Intravenous Vitamin C for Patients Hospitalized With COVID-19: Two Harmonized Randomized Clinical Trials. LOVIT-COVID Investigators, on behalf of the Canadian Critical Care Trials Group,, Investigators, t. R., Adhikari, N. K. J., Hashmi, M., Tirupakuzhi Vijayaraghavan, B. K., Haniffa, R., Beane, A., Webb, S. A., Angus, D. C., Gordon, A. C., Cook, D. J., Guyatt, G. H., Berry, L. R., Lorenzi, E., Mouncey, P. R., Au, C., Pinto, R., Ménard, J., Sprague, S., Masse, M., Huang, D. T., Heyland, D. K., Nichol, A. D., McArthur, C. J., de Man, A., Al-Beidh, F., Annane, D., Anstey, M., Arabi, Y. M., Battista, M., Berry, S., Bhimani, Z., Bonten, M. J. M., Bradbury, C. A., Brant, E. B., Brunkhorst, F. M., Burrell, A., Buxton, M., Cecconi, M., Cheng, A. C., Cohen, D., Cove, M. E., Day, A. G., Derde, L. P. G., Detry, M. A., Estcourt, L. J., Fagbodun, E. O., Fitzgerald, M., Goossens, H., Green, C., Higgins, A. M., Hills, T. E., Ichihara, N., Jayakumar, D., Kanji, S., Khoso, M. N., Lawler, P. R., Lewis, R. J., Litton, E., Marshall, J. C., McAuley, D. F., McGlothlin, A., McGuinness, S. P., McQuilten, Z. K., McVerry, B. J., Murthy, S., Parke, R. L., Parker, J. C., Reyes, L. F., Rowan, K. M., Saito, H., Salahuddin, N., Santos, M. S., Saunders, C. T., Seymour, C. W., Shankar-Hari, M., Tolppa, T., Trapani, T., Turgeon, A. F., Turner, A. M., Udy, A. A., van de Veerdonk, F. L., Zarychanski, R., & Lamontagne, F. JAMA, 330(18):1745–1759, November, 2023.
doi  abstract   bibtex   
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).
@article{lovit-covid_investigators_on_behalf_of_the_canadian_critical_care_trials_group_and_the_remap-cap_investigators_intravenous_2023,
	title = {Intravenous {Vitamin} {C} for {Patients} {Hospitalized} {With} {COVID}-19: {Two} {Harmonized} {Randomized} {Clinical} {Trials}},
	volume = {330},
	issn = {1538-3598},
	shorttitle = {Intravenous {Vitamin} {C} for {Patients} {Hospitalized} {With} {COVID}-19},
	doi = {10.1001/jama.2023.21407},
	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).},
	language = {eng},
	number = {18},
	journal = {JAMA},
	author = {{LOVIT-COVID Investigators, on behalf of the Canadian Critical Care Trials Group, and the REMAP-CAP Investigators} and Adhikari, Neill K. J. and Hashmi, Madiha and Tirupakuzhi Vijayaraghavan, Bharath Kumar and Haniffa, Rashan and Beane, Abi and Webb, Steve A. and Angus, Derek C. and Gordon, Anthony C. and Cook, Deborah J. and Guyatt, Gordon H. and Berry, Lindsay R. and Lorenzi, Elizabeth and Mouncey, Paul R. and Au, Carly and Pinto, Ruxandra and Ménard, Julie and Sprague, Sheila and Masse, Marie-Hélène and Huang, David T. and Heyland, Daren K. and Nichol, Alistair D. and McArthur, Colin J. and de Man, Angelique and Al-Beidh, Farah and Annane, Djillali and Anstey, Matthew and Arabi, Yaseen M. and Battista, Marie-Claude and Berry, Scott and Bhimani, Zahra and Bonten, Marc J. M. and Bradbury, Charlotte A. and Brant, Emily B. and Brunkhorst, Frank M. and Burrell, Aidan and Buxton, Meredith and Cecconi, Maurizio and Cheng, Allen C. and Cohen, Dian and Cove, Matthew E. and Day, Andrew G. and Derde, Lennie P. G. and Detry, Michelle A. and Estcourt, Lise J. and Fagbodun, Elizabeth O. and Fitzgerald, Mark and Goossens, Herman and Green, Cameron and Higgins, Alisa M. and Hills, Thomas E. and Ichihara, Nao and Jayakumar, Devachandran and Kanji, Salmaan and Khoso, Muhammad Nasir and Lawler, Patrick R. and Lewis, Roger J. and Litton, Edward and Marshall, John C. and McAuley, Daniel F. and McGlothlin, Anna and McGuinness, Shay P. and McQuilten, Zoe K. and McVerry, Bryan J. and Murthy, Srinivas and Parke, Rachael L. and Parker, Jane C. and Reyes, Luis Felipe and Rowan, Kathryn M. and Saito, Hiroki and Salahuddin, Nawal and Santos, Marlene S. and Saunders, Christina T. and Seymour, Christopher W. and Shankar-Hari, Manu and Tolppa, Timo and Trapani, Tony and Turgeon, Alexis F. and Turner, Anne M. and Udy, Andrew A. and van de Veerdonk, Frank L. and Zarychanski, Ryan and Lamontagne, François},
	month = nov,
	year = {2023},
	pmid = {37877585},
	pmcid = {PMC10600726},
	keywords = {Ascorbic Acid, Bayes Theorem, COVID-19, Critical Illness, Female, Hospital Mortality, Humans, Male, Middle Aged, Randomized Controlled Trials as Topic, Sepsis, Vitamins},
	pages = {1745--1759},
}
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