The efficacy of N-Acetylcysteine in severe COVID-19 patients: A structured summary of a study protocol for a randomised controlled trial

Objectives Severe acute respiratory infection (SARI) caused by the SARS-CoV-2 virus may cause lung failure and the need for mechanical ventilation. Infection with SARS-COV-2 can lead to activation of inflammatory factors, increased reactive oxygen species, and cell damage. In addition to mucolytic effects, N-Acetylcysteine has antioxidant effects that we believe can help patients recover. In this study, we evaluate the efficacy of N-Acetylcysteine in patients with severe COVID-19. Trial design This is a prospective, randomized, single-blinded, phase 3 controlled clinical trial with two arms (ratio 1:1) parallel-group design of 40 patients, using the placebo in the control group. Participants All severe COVID-19 patients with at least one of the following five conditions: (respiration rate > 30 per minute), hypoxemia (O2 ≤ saturation, arterial oxygen partial pressure ratio <300), pulmonary infiltration (> 50% of lung area during 24 48 h), Lactate dehydrogenase (LDH) > 245 U / l, Progressive lymphopenia, and admitted to the intensive care unit of Shahid Mohammadi Hospital in Bandar Abbas and have positive PCR test results for SARS-Cov-2 and sign the written consent of the study will be included. Patients will be excluded from the study if they have a history of hypersensitivity to N-Acetylcysteine, pregnancy, or refuse to participate in the study. Intervention and comparator After randomization, participants in the intervention group receive standard of care (SOC) according to the National Committee of COVID-19 plus N-acetylcysteine (EXI-NACE 200mg/mL, in 10mL ampules of saline for parenteral injection (EXIR pharmaceutical company)) at a dose of 300 mg/kg equivalent to 20 gr as a slow single intravenous injection on the first day of hospitalization. In the control group patients receive SOC and placebo ( Sterile water for injection as the same dose). The placebo is identical in appearance to the N-acetylcysteine injection (EXIR pharmaceutical company as well). Main outcomes The primary endpoint for this study is a composite endpoint for the length of hospitalization in the intensive care unit and the patient's clinical condition. These outcomes were measured at the baseline (before the intervention) and on the 14th day after the intervention or on the discharge day. Randomisation Eligible participants (40) will be randomized in two arms in the ratio of 1: 1 (20 per arm) using online web-based tools and by permuted block randomization method. To ensure randomization concealment, random sequence codes are assigned to patients by the treatment team at the time of admission without knowing that each code is in the intervention or comparator group. Blinding (masking) All participants will be informed about participating in the study and the possible side effects of medication and placebo. Patients participating in the study will not be aware of the assignment to the intervention or control group. The principal investigator, health care personnel, data collectors, and those evaluating the outcome are aware of patient grouping. Numbers to be randomised (sample size) A total of 40 patients participate in this study, which are randomly divided; 20 patients in the intervention group will receive SOC and N-acetylcysteine, 20 patients in the control group will receive SOC and placebo. Trial status First version of the protocol was approved by the Deputy of Research and Technology and the ethics committee of Hormozgan University of Medical Sciences on February 14, 2021, with the local code 990573, and the recruitment started on March 2, 2021 and the expected recruitment end date is April 1, 2021. Trial registration The protocol was registered before starting participant recruitment entitled: Evaluation of the efficacy of N-Acetylcysteine in severe COVID-19 patients: a randomized controlled phase III clinical trial, IRCT20200509047364N3, at Iranian Registry of clinical trials on 20 February 2021. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2). Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05242-4.

according to the National Committee of COVID-19 plus N-acetylcysteine (Exi-Nac 2g / 10ml 23 AMP (EXIR pharmaceutical company)) at a dose of 300 mg/kg equivalent to 20 gr as a slow 24 single intravenous injection on the first day of hospitalization. in the control group patients 25 receive SOC and placebo as the same dose.

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Main outcomes 27 The primary endpoint for this study is a composite endpoint for the length of hospitalization in 28 the intensive care unit and the patient's clinical condition. These outcomes were measured at the 29 baseline (before the intervention) and on the 14th day after the intervention or on the discharge 30 day.

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Eligible participants (40) will be randomized in two arms in the ratio of 1: 1 (20 per arm) using 33 online web-based tools and by permuted block randomization method. To ensure randomization 34 concealment, random sequence codes are assigned to patients by the treatment team at the time 35 of admission without knowing that each code is in the intervention or comparator group.

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Blinding (masking) 37 All participants will be informed about participating in the study and the possible side effects of 38 medication and placebo. Patients participating in the study will not be aware of the assignment to 39 3 the intervention or control group. The principal investigator, health care personnel, data 40 collectors, and those evaluating the outcome are aware of patient grouping.

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Numbers to be randomised (sample size) 42 A total of 40 patients participate in this study, which are randomly divided; 20 patients in the 43 intervention group will receive SOC and N-acetylcysteine, 20 patients in the control group will 44 receive SOC and placebo. Also, vascular smooth muscle cells in tissue culture exposed to AngII increase CD40 expression,    Before assigning groups to individuals eligible to participate in the study, informed consent is 94 completed for grouping individuals. the person who has no role in admitting patients and 95 assigning patients to random codes preparing random sequences using online tools 96 (https://www.sealedenvelope.com/) and by permuted block randomization method.

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Individualized random allocation is done in blocks with sizes 2 and 4, and without stratification. In this study, all participants are aware of participating in this study and enter the study with their 106 consent. All participants are unaware of which group of this study they are in and after grouping 107 6 patients in the groups, Patients receive N-Acetylcysteine in the treatment group and receive a 108 placebo in the control group. The lead researcher, health care personnel, data collection officials, 109 and those who evaluate the outcome are aware of the grouping of patients. Those who prepare 110 the draft of the article are unaware of the groupings if they do not cooperate in the above cases.

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Sample size: 112 Due to the lack of previous studies, the sample size of 40 patients who were divided into two 113 groups of ten for intervention and control was used. Whitney will be used to compare the means of quantitative data.

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Chi-square and Fisher's test were used to compare qualitative variables.  The authors confirm that this trial has received ethical approval from the appropriate ethical 174 committee as described above. Written prospective informed consent will be obtained from 175 participants before involvement in the trial in the Persian language.
176 Consent for publication 177 Written informed consent will be obtained from all participants/subject's legally acceptable 178 representatives before inclusion in the trial for collecting data, analysis, storage, and publishing