Boesing 

et al. Trials (2022) 23:790

https://doi.org/10.1186/s13063-022-06723-w

STUDY PROTOCOL Open Access

Inhaled aviptadil for the possible

treatment of COVID‑19 in patients at high risk
for ARDS: study protocol for a randomized,
placebo‑controlled, and multicenter trial
Maria Boesing1,2*   , Kristin Abig1, Michael Brändle3, Martin Brutsche3, Emanuel Burri1, Björn C. Frye4,
Stéphanie Giezendanner1, Jan C. Grutters5,6, Philippe Haas7, Justian Heisler1,2, Fabienne Jaun1,
Anne B. Leuppi‑Taegtmeyer1,8, Giorgia Lüthi‑Corridori1,2, Joachim Müller‑Quernheim4, Reto Nüesch9,
Wolfgang Pohl10, Frank Rassouli3 and Jörg D. Leuppi1,2 

Abstract 
Background:  Despite the fast establishment of new therapeutic agents in the management of COVID-19 and large-
scale vaccination campaigns since the beginning of the SARS-CoV-2 pandemic in early 2020, severe disease courses
still represent a threat, especially to patients with risk factors. This indicates the need for alternative strategies to
prevent respiratory complications like acute respiratory distress syndrome (ARDS) associated with COVID-19. Aviptadil,
a synthetic form of human vasoactive intestinal peptide, might be beneficial for COVID-19 patients at high risk of
developing ARDS because of its ability to influence the regulation of exaggerated pro-inflammatory proteins and
orchestrate the lung homeostasis. Aviptadil has recently been shown to considerably improve the prognosis of ARDS
in COVID-19 when applied intravenously. An inhaled application of aviptadil has the advantages of achieving a higher
concentration in the lung tissue, fast onset of activity, avoiding the hepatic first-pass metabolism, and the reduction of
adverse effects. The overall objective of this project is to assess the efficacy and safety of inhaled aviptadil in patients
hospitalized for COVID-19 at high risk of developing ARDS.
Methods:  This multicenter, placebo-controlled, double-blinded, randomized trial with 132 adult patients hospitalized
for COVID-19 and at high risk for ARDS (adapted early acute lung injury score ≥ 2 points) is conducted in five public
hospitals in Europe. Key exclusion criteria are mechanical ventilation at baseline, need for intensive care at baseline,
and severe hemodynamic instability. Patients are randomly allocated to either inhale 67 μg aviptadil or normal saline
(three times a day for 10 days), in addition to standard care, stratified by center. The primary endpoint is time from
hospitalization to clinical improvement, defined as either hospital discharge, or improvement of at least two levels on
the nine-level scale for clinical status suggested by the World Health Organization.
Discussion:  Treatment strategies for COVID-19 are still limited. In the context of upcoming new variants of SARS-
CoV-2 and possible inefficacy of the available vaccines and antibody therapies, the investigation of alternative
therapy options plays a crucial role in decreasing associated mortality and improving prognosis. Due to its unique

*Correspondence: [email protected]; [email protected]

2
Faculty of Medicine, University of Basel, Klingelbergstrasse 61, CH‑4056 Basel,
Switzerland
Full list of author information is available at the end of the article

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Boesing et al. Trials (2022) 23:790 Page 2 of 13

immunomodulating properties also targeting the SARS-CoV-2 pathways, inhaled aviptadil may have the potential to
prevent ARDS in COVID-19.
Trial registration: ClinicalTrials.gov, NCT04​536350. Registered 02 September 2020.
Keywords:  Aviptadil, VIP, COVID-19, ARDS, SARS-CoV-2

Administrative information Author details {5a} Maria Boesing, University Clinic

Note: the numbers in curly brackets in this protocol refer of Medicine, Cantonal Hospital
Baselland and Faculty of Medicine,
to SPIRIT checklist item numbers. The order of the items University of Basel
has been modified to group similar items (see http://​ Kristin Abig, University Clinic
www.​e quat​or-​netwo​rk.​org/​repor​ting-​guide​lines/​spirit-​ of Medicine, Cantonal Hospital
Baselland
2013-​state​ment-​defin​ing-​stand​ard-​proto​col-​items-​for-​ Michael Brändle, Cantonal Hospital
clini​cal-​trials/). St. Gallen
Martin Brutsche, Cantonal Hospital
St. Gallen
Title {1} Inhaled Aviptadil for the possible Emanuel Burri, University Clinic
treatment of COVID-19 in patients of Medicine, Cantonal Hospital
at high risk for ARDS: A randomized, Baselland
placebo-controlled, and multicentre Björn C. Frye, Department of Pneu‑
trial. mology, Medical Center University
Trial registration {2a and 2b}. ClinicalTrials.gov, NCT04536350 of Freiburg
Registered on ­2nd September 2020 Stéphanie Giezendanner, Uni‑
https://​clini​caltr​ials.​gov/​ct2/​show/​ versity Clinic of Medicine, Cantonal
NCT04​536350 Hospital Baselland
Protocol version {3} 30.06.2022, Version 8 Jan C. Grutters, St. Antonius
Hospital Nieuwegein and Division
Funding {4} This trial is financed by AdVita of Heart & Lungs, University Medical
Lifescience GmbH, Gundelfingen, Center Utrecht
Germany. Philippe Haas, AdVita Lifescience
Co-Investigator Maria Boesing GmbH
receives a personalized research Justian Heisler, University Clinic
grant within the program “Young of Medicine, Cantonal Hospital
talents in clinical research” from the Baselland and Faculty of Medicine,
Swiss Academy of Medical Sciences. University of Basel
Fabienne Jaun, University Clinic
of Medicine, Cantonal Hospital
Baselland
Anne B. Leuppi-Taegtmeyer,
Department of Clinical Pharmacol‑
ogy and Toxicology, University
Hospital Basel and Cantonal Hospital
Baselland
Giorgia Lüthi-Corridori, University
Clinic of Medicine, Cantonal Hospital
Baselland and Faculty of Medicine,
University of Basel
Joachim Müller-Quernheim,
Department of Pneumology, Medi‑
cal Center University of Freiburg
Reto Nüesch, Hospital Schwyz
Wolfgang Pohl, Karl Landsteiner
Institute for Clinical and Experimen‑
tal Pneumology, Clinic Hietzing
Frank Rassouli, Cantonal Hospital
St. Gallen,
Jörg D. Leuppi, University Clinic
of Medicine, Cantonal Hospital
Baselland and Faculty of Medicine,
University of Basel
 Boesing et al. Trials (2022) 23:790 Page 3 of 13

Name and contact information for Prof. Jörg D. Leuppi, MD, PhD in reducing hospitalization risk and mortality till late
the trial sponsor {5b} Clinical Professor of Internal Medi‑ 2021 but proved to have no benefit for the treatment of
cine, University of Basel
Head of the University Clinic of
the emerging omicron variant [15]. At the time of set-
Medicine ting up this study, other approaches like convalescent
Cantonal Hospital Baselland plasma, further antiviral antibodies and other experi-
Rheinstrasse 26
CH-4410 Liestal
mental substances are being investigated [3, 16–18].
Phone: +41-61-925-21-80 Despite the fast establishment and adaptation of rec-
E-Mail: joerg.​leuppi@​ksbl.​ch ommendations for the clinical management of COVID-
Role of sponsor {5c} Professor Jörg D. Leuppi and his 19, as well as large-scale vaccination campaigns, severe
research team composed this study
protocol together with collaborat‑
disease-courses still represent a threat, especially to
ing partners. The study is conducted patients with risk factors such as old age, arterial hyper-
under the supervision of Jörg D. tension, or diabetes mellitus [19]. This indicates the
Leuppi.
Jörg D. Leuppi and his research
need for alternative strategies to prevent and amelio-
team are responsible for all submis‑ rate respiratory complications associated with COVID-
sions to relevant local authorities in 19, in order to effectively prevent intensive care (ICU)
order to obtain study approval. Prof.
Leuppi is involved and has ultimate
admissions and reduce mortality.
authority in every step of this study, The results of the RECOVERY trial indicate that an
including data collection, manage‑ excessive inflammatory reaction plays an important
ment, and analysis, interpretation
of results, as well as composition of
role in the pathophysiology of severe COVID-19 and
scientific reports and their submis‑ the progression to ARDS [2]. In fact, severe cases of
sion for publication. COVID-19 are associated with elevated serum levels of
AdVita Lifescience GmbH provides
financial means for the conduction
pro-inflammatory mediators [1, 20, 21]. SARS-CoV-2
of this trial. Associates of AdVita specifically targets the surfactant-producing pulmonary
contribute their experience with the alveolar type II (ATII) cells by binding to their angio-
investigational drug and its inhaled
application.
tensin converting enzyme 2 (ACE2-) receptors and
entering the cell [22]. Viral replication and infection
of adjacent ATII cells then lead to a massive cytokine
Introduction release and, consequently, to apoptosis and a critical
Background and rationale {6a} decrease of surfactant production, which disrupts the
The world has been experiencing an exceptional state, alveolar gas exchange resulting in ARDS [22, 23].
due to the SARS-CoV-2 pandemic. In the beginning of Vasoactive intestinal peptide (VIP), a gut peptide
2020, about 20% of individuals with the SARS-CoV-2 hormone containing 28-residue amino acid peptides,
associated corona virus disease (COVID-19) suffered was discovered and first synthesized in the seven-
from a severe course, characterized by significant res- ties [24–26]. Next to fulfilling various effects in the
piratory symptoms including the potentially lethal acute nervous, digestive, cardiovascular, respiratory, and
respiratory distress syndrome (ARDS) [1]. Since then, reproductive systems, VIP is physiologically highly
numerous studies have been initiated in order to evalu- localized in the lungs [27, 28]. There, it binds with
ate therapeutic agents for the treatment of COVID-19. ATII cells via the VPAC1 receptor, the same cell type
To date, an improved outcome in hospitalized patients to which the SARS-CoV-2 virus binds via the ACE2-
has been shown in randomized controlled trials for anti- receptor [22, 27]. When VIP binds to the ATII-cells,
cytokine monoclonal antibodies (tocilizumab), Janus it inhibits NMDA-induced caspase-3 activity inside
kinase inhibitors (baricitinib), and dexamethasone [2–4], the cell, which in turn decreases production of the
which is reflected in current treatment recommendations pro-inflammatory cytokines interleukin-6 and TNF-
by national and international health organizations and alpha [29–33]. It has been proposed as a modulator
societies [5–8]. of lung inflammation and airway constriction [25, 26,
Further available therapy options for early out- 34], and its protective effects on pulmonary tissue
patient treatment in high-risk patients include the have been shown in numerous animal models of lung
monoclonal antibodies sotrovimab and bebtelovimab, injury in rats, guinea pigs, dogs, and sheep [35–37].
antiviral substances remdesivir, nirmatrelvir/rito- VIP was also shown to increase surfactant produc-
navir, and molnupiravir, as well as inhaled corticos- tion by upregulation of choline phosphate cytidylyl-
teroid budesonide and serotonin reuptake inhibitor transferase and C-Fos protein expression in ATII cells
fluvoxamine [9–14]. The monoclonal antibody com- [38–40]. Recent data demonstrated that plasma levels
bination casirivimab/imdevimab had been effective of VIP are higher in patients with severe COVID-19,
Boesing et al. Trials (2022) 23:790 Page 4 of 13

compared to healthy individuals and those with mild Objectives {7}

COVID-19 [41, 42], and that VIP can block SARS- The primary objective of this trial is to investigate the
CoV-2 virus replication in vitro [32]. efficacy and safety of inhaled aviptadil in hospitalized
Aviptadil, a synthetic form of VIP, might prevent COVID-19 patients at high risk for developing ARDS.
COVID-19 patients from developing ARDS due to the The study will assess whether patients with COVID-
above described anti-inflammatory properties. The 19 under high risk for developing ARDS recover faster
presumed primary therapeutic mechanism of action when they receive inhaled aviptadil in addition to
of inhaled aviptadil is a combination of anti-inflamma- standard care, compared to patients receiving standard
tory properties and induction of tolerogenic immune care only. A secondary objective is the investigation of
response of immune cells localized in the lungs [43, the overall course of disease under inhaled aviptadil in
44]. It has been shown to reduce interferon produc- terms of need for mechanical ventilation, time requiring
ing T cells, to dampen Th17-T-cells and to promote oxygen supplementation, infection-related biomarkers,
regulatory T-cells [43, 45, 46]. These immune-damp- and subjective severity of symptoms. The safety objec-
ening effects have been previously described to occur tive is to assess any potential harm of inhaled aviptadil.
in the alveolar compartment of sarcoidosis patients
after inhalation of aviptadil, which demonstrates that
Trial design {8}
its local application by inhalation is feasible and results
This study is a multicenter, placebo-controlled, dou-
in relevant immunological changes [43]. There is fur-
ble-blinded, randomized phase II trial with 132 adult
ther promising evidence from a case report of a patient
patients. In a parallel group design, patients will be ran-
with pneumonitis resulting from check-point-inhibitor
domly allocated in a 1:1 ratio to inhale either aviptadil
therapy for melanoma, in which the administration of
(67 μg three times a day) or normal saline (1 ml three
inhaled aviptadil was well tolerated and led to damp-
times a day) for 10 days, or until hospital discharge, in
ening of alveolar inflammation, radiological and clini-
addition to standard care. The study is conducted as a
cal improvement [47].
superiority trial.
To date, there is no clinical evidence for the efficacy
of inhaled aviptadil in COVID-19. However, it was
recently observed in vitro that VIP can inhibit SARS- Public and patient involvement in the design of this
CoV-2 replication and reduce cellular proinflamma- protocol
tory cytokine production [32]. Two phase II trials have Due to the novelty of the disease under investigation
been announced recently on the US National Library and the prevalent time pressure in the design phase of
of Medicine platform “ClinicalTrials.gov” (COVID- the trial, patient and public involvement in the design
AIV (NCT04311697), AVICOVID-2 (NCT04360096)), of this protocol was not applied.
which investigate aviptadil in patients with COVID-
19 in the USA. Preliminary results of the COVID- Methods: participants, interventions,
AIV trial, which has been recruiting patients with and outcomes
COVID-19 and respiratory failure, indicate a promis- Study setting {9}
ing antiviral effect of the intravenous administration Recruitment of hospitalized patients takes place at the
of aviptadil [42]. In contrast, this current trial inves- Cantonal Hospitals of Liestal and St. Gallen and the
tigates the inhaled application of aviptadil in an ear- Hospital Schwyz in Switzerland, as well as the Clinic
lier stage of disease, in patients at increased risk for Hietzing, Vienna in Austria and the Antonius Hospital
ARDS. Inhaled aviptadil likely circumvents several Nieuwegein in the Netherlands between May 2021 and
potential side effects, like hypotension and tachycar- December 2022 (estimated).
dia [43, 47].
Daily doses of up to 300 μg inhaled aviptadil have
been shown to be safe in phase II trials for the treat- Eligibility criteria {10}
ment of sarcoidosis and pulmonary hypertension, as Hospitalized patients with diagnosed COVID-19 are
well as in a recently published phase I trial in the treat- asked to take part in this study when the following eli-
ment of ARDS [43, 48–50]. Aviptadil has been given gibility criteria are fulfilled:

▪ SARS-CoV-2 infection, verified according to cur-

Orphan Drug Designation in the European Union and
the USA for the treatment of ARDS and the inhaled

▪ High risk for the development of ARDS:

application has been observed to be safe without rent in-house guidelines
severe side effects [43, 47, 51].
 Boesing et al. Trials (2022) 23:790 Page 5 of 13

i.e., within 24 h before inclusion at least 2 the trial and ask for written consent by signature on
points on an adapted EALI (early acute lung the informed consent form. Each potential participant
injury) score, with at least one point from the orig- will be informed that participation in the trial is vol-
inal EALI score [52, 53] untary that he/she may withdraw from the study at any
time with no need of justification and that withdrawal
– Original EALI score: of consent will not affect his/her subsequent medi-
cal assistance and treatment. Consent or assent from
◦ 2–6 l ­O2 supplementation to achieve a ­SaO2 > 90%: authorized surrogates is not intended, patients who are
1 point not able to understand the trial or sign the informed
◦ > 6 l ­ O2 supplementation to achieve a consent form of their own accord are excluded from
­SaO2 > 90%: 2 points participation.
◦ Respiratory rate ≥ 30/min: 1 point
◦ Immunosuppression: 1 point
Additional consent provisions for collection and use
– Modification adapting for risk factors for ARDS in of participant data and biological specimens {26b}
COVID-19 affected patients [54] Additional collection and use of participant data and bio-
logical specimens are not intended.
◦ Arterial hypertension: 1 point
◦ Diabetes: 1 point
◦ Fever > 39 °C: 1 point Interventions

▪ Age ≥ 18 years
Explanation for the choice of comparators {6b}

▪ Ability to comply with the inhalation maneuver

Due to the novelty of the investigated disease COVID-

▪ Ability to understand the clinical trial and sign the

19, global guidelines or a clear definition of standard care
are not available at the time of implementation of the
informed consent study. Additionally, standard treatment strategies may
change during the study period in accordance with new
The presence of any of the following exclusion criteria research findings. At each study center, there are internal
will lead to exclusion of the patient: written guidelines for the clinical management of hospi-

▪ Mechanical ventilation or intensive care treatment

talized COVID-19 patients, depending on the severity
of the case. At the time of implementation of the study,

▪ Nasal high-flow cannula or continuous positive

within current hospitalization elements of the standard care used in the participating
study centers include oxygen therapy, systemic glucocor-
airway pressure (cPAP) ventilation at time of inclu- ticoids, remdesivir, tocilizumab, nutritive measures, and

▪ Inability to conduct inhalation therapy

sion prevention and management of ARDS, bacterial super-

▪ Hemodynamic instability with requirement of

infections, and sepsis, as well as thrombembolic, neuro-
logic, cardiac, and renal complications. Since there is no

▪ Severe comorbidities interfering with the safe par-

vasopressor therapy clear definition of standard care to date, the only ethically
justifiable comparator is the best available care, which

▪ Previous participation in this trial, or current par-

ticipation according to the treating physician is adapted throughout the trial according to the current
state of research.

▪ Pregnancy
ticipation in another interventional study

▪ Systemic immunosuppression for chronic under-

Intervention description {11a}
Patients in the intervention group inhale 1 ml aviptadil
lying condition (corticosteroid treatment as part of solution (67 μg/ml) three times a day (morning, noon,
“standard care” allowed) evening), while participants in the control group inhale
1 ml of NaCl 0.9% three times a day. In both groups, the
“Drop-out” is defined as the patient’s withdrawal of respective treatment is given in addition to standard care
consent at any time after inclusion into the study. and lasts for 10 days, or until hospital discharge, which-

M-neb® dose+mesh nebulizer MN-300/8 in both study

ever occurs first. The study drug is administered with the
Who will take informed consent? {26a}
After a patient is identified as a potential participant, groups, and each application will approximately last for
a Good Clinical Practice (GCP)-trained physician from 10 min.
the study team will inform the patient personally about
Boesing et al. Trials (2022) 23:790 Page 6 of 13

Criteria for discontinuing or modifying allocated Provisions for ancillary and post‑trial care {30}

interventions {11b} Patients are carefully monitored until discharge from the
Dose or device modifications are not intended. If clini- hospital and followed-up until four weeks after inclusion.
cally indicated, treating doctors can stop the treatment Necessary aftercare is organized by treating physicians
with the study drug. Participants are given the possi- independently of this trial. No additional specific ancil-
bility to withdraw from the study at any time. Treating lary and post-trial care is planned. Despite the efforts
physicians can independently decide about additional of the research team to mitigate risks associated with
treatment options and concomitant medication can be the intervention, potential small harms may occur. Any
re-evaluated and changed at any time of this trial. A ter- potential damage or harm to participants in connection
mination of the supplementation is reported to the coor- with this trial is covered by the obligatory trial insurance.
dinating study center immediately.
Outcomes {12}
The primary endpoint is time to clinical improvement up to
Strategies to improve adherence to interventions {11c}
day 28, defined as the time (in days) from randomization to
All participants are hospitalized and medication is
the decrease of at least two levels on the WHO-suggested
administered by qualified ward personnel. Ward person-
nine-level ordinal scale (see Table 1) [55] or alive discharge
nel is responsible that participating patients receive the
from hospital, whichever occurs first. This standardized
study medication in a correct manner and each admin-
primary endpoint allows comparison with other efficacy
istration will be documented in the patient records. Any
studies in the context of the treatment of COVID-19.
complication or non-adherence with the administration
Key secondary endpoints are:
is reported as a note to file.
▪ Need for mechanical ventilation, non-invasive ven-

▪ Occurrence of multi organ dysfunction syndrome

Relevant concomitant care permitted or prohibited tilation, and intensive care during hospitalization
during the trial {11d}

▪ Number of days requiring oxygen supplementation

All treatments considered necessary by treating doc- during hospitalization

▪ Change from baseline to discharge of the following

tors are permitted and their use is recorded in the case
report form. Because inhaled aviptadil does not reach
the systemic circulation and is mainly metabolized in the biomarkers in patients’ blood samples
lung, pharmacokinetic interactions with aviptadil are not
expected. In order to account for potential bias, we aim ◦ C-reactive protein (CRP)
to analyze data from patients, who received potentially ◦ Neutrophil-lymphocyte ratio
biasing concomitant treatment (e.g., immunosuppres- ◦ Interleukin-6
sants or immunomodulators) in an adjusted manner (see ◦ Procalcitonin

▪ Change from baseline to follow-up in patient-reported

Statistical methods for primary and secondary outcomes
{20a}).
dyspnea, cough, and fatigue on a visual analog scale

Table 1  WHO-Ordinal scale for clinical improvement

Patient state Descriptor Score

Uninfected No clinical or virological evidence of infection 0

Ambulatory No limitation of activities 1
Limitation of activities 2
Hospitalized: mild disease Hospitalized, no oxygen therapy 3
Oxygen by mask or nasal prongs 4
Hospitalized: severe disease Non-invasive ventilation or high-flow oxygen 5
Intubation and mechanical ventilation 6
Ventilation + additional organ support – pressors, RRT, ECMO 7
Dead Death 8
From: WHO R&D Blueprint, Novel Coronavirus COVID-19 Therapeutic Trial Synopsis [55]
RRT​renal replacement therapy, ECMO extracorporeal membrane oxygenation
Boesing et al.
Trials (2022) 23:790 Page 7 of 13

▪ Patient-reported impact on health by 12-item Short patients in the experimental group will show a 1.75-
Form Survey version 2 (SF-12v2) at follow-up fold hazard to have a clinical improvement as com-
pared to patients in the control group (hazard ratio
Other clinical endpoints include the length of hospital (HR) = 1.75) [42, 50]. Furthermore, based on previ-
stay until discharge or death (in days) and mortality rate. ously published results for current standard care,
CRP, interleukin-6, and procalcitonin are measured at we assume an overall probability of 80% for reaching
baseline, at least every seven days, and at discharge. The the primary endpoint (clinical improvement) within
safety endpoints adverse events (AEs), including those 28 days (d = 0.8) [56, 57]. Group allocation shall be
leading to discontinuation of treatment, serious adverse divided equally ( 12 n = n1 = n2).
events (SAEs), and death are also reported. Testing for two-sided equality in a Cox proportional
hazards model at a significance level of α = 0.05 and
aimed power of 80% (β = 0.2), we are applying the sam-
Participant timeline {13} ple-size formula in Chow as follows [58]:
The participant timeline is exhibited in Fig. 1. 2
zα/2 + zβ (1.96 + 0.84)2
n= 2 = ≈ 125.2
Sample size {14} b ∗ 0.25 ∗ d log2 (1.75) ∗ 0.25 ∗ 0.8
Based on the effect of aviptadil in previous trials
described in the introductory section, we assume that

Fig. 1  Participant timeline. Asterisk symbol (*) indicates the following: if hospital discharge occurs first, intervention is stopped at discharge.
Superscript digit one (1) indicates the following: demographics, clinical status according to nine-level ordinal scale, medical history, smoking status,
COVID-19 symptoms, and COVID-19 vaccination status. Superscript digit two (2) indicates the following: C-reactive protein, neutrophil-lymphocyte
ratio, interleukin-6, and procalcitonin. Superscript digit three (3) indicates the following: on a visual analog scale from 0 to 10. Superscript digit four
(4) indicates the following: Clinical status on nine-level ordinal scale, admission to ICU, ventilation, mortality, complications. MRC, Medical Research
Council dyspnea scale; SF-12v2, 12-item Short Form Survey version 2
Boesing et al. Trials (2022) 23:790 Page 8 of 13

where b =  log (HR) =  log (1.75). the study and hand out the kits containing the study drug
Estimating a drop-out rate of 3% and considering block in the order of the assigned kit numbers. Group assign-
randomization, we aim to include 132 patients into the ment is pre-defined by order of the kit numbers and the
study. content of the respective kit.

Recruitment {15} Assignment of interventions: blinding

All hospitalized patients at a study center who fulfill the Who will be blinded {17a}
eligibility criteria are asked to take part in this study. In Trial participants, investigators, treating physicians,
order to reach the target sample size within the planned study personnel administering the inhalation, and
time frame, the study is geographically expanded to sev- data analysts are blinded to group allocation. Since the
eral centers within Europe. study drug is filled into identically looking vials and avi-
ptadil solution and placebo are not visually distinguish-
Assignment of interventions: allocation able, blinding is ensured until unblinding procedures are
Sequence generation {16a} actively undertaken.
The group-allocating randomization code is a computer-
generated sequence, using block randomization with Procedure for unblinding if needed {17b}
block size of four. Each block determines assignment of If a treating physician of a participating patient needs to
four patients to the two groups, while two patients are know for medical reasons (i.e., AE, SAE), if the patient
assigned to the intervention group and two patients are is assigned to the interventional or control group, he/
assigned to the control group in a random order. Rand- she can call a 24-h phone hotline to receive information
omization is stratified by study center in order to account about the patient’s group allocation. Unblinding is under-
for differences in standard of care. Block randomization taken by a trained study team member, who opens only
also accounts for differences in standard of care accord- the envelope with the respective kit number.
ing to time elapsed since the start of the pandemic.
Data collection and management
Concealment mechanism {16b} Plans for assessment and collection of outcomes {18a}
The entire concealment process is handled in the phar- All required patient data at baseline, during hospitaliza-
macy that produces the study drug. Identically looking tion, at discharge and follow-up are recorded on paper-
vials with doses of either 3 ml aviptadil solution (67 μg/ based case report forms (CRFs). Trained study personnel
ml, experimental group) or 3 ml NaCl 0.9% (placebo at each site transfer the data into a web-based electronic
group) are filled in the pharmacy in a 1:1 ratio. Kits of case report form. A copy of the CRF used in the trial is
10 vials of the same content (one vial per treatment available on reasonable request. Laboratory analyses
day, for a maximum of 10 days) are then packed and comprise only standard parameters and are performed
labeled with a continuous kit number. The actual con- in the accredited in-hospital laboratories at each site.
tent of each kit (aviptadil or placebo) is determined by Patient dyspnea is assessed at inclusion and follow-up
the randomization sequence described above, while the by means of the Medical Research Council dyspnea scale
kit number represents the concealed randomization (MRC), which has been studied in a variety of respira-
code. For each kit, the description of the actual content tory conditions, including COVID-19. Patient-reported
(aviptadil or placebo) is packed in a separate concealed outcome is assessed at follow-up by means of the instru-
envelope, with only the kit number visible from the ment SF-12v2, which is a validated survey for investigat-
outside. The respectively allocated kits and concealed ing health-related quality of life in a variety of both acute
envelopes are shipped to the coordinating study center and chronic conditions, including lung diseases.
in Liestal. From here, they are distributed to each study
center and used in the order of the kit number indicated Plans to promote participant retention and complete
on the label. Upon inclusion of a patient, the allocated follow‑up {18b}
kit number is documented in the CRF. The concealed Patients participating in the study do not receive financial
envelopes containing the description of group allocation reimbursement. Expenses for the study medication and
are stored at the coordinating study center in Liestal. diagnostics performed only during this study are covered
by the study budget. The 28-day follow-up is a phone call,
Implementation {16c} initiated by a study team member at the respective study
The entire concealment process is handled in the phar- center. In case of withdrawal of consent or premature ter-
macy that produces the study drug. Study physicians at mination of the study, data and samples are evaluated in
the respective study center will enroll participants into encrypted form until termination of the study.
 Boesing et al. Trials (2022) 23:790 Page 9 of 13

Data management {19} respective unadjusted Cox model. The proportionality

Data acquisition and entry into the web-based and pass- assumption for the Cox proportional hazards models will

Trial®) are performed by trained staff at the participating

word-protected electronic data capture system (Secu- be tested by assessing Schoenfeld residuals.
Treatment effects on binary secondary endpoints will
study centers. Personal contact information, which is be analyzed by means of chi-squared test, or Fisher’s
needed for follow-up phone calls, is stored separately exact test, in case expected sub-group size is smaller than
and only accessible for the staff members executing these five. For discrete secondary endpoints, group differences
phone calls. Any paper documents, such as informed will be assessed using a Poisson or negative binomial
consent forms, are stored in locked cabinets in restricted regression, depending on the underlying distribution.
access areas at the respective participating study cent- Treatment effects on patient-reported severity of symp-
ers. Electronic records are stored on a password-pro- toms will be analyzed with an ordinal logistic regression
tected server. All records are archived for a minimum and an additional longitudinal analysis with cumula-
of 10  years after study termination or premature termi- tive link mixed models. Effects on longitudinal changes
nation of the clinical trial at the respective participating in infection-related biomarkers will be assessed using
study center. A data management plan documents details mixed effect linear regression and analysis of covari-
for the data processing and is available from the authors ance. Patient-reported impact on health at day 28 will be
upon reasonable request. compared between the two groups by means of Student’s
T-test, or Mann-Whitney-U test, depending on normal-
Confidentiality {27} ity of the data.
All collected patient data are treated as confidential and All statistical tests will be performed using two-sided
stored and analyzed in a coded way in accordance with tests at the significance level 0.05. Detailed methodology
data protection principles. Results will be published in for statistical analyses of the data collected in this trial is
anonymized fashion. Direct access to source documents documented in a separate statistical analysis plan (SAP).
is permitted for purposes of monitoring, audits, and The SAP is finalized before database closure and can be
inspections. The study data and protocol shall be acces- obtained from the authors upon reasonable request. A
sible to regulatory authorities for at least ten years after summary of the SAP is provided in Additional file 1.
study termination.
Interim analyses {21b}
Plans for collection, laboratory evaluation, and storage Since a relatively small number of patients is studied dur-
of biological specimens for genetic or molecular analysis ing a short study period (max. 28 days) and the treat-
in this trial/future use {33} ment harm is considered to be very small due to the short
The trial does not involve collecting biological specimens treatment period, we do not consider stopping criteria
for genetic or molecular analysis. nor interim analyses to assess the probability that the
benefit exceeds the clinically important difference.
Statistical methods
Statistical methods for primary and secondary outcomes Methods for additional analyses (e.g., subgroup analyses)
{20a} {20b}
R will be used for all statistical analyses [59]. Primary See Statistical methods for primary and secondary out-
and secondary endpoints will be summarized by group comes {20a}.
using descriptive statistics (mean ± standard deviation
for normally distributed data, median and interquartile Methods in analysis to handle protocol non‑adherence
range for other continuous data, absolute and relative and any statistical methods to handle missing data {20c}
frequencies for categorical data). A log-rank test will be The primary analysis will be done in the intention-to-
used to compare Kaplan-Meier curves for the primary treat population and safety analysis will be done on all
endpoint “time to clinical improvement,” with failure to patients who started their assigned treatment. The time
reach clinical improvement or death before day 28 being to clinical improvement will be assessed after all patients
right-censored at day 28. Sensitivity analyses will be per- will have reached day 28, with failure to reach clinical
formed with “death” and “clinical improvement” as com- improvement or death before day 28 considered as right
peting risks. For potential confounders that are not fully censored at day 28. Careful trial planning and conduct
balanced by randomization, adjusted analyses for the will minimize the occurrence of missing data as far as
primary outcome may be performed using Cox regres- possible. In case of missing data, treating physicians are
sion models to estimate hazard ratios with corresponding contacted with the aim to complete missing data from
two-sided 95% confidence intervals to compare with the patients’ records. No data imputation is planned.
Boesing et al. Trials (2022) 23:790 Page 10 of 13

Plans to give access to the full protocol, participant Plans for communicating important protocol amendments
level‑data and statistical code {31c} to relevant parties (e.g., trial participants, ethical
Further and updated trial information can be found at committees) {25}
www.​Clini​calTr​ials.​gov, NCT04536350. Data and mate- Important protocol modifications are submitted to
rials that support this protocol, such as a detailed data the relevant authorities (ethics commission, local drug
management plan, CRFs and informed consent form are authorities) for approval before implementation. Changes
available from the authors on reasonable request. are communicated to other relevant parties (investiga-
tors, study physicians, study nurses) via E-Mail newslet-
Oversight and monitoring ters and personal phone calls.
Composition of the coordinating center and trial steering
committee {5d} Dissemination plans {31a}
The coordinating study center at the Cantonal Hospital Our aim is to publish the results of this study in a peer-
Baselland, Liestal, Switzerland, consisting of the sponsor- reviewed journal, without the engagement of professional
investigator, co-investigators, study coordinators, study writers.
physicians, study nurses, and study statistician super-
vises and coordinates the study. This includes trial man- Discussion
agement and coordination, statistical, and economic and Our described study protocol presents the design for
data management, as well as organizational support for a randomized controlled trial to investigate the efficacy
participating study centers. It furthermore acts as a trial and safety of inhaled aviptadil in patients hospitalized
steering committee. for COVID-19 at high risk for ARDS. In the context of
upcoming new variants of SARS-CoV-2 and a possi-
Composition of the data monitoring committee, its role ble future endemic state, the investigation of alternative
and reporting structure {21a} therapy options still plays a crucial role in decreasing
The monitoring of this study is performed by the inde- associated mortality and improving prognosis. Due to its
pendent clinical trial unit (CTU) of the University Hos- unique immunomodulating properties specifically tar-
pital Basel, Switzerland, in collaboration with qualified geting the SARS-CoV-2 pathways, inhaled aviptadil may
personnel of the coordinating study center. Reporting is have the potential to prevent ARDS in COVID-19.
done directly to the Investigator. The CTU is independ- This trial is conducted in different European hospitals
ent of the sponsor and without competing interests. in order to ensure generalizability and meet the recruit-
ment target. Patients of all adult age groups and with
Adverse event reporting and harms {22} a wide range of co-morbidities are included into the
During the entire duration of the trial, all AEs and SAEs study, allowing for a broad representation of COVID-
are collected, fully investigated, and documented, irre- 19 patients. The primary endpoint as suggested by the
spective of whether they are related or unrelated. Partici- WHO allows a comparison with other investigated sub-
pating study centers are obliged to report SAEs within stances for the management of COVID-19. The evalua-
24 h to the sponsor-investigator, who, in case of death, tion of the secondary endpoints will give further insight
reports to the ethics committee within 7  days. AEs and into the effects of inhaled aviptadil with regard to sys-
SAEs are followed up until resolution or stabilization. temic inflammation markers, as well as patient-reported
Adverse events will be reported in any associated rel- outcomes.
evant publication arising from this trial. Due to the novelty of the disease and new research
results, standard care is constantly adapted, which may
Frequency and plans for auditing trial conduct {23} lead to changes in the relative effect of aviptadil over
The study is conducted in accordance with the cur- time. However, the block-randomization with a small
rently approved protocol, GCP standards, and relevant block-size ensures that this circumstance will not bias the
regulations. Regular monitoring is performed follow- results. Furthermore, with COVID-19 being the research
ing GCP and the trial monitoring plan. Data is evalu- focus of many current projects, which are “compet-
ated for protocol compliance, integrity, and accuracy ing” for participating patients, recruitment may become
in relation to source documents. Authorities can audit difficult. This challenge is addressed by increasing the
this trial independently from the Sponsor-Investiga- number of collaborating centers and assuring, that no
tor and the data monitoring committee. Study docu- competing projects are recruiting at the involved sites.
mentation and data are accessible to auditors and all To date, there are no published data about the admin-
involved parties must treat participant data as strictly istration of inhaled aviptadil in COVID-19. Because of
confidential. the promising properties of aviptadil, there is an urgent
 Boesing et al. Trials (2022) 23:790 Page 11 of 13

need to close this research gap with a well-designed ran- Availability of data and materials {29}
Data and materials that support this protocol, such as a detailed data manage‑
domized controlled trial. If the results of this study show ment plan, CRFs, and informed consent form are available from the authors on
that inhaled aviptadil is effective and safe, they may ulti- reasonable request. Following completion of the trial, anonymized datasets
mately lead to the introduction of a new substance for the and statistical code used in this study will be available from the authors on
reasonable request.
management of COVID-19.

Declarations
Trial status Ethics approval and consent to participate {24}
The first patient was enrolled into this study on May 18, Ethics approval to conduct this trial has been first granted for the sites
Baselland and St. Gallen by the Ethics Commission for North-Western and
2021. The study is currently ongoing with active recruit- Central Switzerland (EKNZ) and the Ethics Commission for Eastern Switzer‑
ment under protocol version 8, dated June 30, 2022. land (EKOS) on December 3, 2020 (Project-ID: 2020-01902). Six amendments
Recruitment is anticipated to be completed in December regarding additional study sites (Schwyz, Vienna, and Nieuwegein), eligibility
criteria, structural changes of the CRF, study duration, and sample size have
2022. been approved by the EKNZ and EKOS between December 2020 and July
2022. Furthermore, we are currently awaiting ethics approval from the local
ethics committees for the study sites in Vienna (Austria) and Nieuwegein
Abbreviations (Netherlands).
AE: Adverse event; ARDS: Acute respiratory distress syndrome; ATII: Alveolar The trial meets the criteria and principles of the Declaration of Helsinki and
type-II; cPAP: Continuous positive airway pressure; CRF: Case report form; CRP: has been registered in the Clinicaltrials.gov database (Trial registration num‑
C-reactive protein; CTU​: Clinical trial unit; DMC: Data monitoring commit‑ ber: NCT04536350).
tee; EALI: Early acute lung injury; EKNZ: Ethics Committee for the Region of Informed consent to participate in the trial is obtained by the recruiting study
Northwestern and Central Switzerland; EKOS: Ethics Commission for Eastern physicians from all patients prior to study entry. Each patient will be informed
Switzerland; GCP: Good Clinical Practice; ICU: Intensive care unit; SAE: Serious that participation in the study is voluntary, that he/she may withdraw from
adverse event; SAP: Statistical analysis plan; SF-12v2: 12-item Short Form the study at any time with no need for justification, and that withdrawal of
survey, version 2; VIP: Vasoactive intestinal polypeptide; WHO: World Health consent will not affect his/her subsequent medical assistance and treatment.
Organization. On the consent form, participants are asked for permission to use of their data
should they choose to withdraw from the trial. Participants are also asked for
permission for personal data being shared with regulatory authorities, when
Supplementary Information relevant. Furthermore, the patient will be informed on an obligatory basis that
The online version contains supplementary material available at https://​doi.​ his/her medical records may be examined by authorized individuals other
org/​10.​1186/​s13063-​022-​06723-w. than their treating physician. All patients are covered by liability insurance for
the total study duration.
Additional file 1. Summary of statistical analysis plan.
Consent for publication {32}
No personal data of any patient is used in this manuscript, therefore a consent
Acknowledgements for publication is not needed.
The authors thank Dorian Bevec, Alexander Brett, Helmi van Hirtum, Wolfgang
Hoppe, Andrea Kloetzer, Sabrina Maier, Katrin Schmelzle, Philip Tarr, Sandra Competing interests {28}
Widmer, the team from the CTU Basel, and all study physicians for guid‑ The authors declare that they have no competing interests.
ance, assistance, support, protocol-conform implementation, and valuable
feedback. Author details
1
 University Clinic of Medicine, Cantonal Hospital Baselland, Rheinstrasse
Authors’ contributions {31b} 26, CH‑4410 Liestal, Switzerland. 2 Faculty of Medicine, University of Basel,
Sponsor-investigator, responsibility for conception, design and supervision Klingelbergstrasse 61, CH‑4056 Basel, Switzerland. 3 Cantonal Hospital St.
of the trial: JDL. Drafting of manuscript/corresponding author: MBoe. Study Gallen, Rorschacherstrasse 95, CH‑9007 St. Gallen, Switzerland. 4 Depart‑
concept and design: MBoe, KA, PH, JDL. Global study coordination: MBoe, KA. ment of Pneumology, Medical Center University of Freiburg, Kilianstrasse 5,
Administrative supervision and submission to relevant authorities: KA. Local 79106 Freiburg, Germany. 5 St. Antonius Hospital Nieuwegein, Koekoekslaan
study supervision/principal investigators: JDL, MBra, RN, JCG, WP. Statistical 1, NL‑3435 Nieuwegein, Netherlands. 6 Division of Heart & Lungs, University
analysis plan and sample size calculation: MBoe, SG. First version of protocol: Medical Center Utrecht, Heidelberglaan 100, NL‑3584 Utrecht, Netherlands.
7
JH, KA, ALT, JDL. Critical revision of manuscript for important intellectual con‑  AdVita Lifescience GmbH, Alte Bundesstrasse 20, 79194 Gundelfingen,
tent: MBoe, KA, MBra, MBru, EB, BCF, SG, JCG, PH, JH, FJ, ALT, GLC, JMQ, RN, WP, Germany. 8 Department of Clinical Pharmacology and Toxicology, Univer‑
FR, JDL. All authors read and approved the final manuscript. sity Hospital Basel, University of Basel, Basel, Switzerland. 9 Hospital Schwyz,
Waldeggstrasse 10, CH‑6430 Schwyz, Switzerland. 10 Karl Landsteiner Institute
Funding {4} for Clinical and Experimental Pneumology, Clinic Hietzing, Wolkersbergen‑
This trial is mainly financed by AdVita Lifescience GmbH, Gundelfingen, strasse 1, A‑1130 Vienna, Austria.
Germany. In addition to financial and material support, AdVita Lifescience
provides technical support for the used nebulizer devices. Qualified parties Received: 30 March 2022 Accepted: 8 September 2022
of the funding body share their prior experiences and knowledge about the
investigational product with the study team in order to support with design-
related and logistic decisions. However, the sponsor-investigator JDL takes full
responsibility and ultimate authority for study design, data collection, data
management, data analysis, interpretation of data, and decisions concerning References
publication. The Cantonal Hospital Baselland has full ownership of any study 1. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and
related patient data and results. clinical characteristics of 99 cases of 2019 novel coronavirus pneumo‑
Furthermore, MBoe receives a personal research grant from the Swiss nia in Wuhan, China: a descriptive study. Lancet (London, England).
Academy of Medical Sciences within the program “Young Talents in Clinical 2020;395(10223):507–13.
Research.”
Boesing et al. Trials (2022) 23:790 Page 12 of 13

2. Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, et al. 24. Said SI, Mutt V. Potent peripheral and splanchnic vasodilator peptide from
Dexamethasone in hospitalized patients with COVID-19. N Engl J Med. normal gut. Nature. 1970;225(5235):863–4.
2021;384(8):693–704. 25. Bodanszky M, Klausner YS, Lin CY, Mutt V, Said SI. Synthesis of the vasoac‑
3. Swiss National COVID-19 Science Task Force, Clinical Care Group Writ‑ tive intestinal peptide (VIP). J Am Chem Soc. 1974;96(15):4973–8.
ing committee. Reduction of COVID-19-associated mortality by drug 26. Bodansky M, Natarajan S, Gardner JD, Makhlouf GM, Said SI. Synthesis
therapies. 2021. https://​scien​cetas​kforce.​ch/​en/​policy-​brief/​reduc​tion-​of-​ and some pharmacological properties of the 23-peptide 15-lysine-secre‑
covid-​19-​assoc​iated-​morta​lity-​by-​drug-​thera​pies/. Accessed 21 July 2022. tin-(5--27). Special role of the residue in position 15 in biological activity of
4. Marconi VC, Ramanan AV, de Bono S, Kartman CE, Krishnan V, Liao R, the vasoactive intestinal polypeptide. J Med Chem. 1978;21(11):1171–3.
et al. Efficacy and safety of baricitinib for the treatment of hospitalised 27. Mathioudakis A, Chatzimavridou-Grigoriadou V, Evangelopoulou E,
adults with COVID-19 (COV-BARRIER): a randomised, double-blind, Mathioudakis G. Vasoactive intestinal peptide inhaled agonists: potential
parallel-group, placebo-controlled phase 3 trial. Lancet Respir Med. role in respiratory therapeutics. Hippokratia. 2013;17(1):12–6.
2021;9(12):1407–18. 28. Virgolini I, Kurtaran A, Raderer M, Leimer M, Angelberger P, Havlik E,
5. World Health Organization: Therapeutics and COVID-19: living guideline. et al. Vasoactive intestinal peptide receptor scintigraphy. J Nucl Med.
2022. https://​www.​who.​int/​publi​catio​ns/i/​item/​WHO-​2019-​nCoV-​thera​ 1995;36(10):1732–9.
peuti​cs-​2022.4. Accessed 26 July 2022. 29. Delgado M, Munoz-Elias EJ, Kan Y, Gozes I, Fridkin M, Brenneman DE, et al.
6. Infectious Diseases Society of America: IDSA guidelines on the treatment Vasoactive intestinal peptide and pituitary adenylate cyclase-activating
and management of patients with COVID-19. 2022. https://​www.​idsoc​ polypeptide inhibit tumor necrosis factor alpha transcriptional activation
iety.​org/​pract​ice-​guide​line/​covid-​19-​guide​line-​treat​ment-​and-​manag​ by regulating nuclear factor-kB and cAMP response element-binding
ement/. Accessed 26 July 2022. protein/c-Jun. J Biol Chem. 1998;273(47):31427–36.
7. National Institutes of Health: Coronavirus disease 2019 (COVID-19) treat‑ 30. Sharma V, Delgado M, Ganea D. Granzyme B, a new player in activa‑
ment guidelines. 2022. https://​www.​covid​19tre​atmen​tguid​elines.​nih.​ tion-induced cell death, is down-regulated by vasoactive intestinal
gov/. Acessed 26 July 2022. peptide in Th2 but not Th1 effectors. J Immunol (Baltimore, Md: 1950).
8. Swiss Society of Infectiology: SARS-CoV-2 /COVID-19 - antiviral and 2006;176(1):97–110.
immunomodulatory treatment considerations. 2022. https://​ssi.​guide​ 31. Li L, Luo ZQ, Zhou FW, Feng DD, Guang CX, Zhang CQ, et al. Effect of
lines.​ch/​guide​line/​3352/​de/​31355. Accessed 26 July 2022. vasoactive intestinal peptide on pulmonary surfactants phospholipid
9. Gupta A, Gonzalez-Rojas Y, Juarez E, Crespo Casal M, Moya J, Falci DR, synthesis in lung explants. Acta Pharmacol Sin. 2004;25(12):1652–8.
et al. Early treatment for COVID-19 with SARS-CoV-2 neutralizing antibody 32. Temerozo JR, Sacramento CQ, Fintelman-Rodrigues N, Pão CRR, de Freitas
sotrovimab. N Engl J Med. 2021;385(21):1941–50. CS, da Silva Gomes Dias S, et al. The neuropeptides VIP and PACAP inhibit
10. Dougan M, Azizad M, Chen P, Feldman B, Frieman M, Igbinadolor A, et al. SARS-CoV-2 replication in monocytes and lung epithelial cells, decrease
Bebtelovimab, alone or together with bamlanivimab and etesevimab, as the production of proinflammatory cytokines, and VIP levels are associ‑
a broadly neutralizing monoclonal antibody treatment for mild to mod‑ ated with survival in severe Covid-19 patients. bioRxiv [Preprint]; 2020.
erate, ambulatory COVID-19. medRxiv [Preprint]; 2022. Available from: https://​doi.​org/​10.​1101/​2020.​07.​25.​220806.
https://​doi.​org/​10.​1101/​2022.​03.​10.​22272​100. 33. Tanaka T, Narazaki M, Kishimoto T. IL-6 in inflammation, immunity, and
11. Gottlieb RL, Vaca CE, Paredes R, Mera J, Webb BJ, Perez G, et al. Early rem‑ disease. Cold Spring Harb Perspect Biol. 2014;6(10):a016295.
desivir to prevent progression to severe COVID-19 in outpatients. N Engl J 34. Said SI. VIP as a modulator of lung inflammation and airway constriction.
Med. 2022;386(4):305–15. Am Rev Respir Dis. 1991;143(3 Pt 2):S22–4.
12. Hammond J, Leister-Tebbe H, Gardner A, Abreu P, Bao W, Wisemandle W, 35. Berisha H, Foda H, Sakakibara H, Trotz M, Pakbaz H, Said SI. Vasoactive
et al. Oral nirmatrelvir for high-risk, nonhospitalized adults with COVID-19. intestinal peptide prevents lung injury due to xanthine/xanthine oxidase.
N Engl J Med. 2022;386(15):1397–408. Am J Physiol. 1990;259(2 Pt 1):L151–5.
13. Jayk Bernal A, Gomes da Silva MM, Musungaie DB, Kovalchuk E, Gonzalez 36. Pakbaz H, Foda HD, Berisha HI, Trotz M, Said SI. Paraquat-induced lung
A, Delos Reyes V, et al. Molnupiravir for oral treatment of COVID-19 in injury: prevention by vasoactive intestinal peptide and related peptide
nonhospitalized patients. N Engl J Med. 2022;386(6):509–20. helodermin. Am J Physiol. 1993;265(4 Pt 1):L369–73.
14. Reis G, Dos Santos Moreira-Silva EA, Silva DCM, Thabane L, Milagres AC, 37. Said SI, Dickman KG. Pathways of inflammation and cell death in
Ferreira TS, et al. Effect of early treatment with fluvoxamine on risk of the lung: modulation by vasoactive intestinal peptide. Regul Pept.
emergency care and hospitalisation among patients with COVID-19: 2000;93(1-3):21–9.
the TOGETHER randomised, platform clinical trial. Lancet Glob Health. 38. Delgado M, Martinez C, Pozo D, Calvo JR, Leceta J, Ganea D, et al. Vasoac‑
2022;10(1):e42–51. tive intestinal peptide (VIP) and pituitary adenylate cyclase-activation
15. Weinreich DM, Sivapalasingam S, Norton T, Ali S, Gao H, Bhore R, et al. polypeptide (PACAP) protect mice from lethal endotoxemia through
REGEN-COV antibody combination and outcomes in outpatients with the inhibition of TNF-alpha and IL-6. J Immunol (Baltimore, Md: 1950).
COVID-19. N Engl J Med. 2021;385(23):e81. 1999;162(2):1200–5.
16. Gavriatopoulou M, Ntanasis-Stathopoulos I, Korompoki E, Fotiou D, 39. Berisha HI, Bratut M, Bangale Y, Colasurdo G, Paul S, Said SI. New evidence
Migkou M, Tzanninis IG, et al. Emerging treatment strategies for COVID-19 for transmitter role of VIP in the airways: impaired relaxation by a catalytic
infection. Clin Exp Med. 2021;21(2):167–79. antibody. Pulm Pharmacol Ther. 2002;15(2):121–7.
17. Rabie AM. Teriflunomide: a possible effective drug for the comprehensive 40. Li L, She H, Yue SJ, Qin XQ, Guan CX, Liu HJ, et al. Role of c-fos gene in
treatment of COVID-19. Curr Res Pharmacol Drug Discov. 2021;2:100055. vasoactive intestinal peptide promoted synthesis of pulmonary sur‑
18. Rabie AM. Two antioxidant 2,5-disubstituted-1,3,4-oxadiazoles (CoViTris2020 factant phospholipids. Regul Pept. 2007;140(3):117–24.
and ChloViD2020): successful repurposing against COVID-19 as the first 41. Temerozo JR, Sacramento CQ, Fintelman-Rodrigues N, Pão CRR, de Freitas
potent multitarget anti-SARS-CoV-2 drugs. New J Chem. 2021;45(2):761–71. CS, Dias SSG, et al. VIP plasma levels associate with survival in severe
19. Gao YD, Ding M, Dong X, Zhang JJ, Kursat Azkur A, Azkur D, et al. Risk COVID-19 patients, correlating with protective effects in SARS-CoV-
factors for severe and critically ill COVID-19 patients: a review. Allergy. 2-infected cells. J Leukoc Biol. 2022;111(5):1107–21.
2021;76(2):428–55. 42. Youssef J, Lee R, Javitt J, Lavin P, Lenhardt R, Park D, et al. Intravenous avi‑
20. Ragab D, Salah Eldin H, Taeimah M, Khattab R, Salem R. The COVID-19 ptadil is associated with increased recovery and survival in patients with
cytokine storm; what we know so far. Front Immunol. 2020;11:1446. COVID-19 respiratory failure: results of a 60-day randomized controlled
21. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of trial. SSRN [Preprint]; 2021. https://​doi.​org/​10.​2139/​ssrn.​38300​51.
patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 43. Prasse A, Zissel G, Lützen N, Schupp J, Schmiedlin R, Gonzalez-Rey E, et al.
(London, England). 2020;395(10223):497–506. Inhaled vasoactive intestinal peptide exerts immunoregulatory effects in
22. Mason RJ. Thoughts on the alveolar phase of COVID-19. Am J Physiol sarcoidosis. Am J Respir Crit Care Med. 2010;182(4):540–8.
Lung Cell Mol Physiol. 2020;319(1):L115–l20. 44. Ran WZ, Dong L, Tang CY, Zhou Y, Sun GY, Liu T, et al. Vasoactive intestinal
23. Mossel EC, Wang J, Jeffers S, Edeen KE, Wang S, Cosgrove GP, et al. SARS- peptide suppresses macrophage-mediated inflammation by downregu‑
CoV replicates in primary human alveolar type II cell cultures but not in lating interleukin-17A expression via PKA- and PKC-dependent pathways.
type I-like cells. Virology. 2008;372(1):127–35. Int J Exp Pathol. 2015;96(4):269–75.
 Boesing et al. Trials (2022) 23:790 Page 13 of 13

45. Anderson P, Gonzalez-Rey E. Vasoactive intestinal peptide induces cell

cycle arrest and regulatory functions in human T cells at multiple levels.
Mol Cell Biol. 2010;30(10):2537–51.
46. Gonzalez-Rey E, Fernandez-Martin A, Chorny A, Delgado M. Vasoac‑
tive intestinal peptide induces CD4+,CD25+ T regulatory cells with
therapeutic effect in collagen-induced arthritis. Arthritis Rheum.
2006;54(3):864–76.
47. Frye BC, Meiss F, von Bubnoff D, Zissel G, Muller-Quernheim J. Vasoactive
intestinal peptide in checkpoint inhibitor-induced pneumonitis. N Engl J
Med. 2020;382(26):2573–4.
48. Petkov V, Mosgoeller W, Ziesche R, Raderer M, Stiebellehner L, Vonbank K,
et al. Vasoactive intestinal peptide as a new drug for treatment of primary
pulmonary hypertension. J Clin Invest. 2003;111(9):1339–46.
49. Leuchte HH, Baezner C, Baumgartner RA, Bevec D, Bacher G, Neurohr C,
et al. Inhalation of vasoactive intestinal peptide in pulmonary hyperten‑
sion. Eur Respir J. 2008;32(5):1289–94.
50. Javitt J, Youssef G, Javitt M. Treatment of sepsis-related acute respiratory
distress syndrome with vasoactive intestinal peptide. Am J Respir Crit
Care Med. 2021;203:A2490.
51. Mukherjee T, Behl T, Sharma S, Sehgal A, Singh S, Sharma N, et al. Antici‑
pated pharmacological role of Aviptadil on COVID-19. Environ Sci Pollut
Res Int. 2022;29(6):8109–25.
52. Levitt JE, Calfee CS, Goldstein BA, Vojnik R, Matthay MA. Early acute lung
injury: criteria for identifying lung injury prior to the need for positive
pressure ventilation. Crit Care Med. 2013;41(8):1929–37.
53. Gajic O, Dabbagh O, Park PK, Adesanya A, Chang SY, Hou P, et al. Early
identification of patients at risk of acute lung injury: evaluation of lung
injury prediction score in a multicenter cohort study. Am J Respir Crit
Care Med. 2011;183(4):462–70.
54. Wu C, Chen X, Cai Y, Ja X, Zhou X, Xu S, et al. Risk factors associated
with acute respiratory distress syndrome and death in patients with
coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med.
2020;180(7):934–43.
55. World Health Organization: WHO R&D Blueprint, novel coronavirus
COVID-19 therapeutic trial synopsis. 2020. https://​www.​who.​int/​bluep​
rint/​prior​ity-​disea​ses/​key-​action/​COVID-​19_​Treat​ment_​Trial_​Design_​
Master_​Proto​col_​synop​sis_​Final_​18022​020.​pdf. Accessed 29 Mar 2022.
56. Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A, et al. Com‑
passionate use of remdesivir for patients with severe COVID-19. N Engl J
Med. 2020;382(24):2327–36.
57. Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults
with severe COVID-19: a randomised, double-blind, placebo-controlled,
multicentre trial. Lancet (London, England). 2020;395(10236):1569–78.
58. Chow S, Shao J, Wang H. Sample size calculations in clinical research. 2nd
ed. New York: Chapman & Hall; 2007.
59. R Core Team. R: a language and environment for statistical computing.
Vienna: R Foundation for Statistical Computing; 2020. https://​www.R-​
proje​ct.​org/. Accessed 29 Mar 2022

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions