recruiting them in the emergency department or on a hospital ward.
The study was originally conceived in the Hospital Complex of Navarra, but it was envisaged that other centres would be able to join the study, at the discretion of the study coordinator, and it has been extended to Hospital Moisès Broggi (Sant Joan Despí, Barcelona), researchers from this second hospital having been involved in the development of this version of the study protocol. Each patient will be followed up throughout their stay on a hospital ward and to at least 28 days after the date of randomisation, any patients discharged from hospital earlier being contacted by phone. Patients will be censored when they reach the primary endpoint, are lost to follow-up or die. Patient recruitment will finish when we reach a fixed sample size. It is expected that patients will start to be included and followed up as of April 2020 and that follow-up will be completed in May 2020 [In fact, recruitment began on 28 May 2020 and is expected to be completed by February 2021]. Interim analysis of the results is due to be performed when recruitment reaches 50% of the fixed sample size.

STUDY SUBJECTS
The sample is to be selected from all patients who require hospital admission with a diagnosis of pneumonia due to SARS-CoV-2 based on reverse-transcription polymerase

Criteria for study withdrawal:
In accordance with the current version of the Declaration of Helsinki and legislation, patients have the right to withdraw from the study at any point and for any reason, without Any patients withdrawn will not be eligible for future inclusion in the study again.
Patients may be withdrawn from the study for any of the following criteria for withdrawal: • Withdrawal of consent by the patient and/or refusal of treatment and/or lack of cooperation • Toxicity, adverse events, or intercurrent illness that, in the opinion of the researcher, warrant withdrawal o SpO2 in ambient air falling to < 90% or PaO2 in ambient air to < 60 mmHg or PaO 2 /FiO 2 < 300 mmHg + radiological progression.

SECONDARY ENDPOINTS
• Mortality within 28 days after randomisation Data collected will be entered into an electronic case report form; only study researchers will have access to these data and all the requirements in terms of data protection will be met.
(1) Hydroxychloroquine: 200 mg orally, 2 tables q12h on day 1, followed by 1 tablet q12h for 5 days. (2) Lopinavir/ritonavir: 200/50 mg orally, 2 tablets q12h for 7 to 14 days. (3) Single dose of TCZ, dose may be repeated 12-24 hours after the first dose in the event of worsening in laboratory parameters, in accordance with the recommendations of the Spanish Agency of Medicines and Medical Devices. Patients in both arms will be given omeprazole concomitantly. Note: This base regimen may be modified in both arms if there are changes in standard of care at the participating hospitals.

RANDOMISATION
After obtaining patient informed consent, the treatment strategy will be decided by block randomisation stratified by age into two groups (<75 and ≥75 years old). Randomisation will be performed with the randomizeR package in R software, using two blocks sizes (sized 4 and 6), with random permutation. The sequence will be generated by a unit (the Clinical Trials Platform of Navarrabiomed) independent of the researchers who will carry out patient recruitment and implement the protocol. These researchers will be blinded to the arm to which patients are to be allocated until the start of the intervention. The Clinical  Trials Platform will inform the hospital pharmacy concerning the group allocation of each patient included in the trial.

INTERVENTION
During the randomisation, patients with be randomly allocated to the experimental or control group (Figure 2 The doses of methylprednisolone (120 mg IV) or placebo (NaCl 0.9% IV) will be prepared and dispensed by the hospital pharmacy. Only the staff responsible for preparing the medication will know patient group allocation. That is, neither the researcher nor nurses administering the treatment will know the content of the bags supplied.
Patients in both groups will be treated with tocilizumab if the following is observed: • SpO2 in ambient air falling to < 90% or PaO2 in ambient air < 60 mmHg or PaO2/FiO2 below 300 mmHg not explained by any other condition.

Baseline assessment
All the patients included in the study will be assessed at baseline in the emergency department or on the hospital ward. This baseline assessment will include the following elements: • Chest X-ray (interpreted by a pulmonary radiologist).

Follow-up
During hospital admission, patients will be followed-up in accordance with standard procedures for COVID-19 (11), with close monitoring of their vital signs (temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation). All patients in the study will be assessed in person at least once a day by a doctor who is a member of a specialized COVID-19 team, in accordance with the established treatment protocol. The detection of any significant clinical change will prompt an addition assessment of vital signs and medical examination.
Blood tests involving a blood count, coagulation tests including D-dimer, and the measurement of renal function and levels of CPR, procalcitonin, ferritin, LDH and IL-6, will be performed every 48 hours and whenever there is a significant clinical change, at the discretion of the doctor in charge. Further, a chest X-ray will be performed every 48 hours and in the event of a significant clinical change, at the discretion of the doctor in charge, and the results will be interpreted by a pulmonary radiologist.
A follow-up RT-PCR will be performed before administrative discharge and this is to be performed at least 7 days after the first PCR.

SAMPLE SIZE
It was estimated that 60 patients (30 in each arm) were needed to detect as significant (two-tailed type I error of 0.05 and a type II error of 0.2) an absolute difference of 25% in the primary endpoint between the groups: 35% in the control group and 10% in the intervention group. Assuming a loss to follow-up of 20%, it is necessary to recruit a total of 72 patients.

STATISTICAL ANALYSIS
Initially, univariate descriptive analysis will be performed: calculating measures of central tendency and dispersion (means, standard deviation and confidence intervals or median and interquartile range depending on the distribution of the data) for continuous variables and frequencies for qualitative variables with their corresponding confidence intervals for the overall rates. Kolgomorov-Smirnov tests will be used to assess whether the continuous data follow a normal distribution and therefore parametric tests can be used.
Subsequently, it will be assessed whether randomisation achieved balance between the two arms: comparing the means of quantitative variables using Student's t or the Mann-Whitney U tests, as appropriate, and qualitative variables using the chi-squared test or Fisher´s exact tests. If the desired balance is achieved, the primary endpoint will be compared between the groups to test the null hypothesis (H0) that the proportions are equal, assuming that the statistic for assessing the differences follows a normal distribution with a mean of 0 and standard deviation of 1; otherwise, multivariate analysis will be performed using logistic regression to assess the risk of treatment failure, estimating the effect of the intervention as an odds ratio with the corresponding 95% confidence interval.
The analysis will be performed on an intention-to-treat basis

SERIOUS ADVERSE EVENTS
A serious adverse event is any untoward medical occurrence in a patient on trial medication that at any dose that • results in patient death, • is a life-threatening • requires hospitalisation or prolongation of the current hospital stay • results in persistent or significant disability/incapacity • causes a congenital anomaly or birth defect • is medically relevant.
Adverse events will be closely monitored until the condition resolves or is considered permanent, and at each appointment (or more often if required), the following will be assessed: any change in the severity, the suspected relationship with the drug of interest, and the interventions required to treat it and the outcome. All the adverse events (serious and non-serious) will be recorded in the corresponding electronic case report form of the study.

PROCEDURE FOR REPORTING SERIOUS ADVERSE EVENTS
The researcher will report any serious adverse events within the first 24 hours of learning of their occurrence to the person in charge of pharmacovigilance: Email: ruth.garcia.rey@navarra.es.
For this purpose, we will use the serious event report form. The person in charge of the pharmacovigilance will check the form received and request further information from the researcher as appropriate.

8.-COMPLETION AND DISCONTINUATION OF THE CLINICAL TRIAL
The clinical trial will end when all patients have completed the follow-up. Nonetheless, under certain circumstances, it may be halted at an earlier stage. Circumstances that my warrant termination of the trial include, but are not limited to: • Identification of unexpected, significant or unacceptable risks to participants • Inability to recruit an acceptable number of patients In this study, data are to be collected prospectively. The sources of information include patient's electronic health records and data provided by doctors. All the information and documents associated with the study should be kept in the participating hospital.
Patients included in the study will be identified by a numerical code. In this way, the data collected by researchers will not include personal information, safeguarding patient confidentiality. The transmission, processing and dissemination of personal data from all the participating patients will be handled in accordance with Regulation (

PATIENT INFORMATION AND INFORMED CONSENT FORM
The researchers will be in charge of providing each patient or their legal representative with the patient information sheet and informed consent form. Individuals participating in the trial or their legal representative will be asked to sign and date the informed consent form prior to inclusion in the study, that is, before the performance of any intervention.
The researcher will explain the nature of the trial, its purpose, the procedures involved, expected duration, and potential risks and benefits, as well as the fact that they have the right to withdraw at any time without giving a reason and without it affecting the medical care received. The researchers will give participants a copy of the patient information sheet and informed consent form and allow patients sufficient time to consider their decision about whether to participate in the trial.
In the event of amendments to the protocol that might directly affect the study participants, the information sheet and informed consent form will be modified to include the new information. Participants will then be asked to sign the new version of the form.

CONFIDENTIALITY AND PERSONAL DATA PROTECTION
The collection, processing and dissemination of personal data of patients participating in this study will be carried out in accordance with the current legislation on personal data protection, in particular in compliance with the General Data Protection Regulation, namely, Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016. When collecting and processing patient personal data, all reasonable and appropriate measures will be taken to safeguard these data and preserve patient anonymity in relation to their health and medical records.
Participant identity will be coded in study documents, such that patient health records cannot be linked to an identified or identifiable person, and only authorised individuals Version 7.0 24th April 2020 20 (members of the research team, CREC or health authorities or the study monitor) for the proper performance of their duties, will have access to identifiable personal data.
At all times, the patient will be able to exercise the right, through the researcher, to access, rectify, erase or object to the use of their personal data.

11.-DISSEMINATION OF RESULTS
1. The results of the study will be published in scientific journals, mentioning the CREC that approved the study.
2. The anonymity of participating patients will be safeguarded at all times.
3. We will seek to publish the results and conclusions of this study in scientific journals before their dissemination to the general public.