Evaluation of the efficacy and safety of recombinant erythropoietin on the improvement of hospitalised COVID-19 patients: A structured summary of a study protocol for a randomised controlled trial

Objectives To evaluate the effect of recombinant erythropoietin on hospitalised COVID-19 patients. Trial design Concealed, randomized, single-blinded, phase 2 controlled clinical trial with two arm parallel-group design of 20 patients allocated with 1:1 ratio and using the placebo in the control group. Participants This study will be performed at Shahid Mohammadi Hospital in Bandar Abbas, Hormozgan in Iran. All positive (PCR confirmed) COVID-19 patients ≤65 years old who have Hb≤9 and at least one of the severe COVID-19 symptoms (tachypnea (breathing rate> 30 beats per minute), hypoxemia (O2 ≤93 saturation, the partial pressure ratio of arterial oxygen <300), Lung infiltration (> 50% of lung field within 24 to 48 hours), progressive lymphopenia, LDH>245 U/I, CRP>100) and are willing to cooperate in this project will be included in the study. Patients with a history of coronary heart disease, thrombosis, deep vein thrombosis, chronic lung disease, diabetes mellitus, weakened immune system, end-stage renal disease, liver disease, and patients with a history of taking oral contraceptive pills, systolic blood pressure more than 160 mm Hg, diastolic blood pressure more than 90 mm Hg and age over 65 and erythropoietin above 500 are excluded. Intervention and comparator Patients will receive the standard of care (SOC) based on the treatment protocols of the Iranian National Committee of COVID-19 and recombinant erythropoietin (EPREX Manufactured by Johnson and Johnson Pharmaceutical Company) 300 units / Kg or 4000IU as subcutaneous (SQ) injection three times a day for 5 days and simultaneously Enoxaparin 1 mg/kg SQ daily is also taken to prevent thrombosis in the intervention group. Patients' blood pressure, along with other vital signs, are checked regularly and at regular intervals. In the control group, patients received SOC and the placebo (distilled water) is given as a subcutaneous injection three times a day for 5 days. We use sterile water for injection (EXIRpharmaceutical company) as the placebo. To the same appearance of the placebo and the recombinant erythropoietin, they are taken in a separate room in the same size syringes and cover with labels before injection. Main outcomes The main outcome for this study is a composite endpoint for Patient clinical symptoms (Respiratory rate, Oxygen saturation state and arterial oxygen partial pressure ratio, Lung infiltration status, blood pressure), Laboratory tests (LDH, CRP, Lymphocyte count, Endogenous erythropoietin, and Haemoglobin level). All of these will be assessed at the beginning of the study (before the intervention) and day 5 after the intervention. The study will also evaluate side effects and how to manage them. Randomisation Eligible participants (20) will be randomized in two arms in the ratio of 1: 1 (10 per arm) by permuted block randomization method using online web-based tools. Blinding (masking) 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 20 patients will participate in this study, who are randomly allocated to the 2 arms with a 1:1 ratio; 10 patients in the intervention group will receive SOC and recombinant erythropoietin, and 10 patients in the control group will receive SOC and placebo. Trial Status The protocol version is 3.0, approved by the Deputy of Research and Technology and the ethics committee of Hormozgan University of Medical Sciences on 6th June 2020, with the local grant number of 990108. The expected recruitment end date was on 21th December 2020 but since we had a wide and careful exclusion criteria because of the adverse reactions of the medication, the recruitment (for both cases and controls) was not so easy and did not finish on the expected date and we are still recruiting now. Recruitment began on 17th August 2020 and the updated expected recruitment end date is 1st August 2021. Trial registration The protocol was registered before starting subject recruitment under the title: Evaluation of the effect of recombinant erythropoietin on the improvement of COVID-19 patients, IRCT20200509047364N1, at Iranian Registry of clinical trials (https://en.irct.ir/trial/49282) on 2020/08/09. 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/s13063-021-05363-w.


Intervention and comparator
Patients will receive the standard of care (SOC) based on the treatment protocols of the Iranian National Committee of COVID-19 and recombinant erythropoietin (EPREX Manufactured by Johnson and Johnson Pharmaceutical Company) 300 units / Kg or 4000IU as subcutaneous (SQ) injection three times a day for 5 days and simultaneously Enoxaparin 1 mg/kg SQ daily is also taken to prevent thrombosis in the intervention group. Patients' blood pressure, along with other vital signs, are checked regularly and at regular intervals. In the control group, patients received SOC and the placebo (distilled water) is given as a subcutaneous injection three times a day for 5 days We use sterile water for injection (EXIR pharmaceutical company) as the placebo. To the same appearance of the placebo and the recombinant erythropoietin, they are taken in a separate room in the same size syringes and cover with labels before injection.

Main outcomes
The main outcome for this study is a composite endpoint for Patient clinical symptoms(Respiratory rate, Oxygen saturation state and arterial oxygen partial pressure ratio, Lung infiltration status, blood pressure), Laboratory tests (LDH, CRP, Lymphocyte count, Endogenous erythropoietin, and Haemoglobin level). All of these will be assessed at the beginning of the study (before the intervention) and day 5 after the intervention. The study will also evaluate side effects and how to manage them.

Randomisation
Eligible participants (20) will be randomized in two arms in the ratio of 1: 1 (10 per arm) by permuted block randomization method using online web-based tools.Blinding (masking) 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 20 patients will participate in this study, who are randomly allocated to the 2 arms with a 1:1 ratio; 10 patients in the intervention group will receive SOC and recombinant erythropoietin, and 10 patients in the control group will receive SOC and placebo.

Trial Status
The protocol version is 3.0, approved by the Deputy of Research and Technology and the ethics committee of Hormozgan University of Medical Sciences on 6th June 2020, with the local grant number of 990108. The expected recruitment end date was on 21th December 2020 but since we had a wide and careful exclusion criteria because of the adverse reactions of the medication, the recruitment (for both cases and controls) was not so easy and did not finish on the expected date and we are still recruiting now. Recruitment began on 17th August 2020 and the updated expected recruitment end date is 1st August 2021.

Trial registration
The protocol was registered before starting subject recruitment under the title: Evaluation of the effect of recombinant erythropoietin on the improvement of COVID-19 patients, IRCT20200509047364N1, at Iranian Registry of clinical trials (https://en.irct.ir/trial/49282) on 2020/08/09.

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). Keywords COVID-19, Randomised controlled trial, protocol, recombinant erythropoietin, erythropoietin Phase 2.

Ethics approval and consent to participate
The protocol was approved by the ethics committee of Hormozgan University of Medical Sciences on 2020/06/06, with the code IR.HUMS.REC.1399.165. The authors authenticate that this trial has received ethical approval from the appropriate ethical committee as described above. Written prospective informed consent will be obtained from participants before involvement in the trial in the Persian language. Consent for publication Not applicable Availability of data and materials The researchers in this study have not yet made a comprehensive decision to share information.

Competing interests
The authors declare that they have no competing interests Funding This trial is supported by the Deputy of Research and Technology of Hormozgan University of Medical Sciences. This sponsor and founder has no role in designing the study, collection, storage, and analysis of information and in preparing the manuscript. Authors' contributions MKJ is the Chief Investigator; she conceived the study, led the proposal and protocol development. HRS contributed to study design and to development of the proposal. MA was the lead trial methodologist. DH collaborated in designing the study and writing the reports. MHA, MH, MA, have contributed to the data collection. All authors read and approved the final manuscript.

Study aim
This study aims to investigate the effect of recombinant erythropoietin on the recovery process of COVID-19 patients. Design concealed, randomized, single blinded, phase 2 controlled clinical trial with two arm parallel group design of 20 patients, using the placebo in the control group.

Settings and conduct
This study will be performed at Shahid Mohammadi Hospital in Bandar Abbas. Patients enter the study after obtaining written consent, but will not know which group they belong to.

Participants/Inclusion and exclusion criteria
All positive COVID-19 patients who have Hb≤9 and at least one of the severe COVID-19 symptoms and are willing to cooperate in this project will be included in the study. Patients with a history of coronary heart disease, thrombosis, deep vein thrombosis, chronic lung disease, diabetes mellitus, weakened immune system, end stage renal disease, liver disease, and patients with a history of taking oral contraceptive pills, systolic blood pressure more than 160 mm Hg, diastolic blood pressure more than 90 mm Hg and age over 65 and erythropoietin above 500 are excluded.

Intervention groups
Patients are divided into two groups. In group A, the standard treatment for COVID-19 patients with recombinant erythropoietin is prescribed. In group B, patients receive standard COVID-19 treatment with the placebo.

Main outcome variables
Patient clinical symptoms, Laboratory examinations of patients and Hemoglobin

Sample size
Target sample size: 20

Randomization description
Before assigning groups to individuals eligible to participate in the study, informed consent is completed for grouping individuals. the person who has no role in admitting patients and assigning patients to random codes preparing random sequences using online tools (https://www.sealedenvelope.com/) and by permuted block randomization method. Individualized random allocation is done in blocks with sizes 2 and 4, and with stratification based on gender. eligibility criteria are monitored by the person responsible for admitting patients. Codes in a random sequence are assigned to patients by the treatment team without knowing that each code is in the intervention or placebo group. Patient codes are then matched to randomly generated sequence information for interventions. (randomization concealment is done by the treatment team without informing the person responsible for admitting patients and the person who prepared the random sequence.)

Blinding description
In this study, all participants are aware of participating in this study and enter the study with their consent. All participants are unaware of which group of this study they are in and after grouping patients in the groups, Patients receive recombinant erythropoietin in the treatment group and receive a placebo in the control group. The lead researcher, health care personnel, data collection officials, and those who evaluate the outcome are aware of the grouping of patients. Those who prepare the draft of the article are unaware of the groupings if they do not cooperate in the above cases.

Respiratory rate Timepoint
At the beginning of the study (before the intervention) and day 5 after the intervention

Method of measurement
Pulse oximeter

Description
Oxygen saturation state and arterial oxygen partial pressure ratio Timepoint At the beginning of the study (before the intervention) and day 5 after the intervention

Method of measurement
Pulse oximeter

Lung infiltration status Timepoint
At the beginning of the study (before the intervention) and day 5 after the intervention Method of measurement chest x-ray 4 Description

LDH level's Timepoint
At the beginning of the study (before the intervention) and day 5 after the intervention Method of measurement pathobiology laboratory

CRP level's Timepoint
At the beginning of the study (before the intervention) and day 5 after the intervention Method of measurement pathobiology laboratory

Lymphocyte count Timepoint
At the beginning of the study (before the intervention) and day 5 after the intervention Method of measurement pathobiology laboratory

Endogenous erythropoietin level's Timepoint
Beginning of study (before intervention)

Method of measurement
Pathobiology laboratory

Description
Patients' blood pressure Timepoint At the beginning of the study (before the intervention), during the intervention (5-day erythropoietin administration)

Secondary outcomes 1 Description
Patients' blood hemoglobin levels Timepoint Start of study (before the intervention), day 5 after the intervention and 2 to 4 weeks after the intervention

Method of measurement
Pathobiology laboratory

Intervention groups 1 Description
Intervention group: Group A.: The standard drug treatment is based on the treatment protocols of the National Committee of COVID-19 and erythropoietin recombinant (EPREX Manufactured by Johnson and Johnson Pharmaceutical Company) 300 units / Kg or 4000IU as subcutaneous injection five times a day for 5 days and simultaneously Enoxaparin 1mg / kg SQ daily is also taken to prevent thrombosis. Patients' blood pressure, along with other vital signs, is checked regularly and at regular intervals. Standard drug treatment according to the treatment protocols of the National Committee for COVID-19 includes Hydroxychloroquine / Chloroquine Phosphate:• Hydroxychloroquine sulfate tablets 200 mg or chloroquine phosphate tablets 250 mg (equivalent to 150 mg base dose) 2 tablets every 12 hours on the first day and then one tablet every 12 hours for at least 7 days and up to 14 days. One of the following medications at the discretion and diagnosis of the treating physician:• Caltrate tablets (Lopinavir / Ritonavir) 50/200 mg every 12 hours 2 pieces after meals for at least 7 days and a maximum of 14 days• Tablets (Atazanavir / Ritonavir) 300/100 One tablet daily with food or Atazanavir 400 mg daily for at least 7 days and up to 14 days Category