Multicenter, Randomized, Parallel and Proof of Concept Study to Evaluate the Safety Profile of Three Doses of Plitidepsin in Patients With COVID-19 Requiring Hospitalization
Phase: PHASE1
Conditions: COVID-19
Sponsor: PharmaMar

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 1/94  
 
COORDINATING INVESTIGATORS:   
 
Dr Vicente Estrada 
Hospital Clínico San Carlos, Department of Infectious Diseases 
 
Dr Jesús Fortún Abete 
Hospital Ramón y Cajal, Department of Infectious Diseases 
 
Dr José Barberán 
Hospital HM Montepríncipe, Department of Internal Medicine  
 
PROTOCOL CODE: APLICOV-PC (APL-D-002-20) 
EudraCT number: 2020-001993-31 
SPONSOR: Pharma Mar, SA 
Previous versions of the protocol/amendments (number and 
date):  
- Version 1.0, dated 22/Apr/2020 
- Version 2.0, dated 25/Apr/2020 
- Version 3.0, dated 13/ May/2020 
- Version 4.0, dated 18/Jun/2020 
- Version 5.0, dated 13/ Aug/2020 
- Version 6.0, dated 11/ Sep/2020 
Current version (number and date):    
 
- Version 7.0, dated 29/ Sep/2020 
CONFIDENTIAL: The information and data included in this protocol contain trade 
secrets and classified or confidential information that is the property of the sponsor. No 
Multicenter, randomized, parallel and proof of 
concept study to evaluate the safety profile 
of three doses of Plitidepsin in patients with 
COVID-19 requiring hospitalization 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 2/94  
person is authorised to make this information public without the written permission of 
the sponsor. These limitations will also apply to all information deemed classified or 
confidential that is provided in the future. This document may be disclosed and used by 
your team and collaborators, as necessary to carry out the clinical study. 
1. PROTOCOL SUMMARY 
1.1. Sponsor identification 
Name:  
Pharma Mar, SA 
Contact Person:  
Dr Maria José Pontes Valero 
Associate International Medical Affairs Director 
E-mail: mjpontes@pharmamar.com 
Tel: + 34 91 823 46 31/ +34 606 669 744 
Fax: + 34 91 846 60 03 
 
Dra. Belen Sopesen Veramendi,  
Director of Corporate Affairs 
e-mail: bsopesen@pharmamar.com 
Tel: + 34 91 44 44 500/ + 34 680 652 394  
Postal address:  
Avda. de los Reyes, 1. 
Polígono Industrial “La Mina”. 
28770 Colmenar Viejo. 
Madrid, Spain. 
Pharmacovigilance contact person:  
Hervé Dhellot 
EEA Qualified Person for Pharmacovigilance and Senior Pharmacovigilance 
Manager 
e-mail: hdhellot@pharmamar.com / phv@pharmamar.com 
Tel (24 hours): + 34 91 823 45 56 
Tel: + 34 91 846 60 55 
Fax: + 34 91 846 60 04 
Postal address:  
Avda. de los Reyes, 1. 
Polígono Industrial “La Mina”. 
28770 Colmenar Viejo. 
Madrid, Spain. 
Coordinating investigators:  
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 3/94  
Dr Vicente Estrada 
Hospital Clínico San Carlos  
Department of Infectious Diseases 
 
Dr Jesús Fortún Abete 
Hospital Ramon y Cajal 
Department of Infectious Diseases 
 
Dr José Barberán 
Hospital HM Montepríncipe,  
Department of Internal Medicine  
 
1.2. Study title  
Multicenter, randomized, parallel and proof of concept study to evaluate the 
safety profile of three doses of Plitidepsin in patients with COVID-19 requiring 
hospitalization 
1.3. Protocol code 
APLICOV-PC (APL-D-002-20) 
1.4. Drug Research Ethics Committee (CEIm) 
Drug Research Ethics Committee of HM Hospitales  
1.5. Company responsible for monitoring 
APICES 
Av. Antonio López, 16 - 1ºA 
 
28320 Pinto (MADRID) 
Tel: +34 91 816 68 04 
Fax: +34 91 816 91 72 
E-mail: ana.moreno@apices.es 
1.6. Investigational product 
Plitidepsin 
1.7. Clinical trial phase 
Proof of concept 
1.8. Study objectives  
Primary objective: 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 4/94  
To determine the safety and toxicological profile of plitidepsin at each 
dose level administered according to the proposed administration 
scheme in patients admitted for COVID-19. 
Secondary objectives: 
- 
To assess the efficacy of plitidepsin in patients with COVID-19 at the 
proposed dose levels by: 
o Change in SARS-CoV-2 viral load from baseline  
o Time until negative detection of SARS-CoV-2 by PCR  
o Cumulative incidence of disease severity. The evaluation will be 
based on:  
 Mortality 
 Need for invasive mechanical ventilation and/or ICU 
admission 
 Need for non-invasive mechanical ventilation 
 Need for oxygen therapy  
- 
Selection of the recommended dose levels of plitidepsin for a phase II/III 
efficacy study 
1.9. Study design 
Multicentre, randomised clinical trial with three treatment arms.  
Three cohorts of 9 patients will be included in the study. Each of the cohorts of 
9 patients will include 3 arms (A, B, and C) at different dose levels with 3 
patients in each arm, up to a maximum of 27 patients evaluable for safety. 
The established dosage levels are as follows: 
- 
Arm A) 1.5 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days. 
- 
Arm B) 2.0 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days.  
- 
Arm C) 2.5 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days. 
 
ARM 
Dosage level 
Daily dose (mg) 
Total dose (mg) 
Arm A 
1 
1.5 mg x 3 days 
4.5 mg 
Arm B 
2 
2.0 mg x 3 days 
6.0 mg 
Arm C 
3 
2.5 mg x 3 days 
7.5 mg 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 5/94  
Recruitment will be sequential in each of the three arms. The first cohort of 3 
patients in arms B and C (2.0 mg and 2.5 mg) will not open until the data have 
been analysed for the first 3 patients at the dose level immediately below (arms 
A or B) without observing any unacceptable toxicity, taking into account the data 
of the three patients included in each arm with a 12-day follow-up from the end 
of treatment (day +15 from the start of treatment).  
When patients are to be included at more than one dose level (arm), patients 
will be randomised in a 1:1 or 1:1:1 ratio as appropriate.  
The following criteria have been established to continue the inclusion of patients 
in the different arms: 
- 
If 0-1 of the first three patients treated with the dose of 1.5 mg x 3 days 
experience any adverse event classed as grade 3 or higher within twelve 
days after administration of the last dose, three additional patients will be 
enrolled in the 1.5 mg arm and recruitment of the first three patients in 
the 2.0 mg arm will start. Recruitment in the 2.5 mg arm will be opened 
after it has been proven that only 0-1 of the three patients in the first 
cohort in the 2.0 mg arm have grade 3 or greater toxicity within twelve 
days of follow-up after administration of the last dose of 2.0 mg. 
- 
 
- 
If 2 or more patients in any of the arms present an adverse event classed 
as grade 3 or higher, the sponsor will interrupt the recruitment of new 
patients and will jointly assess with the Spanish Agency of Medicines and 
Medical Devices whether or not to continue recruitment in that arm and in 
arms with a higher dose. 
Intra-patient dose change/increase is not allowed. 
Once the 27 patients (9 at each dose level) contemplated in the study protocol 
have been included, an extension period will be opened to include 18 additional 
patients (6 at each plitidepsin dose level) to extend the collection of safety 
information on the different doses and additionally to collect efficacy data. After 
this extension period, data will be available for 15 patients at each plitidepsin 
dose level. 
During the extension period, patients will be randomised in a 1:1:1 ratio as 
appropriate to each dose level (arm). 
During the extension period of the study, if in any of the arms, 2 or more 
patients present an adverse event classed as grade 3 or higher related to 
plitidepsin, the sponsor will interrupt the recruitment of new patients at that dose 
level and higher, and will assess jointly with the Spanish Agency of Medicines 
and Medical Devises the convenience of continuing recruitment in that arm and 
in arms with a higher dose. Additionally, the sponsor will forward weekly follow 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 6/94  
up records to the Spanish Agency of Medicines and Medical Devices, with the 
information of all the adverse event classed as grade 3 or higher, reported, 
whether or not related to plitidepsin, for review and joint assessment if 
necessary. 
After the joint evaluation of the safety and efficacy data obtained in the present 
study between the sponsor and the Spanish Agency of Medicines and Medical 
Devices, the recommended dose level will be selected to evaluate the efficacy 
of the treatment in patients with COVID-19 in a subsequent randomised phase 
II/III study. 
The final statistical analysis that will be the basis of the final report of the study 
will be done on the  total population of 45 patients once the extension of the 
study has been completed.. The data of the first 27 patients will be analysed in 
an intermediate statistical analysis. 
1.10.  Disease under study 
COVID-19 infection 
1.11.  Endpoints 
Primary endpoint: 
To determine the safety and toxicological profile of plitidepsin at each dose level 
administered in patients admitted for COVID-19, the following endpoints will be 
analysed: 
- 
Frequency of the following ≥ grade 3 adverse events according to the 
NCI-CTCAE criteria v 5.0 at 3, 7, 15 and 31 days:  
• Haematological 
o Neutropenia  
o Thrombopenia  
o Anaemia  
o Lymphopenia 
• 
Non-haematological 
o CPK increase 
o ALT and/or AST increase 
o Total bilirubin or direct bilirubin increase  
o Neurotoxicity  
o QT-QTc interval prolongation  
• 
Other ≥ grade 3 adverse events  
- 
Percentage of patients in which treatment cannot be completed and 
reasons. 
- 
Percentage of patients with AEs and SAEs at days 3, 7, 15 and 31. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 7/94  
- 
Changes from baseline (day -1 or day 1 before administration of the 
study drug) in haematological and non-haematological parameters on 
days 3, 7, 15 and 31.  
- 
Percentage of patients with ECG abnormalities on days 2, 3, 4, 5, 6, 7, 
15 and 31. 
Secondary endpoints: 
- 
Change in SARS-CoV-2 viral load from baseline (day -1 or day 1 before 
administration of the study drug) measured at days 3, 4, 7, 15 and 31. 
- 
Time until the detection of COVID-19 by PCR obtained from 
nasopharyngeal exudate or sample from the lower respiratory tract 
compared to baseline (day -2 or -1 or day 1 before administration of the 
study drug).  
- 
Mortality at 7, 15 and 31 days. 
- 
Percentage of patients requiring invasive mechanical ventilation and/or 
ICU admission at 7, 15 and 31 days. 
- 
Percentage of patients requiring non-invasive mechanical ventilation at 7, 
15 and 31 days. 
- 
Percentage of patients requiring oxygen therapy at 7, 15 and 31 days. 
- 
The recommended dose level will be selected after the joint evaluation of 
the safety and efficacy data obtained in this study between the sponsor 
and the Spanish Agency of Medicines and Medical Devices.  
1.12. Study population and total number of patients  
The primary objective of the study is to evaluate the safety and toxicology 
profile of plitidepsin at each dose level administered once a day for 3 
consecutive days. 
Three cohorts of 9 patients at each of the three dose levels will be included in 
the study and the recruitment will be sequential in blocks of 3 patients each until 
a maximum of 27 patients are included in the study.  
During the extension period of the study that will start after the recruitment of 
the 27 patients initially planned an additional 18 patients will be included (6 at 
each dose level). 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 8/94  
1.13. Inclusion and exclusion criteria 
1.13.1. Inclusion criteria 
1. Patient who agrees to participate in the study by signing the informed 
consent. 
2. Men and women (non-pregnant) aged ≥18 years. 
3. PCR-confirmed COVID-19 infection obtained from nasopharyngeal 
exudate or sample from the lower respiratory tract. 
4. Patients who require hospitalisation for COVID-19  
5. Onset of symptoms no later than 10 days prior to study inclusion. 
6. Men and women with reproductive capacity must agree to use highly 
effective contraceptive methods (diaphragm plus spermicide or male 
condom plus spermicide, oral contraceptive combined with a second 
method of contraceptive implant, injectable contraceptive, permanent 
intrauterine device, sexual abstinence or vasectomy) during their 
participation in the study and in the 6 months following the last 
administration of plitidepsin. 
7. In addition, women participating in the study with reproductive capacity 
must have a negative pregnancy test at enrolment. 
1.13.2. 
Exclusion criteria 
1. Patients participating in another clinical trial for COVID-19 infection. 
2. Patients receiving treatment with antivirals, interleukin-6 receptor 
inhibitors and immunomodulatory drugs for COVID-19. 
3. Patients who are receiving treatment with chloroquine and derivatives.  
4. Evidence of multi-organ failure. 
5. Patients requiring support with mechanical ventilation (invasive or non-
invasive) at the time of inclusion. 
6. D-dimer>4 x LSN. 
7. Hb < 9 g/dl. 
8. Neutrophils <1000/mm3. 
9. Platelets <100,000/mm3. 
10. Lymphopenia <800/µl. 
11. GOT / GPT > 3 X ULN. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 9/94  
12. Bilirubin > 1 X ULN.   
13. CPK > 2.5 X ULN. 
14. Creatinine clearance <30 ml/min. 
15. Troponin elevation > 1.5 x ULN. 
16. Clinically relevant heart disease (NYHA> 2).  
17. Clinically relevant arrhythmia or previous history/presence of prolonged 
QT-QTc interval ≥ 450 ms. 
18. Pre-existing neuropathies of any type ≥ grade 2. 
19. Hypersensitivity to the active substance or to any of the excipients 
(macrogolglycerol ricinoleate and ethanol) 
20. Patients who require or are being treated with strong CYP3A4 inhibitors 
and inducers (See annex 5).  
21. Patients who for any reason should not be included in the study 
according to the evaluation of the research team. 
1.14.  Study schedule 
Inclusion start date: May 2020 
Extension start date: September-October 2020 
The study will end with the last follow-up visit of the last patient. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 10/94  
2. CONTENTS 
 
1. 
PROTOCOL SUMMARY........................................................................................ 2 
1.1. 
SPONSOR IDENTIFICATION ............................................................................................................. 2 
1.2. 
STUDY TITLE ................................................................................................................................. 3 
1.3. 
PROTOCOL CODE ........................................................................................................................... 3 
1.4. 
DRUG RESEARCH ETHICS COMMITTEE (CEIM) ............................................................................. 3 
1.5. 
COMPANY RESPONSIBLE FOR MONITORING ................................................................................... 3 
1.6. 
INVESTIGATIONAL PRODUCT ......................................................................................................... 3 
1.7. 
CLINICAL TRIAL PHASE .................................................................................................................. 3 
1.8. 
STUDY OBJECTIVES ....................................................................................................................... 3 
1.9. 
STUDY DESIGN .............................................................................................................................. 4 
1.10. 
DISEASE UNDER STUDY ............................................................................................................. 6 
1.11. 
ENDPOINTS ................................................................................................................................ 6 
1.12. 
STUDY POPULATION AND TOTAL NUMBER OF PATIENTS ............................................................ 7 
1.13. 
INCLUSION AND EXCLUSION CRITERIA ....................................................................................... 8 
1.13.1. Inclusion criteria ...................................................................................................................... 8 
1.13.2. Exclusion criteria ..................................................................................................................... 8 
1.14. 
STUDY SCHEDULE...................................................................................................................... 9 
2. 
CONTENTS .......................................................................................................... 10 
3. 
ABBREVIATIONS ............................................................................................... 13 
4. 
STUDY CHARACTERISTICS .............................................................................. 14 
4.1. 
STUDY IDENTIFICATION ............................................................................................................... 14 
4.2. 
STUDY PHASE .............................................................................................................................. 14 
4.3. 
INVESTIGATIONAL PRODUCT DESCRIPTION .................................................................................. 14 
4.4. 
SPONSOR INFORMATION .............................................................................................................. 14 
4.5. 
DRUG RESEARCH ETHICS COMMITTEE (CEIM) ........................................................................... 15 
4.6. 
COMPANY RESPONSIBLE FOR MONITORING ................................................................................. 16 
4.7. 
EXPECTED DURATION OF THE STUDY ........................................................................................... 16 
5. 
JUSTIFICATION AND OBJECTIVES ................................................................. 16 
5.1. 
INTRODUCTION ............................................................................................................................ 16 
5.2. 
JUSTIFICATION OF THE STUDY ..................................................................................................... 16 
5.3. 
STUDY OBJECTIVES ..................................................................................................................... 23 
6. 
STUDY DESIGN ................................................................................................... 23 
6.1. 
DESIGN ........................................................................................................................................ 23 
6.2. 
PRIMARY ENDPOINT .................................................................................................................... 25 
6.3. 
SECONDARY ENDPOINTS .............................................................................................................. 26 
7. 
SCREENING OF PATIENTS ................................................................................ 26 
7.1. 
INCLUSION CRITERIA ................................................................................................................... 27 
7.2. 
EXCLUSION CRITERIA .................................................................................................................. 27 
7.3. 
RANDOMISATION PROCEDURES ................................................................................................... 28 
7.4. 
MASKING PROCEDURES ............................................................................................................... 28 
8. 
WITHDRAWAL AND DISCONTINUATION CRITERIA ..................................... 28 
8.1. 
REASON FOR WITHDRAWAL ......................................................................................................... 28 
8.2. 
MANAGEMENT OF WITHDRAWALS ............................................................................................... 29 
8.3. 
REPLACEMENT OF SUBJECTS AND RESERVE SUBJECTS ................................................................. 29 
9. 
INVESTIGATIONAL PRODUCT ......................................................................... 29 
9.1. 
DESCRIPTION OF THE INVESTIGATIONAL PRODUCT ...................................................................... 29 
9.1.1. Description ............................................................................................................................. 29 
9.1.2. Packaging ............................................................................................................................... 29 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 11/94  
9.1.3. Shipping, storage and destruction .......................................................................................... 30 
9.2. 
DOSAGE AND ADMINISTRATION .................................................................................................. 30 
9.3. 
DURATION OF TREATMENT .......................................................................................................... 31 
9.4. 
CRITERIA FOR DOSAGE MODIFICATION ........................................................................................ 31 
9.5. 
MANAGEMENT OF INFUSION REACTIONS (E.G. HYPERSENSITIVITY REACTION) ............................ 31 
9.6. 
TREATMENT ACCOUNTING AND COMPLIANCE ............................................................................. 32 
9.7. 
PROHIBITED DRUGS ..................................................................................................................... 32 
9.8. 
DRUG INTERACTIONS .................................................................................................................. 32 
10. 
EVALUATION CALENDAR ............................................................................. 35 
11. 
ADVERSE EVENTS .......................................................................................... 37 
11.1. 
DEFINITIONS ............................................................................................................................ 37 
11.1.1 Adverse Event (AE) .................................................................................................................. 37 
11.1.2 Serious Adverse Event (SAE) ................................................................................................... 37 
11.1.3 Adverse reaction ...................................................................................................................... 38 
11.2. 
CHARACTERISTICS OF AN ADVERSE EVENT .............................................................................. 38 
11.2.1. Severity ................................................................................................................................... 38 
11.2.2 Determination of causality ...................................................................................................... 38 
11.2.3 Expectability ............................................................................................................................ 38 
11.2.4 Severity .................................................................................................................................... 39 
11.2.5 Additional considerations ........................................................................................................ 39 
11.3. 
REPORTING PROCEDURES ........................................................................................................ 39 
11.3.1. Reporting of Adverse Events (AEs) ......................................................................................... 39 
11.3.2. Reporting Serious Adverse Events (SAEs) .............................................................................. 40 
11.3.3. Reporting of Serious Adverse Events to the Health Authorities ............................................. 40 
11.3.4. Monitoring of AEs and SAEs .................................................................................................. 40 
11.3.5. AEs or SAEs that occurred after the end of the study ............................................................. 41 
11.3.6. Pregnancy and breastfeeding ................................................................................................. 41 
11.3.7. Overdose ................................................................................................................................. 42 
12. 
STATISTICAL CONSIDERATIONS ................................................................. 42 
12.1. 
GENERAL CONSIDERATIONS .................................................................................................... 42 
12.2. 
SAMPLE CALCULATION ............................................................................................................ 42 
12.3. 
ANALYSIS POPULATIONS ......................................................................................................... 43 
12.4. 
ANALYSIS OF THE PRIMARY ENDPOINT .................................................................................... 43 
12.5. 
ANALYSIS OF SECONDARY ENDPOINTS .................................................................................... 44 
12.5.1. Efficacy assessments ............................................................................................................... 44 
12.5.2. Secondary safety endpoints .................................................................................................... 44 
12.5.3. Interim safety analysis ............................................................................................................ 45 
13. 
DATA MANAGEMENT AND QUALITY ASSURANCE ..................................... 45 
13.1. 
CLINICAL TRIAL MONITORING AND AUDITS ............................................................................. 45 
13.2. 
AUDITS .................................................................................................................................... 45 
13.3. 
INSPECTIONS ........................................................................................................................... 46 
13.4. 
REPORTING OF SERIOUS BREACHES ......................................................................................... 46 
13.5. 
DATA MANAGEMENT ............................................................................................................... 46 
13.6. 
ELECTRONIC CASE REPORT FORMS (ECRF) ............................................................................ 47 
13.7. 
WEB-BASED ELECTRONIC CRF................................................................................................ 47 
13.8. 
DATA RECORDING IN THE ELECTRONIC CRF ........................................................................... 47 
13.9. 
QUERY MANAGEMENT ............................................................................................................. 48 
13.10. 
SOURCE DOCUMENTS .............................................................................................................. 48 
13.11. 
USER IDENTIFIER ..................................................................................................................... 48 
13.12. 
CHANGE CONTROL .................................................................................................................. 49 
13.13. 
DOCUMENTATION STORAGE .................................................................................................... 49 
14. 
ADMINISTRATIVE CONSIDERATIONS ......................................................... 49 
14.1. 
LEGAL CONSIDERATIONS ......................................................................................................... 49 
14.2. 
REVIEW BY THE DRUG RESEARCH ETHICS COMMITTEE .......................................................... 50 
14.3. 
PROTOCOL MODIFICATIONS ..................................................................................................... 50 
14.4. 
INFORMED CONSENT ................................................................................................................ 51 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 12/94  
14.5. 
CONFIDENTIALITY ................................................................................................................... 52 
14.6. 
INSURANCE POLICY ................................................................................................................. 52 
14.7. 
PUBLICATIONS......................................................................................................................... 52 
15. 
ACCEPTANCE OF THE PROTOCOL BY THE SPONSOR ............................... 54 
16. 
ACCEPTANCE OF THE PROTOCOL BY THE PRINCIPAL INVESTIGATOR 
AND COLLABORATORS ........................................................................................... 55 
17. 
BIBLIOGRAPHIC REFERENCES .................................................................... 56 
ANNEX 1. DECLARATION OF HELSINKI ................................................................ 57 
ANNEX 2. LIST OF SITES / PRINCIPAL INVESTIGATORS .................................... 63 
ANNEX 3. SAMPLE PATIENT INFORMATION SHEET AND INFORMED CONSENT 
FORM ......................................................................................................................... 64 
ANNEX 4. PREPARATION GUIDE FOR PLITIDEPSIN INFUSION .......................... 65 
ANNEX 5. CYP3A4 INDUCERS AND INHIBITORS ................................................... 67 
ANNEX 6. NCI-CTCAE CRITERIA ............................................................................ 69 
ANNEX 7: PLITIDEPSIN SAFETY INFORMATION ................................................. 70 
1. 
SAFETY ........................................................................................................................................ 70 
1.1.1. Summary of adverse events in completed studies with plitidepsin as a single agent . 70 
1.1.2. APL-A-004-98 phase I trial evaluating plitidepsin from Day 1 to Day 5 in patients with 
solid tumours and low-intermediate grade non-Hodgkin lymphoma ....................................... 72 
2. 
PHARMACOKINETICS .............................................................................................................. 91 
2.1. 
ADMINISTRATION OF PLITIDEPSIN IN SPECIAL POPULATIONS.................................................... 93 
3. 
REFERENCES .................................................................................................................................. 94 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 13/94  
3. ABBREVIATIONS 
 
Abbreviation 
Term 
AE 
Adverse Event 
AEMPS 
Spanish Agency of Medicines and Medical Devices 
AUC 
Area Under the Curve 
bpm 
Beats per minute 
bpm 
Breaths per minute 
CEIm 
Drug Research Ethics Committee 
CPK 
Creatine-phosphokinase  
CRF 
Case Report Form 
EC 
European Community 
ECG 
Electrocardiogram 
eCRF 
Electronic Case Report Form 
eEF1A 
Eukaryotic elongation factor 
EU 
European Union 
GCP 
Good Clinical Practice 
GOT 
Glutamic oxaloacetic transaminase 
GPT 
Glutamate-pyruvate transaminase 
HR 
Heart rate 
IC50 
Inhibitory concentration 50 
IC90 
Inhibitory concentration 90 
ICH 
International Council for Harmonisation 
ICU 
Intensive care unit 
ID 
Identification number 
IgE 
Immunoglobulin E 
IL-6 
Interleukin 6 
IMV 
Invasive mechanical ventilation 
ITT 
Intention-to-treat 
LBR 
Lung-blood ratio 
LPR 
Lung-plasma ratio 
N 
Nucleocapsid 
NIMV 
Non-invasive mechanical ventilation 
OTI 
Orotracheal intubation 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 14/94  
Abbreviation 
Term 
PR 
PR interval  
Q1 
First quartile 
Q3 
Third quartile 
QT 
QT interval 
RR 
Respiratory rate 
SAE 
Serious Adverse Event 
SBP 
Systolic blood pressure 
WMA 
World Medical Association 
 
 
4. STUDY CHARACTERISTICS 
4.1. Study identification 
Protocol code:  
APLICOV-PC (APL-D-002-20). 
 
Title:  
Multicenter, randomized, parallel and proof of concept study to evaluate the 
safety profile of three doses of Plitidepsin in patients with COVID-19 requiring 
hospitalization. 
4.2. Study phase 
Proof of concept. 
4.3. Investigational product description 
Plitidepsin. 
4.4. Sponsor information 
Pharma Mar, SA 
Contact Person:  
Dr Maria José Pontes Valero 
Associate International Medical Affairs Director 
E-mail: mjpontes@pharmamar.com 
Tel: + 34 91 823 46 31/ +34 606 669 744 
Fax: + 34 91 846 60 03 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 15/94  
 
Dr María-Angeles Forés,  
International Medical Affairs Director 
e-mail: mafores@pharmamar.com 
Tel: + 34 91 846 60 30 / + 34 650 113 652 
Postal address:  
Avda. de los Reyes, 1. 
Polígono Industrial “La Mina”. 
28770 Colmenar Viejo. 
Madrid, Spain. 
Pharmacovigilance contact person:  
Hervé Dhellot 
EEA Qualified Person for Pharmacovigilance and Senior Pharmacovigilance 
Manager 
E-mail: hdhellot@pharmamar.com/ phv@pharmamar.com 
Tel (24 hours): + 34 91 823 45 56 
Tel: + 34 91 846 60 55 
Fax: + 34 91 846 60 04 
Postal address:  
Avda. de los Reyes, 1. 
Polígono Industrial “La Mina”. 
28770 Colmenar Viejo. 
Madrid, Spain. 
Coordinating investigators:  
 
Dr Vicente Estrada 
Hospital Clínico San Carlos  
Department of Infectious Diseases 
 
Dr Jesús Fortún Abete 
Hospital Ramon y Cajal 
Department of Infectious Diseases 
 
Dr José Barberán 
Hospital HM Montepríncipe,  
Department of Internal Medicine  
 
4.5. Drug Research Ethics Committee (CEIm) 
Drug Research Ethics Committee of HM Hospitales 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 16/94  
4.6. Company responsible for monitoring 
APICES 
Av. Antonio López, 16 - 1ºA 
 
28320 Pinto (MADRID) 
Tel: +34 91 816 68 04 
Fax: +34 91 816 91 72 
E-mail: ana.moreno@apices.es 
4.7. Expected duration of the study 
Inclusion start date: May 2020 
Extension start date: September-October 2020 
The study will end with the last follow-up visit of the last patient. 
 
5. JUSTIFICATION AND OBJECTIVES  
5.1. Introduction 
Last December, the World Health Organisation received information on a group 
of cases of pneumonia of unknown aetiology. The cause of this pneumonia was 
identified as a new virus in the Coronaviridae family (SARS-CoV-2) and the 
clinical picture associated with the virus has been named COVID-19. 
In January 2020 the first case was reported in Spain and in mid-February the 
first patient died of it. The growth of confirmed cases has been exponential 
since then, with the Community of Madrid being the most affected region.  
As of April 22, the Coordination Centre for Health Alerts and Emergencies of 
the Ministry of Health has reported that in Spain there have been 208,389 
cases, 21,717 deaths and 85,915 patients cured. The Autonomous 
Communities with the highest cumulative incidence in the last 14 days are La 
Rioja, Madrid, Castilla León and Castilla-La Mancha. 
COVID-19 is currently a public health emergency. The onset of a virus 
unknown until now has made it necessary to take measures taking into account 
the existing scientific knowledge with similar viruses and past situations.  
5.2. Justification of the study 
Mortality associated with COVID-19 disease appears to be associated with a) 
severe respiratory failure secondary to respiratory distress and b) an 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 17/94  
inflammatory status caused by a cytokine storm. Thus, the proportion of 
patients with severe disease requiring hospitalisation with or without high-flow 
oxygen supplements and patients requiring mechanical ventilatory support was 
estimated to be close to 15% and 5%, respectively, in the initial series from 
China. However, in our setting, the figures reported by the health authorities 
are much higher, reaching 30% of serious cases requiring hospitalisation in the 
city of Madrid without the need for mechanical ventilation and close to 10% of 
patients requiring mechanical ventilation. Likewise, the duration of the need for 
mechanical ventilation in the Chinese series is much shorter than that reported 
in cities such as Madrid, so the usual flow of patients to intensive care units is 
being altered by the prolonged stay of patients. This is putting an enormous 
burden on hospital services, which has made it necessary to take 
extraordinary, unprecedented measures. In any case, it is not known whether 
the magnitude of the complications initially described can be avoided or 
reduced through the use of antivirals in patients with early-stage COVID-19 
pneumonia, since once the cytokine storm and respiratory distress take place, 
it is very difficult for an antiviral drug to have a beneficial therapeutic effect. 
Plitidepsin is a cyclic depsipeptide originally isolated from a Mediterranean 
marine tunicate (Aplidium albicans) and currently manufactured by full chemical 
synthesis. It is licensed and marketed in Australia under the brand name 
plitidepsin for the treatment of multiple myeloma. It belongs to the family of 
didemnins, discovered in the 1980s, which have a powerful capacity against 
DNA and RNA viruses [1,2].  
In eukaryotic cells, plitidepsin has been unequivocally shown to target the 
eukaryotic elongation factor (eEF1A) [3], which has a key role in modulating 
interaction with other proteins [4], some of which may be essential in the 
replication of various viruses. It is noteworthy that one of the aforementioned 
proteins is the coronavirus N protein, which is produced abundantly within 
infected cells and is known to interact with elongation factor EF1A [5]. The 
interaction between plitidepsin and EF1A could therefore reduce the efficacy of 
de novo viral capsid synthesis and consequently entail a decrease in viral load.  
With these arguments, the in vitro antiviral activity of plitidepsin in a human 
hepatoma cell line (Huh-7) infected with the HCoV-229E-GFP virus was studied 
[6,7]. In this sense, it must be highlighted that the N protein of this coronavirus 
has a protein homology of more than 90% with the SARS-CoV-2 homologous 
protein and, although it has not been described, all coronaviruses need their N 
(nucleocapsid) protein to bind to EF1A in order to replicate effectively and 
synthesise viral proteins. No binding of N to EF1A means no viability for the 
spread of the virus. For a short while, confluent cultures of Huh-7 were infected 
at a multiplicity of infection (MOI) of 0.01 pfu/cell, with a viral inoculum of 3x107 
pfu/ml and after 8 hours, plitidepsin was added at concentrations ranging from 
0.5 nM to 50 µM. The cultures with plitidepsin were incubated for 48 hours and 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 18/94  
then viral viability was measured by fluorescence. The results obtained showed 
an antiviral effect induced by plitidepsin at concentrations as low as 0.5 nM 
(0.555 µg/l), much lower than those reported with other antivirals [8].  
Estimate of target concentrations in vitro. 
Assuming that the IC50 of the aforementioned in vitro experiment (0.5 nM or 
0.555 µg/l) and the unbound fraction of plitidepsin in human plasma (fu) is 1%, 
and using equation 2 (assuming a Hill slope of 1), IC90 has been estimated at 
4.995 µg/l. 
Eq.1 
 =  · 	
	 · 
(50 + 	
	 · ) 
Eq.2 
50 	
 =  · 	
	 ·  −  · 	
	 · 

 
Since the cells of the experiment were cultured in a medium with 10% bovine 
serum, an unbound fraction above 0.96 was estimated. Therefore, to ensure 
active plitidepsin concentrations in tissues (e.g. lung) with high tropism of 
coronavirus, the concentration should be ≥ 0.555 µg/l. 
Selection of the dosage regimen for the treatment of SARS-CoV-2 
infection. 
For the estimation of the total target plasma concentration of plitidepsin 
associated with the concentration in lungs above IC50 (≥ 0.555 µg/l), the lung-
plasma ratio and the unbound fraction of plitidepsin obtained were taken into 
account in the studies below. 
Tissue distribution data  
In an in vivo distribution study in rats [9], in which an intravenous bolus dose 
(0.2 mg/kg) of 14C-plitidepsin was administered, a significant increase in 
radioactivity was observed in the lungs of animals. This preferential distribution 
indicates a lung-blood (LBR) and lung-plasma (LPR) AUC ratio of around 8- and 
543-fold, respectively. 
Plasma protein binding 
In human and rat plasma, plasma protein binding of plitidepsin was independent 
of drug concentration (100, 200 and 500 ng/ml), estimated at 98% and 96%, 
respectively [10].  
Estimation of the total plasma concentrations associated with the target 
concentrations (IC50, IC90 and 3xIC90) in vitro. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 19/94  
The total plasma concentration (µg/l) of plitidepsin associated with a lung 
exposure above the in vitro target concentration (IC50 = 0.555 µg/l) was 
estimated at 0.05 µg/l, by means of equation 3 (see below), assuming that 1) 
SARS-CoV-2 IC50total, in vitro is similar to that described for HCoV-229E, and 2) 
the lung distribution in humans is similar to that observed in rats. 
Eq.3 
IC50, !" = 50	
	,    	
,# · $%&	
 
 
where IC50total plasma is the total target plasma concentration (µg/l), IC50total in vitro 
is the concentration used in the in vitro experiment (µg/l), fu, human is the unbound 
fraction in human plasma and LBRrat is the lung-blood ratio in the distribution 
study in rats. 
The total plasma concentration (µg/l) of plitidepsin associated with lung 
exposure above the target IC90 in vitro concentration (IC90 = 4.995 µg/l) was 
estimated to be 0.46 µg/l, using the equation above. Therefore, total plasma 
plitidepsin concentrations above 1.38 µg/l would be associated with a lung 
exposure 3 times higher than the target IC90 in vitro concentration. 
Phase 1 studies with plitidepsin 
In order to define the dosage and regimen of plitidepsin as a single agent, an 
extensive phase 1 clinical development programme was carried out, which 
explored five administration schedules, including a total of 215 adult patients 
with various types of tumours, both solid and haematological. Table 1 shows the 
dosing schedules tested during phase 1, as well as the number of patients, the 
maximum tolerated dose, the recommended dose and the intensity of the 
weekly dose. 
Table 1: Phase 1 studies of plitidepsin as a single agent. 
 
24-hour 
D1,8,15 
q4wk 
3-hour 
D1,15 
q4wk 
1-hour 
D1,8,15 
q4wk 
24-hour D1,15 q4wk
1-hour iv 
D1-5 
q3wk 
Plitidepsin  
Plitidepsin +
L-carnitine 
No. of patients
35 
27 
48 
67 
20 
37 
MTD (mg/m2) 
4.50 
6 
3.60 
6 
8 
1.35 
RD (mg/m2) 
3.75 
5 
3.2 
5 
7 
1.2 
DI at RD 
(mg/m2/week) 
2.8 
2.5 
2.4 
2.5 
3.5 
2.0 
D, day; MTD, maximum tolerated dose; RD: recommended dose; DI: Dose intensity; iv, intravenous. 
 
Figure 1 shows these phase 1 studies together with phase 2 and 3 studies in the 
same dosing schedule, in which a pharmacokinetic sub-study was also 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 20/94  
performed.  
 
Figure 1: Clinical studies with pharmacokinetic sub-study, sorted by dosing schedule 
and phase. 
 
n: number of patients treated with plitidepsin; % w/PK: percentage of treated patients who 
participated in the pharmacokinetic sub-study. 
 
 
Daily schedule (D1-5 every three weeks)  
Among all the dosing schedules explored, the one used in study APL-A-004-98 
[11] in 37 patients with solid tumours is considered the ideal one for a non-
oncological population, maintaining sustained exposure and allowing daily 
adjustments of treatment based on the patient's response. At the recommended 
dose for cancer patients, 1.2 mg/m2 (equivalent to a flat dose of 2.2 mg), this 
plitidepsin schedule showed a favourable safety profile compared to other 
oncological agents.  
Dose selection 
A validated pharmacokinetic population model of plitidepsin [12] was used to 
identify at what doses the total plasma concentrations would reach the 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 21/94  
estimated target concentrations of antiviral activity set at 0.05 µg/l (IC50), 0.46 
µg/l (IC90) and 1.38 µg/l (3xIC90) (see above).  
In the pharmacokinetic population model of plitidepsin, a link between body 
surface area (BSA) (1.2-2.5 m²) and plasma clearance of plitidepsin was not 
observed, therefore flat dosing is considered preferable in order to facilitate the 
administration of the compound at the sites.  
Plitidepsin is preferentially distributed in the erythrocyte, resulting in a 
blood/plasma ratio of between 3.37 and 4.45.  
It should be noted that the half-life value of plitidepsin of 6.7 days corresponds 
to the pharmacokinetic population analysis performed with concentrations of 
whole blood and not plasma. Quantifications in whole blood allow detectable 
concentrations of plitidepsin to be obtained several days after administration, 
resulting in a long elimination phase and a long half-life. However, during this 
elimination phase, plasma concentrations, which are effective from the point of 
view of activity, safety and potential interactions, are undetectable. 
As proof of this, the half-life calculated with non-compartmental analysis based 
on plasma concentrations (study APL-B-015-14) is 48.1 hours.  
Figure 2 illustrates the simulation of the total plasma plitidepsin concentration 
profiles vs. time after a daily dose (D1-D3) of 1.5 mg, 2.0 mg and 2.5 mg.  
 
Figure 2: Total plasma concentration profiles vs. plitidepsin time predicted for the 
proposed dosing schedule and administration.  
 
 
The horizontal black lines represent the total plasma concentrations associated with 
concentrations in lungs equivalent to IC50, IC90 and 3xIC90 in vitro. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 22/94  
 
 
With all three dosage levels (1.5 mg, 2.0 mg and 2.5 mg), plasma 
concentrations above IC50 would be obtained throughout the treatment period 
and would remain above IC90 during most of the administration interval. 
Accumulation after three repeated administrations is minimal. 
The cumulative doses associated with the proposed administration schedules 
(7.5 mg, 6.0 mg and 4.5 mg) are approximately 70%, 55% and 40% of that 
defined in the phase I study APL-A-004-98 (8.4-12.0 mg), recommended for 
patients with solid tumours based on safety criteria. Phase I study of 
plitidepsin (APL-A-004-98) 
In the phase I study (APL-A-004-98) 37 patients were treated with plitidepsin 
once daily with a 1-hour infusion for 5 days at different dose levels.  
Patients were included in 10 cohorts at different doses from 0.08 mg/m2 to 
1.5 mg/m2, on days 1 to 5, with the maximum tolerated dose being 1.35 mg/m2. 
Since fixed doses of plitidepsin are to be administered in the proposed study, an 
analysis of the adverse events observed has been conducted in study APL-A-
004-98 in 19 patients treated at total doses of 0.5 mg to 2.5 mg separated into 5 
groups.  
1) 0.5 mg dose level (± 0.2 mg). Total dose for 5 days 2.5 mg. N = 3 
2) 1.0 mg dose level (± 0.2 mg). Total dose for 5 days 5.0 mg. N = 5 
3) 1.5 mg dose level (± 0.2 mg). Total dose for 5 days 7.5 mg. N = 4 
4) 2.0 mg dose level (± 0.2 mg). Total dose for 5 days 10.0 mg. N = 3 
5) 2.5 mg dose level (± 0.2 mg). Total dose for 5 days 12.5 mg. N = 4 
 
The proposed doses for the clinical trial of plitidepsin in COVID 19 would be 1.5 
(3-day total dose of 4.5 mg), 2 mg for 3 days (3-day total dose of 6 mg) and 
2.5 mg during 3 days (7.5 mg total 3-day dose), bringing dose levels between 
dose level 1 and 3 of the phase I study (APL-A-004-98). 
Taking into account that the safety data available today comes from patients 
with solid tumours previously treated with chemotherapy and treated with an 
administration regimen of plitidepsin for 5 consecutive days, we propose a 
multicentre, uncontrolled, proof-of-concept clinical trial, with three treatment 
arms to evaluate the safety profile of an administration scheme over three 
consecutive days at three different dose levels of plitidepsin, in adult patients 
with a confirmed diagnosis of COVID-19 who require hospitalisation. 
Additional safety information for plitidepsin is included in Annex 7.  

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 23/94  
5.3. Study objectives 
Primary objective:  
To determine the safety and toxicology profile of plitidepsin at each dose 
level administered in patients admitted for COVID-19 according to the 
proposed administration scheme. 
Secondary objectives: 
- 
To assess the efficacy of plitidepsin in patients with COVID-19 at the 
proposed dose levels by: 
o Change in SARS-CoV-2 viral load from baseline  
o Time until negative detection of SARS-CoV-2 by PCR  
o Cumulative incidence of disease severity. The evaluation will be 
based on:  
 Mortality 
 Need for invasive mechanical ventilation and/or ICU 
admission 
 Need for non-invasive mechanical ventilation 
 Need for oxygen therapy  
- 
Selection of the recommended dose levels of plitidepsin for a phase II/III 
efficacy study  
 
6. STUDY DESIGN   
6.1. Design 
Multicentre, randomised clinical trial with three treatment arms.  
Three cohorts of 9 patients will be included in the study. Each of the cohorts of 
9 patients will include 3 arms (A, B, and C) at different dose levels with 3 
patients in each arm, up to a maximum of 27 patients evaluable for safety. 
The established dosage levels are as follows: 
- 
Arm A) 1.5 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days. 
- 
Arm B) 2.0 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days.  
- 
Arm C) 2.5 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days. 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 24/94  
ARM 
Dosage level 
Daily dose (mg) 
Total dose (mg) 
Arm A 
1 
1.5 mg x 3 days 
4.5 mg 
Arm B 
2 
2.0 mg x 3 days 
6.0 mg 
Arm C 
3 
2.5 mg x 3 days 
7.5 mg 
 
Recruitment will be sequential in each of the three arms. The first cohort of 3 
patients in arms B and C (2.0 mg and 2.5 mg) will not open until the data have 
been analysed for the first 3 patients at the dose level immediately below (arms 
A or B) without observing any unacceptable toxicity, taking into account the data 
of the three patients included in each arm with a 12-day follow-up from the end 
of treatment (day +15 from the start of treatment).  
When patients are to be included at more than one dose level (arm), patients 
will be randomised in a 1:1 or 1:1:1 ratio as appropriate.  
The following criteria have been established to continue the inclusion of patients 
in the different arms: 
- 
If 0-1 of the first three patients treated with the dose of 1.5 mg x 3 days 
experience any adverse event classed as grade 3 or higher within twelve 
days after administration of the last dose, three additional patients will be 
enrolled in the 1.5 mg arm and recruitment of the first three patients in 
the 2.0 mg arm will start. Recruitment in the 2.5 mg arm will be opened 
after it has been proven that only 0-1 of the three patients in the first 
cohort in the 2.0 mg arm have grade 3 or greater toxicity within twelve 
days of follow-up after administration of the last dose of 2.0 mg. 
- 
 
- 
If 2 or more patients in any of the arms present an adverse event classed 
as grade 3 or higher, the sponsor will interrupt the recruitment of new 
patients and will jointly assess with the Spanish Agency of Medicines and 
Medical Devices whether or not to continue recruitment in that arm and in 
arms with a higher dose. 
Intra-patient dose change/increase is not allowed. 
Once the 27 patients (9 at each dose level) contemplated in the study protocol 
have been included, an extension period will be opened to include 18 additional 
patients (6 at each plitidepsin dose level) to extend the collection of safety 
information on the different doses and additionally to collect efficacy data. After 
this extension period, data will be available for 15 patients at each plitidepsin 
dose level. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 25/94  
During the extension period, patients will be randomised in a 1:1:1 ratio as 
appropriate to each dose level (arm). 
During the extension period of the study, if in any of the arms, 2 or more 
patients present an adverse event classed as grade 3 or higher related to 
plitidepsin, the sponsor will interrupt the recruitment of new patients at that dose 
level and higher, and will assess jointly with the Spanish Agency of Medicines 
and Medical Devises the convenience of continuing recruitment in that arm and 
in arms with a higher dose. Additionally, the sponsor will forward weekly follow 
up records to the Spanish Agency of Medicines and Medical Devices, with the 
information of all the adverse event classed as grade 3 or higher, reported, 
whether or not related to plitidepsin, for review and joint assessment if 
necessary. 
After the joint evaluation of the safety and efficacy data obtained in the present 
study between the sponsor and the Spanish Agency of Medicines and Medical 
Devices, the recommended dose level will be selected to evaluate the efficacy 
of the treatment in patients with COVID-19 in a subsequent randomised phase 
II/III study. 
The final statistical analysis that will be the basis of the final report of the study 
will be done on the total population of 45 patients once the extension of the 
study has been completed  The data of the first 27 patients will be analysed in 
an intermediate statistical analysis. 
 
6.2. Primary endpoint 
Primary endpoint: 
To determine the safety and toxicological profile of plitidepsin at each dose level 
administered in patients admitted for COVID-19, the following endpoints will be 
analysed: 
- 
Frequency of the following ≥ grade 3 adverse events according to the 
NCI-CTCAE criteria v 5.0 at 3, 7, 15 and 31 days:  
• Haematological 
o Neutropenia  
o Thrombopenia  
o Anaemia  
o Lymphopenia 
• 
Non-haematological 
o CPK increase 
o ALT and/or AST increase 
o Total bilirubin or direct bilirubin increase  
o Neurotoxicity  

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 26/94  
o QT-QTc interval prolongation  
• Other ≥ grade 3 adverse events  
- 
Percentage of patients in which treatment cannot be completed and 
reasons. 
- 
Percentage of patients with AEs and SAEs at days 3, 7, 15 and 31. 
- 
Changes from baseline (day -1 or day 1 before administration of the 
study drug) in haematological and non-haematological parameters on 
days 3, 7, 15 and 31.  
- 
Percentage of patients with ECG abnormalities on days 2, 3, 4, 5, 6, 7, 
15 and 31. 
6.3. Secondary endpoints 
- 
Change in SARS-CoV-2 viral load from baseline (day -1 or day 1 before 
administration of the study drug) measured at days , 4, 7, 15 and 31. 
- 
Time until the detection of COVID-19 by PCR obtained from 
nasopharyngeal exudate or sample from the lower respiratory tract 
compared to baseline (day -2 or -1 or day 1 before administration of the 
study drug).  
- 
Mortality at 7, 15 and 31 days. 
- 
Percentage of patients requiring invasive mechanical ventilation and/or 
ICU admission at 7, 15 and 31 days. 
- 
Percentage of patients requiring non-invasive mechanical ventilation at 7, 
15 and 31 days. 
- 
Percentage of patients requiring oxygen therapy at 7, 15 and 31 days. 
- 
The recommended dose level will be selected after the joint evaluation of 
the safety and efficacy data obtained in this study between the sponsor 
and the Spanish Agency of Medicines and Medical Devices.  
 
7. SCREENING OF PATIENTS 
When a patient is considered eligible to participate in the study, they will be 
offered to participate in it and receive the Patient Information Leaflet along with 
all additional information required to obtain informed consent. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 27/94  
7.1. Inclusion criteria 
1. Patient who agrees to participate in the study by signing the informed 
consent. 
2. Men and women (non-pregnant) aged ≥18 years. 
3. PCR-confirmed COVID-19 infection obtained from nasopharyngeal 
exudate or sample from the lower respiratory tract. 
4. Patients who require hospitalisation for COVID-19  
5. Onset of symptoms no later than 10 days prior to study inclusion. 
6. Men and women with reproductive capacity must agree to use highly 
effective contraceptive methods (diaphragm plus spermicide or male 
condom plus spermicide, oral contraceptive combined with a second 
method of contraceptive implant, injectable contraceptive, permanent 
intrauterine device, sexual abstinence or vasectomy) during their 
participation in the study and in the 6 months following the last 
administration of plitidepsin. 
7. In addition, women participating in the study with reproductive capacity 
must have a negative pregnancy test at enrolment. 
7.2. Exclusion criteria 
1. Patients participating in another clinical trial for COVID-19 infection. 
2. Patients receiving treatment with antivirals, interleukin-6 receptor 
inhibitors and immunomodulatory drugs for COVID-19. 
3. Patients who are receiving treatment with chloroquine and derivatives.  
4. Evidence of multi-organ failure. 
5. Patients requiring support with mechanical ventilation (invasive or non-
invasive) at the time of inclusion. 
6. D-dimer> 4 x LSN. 
7. Hb < 9 g/dl. 
8. Neutrophils <1000/mm3. 
9. Platelets <100,000/mm3. 
10. Lymphopenia <800/µl. 
11. GOT / GPT > 3 X ULN. 
12. Bilirubin > 1 X ULN.   
13. CPK > 2.5 X ULN. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 28/94  
14. Creatinine clearance <30 ml/min. 
15. Troponin elevation > 1.5 x ULN. 
16. Clinically relevant heart disease (NYHA> 2).  
17. Clinically relevant arrhythmia or previous history/presence of prolonged 
QT-QTc interval ≥ 450 ms. 
18. Pre-existing neuropathies of any type ≥ grade 2. 
19. Hypersensitivity to the active substance or to any of the excipients 
(macrogolglycerol ricinoleate and ethanol) 
20. Patients who require or are being treated with strong CYP3A4 inhibitors 
and inducers (See annex 5). 
21. Patients who for any reason should not be included in the study 
according to the evaluation of the research team. 
7.3. Randomisation procedures 
Patients will be randomised, provided patients are included at more than one 
dose level (arm), in a 1:1 or 1:1:1 ratio as appropriate, once the investigator has 
confirmed that they meet the selection criteria and the patient has given 
informed consent.  
During the extension period, patients will be randomised in a 1:1:1 ratio as 
appropriate to each dose level (arm). 
The randomisation will be done in blocks.  
Randomisation will be done through registration in the study's eCRF. The 
system will assign a unique randomisation number for each patient. This 
number should be included in all study documents related to the patient.   
7.4. Masking procedures 
Not applicable. 
8. WITHDRAWAL AND DISCONTINUATION CRITERIA 
8.1. Reason for withdrawal 
Patients will be excluded or withdrawn from the study for any of the following 
reasons: 
- 
Withdrawal of consent by the patient. 
- 
Administration of treatments not allowed in the protocol. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 29/94  
All cases of a patient's withdrawal from the study must be documented in the 
Case Report Form. 
8.2. Management of withdrawals 
Patients who receive at least one dose of plitidepsin and withdraw from the 
study will be followed for at least 28 days after administration of the last dose of 
plitidepsin to follow up on possible open adverse events at withdrawal.  
8.3. Replacement of subjects and reserve subjects 
Patients who sign the study consent and are not randomised will be replaced. 
Patients who discontinue study treatment before the end of the three proposed 
administrations for reasons other than ≥ grade 3 adverse events will be 
replaced.  
9. INVESTIGATIONAL PRODUCT 
9.1. Description of the investigational product 
Plitidepsin is licensed in Australia for the treatment of multiple myeloma.  
Safety information for plitidepsin is included in Annex 7.  
9.1.1. Description 
Plitidepsin is supplied as a powder for concentrate for solution for infusion at a 
concentration of 2 mg/vial. Before use, the vials are reconstituted with 4 ml of 
reconstitution solution to obtain a colourless to slightly yellowish solution 
containing 0.5 mg/ml of plitidepsin, 25 mg/ml of mannitol, 0.15 ml/ml of 
macrogolglycerol ricinoleate oil, 0.15 ml/ml of ethanol and 0.70 ml/ml of water 
for injection. An additional dilution should be made in any suitable intravenous 
solution prior to infusion. 
9.1.2. Packaging 
Plitidepsin 2 mg is supplied in a Type I clear glass vial with a bromobutyl rubber 
stopper covered with an aluminium seal. Each vial contains 2 mg of plitidepsin. 
The solvent for the reconstitution of macrogolglycerol ricinoleate (polyoxyl 35 
castor oil)/absolute ethanol/water for injection, 15%/15%/70% (v/v/v) is supplied 
in a Type I colourless glass vial. The ampoules have a volume of 4 ml. 
Plitidepsin will be labelled with the study protocol code, the batch number, the 
content, the expiry date, the storage conditions, the name of the investigator 
and the sponsor. The study drug will be labelled in accordance with Annex 13 of 
the European Good Manufacturing Practices. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 30/94  
9.1.3. Shipping, storage and destruction 
Plitidepsin should be stored between 2ºC and 8ºC and the vials should be kept 
in the outer carton to protect them from light.  
The drug in these conditions is stable for 60 months. 
Any unused product or waste materials must be disposed of in accordance with 
local requirements for cytotoxic drugs. 
9.2. Dosage and administration 
Patients included in the study will be randomised in a 1:1:1 ratio to receive:  
 
- 
Arm A) 1.5 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days. 
- 
Arm B) 2.0 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days.  
- 
Arm C) 2.5 mg of plitidepsin administered as a 1.5-hour infusion, once a 
day for 3 consecutive days. 
 
See guidelines for medication preparation in Annex 4.  
Personnel should be trained and qualified to reconstitute and dilute the 
medication and should wear protective clothing including a mask, goggles and 
gloves during reconstitution and dilution.  
Accidental contact with skin, eyes or mucous membranes should be treated 
immediately with large amounts of water. 
All patients should receive the following prophylactic medications 20-30 minutes 
before the infusion of plitidepsin: 
- 
Diphenhydramine hydrochloride 25 mg iv or equivalent.  
- 
Ranitidine 50 mg iv or equivalent. 
- 
Dexamethasone 8 mg intravenous. 
- 
Ondansetron 8 mg i.v. slow infusion 15 minutes or equivalent 
 
Ondansetron 4 mg oral will be administered every 12 hours until 48 hours after 
the last administration of plitidepsin. 
After reconstitution of the 2 mg plitidepsin vial with 4 ml of the solution for 
reconstitution of macrogolglycerol ricinoleate/ethanol/water for injection, the 
reconstituted solution should be diluted and used immediately after preparation. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 31/94  
If not used immediately, storage times and conditions until use are the 
responsibility of the user. 
The reconstituted concentrated solution of the drug product has been shown to 
be physically, chemically and microbiologically stable for 24 hours under 
refrigerated conditions (5ºC±3ºC) and for 6 hours when stored in the original vial 
under indoor light at room temperature. 
If storage is required before administration, solutions should be stored 
refrigerated and protected from light and should be used within 24 hours after 
reconstitution. 
9.3. Duration of treatment 
Patients included of the study will receive treatment for 3 days.  
9.4. Criteria for dosage modification 
No dose reduction has been contemplated. 
9.5. Management of infusion reactions (e.g. hypersensitivity reaction)  
In the event of a serious/life-threatening infusion reaction (grade ≥ 3), the 
plitidepsin infusion should be discontinued and immediate treatment with 
oxygen and bronchodilators should be considered. Treatment should be 
administered with diphenhydramine iv 50 mg or equivalent, hydrocortisone iv 
100 mg and epinephrine (adrenaline) should be added if clinically indicated. The 
infusion should not be resumed and treatment with plitidepsin should be 
discontinued. 
For mild or moderate/non-life threatening reactions (grade ≤ 2) such as allergic 
symptoms, the infusion should be stopped immediately and vital signs and 
pulse oximetry will be continuously monitored. Before resuming infusion of 
plitidepsin, iv dexamethasone 4 mg premedication (or equivalent) must be 
administered 20-30 minutes beforehand. If symptoms persist after stopping the 
infusion and administering dexamethasone, diphenhydramine 50 mg iv or 
equivalent and hydrocortisone 100 mg bolus iv or equivalent will be 
administered.  
Symptoms and vital signs should be re-evaluated after 30 min. If they are 
normal or have improved, the infusion may be resumed at a third of the initial 
infusion rate during the first hour. Signs and symptoms should be continuously 
monitored during the infusion. Subsequently, the infusion rate could be 
increased according to tolerance. Any additional infusion will be started at a 
reduced infusion rate and IV prophylactic premedication will be administered as 
described above. The patient will be monitored during the first hour after the 
infusion to detect symptoms. If no hypersensitivity reactions are observed, the 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 32/94  
infusion rate could be increased again. In any case, if symptoms do not improve 
after 30 minutes, anti-H1 and/or corticosteroids will be administered until 
resolution, and treatment with plitidepsin will be discontinued. 
9.6. Treatment accounting and compliance 
Study medication should be stored in a safe place with limited access, under 
the conditions established in the investigator's brochure. The medication will be 
labelled with the study protocol code, batch number, content, expiry date, 
storage conditions, investigator and name of the sponsor.  
The monitor will supervise the study medication in the hospital pharmacy prior 
to destruction, after accounting for the medication has been completed. 
Medication accounting will be documented and amounts shipped, dispensed, 
returned and destroyed will be verified. 
All unused medication provided by the sponsor will be destroyed at each 
participating site and properly documented. If requested by the sponsor, unused 
medication will be returned to the sponsor. 
All study drug inventory forms should be available for inspection by authorised 
representatives of the sponsor or by health authority inspectors. The 
investigator is responsible for counting all used and unused study supplies at 
their site. 
 
9.7. Prohibited drugs 
Concomitant 
administration 
of 
interleukin-6 
receptor 
inhibitors 
and 
immunomodulatory drugs is not permitted. 
Concomitant use of chloroquine and derivatives is not permitted.  
Patients may receive other pharmacological treatments for COVID-19 at the 
discretion of the investigator after 24 hours from the administration of the last 
dose of plitidepsin. 
9.8. Drug interactions 
There have been no clinical studies on drug interactions. 
If the patient is already under treatment with chloroquine or one of its 
derivatives and given its arrhythmogenic potential, the patient may not be 
included in the study. 
     Effect of other medicinal products on plitidepsin 
Interactions with CYP3A4 inhibitors and inducers 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 33/94  
In vitro studies indicate that CYP3A4 is the major enzyme involved in plitidepsin 
metabolism, followed by CYP2A6 and CYP2E1. However, a pharmacokinetic 
population analysis of plitidepsin including 283 patients indicated that 
concomitant administration of CYP3A4* inhibitors and inducers does not affect 
exposure to plitidepsin [12]. However, it cannot be ruled out that concomitant 
treatments that inhibit or induce CYP3A4 may modify the efficacy and/or 
increase the probability of side effects associated with plitidepsin, so they 
should be avoided.  
• 
Co-administration with CYP3A4 inhibitors and inducers should be avoided, as 
they may affect the plasma concentration of plitidepsin. 
 
• 
Co-administration with CYP3A4 inhibitors and moderated inducers should be 
used with caution, as an effect on plitidepsin exposure cannot be excluded. 
 
Interactions with CYP3A4 inhibitors  
Plitidepsin should not be administered with potent inhibitors CYP3A4 (e.g. 
grapefruit 
juice, 
clarithromycin, 
itraconazole, 
nefazodone, 
telithromycin, 
voriconazole). Potent inhibitors CYP3A4 should be discontinued before starting 
treatment and during treatment with plitidepsin. They may be re-administered 
24 hours after the last dose of plitidepsin. 
Moderate inhibitors CYP3A4 (e.g., aprepitant, diltiazem, erythromycin, 
fluconazole, verapamil) should be used with caution, as increased exposure to 
plitidepsin cannot be excluded 
Interactions with CYP3A4 inducers 
To avoid a decrease in the effectiveness of plitidepsin, plitidepsin should not be 
administrated with potent inducers of   CYP3A4 enzyme, such as 
anticonvulsants (phenytoin, phenobarbital or carbamazepine), rifampicin, 
rifabutin and St. John's wort, unless there are no therapeutic alternatives. The 
appropriate initial dose for patients taking potent inducers has not been defined. 
They may be administered again 24 hours after the last dose of plitidepsin. 
CYP3A4 moderate inducers  (e.g. bosetan, modafinil, nafcillin) should be used 
with caution, as a reduction of exposure to plitidepsin cannot be excluded. 
A list of CYP3A4 inducers and inhibitors is included in Annex 5.  
 
Effect of plitidepsin on other drugs 
In vitro studies did not show a potential for plitidepsin to inhibit or induce 
metabolism of other drugs. However, the results for ruling out the potential 
inducing effect of plitidepsin on the CYP2B6 enzyme were inconclusive. The 
potential effect of plitidepsin on CYP2B6 has not been studied in vivo. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
Page 34/94  
Therefore, decreases in plasma concentrations of drugs that are substrates of 
this enzyme cannot be ruled out when co-administered with plitidepsin.

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 35/94  
10. 
 EVALUATION CALENDAR  
 
Baseline 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 15  
(± 1 day) 
Day 31   
(± 3 days)14 
Informed consent1 
X 
 
 
 
 
 
 
 
 
 
Selection criteria2 
X 
 
 
 
 
 
 
 
 
 
Medical record 
X 
 
 
 
 
 
 
 
 
 
Vital signs3 
X 
X 
X 
X 
X  
X 
X 
X 
X 
X 
Demographics  
X 
 
 
 
 
 
 
 
 
 
Physical examination 
X 
 
 
 
 
 
 
 
 
 
Electrocardiogram4 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Complete blood count5 
X 
X* 
X 
X 
X 
X 
X 
X 
X 
X 
Biochemistry6 
X 
X* 
X 
X 
X 
X 
X 
X 
X 
X 
Coagulation7 
X 
X* 
X 
X 
X 
X 
X 
X 
X 
X 
C-reactive protein8 
X 
X* 
X 
X 
X  
X 
X 
X 
X 
X 
Viral load15  
X 
 
 
 
X 
 
 
X 
X 
X 
PCR COVID-199 
X 
 
 
 
X 
 
 
X 
X 
X 
Chest x-ray10 
X 
Based on clinical criteria 
Pregnancy test11 
X 
 
 
 
 
 
 
 
 
 
Treatment 
 
X 
X 
X 
 
 
 
 
 
 
Other pharmacological treatments 
for COVID-1912 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse events13 
X 
X 
X 
X 
X  
X 
X 
X 
X 
X 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 36/94  
 
 
* It will not be necessary to repeat the tests on day 1 if they were carried out in the 24 hours prior to administration of plitidepsin.  
1 The patient will sign the informed consent before undergoing any specific study procedure that is not part of normal clinical practice. 
 
2 The patient must meet all the inclusion criteria and none of the exclusion criteria in order to be included in the study. 
 
3 Vital signs will be measured every 8 hours or every nursing shift until discharge: temperature, blood pressure, heart rate, respiratory rate, O2 saturation (including oxygenation method). Once the 
patient has been discharged, a single measurement of vital signs will be made at the study visits detailed in the table.  
 
4 The electrocardiogram will be performed during the baseline visit and on days 1, 2, 3, 4, 5, 6, 7, 15 and 31 from the start of treatment with plitidepsin. The PR interval and the QT interval will be 
measured.  
 
5 Complete blood count on days 1, 2, 3, 4, 5, 6, 7, 15 and 31. 
 
6 Basic biochemistry on days 1, 2, 3, 4, 5, 6, 7, 15 and 31. It will include transaminases, bilirubin, alkaline phosphatase, LDH, CK, ferritin and troponin. 
 
7 Coagulation on days 1, 2, 3, 4, 5, 6, 7, 15 and 31, including D-dimer. 
 
8 C-reactive protein on days 1, 2, 3, 4, 5, 6, 7, 15 and 31.  
 
9 The first time the patient tested positive for COVID-19 will be included as well. The test will be repeated in the 48 hours prior to administration of plitidepsin and on days 4, 7, 15 and 31, if negative 
detection does not occur before then. Qualitative PCR shall be obtained on nasopharyngeal exudate (preferably) or a sample from the lower respiratory tract. 
 
 
10 A chest X-ray will be performed at baseline and subsequently based on clinical discretion.  
 
11 Only fertile women. 
 
12 Patients may receive other pharmacological treatments for COVID-19 at the discretion of the investigator 24 hours after administration of the last dose of plitidepsin. 
 
13 Adverse events (serious and non-serious) will be recorded from signing of the informed consent up to 28 days after administration of the last dose of plitidepsin.  
 
14 A safety visit will be made 28 days (+3 days) after the last dose of plitidepsin.  
15 The viral load should be determined in a sample obtained from nasopharyngeal exudate (preferably) or a sample from the lower respiratory tract. 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 37/94  
 
11. 
 ADVERSE EVENTS  
Safety information in clinical studies must be collected efficiently and consistently. 
Adverse events should be identified and reported promptly, so that potential risks to 
patients can be determined and regulatory requirements for reporting of adverse events 
can be met.  
11.1. 
Definitions 
11.1.1 Adverse Event (AE) 
An AE is any undesirable event that occurs to a patient undergoing clinical research, 
temporarily associated with the use of a drug, whether or not it is deemed to be related 
to the investigational products. Therefore, an adverse event can be any unintended and 
unfavourable sign (including an abnormal analytical result), symptom or disease that is 
temporarily associated with the use of a drug, whether or not it is deemed to be related 
to it. Pre-existing conditions that worsen during the study will be reported as Adverse 
Events. 
AEs include pre or post-treatment events that occur as a consequence of study 
procedures (e.g. invasive procedures or modification of the patient's previous 
medication). 
11.1.2 Serious Adverse Event (SAE) 
An SAE is an undesirable medical event that, at any dosage: 
• Causes death. 
• Is life-threatening (NOTE: The term “life-threatening” refers to the investigator's 
judgement that the patient is at risk of death as a consequence of said event. 
However, this term does not refer to the fact that if the AE had been more 
intense, it would have placed the patient at imminent risk of death).  
• Causes hospitalisation or prolongs a previous hospitalisation (NOTE: 
Hospitalisation is generally understood to mean that the patient has stayed in the 
hospital or emergency department for at least 24 hours. Complications that occur 
during hospitalisation are AEs. If a complication prolongs hospitalisation or 
meets any of the other severity criteria, then the event will be considered an 
SAE. When in doubt as to whether or not “hospitalisation” has occurred, the AE 
will be considered serious. Hospitalisation to carry out a scheduled treatment of 
a disease prior to the subject entering the study and that has not worsened with 
respect to their baseline situation is not considered an SAE). Hospitalisation due 
to social reasons is not considered an AE. 
• Causes impairment or disability (NOTE: Impairment involves significant impact 
on a person's ability to carry out their daily tasks, but not that caused by minor 
medical conditions such as headaches, nausea, vomiting, diarrhoea, influenza or 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 38/94  
accidental trauma (such as a ankle sprain), which can hinder or interfere with 
activities of daily living, but do not significantly impair them). 
• Results in a congenital anomaly or birth defect. 
• Is medically important (that is, a medically important adverse event may not be 
immediately life-threatening or result in immediate hospitalisation or death. 
However, if it is determined that the event may harm the patient and/or may 
require intervention to prevent one of the outcomes specified above, this event 
should be reported as serious). 
11.1.3 Adverse reaction 
Any harmful and unintended response to a medication, including adverse reactions 
resulting from any use outside the terms of the marketing authorisation, abuse and 
error in the medication. There is a confirmed causal relationship with it. 
11.2. 
Characteristics of an adverse event 
11.2.1. 
Severity 
See definition of Serious Adverse Event (11.2 Serious Adverse Event (SAE)). 
11.2.2 Determination of causality 
The investigator is required to establish the causal link between the investigational drug 
and the adverse event (whether serious or not). A “reasonable possibility” is proposed 
to define cases where there are facts/evidence or arguments to suggest a causal link. 
The investigator will use clinical judgement to determine the relationship.  
Alternative causes, such as the natural history of underlying diseases, concomitant 
treatment, other risk factors and the temporal link between the event and the 
investigational drug will be considered and investigated. The investigator will also 
consult the investigator's brochure for this evaluation. 
There may be situations when an AE occurs where the investigator has minimal 
information to include in the initial report for the Sponsor. However, it is very important 
that the investigator always make a causality assessment for each event before 
submitting the data to the Sponsor. The investigator may change their opinion on 
causality based on information that arises during follow-up, so the report on the AE 
must be modified. Assessment of causality is one of the criteria that determine whether 
or not a case meets the reporting criteria for referral to the health authorities. 
11.2.3 Expectability 
An unexpected adverse reaction is any that generates an unexpected adverse 
response that is related to the administration of the study drug at any dose and that is 
not consistent with the information in the investigator's brochure for the investigational 
product. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 39/94  
The sponsor will classify Adverse Reactions as expected or unexpected according to 
the Reference Safety Information included in the investigator's brochure. 
11.2.4 Severity 
The intensity of AEs will be evaluated using the CTCAE scale v. 5.0 (see Annex 6).  If a 
CTCAE code does not exist, the following guide will be used:   
Grade Description 
0 
No adverse event 
1 
Mild; asymptomatic or mild symptoms; only requires clinical or symptomatic 
observation 
2 
Moderate; minimal, local or non-invasive intervention 
3 
Severe or medically important, but not immediately life-threatening; 
hospitalisation or extension of hospital stay 
4 
Life-threatening; requires urgent intervention 
5 
Death related to the adverse event 
 
The grading of AEs is based on specific clinical criteria and requires evaluation by the 
site’s investigator.  
11.2.5 Additional considerations  
Alterations in laboratory parameters (haematology, biochemistry or urine analysis) 
should be recorded as an AE or SAE, as well as abnormal results of other tests (such 
as ECGs, radiological tests, measurements of vital signs), including those that worsen 
from baseline values, which according to the investigator's medical and scientific 
criteria are considered clinically relevant. 
In contrast, clinically significant changes in safety parameters associated with the study 
disease will not be classified as an AE or SAE unless the investigator determines that 
they are more serious than expected taking into account the patient's condition. 
11.3. 
Reporting procedures 
11.3.1. 
Reporting of Adverse Events (AEs)  
During the visits, the investigator will try to obtain, by means of examination or 
questioning the patient directly, all the information related to adverse events that have 
occurred.  
All information regarding adverse events should be recorded in the corresponding 
section of the case report form. All adverse events occurring during the period covered 
will be recorded, from the moment the patient is included in the study (from signing of 
the consent form) up to 28 days after the last dose of the investigational product. When 
one or more signs or symptoms correspond to a disease, the main diagnosis or 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 40/94  
syndrome will be reported. All adverse events will be followed up until resolution, 
stabilisation or until it is determined that study treatment or participation in the study 
was not the cause of the event. All adverse events that continue at the end of the study 
period should also be followed up to determine their final outcome. 
11.3.2. 
Reporting Serious Adverse Events (SAEs)  
All serious adverse events that occur during the trial, whether or not they are related to 
the study medication, must be reported immediately by email or by fax (completing the 
SAE form) within 24 hours of being reported by the investigator:  
 
ATT. SAFETY DEPARTMENT 
Fax: +34 91-846-60-04 
Email: phv@pharmamar.com  
 
The investigator will record the information regarding the SAE on the corresponding 
form. At least these 4 elements are mandatory in order to report any adverse event: 
• Name or identifier of the person reporting the SAE 
• Patient number or identifier 
• The suspected drug used in the trial: dose, route of administration, start and end 
date of treatment 
• Information related to the Adverse Event: 
• Adverse Event term  
• Severity criteria 
• Assessment of causality 
11.3.3. 
Reporting of Serious Adverse Events to the Health Authorities 
It is the responsibility of the sponsor to notify the Health Authorities of all suspected 
serious and unexpected adverse reactions that have occurred in the clinical trial. This 
will be communicated within the time limits established in accordance with current 
regulations.  
11.3.4. 
Monitoring of AEs and SAEs 
After the initial AE or SAE report, the investigator is required to follow up on each case 
and obtain more information about its status. All AEs and SAEs documented on 
previous visits should be reviewed on subsequent visits. All AEs and SAEs must be 
evaluated until their resolution. This applies to all patients, including those who 
withdraw early. 
The investigator will include in the follow-up any additional investigation that may clarify 
the nature and/or cause of the AE or SAE. This may include additional laboratory tests 
or investigations, histopathological examinations or consultation with other healthcare 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 41/94  
professionals. Any co-investigator may request that the investigator carry out additional 
evaluations to clarify the nature and/or cause of the AE or SAE. If the patient dies 
during participation in the study or during an established follow-up period, the 
investigator will provide a copy of any post-mortem findings, including histopathology, 
that are requested. 
11.3.5. 
AEs or SAEs that occurred after the end of the study 
Post-study AEs or SAEs are defined as any event occurring outside the follow-up 
period defined in the protocol. The investigator is not required to actively search for the 
onset of AEs or SAEs that have occurred in patients who have participated in the 
clinical trial in the past. However, if at any time after a patient withdrew from the study 
the investigator should become aware of the existence of any AE or SAE, including the 
patient's death, that is deemed to be related to the study drug, the investigator should 
promptly notify the sponsor. 
11.3.6. 
Pregnancy and breastfeeding 
Study patients should be advised to notify the investigator immediately if they become 
pregnant during the study. Pregnant patients will stop receiving the study treatment. 
Patients will also be advised to report any pregnancy that occurred after the last visit if 
they believe conception occurred during their participation in the study.  
A pregnancy in itself is not an AE unless there is a possibility that the investigational 
drug has interfered with the effectiveness of any of the contraceptive methods used. 
However, the investigator must notify pregnancies in accordance with the procedures 
and deadlines described for SAE reporting (section 11.3.2). The pregnancy reporting 
form should be used.  
The pregnancy reporting forms must be submitted within 24 hours after the investigator 
becomes aware of the event:  
 
ATT. SAFETY DEPARTMENT 
Fax: +34 91-846-60-04 
Email: phv@pharmamar.com  
 
In accordance with local data privacy laws, the sponsor may request the contact 
information of the subject's doctor in order to follow the pregnancy until the outcome of 
the birth. 
The pregnant patient or the patient’s pregnant partner will be monitored until the end of 
the pregnancy. Any complications during pregnancy or lactation should preferably be 
reported as AEs. The outcome of the pregnancy must be reported on the pregnancy 
reporting form. Any miscarriage, stillbirth, birth defect/abnormality, death or other 
serious conditions of the baby should be reported and followed up as if it were an SAE. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 42/94  
11.3.7. 
Overdose 
An overdose is defined as any dose greater than the highest dose included in the 
protocol. Consult the infusion guide for detailed instructions on preparing, storing and 
administering the investigational drug. 
Any overdose should be noted in the CRF as an Adverse Event and the investigator 
must report them in accordance with the procedures and deadlines described for SAE 
reporting (section 11.3.2) if the overdose is related to a serious adverse event. 
 
12. 
STATISTICAL CONSIDERATIONS 
12.1. 
General considerations 
This section describes the main analyses that will be carried out. The statistical analysis 
plan to be approved by the sponsor will include additional information on analyses, 
management of unavailable data and analytical methods. All data will be analysed with 
the SAS statistical analysis system. All analyses will be carried out mainly by 
descriptive statistical methods. Continuous endpoints will be described using mean and 
standard deviation, median, minimum, maximum, Q1 and Q3. Categorical endpoints 
will be described with frequencies and percentages as well as the exact 95% 
confidence interval of the relevant study variables. All results will be presented 
separately by treatment arm. 
The final statistical analysis that will be the basis of the final report of the study will be 
done on the total population of 45 patients once the extension of the study has been 
completed. The data of the first 27 patients will be analysed in an intermediate 
statistical analysis. 
 
12.2. 
Sample calculation 
The primary objective of the study is to evaluate the safety and toxicology profile of 
plitidepsin at each dose level administered once a day for 3 consecutive days. 
Groups of 9 patients will be included and will be randomly assigned to each of the 3 
arms. Depending on the safety analysis of each group of 3 patients included in each 
arm, it will be decided whether it is possible to include 3 more patients in the same arm, 
up to a maximum of 9 patients in each arm and a maximum of 27 patients in the study. 
During the extension period of the study that will start after the recruitment of the 27 
patients initially planned, an additional 18 patients will be included (6 at each dose 
level). 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 43/94  
12.3. 
Analysis populations 
Safety population: 
The population for the safety analysis will consist of all randomised patients who 
receive at least one dose (complete or not) of plitidepsin.  
Efficacy population: 
Patients are considered evaluable for efficacy if they have received all three doses of 
treatment and have completed a follow-up period of at least 2 weeks. Patients who do 
not complete the treatment period because the disease has evolved unfavourably will 
also be evaluable for efficacy.  
12.4. 
Analysis of the primary endpoint 
The safety analysis will be performed in the safety population, that is, in patients who 
have received at least one dose of treatment. Patients will be analysed in the 
administered treatment arm.  
Safety and tolerability analyses will be presented by treatment arm as well as by 
treatment arm according to age group (<65 years; ≥65 years). Adverse events will be 
coded using the latest version of the MedDRA dictionary and assessed using the NCI-
CTCAE criteria v. 5.0. 
The number and percentage of patients presenting the following ≥ grade 3 adverse 
events will be provided, according to the NCI-CTCAE criteria v. 5.0 at 3, 7, 15 and 
31 days after the start of study treatment:  
• Haematological 
o Neutropenia  
o Thrombopenia  
o Anaemia  
o Lymphopenia 
• 
Non-haematological 
o CPK increase 
o ALT and/or AST increase 
o Total bilirubin or direct bilirubin increase  
o Neurotoxicity  
o QT-QTc interval prolongation  
• 
Other ≥ grade 3 adverse events  
- 
The number and percentage of patients in whom treatment cannot be completed 
and the reasons will be provided. 
- 
The number and percentage of patients with AEs and SAEs will be provided at 3, 
7, 15 and 31 days. 
- 
The evolution of haematological and non-haematological parameters from the 
baseline visit on days 3, 7, 15 and 31 will be provided. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 44/94  
- 
The number and percentage of patients with ECG abnormalities on days 1, 2, 3, 
4, 5, 6, 7, 15 and 31 will be provided. Any alterations detected will be described 
in detail. 
12.5. 
Analysis of secondary endpoints 
12.5.1. 
Efficacy assessments 
Efficacy analyses will be performed on the efficacy population defined above. For the 
evaluation of efficacy endpoints, the following analyses will be carried out separately for 
each dosage level: 
• The evolution of the viral load from the baseline visit on days 3, 4, 7, 15 and 31 
will be provided. 
• The time to negative detection of COVID-19 by PCR will be calculated as the time 
that elapses in days from the date of randomisation to the first date of PCR with a 
negative result. The time to negative detection will be analysed following the 
Kaplan-Meier methodology, providing the median and the corresponding 95% 
confidence interval.  
• The number and percentage of patients who die 7, 15 and 31 days after starting 
the treatment with plitidepsin shall be described. 
• The number and percentage of patients who require mechanical ventilation 
and/or ICU admission at 7, 15 and 31 days will be provided.  
• The number and proportion of patients requiring invasive mechanical ventilation 
shall be stated. 
• The number and proportion of patients requiring non-invasive mechanical 
ventilation shall be stated. 
• The number and proportion of patients requiring oxygen therapy shall be stated. 
 
12.5.2. 
Secondary safety endpoints 
The number and percentage of patients who present an adverse event during the study 
will be provided. The lists per patient of all adverse events that occurred during the 
study will be presented, indicating the severity, relationship and intensity.  
Adverse events per patient (number and percentage) will be provided, calculating the 
maximum grade for each of the events recorded throughout the study for each of the 
patients. The adverse events analysed will be the ones described in the corresponding 
section of the case report form. 
These analyses will be performed in the same way for new adverse events that the 
investigator deems related to the study drug. If the relationship of an adverse event with 
the study medication cannot be ruled out, it will be considered to be related.  
The number and percentage of patients who present a serious adverse event during 
the study will be provided. The lists per patient of all serious adverse events that 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 45/94  
occurred during the study will be presented, indicating the severity, relationship and 
intensity. 
12.5.3. 
Interim safety analysis  
Given the characteristics of the study, it is planned to carry out continuous safety 
analyses up to 12 days after the last administration of plitidepsin for each patient 
evaluable for safety in each arm of each group of 9 patients. These analyses will be 
carried out for the 3 patients included in each arm of each cohort before continuing the 
inclusion of patients in the study.    
This analysis will be purely descriptive and the data will be presented by treatment arm.  
The analyses to be provided will be identical to those detailed in section 12.4 for the 
main objective.   
The sponsor will assess the results of the intermediate analyses with the Spanish 
Agency of Medicines and Medical Devices.   
 
13. 
 DATA MANAGEMENT AND QUALITY ASSURANCE 
13.1. 
Clinical trial monitoring and audits 
The sites participating in the study will be supervised by monitors appointed by the 
sponsor, with specific training for this clinical trial, making periodic visits to the site 
before, during and at the end of the trial. These follow-up visits will be carried out in 
accordance with the ICH E6 (R2) guidelines. Visits can be supplemented by telephone 
contact or written communication. 
Priority will be given to centralised monitoring and/or remote monitoring of the 
participating sites, avoiding overloading the site staff with tasks or reviewing source 
data and postponing, as far as possible, the verification of source data until it is 
possible to access the medical history directly. The sponsor will agree the conditions for 
such monitoring with the participating sites and teams. 
Procedures will be established to ensure the quality of any aspect related to the trial. 
13.2. 
Audits 
The sponsor may carry out periodic audits of ongoing clinical studies. Audits are 
independent of, and separate from, routine monitoring or quality control functions and 
are conducted to ensure compliance with the protocol, applicable regulations and ICH 
E6 (R2) guidelines. 
During the clinical trial, the Quality Department of Pharma Mar SA or external auditors 
contracted by the sponsor may make audit visits to the site (ICH Topic E6 Guideline for 
GCP, Section 1.6). 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 46/94  
13.3. 
Inspections 
Participation in this clinical trial implies acceptance of possible inspection by national or 
foreign regulatory authorities.  
13.4. 
Reporting of serious breaches 
Serious breaches of the authorised protocol or of Royal Decree 1090/2015 that occur in 
Spain must be reported by the sponsor without undue delay and no later than seven 
calendar days from the detection of the breach to the Spanish Agency of Medicines and 
Medical Devices (AEMPS) and the CEIm. 
For this purpose, a serious breach will be defined as any non-compliance that may 
significantly affect the safety and rights of the study subjects or the reliability and 
integrity of the data generated in the clinical trial. 
Only serious breaches will be reported to the AEMPS and the CEIm, and breaches that 
do not constitute a serious breach will not have to be reported. 
Each investigator has to document and explain in the clinical history of the subjects any 
breach to the approved protocol and/or Royal Decree 1090/2015. Investigators can 
implement a protocol breach to eliminate an immediate safety risk to the subject without 
prior CEIm approval, but such a breach must be reported to the study monitor within 
one business day. These incidents will be evaluated and, if appropriate, an amendment 
to the protocol will be prepared.   
The monitor will document breaches during monitoring visits. The monitor will notify the 
investigator of the breach during the visit and the “Breach Form” document will be 
completed and signed by the investigator and monitor.  
13.5. 
Data management 
APICES will be responsible for processing and quality control of the data. Data 
management will be performed according to the Data Management Plan, standard 
operating procedures and the current regulations. 
Data management based on Good Clinical Practice (GCP) standards refers to the 
activities defined to achieve safe routines for the efficient input of information in the 
study database, avoiding errors. Routines include procedures for CRF handling, 
application design and management, data entry and verification, data validation, 
database quality control and documentation of activities performed, including 
information on discrepancies found during the process. The database, data input 
screens and programming will be designed by APICES in accordance with the clinical 
trial protocol. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 47/94  
13.6. 
Electronic Case Report Forms (eCRF) 
The collection of study data will consist of the electronic recording of all the information 
required by the eCRF. APICES will provide the eCRF. 
All investigators agree to keep eCRFs filled in with truthful and accurate information as 
well as source documents that are part of medical records. 
All the requested information must be completed in each patient's eCRF. If a patient is 
included in the study but does not receive treatment (e.g. screening error), only minimal 
data such as demographics and date of informed consent will be collected in the eCRF, 
as well as the reason for the screening error. In general, no queries will be issued for 
the data of these patients indicated in the eCRF as “Not done” or “Not available”. 
For the patients included in the study, the information from the source documents will 
be included in each patient's eCRF by the staff of the research team of the site for this 
study and this information will be supervised by an APICES monitor. If the information 
requested on any variables is not available or does not apply, the reason must be 
included. Data should not be missing unless otherwise stated. Modifications to the 
eCRF must be made following the procedure described in the eCRF user guide and will 
be recorded in the eCRF. 
Each completed eCRF must be reviewed, signed and dated by the Principal 
Investigator of the study without delay. The completed eCRF will be reviewed by the 
study monitor as soon as possible after completion. The site will be provided with an 
electronic copy of the final, approved and signed eCRF, which must be stored in the 
corresponding file. 
13.7. 
Web-based electronic CRF 
Clinical data (including adverse events and concomitant medication) will be entered into 
an application designed to collect study data. Access to the eCRF is password 
protected and includes internal quality controls, such as automatic data entry range 
controls, to identify inconsistent, incomplete or inaccurate data. The clinical data will be 
entered in the application based on the source documents. The profiles and data entry 
permits for the eCRF at each participating site will be established in advance. Only 
study staff from each site designated by the principal investigator will be authorised to 
enter the data in the eCRF. The principal investigator and the research team will 
receive the necessary training to complete the eCRF and will be informed, before the 
start of the study and before any study data are entered in the eCRF, of the security 
measures that they must take into account. 
13.8. 
Data recording in the electronic CRF 
All data must be entered in Spanish. The eCRFs should always reflect the latest 
observations of the patients participating in the study. Therefore, eCRFs should be 
completed as soon as possible during or after the patient's visit. The principal 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 48/94  
investigator of each participating site must verify that all the data entered in the eCRFs 
are accurate and correct. 
If some evaluations are not carried out, or if certain information is not available, not 
applicable or unknown, the investigator or any other authorised person must state it in 
the eCRF. The investigator will approve the data by means of an electronic signature, 
and this approval will serve to confirm the accuracy of the recorded data. 
13.9. 
Query management 
The monitor will review the eCRFs and evaluate their completion and consistency. 
Each eCRF will be compared against the respective source documents to ensure that 
there are no discrepancies in critical data. The investigator or other authorised 
personnel will carry out the data entry, corrections and modifications. The monitor 
cannot fill in data in eCRFs. 
Once the clinical data of the eCRF have been recorded in the application, the 
corrections made to each of the variables will be recorded in the audit trail (e.g. the 
reason for any change, the name of the person who made the change, the time and 
date). If additional corrections to the data are required, the monitor in charge at the site 
or the data manager will include a query in the eCRF. The authorised site personnel will 
answer the queries generated in the application. This entire process will be recorded in 
the audit trail along with the name of the person who made the change, the time and 
the date. 
13.10. 
Source documents 
The eCRF is essentially considered a data entry form and should not replace the 
original medical records (or source document) unless otherwise specified in the study 
protocol. Source documents are all documents used by the investigator or the hospital 
that relate to the patient's medical history, which verify the patient's existence, the 
inclusion and exclusion criteria, and all the records that justify the patient's participation 
in the study. These include patient enrolment and randomisation, medication 
accounting record, analyses, laboratory tests, reports, dispensed material records for 
distribution, patient file, etc. 
Each investigator is responsible for maintaining source documents. These will be 
available for inspection by the study monitor at each monitoring visit. All additional 
documentation completed in the eCRF, such as laboratory data, must be clearly 
identified with the study, visit and patient number. Any personal information (e.g. 
subject's name, initials) must be removed or redacted to preserve patient 
confidentiality. 
13.11. 
User identifier 
In each record included in the eCRF, the user's identification will be automatically 
added through their unique ID. The data for each of the patients included in the study 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 49/94  
will be electronically signed by the investigator to document their review and 
confirmation that the data are accurate. This will be done using the Investigator's ID 
and password; the date and time of signing will be automatically added at the time of 
the electronic signature. Should it be necessary to modify data in an eCRF, the 
correction must be made according to the procedures of the software used. 
13.12. 
Change control 
To comply with regulatory requirements, eCRF data will be electronically filed in the file 
of each participating site. All changes are recorded in a protected audit trail, and it will 
be necessary to enter the reason for the change. Once all data have been entered, 
verified and validated, the database will be locked to prevent further changes to the 
study data. 
13.13. 
Documentation storage 
Essential documents and eCRF data should be kept for 25 years after the end of the 
trial, or for a longer period if other requirements apply, such as if the study is presented 
as a basis for drug registration in which Annex I of Royal Decree 1345/2007, of October 
11, must be complied with. 
The clinical history of the test subject must be kept in accordance with the provisions of 
Law 41/2002, of November 14, and according to the maximum period allowed by the 
hospital, institution or private practice. 
 
14. 
 ADMINISTRATIVE CONSIDERATIONS 
The following administrative aspects are intended to guide the investigators 
participating in the study, but may be subject to changes based on the sponsor's 
procedures, legislation, or working documents or guidelines. 
14.1. 
Legal considerations 
This clinical trial will be carried out in accordance with the ethical principles in the 
Declaration of Helsinki developed by the World Medical Association (WMA) and 
following the standards of good clinical practice and applicable legislation. 
The staff involved in conducting this trial will be trained and have sufficient experience 
to perform the necessary tasks. 
The study will be carried out in accordance with the protocol. The protocol, any 
amendment and the informed consent form will be approved by a CEIm before the start 
of the study, in accordance with current legislation. 
The decision of the CEIm on the execution of the study will be stated in writing. The 
investigator and/or sponsor are responsible for keeping the CEIm informed of any 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 50/94  
relevant information about the study drug. All protocol amendments will be agreed upon 
by the sponsor and the investigator. 
Administrative changes to the protocol are considered minor corrections and/or 
clarifications that have no impact on the way the study will be conducted. 
14.2. 
Review by the Drug Research Ethics Committee 
The ICH guidelines require the approval of the health authorities and a favourable 
opinion from an accredited Clinical Research Ethics Committee (in Spain CEIm) before 
patients can be included in clinical trials. Before the start of the study, the protocol, the 
informed consent form, the materials that will be used for patient recruitment (if 
applicable) and any other written information regarding the trial that is provided to the 
patient will be approved by the CEIm. The clinical trial can only be started when both 
the Health Authorities and the CEIm have considered that the expected benefits for the 
study patients and society justify the risks; in addition, this criterion must be 
continuously reviewed to continue with the trial with guarantees. 
APICES will obtain the favourable opinion of the CEIm on behalf of the sponsor and the 
investigators. All regulatory approvals will be signed by the President of the CEIm, or 
the person appointed by them, and must identify the name and address of the CEIm, 
the trial protocol using the protocol title and/or code, and the date of approval or date on 
which the favourable opinion is granted. Documentation related to authorisation by the 
CEIm and the health authorities and CEIm compliance with ICH E6 (R2) guidelines will 
be kept at the site and will be available for review. 
14.3. 
Protocol modifications 
Any change to the approved protocol will require an amendment to the protocol. The 
investigator should not make any changes to the study without the favourable opinion of 
the CEIm and the authorisation of the health authorities (if applicable), except when 
necessary to eliminate an imminent and obvious risk for the patients or in the case of 
administrative changes. Modifications to the protocol to eliminate an imminent and 
obvious risk can be implemented immediately, but must subsequently be documented 
in an amendment, notified to the CEIm and the relevant health authorities within the 
required period. 
Any major modifications to the protocol must be sent to the CEIm and the health 
authorities for approval before the changes proposed in the amendment can be applied. 
Depending on the magnitude of the change, recruitment could be temporarily 
suspended. 
The sponsor does not have to notify minor modifications to the health authorities or the 
CEIm. However, a record will be kept of minor modifications, filed with the study 
documentation and notified when sending another notification or when a major 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 51/94  
modification is submitted. Documentation related to minor modifications will be 
available for inspection in the study file at the site or at the sponsor's facilities. 
14.4. 
Informed consent 
Before the patient is included in the study or before any specific procedure is carried 
out, informed consent must be obtained in writing from the patient or their legal 
representative, in accordance with ICH E6 guidelines. During the study, blood and 
serum samples will be collected before treatment and 7 days after treatment (two 6 ml 
tubes) to carry out a biomarker sub-study for which patients will have to give their 
consent. 
The samples will initially be kept at each of the participating centres and will be sent for 
analysis to a central laboratory not yet selected by the sponsor, within the European 
Union.  
For obtaining and documenting informed consent, the investigator must comply with 
applicable legislation, and must adhere to the standards of Good Clinical Practices as 
well as the ethical principles of the Declaration of Helsinki. The patient information 
leaflet and the informed consent form and any revisions thereof must be approved by 
the CEIm before being given to patients who are deemed eligible to participate in the 
study or to their legal representatives.  
The sponsor will provide the research team of each participating site with the patient 
information leaflet and the informed consent form approved by the CEIm. 
Before performing any study procedure on the patient, it is the responsibility of the 
principal investigator (or person appointed by them) to obtain consent, freely given in 
writing, from the patient or their legal representative after adequately explaining the 
objectives, methods, expected benefits and potential risks of the study and before any 
protocol-specific screening procedure is performed or study drug is administered. 
Patients or their legal representatives should have the opportunity to ask questions and 
receive the requested information, and they will have sufficient time to decide whether 
or not they want to participate in the study. Once the investigator makes sure that the 
patient understands the implications of participating in the study, they will be asked to 
sign the informed consent in order to obtain their consent to participate in the study. 
The informed consent form must be personally signed and dated by the patient or their 
legal representative and by the study doctor who carried out the informed consent 
process (Principal Investigator or appointed person).  
The acquisition of written informed consent must also be documented in the patient's 
medical history. 
The investigator must provide a copy of the signed informed consent form to the patient 
or their legal representative. Another original copy of the document will be filed in the 
investigator's study file at the site. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 52/94  
If the informed consent form is reviewed and modified during the study, active 
participating subjects must sign the document reviewed and approved by the CEIm. 
The patient participating in the clinical trial, or their legal representative, can withdraw 
consent at any time, without giving any explanation and without this entailing any harm 
to the patient. 
14.5. 
Confidentiality  
The collection and processing of personal data of the patients included in this clinical 
trial will be limited to the data that are necessary to investigate the efficacy, safety, 
quality and usefulness of the study medication used in this trial. 
It is the investigator's responsibility to keep sufficient information to allow patient 
identification. 
The trial monitor, sponsor auditors, CEIm and Competent Authorities should have direct 
access to all trial-related information and agree to keep the identity of study patients 
confidential. 
The data must be collected and processed with the appropriate precautions to 
guarantee confidentiality and compliance with the current legislation regarding data 
privacy. 
Explicit consent of the patients or their representatives for the treatment of personal 
data will be obtained before data collection, if necessary, and this consent will include 
the transfer of the data to other companies and countries. 
Pharma Mar SA will comply with Regulation (EU) 2016/679 of the European Parliament 
and of the Council of 27 April 2016 on the protection of natural persons with regard to 
the processing of personal data and on the free movement of such data. 
14.6. 
Insurance policy  
The sponsor has contracted an insurance policy to cover the responsibilities of the 
investigators and the other parties participating in the study in accordance with the 
applicable regulatory requirements. 
14.7. 
Publications  
Before the investigators of this study send a manuscript or abstract for publication or 
publicly disclose information related to the study drug or products, they will provide this 
publication to Pharma Mar SA at least 60 days beforehand for review and approval, to 
guarantee that confidential data and data ownership are protected. 
If Pharma Mar SA determines that any patentable aspect is disclosed in the proposed 
publication or communication, it will withhold the publication or communication for a 
period of time that it deems appropriate. If the study is part of a multi-centre study, the 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 53/94  
first publication of the study will be carried out with the global results of the study, taking 
into account the investigators and institutions of all participating sites that have 
contributed data, analysis and comments. However, if such publication of the global 
results is not presented within 12 months after the end of the study in all the sites, the 
study could be published individually according to the procedure established above. 
The order of the co-authors will reflect the relative contribution of each of them in the 
development of the study and in the analysis. In general, the first author will be the 
investigator who has recruited the largest number of patients with information that is 
ultimately available for data analysis. Pharma Mar SA staff who have fully participated 
in the study should be considered for co-authorship in the publication. 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 54/94  
15. 
ACCEPTANCE OF THE PROTOCOL BY THE SPONSOR 
 
 
Clinical trial title: Multicenter, randomized, parallel and proof of concept study to 
evaluate the safety profile of three doses of Plitidepsin in patients with COVID-19 
requiring hospitalization. 
Protocol code: APLICOV-PC (APL-D-002-20) 
Version (number and date): Version 7.0 of  29  September 2020 
 
 
 
Position 
(pre-printed name) 
 Signature  
 Signature Date 
 (DD-Mmm-YYYY) 
 
 
 
Position 
(pre-printed name) 
 Signature  
 Signature Date 
 (DD-Mmm-YYYY) 
 
 
 
Position 
(pre-printed name) 
 Signature 
 Signature Date 
 (DD-Mmm-YYYY) 
 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 55/94  
16. 
ACCEPTANCE OF THE PROTOCOL BY THE PRINCIPAL 
INVESTIGATOR AND COLLABORATORS 
 
 
Clinical trial title: Multicenter, randomized, parallel and proof of concept study to 
evaluate the safety profile of three doses of Plitidepsin in patients with COVID-19 
requiring hospitalization  
Protocol code: APLICOV-PC (APL-D-002-20) 
Version (number and date): Version 7.0 of   29  September  2020 
I have read and carefully reviewed the study protocol. Having read and understood the 
requirements and conditions of the study protocol, I agree to carry out the clinical study 
according to the international principles of Good Clinical Practice and the requirements 
of the regulatory authorities for the verification of the original documents and the 
audit/inspection of the study. I agree to use the study material, including the medication, 
only as specified in the protocol. 
I understand that the changes made to the protocol must be made in the form of an 
amendment with the sponsor's prior written approval. I understand that any breach of 
the protocol may lead to early termination of the study. 
 
 
Signature of the Principal Investigator 
 
Signature Date 
(DD-Mmm-YYYY) 
 
 
 
 
 
Investigator's name (uppercase) 
 
 
 
 
 
Signature of the Co-investigator 
 
Signature Date 
(DD-Mmm-YYYY) 
 
 
 
 
 
Investigator's name (uppercase) 
 
 
 
 
 
Signature of the Co-investigator 
 
Signature Date 
(DD-Mmm-YYYY) 
 
 
 
 
 
Investigator's name (uppercase) 
 
 
 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 56/94  
17. 
 BIBLIOGRAPHIC REFERENCES 
 
1. Rinehart KL Jr, Gloer JB, Hughes RG et al. Didemnins: antiviral and antitumor 
depsipeptides from a Caribbean tunicate. Science. 1981 May 22; 212 (4497): 
933-5. 
2. Canonico PG, Pannier WL, Huggins JW, Rienehart KL. Inhibition of RNA viruses 
in vitro and in Rift Valley fever-infected mice by didemnins A and B. Antimicrob 
Agents Chemother. 1982 Oct; 22 (4): 696-7. 
3. Losada, A., et al., Translation Elongation Factor eEF1A2 is a Novel Anticancer 
Target for the Marine Natural Product Plitidepsin. Sci Rep, 2016. 6: p. 35100. 
4. Mateyak, M.K. and T.G. Kinzy, eEF1A: thinking outside the ribosome. J Biol 
Chem, 2010. 285(28): p. 21209-13. 
5. Zhou, B., et al., The nucleocapsid protein of severe acute respiratory syndrome 
coronavirus inhibits cell cytokinesis and proliferation by interacting with 
translation elongation factor 1alpha. J Virol, 2008. 82(14): p. 6962-71. 
6. Ma-Lauer, Y., et al., Influences of cyclosporin A and non-immunosuppressive 
derivatives on cellular cyclophilins and viral nucleocapsid protein during human 
coronavirus 229E replication. Antiviral Res, 2020. 173: p. 104620. 
7. Cervantes-Barragan, L., et al., Dendritic cell-specific antigen delivery by 
coronavirus vaccine vectors induces long-lasting protective antiviral and 
antitumor immunity. mBio, 2010. 1(4). 
8. Wang M, Cao R, Zhang L, et al. Remdesivir and chloroquine effectively inhibit 
the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Research 
2020; 30: 269–271. 
9. PharmaMar, data on file; VPT1992/2014. 
10. PharmaMar, data on file; VPT2678/2014. 
11. Maroun, J.A., et al., Phase I study of Aplidine in a dailyx5 one-hour infusion 
every 3 weeks in patients with solid tumors refractory to standard therapy. A 
National Cancer Institute of Canada Clinical Trials Group study: NCIC CTG IND 
115. Ann Oncol, 2006. 17(9): p. 1371-8. 
12. Nalda-Molina R, et al. Population pharmacokinetics meta-analysis of plitidepsin 
(Aplidin) in cancer subjects. Cancer Chemother Pharmacol. 2009 Jun;64(1):97-
108. doi: 10.1007/s00280-008-0841-4. 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 57/94  
 
Annex 1. Declaration of Helsinki 
WMA Declaration of Helsinki - Ethical principles for medical research involving human subjects 
Adopted by the 
18th WMA General Assembly, Helsinki, Finland, June 1964 
and amended by the 
29th WMA General Assembly, Tokyo, Japan, October 1975 
35th WMA General Assembly, Venice, Italy, October 1983 
41st WMA General Assembly, Hong Kong, September 1989 
48th WMA General Assembly, Somerset West, South Africa, October 1996 
52nd WMA General Assembly, Edinburgh, Scotland, October 2000 
53rd WMA General Assembly, Washington DC, USA October 2002 (Note of Clarification added) 
55th WMA General Assembly, Tokyo, Japan 2004 (Note of Clarification added) 
59th WMA General Assembly, Seoul, Korea, October 2008 
64th WMA General Assembly, Fortaleza, Brazil, October 2013 
Preamble 
1. The World Medical Association (WMA) has developed the Declaration of Helsinki as 
a statement of ethical principles for medical research involving human subjects, 
including research on identifiable human material and data. 
The Declaration is intended to be read as a whole and each of its constituent 
paragraphs should be applied with consideration of all other relevant paragraphs. 
2. Consistent with the mandate of the WMA, the Declaration is addressed primarily to 
physicians. The WMA encourages others who are involved in medical research 
involving human subjects to adopt these principles.  
General principles 
3. The Declaration of Geneva of the WMA binds the physician with the words, “The 
health of my patient will be my first consideration,” and the International Code of 
Medical Ethics declares that, “A physician shall act in the patient’s best interest when 
providing medical care.” 
4. It is the duty of the physician to promote and safeguard the health, well-being and 
rights of patients, including those who are involved in medical research. The 
physician’s knowledge and conscience are dedicated to the fulfilment of this duty.  
5. Medical progress is based on research that ultimately must include studies involving 
human subjects. 
6. The primary purpose of medical research involving human subjects is to understand 
the causes, development and effects of diseases and improve preventive, diagnostic 
and therapeutic interventions (methods, procedures and treatments). Even the best 
proven interventions must be evaluated continually through research for their safety, 
effectiveness, efficiency, accessibility and quality. 
7. Medical research is subject to ethical standards that promote and ensure respect for 
all human subjects and protect their health and rights. 
8. While the primary purpose of medical research is to generate new knowledge, this 
goal can never take precedence over the rights and interests of individual research 
subjects. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 58/94  
9. It is the duty of physicians who are involved in medical research to protect the life, 
health, dignity, integrity, right to self-determination, privacy, and confidentiality of 
personal information of research subjects. The responsibility for the protection of 
research subjects must always rest with the physician or other health care 
professionals and never with the research subjects, even though they have given 
consent. 
10. 
Physicians must consider the ethical, legal and regulatory norms and standards 
for research involving human subjects in their own countries as well as applicable 
international norms and standards. No national or international ethical, legal or 
regulatory requirement should reduce or eliminate any of the protections for research 
subjects set forth in this Declaration. 
11. 
Medical research should be conducted in a manner that minimises possible harm 
to the environment.  
12. 
Medical research involving human subjects must be conducted only by 
individuals with the appropriate ethics and scientific education, training and 
qualifications. Research on patients or healthy volunteers requires the supervision of 
a competent and appropriately qualified physician or other health care professional. 
13. 
Groups that are underrepresented in medical research should be provided 
appropriate access to participation in research. 
14. 
Physicians who combine medical research with medical care should involve their 
patients in research only to the extent that this is justified by its potential preventive, 
diagnostic or therapeutic value and if the physician has good reason to believe that 
participation in the research study will not adversely affect the health of the patients 
who serve as research subjects. 
15. 
Appropriate compensation and treatment for subjects who are harmed as a 
result of participating in research must be ensured. 
Risks, Burdens and Benefits 
16. 
In medical practice and in medical research, most interventions involve risks and 
burdens. 
Medical research involving human subjects may only be conducted if the importance 
of the objective outweighs the risks and burdens to the research subjects. 
17. 
All medical research involving human subjects must be preceded by careful 
assessment of predictable risks and burdens to the individuals and groups involved 
in the research in comparison with foreseeable benefits to them and to other 
individuals or groups affected by the condition under investigation. 
Measures to minimise the risks must be implemented. The risks must be 
continuously monitored, assessed and documented by the researcher. 
18. 
Physicians may not be involved in a research study involving human subjects 
unless they are confident that the risks have been adequately assessed and can be 
satisfactorily managed. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 59/94  
When the risks are found to outweigh the potential benefits or when there is 
conclusive proof of definitive outcomes, physicians must assess whether to continue, 
modify or immediately stop the study. 
Vulnerable Groups and Individuals 
19. 
Some groups and individuals are particularly vulnerable and may have an 
increased likelihood of being wronged or of incurring additional harm. 
All vulnerable groups and individuals should receive specifically considered 
protection. 
20. 
Medical research with a vulnerable group is only justified if the research is 
responsive to the health needs or priorities of this group and the research cannot be 
carried out in a non-vulnerable group. In addition, this group should stand to benefit 
from the knowledge, practices or interventions that result from the research. 
Scientific Requirements and Research Protocols 
21. 
Medical research involving human subjects must conform to generally accepted 
scientific principles, be based on a thorough knowledge of the scientific literature, 
other relevant sources of information, and adequate laboratory and, as appropriate, 
animal experimentation. The welfare of animals used for research must be 
respected. 
22. 
The design and performance of each research study involving human subjects 
must be clearly described and justified in a research protocol. 
The protocol should contain a statement of the ethical considerations involved and 
should indicate how the principles in this Declaration have been addressed. The 
protocol should include information regarding funding, sponsors, institutional 
affiliations, potential conflicts of interest, incentives for subjects and information 
regarding provisions for treating and/or compensating subjects who are harmed as a 
consequence of participation in the research study. 
In clinical trials, the protocol must also describe appropriate arrangements for post-
trial provisions. 
Research Ethics Committees 
23. 
The research protocol must be submitted for consideration, comment, guidance 
and approval to the concerned research ethics committee before the study begins. 
This committee must be transparent in its functioning, must be independent of the 
researcher, the sponsor and any other undue influence and must be duly qualified. It 
must take into consideration the laws and regulations of the country or countries in 
which the research is to be performed as well as applicable international norms and 
standards but these must not be allowed to reduce or eliminate any of the 
protections for research subjects set forth in this Declaration. 
The committee must have the right to monitor ongoing studies. The researcher must 
provide monitoring information to the committee, especially information about any 
serious adverse events. No amendment to the protocol may be made without 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 60/94  
consideration and approval by the committee. After the end of the study, the 
researchers must submit a final report to the committee containing a summary of the 
study’s findings and conclusions. 
Privacy and Confidentiality 
24. 
Every precaution must be taken to protect the privacy of research subjects and 
the confidentiality of their personal information. 
Informed Consent 
25. 
Participation by individuals capable of giving informed consent as subjects in 
medical research must be voluntary. Although it may be appropriate to consult family 
members or community leaders, no individual capable of giving informed consent 
may be enrolled in a research study unless he or she freely agrees. 
26. 
In medical research involving human subjects capable of giving informed 
consent, each potential subject must be adequately informed of the aims, methods, 
sources of funding, any possible conflicts of interest, institutional affiliations of the 
researcher, the anticipated benefits and potential risks of the study and the 
discomfort it may entail, post-study provisions and any other relevant aspects of the 
study. The potential subject must be informed of the right to refuse to participate in 
the study or to withdraw consent to participate at any time without reprisal. Special 
attention should be given to the specific information needs of individual potential 
subjects as well as to the methods used to deliver the information. 
After ensuring that the potential subject has understood the information, the 
physician or another appropriately qualified individual must then seek the potential 
subject’s freely-given informed consent, preferably in writing. If the consent cannot 
be expressed in writing, the non-written consent must be formally documented and 
witnessed. 
All medical research subjects should be given the option of being informed about the 
general outcome and results of the study. 
27. 
When seeking informed consent for participation in a research study the 
physician must be particularly cautious if the potential subject is in a dependent 
relationship with the physician or may consent under duress. In such situations the 
informed consent must be sought by an appropriately qualified individual who is 
completely independent of this relationship. 
28. 
For a potential research subject who is incapable of giving informed consent, the 
physician must seek informed consent from the legally authorised representative. 
These individuals must not be included in a research study that has no likelihood of 
benefit for them unless it is intended to promote the health of the group represented 
by the potential subject, the research cannot instead be performed with persons 
capable of providing informed consent, and the research entails only minimal risk 
and minimal burden. 
29. 
When a potential research subject who is deemed incapable of giving informed 
consent is able to give assent to decisions about participation in research, the 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 61/94  
physician must seek that assent in addition to the consent of the legally authorised 
representative. The potential subject’s dissent should be respected. 
30. 
Research involving subjects who are physically or mentally incapable of giving 
consent, for example, unconscious patients, may be done only if the physical or 
mental condition that prevents giving informed consent is a necessary characteristic 
of the research group. In such circumstances the physician must seek informed 
consent from the legally authorised representative. If no such representative is 
available and if the research cannot be delayed, the study may proceed without 
informed consent provided that the specific reasons for involving subjects with a 
condition that renders them unable to give informed consent have been stated in the 
research protocol and the study has been approved by a research ethics committee. 
Consent to remain in the research must be obtained as soon as possible from the 
subject or a legally authorised representative. 
31. 
The physician must fully inform the patient which aspects of their care are related 
to the research. The refusal of a patient to participate in a study or the patient’s 
decision to withdraw from the study must never adversely affect the patient-physician 
relationship. 
32. 
For medical research using identifiable human material or data, such as research 
on material or data contained in biobanks or similar repositories, physicians must 
seek informed consent for its collection, storage and/or reuse. There may be 
exceptional situations where consent would be impossible or impracticable to obtain 
for such research. In such situations the research may be done only after 
consideration and approval of a research ethics committee. 
Use of Placebo 
33. 
The benefits, risks, burdens and effectiveness of a new intervention must be 
tested against those of the best proven intervention(s), except in the following 
circumstances: 
Where no proven intervention exists, the use of placebo, or no intervention, is 
acceptable; or Where for compelling and scientifically sound methodological reasons 
the use of any intervention less effective than the best proven one, the use of 
placebo, or no intervention is necessary to determine the efficacy or safety of an 
intervention  
and the patients who receive any intervention less effective than the best proven 
one, placebo, or no intervention will not be subject to additional risks of serious or 
irreversible harm as a result of not receiving the best proven intervention. 
Extreme care must be taken to avoid abuse of this option. 
Post-Trial Provisions 
34. 
In advance of a clinical trial, sponsors, researchers and host country 
governments should make provisions for post-trial access for all participants who still 
need an intervention identified as beneficial in the trial. This information must also be 
disclosed to participants during the informed consent process. 
Research Registration and Publication and Dissemination of Results 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 62/94  
35. 
Every research study involving human subjects must be registered in a publicly 
accessible database before recruitment of the first subject. 
36. 
Researchers, authors, sponsors, editors and publishers all have ethical 
obligations with regard to the publication and dissemination of the results of 
research. Researchers have a duty to make publicly available the results of their 
research on human subjects and are accountable for the completeness and 
accuracy of their reports. All parties should adhere to accepted guidelines for ethical 
reporting. Negative and inconclusive as well as positive results must be published or 
otherwise made publicly available. Sources of funding, institutional affiliations and 
conflicts of interest must be declared in the publication. Reports of research not in 
accordance with the principles of this Declaration should not be accepted for 
publication. 
Unproven Interventions in Clinical Practice 
37. 
In the treatment of an individual patient, where proven interventions do not exist 
or other known interventions have been ineffective, the physician, after seeking 
expert advice, with informed consent from the patient or a legally authorised 
representative, may use an unproven intervention if in the physician’s judgement it 
offers hope of saving life, re-establishing health or alleviating suffering. This 
intervention should subsequently be made the object of research, designed to 
evaluate its safety and efficacy. In all cases, new information must be recorded and, 
where appropriate, made publicly available. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 63/94  
Annex 2. List of Sites / Principal Investigators 
Attached in a separate document. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 64/94  
Annex 3. Sample Patient Information Sheet and Informed Consent 
Form 
Attached in a separate document. 
 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 65/94  
Annex 4. Preparation guide for plitidepsin infusion  
 
Preparation for PLITIDEPSIN intravenous infusion  
Appropriate aseptic techniques must be used. Aplidin 2 mg must be reconstituted and 
further diluted prior to infusion. 
Each vial of Aplidin 2 mg is reconstituted with 4 ml of the solution for reconstitution 
macrogolglycerol ricinoleate (polyoxyl 35 castor oil)/Absolute Ethanol/Water for 
Injection, 15%/15%/70% (v/v/v).  
 
Instructions for reconstitution 
A syringe should be used to inject the 4 ml of solution for reconstitution into the vial. 
Shake the vial until complete dissolution. The reconstituted solution results in a clear, 
colourless or slightly off-yellow solution and free of visible particles. 
This reconstituted solution contains 0.5 mg/ml of plitidepsin. It requires further dilution 
and is for single-use only.  
 
Instructions for dilution 
The reconstituted solution should be diluted with sodium chloride 9 mg/ml (0.9%) 
solution for infusion or glucose 50 mg/ml (5%) solution for infusion for administration as 
an intravenous infusion.  
For a dose of 1.5 mg plitidepsin: 3 ml of plitidepsin reconstituted solution should be 
withdrawn from the vial and added to a suitable infusion container containing 300 ml of 
sodium chloride 9 mg/ml (0.9%) or glucose 50 mg/ml (5%) solution for infusion. 
For a dose of 2 mg plitidepsin: 4 ml of plitidepsin reconstituted solution should be 
withdrawn from the vial and added to a suitable infusion container containing 400 ml of 
sodium chloride 9 mg/ml (0.9%) or glucose 50 mg/ml (5%) solution for infusion. 
For a dose of 2.5 mg plitidepsin: 5 ml of plitidepsin reconstituted solution should be 
withdrawn from the vial and added to a suitable infusion container containing 500 ml of 
sodium chloride 9 mg/ml (0.9%) or glucose 50 mg/ml (5%) solution for infusion. 
 
Instructions for IV administration 
Plitidepsin infusion solution should be administered by intravenous infusion via 
peripheral or central line using infusion sets with a 0.2 micron polyethersulfone (PES) or 
Nylon in-line filter to remove air bubbles caused by the surfactant and to minimise the 
risk of exposure to adventitious pathogens that may be introduced during solution 
preparation.  
Plitidepsin infusion solution should be administered within a maximum of 6 hours after 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 66/94  
preparation at room temperature and ambient indoor light. This 6 hours period should 
be inclusive of the product administration period.  
If the infusion solution is expected to be administered later than 6 h post dilution, the 
infusion solution must be protected from light. 
Infusion solutions for plitidepsin doses of 1.5, 2.0 and 2.5 mg should be IV infused 
through a pump device over one hour and half (1h, 30 min). 
Please refer to the clinical protocol for specific details regarding the appropriate 
dosage and infusion time to be used. 
 
Infusion systems COMPATIBILITIES 
Plitidepsin infusion solution should be administered with an infusion set and a sterile, 
non-pyrogenic, low-protein-binding filter (with a pore size of 0.2 µm) using an automated 
infusion pump. 
Plitidepsin infusion solution is compatible with: 
- 
Glass and polyolefin containers (polyethylene, polypropylene and mixtures). 
- 
PVC DEHP-free and polyolefin infusion sets (polyethylene, polypropylene and 
mixtures). 
- 
Polyethersulfone and nylon in-line filters with pore sizes of 0.2 µm. 
- 
Implantable venous access systems with titanium and plastic resin ports and 
with polyurethane or silicone intravenous catheters. Polyurethane intravenous 
catheters can be used as no adsorption has been observed under these 
circumstances. 
 
Incompatibilities  
Medical devices containing PVC plasticised with DEHP as the main component in 
contact with plitidepsin are not compatible due to leaching of DEHP. 
Polyurethane infusion lines are not compatible due to high adsorption values of 
plitidepsin to the plastic material.  
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 67/94  
Annex 5. CYP3A4 inducers and inhibitors  
INHIBITORS 
1ª2 
2B6 
2C8 
2C9 
2C19 
2D6 
2E1 
3ª4,5,7 
fluvoxamine 
ciprofloxacin 
cimetidine 
amiodarone 
fluoroquinolones 
furafylline 
interferon 
methoxsalen 
mibefradil 
thiotepa 
ticlopidine 
gemfibrozil 
trimethoprim 
glitazones 
montelukast 
quercetin 
fluconazole 
amiodarone 
fenofibrate 
fluvastatin 
fluvoxamine 
isoniazid 
lovastatin 
phenylbutazone 
probenecid 
sertraline 
sulfamethoxazole 
sulfaphenazole 
teniposide 
voriconazole 
zafirlukast 
PPIs: 
lansoprazole 
omeprazole 
pantoprazole 
rabeprazole 
chloramphenicol 
cimetidine 
felbamate 
fluoxetine 
fluvoxamine 
indomethacin 
ketoconazole 
modafinil 
oxcarbazepine 
probenecid 
ticlopidine 
topiramate 
bupropion 
fluoxetine 
paroxetine 
quinidine 
duloxetine 
terbinafine 
amiodarone 
cimetidine 
sertraline 
celecoxib 
chlorpheniramine 
chlorpromazine 
citalopram 
clemastine 
clomipramine 
cocaine 
diphenhydramine 
doxepin 
doxorubicin 
escitalopram 
halofantrine 
histamine H1 
receptor antagonists 
hydroxyzine 
levomepromazine 
methadone 
metoclopramide 
mibefradil 
midodrine 
moclobemide 
perphenazine 
ranitidine 
red-haloperidol 
ritonavir 
ticlopidine 
tripelennamine 
Diethyl- 
dithiocarbamate 
disulfiram 
HIV Antivirals: 
indinavir 
nelfinavir 
ritonavir 
clarithromycin 
itraconazole 
ketoconazole 
nefazodone 
saquinavir 
telithromycin 
aprepitant 
erythromycin 
fluconazole 
grapefruit juice 
verapamil 
diltiazem 
cimetidine 
amiodarone 
NOT azithromycin 
chloramphenicol 
ciprofloxacin 
delavirdine 
diethyldithiocarbamate 
fluvoxamine 
gesture 
imatinib 
mibefradil 
mifepristone 
norfloxacin 
norfluoxetine 
star fruit 
voriconazole 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 68/94  
 
INDUCERS 
1ª2 
2B6 
2C8 
2C9 
2C19 
2D6 
2E1 
3ª4,5,7 
broccoli 
Brussels sprouts 
char-grilled meat 
insulin 
methylcholanthrene 
modafinil 
nafcillin 
beta-
Naphthoflavone 
omeprazole 
tobacco 
phenobarbital 
rifampin 
rifampin 
rifampin 
secobarbital 
carbamazepine 
norethindrone 
NOT pentobarbital 
prednisone 
rifampin 
dexamethasone 
rifampin 
ethanol 
isoniazid 
HIV Antivirals: 
efavirenz 
nevirapine 
barbiturates 
carbamazepine 
efavirenz 
glucocorticoids 
modafinil 
nevirapine 
oxcarbazepine 
phenobarbital 
phenytoin 
pioglitazone 
rifabutin 
rifampin 
St John's wort 
troglitazone 
 
 
The list of potent CYP3A4 inducers and inhibitors can be found at the following Internet address: 
https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-
inducers 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 69/94  
Annex 6. NCI-CTCAE criteria 
 
The common terminology criteria for the classification of adverse events version 5.0 
(NCI-CTCAE v. 5.0) can be consulted at the following Internet address: 
 
 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_
Quick_Reference_8.5x11.pdf 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 70/94  
Annex 7: Plitidepsin safety information 
 
1. SAFETY 
 
1.1.1. Summary of adverse events in completed studies with plitidepsin as a 
single agent 
The following safety profile has been described from the doses and dosing schedules 
explored in 258 patients from Phase I studies (220 adults and 38 paediatric patients) 
and 417 patients from phase II studies treated in weekly and 2-weekly schedules with 
solid tumours and haematological diseases. 
Muscular adverse events 
Muscle pain (or myalgia), muscle weakness and increase in serum CPK (non-cardiac 
fraction) were the most common muscular adverse events (AEs), both as dose-limiting 
toxicity and at the recommended dose (RD) in the dose-escalating phase I studies. 
Muscle pain usually starts in the shoulders, neck or thighs, and typically appears about 
three weeks after the initiation of plitidepsin therapy. Muscle weakness, if it occurs, 
usually starts two weeks later and this is also the typical time interval before a rise in 
CPK levels occurs. Resolution of myalgia or muscle weakness was typically observed  
1-3 weeks after initiation of therapy. Myalgia and increases in CPK levels are not 
associated in all patients. Asymptomatic CPK increases may occur, as well as myalgia 
or muscle cramps without CPK elevation. No deaths occurred as consequence of 
muscular disorders. 
Muscular events are relatively common and have been also described in 49% of 
patients treated in phase II studies, sharing similar characteristics to those seen in 
phase I studies. Only 3.7% of patients in these studies experienced severe muscle-
related AEs. 
One episode of grade 4 rhabdomyolysis occurred concomitantly with influenza B virus 
infection, together with myalgia and CPK increase with preserved renal function in the 
APL-B-022-1 phase II study, in which plitidepsin was administered at 5 mg/m2 on day 1 
and day 15 with dexamethasone 40 mg on days 1, 8, 15 and 22 and bortezomib 
1.3 mg/m2 on days 1, 4, 8 and 11.  This AE occurred during cycle 2 and was 
considered to be related to plitidepsin, despite having other confounding factors, and it 
contributed to treatment discontinuation. 
Overall, muscle toxicity induced by plitidepsin is generally mild to moderate, 
manageable and reversible. 
The muscular AEs described in paediatric patients treated with plitidepsin do not seem 
to differ significantly to those seen in adults. 
Liver function tests 
The other relevant dose-limiting toxicity in adult patients treated in phase I studies was 
increase in liver enzymes, most frequently consisting of increased blood levels of 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 71/94  
transaminases that were mostly mild or moderate and not associated with jaundice. In 
phase II studies, these abnormalities were asymptomatic, reversible and non-
cumulative. 
Grade 3/4 transaminase increases were observed in 13 paediatric patients (42%), but 
all were transient and lasted for one or two treatment cycles.  
Gastrointestinal symptoms 
Despite maximum antiemetic prophylaxis, severe emesis was reported as a dose-
limiting toxicity in phase I studies. The use of prophylactic treatment for emesis resulted 
in a low incidence of grade 3/4 vomiting in phase II studies (2%), which was also the 
incidence of grade 3/4 nausea. 
Severe vomiting is rare in paediatric patients; a single grade 3 case has been found at 
a dose of 4 mg/m2.  
Grade 3 diarrhoea was reported as a dose-limiting toxicity in phase I studies, and in 1% 
of adult patients treated in phase II trials. Mild stomatitis was described in less than 3% 
of the patients. 
Haematological abnormalities 
Haematological abnormalities were not dose-limiting toxicities for any of the dosing 
regimens used in phase I studies. The most common grade 3/4 abnormalities reported 
in phase II studies are lymphopenia (18% of patients), anaemia (13%) and 
thrombocytopenia (11%). Grade 3/4 leukopenia and grade 3/4 neutropenia were 
observed in ≤ 7% of the patients. Bone marrow toxicity was more common in studies 
evaluating the 3-hour and 1-hour infusion schedules, due to the higher proportion of 
patients with haematological malignancies in these studies compared to study APL-B-
001-01, which was the only trial to assess the 24-hour infusion schedule. 
Most haematological abnormalities in paediatric patients were mild or moderate, and 
the most common are anaemia and lymphopenia. Severe abnormalities affected three 
patients (20%) and lasted for one or two treatment cycles. 
Constitutional symptoms 
Asthenia and fatigue are the most frequent constitutional adverse events in phase II 
studies (41%). Non-infectious pyrexia has been documented in 10% of patients. 
Hypersensitivity 
Twenty-two grade 3/4 hypersensitivity reactions have been reported among the 
population exposed to plitidepsin in clinical trials (n=860 patients; 2.6%). Eighteen of 
these cases occurred in the adult population (n=822 patients, 2.2%). All cases were 
rapidly reversible after stopping infusion and administering supportive measures. 
Currently, all new trials with plitidepsin at the dosages used in haematology-
oncology require premedication with histamine H1- and H2-receptor antagonists and 
glucocorticoids. 
Injection site reactions 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 72/94  
Injection site reactions after peripheral administration of plitidepsin were observed in 
23 adult patients (5%) in phase II studies; four of these reactions were severe, but none 
reached grade 4. 
During phase I clinical trials, two patients with central venous catheters experienced 
intense acute local pain during infusion. The catheters implanted in these patients 
contained polyurethane. A non-clinical study using different concentrations of plitidepsin 
and either silicone or polyurethane central catheters did not report any chemical 
incompatibility with either substance. In particular, there was no evidence of permeation 
of plitidepsin through the catheter wall. 
In case of extravasation, standard management is advised as soon as possible in order 
to limit tissue damage; no specific measures or antidotes are currently advised. 
Cardiac events 
A total of 67 cardiac events occurred in completed phase II studies (417 patients) with 
plitidepsin, particularly in three studies conducted in patients with pancreatic cancer, 
prostate cancer and myelofibrosis. None of the patients who experienced a cardiac 
adverse event, whether related, unrelated or unknown relationship, had a fatal outcome 
as a consequence. 
The most frequent type of cardiac adverse event in patients treated with plitidepsin (661 
patients) was “rhythm abnormalities” (n=46; 7.0%), with irregular supraventricular 
tachycardia (n=16; 2.4%) as the most common (atrial fibrillation accounting for most 
cases; n=12, 1.8%). No life-threatening ventricular arrhythmias were reported. The 
“myocardial injury” pattern (n=24; 3.6%) was relatively rare and included possible 
ischaemia-related 
events as 
well 
as other myocardial 
injury 
events. 
The 
“miscellaneous” category (n=10; 1.5%) included all other cardiac events that did not fit 
into the aforementioned categories. 
Relevant predisposing factors identified in univariate and multivariate analyses were 
mostly related to the patient’s baseline characteristics and disease-related 
characteristics rather than to drug exposure or treatment-related characteristics, and 
none of the pharmacokinetic parameters explored showed a correlation, although other 
potential relevant factors are yet to be identified and further characterised. 
In conclusion, cardiac safety does not seem to be of special concern with plitidepsin.  
 
1.1.2. APL-A-004-98 phase I trial evaluating plitidepsin from Day 1 to Day 5 in 
patients with solid tumours and low-intermediate grade non-Hodgkin 
lymphoma  
 
In the phase I study (APL-A-004-98) 37 patients were treated with plitidepsin once daily 
with a 1-hour infusion for 5 days.  

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 73/94  
Patients were included in 10 cohorts at different doses from 0.08 mg/m2 to 1.5 mg/m2, 
on days 1 to 5, the maximum tolerated dose was 1.35 mg/m2 (cohort IX) and the 
recommended dose 1.2 mg/m2 (cohort VIII). 
The tables below describe the events observed in the 19 patients in study APL-A-004-
98 treated at total doses of 0.5 mg to 2.5 mg separated into 5 groups.  
1) 0.5mg dose level (± 0.2mg). Total dose for 5 days 2.5 mg. N = 3 
2) 1mg dose level (± 0.2mg). Total dose for 5 days 5mg. N = 5 
3) 1.5mg dose level (± 0.2mg). Total dose for 5 days 7.5 mg. N = 4 
4) 2 mg dose level (± 0.2mg). Total dose for 5 days 10 mg. N = 3 
5) 2.5 mg dose level (± 0.2mg). Total dose for 5 days 12.5 mg. N = 4 
 
The proposed doses for the clinical trial of plitidepsin in COVID-19 would be 1.5, ( total 
dose for 3 days of 4.5 mg)  2 mg for 3 days (total dose for 3 days of 6 mg) and 2.5 mg 
for 3 days (total dose for 3 days of 7.5 mg), thus, the dose levels would be between 
dose level 1 and 3 of the phase I study (APL-A-004-98). Data related to these dose 
levels are highlighted in the tables in this document to facilitate review.  
The baseline characteristics of the 19 patients treated at the proposed doses are 
described below, as well as the therapies previously received for their oncological 
pathology.  
Table 1. Age by dose level. 
 
Age (years) 
N 
Median 
Min. 
Max. 
DL 0.4-0.6 mg/day (n = 3) 
3 
44.0 
38 
49 
DL 0.9-1.2 mg/day (n = 5) 
5 
62.0 
45 
66 
DL 1.4-1.7 mg/day (n = 4) 
4 
56.5 
40 
73 
DL 1.9-2.2 mg/day (n = 3) 
3 
52.0 
43 
69 
DL 2.4-2.7 mg/day (n = 4) 
4 
54.0 
24 
66 
Total 
19 
52.0 
24 
73 
DL, dose level; Max., Maximum; Min., Minimum. 
 
Table 2. ECOG PS by dose level. 
PS
DL 0.4-
0.6 mg/day 
(n=3) 
DL 0.9-
1.2 mg/day 
(n=5) 
DL 1.4-
1.7 mg/day 
(n=4) 
DL 1.9-
2.2 mg/day 
(n=3) 
DL 2.4-
2.7 mg/day 
(n=4) 
Total 
N 
N 
N 
N 
N 
N 
% 
0 
. 
1 
1 
. 
1 
3 
15.8 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 74/94  
1 
3 
3 
1 
2 
3 
12 
63.2 
2 
. 
1 
2 
1 
. 
4 
21.1 
DL, dose level; ECOG; Eastern Cooperative Oncology Group; PS, performance status. 
 
Table 3. Tumour type by dose level. 
Tumour type 
DL 0.4-
0.6 mg/day  
(n=3) 
DL 0.9-
1.2 mg/day  
(n=5) 
DL 1.4-
1.7 mg/day  
(n=4) 
DL 1.9-
2.2 mg/day  
(n=3) 
DL 2.4-
2.7 mg/day  
(n=4) 
Total 
N 
N 
N 
N 
N 
N
% 
Colorectal 
1 
1 
. 
1 
. 
3 
15.8
Sarcoma 
1 
. 
1 
. 
1 
3 
15.8
SCLC 
. 
. 
. 
1 
2 
3 
15.8
Head & Neck 
. 
. 
1 
1 
. 
2 
10.5
NSCLC 
. 
. 
1 
. 
1 
2 
10.5
Breast 
. 
1 
. 
. 
. 
1 
5.3 
Gastric 
. 
1 
. 
. 
. 
1 
5.3 
Mesothelioma 
. 
1 
. 
. 
. 
1 
5.3 
Ovary 
1 
. 
. 
. 
. 
1 
5.3 
Renal 
. 
1 
. 
. 
. 
1 
5.3 
Thyroid-non MTC
. 
. 
1 
. 
. 
1 
5.3 
DL, dose level; MTC, medullary thyroid carcinoma; NSCLC, Non-small cell lung cancer; SCLC, Small cell lung 
cancer. 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 75/94  
Table 4. Number of chemotherapy lines per dose level.  
 
DL 0.4-
0.6 mg/day  
(n=3) 
DL 0.9-
1.2 mg/day 
(n=5) 
DL 1.4-
1.7 mg/day  
(n=4) 
DL 1.9-
2.2 mg/day  
(n=3) 
DL 2.4-
2.7 mg/day  
(n=4) 
Total 
N 
N 
N 
N 
N 
N 
% 
0 
. 
1 
2 
. 
. 
3 
15.8 
1 
. 
. 
. 
1 
. 
1 
5.3 
2 
1 
1 
1 
2 
2 
7 
36.8 
3 or more 
2 
3 
1 
. 
2 
8 
42.1 
Total 
3 
5 
4 
3 
4 
19 
100.0 
DL, dose level. 
 
Table 5. Antineoplastic therapies used by dose level. 
 
DL 0.4-
0.6 mg/day 
(n = 3) 
DL 0.9-
1.2 mg/day 
(n = 5) 
DL 1.4-
1.7 mg/day 
(n = 4) 
DL 1.9-
2.2 mg/day 
(n = 3) 
DL 2.4-
2.7 mg/day 
(n = 4) 
Total 
N 
N 
N 
N 
N 
N 
Nitrogen mustard analogues 
2 
1 
1 
1 
2 
7 
Folic acid analogues 
1 
. 
. 
. 
. 
1 
Pyrimidine analogues 
1 
4 
. 
2 
1 
8 
Vinca alkaloids and analogues 
. 
2 
1 
1 
3 
7 
Podophyllotoxin derivatives 
1 
2 
1 
1 
3 
8 
Taxanes 
1 
2 
. 
. 
2 
5 
Actinomycines 
. 
. 
. 
. 
1 
1 
Anthracyclines and rel. substances 
1 
2 
1 
1 
2 
7 
Other cytotoxic antibiotics 
. 
1 
. 
. 
. 
1 
Platinum compounds 
1 
2 
2 
2 
4 
11 
Other antineoplastic agents 
2 
2 
1 
1 
. 
6 
DL, dose level. 
 
These are cancer patients with heterogeneous solid tumours. The most frequent is 
colorectal cancer, sarcoma and SCLC. Most of the patients were admitted with ECOG 
1/2 and the majority had received 3 or more previous lines. The most frequently 
received treatments were platinum analogues, pyrimidines such as 5-Fluorouracil, and 
podophyllotoxin derivatives such as etoposide. 
Table 6 describes the events observed in these 15 patients, regardless of the 
relationship with treatment.  

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 76/94  
Table 6. Adverse events regardless of relationship with treatment (worst grade per 
patient). 
Category/
MedDRA code 
 
Plitidepsin (mg/day) dose level 
DL 0.4-0.6 mg/day 
(n = 3) 
DL 0.9-
1.2 mg/day  
(n=5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-2.2 mg/day 
(n = 3) 
DL 2.4-2.7 mg/day 
(n = 4) 
NCI-CTCAE grade
NCI-CTCAE 
grade 
NCI-CTCAE grade NCI-CTCAE grade
NCI-CTCAE grade
1 2 3
Total 
1 2 3 4
Total 1 2 3 4
Total 
1 2 3 4
Total 
1 2 3 4
Total 
n n n n
% 
N n n n n
% 
n n n n n
% 
n n n n n
% 
n n n n n
% 
Allergic reactions
Hypersensitivity NOS 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
1
.
1
25 
Rhinitis allergic NOS 
1
.
.
1
33.3 
. 1 . . 1
20 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Ear and labyrinth disorders
Inner ear disorder NOS 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Cardiac Disorders
Hypertension NOS 
.
.
.
.
. 
. 1 . . 1
20 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Oedema NOS 
.
.
1 1
33.3 
1 . . . 1
20 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Endocardial ischaemia 
.
.
.
.
. 
1 . . . 1
20 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Endocrine and Nutrition Disorder
Cushingoid 
.
1
.
1
33.3 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
General disorders and administration site conditions
Fatigue
.
2 1 3
100
. 2 1 1 4
80
1 2 .
.
3
75
1 1 . 1 3
100
2 .
2
.
4
100
Influenza-like illness 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Pyrexia 
1
.
.
1
33.3 
1 1 . . 2
40 
1
.
.
.
1
25 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Rigors 
.
.
.
.
. 
1 . . . 1
20 
.
.
.
.
.
. 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Gastrointestinal disorders
Anorexia
1 1
.
2
66.7
1 2 . . 3
60
1 1 .
1 3
75
1 1 1 . 3
100
1 2
.
.
3
75
Constipation
.
1 1 2
66.7
3 1 . . 4
80
.
1 .
.
1
25
1 1 1 . 3
100
1 .
1
.
2
50
Diarrhoea NOS
2 1
.
3
100
2 . . . 2
40
1
.
.
.
1
25
2 .
.
. 2
66.7
.
.
1
.
1
25
Dry mouth 
.
.
.
.
. 
. 1 . . 1
20 
.
1 .
.
1
25 
1 1 .
. 2
66.7 1 .
.
.
1
25 
Dysgeusia 
.
1
.
1
33.3 
1 . . . 1
20 
1
.
.
.
1
25 
.
.
.
.
.
. 
1 .
.
.
1
25 
Dyspepsia 
.
.
.
.
. 
. . . . .
. 
1
.
.
.
1
25 
2 .
.
. 2
66.7 
.
.
.
.
. 
. 
Dysphagia 
.
.
.
.
. 
. . . . .
. 
.
.
.
1 1
25 
.
.
.
.
.
. 
1 .
.
.
1
25 
Nausea
3
.
.
3
100
3 . 1 . 4
80
2 1 .
.
3
75
3 .
.
. 3
100
3 1
.
.
4
100
Stomatitis 
1
.
.
1
33.3 
. . . . .
. 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 77/94  
Category/
MedDRA code 
 
Plitidepsin (mg/day) dose level 
DL 0.4-0.6 mg/day 
(n = 3) 
DL 0.9-
1.2 mg/day  
(n=5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-2.2 mg/day 
(n = 3) 
DL 2.4-2.7 mg/day 
(n = 4) 
NCI-CTCAE grade
NCI-CTCAE 
grade 
NCI-CTCAE grade NCI-CTCAE grade
NCI-CTCAE grade
1 2 3
Total 
1 2 3 4
Total 1 2 3 4
Total 
1 2 3 4
Total 
1 2 3 4
Total 
n n n n
% 
N n n n n
% 
n n n n n
% 
n n n n n
% 
n n n n n
% 
Vomiting NOS
1 1
.
2
66.7
2 . . . 2
40
1
.
.
.
1
25
1 1 .
. 2
66.7
1 1
.
.
2
50
Renal and urinary disorders
Urinary frequency 
.
.
1 1
33.3 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Urinary retention 
1
.
.
1
33.3 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Incontinence NOS 
.
1
.
1
33.3 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Haemorrhage
Haemoptysis 
.
.
.
.
. 
. . . . .
. 
1
.
.
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Infections and infestations
Infection NOS 
.
.
.
.
. 
. 1 . . 1
20 
1
.
.
.
1
25 
1 .
.
. 1
33.3 
. 2
.
.
2
50 
Lymphoedema NOS 
.
.
.
.
. 
. . 1 . 1
20 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Metabolic and Nutrition Disorders
Hypercalcaemia 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Nervous system disorders
Anxiety NEC 
1
.
.
1
33.3 
. 2 . . 2
40 
3
.
.
.
3
75 
2 .
.
. 2
66.7 1 1
.
.
2
50 
Confusion 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Depression NOS 
.
.
.
.
. 
. 1 . . 1
20 
.
1 .
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Dizziness (excl. vertigo) 
.
.
.
.
. 
. . . . .
. 
1
.
.
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Insomnia 
.
1
.
1
33.3 
. 1 . . 1
20 
.
1 .
.
1
25 
.
.
.
.
.
. 
. 2
.
.
2
50 
Loss of consciousness 
.
.
.
.
. 
. . . . .
. 
1
.
.
.
1
25 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Peripheral 
motor 
neuropathy 
.
.
.
.
. 
1 1 1 . 3
60 
.
.
.
.
.
. 
.
. 2 . 2
66.7 
.
.
.
.
. 
. 
Peripheral 
sensory 
neuropathy 
.
.
.
.
. 
3 1 1 . 5 100
.
1 .
.
1
25 
1 1 .
. 2
66.7 1 1
.
.
2
50 
Peroneal nerve palsy 
.
.
.
.
. 
. . . . .
. 
.
1 .
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Tremor 
.
.
.
.
. 
. . . . .
. 
1
.
.
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Vertigo 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Eye disorder
Photopsia 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Musculoskeletal and connective tissue disorders

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 78/94  
Category/
MedDRA code 
 
Plitidepsin (mg/day) dose level 
DL 0.4-0.6 mg/day 
(n = 3) 
DL 0.9-
1.2 mg/day  
(n=5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-2.2 mg/day 
(n = 3) 
DL 2.4-2.7 mg/day 
(n = 4) 
NCI-CTCAE grade
NCI-CTCAE 
grade 
NCI-CTCAE grade NCI-CTCAE grade
NCI-CTCAE grade
1 2 3
Total 
1 2 3 4
Total 1 2 3 4
Total 
1 2 3 4
Total 
1 2 3 4
Total 
n n n n
% 
N n n n n
% 
n n n n n
% 
n n n n n
% 
n n n n n
% 
Neuropathic pain 
.
.
1 1
33.3 
. . . . .
. 
.
.
.
.
.
. 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Arthralgia 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
1 .
1
.
2
50 
Chest pressure sensation 
.
.
.
.
. 
. . . . .
. 
.
1 .
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Headache NOS 
.
.
.
.
. 
1 . . . 1
20 
1
.
.
.
1
25 
1 .
.
. 1
33.3 
. 1
.
.
1
25 
Myalgia
1
.
.
1
33.3
1 . . 1 2
40
.
.
.
.
.
.
1 1 .
. 2
66.7
.
.
1
.
1
25
Pain NOS 
.
.
.
.
. 
. 1 . . 1
20 
.
.
.
.
.
. 
. 1 .
. 1
33.3 
.
.
.
.
. 
. 
Pleuritic pain 
.
.
.
.
. 
1 . . . 1
20 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Proctalgia 
.
1
.
1
33.3 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
1
.
1
25 
Tumour pain 
1
.
2 3
100 
. 1 1 1 3
60 
2
. 1
.
3
75 
. 1 1 . 2
66.7 
. 1 2
.
3
75 
Respiratory, thoracic and mediastinal disorders
Cough 
.
.
.
.
. 
. 2 . . 2
40 
1 1 .
.
2
50 
2 .
.
. 2
66.7 
. 2
.
.
2
50 
Dysphonia 
.
.
.
.
. 
1 . . . 1
20 
.
.
.
.
.
. 
.
.
.
.
.
. 
. 1
.
.
1
25 
Dyspnoea NOS 
.
.
.
.
. 
. 1 2 . 3
60 
.
3 1
.
4
100 
. 1 1 . 2
66.7 
. 1 2 1 4
100 
Skin and subcutaneous tissue disorders
Radiation 
recall 
neck 
reaction 
.
.
.
.
. 
. . . . .
. 
1
.
.
.
1
25 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Alopecia 
.
.
.
.
. 
1 . . . 1
20 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Flushing 
.
.
.
.
. 
. . . . .
. 
.
1 .
.
1
25 
.
.
.
.
.
. 
1 .
.
.
1
25 
Injection site reaction NOS .
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Pruritus NOS 
1
.
.
1
33.3 
. . . . .
. 
.
.
.
.
.
. 
.
.
.
.
.
. 
.
.
.
.
. 
. 
Rash NOS 
.
1
.
1
33.3 
1 . . . 1
20 
1
.
.
.
1
25 
.
.
.
.
.
. 
1 .
.
.
1
25 
Vulvar laceration 
.
.
.
.
. 
. . . . .
. 
.
.
.
.
.
. 
1 .
.
. 1
33.3 
.
.
.
.
. 
. 
Data shown are n of patients (%).  
DL, dose level; MedDRA, Medical Dictionary for Regulatory Activities; NCI-CTCAE, National Cancer Institute Common 
Terminology Criteria for Adverse Events; NEC, not elsewhere classifiable; NOS, not otherwise specified. 
The most frequent adverse event, regardless of its relationship with the medication, 
was fatigue, which was present in 17 of the 19 patients treated.  
Grade 3/4 fatigue occurred in six patients distributed in all the cohorts. In four of these 
events, the relationship with treatment was considered unlikely and in two, it was 
deemed possible. One of these grade 3 fatigue events in the 2.5 mg cohort was 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 79/94  
considered DLT (dose limiting toxicity). This patient belonged to the 1.35 mg/m2 cohort, 
which was the cohort considered MTD (maximum tolerated dose) and that would be 
equivalent to a total dose of 12.15 mg. Four of these patients had fatigue and/or 
dyspnoea at the start of the study. For further details see annex 1.  
The next most frequent events regardless of relationship were gastrointestinal events, 
which occurred at all dose levels.  Nausea and vomiting occurred in 17 and 9 patients, 
respectively, mostly grade 1 and 2, with only one grade 3 case of nausea in the 1 mg 
cohort. From the 1.2 mg/m2 dose (equivalent to approximately 2 mg/day), antiemetic 
treatment was added as prophylaxis in this and higher levels.  
Constipation was an event described in 12 patients. These are mostly patients with 
concomitant treatment with opioids.  Three of these 12 events were grade 3, and 
occurred in the 0.5 mg, 2 mg, and 2.5 mg cohorts, respectively. Two were considered 
unlikely and one was deemed possible. They appeared in C4, C1 and C5, respectively. 
One of the patients had baseline grade 2 constipation.  
Diarrhoea occurred in nine patients, mostly grade 1 and 2, only one case grade 3 in the 
2.5 mg cohort, with onset during cycle 1 with possible relationship to treatment. The 
event lasted 3 days and was considered DLT. This patient belonged to the 1.35 mg/m2 
cohort, the cohort considered MTD.  
The relationship-independent cardiac events observed in these cohorts are limited to 
oedema (2 patients) and hypertension (1 patient). A single case of unrelated grade 3 
oedema occurred at the 0.5 mg dose level, in cycle 3, in a patient with baseline G1 
oedema and a history of hypothyroidism.  
The unrelated grade 1 endocardial ischaemia event at the 1 mg dose level took place in 
a patient who already presented this event at enrolment. 
There are no reported cases of rhythm disturbances on electrocardiogram, LVEF 
alterations or sudden deaths. 
The most frequent muscular events regardless of relationship with treatment was the 
myalgia observed in six patients, two of them grade 3-4. Both were deemed to have an 
unlikely relationship with treatment and with normal CPK. The grade 3 event occurred 
in a patient in the 2.5 mg cohort (MTD) who had grade 1 basal myalgia. The grade 4 
event occurred in a patient in the 1 mg cohort with a history of baseline grade 3 
sensory-motor neuropathy and treatment with dexamethasone at enrolment. See 
details of the six patients in annex 2.  
The most frequent neurological events regardless of relationship in these patients 
include peripheral sensory-motor neuropathy in the 1 mg cohort. Five patients 
presented motor neuropathy, three of them G3, two of whom had G1 and G2 symptoms 
prior to treatment and the third patient who had neuropathic pain.   

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 80/94  
Ten patients presented sensory neuropathy regardless of treatment, one of them G3. 
This was the same patient with G3 motor neuropathy, who had entered the study with 
both G3 events (protocol deviation, not eligible).   
It must be noted this population are patients with solid tumours previously treated with 
neurotoxic chemotherapeutic agents such as platins, taxanes and vinca alkaloids.  All 
except one had baseline neuropathy, so all events except one were considered 
unrelated or unlikely to be related to treatment. See details in annex 3.  
Regarding the pulmonary events observed, they were generally grade 2 cough and 
dyspnoea, except for two cases of grade 3 dyspnoea. In the 1 mg cohort, one patient 
had grade 3 dyspnoea only on day 1 of cycle 2 of a total of 6 cycles. In the 1.5 mg 
cohort, one patient presented grade 3 dyspnoea. This patient was diagnosed with 
rhabdomyosarcoma with lung lesions and baseline pleural effusion, as well as baseline 
grade 2 dyspnoea. No bronchospasm events were reported at the proposed dose 
levels. 
Table 7 details the adverse events described as related to treatment or unknown 
relationship with treatment. These categories include: unlikely, probable, possible and 
certainly related. 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 81/94  
Table 7. Adverse events related to treatment or with unknown relationship with 
treatment (worst grade per patient). 
Category/ 
MedDRA code 
DL 0.4-0.6 mg/day 
(n=3) 
DL 0.9-1.2 mg/day 
(n=5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-2.2 mg/day 
(n=3) 
DL 2.4-2.7 mg/day
(n=4) 
NCI-CTCAE grade 
NCI-CTCAE grade 
NCI-CTCAE grade
NCI-CTCAE grade 
NCI-CTCAE grade
1
2
3
Total
1
2
3
4
Total
1
2
3
Total
1
2
3
4
Total
1
2
3
Total
n
n
n
n
%
n
n
n
n
n
%
n
n
n
n
%
n
n
n
n
n
%
n
n
n
n
%
Allergic reaction 
Rhinitis 
allergic 
NOS 
1
. 
. 
1 
33.3 
. 
1
. 
. 
1 
20
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Ear and labyrinth disorders 
Inner 
ear 
disorder NOS 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 33.3
. 
. 
. 
. 
. 
Cardiac Disorders 
Hypertension 
NOS 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
20
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
General disorders and administration site conditions 
Fatigue 
. 
2
1
3 
100 
. 
2
1
1
4 
80
1
2 
. 
3 
75
1
. 
. 
1 
2 66.7 2
. 
2
4
100
Influenza-like 
illness 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
. 
1 33.3
. 
. 
. 
. 
. 
Pyrexia 
1
. 
. 
1 
33.3 
. 
1
. 
. 
1 
20
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Gastrointestinal Disorders 
Anorexia 
. 
1
. 
1 
33.3 
1
2
. 
. 
3 
60
. 
. 
. 
. 
. 
1
. 
. 
. 
1 33.3 1
2
. 
3
75 
Constipation 
. 
. 
1
1 
33.3 
1
1
. 
. 
2 
40
. 
1 
. 
1 
25
1
. 
1 
. 
2 66.7 1
. 
1
2
50 
Diarrhoea NOS 
1
1
. 
2 
66.7 
2
. 
. 
. 
2 
40
1
. 
. 
1 
25
1
. 
. 
. 
1 33.3
. 
. 
1
1
25 
Dry mouth 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
20
. 
. 
. 
. 
. 
1
. 
. 
. 
1 33.3 1
. 
. 
1
25 
Dysgeusia 
1
. 
. 
1 
33.3 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
1
. 
. 
1
25 
Dyspepsia 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
25
1
. 
. 
. 
1 33.3
. 
. 
. 
. 
. 
Nausea 
3
. 
. 
3 
100 
3
. 
1
. 
4 
80
2
. 
. 
2 
50
2
. 
. 
. 
2 66.7 3
1
. 
4
100
Stomatitis 
1
. 
. 
1 
33.3 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Vomiting NOS 
1
1
. 
2 
66.7 
1
. 
. 
. 
1 
20
1
. 
. 
1 
25
1
1
. 
. 
2 66.7
. 
1
. 
1
25 
Infections and infestations 
Infection NOS 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
2
. 
2
50 
Nervous system disorders 
Anxiety NEC 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
20
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
1
25 
Depression NOS
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Dizziness (excl. 
vertigo) 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 82/94  
Category/ 
MedDRA code 
DL 0.4-0.6 mg/day 
(n=3) 
DL 0.9-1.2 mg/day 
(n=5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-2.2 mg/day 
(n=3) 
DL 2.4-2.7 mg/day
(n=4) 
NCI-CTCAE grade 
NCI-CTCAE grade 
NCI-CTCAE grade
NCI-CTCAE grade 
NCI-CTCAE grade
1
2
3
Total
1
2
3
4
Total
1
2
3
Total
1
2
3
4
Total
1
2
3
Total
n
n
n
n
%
n
n
n
n
n
%
n
n
n
n
%
n
n
n
n
n
%
n
n
n
n
%
Peripheral motor 
neuropathy 
. 
. 
. 
. 
. 
. 
1
1
. 
2 
40
. 
. 
. 
. 
. 
. 
. 
1 
. 
1 33.3
. 
. 
. 
. 
. 
Peripheral 
sensory 
neuropathy 
. 
. 
. 
. 
. 
1
1
1
. 
3 
60
. 
1 
. 
1 
25
1
1
. 
. 
2 66.7 1
. 
. 
1
25 
Eye disorders 
Photopsia 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
. 
1 33.3
. 
. 
. 
. 
. 
Musculoskeletal 
and connective 
tissue disorders
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Neuropathic pain . 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 33.3
. 
. 
. 
. 
. 
Arthralgia 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
1
25 
Chest 
pressure 
sensation 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Headache NOS 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
1
. 
1
25 
Myalgia 
1
. 
. 
1 
33.3 
. 
. 
. 
1
1 
20
. 
. 
. 
. 
. 
1
1
. 
. 
2 66.7
. 
. 
1
1
25 
Pain NOS 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
20
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Tumour pain 
1
. 
. 
1 
33.3 
. 
. 
. 
1
1 
20
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Respiratory, thoracic and mediastinal disorders 
Cough 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
20
. 
1 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Dyspnoea NOS 
. 
. 
. 
. 
. 
. 
1
1
. 
2 
40
. 
2 
1 
3 
75
. 
1
. 
. 
1 33.3
. 
. 
. 
. 
. 
Skin and subcutaneous tissue disorders 
Radiation 
recall 
neck reaction 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Flushing 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1 
. 
1 
25
. 
. 
. 
. 
. 
. 
1
. 
. 
1
25 
Injection 
site 
reaction NOS 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
1
. 
. 
. 
1 33.3
. 
. 
. 
. 
. 
Pruritus NOS 
1
. 
. 
1 
33.3 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
. 
Rash NOS 
. 
. 
. 
. 
. 
1
. 
. 
. 
1 
20
1
. 
. 
1 
25
. 
. 
. 
. 
. 
. 
1
. 
. 
1
25 
Data shown are n of patients (%). 
DL, dose level; MedDRA, Medical Dictionary for Regulatory Activities; NCI-CTCAE, National Cancer Institute Common Terminology 
Criteria for Adverse Events; NEC, not elsewhere classifiable; NOS, not otherwise specified. 
 
Table 8 describes the haematological changes observed.  
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 83/94  
Table 8. Haematological abnormalities regardless of relationship: worst grade per 
patient per dose level.  
Plitidepsin (mg/day) dose level
DL 0.4-0.6 mg/day 
(n = 3) 
DL 0.9-1.2 mg/day 
(n = 5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-2.2 mg/day 
(n = 3) 
DL 2.4-2.7 mg/day 
(n = 4) 
NCI-CTCAE grade NCI-CTCAE grade NCI-CTCAE grade NCI-CTCAE grade NCI-CTCAE grade
1 2 3
Total 
1
2
3
Total 
1
2
3
Total 
1 2 3
Total 
1
2
3
Total 
n n n n
%
n n n n
%
n n n n
%
n n n n
%
n n n n
%
WBC 
.
.
.
.
. 
1
. 
. 1
20.0 
1
. 
. 1
25.0 
.
.
.
.
. 
.
.
.
. 
. 
Haemoglobin 1 1
.
2
66.7
1
3
.
4
80.0
1
1
1
3
75.0
1 1 1 3
100.0
2
1
.
3
75.0
Platelets 
.
.
.
.
. 
. 
. 
. 
. 
. 
.
. 
. 
. 
. 
.
.
.
.
. 
.
.
.
. 
. 
Neutrophils 
.
.
.
.
. 
. 
. 
. 
. 
. 
.
. 
. 
. 
. 
.
.
.
.
. 
.
.
.
. 
. 
Lymphocytes .
2 1 3
100.0
.
3
1
4
80.0
.
.
3
3
75.0
.
.
2 2
66.7
.
1
2
3
75.0
Data shown are n of patients (%). 
DL, dose level; NCI-CTCAE, National Cancer Institute Common Terminology Criteria for Adverse Events; WBC, 
white blood cells. 
 
The most frequent haematological abnormality was anaemia, which was present in 15 
of the 19 patients treated. Mostly grade 1 and 2 with grade 3 values found at higher 
doses. Both patients with grade 3 anaemia had grade 2 and grade 3 anaemia prior to 
initiation of treatment. 
Lymphopenia was the second most frequent haematological disorder observed in 15 of 
the 19 patients treated at these five dose levels. Grade 3 lymphopenia was observed in 
nine patients, distributed in all cohorts, with predominance in the cohorts of 1.5 mg 
(n=3), 2 mg (n=2) and 2.5 mg (n=3).  
Of the nine patients with G3 lymphopenia, seven already had G2 or G3 prior to day 1 of 
cycle 1. 
Annex 4 details the graphs of the evolution of lymphopenia in these nine patients.  
Table 9 describes the observed biochemical changes.  
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 84/94  
Table 9. Biochemical abnormalities regardless of relationship: worst grade per 
patient per dose level. 
Plitidepsin (mg/ day) dose level
DL 0.4-0.6 mg/day 
(n=3) 
DL 0.9-1.2 mg/day
 (n=5) 
DL 1.4-1.7 mg/day 
(n = 4) 
DL 1.9-
2.2 mg/day 
(n=3) 
DL 2.4-
2.7 mg/day 
(n=4) 
NCI-CTCAE grade
NCI-CTCAE grade
NCI-CTCAE grade
NCI-CTCAE 
grade 
NCI-CTCAE 
grade 
1
Total
1
2
Total
1
Total
1
2 3 Total
1
2
Total
n n
%
n
n n
%
n
n
%
n
n n
n
%
n n n
%
 
 
 
 
 
 
 
 
 
 
 
 
 
Bilirubin .
.
. 
. 
. .
. 
. 
.
. 
1 
. .
1 
33.3 1 . 1 25.0
AP 
2 2
66.7 
3 
1 4
80.0 
2 
2
50.0 
1 
. 1
2 
66.7 .
.
.
. 
AST
3 3
100.0
3
. 3
60.0
2
2
50.0
1
1 .
2
66.7 1 . 1 25.0
ALT
2 2
66.7
2
. 2
40.0
1
1
25.0
2
. .
2
66.7 . 1 1 25.0
LDH 
.
.
. 
1 
. 1
100.0 
. 
.
. 
. 
. .
. 
. 
.
.
.
. 
Data shown are n of patients (%). 
ALT, alanine aminotransferase; AP, alkaline phosphatase; AST, aspartate aminotransferase; CPK, creatine 
phosphokinase; DL, dose level; LDH, Lactate dehydrogenase; NCI-CTCAE, National Cancer Institute Common 
Terminology Criteria for Adverse Events. 
 
No relevant biochemical changes were observed in the described cohorts. Most of them 
were grade 1 and grade 2. 
CPK elevation was described in two patients, both grade 1 and without associated 
musculoskeletal symptoms. In both patients the CPK elevation was reversible. One of 
the patients had this grade 1 symptom prior to the start of treatment.  
Elevation of AST/ALT transaminases was described in 11 and 8 patients, respectively, 
all being grade 1 except one grade 2 AST and one grade 2 ALT. 
 
CONCLUSIONS - DOSES EQUIVALENT TO THOSE OF THE COVID-19 TRIAL: 
The 12 patients treated with dose levels equivalent to those proposed in the COVID-19 
trial are patients with solid tumours, most of them previously treated with several 
previous lines of antineoplastic drugs.  
The most frequently observed events related to plitidepsin in the doses equivalent to 
those proposed in the COVID-19 trial are fatigue and gastrointestinal events: 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 85/94  
• Grade 3/4 fatigue occurred in three patients. Two of them  reported dyspnoea or 
fatigue at enrolment. These grades 3/4 were observed in the 0.5 and 1 mg 
cohorts.  
• The gastrointestinal events observed are mostly grade 1 and 2, taking into 
account that no antiemetic treatment was added in these dose cohorts.  
Cardiac events were not relevant, with no presence of rhythm disturbances on the ECG 
and with only one related grade 2 hypertension event in the 1 mg cohort. 
Three muscle events, two grade 1 (one in the 0.5 cohort and one in 1 mg cohort) and one 
grade 4, were observed in the 1 mg cohort. These myalgias did not show CPK 
elevation. The relationship of these events with the treatment was unlikely. 
Neurological events were generally grade 1 and 2. Only two grade 3 cases were 
observed, a sensory and motor neuropathy in the 1 mg cohort in patients previously 
treated with neurotoxic agents and mostly with a previous history of sensory-motor 
neuropathy.  
In relation to haematological disorders, anaemia and lymphopenia (see graphs of 
evolution of lymphopenia in annex) are the most common events, mostly already 
present prior to the start of treatment. 
Regarding biochemical alterations, no severe transaminase elevations or CPK 
elevations are observed with this regimen. 
 
 
 
ANNEXES: 
Annex 1. Description of patients with grade 3/4 fatigue.  
Patient 
Number of 
antineoplastic 
lines 
Daily total 
dose level 
Event 
Relationship 
Baseline event 
Start 
#105 
2 
0.5 mg 
Fatigue G3 
Unlikely 
NO 
Cycle 4 
#108 
NR 
1 mg 
Fatigue G3 
Possible 
Dyspnoea G2 
Cycle 1 
#208 
3 
1 mg 
Fatigue G4 
Unlikely 
Fatigue G2 
Dyspnoea G2 
Cycle 1 
#119 
2 
2 mg 
Fatigue G4 
Unlikely 
Fatigue G2 
Dyspnoea G2 
Cycle 1 
#118* 
3 
2.5 mg 
Fatigue G3 
Possible 
NO 
Cycle 1 
#120 
2 
2.5 mg 
Fatigue G3 
Unlikely 
Fatigue G1 
Dyspnoea G2 
Cycle 6 
*Fatigue considered DLT  
G, grade. 
NR: not reported 
 
 
 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 86/94  
Annex 2. Description of patients with myalgias. 
Patient 
Daily total 
dose level 
Event 
CPK 
Relationship 
Start date 
Resolution date 
#204 
0.5 mg 
Myalgia G1 
Grade 0 
Unlikely 
12/091999  
(Cycle 1) 
NR 
#207 
1 mg 
Myalgia G1 
Grade 1, from 
baseline 
Not related 
20/01/2000 
(Cycle 1) 
NR 
#208a 
1 mg 
Myalgia G4 
Grade 0 
Unlikely 
NR 
(Cycle 1) 
NR 
#114 
2 mg 
Myalgia G2 
Grade 0 
Unlikely 
01/09/2000 
(Cycle 1) 
NR 
#216 
2 mg 
Myalgia G1 
Grade 0 
Possible 
16/05/2001 
(Cycle 2) 
05/06/2001 
#120b 
2.5 mg 
Myalgia G3 
Grade 0 
Unlikely 
26/11/2001 
(Cycle 1) 
28/11/2001 
a Grade 3 baseline sensory-motor neuropathy. Dexamethasone at enrolment. 
b Grade 1 myalgia, baseline 
G, grade; NR, not reported. 
 
 
 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 87/94  
Annex 3. Description of patients with sensory and/or motor neuropathy. 
 
Patient Dosage level
daily total 
Tumour type
Previous 
neurotoxic 
treatment 
Baseline 
neurological 
events 
Event 
Relationship 
Start date
Resolution 
date 
#207 
1 mg 
Gastric 
Adenoca. 
YES 
Grade 1 SN Grade 2 MN
Possible 
04/02/2000
10/02/2000 
Grade 1 SN
Unlikely 
NR 
NR 
#108 
1 mg 
Mesothelioma
NR 
Grade 1 MN 
Grade 1 SN 
Grade 1 MN
Not related 
Baseline 
NR 
Grade 2 SN
Unlikely 
12/02/2000
12/02/2000 
#208a 
1 mg 
Breast cancer
YES 
Grade 3 MN 
Grade 3 SN 
Grade 3 MN
Unlikely 
Baseline 
NR 
Grade 3 SN
Unlikely 
Baseline 
NR 
#209 
1 mg 
Renal cancer
YES 
Grade 1 SN 
Grade 1 SN
Not related 
Baseline 
NR 
#109 
1 mg 
Colorectal 
Adenoca. 
YES 
Grade 1 SN 
Grade 1 SN
Not related 
Baselineb 
06/03/2000 
#112 
1.5 mg 
Non-MTC 
NR 
Grade 1 SN 
Grade 2 SN
Not related 
12/06/2000
12/07/2000 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 88/94  
 
 
 
 
 
 
 
 
#114 
 
2 mg 
Head and 
neck 
YES 
NO 
 
Grade 3 MN
Unlikely 
23/09/2000c
NR 
Grade 2 SN
Unlikely 
01/09/2000
NR 
#119 
2 mg 
SCLC 
YES 
Grade 1 MN Grade 3 MN
Not related 
NR 
NR 
Grade 1 SN
Unlikely 
14/06/2001
15/06/2001 
#120 
2.5 mg 
SCLC 
YES 
Grade 1 SN 
Grade 1 SN
Unlikely 
Baseline 
NR 
#215 
2.5 mg 
NSCLC 
YES 
Grade 1 SN 
Grade 2 SN
Unrelated 
NR 
NR 
a G3 motor and sensory neuropathy from baseline. Protocol deviation.  
b Baseline Day 1 of Cycle 1 24/01/2000. 
c Cycle 2. This patient withdrew from the study due to progression, last administration 22/9/2000.  
Ca, cancer; MTC, medullary thyroid carcinoma; NR, not reported; SN, sensory neuropathy; MN, motor neuropathy; NSCLC, 
non-small cell lung cancer; SCLC, small cell lung cancer. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 89/94  
Annex 4. Lymphocyte evolution graphs.  
The lymphocyte evolution/days of treatment graphs for in the four patients who 
presented grade 3 lymphopenia in the 2 cohorts previously proposed (1 mg, 1.5 mg 
total daily dose) are shown below. It can be seen that most of them entered the study 
with G2 and G3 lymphopenia. 
1 mg cohort (n=1) 
Graph 1 Patient #1 
 
1.5 mg cohort (n=3) 
Graph 2 Patient #2 
 
            
 
 
 
 
 
 
 
 
Grade 4   
Grade 3   
Grade 2   
10^9/L
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
0
10
20
30
40
50
60
70
Patient
108
Grade 4   
Grade 3   
Grade 2   
10^9/L
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
0
10
20
30
40
50
Patient
112

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 90/94  
Graph 3 Patient #3 
 
           G3 lymphopenia was observed in this patient prior to C1D1 administration.  
           
 Graph 4 Patient #4 
 
 
 
 
 
Grade 4   
Grade 3   
Grade 2   
10^9/L
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Patient
210
Grade 4   
Grade 3   
Grade 2   
10^9/L
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
2.2
2.4
2.6
2.8
3.0
0
10
20
30
40
Patient
211

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 91/94  
  
2. PHARMACOKINETICS 
A population pharmacokinetic analysis was carried out in 303 patients with cancer, 
including 182 patients with relapsed/refractory multiple myeloma[9]. These patients 
received plitidepsin at doses ranging from 2.0 to 5.0 mg/m² weekly or every two weeks. 
An extended population PK dataset including 248 additional patients with plitidepsin 
concentrations analysed with the initial bioanalytical method was used to explore the 
effect of renal and hepatic impairment. 
Absorption 
Plitidepsin is administered intravenously and therefore it is immediately and completely 
bioavailable. 
Distribution 
The pharmacokinetics of plitidepsin is characterised by a 3-compartment model. 
Plitidepsin is distributed largely outside the blood volume, with a total volume of 
distribution in plasma of approximately 600 l. Blood cells are an important distribution 
compartment of plitidepsin. The RBC/plasma partitioning equilibrium is mostly reached 
during the infusion and the extent of partitioning can be considered linear up to the 
mean maximal concentration of the compound. In the blood, approximately 20% is 
present in plasma and 80% in blood cells. In plasma, approximately 98% is bound to 
proteins (ranging from 87% to 96% and 72% to 81% for albumin and α-1-acid-
glycoprotein, respectively), regardless of plitidepsin concentration over the 5 to 
100 ng/ml range. 
Biotransformation 
In vitro studies indicate that plitidepsin undergoes microsomal-mediated metabolism to 
some extent, while the contribution of phase II metabolism and plasma degradation is 
negligible. Experiments performed with human microsomes (both sexes) and selective 
chemical inhibitors of CYP isoforms pointed to CYP3A4 as the main isoform involved in 
the phase I metabolism of plitidepsin, followed by CYP2A6 and CYP2E1. 
Plitidepsin has moderate plasma clearance in humans, suggesting the involvement of 
plasma esterases as an additional metabolic pathway. Owing to its distribution in blood 
cells, unchanged plitidepsin was the major circulating component (95% of radioactivity 
in the systemic circulation) in vivo in patients with cancer who received a single dose of 
[14C]-plitidepsin (2.2 mg). In plasma, the radioactivity measured was less explained by 
the parent compound as time after dosing increases, resulting in 30% of the 
administered dose, thus suggesting gradual formation of metabolites. None of them 
was present at a relevant concentration relative to unchanged plitidepsin or total 
radioactivity in plasma. 
The potential of plitidepsin to inhibit the enzymatic activities of the main CYP isoforms 
(CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and CYP3A4) 
in vivo is considered to be remote because the lowest estimated in vitro IC50 was far 
greater than the maximum plasma concentration (Cmax) values achieved in patients. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 92/94  
No induction potential for plitidepsin at 10 ng/ml (for CYP3A4, 1A2 or 2B6) or at 
100 ng/ml (for CYP3A4 or 1A2), although a moderate induction (approx. 2.3-fold) was 
reported for CYP2B6. Consequently, the induction potential of plitidepsin on CYP2B6 
cannot be ruled out. 
Elimination 
Plitidepsin has a low plasma clearance of 5.4 l/h (coefficient of variation [CV] 46%) and 
a long terminal half-life of approximately 6 days. No significant accumulation of 
plitidepsin is observed with biweekly administration. 
Plitidepsin is eliminated primarily by biliary excretion. The transport protein involved in 
the excretion is presently unknown, although preclinical in vitro studies indicate that 
plitidepsin is transported by the P-glycoprotein (Pgp). 
Linearity/non-linearity 
Studies in patients have demonstrated linear pharmacokinetics in the 2.0 to 5.0 mg/m2 
dose range.  
Special populations 
Elderly 
Population pharmacokinetic analyses included patients with ages ranging from 19 to 
86 years old and indicate that age does not influence plitidepsin clearance (plasma 
exposure). 
Renal impairment 
A small fraction of the plitidepsin dose is excreted in the urine, mostly as unchanged 
substance, thus indicating minimal effect of renal impairment on the excretion of 
plitidepsin. In addition, the plasma exposure of plitidepsin is not dependent on the 
glomerular filtration rate (GFR) of patients with mild (GFR of 60-89 ml/min, n=228), 
moderate (GFR of 30-59 ml/min, n=86) or severe (15-29 ml/min, n=5) renal impairment. 
Therefore, adjustments to the starting dose in patients with mild or moderate renal 
impairment are not required. However, the number of patients with severe renal 
impairment is too limited (n=5) to reach a firm conclusion. The pharmacokinetics of 
plitidepsin in patients with end-stage renal disease (GFR of < 15 ml/min) has not been 
studied, so there are no data on the safety and efficacy of plitidepsin in this subgroup of 
patients. 
Hepatic impairment  
A formal clinical study to evaluate the impact of hepatic impairment on the 
pharmacokinetics of plitidepsin was not performed. 
Most plitidepsin is eliminated via the liver; patients with cancer who received a single 
dose of [14C]-plitidepsin (2.2 mg) showed that 70% of total radioactivity was recovered 
in faeces. 
Population pharmacokinetic analyses included patients with mild hepatic impairment 
(n=92, total bilirubin > 1 to ≥ 1.5 x ULN or AST > ULN) and indicate that mild hepatic 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 93/94  
impairment does not influence plitidepsin clearance (plasma exposure). Insufficient data 
are available for patients with moderate (n=3) or severe (n=1) hepatic impairment. 
In addition, plitidepsin clearance is no different in patients with and without liver 
metastases. Plitidepsin should not be used in patients with impaired hepatic function. 
Other intrinsic factors 
Population pharmacokinetic analyses indicate that body weight (44 to 137 kg) and sex 
do not have a clinically relevant effect on plitidepsin clearance in adult patients. No 
differences were found in plitidepsin pharmacokinetics between patients of European 
and Asian descent. 
 
2.1. 
Administration of plitidepsin in special populations   
Elderly 
No age-related dose adjustment is required for plitidepsin in elderly patients.  
In the APL-C-001-09 phase III trial at a dose of 5 mg/m2 on days 1 and 15, myalgia, 
muscular weakness and hyperglycaemia were the most reported adverse drug 
reactions in patients aged ≥ 65 years treated with plitidepsin plus dexamethasone. 
Among patients who experienced hyperglycaemia, 80% had a previous medical history 
of diabetes mellitus. Myalgia and hyperglycaemia were reported as serious adverse 
drug reactions in 1.3% and 5.1% of elderly patients, respectively. No serious adverse 
drug reaction of muscular weakness was observed. None of these events led to 
treatment discontinuation or death. 
Renal impairment 
No dose adjustment is necessary in patients with mild or moderate renal impairment. 
Caution is recommended in patients with severe renal impairment (GFR 15-29 ml/min), 
as experience in this population is limited. Patients with end-stage renal disease 
(GFR < 15 ml/min) have not been included in any clinical study with plitidepsin. There 
are no data on the safety and efficacy of plitidepsin in patients with end-stage renal 
disease. 
Hepatic impairment 
Plitidepsin has not been formally studied in patients with impaired hepatic function. 
Patients with AST > 3 x ULN and/or bilirubin > ULN were not allowed to participate in 
most clinical studies with plitidepsin. Since most administered plitidepsin is eliminated 
by biliary excretion, patients with impaired hepatic function (AST > 3 x ULN and/or 
bilirubin > 1 x ULN) should not be treated with plitidepsin. 

Protocol code: APLICOV-PC (APL-D-002-20) 
 
EudraCT No.: 2020-001993-31 
Version 7.0, dated 29/ Sep/2020 
 
 
 
CONFIDENTIAL 
 
 
Page 94/94  
 
3. References 
 
1. 
Losada, A., et al., Translation Elongation Factor eEF1A2 is a Novel Anticancer Target 
for the Marine Natural Product Plitidepsin. Sci Rep, 2016. 6: p. 35100. 
2. 
Mateyak, M.K. and T.G. Kinzy, eEF1A: thinking outside the ribosome. J Biol Chem, 
2010. 285(28): p. 21209-13. 
3. 
Zhou, B., et al., The nucleocapsid protein of severe acute respiratory syndrome 
coronavirus inhibits cell cytokinesis and proliferation by interacting with translation 
elongation factor 1alpha. J Virol, 2008. 82(14): p. 6962-71. 
4. 
Ma-Lauer, Y., et al., Influences of cyclosporin A and non-immunosuppressive 
derivatives on cellular cyclophilins and viral nucleocapsid protein during human 
coronavirus 229E replication. Antiviral Res, 2020. 173: p. 104620. 
5. 
Cervantes-Barragan, L., et al., Dendritic cell-specific antigen delivery by coronavirus 
vaccine vectors induces long-lasting protective antiviral and antitumor immunity. mBio, 
2010. 1(4). 
6. 
PharmaMar, data on file; VPT1992/2014. 
7. 
PharmaMar, data on file; VPT2678/2014. 
8. 
Maroun, J.A., et al., Phase I study of Aplidine in a dailyx5 one-hour infusion every 3 
weeks in patients with solid tumors refractory to standard therapy. A National Cancer 
Institute of Canada Clinical Trials Group study: NCIC CTG IND 115. Ann Oncol, 2006. 
17(9): p. 1371-8. 
9. 
Population Pharmacokinetic Analysis of Plitidepsin (Aplidin®) in Cancer Subjects. CPR, 
2016. 
10. 
Gelderblom, H., et al., Cremophor EL: the drawbacks and advantages of vehicle 
selection for drug formulation. Eur J Cancer, 2001. 37(13): p. 1590-8.