A Multicenter, Adaptive, Randomized Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for the Treatment of COVID-19 in Hospitalized Adults (ACTT-3)
Phase: PHASE3
Conditions: COVID-19
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

DMID/NIAID/NIH 
CONFIDENTIAL 
Page 1 of 161 
 
 
A Multicenter, Adaptive, Randomized Blinded Controlled Trial of the Safety and 
Efficacy of Investigational Therapeutics for the Treatment of COVID-19  
in Hospitalized Adults  
 
 
 
Short Title: Adaptive COVID-19 Treatment Trial (ACTT) 
 
 
 
DMID Protocol Number: 20-0006 
 
Sponsor:  
Division of Microbiology and Infectious Diseases (DMID), 
National Institute of Allergy and Infectious Diseases,  
National Institutes of Health 
  
Version Number: 8.0 
 
28 September 2020 
 
 
 
 

Protocol 20-0006 
Version 8.0 
Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
Main protocol document 
DMID/NIAID/NIH 
CONFIDENTIAL 
Page 2 of 161 
STATEMENT OF COMPLIANCE 
Each institution engaged in this research will hold a current Federalwide Assurance (FWA) 
issued by the Office of Human Research Protection (OHRP) for federally funded research. The 
Institutional Review Board (IRB)/Independent or Institutional Ethics Committee (IEC) must be 
registered with OHRP as applicable to the research.  
 
The study will be carried out in accordance with the following as applicable: 
 All National and Local Regulations and Guidance applicable at each site 
 The International Council for Harmonisation of Technical Requirements for Registration 
of Pharmaceuticals for Human Use (ICH) E6(R2) Good Clinical Practice, and the 
Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects 
of Research, Report of the National Commission for the Protection of Human Subjects of 
Biomedical and Behavioral Research 
 United States (US) Code of Federal Regulations (CFR) 45 CFR Part 46: Protection of 
Human Subjects 
 US Food and Drug Administration (FDA) Regulations: 21 CFR Part 50 (Protection of 
Human Subjects), 21 CFR Part 54 (Financial Disclosure by Clinical Investigators), 21 
CFR Part 56 (IRBs), 21 CFR Part 11, and 21 CFR Part 312 (Investigational New Drug 
Application), and/or 21 CFR 812 (Investigational Device Exemptions) 
 The policies and procedures of National Institutes of Health (NIH) Office of Extramural 
Research and Division of Microbiology and Infectious Diseases (DMID) 
 
The signature below provides the necessary assurance that this study will be conducted 
according to all stipulations of the protocol including statements regarding confidentiality, and 
according to local legal and regulatory requirements, US federal regulations, and ICH E6(R2) 
GCP guidelines. 
 
Site Investigator Signature: 
 
 
Signed: 
 
Date: 
 
 
Name and Title 
 
 
 
 

Protocol 20-0006 
Version 8.0 
Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
Main protocol document 
DMID/NIAID/NIH 
CONFIDENTIAL 
Page 3 of 161 
TABLE OF CONTENTS 
 
STATEMENT OF COMPLIANCE ................................................................................................ 2 
TABLE OF CONTENTS ................................................................................................................ 3 
LIST OF TABLES ........................................................................................................................ 11 
LIST OF FIGURES ...................................................................................................................... 11 
1. 
OVERALL PROTOCOL SUMMARY ................................................................................ 12 
1.1 
Synopsis ........................................................................................................................ 12 
1.2 
Stages in the adaptive trial ............................................................................................ 17 
1.3 
Schedule of Assessments .............................................................................................. 17 
1.4 
Study Schema................................................................................................................ 18 
2. 
INTRODUCTION ................................................................................................................ 19 
2.1 
Study Rationale ............................................................................................................. 19 
2.2 
Background ................................................................................................................... 19 
2.2.1 
Purpose of Study ................................................................................................... 19 
2.3 
Risk/Benefit Assessment .............................................................................................. 20 
3. 
OBJECTIVES AND ENDPOINTS ...................................................................................... 20 
4. 
STUDY DESIGN.................................................................................................................. 23 
4.1 
Overall Design .............................................................................................................. 23 
4.2 
Scientific Rationale for Study Design........................................................................... 24 
5. 
STUDY POPULATION ....................................................................................................... 24 
5.1 
Inclusion Criteria .......................................................................................................... 24 
5.2 
Exclusion Criteria ......................................................................................................... 25 
5.3 
Specific Populations...................................................................................................... 25 
5.4 
Strategies for Recruitment and Retention ..................................................................... 25 
5.4.1 
Recruitment ........................................................................................................... 25 
5.4.2 
Retention ............................................................................................................... 25 
5.4.3 
Compensation Plan for Subjects ........................................................................... 25 
5.4.4 
Costs ...................................................................................................................... 25 
6. 
STUDY PRODUCT.............................................................................................................. 26 
7. 
STUDY INTERVENTION DISCONTINUATION AND SUBJECT 
DISCONTINUATION/WITHDRAWAL..................................................................................... 26 
7.1 
Halting Criteria and Discontinuation of Study Intervention ......................................... 26 
7.1.1 
Individual Study Product Halting ......................................................................... 26 
7.1.2 
Study Halting ........................................................................................................ 26 
7.2 
Withdrawal from the Study ........................................................................................... 26 
7.3 
Lost to Follow-Up ......................................................................................................... 26 

Protocol 20-0006 
Version 8.0 
Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
Main protocol document 
DMID/NIAID/NIH 
CONFIDENTIAL 
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8. 
STUDY ASSESSMENTS AND PROCEDURES ................................................................ 26 
8.1 
Screening and Efficacy Assessments ............................................................................ 26 
8.1.1 
Screening Procedures ............................................................................................ 26 
8.1.2 
Efficacy Assessments............................................................................................ 28 
8.1.2.1 
Measures of clinical support, limitations and infection control ........................ 28 
8.1.2.2 
Ordinal Scale ..................................................................................................... 28 
8.1.2.3 
National Early Warning Score (NEWS) ........................................................... 29 
8.1.3 
Exploratory assessments ....................................................................................... 30 
8.1.3.1 
Viral Load and/or Shedding .............................................................................. 30 
8.2 
Safety and Other Assessments ...................................................................................... 31 
8.2.1 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings .................................................................................................. 32 
8.2.2 
Unscheduled Visits ............................................................................................... 33 
8.3 
Adverse Events and Serious Adverse Events ............................................................... 33 
8.3.1 
Definition of Adverse Event (AE) ........................................................................ 33 
8.3.2 
Definition of Serious Adverse Event (SAE) ......................................................... 33 
8.3.3 
Suspected Unexpected Serious Adverse Reactions (SUSAR).............................. 34 
8.3.4 
Classification of an Adverse Event ....................................................................... 34 
8.3.4.1 
Severity of Adverse Events ............................................................................... 34 
8.3.4.2 
Relationship to Study Intervention ................................................................... 35 
8.3.5 
Time Period and Frequency for Event Assessment and Follow-Up ..................... 35 
8.3.5.1 
Investigators Reporting of AEs ......................................................................... 35 
8.3.6 
Serious Adverse Event Reporting ......................................................................... 35 
8.3.6.1 
Investigators Reporting of SAEs ...................................................................... 35 
8.3.6.2 
Regulatory Reporting of SAEs ......................................................................... 36 
8.3.7 
Reporting of Pregnancy ........................................................................................ 36 
8.4 
Unanticipated Problems ................................................................................................ 36 
8.4.1 
Definition of Unanticipated Problems .................................................................. 36 
8.4.2 
Unanticipated Problem Reporting......................................................................... 37 
9. 
STATISTICAL CONSIDERATIONS.................................................................................. 37 
10. SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS ....... 37 
10.1 
Regulatory, Ethical, and Study Oversight Considerations............................................ 37 
10.1.1 
Informed Consent Process .................................................................................... 38 
10.1.1.1 
Requirements for Permission by Parents/Guardians and Assent by Children 
(in case of a minor) ........................................................................................................... 38 
10.1.1.2 
Other Informed Consent Procedures ............................................................. 39 
10.1.2 
Study Termination and Closure ............................................................................ 39 
10.1.3 
Confidentiality and Privacy .................................................................................. 40 
10.1.4 
Secondary Use of Stored Specimens and Data ..................................................... 40 
10.1.4.1 
Data Sharing for Secondary Research .......................................................... 40 
10.1.5 
Key Roles and Study Governance ........................................................................ 41 
10.1.6 
Safety Oversight.................................................................................................... 41 
10.1.6.1 
Protocol team oversight ................................................................................ 41 
10.1.6.2 
Data Safety Monitoring Board ...................................................................... 41 
10.1.7 
Clinical Monitoring ............................................................................................... 42 

Protocol 20-0006 
Version 8.0 
Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
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10.1.8 
Data Handling and Record Keeping ..................................................................... 42 
10.1.8.1 
Data Collection and Management Responsibilities ...................................... 42 
10.1.8.2 
Study Record Retention ................................................................................ 43 
10.1.8.3 
Source Records ............................................................................................. 43 
10.1.9 
Protocol Deviations ............................................................................................... 43 
10.1.10 Publication and Data Sharing Policy .................................................................... 44 
10.1.11 Human Data Sharing Plan ..................................................................................... 44 
10.1.12 Publication ............................................................................................................ 44 
10.1.13 Conflict of Interest Policy ..................................................................................... 44 
10.2 
Additional Considerations ............................................................................................ 44 
10.2.1 
Research Related Injuries ..................................................................................... 44 
10.2.2 
Public Readiness and Emergency Preparedness Act ............................................ 45 
10.3 
Abbreviations ................................................................................................................ 46 
10.4 
Protocol Amendment History ....................................................................................... 47 
11. REFERENCES ..................................................................................................................... 53 
Appendix A - ACTT-1: Remdesivir vs Placebo ........................................................................... 57 
Appendix B - ACTT-2: Baricitinib/Remdesivir Vs. Remdesivir Trial......................................... 58 
1. 
PROTOCOL SUMMARY .................................................................................................... 58 
1.1 
ACTT-2 – Synopsis ...................................................................................................... 58 
1.2 
Schedule of Assessments .............................................................................................. 61 
1.3 
Study Schema................................................................................................................ 62 
2. 
INTRODUCTION ................................................................................................................ 62 
2.1 
Background ................................................................................................................... 62 
2.1.1 
ACTT-2 – Baricitinib/Remdesivir vs. Remdesivir Trial ...................................... 62 
2.2 
Risk/Benefit Assessment .............................................................................................. 63 
2.2.1 
Known Potential Risks .......................................................................................... 63 
2.2.2 
Remdesivir ............................................................................................................ 64 
2.2.2.1 
Potential Risks of Remdesivir ........................................................................... 64 
2.2.2.2 
Potential Benefits of Remdesivir ...................................................................... 65 
2.2.2.3 
Assessment of Potential Risks and Benefits of Remdesivir ............................. 65 
2.2.3 
Baricitinib ............................................................................................................. 66 
2.2.3.1 
Potential Risks of Baricitinib ............................................................................ 66 
2.2.3.2 
Potential Benefits of Baricitinib........................................................................ 68 
2.2.3.3 
Assessment of Potential Risks and Benefits of Baricitinib ............................... 68 
3. 
OBJECTIVES AND ENDPOINTS ...................................................................................... 68 
4. 
STUDY DESIGN.................................................................................................................. 71 
4.1 
Overall Design .............................................................................................................. 71 
4.2 
Scientific Rationale for Study Design........................................................................... 71 
4.3 
Justification for Dose .................................................................................................... 72 
4.3.1 
Justification for Dose of Remdesivir .................................................................... 72 
4.3.2 
Justification for Dose of Baricitinib ...................................................................... 72 
5. 
STUDY POPULATION ....................................................................................................... 72 

Protocol 20-0006 
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Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
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DMID/NIAID/NIH 
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5.1 
Inclusion Criteria .......................................................................................................... 72 
5.2 
Exclusion Criteria ......................................................................................................... 73 
5.2.1 
Exclusion of Specific Populations ........................................................................ 74 
5.3 
Inclusion of Vulnerable Subjects .................................................................................. 75 
5.4 
Lifestyle Considerations ............................................................................................... 75 
5.5 
Screen Failures .............................................................................................................. 75 
5.6 
Strategies for Recruitment and Retention ..................................................................... 76 
5.6.1 
Recruitment ........................................................................................................... 76 
5.6.2 
Retention ............................................................................................................... 76 
5.6.3 
Compensation Plan for Subjects ........................................................................... 76 
5.6.4 
Costs ...................................................................................................................... 76 
6. 
STUDY PRODUCT.............................................................................................................. 76 
6.1 
Study Product(s) and Administration............................................................................ 76 
6.1.1 
Study Product Description .................................................................................... 77 
6.1.2 
Dosing and Administration ................................................................................... 77 
6.1.3 
Dose Escalation ..................................................................................................... 78 
6.1.4 
Dose Modifications ............................................................................................... 78 
6.1.5 
Overdosage ........................................................................................................... 79 
6.2 
Preparation/Handling/Storage/Accountability .............................................................. 79 
6.2.1 
Acquisition and Accountability ............................................................................ 79 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ............................................ 80 
6.2.3 
Product Storage and Stability................................................................................ 80 
6.2.4 
Preparation ............................................................................................................ 81 
6.3 
Measures to Minimize Bias: Randomization and Blinding .......................................... 81 
6.3.1 
Randomization ...................................................................................................... 81 
6.3.2 
Blinding and Masking Procedures ........................................................................ 81 
6.4 
Study Intervention Compliance .................................................................................... 82 
6.5 
Concomitant Therapy.................................................................................................... 82 
6.5.1 
Permitted Concomitant Therapy and Procedures ................................................. 82 
6.5.2 
Prohibited Concomitant Therapy .......................................................................... 82 
6.5.3 
Rescue Medicine ................................................................................................... 83 
6.5.4 
Non-Research Standard of Care............................................................................ 83 
7. 
STUDY INTERVENTION DISCONTINUATION AND SUBJECT 
DISCONTINUATION/WITHDRAWAL..................................................................................... 83 
7.1 
Halting Criteria and Discontinuation of Study Intervention ......................................... 84 
7.1.1 
Individual Study Product Halting ......................................................................... 84 
7.1.1.1 
Remdesivir Halting ........................................................................................... 84 
7.1.1.2 
Oral Study Product Halting ............................................................................... 84 
7.1.2 
Study Halting ........................................................................................................ 84 
7.2 
Withdrawal from the Study ........................................................................................... 85 
7.3 
Lost to Follow-Up ......................................................................................................... 85 
7.4 
Readmission .................................................................................................................. 85 
8. 
STUDY ASSESSMENTS AND PROCEDURES ................................................................ 85 
8.1 
Screening and Efficacy Assessments ............................................................................ 85 

Protocol 20-0006 
Version 8.0 
Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
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DMID/NIAID/NIH 
CONFIDENTIAL 
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8.1.1 
Screening Procedures ............................................................................................ 86 
8.1.2 
Efficacy Assessments............................................................................................ 87 
8.1.2.1 
Measures of clinical support, limitations and infection control ........................ 87 
8.1.2.2 
Ordinal Scale ..................................................................................................... 88 
8.1.2.3 
National Early Warning Score (NEWS) ........................................................... 89 
8.1.3 
Exploratory assessments ....................................................................................... 90 
8.1.3.1 
Viral Load and/or Shedding .............................................................................. 90 
8.1.3.2 
Cytokine Assessments ...................................................................................... 91 
8.2 
Safety and Other Assessments ...................................................................................... 92 
8.2.1 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings .................................................................................................. 92 
8.2.2 
Unscheduled Visits ............................................................................................... 93 
8.3 
Adverse Events and Serious Adverse Events ............................................................... 93 
8.3.1 
Definition of Adverse Event (AE) ........................................................................ 93 
8.3.2 
Definition of Serious Adverse Event (SAE) ......................................................... 94 
8.3.3 
Suspected Unexpected Serious Adverse Reactions (SUSAR).............................. 94 
8.3.4 
Classification of an Adverse Event ....................................................................... 95 
8.3.4.1 
Severity of Adverse Events ............................................................................... 95 
8.3.4.2 
Relationship to Study Intervention ................................................................... 95 
8.3.5 
Time Period and Frequency for Event Assessment and Follow-Up ..................... 96 
8.3.5.1 
Investigator Reporting of AEs .......................................................................... 96 
8.3.6 
Serious Adverse Event Reporting ......................................................................... 96 
8.3.6.1 
Investigators Reporting of SAEs ...................................................................... 96 
8.3.6.2 
Regulatory Reporting of SAEs ......................................................................... 97 
8.3.7 
Reporting of Pregnancy ........................................................................................ 97 
8.4 
Unanticipated Problems ................................................................................................ 97 
8.4.1 
Definition of Unanticipated Problems .................................................................. 97 
8.4.2 
Unanticipated Problem Reporting......................................................................... 97 
9. 
STATISTICAL CONSIDERATIONS.................................................................................. 98 
9.1 
Statistical Hypotheses ................................................................................................... 98 
9.2 
Sample Size Determination........................................................................................... 98 
9.3 
Populations for Analyses ............................................................................................ 102 
9.4 
Statistical Analyses ..................................................................................................... 102 
9.4.1 
General Approach ............................................................................................... 102 
9.4.2 
Analysis of the Primary Efficacy Endpoint ........................................................ 102 
9.4.3 
Analysis of the Secondary Endpoint(s)............................................................... 102 
9.4.4 
Safety Analyses ................................................................................................... 103 
9.4.5 
Baseline Descriptive Statistics ............................................................................ 103 
9.4.6 
Planned Interim and Early Analyses ................................................................... 103 
9.4.6.1 
Interim Safety Analyses .................................................................................. 103 
9.4.6.2 
Interim Efficacy Review ................................................................................. 104 
9.4.7 
Sub-Group Analyses ........................................................................................... 104 
9.4.8 
Exploratory Analyses .......................................................................................... 104 
10. SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS – ALL 
STAGES ..................................................................................................................................... 104 

Protocol 20-0006 
Version 8.0 
Adaptive COVID-19 Treatment Trial (ACTT) 
 
28 Sep 2020 
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Appendix C - ACTT-3: Remdesivir + Interferon beta-1a .......................................................... 105 
1. 
PROTOCOL SUMMARY .................................................................................................. 105 
1.1 
ACTT-3 – Synopsis .................................................................................................... 105 
1.2 
Schedule of Assessments ............................................................................................ 108 
2. 
INTRODUCTION .............................................................................................................. 109 
2.1 
Background ................................................................................................................. 109 
2.1.1 
ACTT-3 – Interferon beta-1a /Remdesivir vs. Placebo/Remdesivir Trial .......... 109 
2.2 
Risk/Benefit Assessment ............................................................................................ 111 
2.2.1 
Known Potential Risks ........................................................................................ 111 
2.2.2 
Remdesivir .......................................................................................................... 112 
2.2.2.1 
Potential Risks of Remdesivir ......................................................................... 112 
2.2.2.2 
Potential Benefits of Remdesivir .................................................................... 114 
2.2.2.3 
Assessment of Potential Risks and Benefits of Remdesivir ........................... 114 
2.2.3 
Subcutaneous Interferon beta-1a ......................................................................... 114 
2.2.3.1 
Potential Risks of Subcutaneous Interferon beta-1a ....................................... 114 
2.2.3.2 
Potential Benefits of Subcutaneous Interferon beta-1a ................................... 117 
2.2.3.3 
Assessment of Potential Risks and Benefits of Subcutaneous Interferon beta-1a
 
117 
3. 
OBJECTIVES AND ENDPOINTS .................................................................................... 117 
4. 
STUDY DESIGN................................................................................................................ 121 
4.1 
Overall Design ............................................................................................................ 121 
4.2 
Scientific Rationale for Study Design......................................................................... 122 
4.3 
Justification for Dose .................................................................................................. 122 
4.3.1 
Justification for Dose of Remdesivir .................................................................. 122 
4.3.2 
Justification for Dose of Subcutaneous Interferon beta-1a ................................. 122 
5. 
STUDY POPULATION ..................................................................................................... 123 
5.1 
Inclusion Criteria ........................................................................................................ 123 
5.2 
Exclusion Criteria ....................................................................................................... 123 
5.2.1 
Exclusion of Specific Populations ...................................................................... 124 
5.3 
Inclusion of Vulnerable Subjects ................................................................................ 125 
5.4 
Lifestyle Considerations ............................................................................................. 125 
5.5 
Screen Failures ............................................................................................................ 125 
5.6 
Strategies for Recruitment and Retention ................................................................... 126 
5.6.1 
Recruitment ......................................................................................................... 126 
5.6.2 
Retention ............................................................................................................. 126 
5.6.3 
Compensation Plan for Subjects ......................................................................... 127 
5.6.4 
Costs .................................................................................................................... 127 
6. 
STUDY PRODUCT............................................................................................................ 127 
6.1 
Study Product(s) and Administration.......................................................................... 127 
6.1.1 
Study Product Description .................................................................................. 127 
6.1.2 
Dosing and Administration ................................................................................. 128 
6.1.3 
Dose Escalation ................................................................................................... 128 

Protocol 20-0006 
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28 Sep 2020 
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6.1.4 
Dose Modifications ............................................................................................. 128 
6.1.5 
Overdosage ......................................................................................................... 129 
6.2 
Preparation/Handling/Storage/Accountability ............................................................ 129 
6.2.1 
Acquisition and Accountability .......................................................................... 129 
6.2.2 
Formulation, Appearance, Packaging, and Labeling .......................................... 130 
6.2.3 
Product Storage and Stability.............................................................................. 131 
6.2.4 
Preparation .......................................................................................................... 131 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................ 132 
6.3.1 
Randomization .................................................................................................... 132 
6.3.2 
Blinding and Masking Procedures ...................................................................... 132 
6.4 
Study Intervention Compliance .................................................................................. 133 
6.5 
Concomitant Therapy.................................................................................................. 133 
6.5.1 
Permitted Concomitant Therapy and Procedures ............................................... 133 
6.5.2 
Prohibited Concomitant Therapy ........................................................................ 134 
6.5.3 
Rescue Medicine ................................................................................................. 135 
6.5.4 
Non-Research Standard of Care.......................................................................... 135 
7. 
STUDY INTERVENTION DISCONTINUATION AND SUBJECT 
DISCONTINUATION/WITHDRAWAL................................................................................... 135 
7.1 
Halting Criteria and Discontinuation of Study Intervention ....................................... 135 
7.1.1 
Individual Study Product Halting ....................................................................... 135 
7.1.1.1 
Remdesivir Halting ......................................................................................... 136 
7.1.1.2 
Subcutaneous Interferon beta-1a and Placebo Injections Halting .................. 136 
7.1.2 
Study Halting ...................................................................................................... 136 
7.2 
Withdrawal from the Study ......................................................................................... 136 
7.3 
Lost to Follow-Up ....................................................................................................... 137 
7.4 
Readmission ................................................................................................................ 137 
8. 
STUDY ASSESSMENTS AND PROCEDURES .............................................................. 137 
8.1 
Screening and Efficacy Assessments .......................................................................... 138 
8.1.1 
Screening Procedures .......................................................................................... 138 
8.1.2 
Efficacy Assessments.......................................................................................... 139 
8.1.2.1 
Measures of clinical support, limitations and infection control ...................... 140 
8.1.2.2 
Ordinal Scale ................................................................................................... 141 
8.1.2.3 
National Early Warning Score (NEWS) ......................................................... 142 
8.1.3 
Exploratory Assessments and Secondary Research Samples ............................. 142 
8.1.3.1 
SARS-CoV-2 Viralology Exploratory Assessment ........................................ 144 
8.1.3.2 
Immunophenotyping Exploratory Assessment ............................................... 144 
8.2 
Safety and Other Assessments .................................................................................... 146 
8.2.1 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings ................................................................................................ 148 
8.2.2 
Unscheduled Visits ............................................................................................. 148 
8.3 
Adverse Events and Serious Adverse Events ............................................................. 148 
8.3.1 
Definition of Adverse Event (AE) ...................................................................... 148 
8.3.2 
Definition of Serious Adverse Event (SAE) ....................................................... 150 
8.3.3 
Suspected Unexpected Serious Adverse Reactions (SUSAR)............................ 151 
8.3.4 
Classification of an Adverse Event ..................................................................... 151 

Protocol 20-0006 
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8.3.4.1 
Severity of Adverse Events ............................................................................. 151 
8.3.4.2 
Relationship to Study Intervention ................................................................. 152 
8.3.5 
Time Period and Frequency for Event Assessment and Follow-Up ................... 152 
8.3.5.1 
Investigator Reporting of AEs ........................................................................ 152 
8.3.6 
Serious Adverse Event Reporting ....................................................................... 152 
8.3.6.1 
Investigators Reporting of SAEs .................................................................... 152 
8.3.6.2 
Regulatory Reporting of SAEs ....................................................................... 153 
8.3.7 
Reporting of Pregnancy ...................................................................................... 153 
8.4 
Unanticipated Problems .............................................................................................. 153 
8.4.1 
Definition of Unanticipated Problems ................................................................ 153 
8.4.2 
Unanticipated Problem Reporting....................................................................... 154 
9. 
STATISTICAL CONSIDERATIONS................................................................................ 154 
9.1 
Statistical Hypotheses ................................................................................................. 154 
9.2 
Sample Size Determination......................................................................................... 155 
9.3 
Populations for Analyses ............................................................................................ 158 
9.4 
Statistical Analyses ..................................................................................................... 159 
9.4.1 
General Approach ............................................................................................... 159 
9.4.2 
Analysis of the Primary Efficacy Endpoint ........................................................ 159 
9.4.3 
Analysis of the Secondary Endpoint(s)............................................................... 159 
9.4.4 
Analysis of Exploratory Objectives and Endpoints ............................................ 160 
9.4.5 
Safety Analyses ................................................................................................... 160 
9.4.6 
Baseline Descriptive Statistics ............................................................................ 160 
9.4.7 
Planned Interim and Early Analyses ................................................................... 160 
9.4.7.1 
Interim Safety Analyses .................................................................................. 161 
9.4.7.2 
Interim Efficacy Review ................................................................................. 161 
9.4.8 
Sub-Group Analyses ........................................................................................... 161 
9.4.9 
Exploratory Analyses .......................................................................................... 161 
10. SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS – ALL 
STAGES ..................................................................................................................................... 161 
 
 
 

Protocol 20-0006 
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28 Sep 2020 
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DMID/NIAID/NIH 
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LIST OF TABLES 
Table 1. Schedule of Assessments (SOA) .................................................................................... 17 
Table 2. National Early Warning Score (NEWS) ......................................................................... 30 
Table 3. Venipuncture Volumes1 .................................................................................................. 32 
Table 1. Schedule of Assessments (SOA) .................................................................................... 61 
Table 2. National Early Warning Score (NEWS) ......................................................................... 90 
Table 3. Venipuncture Volumes1 .................................................................................................. 92 
Table 4. Hypothesis tests of interest for ACTT-1 and ACTT-2 ................................................... 98 
Table 5. Number of recoveries needed for 85% power assuming a type I error rate of 5% for 
various recovery ratios. ................................................................................................................. 99 
Table 6: Possible scenarios for the distribution of ordinal outcomes for the control arm at Day 
15................................................................................................................................................. 100 
Table 7: Sample size calculations for scenarios in Table 6 for a two-arm study assuming 85% 
power, a two-sided type I error rate of 5%, and various true odds ratios. .................................. 101 
Table 8. Treatment ordinal outcome proportions under an odds ratio of 1.75 for five scenarios in 
Table 5 at Day 15. ....................................................................................................................... 101 
Table 1. Schedule of Assessments (SOA) .................................................................................. 108 
Table 2. National Early Warning Score (NEWS) ....................................................................... 142 
Table 3. Venipuncture Volumes1 ................................................................................................ 146 
Table 4. Hypothesis tests of interest for ACTT-3 ....................................................................... 154 
Table 5. Number of recoveries needed for 85% power assuming a type I error rate of 5% for 
various recovery ratios. ............................................................................................................... 155 
Table 6: Possible scenarios for the distribution of ordinal outcomes for the control arm at Day 
15................................................................................................................................................. 156 
Table 7: Sample size calculations for scenarios in Table 6 for a two-arm study assuming 85% 
power, a two-sided type I error rate of 5%, and various true odds ratios. .................................. 157 
Table 8. Treatment ordinal outcome proportions under an odds ratio of 1.75 for five scenarios in 
Table 5 at Day 15. ....................................................................................................................... 157 
 
 
LIST OF FIGURES 
No table of figures entries found. 
 

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1. 
OVERALL PROTOCOL SUMMARY 
 
1.1 
Synopsis 
Rationale for Proposed Clinical Study 
In December 2019, the Wuhan Municipal Health Committee identified an outbreak of viral 
pneumonia cases of unknown cause. Coronavirus RNA was quickly identified in some of these 
patients. This novel coronavirus has been designated severe acute respiratory syndrome 
coronavirus 2 (SARS-CoV-2), and the disease caused by this virus has been designated 
Coronavirus Disease 2019 (COVID-19). There were 59 cases on January 5, 2020, 278 cases on 
January 20, 2020, 318,000 cases on March 22, 2020, and more than 1,800,000 cases and 113,000 
deaths as of April 12, 2020 according to various international health reporting agencies (1). 
Currently there are no approved therapeutic agents available for coronaviruses.  
 
Study Design 
This study is an adaptive randomized double-blind placebo-controlled trial to evaluate the safety 
and efficacy of novel therapeutic agents in hospitalized adults diagnosed with COVID-19. The 
study is a multicenter trial that will be conducted in up to approximately 100 sites globally. The 
study will compare different investigational therapeutic agents to a control arm. New arms can 
be introduced according to scientific and public health needs. There will be interim monitoring to 
allow early stopping for futility, efficacy, or safety. If one therapy proves to be efficacious, then 
this treatment may become the control arm for comparison(s) with new experimental 
treatment(s). Any such change would be accompanied by an updated sample size. This adaptive 
platform is used to rapidly evaluate different therapeutics in a population of those hospitalized 
with moderate to severe COVID-19. The platform will provide a common framework sharing a 
similar population, design, endpoints, and safety oversight. New stages with new therapeutics 
can be introduced and will be described in a stage-specific appendix. One independent Data and 
Safety Monitoring Board (DSMB) will actively monitor interim data in all stages to make 
recommendations about early study closure or changes to study arms.  
 
Subjects will be assessed daily while hospitalized. See section study specific Schedule of 
Assessment for details. All subjects will undergo a series of efficacy, safety, and laboratory 
assessments. See stage specific schedule of assessment for details.  
 
The primary outcome is time to recovery by Day 29 (see table below for definition based on the 
ordinal scale). A key secondary outcome evaluates treatment-related improvements in the 8-point 
ordinal scale at Day 15. Each stage may prioritize different secondary endpoints for the purpose 
of multiple comparison analyses. 
 
Study Objectives  
OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
Primary 
 
To evaluate the clinical efficacy, as assessed 
by time to recovery, of different 
Day of recovery is defined as the first day on 
which the subject satisfies one of the 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
investigational therapeutics as compared to 
the control arm. 
following three categories from the ordinal 
scale: 
 Hospitalized, not requiring supplemental 
oxygen - no longer requires ongoing 
medical care; 
 Not hospitalized, but new or increased 
limitation on activities and/or requiring 
new or increased home oxygen; 
 Not hospitalized, no limitations on 
activities. 
Recovery is evaluated up until Day 29. 
Secondary 
 
To evaluate the clinical efficacy of different 
investigational therapeutics relative to the 
control arm in adults hospitalized with 
COVID-19 according to clinical status (8-
point ordinal scale) at Day 15 
 
 
 
 Death; 
 Hospitalized, on invasive mechanical 
ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation 
or high flow oxygen devices; 
 Hospitalized, requiring supplemental 
oxygen; 
 Hospitalized, not requiring supplemental 
oxygen - requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental 
oxygen - no longer requires ongoing 
medical care; 
 Not hospitalized, but new or increased 
limitation on activities and/or requiring 
new or increased home oxygen; 
 Not hospitalized, no limitations on 
activities. 
1. To evaluate the clinical efficacy of 
different investigational therapeutics as 
compared to the control arm as assessed by: 
 Clinical Severity 
o Ordinal scale: 
▪ Time to an improvement of one 
category and two categories from 
Day 1 (baseline) using an ordinal 
scale. 
▪ Subject clinical status using ordinal 
scale at Days 3, 5, 8, 11, 15, 22, and 
29.  
 
 
 
 Clinical outcome assessed using ordinal 
scale daily while hospitalized and on Days 
15, 22, and 29. 
 
 
 
 
 
 
 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
▪ Mean change in the ordinal scale 
from Day 1 to Days 3, 5, 8, 11, 15, 
22, and 29. 
 
o National Early Warning Score 
(NEWS): 
▪ Time to discharge or to a NEWS of 
≤ 2 and maintained for 24 hours, 
whichever occurs first.  
▪ Change from Day 1 to Days 3, 5, 8, 
11, 15, and 29 in NEWS.  
 
 
 
 NEWS assessed daily while hospitalized 
and on Days 15 and 29 (if the subject 
attends an in-person visit or still 
hospitalized) 
o Oxygenation: 
▪ Oxygenation use up to Day 29. 
▪ Incidence and duration of new 
oxygen use during the study. 
 
 
 Days of supplemental oxygen (if 
applicable) up to Day 29 
 
o Non-invasive ventilation/high flow 
oxygen: 
▪ Non-invasive ventilation/high flow 
oxygen use up to Day 29. 
▪ Incidence and duration of new non-
invasive ventilation or high flow 
oxygen use during the study. 
 
 Days of non-invasive ventilation/high 
flow oxygen (if applicable) up to Day 29 
o Invasive Mechanical Ventilation / 
extracorporeal membrane oxygenation 
(ECMO): 
▪ Ventilator / ECMO use up to Day 
29. 
▪ Incidence and duration of new 
mechanical ventilation or ECMO use 
during the study.  
 
 
 Days of invasive mechanical 
ventilation/ECMO (if applicable) up to 
Day 29. 
 
 Hospitalization 
o Duration of hospitalization (days).  
 
 
 Days of hospitalization up to Day 29 
 Mortality 
o 14-day mortality 
o 28-day mortality 
 
 
 Date and cause of death (if applicable) 
 
2. To evaluate the safety of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 
 
 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 Cumulative incidence of SAEs through 
Day 29. 
 Cumulative incidence of Grade 3 and 4 
clinical and/or laboratory AEs through 
Day 29. 
 Discontinuation or temporary 
suspension of study product 
administrations (for any reason) 
 Changes in white blood cell (WBC) 
count with differential, hemoglobin, 
platelets, creatinine, glucose, total 
bilirubin, alanine aminotransferase 
(ALT), aspartate aminotransferase 
(AST), and prothrombin time (PT 
reported as INR) over time (analysis of 
lab values in addition to AEs noted 
above). 
 SAEs 
 Grade 3 and 4 AEs  
 WBC with differential, hemoglobin, 
platelets, creatinine, glucose, total 
bilirubin, ALT, AST, and PT/INR on 
Day 1; Days 3, 5, 8, and 11 (while 
hospitalized); and Days 15 and 29 (if 
attends in-person visit or still 
hospitalized). 
 
Exploratory  
 
To evaluate the virologic efficacy of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 Percent of subjects with SARS-CoV-2 
detectable in OP sample at Days 3, 5, 
8, 11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in OP 
sample at Days 3, 5, 8, 11, 15, and 29. 
 Development of resistance of SARS-
CoV-2 in OP sample at Days 3, 5, 8, 
11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in 
blood at Days 3, 5, 8, and 11. 
 
 
 
 
 Qualitative and quantitative polymerase 
chain reaction (PCR) for SARS-CoV-2 in 
OP swab on Day 1; Days 3, 5, 8, and 11 
(while hospitalized); and Days 15 and 29 
(if attends in-person visit or still 
hospitalized). 
 Qualitative and quantitative PCR for 
SARS-CoV-2 in blood on Day 1; Days 3, 
5, 8, and 11 (while hospitalized). 
 
Study Population 
This trial will study putative therapeutics in a hospitalized population with moderate to severe 
COVID-19. The platform trial will have common inclusion criteria but may be modified for each 
stage for the unique risk of the study product in that stage. Exclusion criteria are described in 
each stage specific appendix.  
 
Inclusion Criteria 
1. Admitted to a hospital with symptoms suggestive of COVID-19. 
2. Subject (or legally authorized representative) provides informed consent prior to 
initiation of any study procedures. 

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3. Subject (or legally authorized representative) understands and agrees to comply with 
planned study procedures. 
4. Male or non-pregnant female adult ≥18 years of age at time of enrollment. 
5. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR or other 
commercial or public health assay in any specimen, as documented by either of the 
following:  
 PCR positive in sample collected < 72 hours prior to randomization; OR 
 PCR positive in sample collected ≥ 72 hours prior to randomization, documented 
inability to obtain a repeat sample (e.g. due to lack of testing supplies, limited 
testing capacity, results taking > 24 hours, etc.) AND progressive disease 
suggestive of ongoing SARS-CoV-2 infection. 
6. Illness of any duration, and at least one of the following: 
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR 
 SpO2 ≤ 94% on room air, OR 
 Requiring supplemental oxygen, OR 
 Requiring mechanical ventilation. 
7. Women of childbearing potential must agree to either abstinence or use at least one 
primary form of contraception not including hormonal contraception from the time of 
screening through Day 29.  
8. Agrees to not participate in another clinical trial for the treatment of COVID-19 through 
Day 29. 
 
Exclusion Criteria 
Exclusion criteria are described in each stage specific appendix. 
 
 
Study Phase 
 Phase 3 
 
Study Population 
Hospitalized adults (≥18 years old) with COVID-19. 
 
Study Sites 
There will be up to approximately 100 sites globally. Site selection will be determined as 
information becomes available about the epidemiology of COVID-19. Multiple sites will be 
IRB-approved, but site activation will be dependent on the incidence of COVID-19 at the site.  
 
Study Intervention 
Each stage specific appendix will detail the stage specific study intervention 
 
Study Duration 
The full adaptive study will last for up to 3 years.  
 
Participant Duration 
An individual subject will complete the study in about 29 days, from screening at Day -1 or 1 to 
follow-up on Day 29 ± 3 days.  

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Safety 
 Given the potential severity of COVID-19 and limited information about the expected 
clinical course, there are no pre-specified study stopping rules (except as noted under 
DSMB). A subset of the protocol team will review blinded/pooled data of Grade 3 and 4 
AE / SAE every 2 weeks. If there is a pattern of unexpected AEs that is out of proportion 
to the current understanding of the natural history of the disease, the DSMB will be asked 
to review unblinded safety data in an ad hoc meeting. 
 The DSMB will have access to safety data electronically in real time, will have formal 
safety/efficacy reviews after approximately every 200 subjects have met recovered status 
for each pairwise comparison. Additionally, the DSMB will be available for ad hoc 
reviews for safety concerns as described above. The study will not stop enrollment 
awaiting these DSMB reviews, though the DSMB may recommend temporary or 
permanent cessation of enrollment based on their safety reviews. 
  
1.2 
Stages in the adaptive trial 
Each new intervention represents a new stage in the adaptive design clinical trial. In order to 
clearly convey the protocol elements, interventions, objectives and endpoints for each stage, 
common elements are described in the main protocol document while each stage is noted in a 
stage specific appendix.  
 
The stages in the clinical trial include: 
ACTT-1: Remdesivir vs Placebo Trial 
ACTT-2: Baricitinib/Remdesivir vs. Remdesivir Trial 
ACTT-3: Interferon beta-1a/Remdesivir vs. Remdesivir Trial 
 
1.3 
Schedule of Assessments 
Table 1. Schedule of Assessments (SOA) 
  
Screen 
Baseline  Study Intervention Period 
Follow-up Visits  
Day +/- Window 
−1 or 1 
1 
Daily until hospital 
discharge 
157  
± 2 
227 
± 3 
297 
± 3 
ELIGIBILITY 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
Demographics & Medical History 
X 
 
 
 
 
 
Targeted physical exam 
X 
 
 
 
 
 
Review SARS-CoV-2 results 
X 
 
 
 
 
 
 
 
 
 
 
 
 
STUDY INTERVENTION 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
Administration of investigational 
agent 
 
Detailed in the stage specific 
appendix. 
 
 
 
 
 
 
 
 
 
STUDY PROCEDURES 
 
 
 
 
 
 
Vital signs including SpO2 
 
X4 
Daily until discharge 
X7 
 
X7 
Clinical data collection1  
 
X4 
Daily until discharge 
X7 
X7 
X7 

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Adverse event evaluation 
 
X4 
Daily until discharge 
X7 
X7 
X7 
Concomitant medication review 
 
X4 
Detailed in the stage 
specific appendix 
 
 
 
 
 
 
 
 
 
 
SAFETY LABORATORY 
 
 
 
 
 
 
Safety hematology, chemistry and 
liver tests 
X2,3 
X4,5,6 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized5,6 
X7 
 
X7 
Pregnancy test for females of 
childbearing potential 
X2,3 
 
 
 
 
 
 
 
 
 
 
 
 
RESEARCH LABORATORY  
 
 
 
 
 
 
Blood for plasma to test for PCR 
SARS-CoV-2 
 
X5 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized 
 
 
 
Oropharyngeal swab 8 
 
X5 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized 
X7 
 
X7 
Blood for serum (secondary 
research) 
 
X5 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized 
X7 
 
X7 
Notes: 
1 Refer to Section 8.1 of the protocol for details of clinical data to be collected including ordinal score, NEWS, oxygen 
requirement, mechanical ventilator requirement, etc. 
2 Screening laboratory tests include: ALT, AST, creatinine (and calculate an estimated glomerular filtration rate (eGFR) 
the formula used is determined by the sites, but should be consistent throughout the study), and pregnancy test. See stage-
specific appendix as additional screening laboratory tests may be added based on study product risk profile. 
3 Laboratory tests performed in the 48 hours prior to enrollment will be accepted for determination of eligibility. 
4 Baseline assessments should be performed prior to first study product administration. Laboratory tests performed as part 
of routine clinical care in the 24 hours prior to first dose will be accepted for the baseline safety laboratory tests. Baseline 
may be the same as the screening laboratory tests.  
5Safety laboratory tests include WBC with differential, hemoglobin, platelets, creatinine, glucose, total bilirubin, ALT, AST, 
and PT. See stage-specific appendix as additional safety laboratory tests may be added based on study product risk profile. 
6 Any laboratory tests performed as part of routine clinical care within the specified visit window can be used for safety 
laboratory testing. Window during the 10 days of dosing is ±1 day. 
7 In-person visits are preferred but recognizing quarantine and other factors may limit the subject’s ability to return to the 
site for the visit. In this case, the visit may be performed by phone. 
 
If still hospitalized at Day 15 and 29 or returns to the site for an in-person visit: collect clinical data (ordinal and 
NEWS), vital signs, safety laboratory tests, and research laboratory samples (OP swab and serum only) as able.  
 
If phone call only on Days 15 and 29 and all Day 22 visits: assess adverse events, clinical status (ordinal scale), 
readmission to a hospital, and mortality only. 
8 Oropharyngeal swabs are preferred, but if these are not obtainable, nasopharyngeal or nasal swabs may be substituted.  
 
1.4 
Study Schema 

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2. 
INTRODUCTION 
2.1 
Study Rationale 
COVID-19 is a respiratory disease caused by a novel coronavirus (SARS-CoV-2) and causes 
substantial morbidity and mortality. There is currently no vaccine to prevent infection with 
SARS-CoV-2 or therapeutic agent to treat COVID-19. This clinical trial is designed to evaluate 
investigational therapeutics for the treatment of adults hospitalized with COVID-19. 
2.2 
Background 
2.2.1 
Purpose of Study 
Coronavirus (CoVs) are positive-sense, single stranded, enveloped RNA viruses, many of which 
are commonly found in humans and cause mild symptoms. Over the past two decades, emerging 
pathogenic CoVs capable of causing life-threatening disease in humans and animals have been 
identified, namely, severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002-2003 
and Middle East respiratory syndrome coronavirus (MERS-CoV) in 2012.  
 
In December 2019, the Wuhan Municipal Health Committee (Wuhan, China) detected an outbreak 
of viral pneumonia cases of unknown cause. Coronavirus RNA was quickly identified in some 
patients. This novel coronavirus has been designated as SARS-COV-2 and has 89% nucleotide 
identity with bat SARS-like-CoVZXC21 and 82% with that of human SARS-CoV-1. The human 
disease caused by SARS-CoV-2 has been designated COVID-19. In most (~80%) cases, COVID-
19 presents as a mild-to-moderately severe, self-limited acute respiratory illness with fever, cough, 
and shortness of breath. Symptoms are thought to appear 2 to 14 days after exposure. COVID-19 
can be severe, resulting in pneumonia, severe acute respiratory syndrome (ARDS), kidney failure, 
and death. The first US COVID-19 death occurred on February 29, 2020. 
 
During this COVID-19 outbreak, the incidence of cases has rapidly increased such that on January 
5, 2020 there were 59 confirmed cases, 278 cases on January 20, 2020, and more than 318,000 
cases and 13,000 deaths as of March 22, 2020 according to various international health reporting 
agencies. As a result, on January 30, 2020, the International Health Regulations Emergency 
Drug X 

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Committee of the World Health Organization (WHO) declared the COVID-19 outbreak a Public 
Health Emergency of International Concern. On January 31, 2020, the US Department of Health 
and Human Services declared a public health emergency in the United States. On March 11, 2020, 
the WHO declared the COVID-19 outbreak a pandemic. Outbreak forecasting and modeling 
suggest that these numbers will continue to rise (2).  
 
Global efforts to evaluate novel antivirals and therapeutic interventions to treat COVID-19 have 
intensified. There is currently no vaccine to prevent SARS-CoV-2 infection or therapeutic agent 
to treat COVID-19. Therefore, there is an urgent public health need for rapid development of 
novel interventions.  
 
2.3 
Risk/Benefit Assessment 
Each stage will detail the stage and study specific risk/benefit assessment.  
3. 
OBJECTIVES AND ENDPOINTS 
The overall objective of the study is to evaluate the clinical efficacy and safety of different 
investigational therapeutics relative to the control arm among hospitalized adults who have 
COVID-19. 
 
OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
Primary 
 
To evaluate the clinical efficacy, as assessed 
by time to recovery, of different 
investigational therapeutics as compared to 
the control arm. 
Day of recovery is defined as the first day on 
which the subject satisfies one of the 
following three categories from the ordinal 
scale: 
 Hospitalized, not requiring supplemental 
oxygen - no longer requires ongoing 
medical care; 
 Not hospitalized, but new or increased 
limitation on activities and/or requiring 
new or increased home oxygen; 
 Not hospitalized, no limitations on 
activities. 
Recovery is evaluated up until Day 29. 
Key Secondary 
 
To evaluate the clinical efficacy of different 
investigational therapeutics relative to the 
control arm in adults hospitalized with 
COVID-19 according to clinical status (8-
point ordinal scale) at Day 15 
 
 
 
 Death; 
 Hospitalized, on invasive mechanical 
ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation 
or high flow oxygen devices; 
 Hospitalized, requiring supplemental 
oxygen; 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 Hospitalized, not requiring supplemental 
oxygen - requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Not hospitalized, but new or increased 
limitation on activities and/or requiring 
new or increased home oxygen; 
 Not hospitalized, no limitations on 
activities. 
Additional Secondary  
 
1. To evaluate the clinical efficacy of 
different investigational therapeutics as 
compared to the control arm as assessed by: 
 Clinical Severity 
o Ordinal scale: 
▪ Time to an improvement of one 
category and two categories from 
Day 1 (baseline) using an ordinal 
scale. 
▪ Subject clinical status using ordinal 
scale at Days 3, 5, 8, 11, 15, 22, and 
29.  
▪ Mean change in the ordinal scale 
from Day 1 to Days 3, 5, 8, 11, 15, 
22, and 29. 
 
 
 
 
 Clinical outcome assessed using ordinal 
scale daily while hospitalized and on Days 
15, 22, and 29. 
 
 
 
 
 
 
 
o National Early Warning Score 
(NEWS): 
▪ Time to discharge or to a NEWS of 
≤ 2 and maintained for 24 hours, 
whichever occurs first.  
▪ Change from Day 1 to Days 3, 5, 8, 
11, 15, and 29 in NEWS.  
 
 
 
 NEWS assessed daily while hospitalized 
and on Days 15 and 29. 
o Oxygenation: 
▪ Oxygenation use up to Day 29. 
▪ Incidence and duration of new 
oxygen use during the study. 
 
 
 Days of supplemental oxygen (if 
applicable) up to Day 29 
 
o Non-invasive ventilation/high flow 
oxygen: 
▪ Non-invasive ventilation/high flow 
oxygen use up to Day 29. 
 Days of non-invasive ventilation/high 
flow oxygen (if applicable) up to Day 29 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
▪ Incidence and duration of new non-
invasive ventilation or high flow 
oxygen use during the study. 
 
o Invasive Mechanical Ventilation / 
extracorporeal membrane oxygenation 
(ECMO): 
▪ Ventilator / ECMO use up to Day 
29. 
▪ Incidence and duration of new 
mechanical ventilation or ECMO use 
during the study.  
 
 
 Days of invasive mechanical 
ventilation/ECMO(if applicable) up to 
Day 29. 
 
 Hospitalization 
o Duration of hospitalization (days).  
 
 
 Days of hospitalization up to Day 29 
 Mortality 
o 14-day mortality 
o 28-day mortality 
 
 
 Date and cause of death (if applicable) 
 
2. To evaluate the safety of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 Cumulative incidence of SAEs through 
Day 29. 
 Cumulative incidence of Grade 3 and 4 
clinical and/or laboratory AEs through 
Day 29. 
 Discontinuation or temporary 
suspension of study product 
administrations (for any reason) 
 Changes in white blood cell (WBC) 
count with differential, hemoglobin, 
platelets, creatinine, glucose, total 
bilirubin, alanine aminotransferase 
(ALT), aspartate aminotransferase 
(AST), and prothrombin time (PT) over 
time (analysis of lab values in addition 
to AEs noted above). 
 
 
 
 SAEs 
 Grade 3 and 4 AEs  
 WBC with differential, hemoglobin, 
platelets, creatinine, glucose, total 
bilirubin, ALT, AST, and PT on Day 1; 
Days 3, 5, 8, and 11 (while hospitalized); 
and Days 15 and 29 (if attends in-person 
visit or still hospitalized). 
 
Exploratory  
 
To evaluate the virologic efficacy of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 
 
 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 Percent of subjects with SARS-CoV-2 
detectable in OP sample at Days 3, 5, 
8, 11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in OP 
sample at Days 3, 5, 8, 11, 15, and 29. 
 Development of resistance of SARS-
CoV-2 in OP sample at Days 3, 5, 8, 
11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in 
blood at Days 3, 5, 8, and 11. 
 
 Qualitative and quantitative polymerase 
chain reaction (PCR) for SARS-CoV-2 in 
OP swab on Day 1; Days 3, 5, 8, and 11 
(while hospitalized); and Days 15 and 29 
(if attends in-person visit or still 
hospitalized). 
 Qualitative and quantitative PCR for 
SARS-CoV-2 in blood on Day 1; Days 3, 
5, 8, and 11 (while hospitalized). 
  
4. 
STUDY DESIGN 
4.1 
Overall Design 
This study is an adaptive randomized double-blind placebo-controlled trial to evaluate the safety 
and efficacy of novel therapeutic agents in hospitalized adults diagnosed with COVID-19. The 
study is a multicenter trial that will be conducted in up to approximately 100 sites globally. The 
study will compare different investigational therapeutic agents to a control arm. New arms can 
be introduced according to scientific and public health needs. There will be interim monitoring to 
allow early stopping for futility, efficacy, or safety. If one therapy proves to be efficacious, then 
this treatment may become the control arm for comparison(s) with new experimental 
treatment(s). Any such change would be accompanied by an updated sample size. This adaptive 
platform is used to rapidly evaluate different therapeutics in a population of those hospitalized 
with moderate to severe COVID-19. The platform will provide a common framework sharing a 
similar population, design, endpoints, and safety oversight. New stages with new therapeutics 
can be introduced and will be described in a stage-specific appendix. One independent Data and 
Safety Monitoring Board (DSMB) will actively monitor interim data in all stages to make 
recommendations about early study closure or changes to study arms.  
 
Subjects will be assessed daily while hospitalized. See section study specific Schedule of 
Assessment for details. All subjects will undergo a series of efficacy, safety, and laboratory 
assessments. See stage specific schedule of assessment for details.  
 
The primary outcome is time to recovery by Day 29 (see table below for definition based on the 
ordinal scale). A key secondary outcome evaluates treatment-related improvements in the 8-point 
ordinal scale at Day 15. Each stage may prioritize different secondary endpoints for the purpose 
of multiple comparison analyses. 
 
The sample size will be described in each stage specific appendix.  
 

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4.2 
Scientific Rationale for Study Design 
This study utilizes an adaptive platform design that increases efficiency to identify safe and 
efficacious therapeutic agents for patients with COVID-19 during the current outbreak. Some 
investigational products may be in limited supply and this study design enables continuation of 
the study even if a product becomes unavailable. In addition, the adaptive design allows for the 
evaluation of new therapeutic agents as they are identified and ready for testing in clinical trials. 
As the study is a multicenter, multinational randomized controlled study, we will be able to 
acquire rigorous data about the safety and efficacy of investigational therapeutic agents for 
COVID-19 that will lead to generalizable evidence. Randomization is essential for establishing 
efficacy of these new therapeutic agents. Last, collecting clinical and virologic data on enrolled 
subjects using a standardized timeline and collection instruments should provide valuable 
information about the clinical course of and morbidities associated with COVID-19 in a diverse 
group of hospitalized adults. 
 
5. 
STUDY POPULATION 
This trial will study putative therapeutics in a hospitalized population with moderate to severe 
COVID-19. The platform trial will have common inclusion criteria but may be modified in each 
stage-specific appendix for the unique risk associated with the study product used in that stage. 
Exclusion criteria are described in each stage specific appendix.  
5.1 
Inclusion Criteria 
In order to be eligible to participate in this study, a patient must meet all of the following criteria: 
1. Admitted to a hospital with symptoms suggestive of COVID-19. 
2. Subject (or legally authorized representative) provides informed consent prior to 
initiation of any study procedures. 
3. Subject (or legally authorized representative) understands and agrees to comply with 
planned study procedures. 
4. Male or non-pregnant female adult ≥18 years of age at time of enrollment. 
5. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR or other 
commercial or public health assay in any specimen, as documented by either of the 
following:  
 PCR positive in sample collected < 72 hours prior to randomization; OR 
 PCR positive in sample collected ≥ 72 hours prior to randomization, documented 
inability to obtain a repeat sample (e.g. due to lack of testing supplies, limited 
testing capacity, results taking > 24 hours, etc.) AND progressive disease 
suggestive of ongoing SARS-CoV-2 infection. 
6. Illness of any duration, and at least one of the following: 
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR 
 SpO2 ≤ 94% on room air, OR 
 Requiring supplemental oxygen, OR 
 Requiring mechanical ventilation. 
7. Women of childbearing potential must agree to either abstinence or use at least one 
primary form of contraception not including hormonal contraception from the time of 
screening through Day 29.  

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8. Agrees to not participate in another clinical trial for the treatment of COVID-19 or 
SARS-CoV-2 through Day 29. 
5.2 
Exclusion Criteria 
Exclusion criteria are described in each stage specific appendix. 
5.3 
Specific Populations 
The inclusion of vulnerable subjects and exclusion of specific populations need to be customized 
according to each intervention, with the current understanding of epidemiology and clinical 
disease. Inclusion and exclusion of specific populations will be described for each stage in the 
stage-specific appendices. 
5.4 
Strategies for Recruitment and Retention 
5.4.1 
Recruitment 
It is anticipated that patients with COVID-19 will present to participating hospitals, and that no 
external recruitment efforts towards potential subjects are needed. Recruitment efforts may also 
include dissemination of information about this trial to other medical professionals / hospitals.  
 
The IRB will approve the recruitment process and all materials provided prior to any recruitment 
to prospective subjects directly. 
 
Screening will begin with a brief discussion with study staff. Some will be excluded based on 
demographic data and medical history (i.e., pregnant, < 18 years of age, renal failure, etc.). 
Information about the study will be presented to potential subjects (or legally authorized 
representative) and questions will be asked to determine potential eligibility. Screening 
procedures can begin only after informed consent is obtained. 
 
5.4.2 
Retention 
Retention of subjects in this trial is very important for determining the primary endpoint. As 
such, after hospital discharge, participating subjects will be reminded of subsequent study visits 
and every effort will be made to accommodate the subject’s schedule to facilitate follow-up 
within the specified visit window. Additionally, there are many circumstances that influence the 
ability to obtain outcome information after discharge. Follow-up visits may be conducted by 
phone if in-person visits are not feasible.  
 
5.4.3 
Compensation Plan for Subjects  
Compensation, if any, will be determined locally and in accordance with local IRB requirements, 
and subject to local IRB approval.  
 
5.4.4 
Costs 
There is no cost to subjects for the research tests, procedures/evaluations and study product while 
taking part in this trial. Procedures and treatment for clinical care including costs associated with 
hospital stay may be billed to the subject, subject’s insurance or third party. 

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6. 
STUDY PRODUCT 
Each stage in this platform trial may have different study products. Information about the study 
product(s) for a given stage can be found in the stage specific appendix.  
7. 
STUDY INTERVENTION DISCONTINUATION AND 
SUBJECT DISCONTINUATION/WITHDRAWAL 
7.1 
Halting Criteria and Discontinuation of Study Intervention 
7.1.1 
Individual Study Product Halting 
See the stage specific appendix for specific study product stopping rules.  
 
7.1.2 
Study Halting 
Given the potential severity of COVID-19, there are no pre-specified study stopping rules. 
Instead there will be close oversight by the protocol team and frequent DSMB reviews of the 
safety data.  
 
7.2 
Withdrawal from the Study 
Subjects are free to withdraw from participation in the study at any time upon request, without 
any consequence. Subjects should be listed as having withdrawn consent only when they no 
longer wish to participate in the study and no longer authorize the Investigators to make efforts 
to continue to obtain their outcome data.  
 
Subjects who withdraw from this study or are lost to follow-up after signing the informed 
consent form (ICF) and administration of the study product, will not be replaced. The reason for 
subject withdrawal from the study will be recorded on the appropriate CRF. 
7.3 
Lost to Follow-Up 
A subject will be considered lost to follow-up if he or she fails to appear for all follow-up 
assessments. In lost to follow-up cases, attempts to contact the subject should be made and these 
efforts should be documented in the subject’s records.  
8. 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
Screening and Efficacy Assessments 
8.1.1 
Screening Procedures 
Screening procedures may be done over one to two calendar days (from Day -1 to Day 1). 
However, in many cases all the screening assessments can be done in less than 24 hours. If that is 
the case, Day 1 pre-study product administration baseline assessments, specimen collection and 

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the initial study product administration can occur on the same calendar day as the screening 
procedures.  
 
After the informed consent, the following assessments are performed to determine eligibility and 
obtain baseline data: 
 
Confirm the positive SARS-CoV-2 test result (per inclusion criteria).  
 
Take a focused medical history, including the following information. Additional information 
may be needed based on risk profile of the study product and the exclusion criteria (e.g., 
recent live vaccine history). Please consult stage-specific appendix. The minimum history 
includes:  
 Day of onset of COVID-19 signs and symptoms. 
 History of chronic medical conditions including chronic oxygen requirement prior to 
onset of COVID-19. 
 History of medication allergies. 
 Medications and therapies for this current illness taken in the 7 days prior to Day 1. 
 Ask if they are participating in another clinical trial or plan to enroll in another 
clinical trial in the next 30 days. 
 
Women of childbearing potential should be counseled to either practice abstinence or use at 
least one primary form of contraception not including hormonal contraception from the time 
of screening through Day 29. Women should be confirmed to not be breastfeeding. 
 
Note: If a woman is either postmenopausal (i.e., has had ≥12 months of spontaneous 
amenorrhea) or surgically sterile (i.e., has had a hysterectomy, bilateral ovariectomy 
(oophorectomy), or bilateral tubal ligation), she is not considered to be of 
childbearing potential.  
 
Height and weight (height can be self-reported). 
 
Results of recent radiographic imaging (x-ray or CT scan). 
 
SpO2. 
 
Blood for screening laboratory evaluations if not done as part of routine clinical care in the 
preceding 48 hours. Additional screening laboratory evaluations may be added based on the 
risk profile of the study product for a given stage of the study. Please see stage specific 
appendix. The minimum screening laboratory evaluations include: 
▪ ALT. 
▪ AST. 
▪ Creatinine (and calculate eGFR).  
 Any automated calculation by the clinical laboratory or published formula for this 
calculation is acceptable. The site should select a formula to be used for all 
subjects enrolled at the site for the duration of the study. 
 
Urine or serum pregnancy test (in women of childbearing potential). 

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Clinical screening laboratory evaluations will be performed locally by the site laboratory. The 
volume of venous blood to be collected is presented in Table 3. 
 
The overall eligibility of the subject to participate in the study will be assessed once all screening 
values are available. Complete the Eligibility Checklist on day of enrollment as this form 
includes data needed to register all potential subjects in the Advantage eClinical system. The 
screening process can be suspended prior to complete assessment at any time if exclusions are 
identified by the study team. 
 
Study subjects who qualify will be randomized in the Advantage eClinical system, and all others 
will be registered as screen failures. The study team has 24 hours to complete Day 1 baseline 
assessments prior to the first study product administration including the collection of OP swab 
and blood, assessment of the ordinal scale and NEWS and completing or recording a baseline 
physical examination that was done. 
8.1.2 
Efficacy Assessments 
For all baseline assessments and follow-up visits, refer to the Schedule of Assessments (SOA) 
for procedure to be done, and details below for each assessment. 
 
8.1.2.1 
Measures of clinical support, limitations and infection control 
The subject’s clinical status will be captured on each study day while hospitalized up until and 
including Day 29. If a subject is discharged prior to Day 15, clinical status is captured on Day 15 
and 29 if the subject returns for an in-person clinic visit or by phone if an in-person visit is not 
possible. Clinical status will also be captured on Day 22 during a phone visit. Clinical status is 
largely measured by the ordinal scale and the NEWS. Unlike the NEWS, the ordinal scale can 
also be evaluated over the phone if the discharged subject is unable to return for visits on Day 15 
and 29 as well as on Day 22.  
 
Ideally, complete the ordinal scale concurrently with the NEW Score just prior to study product 
administration, as time permits. The following measures are recorded for the ordinal scale: 
 Hospitalization. 
 Oxygen requirement. 
 Non-invasive mechanical ventilation (via mask) requirement. 
 High flow oxygen requirement. 
 Invasive mechanical ventilation (via endotracheal tube or tracheostomy tube) 
requirement. 
 ECMO requirement. 
 Ongoing medical care preventing hospital discharge (COVID-19 related or other medical 
conditions). 
 Limitations of physical activity (self-assessed). 
 Isolated for infection control purposes. 
 
8.1.2.2 
Ordinal Scale 
The ordinal scale is the primary measure of clinical outcome.  

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The scale used in this study is as follows (from worst to best): 
 Death; 
 Hospitalized, on invasive mechanical ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation or high flow oxygen devices; 
 Hospitalized, requiring supplemental oxygen; 
 Hospitalized, not requiring supplemental oxygen - requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental oxygen - no longer requires ongoing medical 
care; 
o This would include those kept in hospital for quarantine/infection control, awaiting 
bed in rehabilitation facility or homecare, etc. 
 Not hospitalized, but new or increased limitation on activities and/or requiring new or 
increased home oxygen; 
 Not hospitalized, no limitations on activities 
 
8.1.2.3 
National Early Warning Score (NEWS) 
NEWS has demonstrated an ability to discriminate subjects at risk of poor outcomes. (Smith, 
2016). This score is based on 7 clinical parameters (see Table 2). The NEWS is being used as an 
efficacy measure. The NEW Score should be evaluated daily while hospitalized and on Days 15 
and 29. It can be performed concurrently with the Ordinal Scale. This should be evaluated at a 
consistent time for each study day and prior to administration of study product. The 7 parameters 
can be obtained from the hospital chart or electronic medical record (EMR) using the last 
measurement prior to the time of assessment and a numeric score is given for each parameter 
(e.g., a RR of 9 is one point, oxygen saturation of 92 is two points). This is recorded for the day 
obtained (i.e., on Day 3, the vital signs and other parameters from Day 3 are used to obtain NEW 
Score for Day 3). ECMO and mechanically ventilated subjects should be assigned a score of 3 
for RR (RR <8) regardless of the ventilator setting. Subjects on ECMO should get a score of 3 
for heart rate since they are on cardiopulmonary bypass. 
 
 

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Table 2. National Early Warning Score (NEWS) 
 
  Level of consciousness = alert (A), and non-alert and arousable only to voice (V) or pain (P), and 
unresponsive (U).  
 
8.1.3 
Exploratory assessments 
8.1.3.1 
Viral Load and/or Shedding 
As outlined on the SOA, OP swabs and plasma and serum will be collected on Day 1; and Days 
3, 5, 8, and 11 (while hospitalized); and OP swabs and serum on Day 15 and 29 (if attends an in- 
person visit or still hospitalized). Samples are stored as outlined in the MOP. These assays are 
not developed yet, and the ability to test samples at one central lab is not clear. Therefore, while 
viral load/shedding is thought to be an important endpoint, considering the limitations above, it is 
listed as an exploratory endpoint.  
 
OP swabs are preferred, but if these are not obtainable, nasopharyngeal (NP) or nasal swabs may 
be substituted. Due to limited lack of swabs and other supplies at some sites and limitations on 
personal protective equipment (PPE), the inability to obtain these samples are not considered 
protocol deviations and should be documented in the subject’s record.  
 
If virology assays can be set up with enough numbers of specimens tested, these data will be 
submitted as part of the Clinical Study Report (CSR). This may be submitted separately, as a 
supplemental CSR.  
 
Samples collected for viral assessment may be probed for the emergence of antiviral resistance at 
a future date. These data, if available, may be submitted as a supplement report. 
 
The schedule of assessments (SOA, Section 1.3) lists several research laboratory samples. It is 
preferred that these samples are collected and sent to the NIAID repository to be tested in one 

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central laboratory. Current US Centers for Disease Control and Prevention (CDC) guidance is 
these samples can be processed in a Biosafety Laboratory (BSL) 2 environment. However, 
institutions may impose restrictions on processing the samples (i.e., they may require BSL-3) or 
there may be restrictions on sending samples. In these circumstances, the following apply: 
 
Blood for PCR SARS-CoV-2 
 If the samples can be processed but cannot be sent to the repository, the samples may be 
stored locally.  
 The sponsor may elect to have some or all of these samples run locally, pending 
confirmation of the assays to be used and the qualifications of the local laboratory. The 
sponsor will work with the site to determine when this could occur and how these data can 
be imported into the study database.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
Oropharyngeal swab 
 If the samples can be processed but cannot be sent to the repository, the samples may be 
stored locally.  
 The sponsor may elect to have some or all of these samples run locally, pending 
confirmation of the assays to be used and the qualifications of the local laboratory. The 
sponsor will work with the site to determine when this could occur and how these data can 
be imported into the study database.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
Blood for serum (for secondary research) 
 If the samples can be processed and but not sent to the repository, the samples may be 
stored locally.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
8.2 
Safety and Other Assessments 
Study procedures are specified in the SOA. A study physician licensed to make medical 
diagnoses and listed on the 1572 will be responsible for all trial-related medical decisions. 
 
Physical examination:  
A targeted physical examination will be performed at baseline prior to initial study product 
administration on Day 1. The baseline physical examination can be one that is conducted from 
screening to Day 1. Post-baseline physical examinations will be done only when needed to 
evaluate possible adverse event(s) (i.e. any new signs or symptoms). No routine physical exam is 
needed for study visits after Day 1.  
 
Study staff at some sites are not allowed into the subject’s rooms due to a limited supply of PPE 
and the need for strict respiratory isolation measures for COVID-19 patients. Because of limited 
access to subjects, physical  

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s can be performed by any licensed provider at the study hospital even if they are not study staff 
listed on the 1572. The study team can extract information from the hospital chart or EMR.  
 
Clinical laboratory evaluations: 
 Fasting is not required before collection of laboratory samples. 
 Blood will be collected at the time points indicated in the SOA.  
 Minimal clinical safety laboratory tests include WBC, differential, Hgb, PLT, 
creatinine, glucose, total bilirubin, AST, ALT, and PT. Sites that do not have 
access to a test for PT/INR will be allowed to report an international normalized 
ratio (INR). Additional safety laboratory tests may be required for a given stage 
due to the study product risk profile. See safety laboratory in the stage-specific 
appendix. 
 Day 1 clinical laboratory evaluations are drawn prior to initial study product 
administration as a baseline and results do not need to be reviewed to determine if 
initial study product administration should be given. 
 Clinical laboratory testing will be performed at each clinical trial site in real time.  
 
 
Table 3. Venipuncture Volumes1 
 
Screen 
Baseline 
 
 
 
 
 
 
Day +/- Window 
−1 to 1 
1 ± 1 
3 ± 1 
5 ±1 
8 ± 1 
11 ± 1 
15 ± 2 
29 ± 3 
Safety hematology, 
chemistry and liver 
tests 
 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
 X3 
10mL2 
X3 
10mL2 
Blood for Serum 
 
 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
Plasma  
(includes PCR) 
 
X 
8mL 
X 
8mL 
X 
8mL 
X 
8mL 
X 
8mL 
 
 
Total volume 
10mL 
42ml 
42mL 
42ml 
42ml 
42ml 
34mL 
34mL 
Total all study days 
 
 
 
 
 
 
 
268~288 
mL 
1. See SOA in Section 1.3 for specific tests to be performed. 
2. Total volume calculated assumes there are no routine clinical laboratory were done within 48 hours of screening 
that can be used for determining eligibility and no routine clinical laboratory tests were done within the window for 
that visitor 24 hours of Day 1, 3, 5, 8 and 11 and 48 hours for Day 15 and 72 hours for Day 29 if still hospitalized.  
3. Safety laboratory tests will be collected on Day 15 and 29 if the subject is still hospitalized at these time points or 
if they return for an in-person outpatient visit and the site has the capacity to collect blood in the outpatient setting. 
8.2.1 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings 
If a physiologic parameter (e.g., vital signs, or laboratory value) is outside of the protocol-
specified range, then the measurement may be repeated once if, in the judgment of the 
investigator, the abnormality is the result of an acute, short-term, rapidly reversible condition or 
was an error. A physiologic parameter may also be repeated if there is a technical problem with 
the measurement caused by malfunctioning or an inappropriate measuring device (i.e., 
inappropriate-sized BP cuff). 
 

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8.2.2 
Unscheduled Visits 
If clinical considerations require the subject to be contacted or seen prior to the next schedule 
assessment to assure the subject’s well-being, it is permissible in this protocol. However, no 
research data is collected at this visit.  
8.3 
Adverse Events and Serious Adverse Events 
8.3.1 
Definition of Adverse Event (AE) 
AE means any untoward medical occurrence associated with the use of an intervention in 
humans, whether or not considered intervention-related. An AE can therefore be any unfavorable 
and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of medicinal (investigational) product. If multiple abnormalities are part 
of the same clinical syndrome, they can be reported together as one AE under a unifying clinical 
diagnosis. For example, the diagnosis of bacterial sepsis may include hypotension, positive blood 
culture, and increased white blood cell count. 
 
Any medical condition that is present at the time that the subject is screened will be considered 
as baseline and not reported as an AE. However, if the severity of any pre-existing (baseline) 
medical condition increases above baseline to severity grade 3 or 4, it should be recorded as an 
AE. 
 
Given the nature of severity of the underlying illness, subjects will have many symptoms and 
abnormalities in vital signs and laboratory values. Only Grade 3 and 4 AEs will be captured in 
this trial. In addition, the following AEs will be reported: 
 Any Grade 2 or higher suspected drug-related hypersensitivity reactions associated with 
study product administration will be reported as an AE. 
 
Intermittent abnormal laboratory values or vital sign measurements common in the severely ill 
populations (such as electrolyte abnormalities, low blood pressure, hyperglycemia, etc.) that are 
part of the same clinical diagnosis (e.g., uncontrolled diabetic) can be recorded once with the 
worst grade for each adverse event (grade 3 and 4 only for this trial), with the start and stops 
dates of the intermittent syndrome. If there is clear resolution of the event, and then recurrence, it 
should be treated as a separate adverse event. Resolution is defined as return to baseline (either 
normal if was normal at Day 1, or baseline (Day 1) grade if already an abnormality on the 
toxicity table at Day 1) for > 48 hours.  
 
 
8.3.2 
Definition of Serious Adverse Event (SAE) 
An AE or suspected adverse reaction is considered serious (i.e., is an SAE) if, in the view of 
either the investigator or the Sponsor, it results in any of the following outcomes: 
 Death; 
 A life-threatening AE; 
 Inpatient hospitalization or prolongation of existing hospitalization; 

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 A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions; or 
 A congenital anomaly/birth defect. 
 
Important medical events that may not meet the above criteria may be considered serious when, 
based upon appropriate medical judgment, they may jeopardize the subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm requiring intensive treatment in 
an emergency room or at home, blood dyscrasias, convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
 
“Life-threatening” refers to an AE that at occurrence represents an immediate risk of death to a 
subject. An event that may cause death if it occurs in a more severe form is not considered life-
threatening. Similarly, a hospital admission for an elective procedure is not considered a SAE. 
 
All SAEs, as with any AE, will be assessed for severity and relationship to study intervention. 
 
All SAEs will be recorded on the SAE CRF. 
 
All SAEs will be followed through resolution or stabilization by a licensed study physician (for 
IND studies, a physician listed on the Form FDA 1572 as the site PI or Sub-Investigator). 
 
All SAEs will be reviewed and evaluated by DMID and will be sent to the DSMB (for periodic 
review), and the IRB/IEC. 
8.3.3 
Suspected Unexpected Serious Adverse Reactions (SUSAR) 
A SUSAR is any SAE where a causal relationship with the study product is at least reasonably 
possible but is not listed in the IIB, Package Insert, and/or Summary of Product Characteristics. 
8.3.4 
Classification of an Adverse Event 
The determination of seriousness, severity, and causality will be made by an on-site investigator 
who is qualified (licensed) to diagnose AE information, provide a medical evaluation of AEs, 
and classify AEs based upon medical judgment. This includes but is not limited to physicians, 
physician assistants, and nurse practitioners. 
8.3.4.1 
Severity of Adverse Events 
All AEs and SAEs will be assessed for severity using the DAIDS Table for Grading the Severity 
of Adult and Pediatric Adverse Events, version 2.1 (July 2017).  
 
For AEs not included in the Table, the following guidelines will be used to describe severity. In 
addition, all deaths related to an AE are to be classified as grade 5 according to the DAIDS Table.  
 
 
 Moderate (Grade 2): Events that are usually alleviated with additional specific 
therapeutic intervention. The event interferes with usual activities of daily living and 
causes discomfort but poses no significant or permanent risk of harm to the research 
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 Severe (Grade 3): Events that interrupt usual activities of daily living, or significantly 
affect clinical status, or may require intensive therapeutic intervention. Severe events are 
usually incapacitating. 
 
 Severe (Grade 4): Events that are potentially life threatening. 
 
 Deaths (Grade 5): All deaths related to an AE are to be classified as grade 5. (per DAIDS 
Table). 
 
8.3.4.2 Relationship to Study Intervention 
For each reported adverse reaction, the PI or designee must assess the relationship of the event to 
the study product using the following guideline: 
 
 Related – There is a temporal relationship between the study intervention and event, and 
the AE is known to occur with the study intervention or there is a reasonable possibility 
that the study intervention caused the AE. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the study intervention and the AE. 
 
 Not Related – There is not a reasonable possibility that the administration of the study 
intervention caused the event, there is no temporal relationship between the study 
intervention and event onset, or an alternate etiology has been established. 
8.3.5 
Time Period and Frequency for Event Assessment and Follow-Up 
For this study, all Grade 3 and 4 AEs, all SAEs occurring from the time the informed consent is 
signed through the Day 29 visit will be documented, recorded, and reported. In addition, any 
Grade 2 or higher suspected drug-related hypersensitivity reactions associated with study product 
administration will be reported as an AE.  
 
8.3.5.1 
Investigators Reporting of AEs 
Information on all AEs will be recorded on the appropriate CRF. All clearly related signs, 
symptoms, and results of diagnostic procedures performed because of an AE should be grouped 
together and recorded as a single diagnosis. If the AE is a laboratory abnormality that is part of a 
clinical condition or syndrome, it should be recorded as the syndrome or diagnosis rather than 
the individual laboratory abnormality. Each AE will also be described in terms of duration (start 
and stop date), severity, association with the study product, action(s) taken, and outcome. 
8.3.6 
Serious Adverse Event Reporting 
8.3.6.1 
Investigators Reporting of SAEs 
Any AE that meets a protocol-defined criterion as a SAE must be submitted within 24 hours of 
site awareness on an SAE form to the DMID Pharmacovigilance Group, at the following 
address:  
 
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 

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6500 Rock Spring Dr. Suite 650 
Bethesda, MD 20817, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
 
Other supporting documentation of the event may be requested by the DMID Pharmacovigilance 
Group and should be provided as soon as possible. The DMID Medical Monitor will review and 
assess the SAE for regulatory reporting and potential impact on study subject safety and protocol 
conduct. 
 
At any time after completion of the study, if the site PI or appropriate sub-investigator becomes 
aware of an SAE that occurred during the subject’s participation in the study, the site PI or 
appropriate sub-investigator will report the event to the DMID Pharmacovigilance Group. 
8.3.6.2 
Regulatory Reporting of SAEs 
Following notification from the site PI or appropriate sub-investigator, DMID, as the IND 
Sponsor, will report any SUSAR in an IND safety report to the FDA and will notify all 
participating site PIs as soon as possible. DMID will report to the FDA any unexpected fatal or 
life-threatening suspected adverse reaction as soon as possible, but in no case later than 7 
calendar days after the Sponsor’s initial receipt of the information. If the event is not fatal or life-
threatening, the IND safety report will be submitted within 15 calendar days after the Sponsor 
determines that the information qualifies for reporting as specified in 21 CFR Part 312.32. 
Relevant follow up information to an IND safety report will be submitted as soon as the 
information is available. Upon request from the FDA, DMID will submit to the FDA any 
additional data or information that the agency deems necessary, as soon as possible, but in no 
case later than 15 calendar days after receiving the request. 
 
SAEs that are not SUSARs will be reported to the FDA at least annually in a summary format 
which includes all SAEs. 
 
Sites may have additional local reporting requirements (to the IRB and/or national regulatory 
authority).  
8.3.7 
Reporting of Pregnancy 
Pregnancy is not an AE. However, any pregnancy that occurs during study participation should 
be reported to the Sponsor on the appropriate CRF. Pregnancy should be followed to outcome.  
8.4 
Unanticipated Problems 
8.4.1 
Definition of Unanticipated Problems 
An Unanticipated Problem (UP) is any event, incident, experience, or outcome that meets the 
following criteria: 
 Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the IRB-approved research 
protocol and informed consent document; and (b) the characteristics of the subject 
population being studied; 

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▪ Related to participation in the research (meaning there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures involved in the 
research); and 
▪ Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
8.4.2 
Unanticipated Problem Reporting 
To satisfy the requirement for prompt reporting, all UPs will be reported using the following 
timeline: 
▪ UPs that are SAEs will be reported to the IRB and to the Statistical and Data 
Coordinating Center (SDCC)/study Sponsor within 24 hours of the investigator becoming 
aware of the event per the above describe SAE reporting process. 
▪ Any other UP will be reported to the IRB and to the SDCC/study Sponsor within 3 days 
of the investigator becoming aware of the problem. 
9. 
STATISTICAL CONSIDERATIONS 
This is an adaptive platform study is intended to allow for several adaptations: 1) sample size re-
estimation and 2) addition of new experimental arm(s) into one stage, or 3) addition of separate 
study stages. A brief summary is provided the study specific appendix for each stage. Details 
will be described in the statistical analysis plan (SAP) for each stage.  
 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 
Regulatory, Ethical, and Study Oversight Considerations 
This study will be conducted in conformity with the principles set forth in The Belmont Report: 
Ethical Principles and Guidelines for the Protection of Human Subjects of Research (US 
National Commission for the Protection of Human Subjects of Biomedical and Behavioral 
Research; April 18, 1979), and the federal policy for the Protection of Human Subjects codified 
in 45 CFR Part 46, 21 CFR Part 50 (Protection of Human Subjects), and the ICH E6 (R2). 
 
Each institution engaged in this research will hold an OHRP-approved FWA. OHRP-registered 
IRBs will review and approve this protocol, associated informed consent documents, recruitment 
material, and handouts or surveys intended for the subjects, prior to the recruitment, screening, 
and enrollment of subjects. The IRB review shall be in accordance with 45 CFR 46 and 21 CFR 
50, 21 CFR 56 (IRBs), and other federal, state, and local regulations and policies, as applicable. 
 
Site IRBs may have additional national and local regulations. 
 
Any amendments to the protocol or consent materials will be approved by the IRB before they 
are implemented. IRB review and approval will occur at least annually throughout the duration 

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of the study. The investigator will notify the IRB of deviations from the protocol and SAEs, as 
applicable to the IRB policy. 
 
DMID must receive the documentation that verifies IRB-approval for this protocol, informed 
consent documents, and associated documents prior to the recruitment, screening, and enrollment 
of subjects, and any IRB-approvals for continuing review or amendments as required by the 
DMID. 
10.1.1 
Informed Consent Process 
Informed consent is a process that is initiated prior to an individual agreeing to participate in a 
trial and continuing throughout the individual’s trial participation. Investigators or designated 
research staff will obtain a subject’s informed consent in accordance with the requirements of 45 
CFR 46, 21 CFR 50 and 21 CFR 56 for FDA-regulated studies, state and local regulations and 
policy, and ICH E6 GCP before any study procedures or data collection are performed. 
Typically, subjects or their legally authorized representatives (LAR) receive a concise and 
focused presentation of key information about the clinical trial, verbally and with a written 
consent form. Subjects will be asked to read and review the consent form. Subjects (or LAR) 
must sign the ICF prior to starting any study procedures being done specifically for this trial. 
Once signed, a copy of the ICF will be given to the subject or the LAR for their records. 
 
However, due to strict respiratory isolation policies, limited access to COVID-19 patient rooms 
and SARS-CoV-2 transmissibility via droplet-contaminated paper, verbal consent and alternative 
methods of obtaining consent (e.g., by phone) will be allowed if approved by the IRB. In 
addition, if a signed paper copy of the ICF is allowed by hospital policy, how it will be obtained 
and stored will need to be determined. Any variation from the standard consent process due to 
isolation and infection control should be sent to the IRB for approval prior to enrollment. The 
site should document the process in their regulatory files and demonstrate that the process has 
IRB concurrence or approval. 
 
Regardless of the method for obtaining consent, the key information about the study will be 
organized and presented in lay terminology and language that facilitates understanding why one 
might or might not want to participate. The site should translate the consent into non-English 
languages consistent with the local population. Translations should be sent to the sponsor for any 
necessary back translations. New information will be communicated by the site PI to subjects 
who consent to participate in this trial in accordance with IRB requirements. The informed 
consent document will be updated, and subjects will be re-consented per IRB requirements, if 
necessary. 
 
10.1.1.1 
Requirements for Permission by Parents/Guardians and Assent by Children (in 
case of a minor) 
Not Applicable 
 

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10.1.1.2 
Other Informed Consent Procedures 
Subjects will be asked for consent to collect additional blood, the use of residual specimens, and 
samples for secondary research. Extra blood will be drawn for secondary research during each 
visit when a study blood samples are obtained.  
 
The stored samples will be labeled with barcodes to maintain confidentiality. Research with 
identifiable samples and data may occur as needed; however, subject confidentiality will be 
maintained as described for this protocol and with IRB approval. 
 
Samples designated for secondary research use may be used for understanding the SARS-CoV-2 
infection, the immune response to this infection, and the effect of therapeutics on these factors.  
Samples will not be used to create immortal cell lines, neither sold for commercial profit. 
Although the results of any future research may be patentable or have commercial profit, 
subjects will have no legal or financial interest in any commercial development resulting from 
any future research. 
There are no direct benefits to the subject for extra specimens collected or from the secondary 
research. No results from secondary research will be entered into the subject’s medical record. 
Incidental findings will not be shared with the subject, including medically actionable incidental 
findings, unless required by law. 
Subjects may withdraw permission to use samples for secondary use at any time. They will need 
to contact the study site and the samples will be removed from the study repository after this 
study is completed and documentation will be completed that outlines the reason for withdrawal 
of permission for secondary use of samples.  
 
10.1.2 
Study Termination and Closure 
Section 7, Study Intervention Discontinuation and Subject Discontinuation/Withdrawal, 
describes the temporary halting of the study. 
 
This study may be prematurely terminated if there is sufficient reasonable cause, including but 
not limited to: 
• Determination of unexpected, significant, or unacceptable risk to subjects 
• Results of interim analysis 
• Insufficient compliance with protocol requirements 
• Data that are not sufficiently complete and/or not evaluable 
• Regulatory authorities decide that study should be terminated 
If the study is prematurely terminated, then the site PI will promptly inform study subjects and 
the IRB as applicable. The site PI will assure appropriate follow-up for the subjects, as 
necessary. 
 
The Sponsor will notify regulatory authorities as applicable. 

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10.1.3 
Confidentiality and Privacy 
Subject confidentiality is strictly held in trust by the participating investigators, their staff, and 
the Sponsor(s) and their agents. This confidentiality is extended to cover clinical information 
relating to subjects, test results of biological samples, and all other information generated by 
participation in the study. No identifiable information concerning subjects in the study will be 
released to any unauthorized third party. Subject confidentiality will be maintained when study 
results are published or discussed in conferences. 
 
The study monitor, other authorized representatives of the Sponsor, representatives of the IRB, 
and/or regulatory agencies may inspect all documents and records required to be maintained by 
the investigator, including but not limited to medical records (office, clinic, or hospital) and 
pharmacy records for the subjects in this study. The clinical study site will permit access to such 
records. 
 
All source records including electronic data will be stored in secured systems in accordance with 
institutional policies and federal regulations. 
 
All study data and research specimens that leave the site (including any electronic transmission 
of data) will be identified only by a coded number that is linked to a subject through a code key 
maintained at the clinical site. Names or readily identifying information will not be released 
unless DMID approves and it aligns with the consent form, or according to laws for required 
reporting. 
10.1.4 
Secondary Use of Stored Specimens and Data 
This section applies to those subjects who consented to storage of samples for secondary 
research. Secondary Human Subject Research is the re-use of identifiable data or identifiable 
biospecimens that were collected from some other ‘‘primary’’ or ‘‘initial’’ activity, such as the 
data and samples collected in this protocol. Any use of the sample or data for secondary research 
purposes, however, will be presented in a separate protocol and require separate IRB approval. 
 
Each sample will be labeled only with a barcode and a unique tracking number to protect subject 
confidentiality. Secondary research with coded samples and data may occur; however, subject 
confidentiality will be maintained as described for this protocol. An IRB review of the secondary 
research using coded specimens is required. 
 
The subject’s decision can be changed at any time by notifying the study doctors or nurses in 
writing. If the subject subsequently changes his/her decision, the samples will be destroyed if the 
samples have not been used for research or released for a specific research project. 
10.1.4.1 
Data Sharing for Secondary Research 
Data from this study may be used for secondary research. All of the individual subject data 
collected during the trial will be made available after de-identification. The SAP and Analytic 
Code will also be made available. This data will be available immediately following publication, 
with no end date.  
 

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The investigator may request removal of data on individual study subjects from NIH data 
repositories in the event that a research subject withdraws or changes his or her consent. 
However, some data that have been distributed for approved research use cannot be retrieved. 
10.1.5 
Key Roles and Study Governance 
The study is sponsored by DMID. Decisions related to the study will be made by a protocol team 
that includes representatives from all countries, and separate networks within a country. 
10.1.6 
Safety Oversight 
10.1.6.1 
Protocol team oversight 
A subset of the protocol team will review blinded pools of AE data every 2 weeks to ensure no 
significant number of unexpected AEs (AEs that do not fit with the known course of COVID-
19). If there are a significant number of unexpected AEs, the DSMB will be asked to review 
unblinded safety data in an ad hoc meeting.  
10.1.6.2 
Data Safety Monitoring Board 
Safety oversight will be conducted by a DSMB that is an independent group of experts that 
monitors subject safety and advises DMID. The DSMB members will be separate and 
independent of study personnel participating in this trial and should not have scientific, financial 
or other conflicts of interest related to this trial. The DSMB will consist of members with 
appropriate expertise to contribute to the interpretation of the data from this trial. The DSMB 
should be as broadly informed as possible regarding emerging evidence from related studies. The 
DSMB will operate under the guidelines of a DMID-approved charter that will be written at the 
organizational meeting of the DSMB. The DSMB will review SAEs on a regular basis and ad 
hoc during this trial. The DMID Medical Monitor will be responsible for reviewing SAEs in real 
time. The DSMB will review SAEs on a regular basis and ad hoc during this trial. 
 
The DSMB will conduct the following reviews: 
• Intermittent safety reviews at a frequency as determined by the DSMB. The DSMB will 
have access to safety data electronically in real time.  
• Formal safety/efficacy reviews after approximately every 200 subjects have met 
recovered status for each pairwise comparison 
• Ad hoc meeting if the protocol team raises any concerns 
• A final review meeting after final clinical database lock, to review the cumulative 
unblinded safety data for this trial.  
 
The study will not stop enrollment awaiting these DSMB reviews, although the DSMB may 
recommend temporary or permanent cessation of enrollment based on their safety reviews. 
  
Additional data may be requested by the DSMB, and interim statistical reports may be generated 
as deemed necessary and appropriate by DMID. The DSMB may receive data in aggregate and 
presented by treatment arm. The DSMB may also be provided with expected and observed rates 
of the expected AEs in an unblinded fashion and may request the treatment assignment be 
unblinded for an individual subject if required for safety assessment. The DSMB will review 
grouped and unblinded data in the closed session only. At each meeting, the DSMB will make a 
recommendation as to the advisability of proceeding with study interventions (as applicable), and 
to continue, modify, or terminate this trial. 

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10.1.7 
Clinical Monitoring 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial subjects are 
protected and that the reported trial data are accurate, complete, and verifiable. Clinical 
monitoring also ensures that conduct of the trial is in compliance with the currently approved 
protocol/ amendment(s), ICH, GCP, and with applicable regulatory requirement(s) and Sponsor 
requirements. Clinical monitoring will also verify that any critical study procedures are 
completed following specific instructions in the protocol-specific MOP. 
 
Monitoring for this study will be performed by DMID or their designee. Details of clinical site 
monitoring are documented in a clinical monitoring plan (CMP). The CMP describes in detail 
who will conduct the monitoring, at what frequency monitoring will be done, at what level of 
detail monitoring will be performed, and the distribution of monitoring reports. Monitoring visits 
will include, but are not limited to, review of regulatory files, accountability records, CRFs, 
ICFs, medical and laboratory reports, site study intervention storage records, training records, 
and protocol and GCP compliance. Site monitors will have access to each participating site, 
study personnel, and all study documentation according to the DMID-approved site monitoring 
plan. Study monitors will meet with site PIs to discuss any problems and outstanding issues and 
will document site visit findings and discussions. 
10.1.8 
Data Handling and Record Keeping 
10.1.8.1 
Data Collection and Management Responsibilities 
Data collection is the responsibility of the study personnel at the participating clinical study site 
under the supervision of the site PI. The site PI must maintain complete and accurate source 
documentation. 
 
Clinical research data from source documentation (including, but not limited to, AE/SAEs, 
concomitant medications, medical history, physical assessments, clinical laboratory data) will be 
entered by the clinical study site into CRFs via a 21 CFR Part 11-compliant internet data entry 
system provided by the SDCC. The data system includes password protection and internal 
quality checks, such as automatic range checks, to identify data that appear inconsistent, 
incomplete, or inaccurate. AEs and concomitant medications will be coded according to the most 
current versions of MedDRA and WHODrug, respectively. 
 
The SDCC for this study will be responsible for data management, quality review, analysis, and 
reporting of the study data. 
 
The IND Sponsor is responsible for review of data collection tools and processes, and review of 
data and reports. 
 
A separate study specific Study Data Standardization Plan (SDSP) appendix will be developed 
which describes the technical recommendations for the submission of human study data and 
related information in a standardized electronic format throughout product development. 
 
At the end of the study, a copy of all datasets including annotated CRFs and data dictionary will 
be provided to DMID. 

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10.1.8.2 
Study Record Retention 
Study related records, including the regulatory file, study product accountability records, consent 
forms, subject source documents and electronic records should be maintained for a period of 2 
years following the date a marketing application is approved for the investigational product for 
the indication for which it is being investigated; or, if no application is to be filed or if the 
application is not approved for such indication, until 2 years after the investigation is 
discontinued and FDA is notified. These documents should be retained for a longer period, 
however, if required by local policies or regulations. No records will be destroyed without the 
written consent of DMID. Consent forms with specimen retention linked to identifiable 
specimens will be maintained for as long as the specimens remain in identifiable format, and a 
minimum of three years after use of the identifiable specimens in nonexempt human subject 
research. 
10.1.8.3 
Source Records 
Source data are all information in original records (and certified copies of original records) of 
clinical findings, observations, or other activities in a clinical trial necessary for the 
reconstruction and evaluation of the trial. Source data should be attributable, legible, 
contemporaneous, original, accurate, and complete. Each participating site will maintain 
appropriate medical and research records for this trial, in compliance with ICH GCP, regulatory, 
and institutional requirements. Data recorded in the CRF derived from source documents should 
be consistent with the data recorded on the source documents.  
 
It is understood that biocontainment may necessitate alternative processes for storing consents 
and other source documents. Each site will determine and document this process. 
 
Interview of subjects is sufficient for obtaining medical history. Solicitation of medical records 
from the subject’s primary care provider is not required. 
10.1.9 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol, any process that is 
noted in the protocol and refers to details in the protocol-specific MOP, or GCP requirements or 
any critical study procedures with specific instructions in ancillary documents referenced in the 
protocol such as a protocol-specific MOP. 
 
The noncompliance may be either on the part of the subject, the investigator, or the study site 
staff. Following a deviation(s), corrective actions should be developed by the site and 
implemented promptly. All individual protocol deviations will be addressed in subject study 
records. 
 
It is the responsibility of the site PI and personnel to use continuous vigilance to identify and 
report deviations within five working days of identification of the protocol deviation, or within 
five working days of the scheduled protocol-required activity. All deviations must be promptly 
reported to DMID per the protocol deviation reporting procedures. Protocol deviations must be 
sent to the local IRB/IEC per their guidelines. The site PI and personnel are responsible for 
knowing and adhering to their IRB requirements. A completed copy of the DMID Protocol 
Deviation Form must be maintained in the Regulatory File, as well as in the subject’s chart if the 
deviation is subject specific. 

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10.1.10 
Publication and Data Sharing Policy 
Following completion of the study, results of this research will be published in a scientific 
journal. As this is an adaptive study and given the public health urgency to disseminate results, 
data from individual comparisons (i.e. the initial 2 study arms) can be published when those arms 
are fully enrolled and all subjects in those arms are followed through to completion of the study.  
 
Data will be available immediately following publication, with no end date, with data sharing at 
the discretion of the Sponsor. Sites may also obtain individual or country level data from the 
database for separate publications is desired. Publication may occur prior to completion of a final 
clinical study report for the entire trial. 
10.1.11 
Human Data Sharing Plan 
This study will be conducted in accordance with the following publication and data sharing 
policies and regulations: 
 NIH Public Access Policy, which ensures that the public has access to the published 
results of NIH funded research. It requires scientists to submit final peer-reviewed journal 
manuscripts that arise from NIH funds to the digital archive PubMed Central upon 
acceptance for publication. 
10.1.12 
Publication 
Following completion of the study, the protocol team is expected to publish the results of this 
research in a scientific journal. This study will adhere to the following publication and data 
sharing policies and regulations: 
 This study will comply with the NIH Public Access Policy, which ensures that the public 
has access to the published results of NIH funded research. As such, the final peer-
reviewed journal manuscripts will accessible to the public on PubMed Central no later 
than 12 months after publication. 
10.1.13 
Conflict of Interest Policy 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed 
and managed. Furthermore, persons who have a perceived conflict of interest will be required to 
have such conflicts managed in a way that is appropriate to their participation in the design and 
conduct of this trial. DMID has established policies and procedures for all study group members 
to disclose all conflicts of interest and will establish a mechanism for the management of all 
reported dualities of interest. 
10.2 
Additional Considerations 
10.2.1 
Research Related Injuries 
For any potential research related injury, the site PI or designee will assess the subject. Study 
personnel will try to reduce, control, and treat any complications from this study. Immediate 
medical treatment may be provided by the participating study site. As needed, referrals to 
appropriate specialist or other health care facilities will be provided to the subject. The site PI 

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should then determine if an injury occurred as a direct result of the tests or treatments that are 
done for this trial. 
 
Immediate medical treatment may be provided by the participating site, such as giving 
emergency medications to stop immediate allergic reactions. No financial compensation will be 
provided to the subject by NIAID, NIH or the participating site for any injury suffered due to 
participation in this trial. 
 
10.2.2 
Public Readiness and Emergency Preparedness Act 
The drugs remdesivir, baricitinib, interferon beta-1a, and all other study products to be evaluated 
using the ACTT clinical trial platform during this pandemic and the efforts for this clinical trial 
are covered under the Public Readiness and Emergency Preparedness Act (PREP Act) and the 
Declaration issued by the Secretary of the U.S. Department of Health and Human Services under 
that Act. Under the PREP Act and the Declaration, covered persons (such as manufacturers, 
distributers, program planners, and other qualified persons who prescribe, administer or dispense 
study product) are immune from liability from the administration, or use of a covered 
countermeasure, such as remdesivir and baricitinib. The PREP Act provides immunity for 
covered persons from liability, unless the injury was caused by willful misconduct. The 
Declaration invoking the PREP Act for COVID-19 covered countermeasures was made on 
March 17, 2020 and is retroactively effective from February 4, 2020. 
The PREP Act also established the Countermeasures Injury Compensation Program (CICP) to 
provide compensation for serious injuries or death that occur as the direct result of the 
administration or use of certain countermeasures. Any requests for compensation must be filed 
within one year of the administration or use of the covered countermeasure. Requests for 
Benefits must be made to the Health Resources and Services Administration’s (HRSA) 
Countermeasures Injury Compensation Program (http://www.hrsa.gov/cicp/) by filing a Request 
for Benefits Form and all required medical records and supporting documentation. Additional 
information on filing a Request for Benefits is available on the CICP’s website at 
http://www.hrsa.gov/cicp/. Compensation may then be available for reasonable and necessary 
medical benefits, lost wages and/or death benefits to eligible individuals for certain injuries in 
accordance with regulations published by the Secretary of HHS (found at 42 CFR part 110).  
If an individual suffers a serious physical injury or death from the administration or use of a 
covered countermeasure in this study, the individual, the individual’s legal or personal 
representative, the administrator/executor of a deceased individual’s estate, or certain survivors 
may request benefits from the CICP. A serious physical injury means an injury that warranted 
hospitalization (whether or not the person was actually hospitalized) or that led to a significant 
loss of function or disability. The CICP is the payer of last resort. This means that it only covers 
expenses or provides benefits that other third-party payers (such as health insurance, the 
Department of Veterans Affairs, or Workers’ Compensation programs) do not have an obligation 
to pay. 
If the Secretary of HHS does not make a final determination on the individual’s request within 
240 days, or if the individual decides not to accept the compensation, the injured individual or 
his representative may pursue a tort claim in the US District Court for the District of Columbia, 
but only if the claim involves willful misconduct and meets the other requirements for suit under 

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the PREP Act. Any award is reduced by any public or private insurance or worker’s 
compensation available to the injured individual. Awards for non-economic damages, such as 
pain, suffering, physical impairment, mental anguish, and loss of consortium are also limited. If 
the individual accepts compensation, or if there is no willful misconduct, then the individual does 
not have a tort claim that can be filed in a US Federal or a State court. 
10.3 
Abbreviations 
Abbreviation 
Definition 
AE 
Adverse Event 
ALT 
Alanine Transaminase 
ARDS 
Acute Respiratory Distress Syndrome 
AST 
Aspartate Transaminase 
BP 
Blood Pressure 
CFR 
Code of Federal Regulations 
CI 
Confidence Interval 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
CMS 
Clinical Material Services 
Cr 
Creatinine 
CRF 
Case Report Form 
CROMS 
Clinical Research Operations and Management Support 
CSR 
Clinical Study Report 
CMP 
Clinical Monitoring Plan 
CQMP 
Clinical Quality Management Plan 
DHHS 
Department of Health and Human Services 
DMID 
Division of Microbiology and Infectious Diseases 
EC 
Ethics Committee 
eGFR 
Estimated Glomerular Filtration Rate 
EMR 
Electronic Medical Record 
FDA 
Food and Drug Administration 
FWA 
Federal Wide Assurance 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
Hgb 
Hemoglobin 
HR 
Heart Rate 
IB 
Investigator’s Brochure 
ICD 
International Classification of Diseases 
ICF 
Informed Consent Form 
ICH 
International Council for Harmonisation 
IND 
Investigational New Drug Application 
INR 
International Normalized Ratio 
IRB 
Institutional Review Board 
IV 
Intravenous 
JAK 
Janus kinase 
LAR 
Legally Authorized Representative 

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Abbreviation 
Definition 
MCG 
Microgram 
MedDRA 
Medical Dictionary for Regulatory Activities 
MERS 
Middle East Respiratory Syndrome 
MOP 
Manual of Procedures 
N 
Number (typically refers to subjects) 
NDA 
New Drug Application 
NEWS 
National Early Warning Score 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
NP 
Nasopharyngeal 
OHRP 
Office for Human Research Protections 
OP 
Oropharyngeal  
PHI 
Protected Health Information 
PI 
Principal Investigator 
PLT 
Platelet 
PP 
Per Protocol 
PT 
Prothrombin Time 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SARS 
Severe Acute Respiratory Syndrome 
SBECD 
Sulfobutylether-beta-cyclodextrin 
SDCC 
Statistical and Data Coordinating Center 
SDSP 
Study Data Standardization Plan 
SNP 
Single Nucleotide Polymorphisms 
SOA 
Schedule of Assessments 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
T. Bili 
Total Bilirubin 
TNF 
Tumor Necrosis Factor 
UP 
Unanticipated Problem 
US 
United States 
WBC 
White Blood Cell 
10.4 
Protocol Amendment History 
Version/Date 
 
 
Section 
Description of 
Change 
Brief Rationale 
2.0 
2MAR2020 
 
 
 
Overall 
This version addresses the comments received from the US 
FDA, Japanese PDMA, DSMB, IRBs, and NIAID scientific 
review. 

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Improved 
clarity and 
brevity 
Multiple areas throughout the document were reworded to 
improve clarity (recognized after implementation) and edited 
to minimize redundant statements. 
1.1 
Number of 
sites increased 
from 50 to 
approximately 
75 
Given the currently unpredictable epidemiology, additional 
sites will improve the ability to enroll the study in a timely 
manner. 
 
Sample size 
increased 
Version 1 sample size table and statements in the text did not 
align. The new assumptions use a slightly smaller treatment 
effect (OR 1.75) and the 8-category scale and give the 
sample size of 440. 
 
Addition of 
phone call on 
Day 22 
Recent information from the outbreak in China suggest some 
COVID-19 patients worsen between 2 and 4 weeks of 
illness. We added Day 22 because of concerns that the peak 
illness may be missed. There are also concerns if the more 
severe population will be discharged by Day 29. 
 
Ordinal scale 
was increased 
to 8 categories. 
This addresses the concern raised by several reviews that 
“Hospitalized not on oxygen” is two separate populations – 
those still needing medical care and those kept in hospital 
just for infection control. 
 
Objectives and 
endpoints were 
put into table 
format 
Multiple comments that the tabular form of objectives and 
endpoints (that was previously in Section 4) was much easier 
to read and understand. 
 
Added 
inclusion 
criteria for 
admission to 
hospital 
This was implied throughout the document, but never stated 
in the inclusion criteria. 
 
Inclusion 
criteria #8 
Contraceptive requirement aligned to new IB from February 
21, 2020 
 
Phase of study 
Changed to phase 3. After discussion with company, and 
new IB that outlines safety data of > 500 subjects, the 
company thought this was more accurately called a phase 3 
trial. 
1.2 
Schedule of 
Assessments 
updated 
To include Day 22. Footnotes also revised for clarity. 
2.2 
Background 
updated 
To reflect current understanding of SARS-CoV, COVID-19, 
and new data from IB. 
3. 
Separating 
objectives 
about non-
invasive from 
invasive 
Elsewhere in the protocol, it was mentioned that this data 
would be captured separately, but it mistakenly never made 
into an endpoint. 

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mechanical 
ventilation 
 
Added Day 14 
mortality 
To allow better assessment of short and long term mortality. 
4 
Rewritten for 
clarity 
These paragraphs were substantially rewritten, but aside 
from the changes note above the content is not different. 
8 
Screening is 
more detailed 
These edits reflect so ambiguity discovered with the first 
enrollment. 
8.1.2 
Efficacy 
assessments 
more detailed 
More detail is provided to facilitate these assessments. Also, 
each component that contribute to the categories will not be 
captured separately. This will allow the ordinal scale as 
structured, but also will allow analysis of alternative ordinal 
scales. 
8.1.3.1 
Viral load in 
plasma and 
resistance 
The assessment of viral load in plasma and detection of 
resistance was previously noted on the SOA, but never 
discussed in the text. This has now been added in this 
section. 
9.2 
Sample size 
calculations 
With the addition of one category to the ordinal scale, the 
estimates per category must change leading to new tables. 
3.0 
27MAR2020 
 
 
 
Improved 
clarity  
Multiple areas throughout the document were reworded to 
improve clarity (issues that arose with implementation)  
 
Flexibility 
The pandemic has limited ability for people to be seen in 
follow-up due to infection control and restrictions on travel. 
Additionally, staff at some sites have limited ability to go 
into rooms due to limited personal protective equipment. So 
flexibility has been added where possible while still ensuring 
safety and good scientific data.  
1.1 
Sample Size 
Increase 
The sample size was changed to reflect ensuring sufficient 
samples for the endpoint of interest which 400 subjects with 
a “recovered” status (per the primary objective). 
Additionally, enrollment is permitted after the 400 
recoveries up to April 20 to provide additional data about 
important subgroups. 
 
Primary 
Endpoint 
Given evolving data, the precise day of assessment of the 
primary endpoint is not clear. Modeling of the prior endpoint 
suggested if the day is chosen incorrectly, the power is 
significantly decreased. So the primary endpoint has been 
changed from a ordinal scale on a given day to days to 
recovery (the best three categories of the ordinal scale).  
 
Key secondary 
endpoint 
The prior primary endpoint has been labeled as the key 
secondary endpoint. 
 
Inclusion 
Criteria #5 
Given delays of PCR results in some sites (given number of 
tests and throughput within the lab), the PCR positive 

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requirement has been written to allow flexibility if the PCR 
results are delayed.  
 
Inclusion 
Criteria #6 
Removed auscultation requirement given challenges of 
accurate auscultation while in full PPE.  
 
Exclusion 
Criteria #2 
Cutoff of eGFR to 30 was decreased after discussion with 
the manufacturer and FDA.  
 
Sites 
Increased to 100 given unpredictable epidemiology of 
COVID-19 
 
DSMB 
Given the rapid pace of enrollment, the prior plans for 
DSMB oversight are not practical, so this has been modified 
with input from the DSMB on when they would like to have 
interim reviews.  
2.3.2 
Drug 
interaction 
Corrected erroneous statements about CYP inhibition.  
5.3 
Vulnerable 
Subjects 
Allow inclusion of those that are incapable of consent such 
as cognitively impaired. Prior version noted consent by a 
LAR, but it was not described in this section.  
6 
Study Product 
Updated throughout for 2 issues. First, the newly 
manufactured lot of remdesivir is in 100mg vials. Second, 
there is limited supply of placebo and the options for using 
saline with an opaque bag for the control infusion was 
added.  
6.5 
Concomitant 
Therapy 
There has been significant increase in use of off label 
therapies for COVID-19, including many repurposed agents 
and therapies targeting immune response. So additional 
wording was added to cover these scenarios to minimize 
additional confounding medications.  
8.1.3 
Sample 
Processing  
Some sites are reporting needing to process samples in BSL-
3 and/or have limitations on processing, shipping, storage, 
etc. of samples. So wording was added to allow exclusion of 
these samples (which may be cost prohibitive)  
8.2 
Venipuncture 
volume 
This table was corrected for total volumes, but not new 
samples were added.  
9 
Statistical 
Considerations 
This section was rewritten to given the change in sample 
size. 
10.1.1 
Informed 
consent 
Given isolation and infection control issues with COVID-19, 
traditional consenting documentation is not always possible. 
This section was rewritten to allow alternative consent 
processes and documentation as long as these are acceptable 
to the site’s IRB.  
4.0 
13APR2020 
Note – version 4 was submitted to the US FDA and some IRBs, but given the 
interim DSMB findings this version was never implemented.  
 
General, 
Appendix A, 
Appendix B 
As this is an adaptive study, an additional treatment stage 
“ACTT-2” was added. To allow better organization, the 
general protocol was separated from the study specific 

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Appendix A (remdesivir vs placebo) and Appendix B (2x2 
study factorial design of +/- remdesivir and +/- baricitinib). 
 
Appendix B 
Appendix B is a new stage in the platform study that 
describes all study specifics of the 2x2 study factorial design 
of +/- remdesivir and +/- baricitinib 
Appendix B- 
1 
Synopsis 
A new synopsis for ACTT-2 was added. 
App B - 1.2 
SOA 
A revised SOA was added. This is similar to the ACTT-1 
SOA, but footnotes have been edited for clarity.  
App B - 2.2 
Risk 
Risk of baricitinib was added, along with prior language 
about the risk of remdesivir.  
App B - 3 
Objectives 
ACTT-2 will use the same objectives from ACTT-1. 
App B - 4 
Study Design 
The study design and justification for studying baricitinib in 
a factorial study was added.  
App B - 5 
Study 
Population 
ACTT-2 will use similar inclusion and exclusion criteria, 
with some additions unique to the risk or mechanism of 
action of baricitinib. 
App B - 6 
Study Product 
Information about baricitinib was added. 
App B - 9 
Statistical 
Consideration 
While similar to ACTT -1, additional information was added 
for how the factorial design would be analyzed, and how 
arms may be dropped based on ACTT-1 findings.  
5.0 
4MAY2020 
 
 
Appendix B - 
1 
Synopsis 
Information about the preliminary findings from ACTT-1 
was added. 
App B - 1 
Synopsis and 
throughout 
Descriptions of the study design was revised to reflect a 2 
arms study - Baricitinib/Remdesivir Vs. Remdesivir 
App B – 1 
Synopsis and 
9.2 
A new sample size was calculated to reflect the 2 arm 
design, and the likely lower anticipated treatment effect of a 
second agent (i.e. the incremental value of no treatment to 1 
treatment is likely larger than from 1 treatment to a 
combination. 
App B – 1 
Synopsis and 
throughout 
Wording has been added to reflect that all subjects (both 
arms) will receive remdesivir.  
App B – 
2.2.2.2 
Potential 
benefits 
Updated with the preliminary findings from ACTT-1. 
App B – 
2.2.3.1 
Potential Risks 
of Baricitinib 
Updated with additional language about drug-drug 
interactions as requested by the FDA.  
App B – 
6.1.1 
Study Product 
Description 
Additional wording was added to better describe the 
baricitinib placebo. 
App B – 
6.3.1 
Randomization Stratification was revised to match the ordinal scale 
categories rather than separate criteria.  

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App B – 
6.3.2 
Blinding and 
masking 
This section was added to clearly describe the blinding of 
study product (baricitinib only), and the unblinding process 
(both routine and unplanned for given subjects).  
App B – 
8.1.3.2 
Exploratory 
endpoints 
Exploratory endpoints were added for cytokine assessments 
to support the mechanism of action of the baricitinib arm.  
App B – 
8.3.5.1 
Reporting of 
AEs 
Added wording for better reporting of new infections, and 
requested by the FDA.  
App B – 
8.3.6.1 
Investigator 
reporting of 
SAEs 
Revised wording for SAE reporting. All SAEs are saptured 
in the regular database. Only those SAEs that are judged to 
be related to either study product are submitted on a larger 
SAE form.  
6.0 
21MAY2020 
 
 
Appendix B – 
1.1 
Exclusion 
Criteria 
Added exclusion for remdesivir use prior to study entry 
(exclusing 3 or more doses). 
Appendix B – 
1.1 
Exclusion 
Criteria 
Separated prior exclusion based on immunosuppressants into 
different categories with different time periods (based on 
FDA’s comments). Small molecule exclusion shortened to 1 
week and some biologics increased to 3 months.  
Appendix B – 
1.1 
Exclusion 
Criteria 
Revised exclusion for corticosteroid use to permit larger 
amounts prior to enrollment (this is often used for syndromes 
related to COVID such as asthma exacerbation, and the prior 
wording was too restrictive).  
Appendix B – 
4.2 
Scientific 
Rationale for 
Study Design 
This section was blank before, so scientific rationale for 
ACTT-2 was added (scientific rational was previously 
conveyed in the background, but not this section). 
Appendix B – 
5.4 
Lifestyle 
Considerations 
Revised to be more precise regarding what types of studies 
subjects can be co-enrolled in (reflecting questions that have 
arisen during the study). 
Appendix B – 
6.5 
Concomitant 
Medications  
Rewritten extensively for clarity. The one substantive 
change was to permit corticosteroids as needed for standard 
care for non-COVID-19 syndromes.  
7.0 
15Jul2020 
 
 
 
General 
The Public Readiness and Emergency Preparedness Act 
(PREP Act) was moved from Appendix C (for US sites only) 
to the main protocol document as this is available for all sites 
including international sites.  
 
Appendix A 
As ACTT-1 as detailed in Appendix A is completed and the 
database is locked, Appendix A was removed from the 
protocol document (to keep the protocol document a 
manageable size).  
 
Appendix C 
As this is an adaptive study, an additional treatment stage 
“ACTT-3” was added. This stage will evaluate remdesivir + 
interferon beta-1a compared to remdesivir alone (+ placebo 

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11. 
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Appendix A - ACTT-1: Remdesivir vs Placebo 
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APPENDIX A - ACTT-1: REMDESIVIR VS PLACEBO 
ACTT- 1 was closed to enrollment on April 29, 2020. 
All follow up visits have been completed. 
ACTT-1 database was locked on June 25, 2020.  
 
 
This Appendix is removed from the protocol document. 
 
Please see protocol version 6.0 dated 25 May 2020 for the final version of the ACTT-1 stage of 
this protocol. 

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Appendix B - ACTT-2: Baricitinib/Remdesivir vs Remdesivir 
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APPENDIX B - ACTT-2: BARICITINIB/REMDESIVIR VS. REMDESIVIR 
TRIAL  
1. 
PROTOCOL SUMMARY 
1.1 
ACTT-2 – Synopsis 
Study overview 
The cause of ARDS is a hyperinflammatory state characterized by upregulation of multiple 
cytokines. Baricitinib, an orally administered, selective inhibitor of Janus kinase 1 (JAK1) and 
JAK2, could be a therapeutic option because of the potential to inhibit signaling from multiple 
cytokines in COVID-19 patients (2). Baricitinib treatment resulted in a reduction from baseline 
in serum IL-6 at Week 12 in patients with active RA in a Phase 2, randomized, placebo-
controlled study of baricitinib (3). In addition, baricitinib has recently been hypothesized (4) and 
shown (nonclinical data on file) to be a potent inhibitor of numb-associated kinases (NAKs), 
which play a critical role in the host epithelial cell’s ability to facilitate propagation of viruses. 
As these are unique mechanism of actions, the effects of combination therapy may exceed either 
component.  
 
A preliminary review of data from ACTT-1 occurring after 606 recoveries and 103 deaths 
(approximately 67% of the 1063 subjects enrolled) demonstrated that subjects that received 
remdesivir had a 31% faster time to recovery (11 vs 15 days, recovery rate ratio 1.312 (1.119, 
1.541), p<0.001), and a decrease in mortality ( 8.0% vs 11.6%, p = 0.059). The DSMB asked that 
the sponsor be unblinded early given public health implications and implications for ACTT-2. 
Given these findings, there will be no placebo arm in ACTT-2. We will instead investigate 
remdesivir and baricitinib in combination versus remdesivir alone.  
 
Enrollment Period:  
It is anticipated the enrollment may be completed in 2-3 months. 
 
General 
ACTT-2 will evaluate the combination of baricitinib and remdesivir compared to remdesivir 
alone. Subjects will be assessed daily while hospitalized. If the subjects are discharged from the 
hospital, they will have a study visit at Days 15, 22, and 29. For discharged subjects, it is 
preferred that the Day 15 and 29 visits are in person to obtain safety laboratory tests and OP 
swab and blood (serum only) samples for secondary research as well as clinical outcome data. 
However, infection control or other restrictions may limit the ability of the subject to return to 
the clinic. In this case, these visits may be conducted by phone, and only clinical data will be 
obtained. The Day 22 visit does not have laboratory tests or collection of samples and is 
conducted by phone.  
 
We anticipate that this trial will require 732 recoveries. Assuming that 70% of subjects achieve 
recovery in 28 days, the total sample size is approximately 1032.  
 
Study Population 

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Hospitalized adults (≥18 years old) with COVID-19. 
 
Inclusion Criteria 
1. Admitted to a hospital with symptoms suggestive of COVID-19. 
2. Subject (or legally authorized representative) provides informed consent prior to 
initiation of any study procedures. 
3. Subject (or legally authorized representative) understands and agrees to comply with 
planned study procedures. 
4. Male or non-pregnant female adults ≥ 18 years of age at time of enrollment. 
5. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR or other 
commercial or public health assay in any specimen, as documented by either of the 
following:  
 PCR positive in sample collected < 72 hours prior to randomization; OR 
 PCR positive in sample collected ≥ 72 hours prior to randomization, documented 
inability to obtain a repeat sample (e.g. due to lack of testing supplies, limited 
testing capacity, results taking > 24 hours, etc) AND progressive disease 
suggestive of ongoing SARS-CoV-2 infection. 
6. Illness of any duration, and at least one of the following: 
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR 
 SpO2 ≤ 94% on room air, OR 
 Requiring supplemental oxygen, OR 
 Requiring mechanical ventilation or ECMO. 
7. Women of childbearing potential must agree to either abstinence or use at least one 
primary form of contraception not including hormonal contraception from the time of 
screening through Day 29.  
8. Agrees to not participate in another clinical trial for the treatment of COVID-19 through 
Day 29. 
 
Exclusion Criteria 
1. ALT or AST > 5 times the upper limit of normal. 
2. Estimated glomerular filtration rate (eGFR) < 30 ml/min or patient is receiving 
hemodialysis or hemofiltration at time of screening. 
3. Neutropenia (absolute neutrophil count <1000 cells/μL) (<1.0 x 103/μL or <1.0 GI/L). 
4. Lymphopenia (absolute lymphocyte count <200 cells/μL) (<0.20 x 103/μL or <0.20 
GI/L) 
5. Pregnancy or breast feeding. 
6. Anticipated discharge from the hospital or transfer to another hospital which is not a 
study site within 72 hours. 
7. Allergy to any study medication. 
8. Received three or more doses of remdesivir including the loading dose, outside of the 
study under the EUA (or similar mechanism) for COVID-19.  
9. Received convalescent plasma or intravenous immunoglobulin [IVIg]) for COVID-19, 
the current illness for which they are being enrolled. 
10. Received small molecule tyrosine kinase inhibitors (e.g. baricitinib, imatibib, genfinitib), 
in the 1 week prior to screening.  

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11. Received monoclonal antibodies targeting cytokines (e.g., TNF inhibitors, anti-
interleukin-1 [IL-1], anti-IL-6 [tocilizumab or sarilumab]), or T-cells (e.g., abatacept) in 
the 4 weeks prior to screening. 
12. Received monoclonal antibodies targeting B-cell (e.g., rituximab, and including any 
targeting multiple cell lines including B-cells) in the 3 months prior to screening. 
13. Received other immunosuppressants in the 4 weeks prior to screening and in the 
judgement of the investigator, the risk of immunosuppression with baricitinib is larger 
than the risk of COVID-19.  
14. Received ≥20 mg/day of prednisone or equivalent for ≥14 consecutive days in the 4 
weeks prior to screening.  
15. Use of probenecid that cannot be discontinued at study enrollment. 
16. Have diagnosis of current active tuberculosis (TB) or, if known, latent TB treated for less 
than 4 weeks with appropriate anti-tuberculosis therapy per local guidelines (by history 
only, no screening required). 
17. Suspected serious, active bacterial, fungal, viral, or other infection (besides COVID-19) 
that in the opinion of the investigator could constitute a risk when taking investigational 
product. 
18. Have received any live vaccine (that is, live attenuated) within 4 weeks before screening, 
or intend to receive a live vaccine (or live attenuated) during the study. Note: Use of non-
live (inactivated) vaccinations is allowed for all subjects.  
19. Have a history of VTE (deep vein thrombosis [DVT] or pulmonary embolism [PE]) 
within 12 weeks prior to screening or have a history of recurrent (>1) VTE (DVT/PE). 
20. Immunocompromised patients, patients with a chronic medical condition, or those taking 
a medication that cannot be discontinued at enrollment, who, in the judgment of PI, are at 
increased risk for serious infections or other safety concerns given the study products. 
 
Study Intervention 
Subjects will be randomized into two arms (1:1). 
Baricitinib 
Placebo 
Remdesivir 
Arm 1 
Baricitinib tablets + 
remdesivir IV 
Arm 2 
Placebo tablets + 
remdesivir IV 
 
 
All subjects will receive remdesivir as a 200 mg intravenous (IV) loading dose on Day 1, 
followed by a 100 mg once-daily IV maintenance dose for the duration of the hospitalization up 
to a 10-day total course. See Section 6.1.4 for details of dosing and dose modification.  
 
For the baricitinib component, subjects will receive either active product or placebo as follows: 
 Baricitinib will be administered as a 4 mg* orally (po) (two 2mg tablets) or crushed for 
NG tube, daily for the duration of the hospitalization up to a 14-day total course. 
 A placebo will be given as two tablets* po or crushed for NG tube, daily for the duration 
of the hospitalization up to a 14-day total course 
* Patients with eGFR <60 mL/min will receive a dose of one tablet (2-mg or placebo) 
once daily. 

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Duration of therapy: 
 IV remdesivir – 10 days while hospitalized. 
 Oral (baricitinib or placebo) component – 14 days while hospitalized. 
 Both stop on discharge from hospital. 
 
1.2 
Schedule of Assessments 
Table 1. Schedule of Assessments (SOA) 
  
Screen 
Baseline  
Study Intervention Period 
Follow-up Visits  
Day +/- Window 
−1 or 1 
1 
Daily until hospital 
discharge 
157  
± 2 
227 
± 3 
297 
± 3 
ELIGIBILITY 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
Demographics & Medical History 
X 
 
 
 
 
 
Review SARS-CoV-2 results 
X 
 
 
 
 
 
 
 
 
 
 
 
 
STUDY INTERVENTION 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
Administration of investigational 
agent 
 
 Remdesivir daily infusion until day 
10 or discharge.  
 Baricitinib or placebo: daily by 
mouth until day 14 or discharge 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
STUDY PROCEDURES 
 
 
 
 
 
 
Targeted physical exam 
 
X 
 
 
 
 
Vital signs including SpO2 1 
 
X4 
Daily until discharge8 
X9 
 
X9 
Clinical data collection 2  
 
X4 
Daily until discharge8 
X9 
X9 
X9 
Adverse event evaluation 
 
X4 
Daily until discharge8 
X9 
X9 
X9 
Concomitant medication review 
 
X4 
From Day -7 to Day 15 
 
 
 
 
 
 
 
 
 
 
SAFETY LABORATORY 
 
 
 
 
 
 
Safety hematology, chemistry and 
liver tests 
X3 
X4,5,6,7 
Day 3, 5, 8, 11 (all ± 1 day) 
if hospitalized6,7 
X9 
 
X9 
Pregnancy test for females of 
childbearing potential 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
RESEARCH LABORATORY  
 
 
 
 
 
 
Blood for plasma to test for PCR 
SARS-CoV-2 
 
X4,6 
Day 3, 5, 8, 11 (all ± 1 day) 
if hospitalized 
 
 
 
Oropharyngeal swab 10 
 
X4,6 
Day 3, 5, 8, 11 (all ± 1 day) 
if hospitalized 
X9 
 
X9 
Blood for serum (secondary 
research) 
 
X4,6 
Day 3, 5, 8, 11 (all ± 1 day) 
if hospitalized 
X9 
 
X9 
Notes: 
1Vital signs include temperature, systolic blood pressure, heart rate, respiratory rate, O2 saturation and level of 
consciousness. Vital signs collected as part of standard care may be used.  
2 Refer to Section 8.1.2 of the protocol for details of clinical data to be collected including ordinal score, NEWS, oxygen 
requirement, mechanical ventilator requirement, etc. 
3 Screening laboratory tests include: CBC with differential (including absolute neutrophil count and absolute lymphocyte 
count), ALT, AST, creatinine (and calculate an estimated glomerular filtration rate (eGFR) the formula used is determined 

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by the sites, but should be consistent throughout the study), and pregnancy test. Laboratory tests performed in the 48 hours 
prior to enrollment will be accepted for determination of eligibility. 
4 Baseline assessments should be performed within 24 hours prior to first study product administration. Results of Day 1 
(baseline) laboratory assessment do not need to be reviewed to determine if initial study product should be given. 
5 Laboratory tests performed as part of routine clinical care in the 24 hours prior to first dose will be accepted for the 
baseline safety laboratory tests. Baseline may be the same as the screening laboratory tests.  
6 Safety laboratory tests include WBC with differential, hemoglobin, platelets, creatinine, glucose, total bilirubin, ALT, AST, 
INR, d-dimer, and C-reactive protein (CRP). Note: D-dimer and CRP values may predict severity and support assessment 
of outcomes and unlike other safety laboratory values, D-dimer and CRP should not be graded.  
7 Any laboratory tests performed as part of routine clinical care within the specified visit window can be used for safety 
laboratory testing. Window during the 10 days of dosing is ±1 day. 
8 Daily until hospital discharge or end of study, whichever comes first.  
9 In-person visits are preferred but recognizing quarantine and other factors may limit the subject’s ability to return to the 
site for the visit. In this case, the visit may be performed by phone. If subject is still hospitalized during the follow-up 
period, they should get Day 15, 22 and 29 assessments along with the daily clinical data collection. 
 
If still hospitalized at Day 15 and 29 or returns to the site for an in-person visit: collect clinical data, vital signs, 
safety laboratory tests, and research laboratory samples (OP swab and serum only) as able.  
 
If phone call only on Days 15 and 29 and all Day 22 visits: assess adverse events, clinical status (ordinal scale), 
readmission to a hospital, and mortality only. 
10 Oropharyngeal swabs are preferred, but if these are not obtainable, nasopharyngeal or nasal swabs may be substituted.  
  
1.3 
Study Schema 
 
 
 
2. 
INTRODUCTION 
2.1 
Background 
2.1.1 
ACTT-2 – Baricitinib/Remdesivir vs. Remdesivir Trial 
A preliminary review of data from ACTT-1 occurring after 606 recoveries and 103 deaths 
(approximately 67% of the 1063 subjects enrolled) demonstrated that subjects that received 
remdesivir had a 31% faster time to recovery (11 vs 15 days, recovery rate ratio 1.312 (1.119, 
1.541), p<0.001), and a decrease in mortality ( 8.0% vs 11.6%, p = 0.059). The DSMB asked that 
the sponsor be unblinded early given public health implications and implications for ACTT-2. 
While an antiviral appears to have some efficacy in the treatment of COVID-19, the mortality 
rate is still high. Infection by pathogenic coronaviruses (e.g. SARS and SARS-CoV–2) often 
results in excessive cytokine and chemokine action with the development of acute respiratory 
distress syndrome (ARDS) (5-7). It is postulated that this dysregulated inflammatory immune 
response is contributing to the excessive mortality, and targeting this response will further 
improve outcomes.  
 
Baricitinib, an orally administered, selective inhibitor of JAK1 and JAK2, could be a therapeutic 
option because of the potential to inhibit signaling from multiple cytokines in COVID-19 

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patients (2). Baricitinib inhibits signaling of cytokines implicated in COVID-19, including IL-2, 
IL-6, IL-10, IFN-γ, and G-CSF, with lower IC50 values translating to a greater overall inhibition 
of STAT signaling during the dosing interval (5). Baricitinib treatment resulted in a reduction 
from baseline in serum IL-6 at Week 12 in patients with active RA in a Phase 2, randomized, 
placebo-controlled study of baricitinib (data on file). The potent anti-inflammatory effects of 
baricitinib have also been demonstrated by the reduction of serum levels of IFN-γ, IP-10, GM-
CSF and MCP-1 in pediatric patients with steroid-dependent chronic inflammation, resulting in 
control of disease activity and the ability to wean or taper steroids (8).  
 
A recent comment by Richardson et al. published in the Lancet (4), suggested a potential role for 
baricitinib in the treatment of COVID-19. The authors hypothesize that baricitinib, a JAK1/2 
inhibitor, will directly mitigate the inflammatory response triggered by SARS-CoV-2 infection. 
In addition, baricitinib has been identified as a numb-associated kinase (NAK) inhibitor with 
high-affinity for AP2-associated protein kinase 1 (AAK1-8.2 nM, BIKE-20 nM and GAK-120 
nM). AAK1 and GAK were previously described as a crucial regulator of clathrin-mediated 
endocytosis and propagation of coronavirus and other viruses (9). In light of this, baricitinib may 
have an unappreciated antiviral effect by attenuating host-cell propagation of the virus in 
infected COVID-19 patients. 
 
Like all host directed therapeutics, the experience of baricitinib is limited to case series. At the 
Atlanta VA Medical Center to date, ten patients received baricitinib as treatment for COVID-19 
and have recovered (personal communications, Vince Marconi). An additional patient received 
only one day of baricitinib but was made DNR/DNI while on supplemental oxygen. This patient 
died the following day. An additional four patients have received treatment but are pending 
recovery. Of the eleven with complete data by recovery or death, six out of eleven patients met 
criteria for severe disease and required intensive care level management, with two of these 
requiring several days of mechanical ventilation. Initiation of therapy with baricitinib led to 
resolution of fever within 48 hours in 10/11 patients, a downward trend in most inflammation 
markers by the end of treatment, decreased oxygen requirements in 7/8 patients needing 
supplemental oxygen at the time of hospital admission. Complete recovery was observed in 
10/11 patients. Overall, the 10 patients who made a full recovery tolerated the short course of 
treatment with baricitinib and did not develop any secondary bacterial or viral infections during 
the follow-up period (6 to 15 days). 
 
Baricitinib is already approved for treatment of rheumatoid arthritis. It is administered orally 
once a day, with good oral bioavailability. It has a short half-life (approximately 12 hours in RA 
patients), so treatment can be interrupted or stopped if necessary. It has few drug-drug 
interactions (due to low CYP inhibitory activity) so it can be given concomitantly with 
background therapies. Baricitinib has a well-established safety profile, based on clinical trial data 
and post-marketing data in patients with RA. This profile, together with the observation that 
baricitinib is a potent AAK1/BIKE/GAK inhibitor with known anti-cytokine effects, provide the 
rationale to study baricitinib in the context of a randomized, controlled clinical trial in patients 
with COVID-19. 
2.2 
Risk/Benefit Assessment 
2.2.1 
Known Potential Risks 

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Potential risks of participating in this trial are those associated with having blood drawn, the IV 
catheterization, possible reactions to the study interventions (as noted in Section 2.2.2 and 2.2.3), 
and breach of confidentiality. 
 
Drawing blood may cause transient discomfort and fainting. Fainting is usually transient and 
managed by having the subject lie down and elevate his/her legs. Bruising at the blood collection 
sites may occur but can be prevented or lessened by applying pressure to the blood draw site for 
a few minutes after the blood is taken. IV catheterization may cause insertion site pain, phlebitis, 
hematoma formation, and infusate extravasation; less frequent but significant complications 
include bloodstream and local infections. The use of aseptic (sterile) technique will make 
infection at the site where blood will be drawn or at catheter site less likely. 
 
Risks to Privacy 
Subjects will be asked to provide personal health information (PHI). All attempts will be made to 
keep this PHI confidential within the limits of the law. However, there is a chance that 
unauthorized persons will see the subject’s PHI. All study records will be kept in a locked file 
cabinet or maintained in a locked room at the participating clinical site. Electronic files will be 
password protected. Only people who are involved in the conduct, oversight, monitoring, or 
auditing of this trial will be allowed access to the PHI that is collected. Any publication from this 
trial will not use information that will identify subjects. Organizations that may inspect and/or 
copy research records maintained at the participating site for quality assurance and data analysis 
include groups such as the IRB, NIAID and applicable regulatory agencies (e.g., FDA). For more 
information about confidentiality and privacy see Section 10.1.3. 
 
For each new therapeutic agent under investigation, findings from the preclinical and clinical 
studies will be briefly described in this section and a summary of the findings described in the 
Investigator Brochure (IB) will be in an appendix.  
 
2.2.2 
Remdesivir  
2.2.2.1 
Potential Risks of Remdesivir  
Remdesivir is an investigational therapeutic agent. 138 healthy adults have been dosed with 
remdesivir in four Phase 1 clinical trials. Few subjects to date experienced constipation, 
heartburn, itching, unusual feelings in the ear, dizziness, loss of appetite, nausea, vomiting, 
shaking of the leg and arm, headache, loose stool, or upset stomach. These AEs were temporary, 
lasting only a few days, and none were serious. In clinical studies, transient elevations in ALT 
and AST have been observed with single doses of remdesivir up to 225 mg and multiple once 
daily doses of remdesivir 150 mg for up to 14 days. Mild (Grade 1) reversible PT prolongation 
was also noted in some subjects but without any clinically significant change in INR or other 
evidence of hepatic effects. The mechanism of these elevations is currently unknown. Based on 
these clinical observations, patients with ALT or AST >5 times the upper limit of normal will not 
be eligible for study enrollment. Regular laboratory assessments will be performed in order to 
monitor hepatic function and PT. Any observed liver function-related laboratory abnormalities or 
possibly related AEs will be treated appropriately and followed to resolution.  
 

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In nonclinical animal studies, toxicity studies found dose-dependent and reversible kidney injury 
and dysfunction. In clinical studies, no evidence of nephrotoxicity has been observed with single 
doses of remdesivir up to 225 mg or multiple once daily doses of remdesivir 150 mg for up to 14 
days. A 150-mg dose of the solution and lyophilized formulations of remdesivir contains 9 g and 
4.5 g, respectively, of sulfobutylether-beta-cyclodextrin (SBECD), for which the maximum daily 
recommended daily dose (based on a European Medicines Agency (EMA) safety review) is 
approximately 250 mg/kg. Because SBECD is renally cleared, subjects with moderate or severe 
renal impairment may have SBECD exposures greater than those with less severe renal 
impairment or normal renal function. Based on this information, patients with an estimated 
glomerular filtration rate (eGFR) of less than 30 ml/min (including subjects requiring 
hemodialysis or hemofiltration) will not be eligible for study enrollment. 
 
Remdesivir is a substrate for CYP2C8, CYP2D6, and CYP3A4. However, coadministration with 
inhibitors of these CYP isoforms is unlikely to markedly increase remdesivir levels, as its 
metabolism is likely to be predominantly mediated by hydrolase activity. See IB for full 
discussion of clinical experience and risks.  
 
There is the potential of the SARS-CoV-2 developing resistance to remdesivir, which could 
result in decreased efficacy. The clinical impact of the development of resistance is not clear at 
this time.  
 
In vitro induction studies have demonstrated that a clinically relevant interaction with 
contraceptive steroids is considered to be of limited clinical significance. Therefore, the use of 
hormonal contraception with remdesivir is not recommended as the sole method for preventing 
pregnancy. 
 
2.2.2.2 
Potential Benefits of Remdesivir 
A preliminary review of data from ACTT-1 occurring after 606 recoveries and 103 deaths 
(approximately 67% of the 1063 subjects enrolled) demonstrated that subjects that received 
remdesivir had a 31% faster time to recovery (11 vs 15 days, recovery rate ratio 1.312 (1.119, 
1.541), p<0.001), and a decrease in mortality ( 8.0% vs 11.6%, p = 0.059). The DSMB asked that 
the sponsor be unblinded early given public health implications and implications for ACTT-2. As 
a result, all subjects in ACTT-2 will be given remdesivir.  
 
This is a benefit to participation, though at some point this drug may be available outside of 
clinical trials. In addition, society may benefit from their participation in this study resulting 
from insights gained about the efficacy of remdesivir combined with baricitinib, a licensed, 
readily-available drug. Determining if additional clinical benefit can be realized by combining an 
antiviral with an anti-inflammatory medication for the treatment of COVID-19 may benefit 
society during this global COVID-19 pandemic.  
 
2.2.2.3 Assessment of Potential Risks and Benefits of Remdesivir 
Remdesivir is generally a well-tolerated medication. There are liver toxicities that have been 
observed in prior studies. These have been self-limited and resolved after cessation of the 
medication. There is the potential for renal toxicities as observed in pre-clinical data. By excluding 

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those with elevated liver transaminases and decreased kidney function (eGFR < 30 ml/min or 
requires hemodialysis or hemofiltration), and appropriate monitoring during the study, we can 
minimize the risk to subjects. While remdesivir is currently the only therapeutic agent likely to 
effective for COVID-19, there may not be benefits for an individual subject depending on timing 
of initial infusion relative to disease onset and presence of viral replication. However, we will try 
to mitigate this risk by assessing PCR positivity for eligibility and enrolling eligible subjects in a 
timely manner. The potential risks therefore are thought to be acceptable given the potential 
benefits.  
 
2.2.3 
Baricitinib 
2.2.3.1 
Potential Risks of Baricitinib 
Baricitinib is a Janus kinase (JAK) inhibitor indicated for the treatment of adult patients with 
moderately to severely active rheumatoid arthritis who have had an inadequate response to one 
or more TNF antagonist therapies.  
 
The US product labeling indicates a boxed warning for the risk of serious infections, 
malignancies and thrombosis, while warnings and precautions include serious infections, 
thrombosis, gastrointestinal perforations, abnormal laboratory assessments (potential changes in 
lymphocytes, neutrophils, hemoglobin, liver enzymes, and lipids), and avoidance with the use of 
live vaccines.  
 
The Summary of Product Characteristics (SmPC) indicates as special warning and precautions 
for infections, including TB, hematological abnormalities, viral reactivation, use of live vaccines, 
increase in blood lipid parameters, increase in hepatic transaminase, malignancy, venous 
thromboembolism, hypersensitivity, and use of baricitinib with potent immunosuppressive 
medications.  
 
Baricitinib has an established safety profile with a positive benefit/risk profile in rheumatoid 
arthritis. An integrated analysis of patients with active RA exposed to baricitinib with 3770 
patients and 10,127 patient years for a maximum exposure of 7 years (as of February 2018) was 
recently published (10). No significant differences were seen for baricitinib 4-mg vs placebo in 
adverse events leading to permanent drug discontinuation, death, malignancy, serious infection, 
or major adverse cardiovascular events. Incidence rates for deep vein thrombosis/pulmonary 
embolism were numerically higher in baricitinib 4-mg vs placebo; Incidence rates were similar 
by dose in 2-mg/4-mg-extended dataset. Malignancy (excluding non-melanoma skin cancer) 
Incidence rates were 0.8 (2-mg) and 1.0 (4-mg; as-randomized analysis). Fewer than 1% of 
patients discontinued due to abnormal laboratory results. The frequency of Herpes zoster was 
higher for baricitinib 4-mg vs placebo (1.4 vs 0.4) baricitinib 4-mg vs 2-mg (1.4 vs 1.0).  
 
It is difficult to extrapolate the potential risks of baricitinib in rheumatoid arthritis to a COVID-
19 population. The duration of baricitinib treatment will be limited to up to 14 days in this study 
and the half-life is approximately 12 hours which will lead to a very short washout period once 
discontinued. JAK–STAT signal blocking by baricitinib produces an impairment of interferon 
responses. Interferons are important for the innate control of viral replication. Thus baricitinib 

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could potentially increase viral replication (11) though this has not been described in the cases 
series of baricitinib in COVID-19.  
 
Adverse drug reactions of baricitinib include venous thromboembolism (deep vein thrombosis 
/pulmonary embolism). Mitigating the risk of venous thromboembolism will be managed 
through adding appropriate exclusion and discontinuation criteria to the protocol to limit 
participation of patients who are at an increased risk of VTE. There is evidence to suggest that 
COVID-19 patients are at increased risk of thromboembolic events from infection with SARS-
CoV-2. The etiology this may be tissue injury from the SARS-CoV-2 or may be due to 
inflammation via pro-inflammatory cytokine upregulation of tissue factor. It is unknown if 
baricitinib would increase or decrease this risk. Investigators are recommended to add VTE 
prophylaxis in all hospitalized patients given the risk of VTE. As thrombocytopenia can be seen 
in COVID-19, the risk/benefit of VTE prophylaxis should be made by the treating clinician. 
 
Baricitinib is not recommended in patients taking strong Organic Anion Transporter 3 (OAT3) 
inhibitors (probenecid in the main clinically relevant medication). Patients who take probenecid 
and are unable to discontinue it at study entry will not be eligible for the study.  
 
While baricitinib does inhibit OAT1, OAT2, OAT3, organic cation transporter (OCT) 1, OCT2, 
OATP1B3, BCRP, MATE1 and MATE2-K in vitro, clinically meaningful changes in the PK of 
drugs that are substrates for these transporters are unlikely. In vitro, baricitinib did not inhibit the 
transporters Pgp or organic anion transporting polypeptide (OATP) 1B1. Clinical drug-drug 
interaction studies showed no clinically meaningful effects on the PK of digoxin (Pgp substrate) 
or methotrexate (substrate of several transporters) when co-administered with baricitinib. 
 
Drug-drug interactions with concomitantly administered baricitinib and remdesivir are unlikely. 
In vitro, baricitinib is a substrate of cytochrome P450 (CYP) 3A and the following transporters: 
organic anion transporter (OAT) 3, P-glycoprotein (Pgp), breast cancer resistance protein 
(BCRP), and multidrug and toxic extrusion protein (MATE) 2-K. However, in vivo, baricitinib is 
primarily eliminated by the kidneys, with minimal hepatic clearance. The only clinically relevant 
drug-drug interaction observed with baricitinib is with concomitant administration of strong 
inhibitors of OAT3, such as probenecid. Available data for remdesivir does not suggest that 
remdesivir is an OAT3 inhibitor. Therefore, the potential for remdesivir to affect the 
pharmacokinetics (PK) of baricitinib is not likely.  
  
Baricitinib is also unlikely to affect the PK of other drugs, including remdesivir. Available data 
for remdesivir suggests that it is a substrate for CYP2C8, CYP2D6, CYP3A4, OATP1B1, and 
Pgp (EMA 2020). In vitro, baricitinib did not significantly inhibit or induce the activity of CYPs 
3A, 1A2, 2B6, 2C9, 2C19, and 2D6. Additionally, no clinically meaningful changes in the PK of 
several CYP3A substrates were observed when co-administered with baricitinib. Since 
baricitinib does not inhibit these particular CYPs, and transporters, a drug-drug interaction 
between baricitinib and remdesivir is unlikely.  
 
More detailed information about the known risks and reasonably expected adverse events of 
baricitinib may be found in the Investigator’s Brochure (IB).  
 

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2.2.3.2 
Potential Benefits of Baricitinib 
Baricitinib may or may not improve the clinical outcome of an individual subject with COVID-19 
who participates in this trial. However, there is potential benefit to society from their participation 
in this study resulting from insights gained about the therapeutic agents under study as well as the 
natural history of the disease. While there may not be benefits for an individual subject, there may 
be benefits to society if another safe, efficacious therapeutic agent can be identified during this 
global COVID-19 pandemic.  
 
2.2.3.3 
Assessment of Potential Risks and Benefits of Baricitinib 
In the context of the cumulative knowledge for baricitinib regarding the safety profile, the potential 
to mitigate the hyperinflammatory state and cytokine release syndrome (CRS) associated with 
SARS-CoV-2 and the lack of an established effective treatment for the life-threatening 
complications of COVID-19 due to CRS, the benefit/risk balance for this study is assessed to be 
favorable. 
 
3. 
OBJECTIVES AND ENDPOINTS 
The overall objective of the study is to evaluate the clinical efficacy and safety of different 
investigational therapeutics relative to the control arm among hospitalized adults who have 
COVID-19. 
 
OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
Primary 
 
To evaluate the clinical efficacy, as assessed 
by time to recovery, of different 
investigational therapeutics as compared to 
the control arm. 
Day of recovery is defined as the first day on 
which the subject satisfies one of the 
following three categories from the ordinal 
scale: 
 Hospitalized, not requiring supplemental 
oxygen – no longer requires ongoing 
medical care; 
 Not hospitalized, limitation on activities 
and/or requiring home oxygen; 
 Not hospitalized, no limitations on 
activities. 
Recovery is evaluated up until Day 29. 
Key Secondary 
 
To evaluate the clinical efficacy of different 
investigational therapeutics relative to the 
control arm in adults hospitalized with 
COVID-19 according to clinical status (8-
point ordinal scale) at Day 15 
 
 
 
 Death; 
 Hospitalized, on invasive mechanical 
ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation 
or high flow oxygen devices; 
 Hospitalized, requiring supplemental 
oxygen; 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 Hospitalized, not requiring supplemental 
oxygen – requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental 
oxygen – no longer requires ongoing 
medical care; 
 Not hospitalized, limitation on activities 
and/or requiring home oxygen; 
 Not hospitalized, no limitations on 
activities. 
Additional Secondary  
 
To evaluate the clinical efficacy of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 Clinical Severity 
o Ordinal scale: 
▪ Time to an improvement of one 
category and two categories from 
Day 1 (baseline) using an ordinal 
scale. 
▪ Subject clinical status using ordinal 
scale at Days 3, 5, 8, 11, 15, 22, and 
29.  
▪ Mean change in the ordinal scale 
from Day 1 to Days 3, 5, 8, 11, 15, 
22, and 29. 
 
 
 
 
 Clinical outcome assessed using ordinal 
scale daily while hospitalized and on Days 
15, 22, and 29. 
 
 
 
 
 
 
 
o National Early Warning Score 
(NEWS): 
▪ Time to discharge or to a NEWS of 
≤ 2 and maintained for 24 hours, 
whichever occurs first.  
▪ Change from Day 1 to Days 3, 5, 8, 
11, 15, and 29 in NEWS.  
 
 
 
 NEWS assessed daily while hospitalized 
and on Days 15 and 29. 
o Oxygenation: 
▪ Oxygenation use up to Day 29. 
▪ Incidence and duration of new 
oxygen use during the study. 
 
 
 Days of supplemental oxygen (if 
applicable) up to Day 29 
 
o Non-invasive ventilation/high flow 
oxygen: 
▪ Non-invasive ventilation/high flow 
oxygen use up to Day 29. 
 Days of non-invasive ventilation/high 
flow oxygen (if applicable) up to Day 29 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
▪ Incidence and duration of new non-
invasive ventilation or high flow 
oxygen use during the study. 
 
o Invasive Mechanical Ventilation / 
extracorporeal membrane oxygenation 
(ECMO): 
▪ Ventilator / ECMO use up to Day 
29. 
▪ Incidence and duration of new 
mechanical ventilation or ECMO use 
during the study.  
 
 
 Days of invasive mechanical 
ventilation/ECMO(if applicable) up to 
Day 29. 
 
 Hospitalization 
o Duration of hospitalization (days).  
 
 
 Days of hospitalization up to Day 29 
 Mortality 
o 14-day mortality 
o 28-day mortality 
 
 
 Date and cause of death (if applicable) 
 
2. To evaluate the safety of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 Cumulative incidence of SAEs through 
Day 29. 
 Cumulative incidence of Grade 3 and 4 
clinical and/or laboratory AEs through 
Day 29. 
 Discontinuation or temporary 
suspension of study product 
administrations (for any reason) 
 Changes in white blood cell (WBC) 
count with differential, hemoglobin, 
platelets, creatinine, glucose, total 
bilirubin, alanine aminotransferase 
(ALT), aspartate aminotransferase 
(AST), prothrombin time (PT reported 
as INR), d-dimer, and C-reactive protein 
(CRP) over time (analysis of lab values 
in addition to AEs noted above). 
 
 
 
 SAEs 
 Grade 3 and 4 AEs  
 WBC with differential, hemoglobin, 
platelets, creatinine, glucose, total 
bilirubin, ALT, AST, INR, d-dimer, CRP 
on Day 1; Days 3, 5, 8, and 11 (while 
hospitalized); and Days 15 and 29 (if 
attends in-person visit or still 
hospitalized). 
 
Exploratory  
 
To evaluate the virologic efficacy of different 
investigational therapeutics as compared to 
the control arm as assessed by: 
 
 
 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 Percent of subjects with SARS-CoV-2 
detectable in OP sample at Days 3, 5, 
8, 11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in OP 
sample at Days 3, 5, 8, 11, 15, and 29. 
 Development of resistance of SARS-
CoV-2 in OP sample at Days 3, 5, 8, 
11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in 
blood at Days 3, 5, 8, and 11. 
 
 Qualitative and quantitative polymerase 
chain reaction (PCR) for SARS-CoV-2 in 
OP swab on Day 1; Days 3, 5, 8, and 11 
(while hospitalized); and Days 15 and 29 
(if attends in-person visit or still 
hospitalized). 
 Qualitative and quantitative PCR for 
SARS-CoV-2 in blood on Day 1; Days 3, 
5, 8, and 11 (while hospitalized). 
  
4. 
STUDY DESIGN 
4.1 
Overall Design 
ACTT-2 will evaluate the combination of baricitinib and remdesivir compared to remdesivir 
alone. Subjects will be assessed daily while hospitalized. If the subjects are discharged from the 
hospital, they will have a study visit at Days 15, 22, and 29. For discharged subjects, it is 
preferred that the Day 15 and 29 visits are in person to obtain safety laboratory tests and OP 
swab and blood (serum only) samples for secondary research as well as clinical outcome data. 
However, infection control or other restrictions may limit the ability of the subject to return to 
the clinic. In this case, these visits may be conducted by phone, and only clinical data will be 
obtained. The Day 22 visit does not have laboratory tests or collection of samples and is 
conducted by phone.  
 
The primary outcome is time to recovery by Day 29 (see table below for definition based on the 
ordinal scale). A key secondary outcome evaluates treatment-related improvements in the 8-point 
ordinal scale at Day 15.  
4.2 
Scientific Rationale for Study Design 
This study utilizes an adaptive platform design that increases efficiency to identify safe and 
efficacious therapeutic agents for patients with COVID-19 during the current outbreak. Some 
investigational products may be in limited supply and this study design enables continuation of 
the study even if a product becomes unavailable. In addition, the adaptive design allows for the 
evaluation of new therapeutic agents as they are identified and ready for testing in clinical trials. 
As the study is a multicenter, multinational randomized controlled study, we will be able to 
acquire rigorous data about the safety and efficacy of investigational therapeutic agents for 
COVID-19 that will lead to generalizable evidence. Randomization is essential for establishing 
efficacy of these new therapeutic agents. Last, collecting clinical and virologic data on enrolled 
subjects using a standardized timeline and collection instruments should provide valuable 
information about the clinical course of and morbidities associated with COVID-19 in a diverse 
group of hospitalized adults. 

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The ACTT-2 design will specifically evaluate the contributions of blocking inflammatory 
pathways (with the JAK inhibitor) while all subjects receive the antiviral remdesivir.  
 
4.3 
Justification for Dose 
4.3.1 
Justification for Dose of Remdesivir 
The dose of remdesivir used in this study will be the same dose that was used in the Ebola 
clinical trials and the same dose that was used in the initial stage of this trial (ACTT-1).  
 
4.3.2 
Justification for Dose of Baricitinib 
The 4-mg QD dose of baricitinib selected for this study in a patient population with COVID-19 
is based on clinical data showing an effect of baricitinib on inhibition of cytokine signaling. In 
patients with rheumatoid arthritis, the 4-mg dose of baricitinib (but not lower doses) was shown 
to significantly reduce IL-6 levels, assessed after 12 weeks of treatment. In a compassionate use 
program in pediatric patients with chronic atypical neutrophilic dermatosis with lipodystrophy 
and elevated temperature (CANDLE) syndrome, patients on a mean dose of baricitinib 6-mg QD 
showed a striking reduction in cytokine signaling. In healthy volunteers, exposures observed at 
the baricitinib 4 mg (or higher) doses are associated with reduction of IL-6 induced ex vivo 
pSTAT3 activation (12).  
 
In a vaccine response study, individuals treated with 4 mg baricitinib can mount an appropriate 
immune response to a pneumococcal vaccine, suggesting that transient exposure to baricitinib 
will not result in clinically meaningful changes to adaptive immunity (13). In addition, the choice 
of the 4-mg dose is supported by PK, safety, and efficacy data for baricitinib in Phase 2 and 
Phase 3 RA studies. The 4-mg dose of baricitinib is approved in multiple regions globally for the 
treatment of RA. In summary, the potential benefit of the 4-mg dose in reducing the 
hyperinflammatory state caused by COVID-19, and the short duration of treatment with this dose 
with a well-established safety profile, provides the rationale for the assessment of the benefit/risk 
profile of the 4-mg dose of baricitinib in the setting of a randomized, controlled clinical trial in a 
hospital setting. 
5. 
STUDY POPULATION 
Male and non-pregnant female adults ≥18 years of age or older with COVID-19 and who meet 
all eligibility criteria will be enrolled at up to approximately 100 clinical trial sites globally. The 
target population should reflect the community at large. The estimated time from screening (Day 
-1 or Day 1) to end of study for an individual subject is approximately 29 days.  
 
Subject Inclusion and Exclusion Criteria must be confirmed by any clinician named on the 
delegation log. If there is any uncertainty, the PI should make the decision on whether a potential 
subject is eligible for study enrollment. There is no exclusion for receipt of SARS-CoV-2 
vaccine (experimental or licensed). 
 
5.1 
Inclusion Criteria 

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1. Admitted to a hospital with symptoms suggestive of COVID-19. 
2. Subject (or legally authorized representative) provides informed consent prior to 
initiation of any study procedures. 
3. Subject (or legally authorized representative) understands and agrees to comply with 
planned study procedures. 
4. Male or non-pregnant female adults ≥ 18 years of age at time of enrollment. 
5. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR or other 
commercial or public health assay in any specimen, as documented by either of the 
following:  
 PCR positive in sample collected < 72 hours prior to randomization; OR 
 PCR positive in sample collected ≥ 72 hours prior to randomization, documented 
inability to obtain a repeat sample (e.g. due to lack of testing supplies, limited 
testing capacity, results taking > 24 hours, etc.) AND progressive disease 
suggestive of ongoing SARS-CoV-2 infection. 
6. Illness of any duration, and at least one of the following: 
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR 
 SpO2 ≤ 94% on room air, OR 
 Requiring supplemental oxygen, OR 
 Requiring mechanical ventilation or ECMO. 
7. Women of childbearing potential must agree to either abstinence or use at least one 
primary form of contraception not including hormonal contraception from the time of 
screening through Day 29.  
8. Agrees to not participate in another clinical trial for the treatment of COVID-19 through 
Day 29. 
 
5.2 
Exclusion Criteria 
1. ALT or AST > 5 times the upper limit of normal. 
2. Estimated glomerular filtration rate (eGFR) < 30 ml/min or patient is receiving 
hemodialysis or hemofiltration at time of screening. 
3. Neutropenia (absolute neutrophil count <1000 cells/μL) (<1.0 x 103/μL or <1.0 GI/L). 
4. Lymphopenia (absolute lymphocyte count <200 cells/μL) (<0.20 x 103/μL or <0.20 
GI/L) 
5. Pregnancy or breast feeding. 
6. Anticipated discharge from the hospital or transfer to another hospital which is not a 
study site within 72 hours. 
7. Allergy to any study medication. 
8. Received three or more doses of remdesivir, including the loading dose, outside of the 
study under the EUA (or similar mechanism) for COVID-19.  
9. Received convalescent plasma or intravenous immunoglobulin [IVIg]) for COVID-19, 
the current illness for which they are being enrolled. 
10. Received small molecule tyrosine kinase inhibitors (e.g. baricitinib, imatibib, genfinitib), 
in the 1 week prior to screening  

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11. Received monoclonal antibodies targeting cytokines (e.g., TNF inhibitors, anti-
interleukin-1 [IL-1], anti-IL-6 [tocilizumab or sarilumab]), or T-cells (e.g., abatacept) in 
the 4 weeks prior to screening. 
12. Received monoclonal antibodies targeting B-cell (e.g., rituximab, and including any 
targeting multiple cell lines including B-cells) in the 3 months prior to screening. 
13. Received other immunosuppressants in the 4 weeks prior to screening and in the 
judgement of the investigator, the risk of immunosuppression with baricitinib is larger 
than the risk of COVID-19.  
14. Received ≥20 mg/day of prednisone or equivalent for ≥14 consecutive days in the 4 
weeks prior to screening.  
15. Use of probenecid that cannot be discontinued at study enrollment. 
16. Have diagnosis of current active tuberculosis (TB) or, if known, latent TB treated for less 
than 4 weeks with appropriate anti-tuberculosis therapy per local guidelines (by history 
only, no screening required). 
17. Suspected serious, active bacterial, fungal, viral, or other infection (besides COVID-19) 
that in the opinion of the investigator could constitute a risk when taking investigational 
product. 
18. Have received any live vaccine (that is, live attenuated) within 4 weeks before screening, 
or intend to receive a live vaccine (or live attenuated) during the study. Note: Use of non-
live (inactivated) vaccinations is allowed for all subjects.  
19. Have a history of VTE (deep vein thrombosis [DVT] or pulmonary embolism [PE]) 
within 12 weeks prior to screening or have a history of recurrent (>1) VTE (DVT/PE). 
20. Immunocompromised patients, patients with a chronic medical condition, or those taking 
a medication that cannot be discontinued at enrollment, who, in the judgment of PI, are at 
increased risk for serious infections or other safety concerns given the study products. 
 
 
5.2.1 
Exclusion of Specific Populations 
Children and adolescents will not be included in this trial. Remdesivir has only been used in a 
small number of pediatric patients. Baricitinib has been used extensively in pediatric patients. 
Initial information about the epidemiology of COVID-19 indicates that the overwhelming burden 
of severe disease occurs among older adults, especially those with comorbidities. Given 
significant gaps in knowledge in this population, and a low incidence of severe morbidity/ 
mortality in children, and that neither drug has demonstrated efficacy in COVID-19, this 
research is not known to have the prospect of direct benefit to individual child participants, and 
the risk/benefits do not warrant inclusion of this population into this trial at this time.  
 
In nonclinical reproductive toxicity studies, remdesivir demonstrated no adverse effect on 
embryo-fetal development when administered to pregnant animals. Embryonic toxicity was seen 
when remdesivir was initiated in female animals prior to mating and conception, but only at a 
systemically toxic dose. Remdesivir has not been studied in pregnant women. While baricitinib 
is a licensed drug with a known safety profile, the limited human data on use of baricitinib in 
pregnant women are not sufficient to inform a drug-associated risk for major birth defects or 
miscarriage. Because the effects on the fetus and the pregnant woman are not fully known, 
pregnant women will not be eligible for the trial.  
 

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In animal studies, remdesivir metabolites have been detected in the nursing pups of mothers 
given remdesivir. It is not known whether remdesivir is secreted in human milk. Because the 
effects of remdesivir on the breastfeeding infant is not known, women who are breast feeding 
will not be eligible for the trial. 
 
There is no information available on the presence of baricitinib in human milk or the effects of 
the drug on the breastfed infant. Baricitinib is present in the milk of lactating rats. However, the 
clinical relevance of these data is not clear. Because of the potential for serious adverse reactions 
in nursing infants, women who are breast feeding will not be eligible for the trial. 
 
5.3 
Inclusion of Vulnerable Subjects 
Certain human subjects are categorized as vulnerable populations and require special treatment 
with respect to safeguards of their well-being. For this clinical trial, examples include cognitively 
impaired or mentally disabled persons and intubated individuals who are sedated. When it is 
determined that a potential research subject is cognitively impaired, federal and institutional 
regulations permit researchers to obtain consent from a legally authorized representative (LAR). 
The study team will obtain consent from these vulnerable subjects using an IRB-approved 
protocol- specific process for consent using a LAR. 
 
For subjects for whom a LAR gave consent, during the course of the study, if the subject regains 
the capacity to consent, informed consent must be obtained from the subject and the subject 
offered the ability to leave the study if desired. 
 
5.4 
Lifestyle Considerations 
During this study, subjects are asked to: 
 Refrain from drinking alcohol through Day 15.  
 Avoid getting pregnant during the study from Day 1 through Day 29. 
 Agreed not to participate in another clinical trial for the treatment of COVID-19 or 
SARS-CoV-2. This includes interventional trials that evaluate treatment of SARS-CoV-2 
infection as well as the disease pathogenesis (e.g., experimental treatment trials for the 
COVID-19-related thrombo-occlusive disease respiratory complications and dysregulated 
immune response to the virus). Co-enrollment for natural history studies of COVID-19, 
studies of SARS-CoV-2 diagnostics, or strategy trials comparing different standards of 
care for non-COVID treatment (i.e. comparing two VTE prophylaxis regimens) is 
permitted; however, participation in both ACTT and these studies can only occur if the 
recommended blood collection volumes are not exceeded.  
5.5 
Screen Failures 
Following consent, after the screening evaluations have been completed, the investigator or 
designee is to review the inclusion/exclusion criteria and determine the subject’s eligibility for 
the study. If there is any uncertainty, the PI should make the decision on whether a potential 
subject is eligible for study enrollment.  

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Only basic demographic information and the reason(s) for ineligibility will be collected on 
screen failures. Subjects who are found to be ineligible will be told the reason(s) for ineligibility. 
 
Individuals who do not meet the criteria for participation in this study (screen failure) because of 
an abnormal laboratory finding may be rescreened once. 
5.6 
Strategies for Recruitment and Retention 
5.6.1 
Recruitment 
It is anticipated that patients with COVID-19 will present to participating hospitals, and that no 
external recruitment efforts towards potential subjects are needed. Recruitment efforts may also 
include dissemination of information about this trial to other medical professionals / hospitals.  
 
The IRB will approve the recruitment process and all materials provided prior to any recruitment 
to prospective subjects directly. 
 
Screening will begin with a brief discussion with study staff. Some will be excluded based on 
demographic data and medical history (i.e., pregnant, < 18 years of age, renal failure, etc.). 
Information about the study will be presented to potential subjects (or legally authorized 
representative) and questions will be asked to determine potential eligibility. Screening 
procedures can begin only after informed consent is obtained. 
 
5.6.2 
Retention 
Retention of subjects in this trial is very important for determining the primary endpoint. As 
such, after hospital discharge, participating subjects will be reminded of subsequent study visits 
and every effort will be made to accommodate the subject’s schedule to facilitate follow-up 
within the specified visit window. Additionally, there are many circumstances that influence the 
ability to obtain outcome information after discharge. Follow-up visits may be conducted by 
phone if in-person visits are not feasible.  
 
5.6.3 
Compensation Plan for Subjects  
Compensation, if any, will be determined locally and in accordance with local IRB requirements, 
and subject to local IRB approval.  
 
5.6.4 
Costs 
There is no cost to subjects for the research tests, procedures/evaluations and study product while 
taking part in this trial. Procedures and treatment for clinical care including costs associated with 
hospital stay may be billed to the subject, subject’s insurance or third party. 
 
6. 
STUDY PRODUCT 
6.1 
Study Product(s) and Administration  

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Subjects will be randomized into one of two arms (1:1). 
Baricitinib 
Placebo 
Remdesivir 
Arm 1 
Baricitinib tablets + 
remdesivir IV 
Arm 2 
Placebo tablets + 
remdesivir IV 
 
 
6.1.1 
Study Product Description  
Remdesivir is a single diastereomer monophosphoramidate prodrug designed for the intracellular 
delivery of a modified adenine nucleoside analog GS-441524. In addition to the active 
ingredient, the lyophilized formulation of remdesivir contains the following inactive ingredients: 
water for injection, SBECD, and hydrochloric acid and/or sodium hydroxide. 
 
Baricitinib is a Janus kinase (JAK) inhibitor with the chemical name [1-(ethylsulfonyl)-3-(4-
(7Hpyrrolo(2,3-d)pyrimidin-4-yl)-1H-pyrazol-1-yl)azetidin-3-yl]acetonitrile and will be supplied 
in 36 count bottles. The treatment will be allocated as one bottle per subject, with some overage 
per bottle. Each tablet contains 2 mg of baricitinib and the following inactive ingredients: 
croscarmellose sodium, magnesium stearate, mannitol, microcrystalline cellulose, ferric oxide, 
lecithin (soya), polyethylene glycol, polyvinyl alcohol, talc and titanium dioxide. 
 
Placebo tablets also manufactured by Eli Lilly and Company USA, and they contain lactose 
monohydrate, microcrystalline cellulose, croscarmellose sodium, and magnesium stearate. The 
coating for the placebo tablet is identical to that of the corresponding active tablet listed above. 
However, there is no lactose monohydrate in baricitinib, the active oral product. 
 
Baricitinib and placebo tablets will be supplied in 36 count bottles. The treatment will be 
allocated as one bottle per subject, with some overage per bottle.  
 
6.1.2 
Dosing and Administration 
All subjects will receive remdesivir as a 200 mg intravenous (IV) loading dose on Day 1, 
followed by a 100 mg once-daily IV maintenance dose for the duration of the hospitalization up 
to a 10-day total course.  
 
If subjects already received the loading dose as under the EUA or similar mechanism, then start 
at 100 mg/day. Any doses of remdesivir under an EUA (or similar mechanism) prior to 
enrollment will be counted, so the total duration of remdesivir (i.e. EUA + on this trial) is 10 
days (i.e., a maximum of 10 total infusions). If one or two doses of remdesivir were administered 
(under EUA or similar mechanism) prior to study enrollment, this should be documented in 
eClinical as a concomitant medication given prior to Day 1. 
 
For the baricitinib component, subjects will receive either active product or placebo as follows: 
 Baricitinib will be administered as a 4 mg orally (po) (two 2mg tablets) or crushed for 
NG tube, daily for the duration of the hospitalization up to a 14-day total course. 

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 A placebo will be given as two tablets po or crushed for NG tube, daily for the duration 
of the hospitalization up to a 14-day total course.  
 
See Section 6.1.4 for dosing modifications for renal failure. 
 
Dosing of the two medications does not need to occur at the same. 
 
Any dose that is delayed may be given later that calendar day. Any dose that is missed during the 
study due to any reason (not given that calendar day) is not made up. The treatment course 
continues as described above even if the subject becomes PCR negative.  
 
Duration of therapy: 
 IV remdesivir – 10 days while hospitalized (i.e., maximum of 10 total infusions pre-
enrollment and during study). 
 Oral (baricitinib or placebo) component – 14 days while hospitalized (i.e., maximum of 
14 total doses). 
 Both stop on discharge from hospital. If readmitted after discharge, see Section 7.4. 
 
6.1.3 
Dose Escalation 
Not Applicable 
 
6.1.4 
Dose Modifications 
The site should use all available laboratory values to evaluate for potential dose modifications. 
These laboratory values may be drawn as part of standard of care or protocol-required safety 
laboratories done as per the SOA. The protocol-required safety laboratories (per the SOA) are 
anticipated to be sufficient for evaluating for most dose modifications, but if other laboratory 
data obtained as part of standard care are available, these should be also be used in the 
evaluation.  
 
 
Remdesivir component: 
If the eGFR decreases to an eGFR < 25 ml/min, the remdesivir infusion should not be given on 
that day. The infusion may be resumed on the next day if the eGFR returns to ≥ 30 ml/min. If the 
subject’s renal function worsens to the point that they require hemodialysis or hemofiltration, 
remdesivir will be discontinued. 
 
If the ALT and/or AST increases to > 5 times upper limits of normal, the remdesivir infusion 
should be held and not be restarted until the ALT and AST ≤ 5 times upper limits of normal. 
 
Baricitinib/Oral Placebo component: 
Dose of oral study product will be decreased based on eGFR. Specifically, subjects with eGFR 
<60 mL/min will receive a dose of one tablet (2-mg or placebo) once daily. 
 
Oral study product should be temporarily interrupted if the subject develops any of the following 
during the study but may resume when that criteria is no longer fulfilled: 

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 Total white blood cells (WBC) <1000 cells/μL  
 Absolute neutrophil count (ANC) <500 cells/μL  
 Absolute lymphocyte count (ALC) <200 cells/μL  
 ALT or AST >5 times ULN  
 Infection that, in the opinion of the investigator, merits study drug being withheld 
 eGFR < 30 mL/min, resume when eGFR returns to ≥ 30 mL/min.  
o If subject’s renal function worsens to the point that they require hemodialysis or 
hemofiltration, oral study product and remdesivir as discussed above will be 
discontinued. 
 
For laboratory values that meet permanent discontinuation thresholds, study product should be 
discontinued. However, if in the opinion of the investigator, the laboratory abnormality is due to 
intercurrent illness or another identified factor, laboratory tests may be repeated.  
 
6.1.5 
Overdosage 
There is no known antidote for baricitinib. Overdose is not anticipated in the context of a clinical 
trial. However, if a site inadvertently gives a subject 4 mg of oral study product when they 
should be receiving 2 mg because of a eGFR <60 mg/mL, the site should contact the Sponsor. 
The subject should receive supportive therapy based on the subject´s signs and symptoms. 
 
6.2 
Preparation/Handling/Storage/Accountability 
6.2.1 
Acquisition and Accountability 
Investigational products (IP) will be shipped to the site either directly from participating 
companies, from the Sponsor, or from other regional or local drug repositories. All other supplies 
should be provided by the site. Multiple lots of each IP may be supplied. 
 
Study products received at the sites will be open label and not kit specific, unless specified in the 
protocol-specific Manual of Procedures (MOP) or pharmacy manual. Drug preparation will be 
performed by the participating site’s unblinded research pharmacist on the same day of 
administration to the subject. See the MOP Appendices for detailed information on the 
preparation, labeling, storage, and administration of investigational products.  
 
Accountability: 
The site PI is responsible for study product distribution and disposition and has ultimate 
responsibility for study product accountability. The site PI may delegate to the participating 
site’s research pharmacist responsibility for study product accountability. The participating site’s 
research pharmacist will be responsible for maintaining complete records and documentation of 
study product receipt, accountability, dispensation, storage conditions, and final disposition of 
the study product(s). Time of study drug administration to the subject will be recorded on the 
appropriate data collection form (CRF). All study product(s), whether administered or not, must 
be documented on the appropriate study product accountability record or dispensing log. The 
Sponsor’s monitoring staff will verify the participating site’s study product accountability 

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records and dispensing logs per the site monitoring plan. Refer to the protocol-specific MOP for 
details on storing study medications.  
Destruction: 
After the study treatment period has ended or as appropriate over the course of the study after 
study product accountability has been performed, used active and placebo product can be 
destroyed on-site following applicable site procedures with a second staff member observing and 
verifying the destruction.  
Unused product at the end of the study should be saved until instructed by the Sponsor. 
 
6.2.2 
Formulation, Appearance, Packaging, and Labeling 
Remdesivir component 
The lyophilized formulation of remdesivir is a preservative-free, white to off-white or yellow, 
lyophilized solid containing 150 mg or 100 mg of remdesivir to be reconstituted with 29 mL or 
19 mL (respectively) of sterile water for injection respectively and diluted into IV infusion fluids 
prior to IV infusion. Following reconstitution, each vial contains a 5 mg/mL remdesivir 
concentrated solution with sufficient volume to allow withdrawal of 30 mL (150 mg of 
remdesivir) or 20 mL (100 mg of remdesivir).  
 
It is supplied as a sterile product in a single-use, Type 1 clear glass vial. In addition to the active 
ingredient, the lyophilized formulation of remdesivir contains the following inactive ingredients: 
water for injection, SBECD, hydrochloric acid, and/or sodium hydroxide. For more information, 
refer to the MOP. 
 
Remdesivir will be labeled according to manufacturer specifications and include the statement 
“Caution: New Drug Limited by Federal (USA) Law to Investigational Use.” 
 
Baricitinib component 
According to the package insert, baricitinib tablets are available for oral administration as film-
coated, immediate-release tablets. The 2 mg tablet is light pink and oblong. Each tablet contains 
2 mg of baricitinib and the following inactive ingredients: croscarmellose sodium, magnesium 
stearate, mannitol, microcrystalline cellulose, ferric oxide, lecithin (soya), polyethylene glycol, 
polyvinyl alcohol, talc and titanium dioxide. 
 
Oral placebo component 
Placebo tablets match the active product in appearance. The placebo tablets contain lactose 
monohydrate, microcrystalline cellulose, croscarmellose sodium, and magnesium stearate. The 
coating for the placebo tablet is identical to that of the corresponding active tablet listed above. 
Placebo is supplied as 2 mg film-coated, in 36 count bottles, open label.  
 
Study interventions (baricitinib and placebo) will be supplied by the sponsor or its designee in 
accordance with current Good Manufacturing Practice (cGMP). 
 
6.2.3 
Product Storage and Stability 

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The Pharmacy Manual provides instructions for the preparation, handling, and storage of baricitinib 
drug product and placebo, and describes site responsibility and accountability for the administered 
products.  
6.2.4 
Preparation 
Refer to the protocol-specific MOP for details about preparation.  
 
Remdesivir is not considered a hazardous drug as defined by NISOH and ASHP hazard 
classification systems. The study products may be prepared in a clean room but do not need to be 
prepared or handled in a fume hood. Baricitinib is a “Hazardous Chemical" as defined by the 
OSHA Hazard Communication Standard, 29 CFR 1910.1200. 
 
Measures that minimize drug contact with the body should always be considered during 
handling, preparation, and disposal procedures as indicated in the IB. 
6.3 
Measures to Minimize Bias: Randomization and Blinding 
6.3.1 
Randomization  
Randomization will be stratified by: 
 Site 
 Severity of illness at enrollment (by ordinal scale) 
o Severe disease:  
▪ Hospitalized, on invasive mechanical ventilation or ECMO, or 
▪ Hospitalized, on non-invasive ventilation or high flow oxygen devices. 
o Moderate disease:  
▪ Hospitalized, requiring supplemental oxygen, or 
▪ Hospitalized, not requiring supplemental oxygen. 
 
The randomization procedure will be described in the MOP.  
 
6.3.2 
Blinding and Masking Procedures 
As both arms are receiving remdesivir, the remdesivir product is not blinded and study infusions 
can be labeled accordingly.  
 
The baricitinib/placebo component is blinded. Baricitinib and placebo tablets are identical in 
appearance. 
 
Unblinding of the study will occur after all subjects enrolled have reached the end of study, and 
these visits are monitored and data is cleaned, or if the DSMB recommends unblinding.  
 
If AEs occur and investigators are concerned about the treatment allocation, the treatment can be 
discontinued. If a Serious Adverse Event occurs, that is thought to be related to the study drug, 
and the treating clinician believes that knowledge of the treatment arm may change the therapy 
provided to the patient, the individual subject can be unblinded. The procedure for unblinding 
will be further detailed in the Manual of Operations. 
 

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6.4 
Study Intervention Compliance 
Each dose of study product will be administered by a member of the clinical research team who 
is qualified and licensed to administer the study product. Administration and date, and time, will 
be entered into the case report form (CRF). 
 
6.5 
Concomitant Therapy 
6.5.1 
Permitted Concomitant Therapy and Procedures 
Receipt of any exclusionary treatments or medications prior to screening will be assessed to 
determine eligibility as described in the exclusion criteria. This includes use of strong inhibitors 
of organic anion transporter 3 (OAT3) such as probenecid which are prohibited during the study. 
 
For patients that are eligible for the study, other therapy received prior to enrollment with any 
other experimental treatment or off-label use of marketed medications that are intended as 
specific treatment for COVID-19 or the SARS-CoV-2 infection (i.e., post-exposure prophylaxis 
[PEP]) are permitted but must be discontinued on enrollment. There is no waiting period 
between discontinuation of these treatments and administration of study products. However, 
these prior treatments and their end date should be documented on the Concomitant Medication 
(CCM) form in the Advantage eClinical system.  
 
There are two scenarios in which outpatient experimental treatment or off-label use of marketed 
medications that are intended as specific treatment for COVID-19 do not need to be 
discontinued. First, subjects who are taking another antiviral for a concurrent infection (e.g. 
oseltamivir for an influenza virus, lopinavir/ritonavir for HIV, etc.) or another existing medical 
condition (e.g. hydroxychloroquine for lupus, etc.) may continue with the treatment. Note that 
these treatments may be thought of as an off-label medication for COVID-19, however, because 
they were being used prior to study enrollment for another indication, they are allowable. 
Second, if there is a written policy or guideline for the local standard of care and treatment of 
COVID-19 patients or SARS-CoV-2 infection (i.e., not just an individual clinician decision), 
continuation of these outpatient medications are permitted. This could include lopinavir/ritonavir 
(Kaletra), hydroxychloroquine or other agents. There should be plans on how the concomitant 
drugs are stopped in case of additive toxicities. 
 
VTE prophylaxis is recommended for all patients unless there is a major contraindication such as 
active bleeding events or history of heparin-induced thrombosis. 
 
6.5.2 
Prohibited Concomitant Therapy 
A subject cannot participate in another clinical trial for the treatment of COVID-19 until after 
Day 29 (see exclusion criteria).  
 
If there are NO written policies or guidelines for local standard of care and treatment of COVID-
19 patients or SARS-CoV-2 infection, concomitant use of any other experimental treatment or 
off-label use of marketed medications intended as specific treatment for COVID-19 or SARS-
CoV-2 infection are prohibited. This includes medications that target the host immune response. 

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Once enrolled, use of any biologic therapy outside of local written standards of care are 
prohibited. This includes monoclonal antibodies targeting cytokines (e.g., TNF inhibitors; 
interleukin-1[IL-1], IL-6 [tocilizumab or sarilumab]), or T-cells (e.g., abatacept); monoclonal 
antibodies targeting B-cells (e.g., rituximab, and including any targeting multiple cell lines 
including B-cells); JAK inhibitor(s) other than baricitinib (e.g., imatibib, genfinitib); and 
interferon, plasma, or immunoglobulin (IgG) therapies for COVID-19.  
 
Strong inhibitors of organic anion transporter 3 (OAT3) such as probenecid are prohibited during 
the study. 
 
Corticosteroids for the treatment of COVID-19 are prohibited. Several treatment guidelines for 
COVID-19 recommend against the routine use of systemic corticosteroids for the treatment of 
COVID-19 in hospitalized, non-critically ill patients. However, corticosteroids are permitted for 
other standard indications including asthma exacerbation, ARDS, COPD, laryngeal edema, 
adrenal insufficiency, shock, etc.  
 
There is no available data on potential interactions between remdesivir and other anti-SARS-
CoV investigational agents. Administering remdesivir concurrently with other agents may lead to 
antagonism or synergy or may have no effect.  
 
Concomitant medications will be assessed only from 7 days prior to enrollment to Day 15 or 
upon discharge, whichever comes first. Report all prescription medications taken during this time 
period. Record medications once regardless of the number of times it was given during the time 
period. For example, vasopressors or insulin should be recorded when first started (the start date) 
and end date if ended before Day 15 or discharge. Dose of medication is not recorded in 
Advantage eClinical. Record all antipyretics and other medications given for symptomatic care, 
if they are administered while an inpatient. However, record these medications only once, even if 
given multiple times, as needed during hospital course. Do not report medications that the 
subject did not actually receive during study (e.g., prn medications that were never given).  
 
Do not report vitamins, herbal supplements, or topical medications. Do not report over-the-
counter cold medicines and antipyretics that the subject reportedly took at home prior to 
hospitalization. See the MOP for more information about recording concomitant medications. 
 
6.5.3 
Rescue Medicine 
Not Applicable 
 
6.5.4 
Non-Research Standard of Care 
Not Applicable 
 
 
7. 
STUDY INTERVENTION DISCONTINUATION AND 

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SUBJECT DISCONTINUATION/WITHDRAWAL 
7.1 
Halting Criteria and Discontinuation of Study Intervention 
7.1.1 
Individual Study Product Halting  
Study product administration for any given subject may be stopped for SAEs, clinically 
significant adverse events, severe laboratory abnormalities, or any other medical conditions that 
indicate to the Investigator that continued dosing is not in the best interest of the patient. 
For an individual subject, study product must be stopped if they have a suspected drug-related 
event of hypersensitivity (Grade 2 or higher) during or shortly after receiving the IP. While there 
are no criteria for grading “hypersensitivity” in the Division of AIDS (DAIDS) Table for 
Grading the Severity of Adverse Events, sites should use acute allergic reaction from that 
toxicity table. Subjects who have the study product stopped for a safety related issues will not 
continue with dosing. In addition, subjects who have an allergic reaction that is temporally 
associated with study product administration and the PI believes it to be related to study product 
will not receive any more study product. 
In addition, a subject in this clinical study may discontinue study drug at their request for any 
reason. Every effort should be made to encourage subjects to remain in the study for the duration 
of their planned outcome assessments. Subjects should be educated on the continued scientific 
importance of their data, even if they discontinue study drug.  
Unless the subject withdraws consent, those who discontinue study drug early will remain in the 
study. The reason for subject discontinuation of study drug should be documented in the case 
report form. 
 
7.1.1.1 
Remdesivir Halting 
See Section 6.1.4. for information about dosing modifications due to laboratory abnormalities. 
 
7.1.1.2 
Oral Study Product Halting 
See Section 6.1.4. for information about dosing modifications due to laboratory abnormalities. 
 
The subject should not receive any additional oral study product if they develop any of the 
following conditions during the study:  
 Active TB infection or evidence of latent TB (though testing is not required per 
protocol). 
 VTE (DVT/PE). 
 Suspected drug-induced liver injury with the appearance of fatigue, nausea, vomiting, 
right upper-quadrant pain or tenderness, fever, rash, and/or eosinophilia (>5%). 
 New malignancy (except for successfully treated basal or squamous cell skin carcinoma) 
 ALT or AST >8 times ULN  
 
7.1.2 
Study Halting 

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Given the potential severity of COVID-19, there are no pre-specified study stopping rules. 
Instead there will be close oversight by the protocol team and frequent DSMB reviews of the 
safety data.  
 
7.2 
Withdrawal from the Study 
Subjects are free to withdraw from participation in the study at any time upon request, without 
any consequence. Subjects should be listed as having withdrawn consent only when they no 
longer wish to participate in the study and no longer authorize the Investigators to make efforts 
to continue to obtain their outcome data.  
 
Subjects who withdraw from this study or are lost to follow-up after signing the informed 
consent form (ICF) and administration of the study product, will not be replaced. The reason for 
subject withdrawal from the study will be recorded on the appropriate CRF. 
7.3 
Lost to Follow-Up 
A subject will be considered lost to follow-up if he or she fails to appear for all follow-up 
assessments. In lost to follow-up cases, attempts to contact the subject should be made and these 
efforts should be documented in the subject’s records.  
 
7.4 
Readmission  
If a subject is discharged from the hospital and then readmitted prior to Day 14, they may be 
given the remainder of the study product (i.e., infusion until Day 10 and oral product until Day 
14). If the subject did not withdrawal his/her consent to participate in the study, there is no need 
to reconsent upon readmission to the study hospital. However, the site will need to inform them 
that since he/she was readmitted, study product administration will resume and confirm that they 
still agree to receive study product. If the subject is re-admitted with diminished mental capacity, 
the site should discuss continued study participation with a LAR.  
 
The study team will need to notify the study pharmacist of the readmission. The subject will not 
get the doses that they missed after being discharged. Upon readmission, the subject will get 
maintenance doses of infusion only since they already received the loading dose of the study 
product infusion on Day 1. No study product infusions should be given past Day 10 and no oral 
study product should be given past Day 14.  
 
The site should not complete the Discontinuation of Treatment form in Advantage eClinical 
since the subject came back to the study hospital to be readmitted. For all data collection 
procedures required for those readmitted, please see the MOP.  
 
8. 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
Screening and Efficacy Assessments 

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8.1.1 
Screening Procedures 
Screening procedures may be done over one to two calendar days (from Day -1 to Day 1). 
However, in many cases all the screening assessments can be done in less than 24 hours. If that is 
the case, Day 1 pre-study product administration baseline assessments, specimen collection and 
the initial study product administration can occur on the same calendar day as the screening 
procedures.  
 
After the informed consent, the following assessments are performed to determine eligibility: 
 
Confirm the positive SARS-CoV-2 test result (per inclusion criteria).  
 
Take a focused medical history, including the following information:  
 Day of onset of COVID-19 signs and symptoms. 
 
 History of vaccinations within 4 weeks before screening and planned vaccinations.  
 Exclusionary vaccine history includes: 
o Has received any live vaccine (that is, live attenuated) within 4 weeks 
before screening, or intend to receive a live vaccine (or live attenuated) 
during the study. Note: Use of non-live (inactivated) vaccinations is 
allowed for all subjects.  
 
 History of chronic medical conditions, including chronic oxygen requirement, prior to 
onset of COVID-19. See conditions included in exclusion criteria (Section 5.2) and 
on the Medical History (CMX) data collection form. 
 
 History of medication allergies. 
 
 Medications and therapies for this current illness taken in the 7 days prior to Day 1, 
and history of any medication listed in the exclusion criteria. 
 
 Ask if they are participating in another clinical trial or plan to enroll in another 
clinical trial in the next 28 days. 
 
 
Women of childbearing potential should be counseled to either practice abstinence or use at 
least one primary form of contraception not including hormonal contraception from the time 
of screening through Day 29. Women should be confirmed to not be breastfeeding. 
 
Note: If a woman is either postmenopausal (i.e., has had ≥12 months of spontaneous 
amenorrhea) or surgically sterile (i.e., has had a hysterectomy, bilateral ovariectomy 
(oophorectomy), or bilateral tubal ligation), she is not considered to be of 
childbearing potential.  
 
Height and weight (height can be self-reported). 
 
Results of recent radiographic imaging (x-ray or CT scan). 
 
SpO2. 

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 
Blood for screening laboratory evaluations if not done as part of routine clinical care in the 
preceding 48 hours: 
▪ CBC with differential  
 Evaluate if subject is neutropenic (absolute neutrophil count <1000 cells/μL) 
(<1.0 x 103/μL or <1.0 GI/L) and/or lymphopenic (absolute lymphocyte count 
<200 cells/μL) (<0.20 x 103/μL or <0.20 GI/L) 
▪ ALT and AST 
 Assess if ALT or AST > 5 times the upper limit of normal. 
▪ Creatinine (and calculate eGFR).  
 Determine if eGFR < 30 ml/min as these subjects are not eligible. Also, subject 
receiving hemodialysis or hemofiltration are not eligible. 
 Any automated calculation by the clinical laboratory or published formula for this 
calculation is acceptable. The site should select a formula to be used for all 
subjects enrolled at the site for the duration of the study. 
 
Urine or serum pregnancy test (in women of childbearing potential). 
 
Clinical screening laboratory evaluations will be performed locally by the site laboratory. The 
volume of venous blood to be collected is presented in Table 3. 
 
The overall eligibility of the subject to participate in the study will be assessed once all screening 
values are available. The screening process can be suspended prior to complete assessment at 
any time if exclusions are identified by the study team. 
 
Study subjects who qualify will be randomized in the Advantage eClinical system, and all others 
will be registered as screen failures. The ordinal scale and the NEWS should be done at the time 
of randomization; the site will need this data to randomize the subject in eClinical. The study 
team has 24 hours to complete other Day 1 baseline assessments prior to the first study product 
administration including the collection of OP swab and blood and completing or recording a 
baseline physical examination that was done. 
8.1.2 
Efficacy Assessments 
For all baseline assessments and follow-up visits, refer to the Schedule of Assessments (SOA) 
for procedure to be done, and details below for each assessment. 
 
8.1.2.1 
Measures of clinical support, limitations and infection control 
The subject’s clinical status will be captured on each study day while hospitalized through Day 
29 or day after death whichever comes first. See more information about capturing death below. 
If a subject is discharged prior to Day 15, clinical status is collected on Day 15 and 29 if the 
subject returns for an in-person clinic visit or by phone if an in-person visit is not possible. 
Clinical status will also be captured on Day 22 during a phone visit. Clinical status is largely 
measured by the ordinal scale and the NEWS. Unlike the NEWS, the ordinal scale can also be 

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evaluated over the phone if the discharged subject is unable to return for visits on Day 15 and 29 
as well as on Day 22.  
 
Except for on Day 1, when the ordinal scale and the NEWS is captured at the time of 
randomization, a site should try to complete the ordinal scale and the NEWS at approximately 
the same time each day. Ideally, complete the ordinal scale concurrently with NEWS just prior to 
study product administration, as time permits. The following measures are recorded for the 
ordinal scale: 
 Hospitalization. 
 Oxygen requirement. 
 Non-invasive mechanical ventilation (via mask) requirement. 
 High flow oxygen requirement. 
 Invasive mechanical ventilation (via endotracheal tube or tracheostomy tube) 
requirement. 
 ECMO requirement. 
 Ongoing medical care preventing hospital discharge (COVID-19 related or other medical 
conditions). 
 Limitations of physical activity (self-assessed). 
 Isolated for infection control purposes. 
 
8.1.2.2 
Ordinal Scale 
The ordinal scale is the primary measure of clinical outcome.  
 
The scale used in this study is as follows (from worst to best): 
 Death; 
 Hospitalized, on invasive mechanical ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation or high flow oxygen devices; 
 Hospitalized, requiring supplemental oxygen; 
 Hospitalized, not requiring supplemental oxygen – requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental oxygen – no longer requires ongoing medical 
care; 
o This would include those kept in hospital for quarantine/infection control, awaiting 
bed in rehabilitation facility or homecare, etc. 
 Not hospitalized, limitation on activities and/or requiring home oxygen; 
 Not hospitalized, no limitations on activities 
 
To determine a subject’s clinical status using the ordinal scale: On Day 1, report their clinical 
status at randomization. As there should be <24 hours between randomization and infusion, the 
ordinal scale at done at randomization suffices as the Day 1 ordinal scale. After Day 1, collect 
the ordinal scale daily while hospitalized from Day 2 through Day 29 by providing the worst 
clinical assessment for the previous day (i.e., midnight to midnight; 00:00 – 23:59 (24-hr clock)).  

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For those who are discharged prior to Day 15, collect ordinal scale on follow-up Days 15, 22 and 
29 by providing the worst clinical assessment for the previous day (i.e., midnight to midnight; 
00:00 – 23:59 (24-hr clock)). For example, on study Day 3 when completing the form, the worse 
clinical outcome measure of Day 2 is captured with the worst being death followed by ECMO, 
mechanical ventilation, etc. The Day 2 measurement is assessed as occurring anytime in that 24-
hour period (00:00 to 23:59).  
 
It is important to capture all deaths that occur during the study as this is one of the outcomes of 
the study. Death is a category on the ordinal scale. If a subject dies during the study, the site will 
need to complete an ordinal scale assessment for the day after death. If a subject dies within the 
window of the final study visit (i.e., Day 29 ± 3 days), complete an ordinal scale assessment on 
the day after death.  
 
For more information about the data collected for the ordinal scale, see the MOP. 
8.1.2.3 
National Early Warning Score (NEWS) 
Vital signs and other clinical assessments are collected for the calculation of the NEWS, and 
include temperature, systolic blood pressure, heart rate, respiratory rate, O2 saturation and level 
of consciousness. Vital signs collected per standard of care can be used. NEWS has 
demonstrated an ability to discriminate subjects at risk of poor outcomes. (Smith, 2016). This 
score is based on 7 clinical parameters (see Table 2). The NEWS is being used as an efficacy 
measure. The NEW Score should be evaluated daily while hospitalized and on Days 15 and 29. It 
can be performed concurrently with the Ordinal Scale. This should be evaluated at a consistent 
time for each study day and prior to administration of study product. The 7 parameters can be 
obtained from the hospital chart or electronic medical record (EMR) using the last measurement 
prior to the time of assessment (including parameters collected prior to the time of consent) and a 
numeric score is given for each parameter (e.g., a RR of 9 is one point, oxygen saturation of 92 is 
two points). This is recorded for the day obtained (i.e., on Day 3, the vital signs and other 
parameters from Day 3 are used to obtain NEW Score for Day 3). ECMO and mechanically 
ventilated subjects should be assigned a score of 3 for RR (RR <8) regardless of the ventilator 
setting. Subjects on ECMO should get a score of 3 for heart rate since they are on 
cardiopulmonary bypass. 
 
 

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Table 2. National Early Warning Score (NEWS) 
 
 Level of consciousness = alert (A), and non-alert and arousable only to voice (V) or pain (P), and unresponsive 
(U).  
If the subject is on ECMO or invasive mechanical ventilation, they will be given score of 3 (≤8 RR) for 
respiratory rate regardless of ventilator setting. For subjects on ECMO, they will also receive a score of 3 
(≤40 HR) for heart rate. 
 
8.1.3 
Exploratory assessments 
8.1.3.1 
Viral Load and/or Shedding 
As outlined on the SOA, OP samples (collected by swab) and plasma and serum will be collected 
on Day 1; and Days 3, 5, 8, and 11 (while hospitalized); and OP swabs and serum on Day 15 and 
29 (if attends an in- person visit or still hospitalized). Samples are stored as outlined in the MOP. 
These assays are not developed yet, and the ability to test samples at one central lab is not clear. 
Therefore, while viral load/shedding is thought to be an important endpoint, considering the 
limitations above, it is listed as an exploratory endpoint.  
 
OP samples are preferred, but if these are not obtainable, nasopharyngeal (NP) samples 
(collected by NP swab) or nasal swab may be substituted. Due to limited lack of swabs and other 
supplies at some sites and limitations on personal protective equipment (PPE), the inability to 
obtain these samples are not considered protocol deviations and should be documented in the 
subject’s record.  
 
If virology assays can be set up with enough numbers of specimens tested, these data will be 
submitted as part of the Clinical Study Report (CSR). This may be submitted separately, as a 
supplemental CSR.  
 

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Samples collected for viral assessment may be probed for the emergence of antiviral resistance at 
a future date. These data, if available, may be submitted as a supplement report. 
 
The schedule of assessments (SOA, Section 1.2) lists several research laboratory samples. It is 
preferred that these samples are collected and sent to the NIAID repository to be tested in one 
central laboratory. Current US Centers for Disease Control and Prevention (CDC) guidance is 
these samples can be processed in a Biosafety Laboratory (BSL) 2 environment. However, 
institutions may impose restrictions on processing the samples (i.e., they may require BSL-3) or 
there may be restrictions on sending samples. In these circumstances, the following apply: 
 
Blood for PCR SARS-CoV-2 
 If the samples can be processed but cannot be sent to the repository, the samples may be 
stored locally.  
 The sponsor may elect to have some or all of these samples run locally, pending 
confirmation of the assays to be used and the qualifications of the local laboratory. The 
sponsor will work with the site to determine when this could occur and how these data can 
be imported into the study database.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
Oropharyngeal or Nasopharyngeal/nasal specimen 
 If the samples can be processed but cannot be sent to the repository, the samples may be 
stored locally.  
 The sponsor may elect to have some or all of these samples run locally, pending 
confirmation of the assays to be used and the qualifications of the local laboratory. The 
sponsor will work with the site to determine when this could occur and how these data can 
be imported into the study database.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
Blood for serum (for secondary research) 
 If the samples can be processed and but not sent to the repository, the samples may be 
stored locally.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
8.1.3.2 
Cytokine Assessments 
To assess the impact of baricitinib on serum cytokine levels, blood samples will be assessed 
using a multiplex assay that is less sensitive to variability in sample integrity due to sample 
processing limitations during the pandemic. Cytokines to be tested may include (but not be 
limited to) IL-2, IL-19, IL-4, IL-10, IL-8, G-CSF, GM-CSF, MCP-1, MIP1α, IL-7, IL-13, IL-31, 
IL-15, IL-6, IFNα, IFNγ and TNFα. The list of cytokines tested is subject to change as new 
information about the pro-inflammatory state of COVID-19 is known. Given the challenges of 
obtaining samples and evolving knowledge about COVID-19, these will be considered 
exploratory endpoints. The description of the final methodology utilized, and the assay 
performance characteristics will be included in the final study report.  

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8.2 
Safety and Other Assessments 
Study procedures are specified in the SOA. A study physician licensed to make medical 
diagnoses and listed on the 1572 will be responsible for all trial-related medical decisions. 
 
Physical examination:  
A targeted physical examination will be performed at baseline prior to initial study product 
administration on Day 1. The baseline physical examination can be one that is conducted from 
screening to Day 1. No routine physical exam is needed for study visits after Day 1.  
 
Study staff at some sites are not allowed into the subject’s rooms due to a limited supply of PPE 
and the need for strict respiratory isolation measures for COVID-19 patients. Because of limited 
access to subjects, physical exams can be performed by any licensed provider at the study 
hospital even if they are not study staff listed on the 1572. The study team can extract 
information from the hospital chart or EMR.  
 
Clinical laboratory evaluations: 
 Fasting is not required before collection of laboratory samples. 
 Blood will be collected at the time points indicated in the SOA.  
 Clinical safety laboratory tests include WBC, differential, Hgb, PLT, creatinine, 
glucose, total bilirubin, AST, ALT, INR, d-dimer, and C-reactive protein.  
 Day 1 clinical laboratory evaluations are drawn prior to initial study product 
administration as a baseline and results do not need to be reviewed to determine if 
initial study product administration should be given. 
 Clinical laboratory testing will be performed at each clinical trial site in real time.  
 
Table 3. Venipuncture Volumes1 
 
Screen 
Baseline 
 
 
 
 
 
 
Day +/- Window 
−1 to 1 
1 ± 1 
3 ± 1 
5 ±1 
8 ± 1 
11 ± 1 
15 ± 2 
29 ± 3 
Safety hematology, 
chemistry and liver 
tests 
 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
 X3 
10mL2 
X3 
10mL2 
Blood for Serum 
 
 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
Plasma  
(includes PCR) 
 
X 
8mL 
X 
8mL 
X 
8mL 
X 
8mL 
X 
8mL 
 
 
Total volume 
10mL 
42ml 
42mL 
42ml 
42ml 
42ml 
34mL 
34mL 
Total all study days 
 
 
 
 
 
 
 
268~288 
mL 
1. See SOA in Section 1.2 for specific tests to be performed. 
2. Total volume calculated assumes there are no routine clinical laboratory were done within 48 hours of screening 
that can be used for determining eligibility and no routine clinical laboratory tests were done within the window for 
that visitor 24 hours of Day 1, 3, 5, 8 and 11 and 48 hours for Day 15 and 72 hours for Day 29 if still hospitalized.  
3. Safety laboratory tests will be collected on Day 15 and 29 if the subject is still hospitalized at these time points or 
if they return for an in-person outpatient visit and the site has the capacity to collect blood in the outpatient setting. 
8.2.1 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings 

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If a physiologic parameter (e.g., vital signs, or laboratory value) is outside of the protocol-
specified range, then the measurement may be repeated once if, in the judgment of the 
investigator, the abnormality is the result of an acute, short-term, rapidly reversible condition or 
was an error. A physiologic parameter may also be repeated if there is a technical problem with 
the measurement caused by malfunctioning or an inappropriate measuring device (i.e., 
inappropriate-sized BP cuff). 
 
8.2.2 
Unscheduled Visits 
If clinical considerations require the subject to be contacted or seen prior to the next schedule 
assessment to assure the subject’s well-being, it is permissible in this protocol. However, no 
research data is collected at this visit.  
8.3 
Adverse Events and Serious Adverse Events 
8.3.1 
Definition of Adverse Event (AE) 
AE means any untoward medical occurrence associated with the use of an intervention in 
humans, whether or not considered intervention related. An AE can therefore be any unfavorable 
and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of medicinal (investigational) product. If multiple abnormalities are part 
of the same clinical syndrome, they can be reported together as one AE under a unifying clinical 
diagnosis.  
 
Any medical condition that is present at the time that the subject is screened will be considered 
as baseline and not reported as an AE. However, if the severity of any pre-existing (baseline) 
medical condition increases above baseline to severity grade 3 or 4, it should be recorded as an 
AE. 
 
Given the nature of severity of the underlying illness, subjects will have many symptoms and 
abnormalities in vital signs and laboratory values. Only Grade 3 and 4 AEs will be captured in 
this trial. In addition, the following AEs will be reported: 
 Any Grade 2 or higher suspected drug-related hypersensitivity reactions associated with 
study product administration will be reported as an AE. 
 Any venous thromboembolism at any time during the study. 
 
Unsolicited laboratory values collected as part of standard of care, will need to be reported only 
if Grade 3 or above and only if clinically significant and/or part of a diagnosis or a clinical 
syndrome. In this case, if laboratory and vital sign abnormalities are part of the clinical 
syndrome, they should be reported as one AE under one clinical diagnosis or syndrome. 
Example: Low oxygen level/arterial blood gases could be part of respiratory failure diagnosis. 
 
Intermittent abnormal laboratory values or vital sign measurements common in the severely ill 
populations (such as electrolyte abnormalities, low blood pressure, hyperglycemia, etc.) that are 
part of the same clinical diagnosis (e.g., uncontrolled diabetic) can be recorded once with the 
worst grade for each adverse event (grade 3 and 4 only for this trial), with the start and stops 
dates of the intermittent syndrome. If there is clear resolution of the event, and then recurrence, it 
should be treated as a separate adverse event. Resolution is defined as return to baseline (either 

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normal if was normal at Day 1, or baseline (Day 1) grade if already an abnormality on the 
toxicity table at Day 1) for > 48 hours. 
 
D-dimer and CRP should not be graded. There are collected on the same schedule as the safety 
laboratory tests (see SOA). However, they will be used in the assessment of study outcomes.  
 
8.3.2 
Definition of Serious Adverse Event (SAE) 
An AE or suspected adverse reaction is considered serious (i.e., is an SAE) if, in the view of 
either the investigator or the Sponsor, it results in any of the following outcomes: 
 Death; 
 A life-threatening AE; 
 Inpatient hospitalization or prolongation of existing hospitalization; 
 A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions; or 
 A congenital anomaly/birth defect. 
 
Grade 4 AEs (potentially life-threatening events) are not always SAEs unless they are 
imminently life threatening.  
 
Important medical events that may not meet the above criteria may be considered serious when, 
based upon appropriate medical judgment, they may jeopardize the subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. 
Examples of such medical events include allergic bronchospasm requiring intensive treatment in 
an emergency room or at home, blood dyscrasias, convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
 
“Life-threatening” refers to an AE that at occurrence represents an immediate risk of death to a 
subject. An event that may cause death if it occurs in a more severe form is not considered life-
threatening. Similarly, a hospital admission for an elective procedure is not considered a SAE. 
 
All SAEs, as with any AE, will be assessed for severity and relationship to study intervention. 
 
All SAEs will be recorded on the AE CRF and reported to DMID (see Section 8.3.6). 
 
All SAEs will be followed through resolution or stabilization by a licensed study physician (for 
IND studies, a physician listed on the Form FDA 1572 as the site PI or Sub-Investigator). 
 
All SAEs will be reviewed and evaluated by DMID and will be sent to the DSMB (for periodic 
review), and the IRB/IEC. 
8.3.3 
Suspected Unexpected Serious Adverse Reactions (SUSAR) 

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A SUSAR is any SAE where a causal relationship with the study product is at least reasonably 
possible but is not listed in the Investigator Brochure (IB), Package Insert, and/or Summary of 
Product Characteristics. 
8.3.4 
Classification of an Adverse Event 
The determination of seriousness, severity, and causality will be made by an on-site investigator 
who is qualified (licensed) to diagnose AE information, provide a medical evaluation of AEs, 
and classify AEs based upon medical judgment. This includes but is not limited to physicians, 
physician assistants, and nurse practitioners. 
8.3.4.1 
Severity of Adverse Events 
All AEs and SAEs will be assessed for severity using the DAIDS Table for Grading the Severity 
of Adult and Pediatric Adverse Events, version 2.1 (July 2017).  
 
For AEs not included in the Table, the following guidelines will be used to describe severity. In 
addition, all deaths related to an AE are to be classified as grade 5 according to the DAIDS Table.  
 
 Moderate (Grade 2): Events that are usually alleviated with additional specific 
therapeutic intervention. The event interferes with usual activities of daily living and 
causes discomfort but poses no significant or permanent risk of harm to the research 
subject. 
 
 Severe (Grade 3): Events that interrupt usual activities of daily living, or significantly 
affect clinical status, or may require intensive therapeutic intervention. Severe events are 
usually incapacitating. 
 
 Potentially life-threatening event (Grade 4): Events that are potentially life threatening. 
 
 
 Deaths (Grade 5): All deaths related to an AE are classified as grade 5 (per DAIDS 
Table). 
 
 
8.3.4.2 
Relationship to Study Intervention 
For each reported adverse reaction, the PI or designee must assess the relationship of the event to 
the study product using the following guideline: 
 
 Related – There is a temporal relationship between the study intervention and event, and 
the AE is known to occur with the study intervention or there is a reasonable possibility 
that the study intervention caused the AE. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the study intervention and the AE. 
 
 Not Related – There is not a reasonable possibility that the administration of the study 
intervention caused the event, there is no temporal relationship between the study 
intervention and event onset, or an alternate etiology has been established. 
 

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8.3.5 
Time Period and Frequency for Event Assessment and Follow-Up 
For this study, all Grade 3 and 4 AEs, all SAEs occurring from the time the informed consent is 
signed through the Day 29 visit will be documented, recorded, and reported. 
 
8.3.5.1 
Investigator Reporting of AEs 
Information on AEs will be recorded on the appropriate CRF. All clearly related signs, 
symptoms, and results of diagnostic procedures performed because of an AE should be grouped 
together and recorded as a single diagnosis. If the AE is a laboratory abnormality that is part of a 
clinical condition or syndrome, it should be recorded as the syndrome or diagnosis rather than 
the individual laboratory abnormality. Each AE will also be described in terms of duration (start 
and stop date), severity, association with the study product, action(s) taken, and outcome. 
Any new infection that occurs on study, regardless of infecting agent (i.e., viral or non-viral) will 
be captured if it is a Grade 3 or 4 AE or SAE. Completion of the Infection Follow-up eCRF page 
is required for each infection reported as an adverse event or SAE with site of infection and 
source of culture provided, if available. The purpose is to document the occurrence of new 
infections by type of infection and not the duration of the new infections. Therefore, capture the 
first positive result(s) for the new infection (e.g., blood or urine culture, molecular diagnostic test 
result, etc.); there is no need to capture repeatedly positive results unless there is a new pathogen 
identified from the same site (e.g., blood) during the infection event. The sponsor will identify 
infections considered to be opportunistic based on Winthrop et al. 2015. 
8.3.6 
Serious Adverse Event Reporting 
8.3.6.1 
Investigators Reporting of SAEs 
Any AE that meets a protocol-defined criterion as an SAE that is judged to be related to either 
study product must be submitted within 24 hours of site awareness on an SAE form to the DMID 
Pharmacovigilance Group, at the following address:  
 
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Dr. Suite 650 
Bethesda, MD 20817, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
 
Other supporting documentation of the event may be requested by the DMID Pharmacovigilance 
Group and should be provided as soon as possible. The DMID Medical Monitor will review and 
assess the SAE for regulatory reporting and potential impact on study subject safety and protocol 
conduct. At any time after completion of the study, if the site PI or appropriate sub-investigator 
becomes aware of an SAE that occurred during the subject’s participation in the study, the site PI 
or appropriate sub-investigator will report the event to the DMID Pharmacovigilance Group. 
 
SAEs that that are judged to be not related to study product are still captured on the AE case 
report form, but do not require separate reporting to the DMID Pharmacovigilance Group. 

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8.3.6.2 
Regulatory Reporting of SAEs 
Following notification from the site PI or appropriate sub-investigator, DMID, as the IND 
Sponsor, will report any SUSAR in an IND safety report to the FDA and will notify all 
participating site PIs as soon as possible. DMID will report to the FDA any unexpected fatal or 
life-threatening suspected adverse reaction as soon as possible, but in no case later than 7 
calendar days after the Sponsor’s initial receipt of the information. If the event is not fatal or life-
threatening, the IND safety report will be submitted within 15 calendar days after the Sponsor 
determines that the information qualifies for reporting as specified in 21 CFR Part 312.32. 
Relevant follow up information to an IND safety report will be submitted as soon as the 
information is available. Upon request from the FDA, DMID will submit to the FDA any 
additional data or information that the agency deems necessary, as soon as possible, but no case 
later than 15 calendar days after receiving the request. 
 
SAEs that are not SUSARs will be reported to the FDA at least annually in a summary format 
which includes all SAEs. 
 
Sites may have additional local reporting requirements (to the IRB and/or national regulatory 
authority).  
8.3.7 
Reporting of Pregnancy 
Pregnancy is not an AE. However, any pregnancy that occurs during study participation should 
be reported to the Sponsor on the appropriate CRF. Pregnancy should be followed to outcome.  
8.4 
Unanticipated Problems 
8.4.1 
Definition of Unanticipated Problems 
An Unanticipated Problem (UP) is any event, incident, experience, or outcome that meets the 
following criteria: 
 Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the IRB-approved research 
protocol and informed consent document; and (b) the characteristics of the subject 
population being studied; 
▪ Related to participation in the research (meaning there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures involved in the 
research); and 
▪ Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
8.4.2 
Unanticipated Problem Reporting 
To satisfy the requirement for prompt reporting, all Ups will be reported using the following 
timeline: 

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▪ UPs that are SAEs will be reported to the IRB and to the Statistical and Data 
Coordinating Center (SDCC)/study Sponsor within 24 hours of the investigator becoming 
aware of the event per the above describe SAE reporting process. 
▪ Any other UP will be reported to the IRB and to the SDCC/study Sponsor within 3 days 
of the investigator becoming aware of the problem. 
9. 
STATISTICAL CONSIDERATIONS 
9.1 
Statistical Hypotheses 
The primary null hypothesis tests whether the time-to-recovery differs between the experimental 
and control arms.  
 
Table 4. Hypothesis tests of interest for ACTT-1 and ACTT-2 
R=remdesivir, B=baricitinib and C=placebo 
 
ACTT-1 
Primary hypothesis 
R vs C 
ACTT-2  
Primary hypothesis 
R+B vs R 
  
 
A key secondary hypothesis tests the null distribution of a similar distribution of 8-point ordinal 
scale at Day 15. For this, the parameter of interest is the “common odds ratio,” which quantifies 
the shift in the severity distribution resulting from treatment. For an efficacious treatment, an 
odds ratio greater than 1 quantifies an improvement in disease severity; a value of 2 indicates a 
bigger improvement than a value of 1.25. The null hypothesis to be tested is that the odds of 
improvement on the ordinal scale is the same for the control and experimental treatment arms 
(i.e., the common odds ratio is 1). It is worth noting that, for large sample sizes, the test based on 
the proportional odds model is nearly the same as the Wilcoxon rank sum test. 
 
9.2 
Sample Size Determination 
 
Primary endpoint: The log-rank test will be used to compare treatment arms with respect to time 
to recovery. For the log-rank test, the two key determinants of power are the total number of 
events (i.e., recoveries) E and the treatment-to-control ratio of the rate of recovery, R. The 
number of events required for power 1 −𝛽 to detect a recovery rate ratio of θ using a two-tailed 
test at alpha=0.05 is approximately 
𝐸=
4(1.96 + 𝑧𝛽)
2
{ln(𝜃)}2
, 
where 𝑧𝛽 is the 100(1 −𝛽)th percentile of the standard normal distribution. 

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The force of recovery (sometimes loosely referred to as the “recovery ratio”) is the analogue of 
the hazard ratio and the term “recovery rate ratio” is the analogue of the hazard ratio in this 
setting. A recovery rate ratio of 1.31 was reported in Cao, Wang, Wen et al. (2020) for a 
lopinavir/ritonavir trial that used time to improvement by 2 categories as primary endpoint. A 
preliminary review of data from ACTT-1 demonstrated a recovery rate ratio 1.312. It is unlikely 
the second component of treatment will have a similar effect size. Therefore a recovery ratio of 
1.25 is assumed for this trial. A total of 723 recoveries are needed for a recovery ratio of 1.25 
with 85% power. Table 5 provides power for various recovery rate ratios. The study will accrue 
until approximately 723 recoveries have been achieved. The date of study closure will be 
estimated based on enrollment rate and recovery/enrollment percentages. If approximately 70% 
of participants recover, the total sample size will be 1032. 
 
Table 5. Number of recoveries needed for 85% power assuming a type I error rate of 5% 
for various recovery ratios. 
 
Recovery rate 
ratio 
(θ) 
Number of recoveries 
needed for 85% 
power 
1.20 
1080 
1.25 
723 
1.30 
523 
1.35 
400 
1.40 
318 
 
Key secondary: A sample size can be computed using an (assumed) ordinal scale distribution for 
the control arm and the odds ratio representing clinical improvement. The odds ratio represents 
the odds of improvement in the ordinal scale for combination treatment relative to the control 
arm [Whitehead, 1993]. The sample size to detect a given odds ratio for 1:1 randomization using 
a 2-tailed test at level α is given by 
12(𝑧α/2 + 𝑧β)
2
λ2(1 −∑
𝑝𝑖
3
𝐾
𝑖=1
), 
 
where λ is the log odds ratio, 𝑝𝑖 is the overall probability (combined over both arms) of being in 
the ith category of the K ordinal outcomes, and 𝑧α/2 and 𝑧𝛽 are the 1 −α/2 and 1 −β quantiles 
of the standard normal distribution.  
 
Table 6 displays five scenarios considered for outcome probabilities in the control arm for 
sample size determination. There is significant uncertainty with these assumptions given the 
limited data available. Table 6 shows a range of sample sizes for odds ratios ranging from 1.25 to 
2.5 for 85% power. For 90% power, increase the sample size by 17%. Table 8 displays the 
probabilities of being in different categories of the ordinal scale under an odds ratio of 1.75. A 
total sample size of 396 gives approximately 85% power to detect an odds ratio of 1.75 using a 
2-tailed test at level α = 0.05. The categories of the 8-point ordinal scale are: 
 
 Death; 

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 Hospitalized, on invasive mechanical ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation or high flow oxygen devices; 
 Hospitalized, requiring supplemental oxygen; 
 Hospitalized, not requiring supplemental oxygen – requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental oxygen – no longer requires ongoing medical 
care; 
 Not hospitalized, limitation on activities and/or requiring home oxygen; 
 Not hospitalized, no limitations on activities. 
 
Note that the data elements contributing to this scale will be captured separately, in order to 
facilitate different orderings or groupings, as might arise if external data provide information 
about the clinical course of disease.  
 
Table 6: Possible scenarios for the distribution of ordinal outcomes for the control arm at 
Day 15. 
 
Anticipated 
Different scenarios for control arm 
  
Scenario 1 
Scenario 2 
Scenario 3 
Scenario 4 
Scenario 5 
 
 
more mild disease                       more severe disease 
Severity Outcome 
outcome (%) outcome (%) 
outcome (%) outcome (%) outcome (%) 
Death 
2 
1 
1 
2 
3 
Hospitalized, on mechanical 
ventilation or ECMO 
1 
1 
1 
1 
3 
Hospitalized, on non-
invasive ventilation or high 
flow oxygen devices 
2 
1 
1 
2 
4 
Hospitalized, requiring 
supplemental oxygen 
7 
2 
5 
5 
9 
Hospitalized, not requiring 
supplemental oxygen – 
requiring ongoing medical 
care (COVID-19 related or 
otherwise) 
8 
5 
7 
17 
23 
Hospitalized, not requiring 
supplemental oxygen – no 
longer requires ongoing 
medical care 
10 
9 
10 
20 
25 
Not hospitalized, limitation 
on activities and/or requiring 
home oxygen 
30 
36 
35 
25 
18 
Not hospitalized, no 
limitations on activities 
40 
45 
40 
28 
15 
 
 

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Table 7: Sample size calculations for scenarios in Table 6 for a two-arm study assuming 
85% power, a two-sided type I error rate of 5%, and various true odds ratios.  
True odds 
ratio 
Total sample size 
 
Scenario 1 
Scenario 2 
Scenario 3 
Scenario 4 
Scenario 5 
1.25 
2420 
2554 
2459 
2293 
2252 
1.5  
744 
786 
755 
700 
684 
1.75 
396 
419 
401 
370 
360 
2.0 
262 
277 
265 
243 
236 
2.25 
194 
206 
196 
179 
173 
2.5 
154 
163 
155 
141 
136 
 
 
Table 8. Treatment ordinal outcome proportions under an odds ratio of 1.75 for five 
scenarios in Table 5 at Day 15. 
  
Scenario 
1 
Scenario 
2 
Scenario 
3 
Scenario 
4 
Scenario 
5 
 
Anticipated more mild disease                more severe disease 
Severity Outcome 
Control % 
Treatment % 
Control % 
Treatment % 
Control % 
Treatment % 
Control % 
Treatment % 
Control % 
Treatment % 
Death 
2 
1.2 
1 
0.6 
1 
0.6 
2 
1.2 
3 
1.7 
Hospitalized, on mechanical 
ventilation or ECMO 
1 
0.6 
1 
0.6 
1 
0.6 
1 
0.6 
3 
1.8 
Hospitalized, on non-invasive 
ventilation or high flow 
oxygen devices 
2 
1.2 
1 
0.6 
1 
0.6 
2 
1.2 
4 
2.5 
Hospitalized, requiring 
supplemental oxygen 
7 
4.3 
2 
1.2 
5 
3.0 
5 
3.1 
9 
5.8 
Hospitalized, not requiring 
supplemental oxygen – 
requiring ongoing medical 
care (COVID-19 related or 
otherwise) 
8 
5.3 
5 
3.1 
7 
4.4 
17 
11.5 
23 
17.4 
Hospitalized, not requiring 
supplemental oxygen – no 
longer requires ongoing 
medical care; 
10 
7.2 
9 
5.9 
10 
6.8 
20 
16.2 
25 
24.4 
Not hospitalized, limitation 
on activities and/or requiring 
home oxygen 
30 
26.5 
36 
29.3 
35 
30.2 
25 
25.9 
18 
22.7 

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Not hospitalized, no 
limitations on activities 
40 
53.8 
45 
58.9 
40 
53.8 
28 
40.5 
15 
23.6 
Note that columns may not sum to exactly 100 due to rounding errors. 
 
Other key secondaries for testing combination therapy compared to control will be detailed in an 
addendum SAP 
 
9.3 
Populations for Analyses 
The primary analysis will be based on an intention-to-treat population, including all subjects 
randomized. Similarly, safety analyses will be based a modified intent-to-treat population 
consisting of all subjects who received at least one dose of any investigational product.  
 
9.4 
Statistical Analyses 
9.4.1 
General Approach 
This is a double-blind placebo controlled randomized trial testing a superiority hypothesis with a 
two-sided type I error rate of 5%. Secondary hypotheses have been ordered according to relative 
importance, with one key secondary hypothesis highlighted. These will be described according to 
the appropriate summary statistics (e.g., proportions for categorical data, means with 95% 
confidence intervals for continuous data, median for time-to-event data).  
 
A statistical analysis plan will be developed and filed with the study sponsor prior to unblinding 
of study and database lock.  
 
9.4.2 
Analysis of the Primary Efficacy Endpoint 
The primary efficacy analysis is a stratified log-rank test, where stratification is according to 
baseline disease severity (i.e. protocol defined mild/moderate vs severe disease). Deaths will be 
considered as never recovering and censored at Day 29. In ACTT2, the analyses conducted will 
depend on the results from ACTT-1 according to Table 4. 
 
9.4.3 
Analysis of the Secondary Endpoint(s) 
 
1) The ordinal scale will be used to estimate a proportional odds model by disease strata. 
The hypothesis test will perform a stratified test to evaluate whether the common odds 
ratio for treatment is equal to one. The distribution of severity results will be summarized 
by treatment arm as percentages. Efforts to minimize loss-to-follow-up will be 
considerable. However, small amounts of missing data may occur. In such cases, subjects 
without final outcome data will be excluded from the analysis. Sensitivity analyses will 
evaluate the impact of making different assumptions about missing observations. These 
analyses will be defined in the SAP.  
 
2) Differences in time-to-event endpoints (e.g., time to at least a one category improvement 
in ordinal scale) by treatment will be summarized with Kaplan-Meier curves and 95% 

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confidence bounds. The same procedure will be used to compare time to at least a two-
category improvement. 
 
3) Change in ordinal scale at specific time points will be summarized by proportions (e.g., 
proportion who have a 1-, 2-, 3-, or 4-point improvement or 1-, 2-, 3-, 4-point 
worsening). 
4) Duration of event (e.g., duration of mechanical ventilation) will be summarized according 
to median days with quartiles. 
5) Binary data (e.g., incidence of new oxygen use) will be summarized as a percent with 
95% confidence intervals. Comparisons between arms will be presented as differences in 
proportions with 95% confidence intervals. 
6) Categorical data (e.g., 28-day mortality or ordinal scale by day) may be summarized 
according to proportions by category and/or odds ratios with confidence intervals.  
 
Procedures for handling missing data, including informative censoring (e.g., a missing 
duration of oxygen use endpoint due to a death), will be described in the SAP. 
 
9.4.4 
Safety Analyses 
Safety endpoints include death through Day 29, SAEs and Grade 3 and 4 AEs. These events will 
be analyzed univariately and as a composite endpoint. Time-to-event methods will be used for 
death and the composite endpoint. Each AE will be counted once for a given subject and graded 
by severity and relationship to COVID-19 or study intervention. AEs will be coded using the 
current version of the Medical Dictionary for Regulatory Activities (MedDRA). AEs will be 
presented by system organ class, duration (in days), start- and stop-date. Adverse events leading 
to premature discontinuation from the study intervention and serious AEs will be presented 
either in a table or a listing.  
 
9.4.5 
Baseline Descriptive Statistics 
Baseline characteristics will be summarized by treatment arm. For continuous measures the 
mean and standard deviation will be summarized. Categorical variables will be described by the 
proportion in each category (with the corresponding sample size numbers).  
 
9.4.6 
Planned Interim and Early Analyses  
A DSMB will monitor ongoing results to ensure subject well-being and safety as well as study 
integrity. The DSMB will be asked to recommend early termination or modification only when 
there is clear and substantial evidence of a treatment difference. More details about the interim 
analyses are described in section 9.4.6.1 and 9.4.6.2 below as well as a separate guidance 
document for the DSMB.  
 
9.4.6.1 
Interim Safety Analyses 
Safety analyses will evaluate Grade 3 and 4 AE and SAEs by treatment arm. Safety monitoring 
will be ongoing (see section 10.1.6). The unblinded statistical team will prepare these reports for 
review by the DSMB.  
 

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9.4.6.2 
Interim Efficacy Review 
The Lan-DeMets spending function analog of the O’Brien-Fleming boundaries will be used to 
monitor the primary endpoint as a guide for the DSMB for an overall two-sided type-I error rate 
of 0.05. Interim efficacy analyses will be conducted at approximately 33%, and 100% of total 
information.  
 
Conditional power will be presented as an additional guide to the DSMB. Conditional power 
allows computation of the probability of obtaining a statistically significant result by the end of 
the trial given the data accumulated thus far, incorporating and assuming a hypothesized 
treatment effect (e.g., the treatment effect assumed for sample size determination) thereafter. If 
conditional power is less than 20% under the original trial assumptions, consideration should be 
given to stopping the trial.  
 
The unblinded statistical team will prepare these closed reports for DSMB review and 
recommendations. Analyses will be presented with blinded codes for treatment arms to protect 
against the possibility that the DSMB report may fall into the wrong hands. A DSMB charter 
will further describe procedures and membership. An additional document on statistical issues 
related to monitoring will be provided to the DSMB prior to interim analyses.  
 
9.4.7 
Sub-Group Analyses 
Subgroup analyses for the primary outcomes will evaluate the treatment effect across the 
following subgroups: geographic region, duration of symptoms prior to enrollment, baseline 
disease severity (stratification variable of mild/moderate and severe, as well as ordinal scale of 
4/5 vs 6/7) age, race, sex and comorbidities. A forest plot will display confidence intervals across 
subgroups. Interaction tests will be conducted to determine whether the effect of treatment varies 
by subgroup. 
9.4.8 
Exploratory Analyses 
An exploratory analysis will compare treatment efficacy estimates according to the various 
scales outlined in section 8.1.2. Specifically, the probability of falling into category “i” or better 
will be compared between arms for each i.  
 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS – ALL STAGES 
All supporting documentation and operational considerations are applicable to the entire 
platform trial and are not unique to the individual stages. These are therefore covered in the main 
protocol document.  
 

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APPENDIX C - ACTT-3: REMDESIVIR + INTERFERON BETA-1A  
1. 
PROTOCOL SUMMARY 
1.1 
ACTT-3 – Synopsis 
Study overview  
ACTT-3 will evaluate the combination of subcutaneous interferon beta-1a and remdesivir 
compared to placebo and remdesivir. In vitro studies suggest significant suppression of the 
intrinsic interferon response following SARS-CoV-2 infection. (1-6) Recent data from several 
studies indicate that there may be a subset of hospitalized patients with COVID-19 who lack a 
prominent interferon signature despite high viral titers and this phenotype may be associated with 
worse clinical outcomes (14-17). Type 1 interferon can inhibit SARS-CoV, MERS-CoV, and 
SARS-CoV-2 in vitro (18-21) and recent data suggests that SARS-CoV-2 may be more sensitive 
than SARS-CoV to inhibition by interferon (18, 22). Lastly, two small RCTs and an exploratory, 
non-randomized clinical trial in hospitalized adult COVID-19 patients suggest a possible clinical 
benefit from treatment with interferon beta (23-25). In summary, there is emerging data that 
suggests interferon may be a good candidate to improve outcomes of patients with COVID-19. 
 
Enrollment Period 
It is anticipated that enrollment may be completed in 3 to 4 months. 
 
General 
The design of ACTT-3 will follow the design of ACTT-1 and ACTT-2. Subjects will be assessed 
daily while hospitalized. If the subjects are discharged from the hospital, they will have a study 
visit at Days 15, 22, and 29. For discharged subjects, it is preferred that the Day 15 and 29 visits 
are in person to obtain safety laboratory tests and OP swab and blood (serum only) samples for 
secondary research as well as clinical outcome data. However, infection control or other 
restrictions may limit the ability of the subject to return to the clinic. In this case, these visits may 
be conducted by phone, home visit or remote telehealth procedure as per institutional standards. If 
Day 15 and 29 visits are conducted by phone or remotely by telehealth procedure, only clinical 
data will be obtained (i.e., no specimens). The Day 22 visit does not have laboratory tests or 
collection of samples and is conducted by phone or remote telehealth procedure.  
 
The trial will enroll only those subjects with mild moderate disease (defined as being in ordinal 
category 4 and 5). The trial initially enrolled ordinal category 6 (those on high flow oxygen or non-
invasive mechanical ventilation), but enrollment in this category was closed September 4, 2020 
after the DSMB reviewed interim safety data and noted concern for risk in this category. Emerging 
data from ACTT-1 (remdesivir vs placebo) (26) and the RECOVERY trial (dexamethasone vs 
standard of care) (27) suggests that the hospitalized population may be a continuum where control 
of the virus is most important in mild disease and control of the host inflammatory response is 
most important late in the disease. Interferon, having antiviral as well - and anti-inflammatory 
properties, may have increased the inflammation seen in those enrolled as ordinal category 6. 
Therefore neither ordinal category 6 or 7 (those on mechanical ventilation or ECMO) will be 
enrolled in this trial. The DSMB confirmed that there was no signal or concern for harm in ordinal 
4 or 5 categories, and they recommended the study continue to enroll patients in those groups. 

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The trial will accrue until approximately 831 recoveries. Assuming that 90% of subjects achieve 
recovery in 28 days, the total sample size is approximately 923.  
 
Study Population 
Hospitalized adults (≥18 years old) with COVID-19. 
 
Inclusion Criteria 
1. Admitted to a hospital with symptoms suggestive of COVID-19. 
2. Subject (or legally authorized representative) provides informed consent prior to 
initiation of any study procedures. 
3. Subject (or legally authorized representative) understands and agrees to comply with 
planned study procedures. 
4. Male or non-pregnant female adults ≥ 18 years of age at time of enrollment. 
5. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR or other 
commercial or public health assay (e.g., NAAT and antigen tests) in any respiratory 
specimen or saliva, as documented by either of the following:  
 PCR or other assay positive in sample collected < 72 hours prior to 
randomization; OR 
 
PCR or other assay positive in sample collected ≥ 72 hours but < 7 days prior to 
randomization AND progressive disease suggestive of ongoing SARS-CoV-2 
infection. 
Note: if written documentation of the positive test result is not available at the time of 
enrollment (e.g., report came from other institution), the subject may be enrolled but the PCR 
should be repeated at the time of enrollment.  
6. Illness of any duration, and at least one of the following: 
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR 
 SpO2 ≤ 94% on room air, OR 
 Requiring supplemental oxygen 
7. Women of childbearing potential must agree to either abstinence or use at least one 
primary form of contraception not including hormonal contraception from the time of 
screening through Day 29.  
8. Agrees to not participate in another clinical trial (both pharmacologic and other types of 
interventions) for the treatment of COVID-19 through Day 29. 
 
Exclusion Criteria 
1. Anticipated discharge from the hospital or transfer to another hospital which is not a 
study site within 72 hours. 
2. Subject meets criteria for ordinal scale category 6 or 7 at the time of screening.  
3. Subject has a positive test for influenza virus during this current hospital admission 
4. Subjects with an estimated glomerular filtration rate (eGFR) < 30 mL/min are excluded 
unless in the opinion of the PI, the potential benefit of receiving remdesivir outweighs the 
potential risk of study participation. 
5. ALT or AST > 5 times the upper limits of normal. 
6. Total white cell blood cell count (WBC) <1500 cells/µL. 

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7. Platelet count <50,000/µL. 
8. History of chronic liver disease (e.g., jaundice, ascites, hepatic encephalopathy, history of 
bleeding esophageal or gastric varices). No laboratory testing is needed.  
9. Pregnancy or breast feeding (lactating women who agree to discard breast milk from Day 
1 to three weeks after the last study product is given are not excluded). 
10. Allergy to any study medication including history of hypersensitivity to natural or 
recombinant interferon beta or human albumin. 
11. Patient has a chronic or acute medical condition or is taking a medication that cannot be 
discontinued at enrollment, that in the judgement of the PI, places them at unacceptable 
risk for a poor clinical outcome if they were to participate in the study.  
12. Received three or more doses of remdesivir, including the loading dose, outside of the 
study for COVID-19.  
13. Received convalescent plasma or intravenous immunoglobulin [IVIg] for the treatment of 
COVID-19. 
14. Received any interferon product within two weeks of screening, either for the treatment 
of COVID-19 or for a chronic medical condition (e.g., multiple sclerosis, HCV 
infection). 
15. Received any of the following in the two weeks prior to screening as treatment of 
COVID-19: 
 small molecule tyrosine kinase inhibitors (e.g., baricitinib, imatinib, gefitinib, 
acalabrutinib, etc.); 
 monoclonal antibodies targeting cytokines (e.g., TNF inhibitors, anti-interleukin-1 
[IL-1], anti-IL-6 [tocilizumab or sarilumab], etc.);  
 monoclonal antibodies targeting T-cells or B-cells as treatment for COVID-19. 
16. Prior enrollment in ACTT-3 
 
Study Intervention 
Subjects will be randomized into two arms (1:1).  
 
Arm 1 
Arm 2 
Interferon beta-1a SQ injection + 
remdesivir IV 
Placebo SQ injection + remdesivir IV 
 
 
All subjects will receive remdesivir as a 200 mg intravenous (IV) loading dose on Day 1, followed 
by a 100 mg once-daily IV maintenance dose during hospitalization up to a maximum of 10 total 
doses (i.e., loading + maintenance doses received during study and pre-study if applicable). The 
duration of dosing may be adjusted by the site similar to what is described in the emergency use 
authorization and based on a subject’s clinical course and ultimate disease severity.  
 
For the subcutaneous interferon beta-1a or placebo component, subjects will receive either active 
product or placebo as follows: 
 Interferon beta-1a will be administered every other day as a 44-microgram subcutaneous 
dose for a total of 4 doses while hospitalized.  

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 A matching placebo will be administered every other day as a subcutaneous injection for 
a total of 4 doses while hospitalized.  
 
Duration of therapy: 
 IV remdesivir – 5 - 10 consecutive days while hospitalized. A full 10-day course in 
patients still in the hospital is not required per protocol. 
 Subcutaneous (interferon beta-1a or placebo) component – Days 1, 3, 5, and 7 while 
hospitalized. 
 Both stop on discharge from hospital. If readmitted after discharge, see Section 7.4. 
 
1.2 
Schedule of Assessments 
Table 1. Schedule of Assessments (SOA) 
  
Screen 
Baseline  
Study Intervention Period 
Follow-up Visits  
Day +/- Window 
−1 or 
1 
1 
Daily until hospital 
discharge 
157  
± 2 
227 
± 3 
297 
+ 6 
ELIGIBILITY 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
Demographics & Medical Hx 
X 
 
 
 
 
 
Review SARS-CoV-2 results 
X 
 
 
 
 
 
 
 
 
 
 
 
 
STUDY INTERVENTION 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
Administration of 
investigational agent 
 
 Remdesivir daily infusion for 5-10 
days or until discharge.  
 Interferon beta-1a or placebo SQ 
injection on Days 1, 3, 5, and 7, or 
until discharge. 
 
 
 
 
 
 
 
 
 
STUDY PROCEDURES 
 
 
 
 
 
 
Targeted physical exam 
 
X 
 
 
 
 
Vital signs including SpO2 1 
 
X4 
Daily until discharge8 
X9 
 
X9 
Clinical data collection 2  
 
X4 
Daily until discharge8 
X9 
X9 
X9 
Adverse event evaluation 
 
X4 
Daily until discharge8 
X9 
X9 
X9 
Concomitant medication review 
X 
X 
From Day -7 to Day 29 
 
 
 
 
 
 
 
 
 
 
SAFETY LABORATORY 
 
 
 
 
 
 
Safety hematology, chemistry 
and liver tests 
X3 
X4,5,6,7 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized6,7 
X9 
 
X9 
Pregnancy test for females of 
childbearing potential 
X3 
 
 
 
 
 
 
 
 
 
 
 
 
RESEARCH LABORATORY FOR ALL SUBJECTS 
 
 
 
Blood for plasma to test by PCR 
for SARS-CoV-2 and cytokines/ 
inflammatory markers 
 
X4 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized 
 
 
X9 

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Oropharyngeal swab 10 
 
X4 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized 
X9 
 
X9 
Blood for serum (secondary 
research) 
 
X4 
Day 3, 5, 8, 11 (all ± 1 
day) if hospitalized 
X9 
 
X9 
ONLY FOR SUBJECTS CONSENTING FOR GENETIC RESEARCH 
 
 
 
Blood for RNA for transcriptomic 
analysis (in PAXgene tube)  
 
X4 
Day 3, 8 (all ± 1 day) if 
hospitalized 
X9, 11 
 
X9 
Blood for PBMC to T cells/innate 
cells and epigenetics (in CPT) 12 
 
X4,12 
Day 8 (all ± 1 day) if 
hospitalized12 
X9, 11, 12 
 
X9, 12 
Notes: 
1Vital signs include temperature, systolic blood pressure, heart rate, respiratory rate, O2 saturation and level of 
consciousness. Vital signs collected as part of standard care may be used.  
2 Refer to Section 8.1.2 of the protocol for details of clinical data to be collected including ordinal score, NEWS, oxygen 
requirement, mechanical ventilator requirement, etc. 
3 Screening laboratory tests include: white blood cell (WBC) count, platelet count, ALT, AST, and creatinine (and calculate 
an estimated glomerular filtration rate (eGFR) the formula used is determined by the sites, but should be consistent 
throughout the study), and pregnancy test. Laboratory tests performed in the 48 hours prior to enrollment will be accepted 
for determination of eligibility. See Section 8.1.1. for more information about pregnancy tests in post-partum women. 
4 Baseline assessments should be performed prior to first study product administration. Results of Day 1 (baseline) laboratory 
assessment do not need to be reviewed to determine if initial study product should be given. 
5 Laboratory tests performed as part of routine clinical care in the 36 hours prior to first dose will be accepted for the 
baseline safety laboratory tests. Baseline may be the same as the screening laboratory tests.  
6 Safety laboratory tests include WBC count, differential, hemoglobin, platelet count, creatinine, total bilirubin, ALT, AST, 
INR, d-dimer, and C-reactive protein (CRP). Note: D-dimer and CRP values may predict severity and support assessment of 
outcomes and unlike other safety laboratory values, D-dimer and CRP should not be graded.  
7 Any laboratory tests performed as part of routine clinical care within the specified visit window can be used for safety 
laboratory testing.  
8 Daily until hospital discharge or end of study, whichever comes first. See Section 8.1.2.1 for more information about doing 
an ordinal scale assessment on the day after hospital discharge and on the day after a subject dies. 
9 In-person visits are preferred but recognizing quarantine and other factors may limit the subject’s ability to return to the 
site for the visit. In this case, the visit may be performed by phone call, home visit or remote telehealth procedure as per 
institutional standards. If subject is still hospitalized during the follow-up period, they should get Day 15, 22 and 29 
assessments along with the daily clinical data collection. 
 
If still hospitalized at Day 15 and 29 or returns to the site for an in-person visit or home visit: collect clinical data, 
vital signs, safety laboratory tests, and research laboratory samples (OP swab and serum only) as able.  
 
If phone call or remote telehealth visit only on Days 15 and 29 and all Day 22 visits: assess adverse events, clinical 
status (ordinal scale), readmission to a hospital, and mortality only. 
10 Oropharyngeal swabs are preferred, but if these are not obtainable, nasopharyngeal or nasal swabs may be substituted.  
11.Subjects who consented for genetic testing and are discharged prior to Day 8 (or Day 11 for proteomics) should get blood 
drawn at Day 15. That is, if subject is missing either a Day 8 Paxgene or CPT sample, or Day 11 proteomic sample, get 
missing sample (proteomics, PAXgene or PBMC) at the Day 15 visit if site is able to do an in-person visit. 
12. Only collected at selected clinical trial sites that are capable of collecting and processing PBMCs. 
  
 
2. 
INTRODUCTION 
2.1 
Background 
2.1.1 
ACTT-3 – Interferon beta-1a /Remdesivir vs. Placebo/Remdesivir Trial 

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Data from ACTT-1 showed that hospitalized adults with COVID-19 who were randomized to 
receive remdesivir had a shorter time to clinical recovery than those who received placebo (10 vs. 
15 days, recovery rate ratio 1.29 (95% CI 1.12 to 1.49, p<0.001) (26). The odds of improvement 
were higher in the group that received remdesivir than in the placebo group (odds ratio 1.50; 95% 
CI 1.2 to 1.9, p < 0.001). After the release of these preliminary findings, the U.S. Food and Drug 
Administration (FDA) issued an Emergency Use Authorization (EUA) to permit the use of 
remdesivir for treatment of suspected or laboratory-confirmed COVID-19 in adults and children 
hospitalized with severe disease. Remdesivir has also received, full or conditional approval in 
several other countries. On August 28, 2020, the FDA expanded the scope of the EUA to include 
hospitalized patients with suspected or laboratory-confirmed mild or moderate COVID-19 based 
on final data from ACTT-1 and two other clinical studies. 
 
While remdesivir is emerging as the standard of care for COVID-19, significant morbidity and 
mortality still occur despite its use. In ACTT-3, we will evaluate if we can improve clinical 
outcomes among hospitalized COVID-19 adult patients by administering combination therapy 
with subcutaneous interferon beta-1a. Subcutaneous interferon beta-1a was selected because of its 
in vitro potency against SARS-CoV-2, known safety profile, and worldwide availability as a 
licensed drug.  
 
Interferons are naturally occurring proteins and glycoproteins that are produced in response to 
pathogens, cancers and other biologic inducers and effect both innate and adaptive immune 
responses. There are three major classes of interferons with distinct biologic actions: type I 
interferons (-α,-β,-δ,-ε,-ζ,-κ,-τ, and -ω), type II interferons (-γ) and type III interferons (-λ1, -λ2, -
λ3). Interferon beta is produced by several cell types including fibroblasts and macrophages (28, 
29). Natural interferon beta and interferon beta-1a are glycosylated with a single N-linked complex 
carbohydrate. Glycosylation of proteins can affect their stability, activity, aggregation, 
biodistribution, and serum half-life. Interferon beta-1a is a 166 amino acid glycoprotein with a 
molecular weight of approximately 22,500 Daltons. It is produced by recombinant DNA 
technology using genetically engineered Chinese Hamster Ovary cells into which the human 
interferon beta gene has been introduced. The amino acid sequence of interferon beta-1a is 
identical to that of natural human interferon beta. 
Interferon-β has antiviral and anti-inflammatory properties. In response to infection with a single-
stranded RNA virus, type I interferons including interferon beta are initially expressed after 
recognition of double-stranded RNA, the replicative intermediate of the virus, by cellular pattern-
recognition receptors, such as melanoma differentiation-associated gene 5 (MDA-5; also known 
as Ifih1) and toll-like receptors (TLR), leading to activation of interferon regulatory factor (IRF) 
3 and induction of interferon-β expression. Secreted interferon-β then functions in either an 
autocrine or paracrine manner to activate the Janus kinase–signal transducer and activator of 
transcription (STAT) pathway, inducing a wave of de novo transcription of antiviral genes, as well 
as expression of more type I interferon (30). For these reasons, interferon has been suggested as a 
putative therapeutic for SARS-CoV-2 (31, 32).  
Interferon may be a good candidate for the treatment of COVID-19 because in vitro studies suggest 
weak induction of interferon following SARS-CoV-2 infection (18, 20, 22, 33-35). Preliminary 
data from a cohort of hospitalized patients with COVID-19 indicate that there may be a subset of 
patients who lack a prominent interferon signature despite high viral titers and this phenotype may 

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be associated with worse clinical outcomes [(15, 16, 36) and unpublished data, from NIAID’s 
Immune Phenotyping in a COVID-19 Cohort study (IMPACC)]. Type 1 interferon can inhibit 
SARS-CoV, MERS-CoV, and SARS-CoV-2 in vitro (18-20, 37) and recent data suggests that 
SARS-CoV-2 may be more sensitive than SARS-CoV to inhibition by interferon (18, 22).  
Cohort studies evaluating the efficacy of type I interferons for the treatment of SARS-CoV and 
MERS-CoV did not demonstrate clinical benefit (38-40). An uncontrolled cohort study of 
subcutaneous interferon alpha in the SARS-CoV-1 outbreak in Canada in 2003 demonstrated 
interferon plus corticosteroids was associated with reduced disease-associated impaired oxygen 
saturation, more rapid resolution of radiographic lung abnormalities, and lower levels of creatine 
kinase. (41) 
In a cohort study of interferon alpha 2b in Wuhan, Hubei Province, China, nebulized interferon 
therapy decreased time to clearance of virus in upper airway secretions by a mean of seven days 
compared to arbidol (a drug with no known anti-SARS-CoV-2 activity) (25).  
In an open-label, randomized study (NCT04276688) in hospitalized adults with mild COVID-19 
disease evaluated lopinavir/ritonavir (LPV/r) and ribavirin plus subcutaneous interferon beta-1b 
(in those initiating treatment <7 days after onset) compared with a LPV/r control group (24). They 
found that combination treatment was associated with shorter median time from treatment 
initiation to negative RT-PCR result in nasopharyngeal swab (7 vs. 12 days), earlier resolution of 
symptoms (4 vs. 8 days), and shorter hospital stay (9 vs. 14.5 days) compared with control (LPV/r). 
There was no significant difference in time to negative RT-PCR result, time to resolution of 
symptoms, or duration of hospital stay between arms among the subgroup of patients who did not 
receive interferon beta-1b. In this study, interferon beta-1b (8 million units on alternate days) was 
administered for 1, 2, or 3 doses when initiated on day 5-6, 3-4, or 1-2, respectively, following 
symptom onset. Fifty-two of 86 patients randomized to the combination treatment arm received 
all 3 drugs, and 41 patients in control arm received LPV/r.  
An open-label, randomized study in hospitalized adults with severe suspected or RT-PCR-
confirmed COVID-19 in Iran evaluated subcutaneous interferon beta-1a (44 mcg SQ, 3 times per 
week for 2 weeks) plus standard care (7 to 10 days of hydroxychloroquine plus LPV/r or 
atazanavir/ritonavir) compared with standard care alone (42 in combined, 39 in control arm) (23). 
Time to clinical response defined as hospital discharge or 2-score improvement in a 6-category 
ordinal scale did not differ significantly between the arms (9.7 vs. 8.3 days); duration of hospital 
stays, ICU stay, and mechanical ventilation also did not differ between the arms. However, a higher 
proportion (67% vs. 44%) of patients in the treatment arm compared with the control arm were 
discharged by day 14 (OR=2.5; 95%CI: 1.05- 6.37). The 28-day overall mortality was significantly 
lower in the interferon group (19% vs. 44%, p=0.015). There were no significant drug reactions 
within 14 days of treatment. 
In summary, the data suggest that SARS-CoV-2 infection may decrease interferon response, and 
two small RCTs in COVID-19 are suggestive of possible benefit from treatment with interferon 
beta. 
2.2 
Risk/Benefit Assessment 
2.2.1 
Known Potential Risks 

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Risks of Phlebotomy 
Potential risks of participating in this trial are those associated with having blood drawn, the IV 
catheterization, possible reactions to the study interventions (as noted in Section 2.2.2 and 2.2.3), 
and breach of confidentiality. 
 
Drawing blood may cause transient discomfort and fainting. Fainting is usually transient and 
managed by having the subject lie down and elevate his/her legs. Bruising at the blood collection 
sites may occur but can be prevented or lessened by applying pressure to the blood draw site for a 
few minutes after the blood is taken. IV catheterization may cause insertion site pain, phlebitis, 
hematoma formation, and infusate extravasation; less frequent but significant complications 
include bloodstream and local infections. Subcutaneous injections may cause pain and discomfort 
and result in erythema and bruising of the skin at the infection site. The use of aseptic (sterile) 
technique will make infection at the site where blood will be drawn or at catheter site less likely. 
 
Risks to Privacy 
Subjects will be asked to provide personal health information (PHI). All attempts will be made to 
keep this PHI confidential within the limits of the law. However, there is a chance that 
unauthorized persons will see the subject’s PHI. All study records will be kept in a locked file 
cabinet or maintained in a locked room at the participating clinical site. Electronic files will be 
password protected. Only people who are involved in the conduct, oversight, monitoring, or 
auditing of this trial will be allowed access to the PHI that is collected. Any publication from this 
trial will not use information that will identify subjects. Organizations that may inspect and/or 
copy research records maintained at the participating site for quality assurance and data analysis 
include groups such as the IRB, NIAID and applicable regulatory agencies (e.g., FDA). For more 
information about confidentiality and privacy see Section 10.1.3. 
 
Risks of Targeted Genetic Testing (applicable only to subjects consenting for genetic research) 
Study analyses will not result in discoveries about identity or paternity. This study will not involve 
genetic tests intended to discover disease-determining genes. However, study analyses could 
potentially result in medically relevant incidental findings. In the future, novel disease-associated 
phenotypes may be discovered that might be identified in samples stored under this study. During 
the informed consent process, potential subjects will be informed about the transcriptomics and 
interferon-stimulating-gene (ISG) analysis that will be conducted as part of an exploratory 
analysis. They will be given the opportunity to ask questions and decide if they would like to 
participate in that part of the study. Genetic findings can have emotional and psychological 
consequences as well as implications for health, employability, and insurability for the subject and 
family members. Samples and the resulting data will be coded and kept private. Additionally, to 
protect confidentiality, results will be entered into a password-protected database restricted to the 
PI or appointed designees.  
 
2.2.2 
Remdesivir  
2.2.2.1 
Potential Risks of Remdesivir  
Remdesivir is not currently licensed in all countries where this study is conducted. In some 
countries where this study is conducted it is licensed, in some countries it is available under 

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Emergency Use Authorization or conditional approvals, and in some countries, it is still considered 
an investigational therapeutic agent. As such, there are limited clinical data available for 
remdesivir.  
 
Hypersensitivity reactions including infusion-related and anaphylactic reactions have been 
observed during and following administration of remdesivir. Signs and symptoms may include 
hypotension, tachycardia, bradycardia, dyspnea, wheezing, angioedema, rash, nausea, vomiting, 
diaphoresis, and shivering.  
 
Asymptomatic transaminase elevations have been observed in healthy volunteers who received 
200 mg of remdesivir followed by 100 mg doses for up to 10 days. Transaminase elevations have 
also been reported in patients with COVID-19 who received remdesivir in clinical trials. As 
transaminase elevations have been reported as a component of COVID-19, including in patients 
receiving placebo in clinical trials of remdesivir, discerning the contribution of remdesivir to 
transaminase elevations in this patient population is challenging. Preliminary data from a large 
randomized trial (ACTT-1) showed no differences in hepatotoxicity between the remdesivir and 
placebo arm. 
 
In nonclinical animal studies, toxicity studies found dose-dependent and reversible kidney injury 
and dysfunction. In clinical studies, no evidence of nephrotoxicity has been observed with single 
doses of remdesivir up to 225 mg or multiple once daily doses of remdesivir 150 mg for up to 14 
days. A 150-mg dose of the solution and lyophilized formulations of remdesivir contains 9 g and 
4.5 g, respectively, of sulfobutylether-beta-cyclodextrin (SBECD), for which the maximum daily 
recommended daily dose (based on a European Medicines Agency (EMA) safety review) is 
approximately 250 mg/kg. Because SBECD is renally cleared, subjects with moderate or severe 
renal impairment may have SBECD exposures greater than those with less severe renal impairment 
or normal renal function. Based on this information, patients with an estimated glomerular 
filtration rate (eGFR) of less than 30 mL/min will be assessed by the PI and they will be eligible 
only if the benefit of participation outweighs the risk. 
 
See Investigator Brochure (IB) for full discussion of clinical experience and risks.  
 
Coadministration of remdesivir and chloroquine phosphate or hydroxychloroquine sulfate is not 
recommended based on in vitro data demonstrating an antagonistic effect of chloroquine on the 
intracellular metabolic activation and antiviral activity of remdesivir. In a study using human 
epithelium derived from HeLa-T (Hep2) cells, there was a 2-fold increase in ED50 with an increase 
of chloroquine from 0 to160 nM. Another study that evaluated the co-incubation of 1 uM 
remdesivir with either 1 uM chloroquine or 10 uM chloroquine found that there is a dose dependent 
inhibition of the formation of the active nucleoside triphosphate metabolite of remdesivir.  
 
Currently, SARS-CoV-2 is susceptible to remdesivir. There is potential for SARS-CoV-2 
developing resistance to remdesivir during treatment, which could result in decreased efficacy. 
The clinical impact of the development of resistance is not clear at this time.  
 
In vitro induction studies have demonstrated that a clinically relevant interaction with 
contraceptive steroids is considered to be of limited clinical significance. However, for this study, 

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the use of hormonal contraception with remdesivir is not recommended as the sole method for 
preventing pregnancy. 
 
2.2.2.2 
Potential Benefits of Remdesivir 
ACTT-1 demonstrated that subjects that received remdesivir had a 29% faster time to recovery 
(medians of 10 vs 15 days, recovery rate ratio 1.29 (1.12, 1.49), p<0.001), and a decrease in 
mortality (11.4% vs 15.2% by 28 days, p = 0.07). As a result, all subjects in ACTT-3 will be given 
remdesivir.  
 
This drug may be available outside of clinical trials, though given varying states of licensure (as 
described above) and limited availability, one potential benefit of participating may be receiving 
remdesivir as part of the study.  
 
2.2.2.3 
Assessment of Potential Risks and Benefits of Remdesivir 
Remdesivir is generally a well-tolerated medication. There are liver toxicities that have been 
observed in prior studies. These have been self-limited and resolved after cessation of the 
medication. There is the potential for renal toxicities as observed in pre-clinical data. By excluding 
those with elevated liver transaminases and decreased kidney function, and appropriate monitoring 
during the study, we can minimize the risk to subjects. While remdesivir is currently the only 
therapeutic antiviral agent known to be effective for COVID-19, there may not be benefits for an 
individual subject depending on timing of initial infusion relative to disease onset and presence of 
viral replication. However, we will try to mitigate this risk by assessing PCR positivity for 
eligibility and enrolling eligible subjects in a timely manner. The potential risks therefore are 
thought to be acceptable given the potential benefits.  
 
2.2.3 
Subcutaneous Interferon beta-1a 
2.2.3.1 
Potential Risks of Subcutaneous Interferon beta-1a  
Interferon beta-1a was first approved for licensure by the FDA in 1996 for intramuscular injection 
(AVONEX®); a subcutaneous injection was approved in 2002 (Rebif®). Interferon beta-1a is 
indicated for the treatment of patients with relapsing forms of multiple sclerosis and has been 
extensively studied in clinical trials (42, 43).  
In a randomized, double-blind placebo-controlled trial, the most common adverse reactions among 
patients with relapsing multiple sclerosis who received 44 micrograms of subcutaneous interferon 
beta-1a three times per week for two years were depression, headache, influenza-like symptoms 
(e.g., fatigue, fever, rigors, chest pain, back pain, myalgia, arthralgia), abdominal pain, 
lymphadenopathy, leukopenia, transaminitis, and injection site reactogenicity. The most 
frequently reported adverse reactions resulting in clinical intervention (e.g., discontinuation of 
Rebif®, adjustment in dosage, or the need for concomitant medication to treat an adverse reaction) 
were injection site reactions, influenza-like symptoms, depression, and elevation of liver enzymes. 
The influenza-like symptoms typically last for about one day after injection, and the occurrence of 
these symptoms lessen or go away with time. Additional risks have been described with chronic 
treatment with interferon beta. It is unknown to what degree these risks apply to short term 
treatments, though it should be assumed similar risks exist.  

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Interferon beta-1a has been associated with worsening depression and exacerbating psychotic 
disorders. A study by Patten et al., that reviewed data from 23 clinical trials of subcutaneous 
interferon beta-1a involving 3995 multiple sclerosis patients found an association between 
depression and interferon use during the first 6 months of therapy (10% of IFN-treated subjects 
versus 8% of placebo recipients) (44). No association was found between interferon treatment and 
suicide attempts. The most consistent risk factor was a prior history of depression. Depressive 
symptoms are common in the early stages of treatment, but typically peak between 4 and 16 weeks 
(45). Prophylactic treatment with antidepressants reduces the risk of IFN-related depression; 
antidepressants also effectively treat the condition (46). In this inpatient study, it is not feasible to 
assess worsening depression and determine relatedness to study product as critical COVID-19 
illness and long-term confinement in quarantine are likely to worsen symptoms of major 
depression. We will inform potential subjects of the risk at the time of informed consent so they 
can determine whether the benefit of participation outweighs the risk of developing depression or 
having pre-existing symptoms of depression worsen. During the study, subjects with pre-existing 
depression or other psychiatric conditions will continue to receive treatment for these conditions 
as clinically indicated.  
Asymptomatic elevation of liver transaminases can occur among those taking interferon beta-1a. 
These effects are generally transient and transaminase levels normalize upon temporary 
discontinuation of Rebif. Severe hepatic injury including hepatic failure has been reported rarely 
in patients taking interferon beta-1a. In ACTT-3, we will mitigate risk of liver injury by excluding 
patients with elevated AST and/or ALT from participating in the study. For those enrolled, we will 
monitor liver transaminase levels and hold subcutaneous injections when ALT and/or AST >5 
times upper limits of normal. Lastly, we will discontinue subcutaneous injections if subject 
develops symptomatic drug-induced liver injury and/or ALT and/or AST >8 times the upper limits 
of normal.  
Decreased peripheral blood counts have been described among those treated with interferon beta-
1a including leukopenia, thrombocytopenia, neutropenia, lymphocytopenia, and anemia. We will 
mitigate the risk to the subject by limiting participation based on platelet count and WBC count at 
time of screening and actively monitoring the WBC count, differential, and hemoglobin. 
Subcutaneous injections will be held if the subject develops severe leukopenia and/or 
thrombocytopenia. 
Cases of thrombotic microangiopathy (TMA) including thrombotic thrombocytopenic purpura 
(TTP) and hemolytic uremic syndrome have been reported with interferon beta products, including 
Rebif® (47). Some of these cases have been fatal. Cases have been reported several weeks to years 
after starting interferon beta. These adverse reactions have been identified during post-approval 
use of Rebif®. Because these events are passively reported from a population of uncertain size, it 
is not possible to reliably estimate their frequency or relationship to the drug. While the diagnosis 
of TMA may be difficult in hospitalized COVID-19 patients, safety laboratory monitoring will 
enable detection of the characteristic clinical features of TMA including thrombocytopenia, 
microangiopathic hemolytic anemia, and acute kidney injury. The principal treatment of drug-
induced TMA is withdrawal of the suspected drug so subcutaneous injections will be discontinued 
if clinical signs and symptoms and laboratory findings consistent with TMA are detected. Cases 
will be managed as clinically indicated.  
New or worsening autoimmune disorders have been described including systemic lupus 

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erythematosus and autoimmune hepatitis. These adverse reactions have been identified during 
post-approval use of Rebif®. Because these events are passively reported from a population of 
uncertain size, it is not possible to reliably estimate their frequency or relationship to the drug. As 
the risk of COVID-19 is likely larger than these risks, subjects with autoimmune disorders are 
permitted to participate in the study. All potential subjects will be informed of the risk for 
autoimmune diseases worsening or the development of a new autoimmune disorder at the time of 
informed consent. 
Seizures have been temporally associated with interferon beta in clinical trials and post-marketing 
surveillance. It is not known if the events were related to multiple sclerosis, the active drug, or a 
combination of both. According to the package insert, a relationship between occurrence of 
seizures and the use of Rebif® has not been established. The subcutaneous injections (interferon 
beta-1a/placebo) will be discontinued if subject has a seizure that is not attributable to COVID-19, 
a medical complication associated with COVID-19, or other medical condition. 
In clinical trials, the majority of subjects who received Rebif® had inflammation at the injection 
site. Other less common adverse reactions associated with subcutaneous interferon beta-1a 
included necrosis, atrophy, edema and hemorrhage at the injection site. During the study, we will 
alternate the injections site and monitor for signs of local reaction.  
Rebif® contains albumin derived from human blood. Because of this, patients who have a history 
of hypersensitivity to human albumin will not be allowed to participate in the study. In addition, 
patients with a history of hypersensitivity to natural or recombinant interferon or any other 
component of the formulation will not be allowed to participate. Anaphylaxis is a rare complication 
and allergic reactions including skin rash and urticaria can also occur. If a subject develops 
anaphylaxis that is temporally related to subcutaneous injection, the injections will be 
discontinued. 
Data from a large population-based cohort study, as well as other published studies over several 
decades, have not identified a drug-associated risk of major birth defects with the use of interferon 
beta during early pregnancy. Findings regarding a potential risk for low birth weight or miscarriage 
with the use of interferon beta in pregnancy have been inconsistent. However, interferon beta may 
cause harm to the fetus based on animal reproduction studies. While no teratogenic effect on fetal 
development were observed in pregnant non-human primates (NHP) given interferon beta-1a at 
100 times the recommended weekly human dose based on a body surface area comparison, 
abortifacient effects were observed in NHPs after three to five doses were administered at this 
level. There are no adequate and well-controlled studies with interferons in pregnant women to 
determine if interferon can cause miscarriage in humans. Because of this, pregnant women will 
not be allowed to participate in the study. 
 
It is not known whether interferon beta-1a is excreted in human milk. Because of the potential of 
serious adverse reactions in nursing infants, lactating women will need to agree to discard breast 
milk from Day 1 to three weeks after the last study product is given.  
 
See package insert for Rebif® for full discussion of clinical experience and risks.  
 

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2.2.3.2 
Potential Benefits of Subcutaneous Interferon beta-1a 
Subcutaneous interferon beta-1a may or may not improve the clinical outcome of an individual 
subject with COVID-19 who participates in this trial. However, there is potential benefit to society 
from their participation in this study resulting from insights gained about the therapeutic agents 
under study as well as the natural history of the disease. While there may not be benefits for an 
individual subject, there may be benefits to society if another safe, efficacious therapeutic agent 
can be identified during this global COVID-19 pandemic.  
 
2.2.3.3 
Assessment of Potential Risks and Benefits of Subcutaneous Interferon beta-1a  
In the context of the cumulative knowledge for subcutaneous interferon beta-1a regarding the 
safety profile, the potential to inhibit SARS-CoV-2 replication and favorable distribution in tissues 
including the lungs, the benefit/risk balance for this study is assessed to be favorable. Given what 
we learned from our staged enrollment approach including frequent DSMB safety reviews, as of 
September 4, 2020, patients with an ordinal scale score of 6 at enrollment are not eligible for 
enrollment, and those with an ordinal scale score of 4 or 5 at enrollment who progress to a 6 or 7, 
will have injectable study product discontinued. In this way, we maximize the potential benefit for 
subjects enrolled in ACTT-3 while preventing harm.  
 
3. 
OBJECTIVES AND ENDPOINTS 
The overall objective of the study is to evaluate the clinical efficacy and safety of different 
investigational therapeutics relative to the control arm among hospitalized adults who have 
COVID-19. 
 
OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
Primary 
 
To evaluate the clinical efficacy of RDV+ 
interferon beta-1a compared to RDV + 
placebo, as assessed by time to recovery for 
patients with baseline ordinal score 4, 5 and 6. 
Day of recovery is defined as the first day on 
which the subject satisfies one of the 
following three categories from the ordinal 
scale: 
 Hospitalized, not requiring supplemental 
oxygen – no longer requires ongoing 
medical care; 
 Not hospitalized, but new or increased 
limitation on activities and/or new or 
increased requirement for home oxygen; 
 Not hospitalized, no limitations on 
activities. 
Recovery is evaluated up until Day 29 (+ 6 
days). 
Key Secondary  
 
To evaluate the clinical efficacy of RDV+ 
interferon beta-1a compared to RDV + 
placebo, as assessed by clinical status (8-point 
 Death; 
 Hospitalized, on invasive mechanical 
ventilation or ECMO; 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
ordinal scale) at Day 15 for patients with 
baseline ordinal score 4 and 5. 
 
 
 
 Hospitalized, on non-invasive ventilation 
or high flow oxygen devices; 
 Hospitalized, requiring supplemental 
oxygen; 
 Hospitalized, not requiring supplemental 
oxygen – requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental 
oxygen – no longer requires ongoing 
medical care; 
 Not hospitalized, but new or increased 
limitation on activities and/or new or 
increased requirement for home oxygen; 
 Not hospitalized, no limitations on 
activities. 
To evaluate the clinical efficacy of RDV+ 
interferon beta-1a compared to RDV + 
placebo, as assessed by time to recovery for 
patients  with a baseline ordinal score of 4 and 
5. 
 
Day of recovery is defined as the first day on 
which the subject satisfies one of the 
following three categories from the ordinal 
scale: 
 Hospitalized, but not requiring 
supplemental oxygen and– no longer 
requires ongoing medical care; 
 Not hospitalized, but new or increased 
limitations on activities and/or new or 
increased requirement for home oxygen; 
 Not hospitalized, no limitations on 
activities. 
 
Recovery is evaluated up until Day 29 (+ 6 
days). 
Additional Secondary- by baseline severity 
moderate (4 or 5) and severe (6) 
 
To evaluate the clinical efficacy of RDV+ 
interferon beta-1a compared to RDV + 
placebo as assessed by: 
 Clinical Severity 
o Ordinal scale: 
▪ Time to an improvement of one 
category and two categories from 
Day 1 (baseline) using an ordinal 
scale. 
 
 
 
 Clinical outcome assessed using ordinal 
scale daily while hospitalized and on Days 
15, 22, and 29. 
 
 
 
 
 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
▪ Subject clinical status using ordinal 
scale at Days 3, 5, 8, 11, 15, 22, and 
29.  
▪ Mean change in the ordinal scale 
from Day 1 to Days 3, 5, 8, 11, 15, 
22, and 29. 
 
 
 
o National Early Warning Score 
(NEWS): 
▪ Time to discharge or to a NEWS of 
≤ 2 and maintained for 24 hours, 
whichever occurs first.  
▪ Change from Day 1 to Days 3, 5, 8, 
11, 15, and 29 in NEWS.  
 
 
 
 NEWS assessed daily while hospitalized 
and on Days 15 and 29. 
o Oxygenation: 
▪ Oxygenation use up to Day 29. 
▪ Incidence and duration of new 
oxygen use during the study. 
 
 
 Days of supplemental oxygen (if 
applicable) up to Day 29 
 
o Non-invasive ventilation/high flow 
oxygen: 
▪ Non-invasive ventilation/high flow 
oxygen use up to Day 29. 
▪ Incidence and duration of new non-
invasive ventilation or high flow 
oxygen use during the study. 
 
 Days of non-invasive ventilation/high 
flow oxygen (if applicable) up to Day 29 
o Invasive Mechanical Ventilation / 
extracorporeal membrane oxygenation 
(ECMO): 
▪ Ventilator / ECMO use up to Day 
29. 
▪ Incidence and duration of new 
mechanical ventilation or ECMO use 
during the study.  
 
 
 Days of invasive mechanical 
ventilation/ECMO (if applicable) up to 
Day 29. 
 
 Hospitalization 
o Duration of hospitalization (days).  
 
 
 Days of hospitalization up to Day 29 
 Mortality 
o 14-day mortality 
o 28-day mortality 
 
 
 Date and cause of death (if applicable) 
 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 Laboratory efficacy: 
o d-dimer, and C-reactive protein (CRP) 
over time 
 
 
 d-dimer, CRP on Day 1; Days 3, 5, 8, and 
11 (while hospitalized); and Days 15 and 
29 (if attends in-person visit or still 
hospitalized). 
 
2. To evaluate the safety of RDV+ interferon 
beta-1a compared to RDV + placebo as 
assessed overall, and by baseline ordinal scale 
category (categories 4 and 5 versus category 
6) by: 
 Cumulative incidence of SAEs through 
Day 29. 
 Cumulative incidence of Grade 3 and 4 
clinical and/or laboratory AEs through 
Day 29. 
 Discontinuation or temporary 
suspension of study product 
administrations (for any reason) 
 Changes in white blood cell (WBC) 
count with differential, hemoglobin, 
platelets, creatinine, total bilirubin, 
alanine aminotransferase (ALT), 
aspartate aminotransferase (AST), and 
INR over time (analysis of lab values in 
addition to AEs noted above). 
 
 
 
 
 SAEs 
 Grade 3 and 4 AEs  
 WBC count with differential, 
hemoglobin, platelets, creatinine, total 
bilirubin, ALT, AST, and INR on Day 1; 
Days 3, 5, 8, and 11 (while hospitalized); 
and Days 15 and 29 (if attends in-person 
visit or still hospitalized). 
 
Exploratory  
 
To evaluate the virologic efficacy of RDV+ 
interferon beta-1a compared to RDV + 
placebo as compared to the control arm as 
assessed by: 
 Percent of subjects with SARS-CoV-2 
detectable in OP sample at Days 3, 5, 
8, 11, 15, and 29.  
 Quantitative SARS-CoV-2 virus in OP 
sample at Days 3, 5, 8, 11, 15, and 29. 
 
 
 Development of resistance of SARS-
CoV-2 in OP sample at Days 3, 5, 8, 
11, 15, and 29.  
 
 
 
 
 
 Qualitative and quantitative polymerase 
chain reaction (RT-PCR) for SARS-CoV-
2 in OP swab on Day 1; Days 3, 5, 8, and 
11 (while hospitalized); and Days 15 and 
29 (if attends in-person visit or still 
hospitalized). 
 
 Deep sequencing of the SARS-CoV-2 
virus for those subjects with sustained 
viral shedding (to be defined after 
qualitative PCR results are available)_ 

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OBJECTIVES 
ENDPOINTS  
(OUTCOME MEASURES) 
 
 Quantitative SARS-CoV-2 virus in 
blood at Days 3, 5, 8, and 11. 
 
 
 Qualitative and quantitative PCR for 
SARS-CoV-2 in blood on Day 1; Days 3, 
5, 8, and 11 (while hospitalized). 
 
To define immunophenotype of subjects most 
likely to benefit from interferon beta-1a by 
analyzing markers of inflammation, 
transcriptomics, epigenetics and cell 
populations. 
 Proteomic analysis of cytokines, markers 
of inflammation, and other circulating 
proteins Day 1; Days 3, 5, 8, and 11 
(while hospitalized) and Day 29 
 Additionally, in a subset of subjects: 
o Transcriptomic analysis of RNA in 
whole blood and individual immune 
cells on Days 1, 3, 8 and 29 
o Analysis of interferon-stimulated-
gene (ISG) expression levels on 
Days 1, 3, 8 and 29 
o Assessment of T-cell and innate 
immune cells subpopulations in 
PBMCs on Days 1, 3, 8 and 29 
o Epigenetic modifications based on 
analysis of DNA extracted from 
PBMCs on Days 1 and 29 
 
 
 
4. 
STUDY DESIGN 
4.1 
Overall Design 
ACTT-3 will evaluate the combination of subcutaneous interferon beta-1a and remdesivir 
compared to remdesivir plus placebo. Subjects will be assessed daily while hospitalized. If the 
subjects are discharged from the hospital, they will have a study visit at Days 15, 22, and 29. For 
discharged subjects, it is preferred that the Day 15 and 29 visits are in person to obtain safety 
laboratory tests and OP swab and blood (serum only) samples for secondary research as well as 
clinical outcome data. However, infection control or other restrictions may limit the ability of the 
subject to return to the clinic. In this case, these visits may be conducted by phone call, home visit 
or remote telehealth procedure as per institutional standards. If the Day 15 and 29 visits are 
conducted by phone or remotely, only clinical data will be obtained (i.e., no specimens collected). 
The Day 22 visit does not have laboratory tests or collection of samples and is conducted by phone 
or remote telehealth procedure unless the subject is still hospitalized at Day 22 and then the visit 
is conducted in person.  
 

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The primary outcome is time to recovery by Day 29. Recovery is defined by discharge from the 
hospital (i.e., ordinal scale categories 1 or 2) or subject is still hospitalized, but not requiring 
supplemental oxygen and no longer requires ongoing medical care (category 3). See table above 
in Section 3 for more details.  
4.2 
Scientific Rationale for Study Design 
As the study is a multicenter, multinational randomized controlled study, we will be able to acquire 
rigorous data about the safety and efficacy of investigational therapeutic agents for COVID-19 
that will lead to generalizable evidence. Randomization is essential for establishing efficacy of 
these new therapeutic agents. Last, collecting clinical and virologic data on enrolled subjects using 
a standardized timeline and collection instruments should provide valuable information about the 
clinical course of and morbidities associated with COVID-19 in a diverse group of hospitalized 
adults. 
 
The ACTT-3 design will specifically evaluate the contribution of interferon beta-1a antiviral and 
immunomodulatory effect in combination with remdesivir while the control arm will receive the 
monotherapy with remdesivir plus placebo.  
 
4.3 
Justification for Dose 
4.3.1 
Justification for Dose of Remdesivir 
The dose of remdesivir used in this study will be the same dose used in ACTT-1 and ACTT-2 and 
that is available under the EUA, with updates on duration of therapy and dosing for patients with 
low eGFR to reflect the wording in the EUA. The duration of dosing may be adjusted by the site 
similar to what is described in the EUA. The maximum number of doses to be given during 
hospitalization is ten doses. This includes the loading dose and all maintenance doses given during 
the study and pre-study if applicable. 
 
4.3.2 
Justification for Dose of Subcutaneous Interferon beta-1a  
We will be administering a subcutaneous 44 mcg dose of Rebif® (interferon beta-1a) every other 
day for 4 doses while a subject is hospitalized. This is the dose that has been used in other COVID-
19 clinical trials including the World Health Organization’s Solidarity Trial.  
 
Interferon beta has a bioavailability of about 30% after subcutaneous or intramuscular 
administration, demonstrating peak serum concentrations within several hours of a dose (48). 
Serum levels of interferon beta-1a typically peak 3 to 15 hours after intramuscular administration. 
After injection, it is absorbed mainly in the lymphatics. Interferon beta is distributed throughout 
the body, and likely does not cross the blood-brain barrier. It is unclear whether interferon beta 
crosses the placenta. Interferon beta is excreted by hepatic and renal pathways. In healthy 
volunteers, a single subcutaneous injection of 60 mcg of Rebif® resulted in a peak serum 
concentration (Cmax) of 5.1 ± 1.7 IU/mL (mean ± SD), with a median time of peak serum 
concentration (Tmax) of 16 hours. The serum elimination half-life (t1/2) was 69 ± 37 hours. 
Following every other day subcutaneous injections, an increase in AUC of approximately 240% 
was observed, suggesting that accumulation of interferon beta-1a occurs after repeat 
administration. Total clearance is approximately 33-55 L/hours.  

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5. 
STUDY POPULATION 
Male and non-pregnant female adults ≥18 years of age or older with COVID-19 and who meet all 
eligibility criteria will be enrolled at up to approximately 100 clinical trial sites globally. The target 
population should reflect the community at large. The estimated time from screening (Day -1 or 
Day 1) to end of study for an individual subject is approximately 29 days.  
 
Subject Inclusion and Exclusion Criteria must be confirmed by any clinician named on the 
delegation log. If there is any uncertainty, the PI should make the decision on whether a potential 
subject is eligible for study enrollment. There is no exclusion for receipt of SARS-CoV-2 vaccine 
(experimental or licensed). 
 
5.1 
Inclusion Criteria 
1. Admitted to a hospital with symptoms suggestive of COVID-19. 
2. Subject (or legally authorized representative) provides informed consent prior to 
initiation of any study procedures. 
3. Subject (or legally authorized representative) understands and agrees to comply with 
planned study procedures. 
4. Male or non-pregnant female adults ≥ 18 years of age at time of enrollment. 
5. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR or other 
commercial or public health assay (e.g., NAAT and antigen tests) in any respiratory 
specimen or saliva, as documented by either of the following:  
 PCR or other assay positive in sample collected < 72 hours prior to 
randomization; OR 
 
PCR or other assay positive in sample collected ≥ 72 hours but < 7 days prior to 
randomization AND progressive disease suggestive of ongoing SARS-CoV-2 
infection. 
Note: if written documentation of the positive test result is not available at enrollment (e.g. 
report from other institution), the subject may be enrolled but the PCR should be repeated at 
the time of enrollment.  
6. Illness of any duration, and at least one of the following: 
 Radiographic infiltrates by imaging (chest x-ray, CT scan, etc.), OR 
 SpO2 ≤ 94% on room air, OR 
 Requiring supplemental oxygen 
  
7. Women of childbearing potential must agree to either abstinence or use at least one 
primary form of contraception not including hormonal contraception from the time of 
screening through Day 29.  
8. Agrees to not participate in another clinical trial (both pharmacologic and other types of 
interventions) for the treatment of COVID-19 through Day 29. 
 
5.2 
Exclusion Criteria 
1. Anticipated discharge from the hospital or transfer to another hospital which is not a 
study site within 72 hours. 

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2. Subject meets criteria for ordinal scale category 6 or 7 at the time of screening.  
3. Subject has a positive test for influenza virus during this current hospital admission. 
4. Subjects with an estimated glomerular filtration rate (eGFR) < 30 mL/min are excluded 
unless in the opinion of the PI, the potential benefit of receiving remdesivir outweighs the 
potential risk of study participation. 
5. ALT or AST > 5 times the upper limits of normal. 
6. Total white cell blood cell count (WBC) <1500 cells/µL. 
7. Platelet count <50,000/µL. 
8. History of chronic liver disease (e.g., jaundice, ascites, hepatic encephalopathy, history of 
bleeding esophageal or gastric varices). No laboratory testing is needed.  
9. Pregnancy or breast feeding (lactating women who agree to discard breast milk from Day 
1 until three weeks after the last study product is given are not excluded). 
10. Allergy to any study medication including history of hypersensitivity to natural or 
recombinant interferon beta or human albumin. 
11. Patient has a chronic or acute medical condition or is taking a medication that cannot be 
discontinued at enrollment, that in the judgement of the PI, places them at unacceptable 
risk for a poor clinical outcome if they were to participate in the study.  
12. Received three or more doses of remdesivir, including the loading dose, outside of the 
study for COVID-19.  
13. Received convalescent plasma or intravenous immunoglobulin [IVIg]) for the treatment 
of COVID-19. 
14. Received any interferon product within two weeks of screening, either for the treatment 
of COVID-19 or for a chronic medical condition (e.g., multiple sclerosis, HCV infection) 
15. Received any of the following in the two weeks prior to screening as treatment of 
COVID-19: 
 small molecule tyrosine kinase inhibitors (e.g. baricitinib, imatinib, gefitinib, 
acalabrutinib, etc.); 
 monoclonal antibodies targeting cytokines (e.g., TNF inhibitors, anti-interleukin-1 
[IL-1], anti-IL-6 [tocilizumab or sarilumab], etc.);  
 monoclonal antibodies targeting T-cells or B-cells as treatment for COVID-19 
16. Prior enrollment in ACTT-3 
 
5.2.1 
Exclusion of Specific Populations 
Children and adolescents will not be included in this trial. Remdesivir has only been used in a 
small number of pediatric patients. Interferon beta-1a has not been studied in pediatric patients, 
and no formal trials of Rebif® have been conducted in children or adolescents. Initial information 
about the epidemiology of COVID-19 indicates that the overwhelming burden of severe disease 
occurs among older adults, especially those with comorbidities. Given significant gaps in 
knowledge in this population, and a low incidence of severe morbidity/ mortality in children, this 
research is not known to have the prospect of direct benefit to individual child subjects, and the 
risk/benefits do not warrant inclusion of this population into this trial at this time.  
 
In nonclinical reproductive toxicity studies, remdesivir demonstrated no adverse effect on embryo-
fetal development when administered to pregnant animals. Embryonic toxicity was seen when 
remdesivir was initiated in female animals prior to mating and conception, but only at a 

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systemically toxic dose. Remdesivir has not been studied in pregnant women. Toxicology studies 
in all tested animal species (rats, mice and monkeys) showed that subcutaneous interferon beta-1a 
was well tolerated both in single-dose and repeat-dose studies. Interferon beta-1a showed no 
evidence of mutagenicity or teratogenicity, however it may have abortifacient potential. Because 
the effects of the study products on the fetus and the pregnant woman are not fully known, pregnant 
women will not be eligible for the trial.  
 
In animal studies, remdesivir metabolites have been detected in the nursing pups of mothers given 
remdesivir. It is not known whether remdesivir is secreted in human milk. Similar animal studies 
have not been conducted for Rebif® and it is not known whether subcutaneous interferon beta-1a 
is excreted in human milk. Because the effects of remdesivir and subcutaneous interferon beta-1a 
on the breastfeeding infant is not known, women who are breast feeding will not be eligible for 
the trial unless they agree to discard breast milk produced from Day 1 to three weeks after the last 
study product is given.  
 
5.3 
Inclusion of Vulnerable Subjects 
Certain subjects are categorized as vulnerable populations and require special treatment with 
respect to safeguards of their well-being. For this clinical trial, examples include cognitively 
impaired or mentally disabled persons and intubated individuals who are sedated. When it is 
determined that a potential research subject is cognitively impaired, federal and institutional 
regulations permit researchers to obtain consent from a legally authorized representative (LAR). 
The study team will obtain consent from these vulnerable subjects using an IRB-approved 
protocol- specific process for consent using a LAR. For this clinical trial, we will not enroll 
prisoners or detainees as subjects.  
 
For subjects for whom a LAR gave consent, during the course of the study, if the subject regains 
the capacity to consent, informed consent must be obtained from the subject and the subject offered 
the ability to leave the study if desired. 
5.4 
Lifestyle Considerations 
During this study, subjects are asked to: 
 Refrain from drinking alcohol through Day 15.  
 Avoid getting pregnant during the study from Day 1 through Day 29. 
 Agreed not to participate in another clinical trial for the treatment of COVID-19 or SARS-
CoV-2. This includes interventional trials that evaluate treatment of SARS-CoV-2 
infection as well as the disease pathogenesis (e.g., experimental treatment trials for the 
COVID-19-related thrombo-occlusive disease respiratory complications and dysregulated 
immune response to the virus). Co-enrollment for natural history studies of COVID-19 or 
studies of SARS-CoV-2 diagnostics are permitted; however, participation in both ACTT 
and these studies can only occur if the recommended blood collection volumes are not 
exceeded.  
5.5 
Screen Failures 

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Following consent, after the screening evaluations have been completed, the investigator or 
designee is to review the inclusion/exclusion criteria and determine the subject’s eligibility for the 
study. If there is any uncertainty, the PI should make the decision on whether a potential subject 
is eligible for study enrollment.  
 
Only basic demographic information and the reason(s) for ineligibility will be collected on screen 
failures. Subjects who are found to be ineligible will be told the reason(s) for ineligibility. 
 
Individuals who do not meet the criteria for participation in this study (screen failure) because of 
an abnormal laboratory finding may be rescreened once.  
5.6 
Strategies for Recruitment and Retention 
5.6.1 
Recruitment 
It is anticipated that patients with COVID-19 will present for hospitalization to participating 
clinical trial sites, and that no external recruitment efforts towards potential subjects are needed. 
Recruitment efforts may also include dissemination of information about this trial to other medical 
professionals / hospitals. The IRB will approve the recruitment process and all materials provided 
prior to any recruitment to prospective subjects directly. 
 
Screening will begin with a brief discussion with study staff. Some will be excluded based on 
demographic data and medical history (e.g., pregnant, < 18 years of age, chronic liver disease, 
etc.). Information about the study will be presented to potential subjects or LAR and questions will 
be asked to determine potential eligibility. Screening procedures can begin only after informed 
consent is obtained. 
 
5.6.2 
Retention 
Retention of subjects is critical to the success of the trial since the primary endpoint is measured 
through Day 29 (+ 6-day window) and every effort should be made to retain subjects in the study. 
As such, after hospital discharge, subjects will be reminded of subsequent study visits and every 
effort will be made accommodate the subject’s schedule to facilitate follow-up within the specified 
visit window. However, there are many circumstances impact a site’s ability to obtain outcome 
information after discharge. For example, given the clinical course of COVID-19, a subject may 
be readmitted to another hospital after discharge and therefore be unavailable at Day 15 or Day 
22. Even if a study visit is missed or study product is discontinued, every effort should be made to 
keep subjects in the study to monitor for safety, mortality and ordinal scale at Day 29. Subjects 
should not be withdrawn from the study because a site is unable to contact them for a follow-up 
visit.  
 
Another common lost-to-follow-up scenario during ACTT-1, involved subjects (or their LARs) 
asking that the study products and blood draws be discontinued due to terminal illness. These 
subjects should also be encouraged to remain in study for the final Day 29 ordinal scale 
determination by chart review or phone call. To facilitate retention, follow-up visits may be 
conducted by phone, home visit or remote telehealth procedure as per institutional standards if in-
person visits at the clinical site on Days 15 and 29 are not feasible. Day 22 visit is by phone call 
or remote telehealth procedure. 

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5.6.3 
Compensation Plan for Subjects  
Compensation, if any, will be determined locally and in accordance with local IRB requirements 
and approval.  
 
5.6.4 
Costs 
There is no cost to subjects for the research tests, procedures/evaluations and study product while 
taking part in this trial. Procedures and treatment for clinical care including costs associated with 
hospital stay may be billed to the subject, subject’s insurance or third party. 
 
6. 
STUDY PRODUCT 
6.1 
Study Product(s) and Administration  
 
Subjects will be randomized into one of two arms (1:1). 
 
 
Arm 1 
Arm 2 
Interferon beta-1a SQ injection + remdesivir IV 
Placebo SQ injection + remdesivir IV 
 
6.1.1 
Study Product Description  
Remdesivir component: 
Remdesivir is a single diastereomer monophosphoramidate prodrug designed for the intracellular 
delivery of a modified adenine nucleoside analog GS-441524. In addition to the active ingredient, 
the lyophilized and solution formulations of remdesivir contain the following inactive ingredients: 
water for injection, SBECD, and hydrochloric acid and/or sodium hydroxide. 
 
Interferon beta-1a /Subcutaneous Placebo component: 
Rebif®, an interferon beta-1a, is a purified 166 amino acid glycoprotein produced by recombinant 
DNA technology using genetically engineered Chinese Hamster Ovary cells into which the human 
interferon beta gene has been introduced. The amino acid sequence of Rebif® is identical to natural 
fibroblast derived human interferon beta.  
 
Rebif® (interferon beta-1a) is formulated as a sterile solution in a prefilled syringe intended for 
subcutaneous injection. Each prefilled syringe contains 0.5 mL of Rebif®. Each 0.5 mL of Rebif® 
will contain 44 mcg of interferon beta-1a, 4 mg human albumin, USP; 27.3 mg mannitol, USP; 
0.4 mg sodium acetate; and water for injection, USP.  
Placebo subcutaneous injection will be either: 
▪ Matching empty syringes that will be filled with 0.5 mL 0.9% normal saline at each site 
pharmacy; OR 

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▪ Matching syringes prefilled with 0.5 mL 0.9% normal saline or 0.5 mL sterile water for 
injection.  
 
6.1.2 
Dosing and Administration 
All subjects will receive remdesivir as a 200 mg intravenous (IV) loading dose on Day 1, followed 
by a 100 mg once-daily IV maintenance dose up to a 10-day total course while hospitalized. 
Enrollment may proceed for subjects who received one or two doses of remdesivir under EUA or 
similar mechanism prior to randomization. If subjects already received the loading dose, then start 
at 100 mg/day on Day 1. Any doses of remdesivir under an EUA (or similar mechanism) within 1 
week of enrollment will be counted, so the maximum number of remdesivir doses given to a 
subject is 10 (i.e. EUA doses + doses on this trial). If one or two doses of remdesivir were 
administered (under EUA or similar mechanism) prior to study enrollment, this should be 
documented in eClinical as a concomitant medication given prior to Day 1. 
 
For the subcutaneous interferon beta-1a / placebo component, subjects will receive either active 
product or placebo as follows: 
 Interferon beta-1a will be administered every other day as a 44-microgram subcutaneous 
dose for a total of 4 doses while hospitalized  
 A saline placebo will be administered every other day as a subcutaneous injection for a 
total of 4 doses while hospitalized 
 
Study teams will instruct the administering nurse to use a different site for each subcutaneous 
injection. If there is an injection site reaction including skin that is irritated, edematous, reddened, 
bruised, or necrotic, the study product should not be administered into the affected area. If possible, 
select a unique site for each subsequent injection. 
 
Dosing of the two medications does not need to occur at the same time. 
 
Duration of therapy: 
 IV remdesivir – up to 10 consecutive days while hospitalized (i.e., maximum of 10 total 
infusions pre-enrollment and during study). 
 Subcutaneous (Interferon beta-1a or placebo) component – Days 1, 3, 5, and 7, while 
hospitalized.  
 Both stop on discharge from hospital. If readmitted after discharge, see Section 7.4. 
 
6.1.3 
Dose Escalation 
Not Applicable 
 
6.1.4 
Dose Modifications 
The protocol-required safety laboratories (per the SOA) are anticipated to be sufficient for 
evaluating for dose modifications, but if other laboratory data obtained as part of standard care are 
available, these should also be used in the evaluation.  
 
Remdesivir component: 

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The infusion should be held and not given if the subject is found to have any of the following 
laboratory values: 
 
 eGFR decreases to < 20 mL/min 
o Remdesivir infusion will be held until the eGFR increases to a point that the potential 
benefit of giving remdesivir outweighs the potential risk. Note: this is consistent with 
the FDA Fact Sheet instructions for Health Care Providers, US EUA of Veklury® 
(remdesivir): “Veklury is not recommended in adult patients with eGFR less than 30 
mL/min…unless the potential benefit outweighs the potential risk”. 
 ALT and/or AST increases to > 5 times upper limits of normal (ULN) 
o Remdesivir infusion will be held and not be restarted until the ALT and AST ≤ 5 
times ULN. 
 
Interferon beta-1a /Subcutaneous Placebo component: 
The subcutaneous injection should be held and not given if the subject is found to have any of 
the following laboratory values: 
 
 ALT and/or AST increases to > 5 times ULN 
o Subcutaneous injection will be held and resume when ALT and AST ≤ 5 times ULN.  
 Total white cell blood cell count (WBC) <1000 cells/µL 
o Subcutaneous injection will be held and resume when WBC ≥1000 cells/ µL 
 Platelet count <25,000/µL 
o Subcutaneous injection will be held and resume when platelet count ≥ 25,000/µL. 
 
Any dose that is held as described above, may be given later that day if the laboratory parameters 
improve. Any dose that is missed during the study due to any reason is not made up. The treatment 
course continues as described above even if the subject becomes PCR negative while hospitalized.  
 
For laboratory values that meet permanent discontinuation thresholds (see Section 7.1), study 
product should be discontinued. However, if in the opinion of the investigator, the laboratory 
abnormality is due to intercurrent illness or another identified factor, laboratory tests may be 
repeated.  
 
6.1.5 
Overdosage 
Overdose is not anticipated in the context of a clinical trial. Subjects will be given the 
subcutaneous injection every other day and daily infusions of remdesivir. No study product will 
be given after hospital discharge. 
 
6.2 
Preparation/Handling/Storage/Accountability 
 
6.2.1 
Acquisition and Accountability 

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Investigational products (IP) will be shipped to the site either directly from participating 
companies, from the Sponsor, or from other regional or local drug repositories. All other supplies 
should be provided by the site. Multiple lots of each IP may be supplied. 
 
Study products received at the sites will be open label and not kit specific, unless specified in the 
protocol-specific Manual of Procedures (MOP) or pharmacy manual. See the MOP Appendices 
for detailed information on the preparation, labeling, storage, and administration of investigational 
products.  
 
Accountability: 
The site PI is responsible for study product distribution and disposition and has ultimate 
responsibility for study product accountability. The site PI may delegate to the participating site’s 
research pharmacist responsibility for study product accountability. The participating site’s 
research pharmacist will be responsible for maintaining complete records and documentation of 
study product receipt, accountability, dispensation, storage conditions, and final disposition of the 
study product(s). Time of study drug administration to the subject will be recorded on the 
appropriate data collection form (CRF). All study product(s), whether administered or not, must 
be documented on the appropriate study product accountability record or dispensing log. The 
Sponsor’s monitoring staff will verify the participating site’s study product accountability records 
and dispensing logs per the site monitoring plan. Refer to the protocol-specific MOP for details on 
storing study medications.  
Destruction: 
After the study treatment period has ended or as appropriate over the course of the study after 
study product accountability has been performed, used active and placebo product can be 
destroyed on-site following applicable site procedures with a second staff member observing and 
verifying the destruction.  
Unused product at the end of the study should be saved until instructed by the Sponsor. 
 
6.2.2 
Formulation, Appearance, Packaging, and Labeling 
Remdesivir component 
Remdesivir may be supplied in two formulations: 
 The lyophilized formulation of remdesivir is a preservative-free, white to off-white or 
yellow, lyophilized solid containing 150 mg or 100 mg of remdesivir to be reconstituted 
with 29 mL or 19 mL (respectively) of sterile water for injection respectively and diluted 
into IV infusion fluids prior to IV infusion. Following reconstitution, each vial contains a 
5 mg/mL remdesivir concentrated solution with sufficient volume to allow withdrawal of 
30 mL (150 mg of remdesivir) or 20 mL (100 mg of remdesivir). It is supplied as a sterile 
product in a single-use, Type 1 clear glass vial. In addition to the active ingredient, the 
lyophilized formulation of remdesivir contains the following inactive ingredients: water 
for injection, SBECD, hydrochloric acid, and/or sodium hydroxide. For more information, 
refer to the MOP. 
 The concentrated solution is supplied as a single dose vial containing 100 mg/20 mL (5 
mg/mL) of remdesivir per vial for dilution into 0.9% sodium chloride infusion bag. It is a 
sterile, preservative-free, clear, colorless to yellow, aqueous-based concentrated solution 

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that is to be diluted into 0.9% sodium chloride infusion bag prior to administration by 
intravenous infusion. Remdesivir injection, 100 mg/20 mL (5 mg/mL), is supplied in a 
single-dose clear glass vial. For more information, refer to the MOP and EUA Fact Sheet. 
 
Remdesivir will be labeled according to manufacturer specifications. 
 
Subcutaneous Interferon beta-1a component 
 
Rebif® (interferon beta-1a) is formulated as a sterile solution. It is supplied as a prefilled syringe 
intended for subcutaneous injection. Each prefilled syringe contains 0.5 mL of Rebif®. Each 0.5 
mL of Rebif® will contain 44 mcg of interferon beta-1a, 4 mg human albumin, USP; 27.3 mg 
mannitol, USP; 0.4 mg sodium acetate; and water for injection, USP.  
Subcutaneous placebo component 
Placebo will match the active product in appearance. Placebo subcutaneous injection is 0.9% 
normal saline. The placebo will be supplied as either: 
▪ Matching empty syringes that will be filled with approximately 0.5 mL 0.9% normal 
saline at each site pharmacy; OR 
▪ Matching syringes prefilled with 0.5 mL 0.9% normal saline or 0.5 mL sterile water for 
injection.  
 
Study products will be supplied by the sponsor or its designee in accordance with current Good 
Manufacturing Practice (cGMP). 
 
6.2.3 
Product Storage and Stability 
The MOP provides instructions for the preparation, handling, and storage of remdesivir. The 
MOP describes site responsibility and accountability for the administered products. Interferon 
beta-1a drug product will be described in the package insert. See most recent version of package 
insert posted on the Emmes website. 
 
6.2.4 
Preparation 
Refer to the protocol-specific MOP for details about preparation.  
 
Remdesivir is not considered a hazardous drug as defined by NIOSH and ASHP hazard 
classification systems. The study products may be prepared in a clean room but do not need to be 
prepared or handled in a fume hood. Measures that minimize drug contact with the body should 
always be considered during handling, preparation, and disposal procedures as indicated in the 
IB.  
 
For Rebif® (interferon beta-1a) it is supplied as a close system and therefore no specific handling 
is required. See MOP for preparing Placebo for Rebif. 
 

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6.3 
Measures to Minimize Bias: Randomization and Blinding 
 
6.3.1 
Randomization  
Randomization will be stratified by: 
 Site 
 Severity of illness at enrollment (by ordinal scale) 
o Hospitalized, requiring supplemental oxygen, or 
o Hospitalized, not requiring supplemental oxygen. 
 
Note: Category 7 (hospitalized, on invasive mechanical ventilation/ECMO) and Category 6 
(hospitalized, on non-invasive ventilation or high flow oxygen devices) are not eligible for 
enrollment. See description of recommendations made by the DSMB on September 4, 2020 
below. 
 
The randomization procedure will be described in the MOP.  
 
There was the hypothetical concern that interferon may worsen the pro-inflammatory state seen in 
COVID-19 late in the clinical course of the disease. For this reason, enrollment was staged based 
on severity of disease.  
 
 For the first 2 weeks of the study, enrollment was limited to non-intubated, hospitalized 
COVID-19 patients who meet all eligibility criteria (i.e., patients with baseline ordinal 
scale score of 4, 5 or 6).  
 On September 4, 2020, the DSMB met for an interim safety review of the ACTT-3 data. 
After their review, they notified NIAID that their recommendation was to close further 
enrollment to patients with a baseline ordinal score of 6. The DSMB noted there was no 
increase in mortality in this group, but that the risk/benefit in this group did not warrant 
further enrollment. Specifically, it was recommended by the DSMB:  
o No further enrollment of subjects with ordinal score of 6 at time of randomization. 
o Do not enroll subjects with ordinal score of 7 at time of randomization 
o Continue to enroll patients with a baseline ordinal score of 4 and 5.  
 Furthermore, the DSMB recommended: 
o Subjects currently enrolled who have an ordinal score of 6, should not be given any 
more study injections (interferon/placebo) for the remainder of the study.  
o Subjects enrolled as a baseline ordinal 4 or 5 and remain as ordinal 4 or 5, should 
continue to receive study injections (interferon/placebo) and remdesivir per 
protocol.  
o If a subject is enrolled as a baseline ordinal 4 or 5 and progresses to ordinal 6 or 7, 
the study injections (interferon/placebo) should be discontinued for the remainder 
of the study. In this case, the remdesivir infusions would continue per protocol. 
Importantly, all subjects should remain in the study and followed through day 29 
in accordance with the protocol. 
 
6.3.2 
Blinding and Masking Procedures 

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As both arms are receiving remdesivir, the remdesivir product is not blinded and study infusions 
can be labeled accordingly.  
 
The subcutaneous interferon beta-1a/matching placebo component is blinded. Interferon beta-1a 
and placebo will be identical in appearance. 
 
Unblinding of the study will occur after all subjects enrolled have reached the end of study, and 
these visits are monitored and data is cleaned, or if the DSMB recommends unblinding.  
Treatment group-level unblinded analyses of subjects randomized in ordinal score category 6 
may be conducted and published prior to the end of the trial to communicate the safety signal 
observed in this group by the DSMB during a safety review. If this analysis is conducted, only 
members of the unblinded analysis team will have access to subject-level treatment data while 
the study is ongoing; all other members of the study group will remain blinded to individual 
subject treatments as originally planned.  
 
If AEs occur and investigators are concerned about the treatment allocation, the treatment can be 
discontinued. If a Serious Adverse Event occurs, that is thought to be related to the study drug, 
and the treating clinician believes that knowledge of the treatment arm may change the therapy 
provided to the patient, the individual subject can be unblinded. The procedure for unblinding 
will be further detailed in the Manual of Operations. 
 
6.4 
Study Intervention Compliance 
Each dose of study product will be administered by a member of the clinical research team who 
is qualified and licensed to administer the study product. Administration and date, and time, will 
be entered into the case report form (CRF). 
 
6.5 
Concomitant Therapy 
6.5.1 
Permitted Concomitant Therapy and Procedures 
Receipt of any exclusionary treatments or medications prior to screening will be assessed at 
screening to determine eligibility as described in the exclusion criteria. Exclusionary medications 
include the receipt of convalescent plasma or intravenous immunoglobulin [IVIg]) for the 
treatment of COVID-19. It also includes small molecule tyrosine kinase inhibitors (e.g., baricitinib, 
imatinib, gefitinib, acalabrutinib) or monoclonal antibodies targeting cytokines (e.g., TNF 
inhibitors, anti-interleukin-1 [IL-1], anti-IL-6 [tocilizumab or sarilumab]), or T-cells or B-cells, 
taken in the two weeks prior to screening for the treatment of COVID-19. Lastly, those who 
received interferon within 2 weeks of screening either for the treatment of COVID-19 or for a 
chronic medical condition (e.g., multiple sclerosis, HCV infection) will not be eligible for the 
study. 
 
For patients that are eligible for the study, other therapy received prior to enrollment with any other 
experimental treatment or off-label use of marketed medications that are intended as specific 
treatment for COVID-19 or the SARS-CoV-2 infection (i.e., post-exposure prophylaxis [PEP]) are 
permitted but must be discontinued on enrollment. There is no waiting period between 

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discontinuation of these treatments and administration of study products. However, these prior 
treatments and their end date should be documented on the Concomitant Medication (CCM) form 
in the Advantage eClinical system.  
 
Medications used for other non-COVID-19 diseases that also are claimed to be treatments for 
COVID-19, do not need to be discontinued at the time of enrollment. Examples would include 
lopinavir/ritonavir for HIV, hydroxychloroquine for lupus, etc. The disease being treated is 
important: if used as an off-label medication for COVID-19 treatment, they are prohibited; if used 
for non-COVID-19 diseases, they are allowable.  
 
6.5.2 
Prohibited Concomitant Therapy 
A subject cannot participate in another clinical trial for the treatment of COVID-19 until after Day 
29 (see exclusion criteria).  
 
Once enrolled, concomitant medications for the treatment of COVID-19 as described in written 
policy or guideline (i.e., not just an individual clinician decision) are permitted. In the absence of 
a local written standard of care, the National Institutes of Health (NIH) COVID-19 Treatment 
Guidelines may be used (https://www.covid19treatmentguidelines.nih.gov/). This includes anti-
inflammatory medications such as dexamethasone and convalescent plasma. Concomitant use of 
any other experimental treatment or off-label use of marketed medications intended as specific 
treatment for COVID-19 or SARS-CoV-2 infection, and not specified in the local or NIH COVID-
19 Treatment Guidelines are prohibited. Specifically, use of any biologic therapy not specified on 
the written policy or guideline are prohibited including: monoclonal antibodies targeting cytokines 
(e.g., TNF inhibitors; interleukin-1[IL-1], IL-6 [tocilizumab or sarilumab]), or T-cells (e.g., 
abatacept); monoclonal antibodies targeting B-cells (e.g., rituximab, and including any targeting 
multiple cell lines including B-cells); JAK inhibitor(s) (e.g., baricitinib, imatinib, gefitinib, 
acalabrutinib); and any type of interferon, convalescent plasma, or immunoglobulin (IgG) 
therapies for COVID-19. Similarly, the concomitant use of hydroxychloroquine to treat COVID-
19 is prohibited unless it is included in the local institutional treatment guidelines.  
 
On August 23, 2020, the FDA issued an EUA for COVID-19 convalescent plasma for the treatment 
of hospitalized patients with COVID-19.  The NIH COVID-19 Treatment Guidelines were updated 
on September 1, 2020 and concludes that “there are insufficient data to recommend either for or 
against the use of convalescent plasma for the treatment of COVID-19”.  According to the NIH 
Guidelines and the EUA Fact Sheet for Health Care Providers, convalescent plasma should not be 
considered the standard of care for the treatment of patients with COVID-19.  However, if a site 
has adopted convalescent plasma as part of their institutional standard of care for the treatment of 
COVID-19 patients, it is allowed as described above. 
 
Concomitant medications will be assessed from 7 days prior to enrollment to Day 29 or upon 
discharge, whichever comes first. All prescription medications should be recorded during this 
time period with the exceptions listed in the bullets below. All medications, except biologics and 
corticosteroids, can be recorded once regardless of the number of times it was given during the 
time period. For example, vasopressors should be recorded when first dose given (as the start 
date) and the last dose given (as the end date) during the period of assessment.  

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Sites do not need to record any of the following categories of medications in the eClinical system 
during the period from Day -7 through Day 29: 
o All topical medications: ointments, creams, and lotions; 
o All intranasal medications: nasal decongestants, nasal allergy medications, nasal steroids, 
and nasal saline drops/sprays;  
o All ophthalmic medications: ophthalmic allergy medication, ophthalmic medications for 
infection, and ophthalmic medications for eye dryness (e.g., saline eye drops); 
o Antiseptic mouth wash, lozenges; 
o Cough medication: mucolytics, cough suppressants, and expectorates; 
o GI medications: H2 blockers, proton pump inhibitors, GI stimulants, prokinetics, laxatives, 
stool softeners, antacids, anti-diarrheal and anti-nausea medications; 
o Insulin and medications for diabetic control; 
o Symptomatic care medications: antipyretics, antihistamines, decongestants, and NSAIDs;  
o Vitamins, minerals or herbal supplements, dietary supplements, iron/ferrous sulfate, 
magnesium, calcium, electrolyte replacement; 
o Albumin infusions; 
o Melatonin; 
o Nicotine patch, lozenge, gum, or nasal spray, or other product to treat tobacco dependence; 
o Dyes: iodine – based dye, barium sulfate, and diatrizoate sodium. 
 
See the MOP for more information about recording concomitant medications. 
 
6.5.3 
Rescue Medicine 
Not Applicable 
 
6.5.4 
Non-Research Standard of Care 
Not Applicable 
 
7. 
STUDY INTERVENTION DISCONTINUATION AND 
SUBJECT DISCONTINUATION/WITHDRAWAL 
7.1 
Halting Criteria and Discontinuation of Study Intervention 
7.1.1 
Individual Study Product Halting  
Study product administration for any given subject may be stopped for SAEs, clinically significant 
adverse events, severe laboratory abnormalities, or any other medical conditions that indicate to 
the Investigator that continued dosing is not in the best interest of the patient. 
In addition, a subject in this clinical study may discontinue study drug at their request for any 
reason. Every effort should be made to encourage subjects to remain in the study for the duration 
of their planned outcome assessments through Day 29. Subjects should be educated on the 
continued scientific importance of their data, even if they discontinue study drug.  

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Unless the subject withdraws consent, those who discontinue study drug early will remain in the 
study and followed through Day 29. The reason for subject discontinuation of study drug(s) should 
be documented in the case report form. 
 
7.1.1.1 
Remdesivir Halting 
See Section 6.1.4. for information about dosing modifications due to laboratory abnormalities. 
For an individual subject, remdesivir infusions must be stopped if they have a suspected drug-
related event of hypersensitivity (Grade 2 or higher) during or shortly after receiving the infusion. 
While there are no criteria for grading “hypersensitivity” in the Division of AIDS (DAIDS) Table 
for Grading the Severity of Adverse Events, sites should use acute allergic reaction from that 
toxicity table. Subjects who have the infusion stopped for a Grade 2 or higher allergic reaction that 
is temporally associated with the infusion and the PI believes it to be related to study product will 
not receive any more remdesivir. 
 
7.1.1.2 
Subcutaneous Interferon beta-1a and Placebo Injections Halting 
See Section 6.1.4. for information about dosing modifications due to laboratory abnormalities. 
The subject should not receive any additional subcutaneous injections for the remainder of the 
study if a subject develops any of the following conditions during the study:  
 
 Disease progresses to the point that the subject requires high-flow oxygen or other non-
invasive ventilatory support (i.e., a category 6 on ordinal scale) or mechanical ventilation 
or ECMO (category 7). Note: even if they improve to a category 4 or 5 before study Day 
7, no additional subcutaneous injections will be given. 
 Anaphylaxis temporally associated with subcutaneous injection 
 Seizures not attributable to COVID-19, a medical complication of COVID-19 or another 
medical condition 
 Thrombotic microangiopathy including thrombotic thrombocytopenic purpura and 
hemolytic uremic syndrome thought to be due to interferon beta-1a  
 ALT or AST >8 times ULN 
 Suspected drug-induced liver injury with symptomatic disease (i.e., jaundice, right upper 
quadrant pain or tenderness, fatigue, nausea, vomiting, etc.) 
 
7.1.2 
Study Halting 
Given the potential severity of COVID-19, there are no pre-specified study stopping rules. 
Instead there will be close oversight by the protocol team and frequent DSMB reviews of the 
safety data.  
 
7.2 
Withdrawal from the Study 
Subjects are free to withdraw from participation in the study at any time upon request, without 
any consequence. Subjects should be listed as having withdrawn consent only when they no 

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longer wish to participate in the study and no longer authorize the Investigators to make efforts 
to continue to obtain their outcome data or safety assessment. 
  
The investigator may also withdraw a subject from the study. However, the investigator will be 
encouraged to allow subjects to remain in the study to be followed for safety and final outcome 
assessment at Day 29 (i.e., the ordinal scale and mortality) even if they decide to discontinue 
study products and research laboratory draws. Withdrawing a subject from the study due to an 
inability to contact them for the Day 15 and/or Day 22 follow-up visit is discouraged given the 
possibility of readmission and chaotic social circumstances resulting from the pandemic. 
 
Subjects who withdraw from this study or are lost to follow-up after signing the informed 
consent form (ICF) and administration of the study product, will not be replaced. The reason for 
subject withdrawal from the study will be recorded on the appropriate CRF.  
 
7.3 
Lost to Follow-Up 
A subject will be considered lost to follow-up if the site is unable to contact him or her by phone 
or other means such as text, email, fax or letter (as approved by the IRB) for all follow-up 
assessments at Day 15, 22 and 29. In lost to follow-up cases, attempts to contact the subject 
should be made and these efforts should be documented in the subject’s records.  
7.4 
Readmission  
If a subject is discharged from the hospital and then readmitted prior to Day 11, they may be given 
the remainder of the remdesivir infusions and if prior to Day 8, they may be given the remainder 
of the subcutaneous injections. If the subject did not withdraw his/her consent to participate in the 
study, there is no need to reconsent upon readmission to the study hospital. However, the site will 
need to inform them that since he/she was readmitted, study product administration will resume 
and confirm that they still agree to receive study product.  
 
The natural history of COVID-19 and its impact on pre-existing medical conditions is not 
completely understood. Because of this, all readmissions, regardless of reason, should be 
documented and the subject should get daily clinical status assessments (i.e., ordinal scale and 
NEWS) and other procedures done as per the SOA upon readmission. If the subject is re-admitted 
with diminished mental capacity, the site should discuss continued study participation with a LAR.  
 
The study team will need to notify the study pharmacist of the readmission. The subject will not 
get the doses that they missed after being discharged. Upon readmission, the subject will get 
maintenance doses of infusion only since they already received the loading dose of the study 
product infusion on Day 1. No study product infusions should be given past Day 10. No 
subcutaneous injection should be given past Day 7. For all data collection procedures required for 
those readmitted, please see the MOP.  
 
8. 
STUDY ASSESSMENTS AND PROCEDURES 

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8.1 
Screening and Efficacy Assessments 
8.1.1 
Screening Procedures 
Screening procedures may be done over one to two calendar days (from Day -1 to Day 1). 
However, in many cases all the screening assessments can be done in less than 24 hours. If that is 
the case, Day 1 pre-study product administration baseline assessments, specimen collection and 
the initial study product administration can occur on the same calendar day as the screening 
procedures.  
 
After the informed consent, the following assessments are performed to determine eligibility: 
 
Confirm the positive SARS-CoV-2 test result (per inclusion criteria).  
 
Take a focused medical history, including the following information:  
 Day of onset of COVID-19 signs and symptoms. 
 History of chronic medical conditions, including chronic liver disease and chronic 
oxygen requirement. This includes use of continuous positive airway pressure 
(CPAP) ventilatory support at night and oxygen by nasal cannula at home or nursing 
home prior to onset of COVID-19. See conditions included on the Medical History 
(CMX) data collection form. 
 History of medication allergies including history of hypersensitivity to natural or 
recombinant interferon, human albumin, or any other component of the interferon 
beta-1a formulation. 
 Medications and therapies for this current illness taken in the 7 days prior to Day 1, 
and history of any medication listed in the exclusion criteria. 
 Ask if they are participating in another clinical trial or plan to enroll in another 
clinical trial in the next 28 days. 
 
Women of childbearing potential should be counseled to either practice abstinence or use at 
least one primary form of contraception not including hormonal contraception from the time 
of screening through Day 29. Women should be confirmed to not be breastfeeding. 
 
Note: If a woman is either postmenopausal (i.e., has had ≥12 months of spontaneous 
amenorrhea) or surgically sterile (i.e., has had a hysterectomy, bilateral ovariectomy 
(oophorectomy), or bilateral tubal ligation), she is not considered to be of 
childbearing potential.  
 
Height and weight (height can be self-reported). 
 
Results of recent radiographic imaging (x-ray or CT scan). 
 SpO2.  
 
Blood for screening laboratory evaluations if not done as part of routine clinical care in the 
preceding 48 hours: 
▪ ALT and AST 
 Assess if ALT or AST > 5 times ULN 
▪ WBC  

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 Assess if WBC <1500 cells/µL 
▪ Platelet count 
 Assess if platelet count <50,000/µL  
▪ Creatinine (and calculate eGFR).  
 Any automated calculation by the clinical laboratory or published formula for the 
calculation of eGFR is acceptable. The site should select a formula to be used for 
all subjects enrolled at the site for the duration of the study. 
 
Urine or serum pregnancy test (in women of childbearing potential). See instructions below 
for women who are less than 6 weeks postpartum: 
▪ Do not do a pregnancy test if the patient is post-partum and has not left the hospital 
since delivery. The pregnancy test will likely give a false-positive result as serum 
human chorionic gonadotropin (hCG) is usually detected for up to 4 to 6 weeks after 
delivery. 
▪ For women who are less than 6 weeks postpartum and have left the hospital, any 
positive pregnancy test should be repeated to determine if the HCG is declining as 
predicted after delivery and therefore the result is a false-positive. Of note, women who 
are less than 6 weeks postpartum and have had heterosexual intercourse since delivery 
and hospital discharge are unlikely to be pregnant because the average time to first 
ovulation varies from 45 to 94 days postpartum, with the earliest reported ovulations at 
25 and 27 days postpartum.  
 
Clinical screening laboratory evaluations will be performed locally by the site laboratory. The 
volume of venous blood to be collected is presented in Table 3. A screening lab (i.e., from the 
hematology and chemistry laboratory panels) may be repeated once if, in the opinion of the 
investigator, the laboratory abnormality is due to an intercurrent transient condition or it is an 
aberrant laboratory value.  
 
The overall eligibility of the subject to participate in the study will be assessed once all screening 
values are available. The screening process can be suspended prior to complete assessment at any 
time if exclusions are identified by the study team. 
 
Study subjects who qualify will be randomized in the Advantage eClinical system, and all others 
will be registered as screen failures. The ordinal scale and the NEWS should be done at the time 
of randomization; the site will need this data to randomize the subject in eClinical. The study team 
has 24 hours to complete other Day 1 baseline assessments prior to the first study product 
administration including the collection of OP swab and blood and completing or recording a 
baseline physical examination that was done. Clinical laboratory tests collected as part of routine 
care of the patients in the 36 hours prior to first dose qualify for baseline safety tests on Day1. 
 
8.1.2 
Efficacy Assessments 

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For all baseline assessments and follow-up visits, refer to the Schedule of Assessments (SOA) 
for procedure to be done, and details below for each assessment. 
 
8.1.2.1 
Measures of clinical support, limitations and infection control 
The subject’s clinical status, which is largely measured by the ordinal scale and NEWS, will be 
captured on each study day while hospitalized through Day 29 (+ 6-day window) or day after death 
whichever comes first. The ordinal scale will also be captured on the day after discharge from the 
hospital. This will be done so that discharge and death are accurately recorded and captured in the 
eClinical system. For subjects who received oxygen by nasal cannula or CPAP ventilatory support 
at night at home prior to having COVID-19, sites should assign a recovery ordinal scale score of 
1 or 2 when discharged to home after recovery. The assignment of category 1 versus category 2 
will depend on whether they have new or increased physical limitations post-COVID-19 and/or if 
they have new or increased home oxygen requirement compared with the pre-COVID-19 time 
period.  
 
It is important to capture all deaths that occur during the study as this is one of the outcomes of the 
study. Death is a category on the ordinal scale. If a subject dies during the study, an ordinal scale 
assessment should be completed for the day after death because the ordinal scale captures the worst 
clinical assessment for the previous day. If a subject dies within the window of the final study visit 
(i.e., Day 29 + 6-day window), complete an ordinal scale assessment on the day after death.  
 
If a subject is discharged prior to Day 15, clinical status is collected on Day 15 and 29 if the subject 
returns for an in-person clinic visit or by phone, home visit or remote telehealth procedure as per 
institutional standards if an in-person visit at the clinical trial site is not possible. Clinical status 
will also be captured on Day 22 during a phone call or remote telehealth visit. Unlike the NEWS, 
the ordinal scale can also be evaluated over the phone or by a remote telehealth procedure if the 
discharged subject is unable to return to the clinical trial site for visits on Day 15 and 29 as well 
as on Day 22.  
 
Except for Day 1, when the ordinal scale and the NEWS is captured at the time of randomization, 
a site should try to complete the ordinal scale and the NEWS at approximately the same time each 
day. Ideally, complete the ordinal scale concurrently with NEWS just prior to study product 
administration, as time permits. The following measures are recorded for the ordinal scale: 
 
 Hospitalization. 
 Oxygen requirement. 
 Non-invasive mechanical ventilation (via mask) requirement. 
 High flow oxygen requirement. 
 Invasive mechanical ventilation (via endotracheal tube or tracheostomy tube) 
requirement. 
 ECMO requirement. 
 Ongoing medical care preventing hospital discharge (COVID-19 related or other medical 
conditions). 
 Limitations of physical activity (self-assessed and reported as new or increased 
limitations as compared to status prior to the onset of COVID-19). 

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 Isolated for infection control purposes. 
 
8.1.2.2 
Ordinal Scale 
The ordinal scale is the primary measure of clinical outcome. The scale used in this study is as 
follows (from worst to best), and categories 1, 2 and 3 represent recovery for a subject: 
 
Category 8: Death; 
Category 7: Hospitalized, on invasive mechanical ventilation or ECMO; 
Category 6: Hospitalized, on non-invasive ventilation or high flow oxygen devices; 
Category 5: Hospitalized, requiring supplemental oxygen; 
Category 4: Hospitalized, not requiring supplemental oxygen – requiring ongoing 
medical care (COVID-19 related or otherwise); 
 
Category 3: Hospitalized, not requiring supplemental oxygen – no longer requires 
ongoing medical care; This would include those kept in hospital for quarantine/infection 
control, awaiting bed in rehabilitation facility or homecare, etc. 
 
Category 2: Not hospitalized, but new or increased limitation on activities and/or 
requiring new or increased home oxygen; 
 
Category 1: Not hospitalized, no limitations on activities 
 
To determine a subject’s clinical status using the ordinal scale: On Day 1, report their clinical 
status at randomization. As there should be <24 hours between randomization and infusion, the 
ordinal scale at done at randomization suffices as the Day 1 ordinal scale. After Day 1, collect the 
ordinal scale daily while hospitalized from Day 2 through Day 29 by providing the worst clinical 
assessment for the previous day (i.e., midnight to midnight; 00:00 – 23:59 (24-hr clock)).  
 
For those who are discharged prior to Day 15, collect ordinal scale on follow-up Days 15, 22 and 
29 by providing the worst clinical assessment for the previous day (i.e., midnight to midnight; 
00:00 – 23:59 (24-hr clock)). For example, on study Day 3 when completing the form, the worse 
clinical outcome measure of Day 2 is captured with the worst being death followed by ECMO, 
mechanical ventilation, etc. The Day 2 measurement is assessed as occurring anytime in that 24-
hour period (00:00 to 23:59).  
 
It is important to capture all deaths that occur during the study as this is one of the outcomes of the 
study. Death is a category on the ordinal scale. If a subject dies during the study, the site will need 
to complete an ordinal scale assessment for the day after death. If a subject dies within the window 
of the final study visit (i.e., Day 29 + 6-day window), complete an ordinal scale assessment on the 
day after death. For more information about the data collected for the ordinal scale, see the MOP. 
 

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8.1.2.3 
National Early Warning Score (NEWS) 
The NEWS has demonstrated an ability to discriminate subjects at risk of poor outcomes. (Smith, 
2016). The NEWS is being used as an efficacy measure in this study (Table 2). The score is based 
on seven clinical parameters including temperature, systolic blood pressure, heart rate, respiratory 
rate, oxygen saturation, and level of consciousness. The NEWS should be evaluated daily while 
hospitalized and on Days 15 and 29, and can be performed concurrently with the ordinal scale.  
The NEWS and ordinal scale should be evaluated at approximately the same time each study day 
for an individual subject and just prior to the expected infusion time. The seven parameters can be 
obtained from vital signs collected as part of the standard of care and documented in the hospital 
chart or electronic medical record. The last measurement prior to the time of assessment (including 
parameters collected prior to the time of consent) should be recorded. A numeric score is given for 
each parameter (e.g., a RR of 9 is one point, oxygen saturation of 92 is two points). This is recorded 
for the day obtained (i.e., on Day 3, the vital signs and other parameters from Day 3 are used to 
obtain NEW Score for Day 3). ECMO and mechanically ventilated subjects should be assigned a 
score of 3 for RR (RR <8) regardless of the ventilator setting. Subjects on ECMO should get a 
score of 3 for heart rate since they are on cardiopulmonary bypass. 
 
For details about collection of NEWS, refer to the MOP. 
 
 Table 2. National Early Warning Score (NEWS) 
 
Level of consciousness = alert (A), and non-alert and arousable only to voice (V) or pain (P), and unresponsive 
(U).  
If the subject is on ECMO or invasive mechanical ventilation, they will be given score of 3 (≤8 RR) for 
respiratory rate regardless of ventilator setting. For subjects on ECMO, they will also receive a score of 3 
(≤40 HR) for heart rate. 
 
8.1.3 
Exploratory Assessments and Secondary Research Samples 

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The schedule of assessments (SOA, Section 1.2) lists the collection timepoints for specimens for 
both exploratory endpoints and for secondary research.  Sites may opt out of specimen collection 
for secondary research; only serum is collected for secondary research.  Subjects will be consented 
for genetic testing for the second exploratory endpoint. Sites will draw blood (via PAXgene tube) 
for subjects who consent to genetic testing, and at selected sites, blood will be drawn for peripheral 
blood mononuclear cells (PBMC) collection for these consenting subjects.  Proteomic (cytokines 
and other protein) analysis will be done for all subjects using plasma drawn per the schedule 
outlined in the SOA. In some cases, serum may be substituted for plasma for cytokine analyses 
(upon approval by the Sponsor). Data from exploratory assessments may not be submitted as part 
of the primary Clinical Study Report (CSR) for this trial. The data may be submitted separately as 
one or more addenda to the primary CSR. 
 
It is preferred that these samples are collected and sent to the NIAID repository to be tested in one 
central laboratory. Current US Centers for Disease Control and Prevention (CDC) guidance is 
these samples can be processed in a Biosafety Laboratory (BSL) 2 environment. However, 
institutions may impose restrictions on processing the samples (i.e., they may require BSL-3) or 
there may be restrictions on sending samples. In these circumstances, the following apply: 
 
Blood for plasma   
 If the samples can be processed but cannot be sent to the repository, the samples may be 
stored locally.  
 The sponsor may elect to have some of these  samples run locally, pending confirmation 
of the assays to be used and the qualifications of the local laboratory. The sponsor will 
work with the site to determine when this could occur and how these data can be 
imported into the study database.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
Oropharyngeal or Nasopharyngeal/nasal specimen 
 If the samples can be processed but cannot be sent to the repository, the samples may be 
stored locally.  
 The sponsor may elect to have some or all of these samples run locally, pending 
confirmation of the assays to be used and the qualifications of the local laboratory. The 
sponsor will work with the site to determine when this could occur and how these data 
can be imported into the study database.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
Whole blood for transcriptomics analysis and interferon-stimulating-gene (ISG) analysis 
 Subjects who consent to genetic testing will have a whole blood sample (~2.5 mL in 
PAXgene tube) 
 These samples will be tested in a central laboratory, not locally. 
 
Blood for PBMCs 
 Some subjects who consent to genetic testing will have blood for PBMCs collected. This 
will occur only at select clinical trial sites. 

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 PBMCs  will be tested in a central laboratory, not locally 
 
Blood for serum (for secondary research) 
 If the samples can be processed but not sent to the repository, the samples may be stored 
locally.  
 If a BSL-3 environment is needed for processing these samples, these samples may be 
omitted.  
 
8.1.3.1 
SARS-CoV-2 Virology Exploratory Assessment 
As outlined on the SOA, OP samples (collected by swab) and plasma and serum will be collected 
on Day 1; and Days 3, 5, 8, and 11 (while hospitalized) and Day 29; and only OP swabs and serum 
on Day 15 (if attends an in-person visit or still hospitalized). Samples are stored as outlined in the 
MOP. Virologic assessments may include PCR or other nucleic acid tests for duration of viral 
RNA, viral load determination and/or the emergence of antiviral resistance.  
 
OP samples are preferred, but if these are not obtainable, nasopharyngeal (NP) samples (collected 
by NP swab) or nasal swab may be substituted. Due to limited lack of swabs and other supplies at 
some sites and limitations on personal protective equipment (PPE), the inability to obtain these 
samples are not considered protocol deviations and should be documented in the subject’s record.  
 
8.1.3.2 
Immunophenotyping Exploratory Assessment  
As outlined in the SOA, blood will be collected for a plasma proteomic analysis of cytokines, 
chemokines, markers of inflammation, and other circulating proteins; whole blood (PAXgene 
tubes) for a transcriptomic analysis of RNA and interferon stimulated gene (ISG) analysis; and 
whole blood PBMCs for an epigenetic analysis and a T cell and innate immune cell phenotyping 
assessment. Samples will be collected, processed and stored as described in the MOP. Only select 
sites will collect and process PBMCs. All sites should collect PAXgene tube for subjects 
consenting to have their samples used for the targeted genetic analysis. If a BSL-3 environment is 
needed for processing of these samples, or if samples cannot be shipped to a central laboratory, 
these samples may be omitted and the omission documented each time omitted.  
 
Blood for plasma for proteomic analysis 
 An aliquot of the collected plasma will be analyzed for cytokines, chemokines, markers of 
inflammation and other circulating proteins on Days 1, 3, 5, 8 and 11 and Day 29 (see SOA 
for details). This blood volume is not an additional 0.5 mL but considered as part of the 8 
mL plasma taken on these days.  
 A subset will have the sample processed using a high-throughput proteomic assay. The 
remainder of subjects will have their samples processed using an antibody-based assay for 
cytokines.  
 
Whole blood for transcriptomics analysis and ISG analysis 
 Subjects who consent to genetic testing will have a whole blood sample (~2.5 mL in 
PAXgene tube) analyzed using an RNA sequencing assay (RNA-Seq, Illumina). 
Transcriptomics and ISG analysis will be done on Days 1, 3 and 8, and Day 29 (if attends 

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in-person visit or still hospitalized) (See SOA for details). 
 Subjects who consent to genetic testing and are discharged prior to Day 8 and therefore 
miss the PAXgene tube collection at Day 8, this sample will be drawn at Day 15. If the 
subject is discharged prior to Day 11 and they miss the Day 11 blood collection, they will 
have blood for plasma proteomic assessment drawn at Day 15.  
 Analysis may include, but not limited to the following assessments depending on the 
sample quality and quantity: 
 Cellular transcriptional activity in immune cell subsets as analyzed by RNA-seq 
or microarrays;  
 Whole blood transcriptome as analyzed by RNA-seq; 
 Single-cell transcriptome as analyzed by RNA-seq or CITE-seq. 
 Description of blood collection in PAXgene tubes for RNA are provided in the MOP. 
 
Blood of PBMCs 
 Some subjects who consent to genetic testing will have blood for PBMCs collected. This 
will occur only at select clinical trial sites. PBMCs will be used to do T-cell and innate 
immune cell phenotyping using samples from Days 1, 3 and 8, and Day 29 and epigenetics 
using Day 1 and Day 29 samples.  
 If a subject is discharged prior to Day 8, this sample will be drawn at Day 15.  
 Description of blood collection in CPTs and processing of blood for PBMCs are provided 
in the MOP. 
 Analysis of PBMCs may include, but not limited to the following assessments depending 
on the sample quality and quantity: 
 PBMC transcriptome as analyzed by RNA-seq; 
 Frequency of leukocytes (to include lymphocyte subsets) in peripheral blood as 
analyzed by complete blood count (CBC) with differential and clinical and 
research flow cytometry; 
 Cellular chromatin accessibility in immune cell subsets as analyzed by the assay 
for transposase-accessible chromatin using sequencing (ATAC-seq); 
 Serum antibody titers; and  
 Additional “omics” assays for assessing immune receptor repertoires, profiling 
molecular states in cells or for quantifying the relative abundance of circulating 
molecules to assess the state of the immune system, or characterizing the 
microbiome in healthy volunteers. 
 
Proposed Timing of Samples for Immunophenotyping Exploratory Objective  
The estimated peak of pathological inflammation is 21 days post-symptom onset. In ACTT-3, 
patients are not enrolled until 7 to 10 days post-symptom onset. For this reason, we propose 
samples be taken Days 1, 3 and 8 (or if discharged prior to Day 8 then blood is drawn at Day 
15) and then at Day 29.See Table 2 for projected blood volumes for PAXgene and PBMC 
sample collection.  
 
Table 2. Blood Volume for Subjects Consenting for Genetic Testing Involving PAXgene 
and PBMC Collection 

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Study 
Day 
Transcriptomics and ISG analysis 
Cell Phenotyping and Epigenomics* 
1 
2.5 mL blood, PAXgene blood RNA 
tube 
 
25.5 mL blood in 3 Cell Preparation Tube 
(CPT) 
3 
2.5 mL blood, PAXgene tube 
None 
5 
None 
None 
8 
2.5 mL blood, PAXgene tube 
25.5 mL blood in 3 CPT 
11 
None 
None 
15 
None (unless missed Day 8) 
None (unless missed Day 8) 
29 
2.5 mL blood, PAXgene tube 
25.5 mL to 42.5 mL blood in 5 CPTs 
*Epigenetic analysis done using PBMC sample and only done using the Day 1 and Day 29 samples. 
 
8.2 
Safety and Other Assessments 
Study procedures are specified in the SOA. A study physician licensed to make medical diagnoses 
and listed on the 1572 will be responsible for all trial-related medical decisions. 
 
Physical examination:  
A targeted physical examination will be performed at baseline prior to initial study product 
administration on Day 1. The baseline physical examination can be one that is conducted from 
screening to Day 1. No routine physical exam is needed for study visits after Day 1.  
 
Study staff at some sites are not allowed into the subject’s rooms due to a limited supply of PPE 
and the need for strict respiratory isolation measures for COVID-19 patients. Because of limited 
access to subjects, physical exams can be performed by any licensed provider at the study hospital 
even if they are not study staff listed on the 1572. The study team can extract information from the 
hospital chart or EMR.  
 
Clinical laboratory evaluations: 
 Fasting is not required before collection of laboratory samples. 
 Blood will be collected at the time points indicated in the SOA.  
 Clinical safety laboratory tests include WBC count, differential, hemoglobin, 
platelet count, creatinine, total bilirubin, AST, ALT, and INR. C-reactive protein 
and d-dimer are not safety laboratory tests but will be collected at the same time 
as the safety labs.  
 Day 1 clinical laboratory evaluations are drawn prior to initial study product 
administration as a baseline and results do not need to be reviewed to determine if 
initial study product administration should be given. See SOA for details. 
 Clinical laboratory testing will be performed at each clinical trial site in real time.  
 
Table 3a. Venipuncture Volumes for Subjects NOT Consenting for Genetic Testing 
Involving Transcriptomics and Complete Immunophenotyping Analysis 1 
 
Screen 
Baseline 
 
 
 
 
 
 
Day +/- Window 
−1 to 1 
1 ± 1 
3 ± 1 
5 ±1 
8 ± 1 
11 ± 1 
15 ± 2 
29 + 6 

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Safety hematology, 
chemistry and liver 
tests 
 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
 X3 
10mL2 
X3 
10mL2 
Blood for Serum 
 
 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
X 
24mL 
Plasma  
(includes PCR and 
proteomics) 
 
X 
8mL 
X 
8mL 
X 
8mL 
X 
8mL 
X 
8mL 
 
X 
8 mL 
Total volume 
10mL 
42mL 
42mL 
42mL 
42mL 
42mL 
34mL 
42mL 
Total all study days 
 
 
 
 
 
 
 
~296 mL 
1. See SOA in Section 1.2 for specific tests to be performed. 
2. Total volume calculated assumes there are no routine clinical laboratory were done within 48 hours of screening 
that can be used for determining eligibility and no routine clinical laboratory tests were done within the window for 
that visitor 24 hours of Day 1, 3, 5, 8 and 11 and 48 hours for Day 15 and 72 hours for Day 29 if still hospitalized.  
3. Safety laboratory tests will be collected on Day 15 and 29 if the subject is still hospitalized at these time points or 
if they return for an in-person outpatient visit and the site has the capacity to collect blood in the outpatient setting. 
 
Table 4b. Venipuncture Volumes for Subjects Consenting for Genetic Testing At Sites that 
Do NOT Collect PBMCs 1  
 
Screen 
Baseline 
 
 
 
 
 
 
Day +/- Window 
−1 to 1 
1 ± 1 
3 ± 1 
5 ±1 
8 ± 1 
11 ± 1 
15 ± 2 
29 + 6 
Safety hematology, 
chemistry, liver tests 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
 X3 
10mL2 
X3 
10mL2 
Blood for Serum 
 
X 
16 mL 
X 
16mL 
X 
16mL 
X 
16mL 
X 
16mL 
X 
16mL 
X 
16mL 
Plasma (PCR and 
proteomics) 
 
X 
8 mL 
X 
8 mL 
X 
8 mL 
X 
8 mL 
X 
8 mL 
(X)4--- 
X  
8 mL 
Blood in PAXgene 
tube 
 
X 
2.5 mL 
X 
2.5 mL 
--- 
X 
2.5 mL 
--- 
(X)4--- 
X 
2.5 mL 
Total volume if 
involved in 
exploratory analysis 
10mL 
36.5 mL 
36.5m
L 
34 mL 
36.5 mL 
34 mL 
26mL 
36.5 mL 
Total all study days 
 
 
 
 
 
 
 
250 mL 
1. See SOA in Section 1.2 for specific tests to be performed. 
2. Total volume calculated assumes there are no routine clinical laboratory were done within 48 hours of screening 
that can be used for determining eligibility and no routine clinical laboratory tests were done within the window for 
that visitor 24 hours of Day 1, 3, 5, 8 and 11 and 48 hours for Day 15 and 72 hours for Day 29 if still hospitalized.  
3. Safety laboratory tests will be collected on Day 15 and 29 if the subject is still hospitalized at these time points or 
if they return for an in-person outpatient visit and the site has the capacity to collect blood in the outpatient setting. 
4. If subject discharged prior to Day 8 (i.e., PAXGene tube not collected) or Day 11 (i.e., proteomics not collect), 
site will collect Day 8 and/or Day 11 samples at Day 15 follow-up visit 
 
 
Table 5c. Venipuncture Volumes for Subjects Consenting for Genetic Testing At Sites that 
Collect PBMCs 1  
  
Screen 
Baseline 
 
 
 
 
 
 
Day +/- Window 
−1 to 1 
1 ± 1 
3 ± 1 
5 ±1 
8 ± 1 
11 ± 1 
15 ± 2 
29 + 6 
Safety hematology, 
chemistry, liver tests 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
X 
10mL2 
 X3 
10mL2 
X3 
10mL2 

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Blood for Serum 
 
X 
8 mL 
X 
8 mL 
X 
8 mL 
X 
8 mL 
X 
8 mL 
X 
8 mL 
X 
8 mL 
Plasma (PCR and 
proteomics) 
 
GET THIS FROM 
CPT TUBE 
 
X4 
8 mL 
X4 
8 mL 
X4 
8 mL 
X4 
8 mL 
X4 
8 mL 
(X) 4,5--- 
X  
8 mL 
Blood in PAXgene 
tube 
 
X 
2.5 mL 
X 
2.5 mL 
--- 
X 
2.5 mL 
--- 
(X)5--- 
X 
2.5 mL 
Blood for PBMCs in 
Cell Preparation 
Tube (CPT) 
 
X 
25.5 mL 
--- 
--- 
X 
25.5 mL 
--- 
(X) 4,5--- 
X 
25.5 to 
42.5 mL 
Total volume if 
involved in 
exploratory analysis 
10mL 
46 mL 
20.5 mL 
18 mL 
46 mL 
18 mL 
18 mL 
54 -71 
mL 
Total all study days 
 
 
 
 
 
 
 
230.5 to 
247.5 mL 
1. See SOA in Section 1.2 for specific tests to be performed. 
2. Total volume calculated assumes there are no routine clinical laboratory were done within 48 hours of screening 
that can be used for determining eligibility and no routine clinical laboratory tests were done within the window for 
that visitor 24 hours of Day 1, 3, 5, 8 and 11 and 48 hours for Day 15 and 72 hours for Day 29 if still hospitalized.  
3. Safety laboratory tests will be collected on Day 15 and 29 if the subject is still hospitalized at these time points or 
if they return for an in-person outpatient visit and the site has the capacity to collect blood in the outpatient setting. 
4. Plasma will be collected from CPT tube for the proteomics analysis (0.5 mL plasma needed) 
5. If subject discharged prior to Day 8 (i.e., PAXGene tube not collected) or Day 11 (i.e., proteomics not collect), 
site will collect Day 8 and/or Day 11 samples at Day 15 follow-up visit 
 
8.2.1 
Procedures to be Followed in the Event of Abnormal Laboratory Test Values or 
Abnormal Clinical Findings 
If a physiologic parameter (e.g., vital signs, or laboratory value) is outside of the protocol-specified 
range, then the measurement may be repeated once if, in the judgment of the investigator, the 
abnormality is the result of an acute, short-term, rapidly reversible condition or was an error. A 
physiologic parameter may also be repeated if there is a technical problem with the measurement 
caused by malfunctioning or an inappropriate measuring device (i.e., inappropriate-sized BP cuff). 
 
8.2.2 
Unscheduled Visits 
If clinical considerations require the subject to be contacted or seen prior to the next schedule 
assessment to assure the subject’s well-being, it is permissible in this protocol. However, no 
research data is collected at this visit.  
8.3 
Adverse Events and Serious Adverse Events 
8.3.1 
Definition of Adverse Event (AE) 
AE means any untoward medical occurrence associated with the use of an intervention in humans, 
whether or not considered intervention related. If multiple abnormalities are part of the same 
clinical syndrome, they can be reported together as one AE under a unifying clinical diagnosis. 
 
An AE can therefore be any unfavorable and unintended sign (including an abnormal laboratory 
finding), symptom, or disease temporally associated with the use of medicinal (investigational) 

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product. Only Grade 3 and 4 AEs will be captured in this trial and Grade 2 or higher suspected 
drug-related hypersensitivity reactions associated with study product administration. For example, 
worsening respiratory status from Grade 2 (respiratory distress) at Day 1 to Grade 4 (respiratory 
failure) at Day 5 is a condition temporarily associated with use of an intervention and by definition 
is an AE and should be reported even if the investigator believes that this is part of the natural 
history of the disease.  
 
All study required solicited safety laboratory test results will be recorded into the eCRF including 
all Grade 1 and 2 abnormalities.  As the Grade 1 and 2 abnormalities are tracked and available 
within the data system, the Grade 1 and 2 laboratory abnormalities are not expected to be reported 
as adverse events and will not be reviewed by the clinical Monitor. 
 
Given the severity of the underlying illness, subjects will have many symptoms and abnormalities 
in vital signs and laboratory values. As COVID-19 is an emerging, systemic disease involving not 
only the upper and lower respiratory tract, but also the gastrointestinal tract, cardiovascular system, 
endothelial cells, and central nervous system (olfactory neurons), it is important to document 
respiratory AE as well as AEs involving other systems. New symptoms not part of the subject’s 
COVID-19 syndrome at Day 1, should be captured as adverse events. For example, if a subject 
develops new grade 3 gastrointestinal symptoms after Day 1, the gastrointestinal symptoms should 
be reported.  
 
For ACTT-3, the AE reporting window begins with the initial administration of the first study 
product and ends on the last visit (i.e., not from the time the ICF is signed as in ACTT-2). Any 
medical condition that is present at the time that the subject signs the ICF will be considered as 
baseline and not reported as an AE. However, if the severity of any pre-existing (at baseline) 
medical condition increases above baseline to severity grade 3 or 4, it should be recorded as an 
AE. The start date for reporting of an AE/SAE is the date the AE became a Grade 3 AE.  
 
In addition, the following AEs will be reported: 
 
 Any Grade 2 or higher suspected drug-related hypersensitivity reactions associated with 
study product administration will be reported as an AE. 
 
Unsolicited laboratory values collected as part of standard of care, will need to be reported only if 
Grade 3 or above and only if clinically significant and/or part of a diagnosis or a clinical syndrome. 
In this case, if laboratory and vital sign abnormalities are part of the clinical syndrome, they should 
be reported as one AE under one clinical diagnosis or syndrome. Example: Low oxygen 
level/arterial blood gases could be part of respiratory failure diagnosis. 
 
Intermittent abnormal laboratory values or vital sign measurements common in the severely ill 
populations (such as electrolyte abnormalities, low blood pressure, hyperglycemia, etc.) that are 
part of the same clinical diagnosis (e.g., uncontrolled diabetic) can be recorded once with the 
highest grade for each adverse event (grade 3 and 4 only for this trial), with the start and stops 
dates of the intermittent syndrome. If there is clear resolution of the event, and then recurrence, it 
should be treated as a separate adverse event. Resolution is defined as return to baseline (either 

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normal if was normal at Day 1, or baseline (Day 1) grade if already an abnormality on the toxicity 
table at Day 1) for > 48 hours.  
 
D-dimer and CRP should not be graded. These are collected on the same schedule as the safety 
laboratory tests (see SOA). However, they will be used in the assessment of study outcomes.  
 
Standardized reporting of AE is essential to interpretation of data between clinical trial sites in 
multi-site clinical trials. The following recommendations are the result of an internal evaluation of 
safety data collected during ACTT-1 and ACTT-2. 
 Medical conditions that rise to the level of an AE  should be reported as an AE and not the 
procedure used to treat that condition. For example, “respiratory failure with ventilator 
support indicated” should be reported as a Grade 4 respiratory failure AE per the DAIDS 
toxicity table versus reporting an intubation (a surgical procedure) as an AE. 
 Clinical syndromes should be reported rather than each symptom, vital sign, or laboratory 
abnormality separately. For example, respiratory failure should be reported as an AE rather 
than separately reporting respiratory acidosis, hypotension, hypoxia; or AKI should be 
reported instead of low eGFR, high creatinine level and CRRT dialysis procedure. 
 Adverse events that worsen from baseline at Day 1 to a Grade 3 or Grade 4 AE or SAE 
during the study should be reported. This includes worsening of respiratory signs and 
symptoms. An AE is any untoward medical occurrence associated with the use of an 
intervention (including investigational products), whether or not considered intervention 
related. This means that the condition may be associated with the underlying disease 
process (COVID-19), but we would still report as an AE.  
 Readmissions that are due to worsening of medical conditions and requiring inpatient 
hospitalization are SAEs by a definition and should be reported. Readmissions for social 
reasons and not for worsening of medical condition (e.g., readmissions of nursing home 
residents or homeless readmitted for monitoring purposes only) is not an SAE. 
 
8.3.2 
Definition of Serious Adverse Event (SAE) 
An AE or suspected adverse reaction is considered serious (i.e., is an SAE) if, in the view of 
either the investigator or the Sponsor, it results in any of the following outcomes: 
 Death;.  
 A life-threatening AE; 
 Inpatient hospitalization or prolongation of existing hospitalization; 
 A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions; or 
 A congenital anomaly/birth defect. 
 
Grade 4 AEs (potentially life-threatening events) are not always SAEs unless they are imminently 
life threatening.  
 

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Important medical events that may not meet the above criteria may be considered serious when, 
based upon appropriate medical judgment, they may jeopardize the subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this definition. Examples 
of such medical events include allergic bronchospasm requiring intensive treatment in an 
emergency room or at home, blood dyscrasias, convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse. 
 
“Life-threatening” refers to an AE that at occurrence represents an immediate risk of death to a 
subject. An event that may cause death if it occurs in a more severe form is not considered life-
threatening. Similarly, a hospital admission for an elective procedure is not considered a SAE. 
 
All SAEs, as with any AE, will be assessed for severity and relationship to study intervention. 
 
All SAEs will be recorded on the AE CRF and reported to DMID (see Section 8.3.6). 
 
All SAEs will be followed through resolution or stabilization by a licensed study physician (for 
IND studies, a physician listed on the Form FDA 1572 as the site PI or Sub-Investigator). 
 
All SAEs will be reviewed and evaluated by DMID and will be sent to the DSMB (for periodic 
review), and the IRB/IEC. 
 
8.3.3 
Suspected Unexpected Serious Adverse Reactions (SUSAR) 
A SUSAR is any SAE where a causal relationship with the study product is at least reasonably 
possible but is not listed in the Investigator Brochure (IB), Package Insert, and/or Summary of 
Product Characteristics. 
 
8.3.4 
Classification of an Adverse Event 
The determination of seriousness, severity, and causality will be made by an on-site investigator 
who is qualified (licensed) to diagnose AE information, provide a medical evaluation of AEs, 
and classify AEs based upon medical judgment. This includes but is not limited to physicians, 
physician assistants, and nurse practitioners. 
 
8.3.4.1 
Severity of Adverse Events 
All AEs and SAEs will be assessed for severity using the DAIDS Table for Grading the Severity 
of Adult and Pediatric Adverse Events, version 2.1 (July 2017).  
 
For AEs not included in the Table, the following guidelines will be used to describe severity. In 
addition, all deaths related to an AE are to be classified as grade 5 according to the DAIDS Table.  
 
 Moderate (Grade 2): Events that are usually alleviated with additional specific 
therapeutic intervention. The event interferes with usual activities of daily living and 
causes discomfort but poses no significant or permanent risk of harm to the research 
subject. 
 

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 Severe (Grade 3): Events that interrupt usual activities of daily living, or significantly 
affect clinical status, or may require intensive therapeutic intervention. Severe events are 
usually incapacitating. 
 
 Potentially life-threatening event (Grade 4): Events that are potentially life threatening. 
 
 
 Deaths (Grade 5): All deaths related to an AE are classified as grade 5 (per DAIDS 
Table). 
 
8.3.4.2 
Relationship to Study Intervention 
For each reported adverse reaction, the PI or designee must assess the relationship of the event to 
the study product using the following guideline: 
 
 Related – There is a temporal relationship between the study intervention and event, and 
the AE is known to occur with the study intervention or there is a reasonable possibility 
that the study intervention caused the AE. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the study intervention and the AE. 
 
 Not Related – There is not a reasonable possibility that the administration of the study 
intervention caused the event, there is no temporal relationship between the study 
intervention and event onset, or an alternate etiology has been established. 
 
8.3.5 
Time Period and Frequency for Event Assessment and Follow-Up 
For this study, all Grade 3 and 4 AEs, and all SAEs occurring from the time the first study 
product is initially given on Day 1 through the Day 29 visit will be documented, recorded, and 
reported. 
 
8.3.5.1 
Investigator Reporting of AEs 
Information on AEs will be recorded on the appropriate CRF. All clearly related signs, symptoms, 
and results of diagnostic procedures performed because of an AE should be grouped together and 
recorded as a single diagnosis. If the AE is a laboratory abnormality that is part of a clinical 
condition or syndrome, it should be recorded as the syndrome or diagnosis rather than the 
individual laboratory abnormality. Each AE will also be described in terms of duration (start and 
stop date), severity, association with the study product, action(s) taken, and outcome. 
 
8.3.6 
Serious Adverse Event Reporting 
8.3.6.1 
Investigators Reporting of SAEs 
Any AE that meets a protocol-defined criterion as an SAE that is judged to be related to either 
study product must be submitted within 24 hours of site awareness on an SAE form to the DMID 
Pharmacovigilance Group, at the following address:  
 
DMID Pharmacovigilance Group 

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Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Dr. Suite 650 
Bethesda, MD 20817, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
 
Other supporting documentation of the event may be requested by the DMID Pharmacovigilance 
Group and should be provided as soon as possible. The DMID Medical Monitor will review and 
assess the SAE for regulatory reporting and potential impact on study subject safety and protocol 
conduct. At any time after completion of the study, if the site PI or appropriate sub-investigator 
becomes aware of an SAE that occurred during the subject’s participation in the study, the site PI 
or appropriate sub-investigator will report the event to the DMID Pharmacovigilance Group. 
 
SAEs that that are judged to be not related to study product are still captured on the AE case report 
form, but do not require separate reporting to the DMID Pharmacovigilance Group. 
 
8.3.6.2 
Regulatory Reporting of SAEs 
Following notification from the site PI or appropriate sub-investigator, DMID, as the IND Sponsor, 
will report any SUSAR in an IND safety report to the FDA and will notify all participating site PIs 
as soon as possible. DMID will report to the FDA any unexpected fatal or life-threatening 
suspected adverse reaction as soon as possible, but in no case later than 7 calendar days after the 
Sponsor’s initial receipt of the information. If the event is not fatal or life-threatening, the IND 
safety report will be submitted within 15 calendar days after the Sponsor determines that the 
information qualifies for reporting as specified in 21 CFR Part 312.32. Relevant follow up 
information to an IND safety report will be submitted as soon as the information is available. Upon 
request from the FDA, DMID will submit to the FDA any additional data or information that the 
agency deems necessary, as soon as possible, but no case later than 15 calendar days after receiving 
the request. 
 
SAEs that are not SUSARs will be reported to the FDA at least annually in a summary format 
which includes all SAEs. 
 
Sites may have additional local reporting requirements (to the IRB and/or national regulatory 
authority). 
  
8.3.7 
Reporting of Pregnancy 
Pregnancy is not an AE. However, any pregnancy that occurs during study participation should 
be reported to the Sponsor on the appropriate CRF. Pregnancy should be followed to outcome.  
8.4 
Unanticipated Problems 
8.4.1 
Definition of Unanticipated Problems 
An Unanticipated Problem (UP) is any event, incident, experience, or outcome that meets the 
following criteria: 

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 Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the IRB-approved research 
protocol and informed consent document; and (b) the characteristics of the subject 
population being studied; 
▪ Related to participation in the research (meaning there is a reasonable possibility that the 
incident, experience, or outcome may have been caused by the procedures involved in the 
research); and 
▪ Suggests that the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
 
8.4.2 
Unanticipated Problem Reporting 
To satisfy the requirement for prompt reporting, all Ups will be reported using the following 
timeline: 
▪ UPs that are SAEs will be reported to the IRB and to the Statistical and Data 
Coordinating Center (SDCC)/study Sponsor within 24 hours of the investigator becoming 
aware of the event per the above describe SAE reporting process. 
▪ Any other UP will be reported to the IRB and to the SDCC/study Sponsor within 3 days 
of the investigator becoming aware of the problem. 
 
9. 
STATISTICAL CONSIDERATIONS 
9.1 
Statistical Hypotheses 
 
The primary hypothesis tests whether the time-to-recovery by Day 29 differs between the 
experimental and control arms. 
 
Table 6. Hypothesis tests of interest for ACTT-3 
 
ACTT-3  
 
Primary hypothesis 
RDV + interferon-beta-1a versus RDV + placebo 
  
A key secondary hypothesis tests the null distribution of a similar distribution of 8-point ordinal 
scale at Day 15. For this, the parameter of interest is the “common odds ratio,” which quantifies 
the shift in the severity distribution resulting from treatment. For an efficacious treatment, an odds 
ratio greater than 1 quantifies an improvement in disease severity; a value of 2 indicates a bigger 
improvement than a value of 1.25. The null hypothesis to be tested is that the odds of improvement 
on the ordinal scale is the same for the control and experimental treatment arms (i.e., the common 
odds ratio is 1). It is worth noting that, for large sample sizes, the test based on the proportional 
odds model is nearly the same as the Wilcoxon rank sum test. 
 

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9.2 
Sample Size Determination 
 
Primary endpoint: The log-rank test will be used to compare treatment arms with respect to time 
to recovery. For the log-rank test, the two key determinants of power are the total number of 
events (i.e., recoveries) E and the treatment-to-control ratio of the rate of recovery, R. The 
number of events required for power 1 −𝛽 to detect a recovery rate ratio of θ using a two-tailed 
test at alpha=0.05 is approximately 
𝐸= 4(1.96 + 𝑧𝛽)
2
{ln(𝜃)}2
, 
 
 
where 𝑧𝛽 is the 100(1 −𝛽)th percentile of the standard normal distribution. 
The force of recovery (sometimes loosely referred to as the “recovery ratio”) is the analogue of 
the hazard ratio and the term “recovery rate ratio” is the analogue of the hazard ratio in this setting. 
A recovery rate ratio of 1.31 was reported in Cao, Wang, Wen et al. (2020) for a lopinavir/ritonavir 
trial that used time to improvement by 2 categories as primary endpoint. A preliminary review of 
data from ACTT-1 demonstrated a recovery rate ratio 1.312. It is unlikely the second component 
of treatment will have a similar effect size. Therefore a recovery ratio of 1.25 is assumed for this 
trial. A total of 723 recoveries are needed for a recovery ratio of 1.25 with 85% power. Table 5 
provides power for various recovery rate ratios.  
 
 
 
Table 7. Number of recoveries needed for 85% power assuming a type I error rate of 5% 
for various recovery ratios. 
 
Recovery 
rate ratio 
(θ) 
Number of recoveries 
needed for 85% 
power 
1.20 
1080 
1.25 
723 
1.30 
523 
1.35 
400 
1.40 
318 
 
The study will enroll participants until 831 recoveries. Initially the study was powered for 723 
recoveries in those in ordinal score 4-6 at baseline, with an increase to 831 recoveries due to 
anticipated lower efficacy in ordinal score 7. The same assumption will now be made that ordinal 
score 6 will have a lower efficacy, and therefore the number of  recoveries will remain 
unchanged. However, we anticipate that approximately 90% of subjects recover within 28 days, 
and therefore the total sample size will be approximately 923. The date of study closure will be 
estimated based on enrollment rate and recovery/enrollment percentages. 
 
Key secondary: A sample size can be computed using an (assumed) ordinal scale distribution 
for the control arm and the odds ratio representing clinical improvement. The odds ratio 

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represents the odds of improvement in the ordinal scale for combination treatment relative to the 
control arm [Whitehead, 1993]. The sample size to detect a given odds ratio for 1:1 
randomization using a 2-tailed test at level α is given by 
 
12(𝑧α/2 + 𝑧β)
2
λ2(1 −∑
𝑝𝑖
3
𝐾
𝑖=1
), 
 
where λ is the log odds ratio, 𝑝𝑖 is the overall probability (combined over both arms) of being in 
the ith category of the K ordinal outcomes, and 𝑧α/2 and 𝑧𝛽 are the 1 −α/2 and 1 −β quantiles 
of the standard normal distribution.  
 
Table 6 displays five scenarios considered for outcome probabilities in the control arm for 
sample size determination. There is significant uncertainty with these assumptions given the 
limited data available. Table 6 shows a range of sample sizes for odds ratios ranging from 1.25 to 
2.5 for 85% power. For 90% power, increase the sample size by 17%. Table 8 displays the 
probabilities of being in different categories of the ordinal scale under an odds ratio of 1.75. A 
total sample size of 396 gives approximately 85% power to detect an odds ratio of 1.75 using a 
2-tailed test at level α = 0.05. The categories of the 8-point ordinal scale are: 
 
 Death; 
 Hospitalized, on invasive mechanical ventilation or ECMO; 
 Hospitalized, on non-invasive ventilation or high flow oxygen devices; 
 Hospitalized, requiring supplemental oxygen; 
 Hospitalized, not requiring supplemental oxygen – requiring ongoing medical care 
(COVID-19 related or otherwise); 
 Hospitalized, not requiring supplemental oxygen – no longer requires ongoing medical 
care; 
 Not hospitalized, but new or increased limitation on activities and/or requiring new or 
increased home oxygen; 
 Not hospitalized, no limitations on activities. 
 
Note that the data elements contributing to this scale will be captured separately, in order to 
facilitate different orderings or groupings, as might arise if external data provide information 
about the clinical course of disease.  
 
 
Table 8: Possible scenarios for the distribution of ordinal outcomes for the control arm at 
Day 15. 
 
Anticipated 
Different scenarios for control arm 
  
Scenario 1 
Scenario 2 
Scenario 3 
Scenario 4 
Scenario 5 
 
 
more mild disease                       more severe disease 
Severity Outcome 
outcome (%) outcome (%) 
outcome (%) outcome (%) outcome (%) 
Death 
2 
1 
1 
2 
3 

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Hospitalized, on 
mechanical ventilation or 
ECMO 
1 
1 
1 
1 
3 
Hospitalized, on non-
invasive ventilation or 
high flow oxygen devices 
2 
1 
1 
2 
4 
Hospitalized, requiring 
supplemental oxygen 
7 
2 
5 
5 
9 
Hospitalized, not requiring 
supplemental oxygen – 
requiring ongoing medical 
care (COVID-19 related 
or otherwise) 
8 
5 
7 
17 
23 
Hospitalized, not requiring 
supplemental oxygen – no 
longer requires ongoing 
medical care 
10 
9 
10 
20 
25 
Not hospitalized, 
limitation on activities 
and/or requiring home 
oxygen 
30 
36 
35 
25 
18 
Not hospitalized, no 
limitations on activities 
40 
45 
40 
28 
15 
 
 
Table 9: Sample size calculations for scenarios in Table 6 for a two-arm study assuming 
85% power, a two-sided type I error rate of 5%, and various true odds ratios.  
True odds 
ratio 
Total sample size 
 
Scenario 1 
Scenario 2 
Scenario 3 
Scenario 4 
Scenario 5 
1.25 
2420 
2554 
2459 
2293 
2252 
1.5  
744 
786 
755 
700 
684 
1.75 
396 
419 
401 
370 
360 
2.0 
262 
277 
265 
243 
236 
2.25 
194 
206 
196 
179 
173 
2.5 
154 
163 
155 
141 
136 
 
 
Table 10. Treatment ordinal outcome proportions under an odds ratio of 1.75 for five 
scenarios in Table 5 at Day 15. 
  
Scenario 
1 
Scenario 
2 
Scenario 
3 
Scenario 
4 
Scenario 
5 
 
Anticipated more mild disease                more severe disease 

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Severity Outcome 
Control % 
Treatment % 
Control % 
Treatment % 
Control % 
Treatment % 
Control % 
Treatment % 
Control % 
Treatment % 
Death 
2 
1.2 
1 
0.6 
1 
0.6 
2 
1.2 
3 
1.7 
Hospitalized, on mechanical 
ventilation or ECMO 
1 
0.6 
1 
0.6 
1 
0.6 
1 
0.6 
3 
1.8 
Hospitalized, on non-invasive 
ventilation or high flow 
oxygen devices 
2 
1.2 
1 
0.6 
1 
0.6 
2 
1.2 
4 
2.5 
Hospitalized, requiring 
supplemental oxygen 
7 
4.3 
2 
1.2 
5 
3.0 
5 
3.1 
9 
5.8 
Hospitalized, not requiring 
supplemental oxygen – 
requiring ongoing medical 
care (COVID-19 related or 
otherwise) 
8 
5.3 
5 
3.1 
7 
4.4 
17 
11.5 
23 
17.4 
Hospitalized, not requiring 
supplemental oxygen – no 
longer requires ongoing 
medical care; 
10 
7.2 
9 
5.9 
10 
6.8 
20 
16.2 
25 
24.4 
Not hospitalized, limitation 
on activities and/or requiring 
home oxygen 
30 
26.5 
36 
29.3 
35 
30.2 
25 
25.9 
18 
22.7 
Not hospitalized, no 
limitations on activities 
40 
53.8 
45 
58.9 
40 
53.8 
28 
40.5 
15 
23.6 
Note that columns may not sum to exactly 100 due to rounding errors. 
 
Other key secondaries for testing combination therapy compared to control will be detailed in an 
addendum SAP 
 
9.3 
Populations for Analyses 
 
An adjudication or review committee consisting of the DMID MO, her designees and the blinded 
statistical team may review endpoints, medications, deviations, and other special cases where 
expert opinion is requested for handling complicated cases.  
The primary analysis will be based on an intention-to-treat population, including all subjects 
randomized. Similarly, safety analyses will be based a modified intent-to-treat population 
consisting of all subjects who received at least one dose of any investigational product.  
 

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9.4 
Statistical Analyses 
9.4.1 
General Approach 
This is a double-blind placebo controlled randomized trial testing a superiority hypothesis with a 
two-sided type I error rate of 5%. Secondary hypotheses have been ordered according to relative 
importance, with one key secondary hypothesis highlighted. These will be described according to 
the appropriate summary statistics (e.g., proportions for categorical data, means with 95% 
confidence intervals for continuous data, median for time-to-event data).  
 
A statistical analysis plan will be developed and filed with the study sponsor prior to unblinding 
of study and database lock.  
 
9.4.2 
Analysis of the Primary Efficacy Endpoint 
The primary efficacy analysis is a stratified log-rank test, where stratification is according to 
baseline disease severity as defined by ordinal scale. Deaths will be considered as never recovering 
and censored at Day 29. In ACTT-3, the analyses conducted will depend on the results from 
ACTT-1 according to Table 4. 
 
9.4.3 
Analysis of the Secondary Endpoint(s) 
The ordinal scale will be used to estimate a proportional odds model by disease strata. The 
hypothesis test will perform a stratified test to evaluate whether the common odds ratio for 
treatment is equal to one. The distribution of severity results will be summarized by treatment 
arm as percentages. Efforts to minimize loss-to-follow-up will be considerable. However, small 
amounts of missing data may occur. In such cases, subjects without final outcome data will be 
excluded from the analysis. Sensitivity analyses will evaluate the impact of making different 
assumptions about missing observations. These analyses will be defined in the SAP.  
Differences in time-to-event endpoints (e.g., time to at least a one category improvement in 
ordinal scale) by treatment will be summarized with Kaplan-Meier curves and 95% confidence 
bounds. The same procedure will be used to compare time to at least a two-category 
improvement. 
Change in ordinal scale at specific time points will be summarized by proportions (e.g., 
proportion who have a 1-, 2-, 3-, or 4-point improvement or 1-, 2-, 3-, 4-point worsening). 
 
Duration of event (e.g., duration of mechanical ventilation) will be summarized according to 
median days with quartiles. 
 
Binary data (e.g., incidence of new oxygen use) will be summarized as a percent with 95% 
confidence intervals. Comparisons between arms will be presented as differences in proportions 
with 95% confidence intervals. 
 
Categorical data (e.g., 28-day mortality or ordinal scale by day) may be summarized according to 
proportions by category and/or odds ratios with confidence intervals.  
 
Procedures for handling missing data, including informative censoring (e.g., a missing duration 
of oxygen use endpoint due to a death), will be described in the SAP. 

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9.4.4 
Analysis of Exploratory Objectives and Endpoints 
Exploratory objectives and endpoints for immunophenotyping including transcriptomics, 
interferon-simulating gene analysis, proteomics, epigenetics, and T cell and innate immune cell 
phenotyping will be handled in a separate analysis plan. Samples for the exploratory objectives 
are outlined in this protocol and details of sample collection, processing, storage and shipping is 
described in detail the MOP, however, the analysis will not take place in real-time, during study 
enrollment. Depending on the timing of the completion of these assays, exploratory results will 
be submitted as one or more addenda to the primary CSR. 
 
9.4.5 
Safety Analyses 
Safety endpoints include death through Day 29 (+ 6 days), SAEs and Grade 3 and 4 AEs. These 
events will be analyzed univariately and as a composite endpoint. Time-to-event methods will be 
used for death and the composite endpoint. Each AE will be counted once for a given subject and 
graded by severity and relationship to COVID-19 or study intervention. AEs will be coded using 
the current version of the Medical Dictionary for Regulatory Activities (MedDRA). AEs will be 
presented by system organ class, duration (in days), start- and stop-date. Adverse events leading 
to premature discontinuation from the study intervention and serious AEs will be presented either 
in a table or a listing.  
 
9.4.6 
Baseline Descriptive Statistics 
Baseline characteristics will be summarized by treatment arm. For continuous measures the mean, 
median, minimum, maximum and standard deviation will be summarized. Categorical variables 
will be described by the proportion in each category (with the corresponding sample size numbers).  
 
9.4.7 
Planned Interim and Early Analyses  
A DSMB will monitor ongoing results to ensure subject well-being and safety as well as study 
integrity. The DSMB will be asked to recommend early termination or modification only when 
there is clear and substantial evidence of a treatment difference. More details about the interim 
analyses are described in section 9.4.6.1 and 9.4.6.2 below as well as a separate guidance document 
for the DSMB.  
 
On September 4, 2020, the DSMB met for an interim safety review of ACTT-3 data, and they 
recommended that DMID close further enrollment to patients with a baseline ordinal score of 6. 
Given that there are multiple clinical trials evaluating interferon beta for the treatment of COVID-
19 worldwide, a public announcement describing the change in enrollment was made to inform 
the scientific community. If necessary, there may be an early evaluation of safety outcomes for the 
category 6 subjects enrolled in ACTT-3. Specifically, after study Day 29, for all subjects enrolled 
at an ordinal score of 6, those subjects only may be unblinded and an interim analysis may occur. 
This could be done if needed in order to determine the risk in this group of patients and convey 
this risk to other sponsors who can then use this information to make modifications if needed to 
their ongoing studies. This would be followed by a full analysis after the final data cleaning. The 

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SAP has been modified to describe this interim analysis as well as a revised analysis for the ordinal 
6 category.  
 
9.4.7.1 
Interim Safety Analyses 
Safety analyses will evaluate Grade 3 and 4 AE and SAEs by treatment arm. Safety monitoring 
will be ongoing with the DSMB reviewing safety data approximately every two weeks during the 
study. The unblinded statistical team will prepare these reports for review by the DSMB.  
 
9.4.7.2 
Interim Efficacy Review 
The Lan-DeMets spending function analog of the O’Brien-Fleming boundaries will be used to 
monitor the primary endpoint as a guide for the DSMB for an overall two-sided type-I error rate 
of 0.05. Interim efficacy analyses will be conducted at approximately 50% and 100% of total 
information.  
 
Conditional power will be presented as an additional guide to the DSMB. Conditional power 
allows computation of the probability of obtaining a statistically significant result by the end of 
the trial given the data accumulated thus far, incorporating and assuming a hypothesized treatment 
effect (e.g., the treatment effect assumed for sample size determination) thereafter. If conditional 
power is less than 20% under the original trial assumptions, consideration should be given to 
stopping the trial.  
 
The unblinded statistical team will prepare these closed reports for DSMB review and 
recommendations. Analyses will be presented with blinded codes for treatment arms to protect 
against the possibility that the DSMB report may fall into the wrong hands. A DSMB charter will 
further describe procedures and membership.  
 
9.4.8 
Sub-Group Analyses 
Subgroup analyses for the primary outcomes will evaluate the treatment effect across the following 
subgroups: geographic region, duration of symptoms prior to enrollment, baseline disease severity 
(ordinal scale), age, race, ethnicity, sex, and comorbidities. A forest plot will display confidence 
intervals across subgroups. Interaction tests will be conducted to determine whether the effect of 
treatment varies by subgroup. 
9.4.9 
Exploratory Analyses 
An exploratory analysis will compare treatment efficacy estimates according to the various scales 
outlined in section 8.1.3. Specifically, the probability of falling into category “i” or better will be 
compared between arms for each i.  
 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS – ALL STAGES 
All supporting documentation and operational considerations are applicable to the entire platform 
trial and are not unique to the individual stages. These are therefore covered in the main protocol 
document.