A Multicenter, Adaptive, Randomized, Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for Hospitalized Patients With Acute Respiratory Distress Syndrome Associated With COVID-19 (Trial H2: Remdesivir)
Phase: PHASE3
Conditions: Covid19
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

A Multicenter, Adaptive, 
Randomized, Blinded Controlled 
Trial of the Safety and Efficacy of 
Investigational Therapeutics for 
Hospitalized Patients with Acute 
Respiratory Distress Syndrome 
Associated with COVID-19 
Appendix H1: Aviptadil
This document applies to both substudies
 Version 3.0
 08 March 2022 
 NCT06729593
(Master protocol: NCT04843761)

TESICO Appendix H1: Aviptadil version 3.0, 08 March 2022 
1 
The content of this appendix is confidential and should only be viewed by persons covered by the 
relevant CDA between NIAID and the collaborating companies.   
This appendix provides detailed information pertaining to the study of this investigational agents. If 
not stated otherwise in this appendix, the text in the TESICO master protocol provides the approach 
that will be taken to study this agent.   
The principal difference of the study of this agent with the master protocol is that it will be studied, in 
part, using a 2x2 factorial design with remdesivir. Study objectives, randomization and data analyses 
take this factorialization into account and are described in Appendix H2 for remdesivir. 
At the outset of this study, there will not be a shared placebo with another investigational agent. 
1. Introduction and rationale for studying aviptadil
Vasoactive Intestinal Peptide (VIP; aviptadil is the generic name for the synthetic peptide) is a 28-
amino acid signaling peptide that belongs to the glucagon-secretin superfamily. VIP is an abundant 
biologically active peptide endogenous in humans as well as in other species. It is produced by 
neurons in the peripheral and central nervous system, by endocrine cells such as pituitary 
lactotrophs, cells of the endocrine pancreas as well as T-lymphocytes, and B-lymphocytes. This 
natural peptide is one of the signal molecules of the neuroendocrine-immune network. VIP is an 
inhibitory neurotransmitter that binds G-protein coupled receptors named VPAC1 and VPAC2, 
generally leading to an increase in cAMP in target cells. Originally described in the intestinal tract,1 it 
is expressed widely in the body, with multiple functions. The lung is the primary location of binding of 
VIP, as evidenced by radiolabeled VIP perfusion experiments (within 30 minutes, 45% of all infused 
VIP is bound in the lung, with minimal binding in other organs2). Cells expressing VIP receptors in the 
lung include vascular and bronchial smooth muscle cells as well as alveolar type 2 cells (ATII).3 
Critically, ATII cells are also a primary target for SARS-CoV2, the virus causing COVID-19. 
The effects of aviptadil are pleiotropic, with key effects being (1) antiviral effects, (2) immune 
modulation, (3) increase in ATII surfactant production, (4) ATII cell protection, (5) smooth muscle 
relaxation (leading to bronchodilation and vasodilation), (6) decrease in platelet activation. 
Antiviral effects. VIP is known to decrease HIV production within monocytes,4,5 which drove interest in 
evaluating antiviral properties for SARS-CoV2. In a series of experiments, Temerozo and colleagues 
established that VIP decreased viral replication within infected Calu-3 cells (an immortalized lung 
cancer cell line), plus increased monocyte and Calu-3 viability after SARS-CoV2 infection.6 These 
experiments also established that VIP treatment decreased the production of inflammatory cytokines 
within SARS-CoV2-infected monocytes.6 
Immune modulation. VIP has multiple immune-modulatory effects.7 In the lung, VIP decreases 
inflammation through multiple interdependent mechanisms, including inhibition of effector T cells and 
supplementation of regulatory T cells, with an associated decrease in local cytokines, as observed in 
sarcoid.8 In a rat ATII cell model of smoke-associated lung inflammation, VIP decreased inflammation 
and proteinase activity.3 Similar pre-clinical data in sepsis demonstrated decreases in TNFa and 
TGFb with VIP administration.9-11 In terms of post-inflammatory injury, VIP has been shown to 
decrease myofibroblast proliferation in cell models.12 
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Surfactant production. In a lung explant model, VIP directly increased phosphatidylcholine production 
via PKC and C-Fos mechanisms.13,14 In a similar model, VIP increased surfactant protein A 
production in ATII cells.15 
 
ATII cell protection. VIP prevents apoptosis of ATII cells via multiple mechanisms including Granzyme 
and Fas-ligand.16,17 In multiple animal models of ARDS, VIP is protective against acute lung injury.17-
21 
 
Smooth muscle relaxation. VIP is a non-adrenergic pulmonary and systemic vasodilator that in ex vivo 
pulmonary artery is substantially more potent at muscle relaxation than prostacyclin.22 The increases 
in muscle relaxation are independent of the endothelium. VIP is also a direct bronchodilator based on 
relaxation of bronchial smooth muscle.23 In a cat bronchoconstriction model, intravenous (but not 
inhaled) VIP resulted in significant bronchodilation.24 
 
Platelet effects. VIP inhibits pro-inflammatory platelet activation via inhibition of platelet activating 
factor.25 
 
These mechanistic observations in cell and animal models have been corroborated in various human 
observations in a variety of conditions, including ARDS and COVID-19. 
 
Clinical experience with aviptadil 
 
Non-randomized data in other disease states 
 
Sarcoidosis. Twenty patients with chronic sarcoidosis were treated with nebulized aviptadil, which 
was associated with increases in regulatory T cells and decreases in macrophage activation.8 There 
were no important safety concerns. 
 
Checkpoint inhibitor pneumonitis. Inhaled VIP was used successfully to treat pneumonitis caused by 
checkpoint inhibitor therapy in a patient with advanced melanoma. The pneumonitis had recurred 
after an initial course of steroid therapy, and VIP was used in hopes of avoiding a second course of 
steroids.26 The patient recovered from the pneumonitis, and no safety concerns were identified. 
 
Pulmonary hypertension. Twenty patients with pulmonary hypertension (PH) of various etiologies 
received 100mcg of inhaled VIP during right heart catheterization, with an immediate decrease in 
vascular resistance. Among patients with lung disease as the cause of PH, increases in oxygen 
saturation were observed.27 Similar results were observed in a smaller cohort of PH patients.28 No 
important safety concerns were identified. 
 
Non-randomized data in ARDS and COVID-19 
 
Currently, there are multiple case reports and case series of patients with either septic ARDS or 
COVID-19 ARDS who have been treated with intravenous VIP or in whom biological samples have 
been collected. 
 
In the mid-2000s, Youssef, Said and colleagues treated 8 patients with septic ARDS with VIP. They 
used 50 pmol/kg/hr in 5 patients, of whom one had hypotension requiring decrease to 25 pmol/kg/hr. 
The other three patients received 100 pmol/kg/hr, in whom one patient required temporary reduction 
(to 85 pmol/kg/hr) for hypotension. The target dosing duration was 6 or 12 hours. (An intended 
increase to 150 pmol/kg/hr was not undertaken because the senior author retired.) All but 2 patients 
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survived their ARDS.29 VIP infusion appeared safe and feasible, and mortality appeared to be on the 
low end for septic ARDS, suggesting possible clinical efficacy. 
 
During the COVID-19 pandemic, Youssef and colleagues studied 21 patients receiving intravenous 
aviptadil under an expanded access program (EAP). The patients receiving aviptadil were compared 
to non-randomized concurrent controls who were either admitted by physicians who were not 
investigators on the VIP trial or in the two weeks before and after this cohort was assembled. Four-
week survival in the EAP cohort (primarily but not exclusively patients with immune suppression or 
undergoing ECMO therapy who were excluded from a concurrent randomized trial) was 90%; 4 of 
5 ECMO patients were “successfully decannulated.” All patients were treated with glucocorticoids, 
18 of 21 patients were treated with tocilizumab, and 6 of 21 were treated with remdesivir before VIP 
infusion. Hypotension occurred in 5 of 21 (24%) of patients receiving VIP infusion, primarily among 
those on ECMO and/or receiving vasopressors. In the other 16 patients, blood pressure was stable or 
improved during aviptadil infusion. Diarrhea was present in 4 of 21 patients; prophylactic or 
therapeutic loperamide was used in 86% of patients. The survival among the non-randomized 
concurrent controls was substantially lower, suggesting possible clinical efficacy. Approximately 
200 patients have been studied under this EAP at multiple centers in the United States as of 
December 16, 2020. Reports from the full EAP cohort are pending. 
 
In terms of observational data, Temerozo et al studied 24 patients with severe COVID-19 (i.e., 
requiring ICU admission), demonstrating significantly higher endogenous VIP levels among survivors 
than non-survivors.5 In this observational cohort, no aviptadil was administered. 
 
Randomized data in COVID-19. A randomized controlled trial (NCT04311697) has enrolled 
196 patients (2:1 randomization) using the same intravenous dosing schedule as the Phase 1 trial in 
septic ARDS patients and the COVID-19 EAP experience. Final results from this trial are pending; 
preliminary results suggested survival of 71–72% at 28 days in both groups with exploratory signals 
suggesting possible benefit in time to recovery in the largest subgroup, those receiving high-flow 
nasal cannula at randomization. The DSMB did not identify any important safety concerns during 
interim monitoring; hypotension has been uncommon and has not generally resulted in changes to 
aviptadil infusion. Mild-moderate diarrhea occurred in approximately a third of patients. 
 
 
1.1 Potential risk and benefits from aviptadil  
 
Primary effects of VIP infusion, generally dose dependent, include facial flushing, changes in heart 
rate, decrease in blood pressure, and diarrhea. Effects on renal function and fluid status are transient 
and mild, with the possible exception of patients with advanced liver disease. 
 
Facial flushing is common with VIP and is not dangerous. It is generally well tolerated and resolves 
when the VIP infusion is stopped. It is caused by dilation of cutaneous vasculature. 
 
Increases in heart rate are common and rarely clinically significant. The increase in heart rate 
primarily reflects changes in cardiac preload and an adrenergic response to decreased afterload.  
 
The primary known risk of intravenous VIP infusion is of decreased blood pressure. The clinician 
investigators with the most experience with the agent report (personal communication) approximately 
25% incidence of hypotension during infusion in ICU patients with shock present before initiation of 
VIP. These rates are observed in treatment protocols that do not exceed 150 pmol/kg/hr. When 
present, the decrease in blood pressure appears to be approximately 10% of mean arterial pressure 
(e.g., a decrease from 80 mmHg to 72 mmHg). In other settings (generally healthy volunteers at 
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higher doses), a modest decrease in mean arterial pressure in most (but not all) studied populations 
has been observed. This is generally in the range of 10–15% decrease in MAP. The findings in 
normal volunteers are presented in Table 1.  
 
Table 1. Hypotensive Effects Observed During VIP Infusion in Phase 1 or Similar Experience 
Patient type 
Patients infused 
with VIP 
Rate in 
pmol/kg/hr 
Blood pressure 
change 
Study 
Stable patients 
with stable cancer 
79 
300 pmol bolus 
(not adjusted for 
body mass) 
7mm Hg nominal 
decrease 
(probably not 
significant) 
Virgolini et al2 
Healthy 
volunteers 
6 
400 pmol/kg/hr 
MAP decrease by 
12% 
Frase et al30 
Healthy 
volunteers 
6 
180 pmol/kg/hr 
MAP decrease by 
15% 
Erikkson et al31 
Healthy 
volunteers 
8 
360 pmol/kg/hr 
MAP decrease by 
5–10% 
Unwin et al32 
Healthy 
volunteers 
4 
198 pmol/kg/hr 
DBP decrease by 
15%/stable SBP  
Domschke et al33 
Healthy 
volunteers 
6 
360 pmol/kg/hr 
MAP decrease by 
7% 
Calam et al34 
Healthy 
volunteers 
22 
400 pmol/kg/hr 
No change in 
blood pressure 
Krejs et al35 
Healthy 
volunteers 
2 
720 pmol/kg/hr 
No change in 
blood pressure 
Unwin et al36 
Outpatient 
asthmatics 
7 
360 pmol/kg/hr 
DBP decrease by 
10%/stable SBP 
Morice et al37 
Cirrhotic patients 
6 
360 pmol/kg/hr 
BP decrease by 
10% 
Calam et al38 
BP: blood pressure; MAP: mean arterial pressure; DBP: diastolic blood pressure; VIP: vasoactive 
intestinal peptide 
 
The infusion rates used in this study are substantially lower than those used in healthy volunteers. 
Relevant to the proposed population for TESICO is the experience with aviptadil administered to 
patients with ARDS at infusion rates ranging from 50 to 150 pmol/kg/hr. In patients with septic ARDS, 
approximately 25% of patients encountered some decrease in blood pressure during infusion.29 In the 
EAP experience with aviptadil for COVID-19 (unpublished data supplied to investigators by 
NeuroRX), which included patients on vasopressors, ECMO, CRRT, approximately 25% had 
hypotension during infusion, while the balance of patients either had stable or increased blood 
pressure, including several patients who weaned off vasopressors during aviptadil infusion. In the 
preliminary results of the randomized trial, hypotension was observed in 25.2% of aviptadil patients 
and 18.5% of placebo patients. 
 
Diarrhea, which can lead to bicarbonate wasting and metabolic acidosis, was observed in 5 healthy 
volunteers receiving 400 pmol/kg/hr of VIP, reproducing the syndrome of “pancreatic cholera” 
associated with VIP-producing tumors.39 Youssef and colleagues report (personal communication) 
that the diarrhea observed during infusion rates of 50–150 pmol/kg/hr are easily managed with 
enteral loperamide. 
 
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Hemoconcentration, presumably through diarrhea, has been observed with VIP infusion, primarily 
manifesting as a modest increase in hematocrit or serum albumin concentration. While urine output 
may decrease during aviptadil infusion, the glomerular filtration rate (GFR) does not.34 The 
hemoconcentration does not persist after discontinuation of aviptadil infusion. 
 
More detailed information about the known and expected benefits and risks and reasonably expected 
adverse events of aviptadil may be found in the Investigator’s Brochure(s) (IB) and Participant 
Information Leaflet. 
 
Given the high morbidity and mortality of COVID-19 ARDS, the short half-life of aviptadil, the close 
monitoring and early detection of abnormal vital signs present in the settings where the trial will be 
performed, and the ease of management of expected adverse events in care environments treating 
critically ill patients, the overall benefit-risk assessment of this study is considered favorable in the 
clinical settings where the trial will be performed. 
 
1.2 Motivation for agent selection by the ACTIV Agent Selection Committee (ASC) and Trial 
Oversight Committee (TOC) 
 
The ACTIV Agent Prioritization Committee (APC) Subteam reviewed the NeuroRX agent aviptadil 
(VIP) and voted in favor of the agent proceeding into ACTIV-3, and the TOC endorsed that 
recommendation.  NeuroRX’s aviptadil was supported because it binds to VPAC receptors on the 
pulmonary Alveolar Type II cell that is a selective target of SARS-CoV-2. The agent has suggested 
positive effects on lung function and clinical outcomes in small clinical studies of ARDS.  
  
While the reviewers noted the mechanism of action in SARS-CoV-2 infection is not yet well 
elucidated, some published preclinical tests show a ~50% reduction in viral replication in infected 
Calu-3 cells, suggesting partial efficacy as an antiviral5; however, the agent has shown promising 
effects in clinical trials against SARS-CoV-2.  In addition, the company provided a preprint of in vitro 
data, which suggests that this compound is efficacious as an antiviral.  The Subteam also noted that 
its target within the host is a good candidate for preventing fluid accumulation and inflammation in the 
lung, which is a major factor in COVID-19, and the natural endogenous peptide is increased in 
survivors of severe COVID-19. Aviptadil is available in both IV and nebulized formulations, but the 
inhaled version may cause some nasal and respiratory epithelium degeneration; thus, the IV 
formulation is preferred for this trial. At the time of APC review, the Phase 2a trial of 50–150 
pmol/kg/hr was close to completion—the company shared promising interim results from that trial. 
  
Based on the positive response to the data presented for the agent, the Subteam discussed which 
ACTIV trial platform should test it. The agent already has safety data from indications other than 
COVID-19, which could allow it to proceed to a Phase III trial. The Subteam selected ACTIV-3 for 
effective testing of the agent, and the agent would fill a void in the more severely ill patients screened 
for that trial that are not eligible for the neutralizing antibodies currently being tested in the trial.   
  
Finally, the APC Subteam found the manufacturing and scalability strategy for aviptadil sufficient for 
the full trial and beyond.  
  
Statement regarding plans for licensure: NeuroRx, Inc., has filed IND 149,152 for Intravenous Use of 
Aviptadil with the FDA and been awarded Fast Track designation.  FDA has indicated in writing that 
all preclinical data have been submitted that are required for NDA and that an NDA would be 
accepted based on efficacy as demonstrated in adequately controlled studies. EMA licensure will be 
sought by Relief Therapeutics AG (Geneva, Switzerland). 
 
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1.3 Justification for dose selected  
 
Given temporal constraints imposed by the pandemic, selection of the dose and duration of therapy 
are based on preliminary observations from multiple sources, which together provide a reasonable 
basis for the dose and duration selected. Lines of evidence include pre-clinical observations, 
observations from cell models of SARS-CoV-2 infection, known serum pharmacokinetics, rapid 
trafficking to and accumulation in the target organ, lung, and an observational human cohort 
suggesting relevant differences in serum VIP concentrations between survivors and non-survivors.  
 
Half life of VIP. The well-established serum half-life of VIP, due to degradation by serum peptidases, 
is 1 minute. In dogs, only repeat daily administration for 4 weeks was associated with effects that 
persisted for more than a few minutes after discontinuation of the infusion. The precise elimination 
dynamics from lung are not well established, but empirically, the accumulation of aviptadil in lung 
increases over time. In addition, concentrations in serum slowly increase over the course of a 
prolonged infusion.  
 
Observations from cell models of SARS-CoV-2 infection. Temerozo and colleagues identified in 
multiple cell models of SARS-CoV-2 infection that a VIP concentration of approximately 10nM 
provided maximal anti-viral and cell-protective effects, especially in lung cells (Calu-3 cells) and 
monocytes. In some additional experiments, concentrations of 1nM demonstrated a relevant effect.6  
 
An observational cohort of patients with COVID-19 ARDS. In a complementary observational cohort 
of 24 patients with severe COVID-19, Temerozo and colleagues demonstrated that VIP levels of 10–
12 pg/ml were present among non-survivors (N=13), as opposed to 20 pg/ml among survivors 
(N=11). While these data are observational and do not provide causal evidence of the effect of 
~10 pg/ml change in serum VIP levels, they nevertheless suggest the possibility that increases in VIP 
levels may be clinically relevant.  
 
Expected blood and/or lung levels achieved with a given infusion. The infusion rates necessary to 
achieve serum levels have been demonstrated in pre-clinical experiment in dogs. Unverferth and 
colleagues infused 0.02 and 0.05 mcg/kg/min (360 and 900 pmol/kg/hr, respectively) in 12 dogs. The 
dogs had a baseline VIP blood level below the level of detection (<50 pg/ml), and the two infusion 
rates achieve blood levels of 540 pg/ml and 1200 pg/ml, respectively.40 Extrapolating from these 
experiments (assuming a consistent relationship between infusion rate and resulting blood 
concentrations), 50 pmol/kg/hr would be expected to result in 71 pg/ml, and 100 pmol/kg/hr would 
result in 143 pg/ml in this model. These blood levels are substantially higher than those observed 
among survivors in the Temerozo cohort and also substantially higher than the difference between 
survivor and non-survivor VIP levels. 
 
In a 10-hour infusion of 400 pmol/kg/hr of VIP among healthy volunteers, blood VIP levels rose over 
the course of infusion, achieving 782 pg/ml by the end of the 10-hour infusion.39 Extrapolating this 
observed relationship between infusion rate and resulting blood concentrations to a 100 pmol/kg/hr 
infusion rate, we anticipate a blood level of 195 pg/ml by the 10-hour timepoint. 
 
Following an intravenous dose, aviptadil rapidly distributes into tissue with approximately 45% of the 
dose distributing to the lungs within 30 minutes of administration.2 The apparent volume of distribution 
following a 300 pmol dose is 135 mL/kg. Therefore, an initial aviptadil plasma concentration is 
estimated to be 0.03 nM for a 70 kg patient for which 45% of the plasma concentration is anticipated 
to be distributed into the lungs. Assuming dose-proportionality and drug-tissue accumulation, where 
dose escalation proportionally increases drug exposure, a 100 pmol/kg/hr aviptadil dose over 
12 hours is estimated to achieve pulmonary concentrations within 10 nM for a 70 kg patient. A 
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150 pmol/kg/hr for 12 hours would with greater confidence achieve 10nM in lung. The 10nM 
concentration in lung is specific to a cell model of SARS-CoV-2 infection; lower concentrations may 
be protective. Extrapolation from serum concentrations suggest that rates as low as 50 pmol/kg/hr 
may have efficacy. The time course of subsequent decreases in lung concentrations is not well 
established, but the approach of interrupted infusion envisioned in this protocol is thought to 
represent the optimal balance of risk and benefit on the basis of current information.  
 
Clinical experience. When Said and colleagues selected the range of doses/durations for the initial 
phase 1 trial in patients with septic ARDS,29 they did so in the context of the infusion rates that were 
well tolerated in healthy volunteers (~300–400 pmol/kg/hr) and the awareness that even low infusion 
rates were associated with substantial increases in plasma VIP levels. That phase 1 trial envisioned 
dose escalation in small cohorts of patients, from 50 pmol/kg/hr for 6 hours up to 150 pmol/kg/hr for 
12 hours. The investigators completed dosing through the 100 pmol/kg/hr for 12 hours (3 patients 
treated at that infusion rate). According to investigators (personal communication), VIP was infused 
daily for 3 days in the Phase 1 trial. 
 
The COVID-19 experience to date (~200 patients in a 2:1 randomized trial and another ~200 treated 
open label under an expanded access program [EAP]) have employed a sequential dose escalation 
strategy, in which a 12-hour infusion is performed daily for 3 days. The initial dose is 50 pmol/kg/hr, 
followed on day 2 by 100 pmol/kg/hr and on day 3 by 150 pmol/kg/hr. Treatment is not continued after 
the patient leaves the ICU. If a patient develops intolerance at a given infusion rate, the infusion 
period is increased (commonly to 18 hours) without a change in the overall dose administered. These 
rates have been reasonably well tolerated (personal communication). The EAP experience 
(compared with non-randomized concurrent controls) suggested the possibility of clinical efficacy; the 
Phase 2a trial has not yet read out. Unpublished reports (personal communication from Dr. Youssef) 
from the EAP experience suggest that intolerance may be somewhat higher at the conclusion of the 
100 pmol/kg/hr infusion and with the 150 pmol/kg/hr infusion among patients with ARDS and shock. 
 
The maximum infusion rate used to date in COVID-19 (150 pmol/kg/hr) is substantially below the 
infusion rates used in healthy volunteers (300–400 pmol/kg/hr) which either elicited no hypotension or 
elicited an average of 10% decrease in mean arterial pressure. The approach taken in the present 
trial is thus designed to optimize tolerability while achieving adequate blood levels and lung tissue 
concentrations of aviptadil. 
 
Given this context and background, the vanguard cohort of 40 participants (see below) is planned to 
evaluate and fine-tune the approach to managing aviptadil infusions and further assess anticipated 
feasibility/tolerance in the target population. 
 
1.4 Vanguard cohort 
In order to assure timely and sufficient evaluation of aviptadil using an optimal approach to managing 
aviptadil infusion in this target population, a vanguard cohort will be incorporated. It is recognized that 
prior experience with aviptadil in similar populations appears to be safe and well-tolerated, and that 
additional insights relevant to the conduct of the present trial can be gleaned from a vanguard cohort. 
The target population for the vanguard cohort will be identical to the overall trial, with the exception of 
the requirement that vanguard participants be admitted to an intensive care unit to facilitate more 
intensive monitoring. The vanguard cohort will be limited to approximately 10 sites and approximately 
40 patients (randomized 1:1 to aviptadil vs. control). The focus in the vanguard cohort will be in 
understanding the usability and feasibility of infusion management guidelines and making minor 
adjustments to “fine-tune” the infusion guidelines. Investigators will received blinded adherence 
reports for receipt of study drug infusion as would be typical of a DSMB open report. Extensive 
unblinded data will also be provided on a regular basis to the DSMB, detailing blood pressure, heart 
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rate, vasopressors, fluid administration as well as data on the study drug infusions. These features 
will be monitored during the infusions and through 2 hours after the conclusion of the infusion. 
 
In order to protect the overall blind and allow inclusion of vanguard participants in the final analytic 
cohort, investigators will only review (1) interviews with treating clinicians and site investigators 
regarding the utility and clarity of the infusion management guidelines, (2) blinded aggregate data on 
adherence with study drug infusion, and (3) recommendations from the DSMB. Standard firewalls 
between the DSMB and investigators will be maintained during the vanguard cohort. 
 
The vanguard cohort is intended to assess and finetune guidelines for study drug infusion 
management. It is recognized that the small size of the vanguard cohort will not support conclusive 
inferences about safety or efficacy and is focused on feasibility and tolerance. If experience with the 
vanguard cohort reveals that the original infusion management guidelines are infeasible, the infusion 
management guidelines may undergo modification. If necessary, a second vanguard cohort may be 
enrolled to allow further assessment of feasibility/tolerance and further finetuning of the approach to 
management of aviptadil infusion. If a second vanguard cohort is required, the patients in the first 
vanguard cohort will not be included in the final trial analysis. 
 
In general modifications to infusion management guidelines will not require an enrollment pause or 
protocol amendment, but will be managed through a protocol clarification memo and revision to the 
case report forms and PIM. The DSMB will also advise the study team and sponsor on the need for 
changes (or not) to the informed consent based on the experience in the vanguard cohort. 
 
2. Agent-specific eligibility criteria 
2.1  There is no change in inclusion criteria for this agent   
 
2.2 Agent specific exclusion criteria 
• Refractory hypotension, defined as infusion of vasopressors at or above norepinephrine 
equivalent of 0.1 mcg/kg/min (or infusion of more than one simultaneous vasopressor) in prior 
4 hours to maintain MAP > 65 mmHg OR systolic blood pressure <90 mmHg or MAP < 65 
mmHg at time of enrollment (or randomization, if the patient has already been enrolled) 
confirmed on two consecutive measurements at least 5 minutes apart (if a single measurement 
meets those criteria, a second measurement is required). Since aviptadil may induce 
hypotension, as noted above, patients with critical hypotension have a different risk:benefit 
profile that is less likely to favor aviptadil even where aviptadil is efficacious. 
• Severe diarrhea, defined as 3 or more liquid bowel movements within the last 24 hours. Since 
diarrhea is a common side effect of aviptadil, if patients already have severe diarrhea, they 
may have a different risk:benefit profile that is less likely to favor aviptadil. 
• Current C. difficile infection (CDI). CDI generally causes diarrhea, its severity is often gauged 
in part by the volume of diarrhea, and anti-motility agents that may be used to manage 
aviptadil-associated diarrhea are contraindicated in CDI. These factors suggest that the 
risk:benefit ratio in patients with CDI may not be favorable. 
• Pregnancy or current breast-feeding. Aviptadil was associated with involution of embryos in 
animal models and may be associated with changes in visceral and/or placental perfusion. It is 
thus felt not appropriate to infuse aviptadil in pregnant patients or in women who are 
breastfeeding. 
• End-stage liver disease (ESLD), defined as hepatic decompensation in a person with or 
without cirrhosis, usually associated with ascites (fluid in the peritoneal cavity), jaundice, 
variceal hemorrhage or hepatic encephalopathy (confusion, change in behavior, forgetfulness). 
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Liver function tests and/or coagulation profile are usually abnormal. An isolated elevation in 
serum bilirubin does not meet criteria for end-stage liver disease. 
 
 
3. Description of investigational agent 
 
3.1. Administration and duration 
The approach to infusion is based on prior clinical experience with the use of aviptadil. Aviptadil is 
infused over 12 hours per day for three days. The day 1 infusion rate is 50 pmol/kg/hr, the day 2 
infusion rate is 100 pmol/kg/hr, while the day 3 infusion rate is 150 pmol/kg/hr. The primary factors 
defining intolerance to aviptadil infusion are hypotension or diarrhea. The PIM will include infusion 
management guidelines to assist clinicians in responding to hypotension or diarrhea among patients 
receiving aviptadil. The total volume of the infusion (aviptadil vs. saline placebo) is generally less than 
100 ml per day, although infusion volumes will vary by patient weight and dosing day. 
 
3.2. Formulation and preparation 
Aviptadil is a sterile drug product that must be formulated by a hospital pharmacist under sterile 
conditions according to the supplied pharmacy manual.  Formulation is in 0.9% sodium chloride, with 
standard mixing procedures.  Standard intravenous bags and tubing are used. Dosing is at 
50/100/150 pmol/kg/hr. 
 
3.3 Supply, distribution, and accountability 
Procedures for ordering and accepting drug, for maintaining inventory of aviptadil, and for breaking 
the blind in the event of a medical emergency will be described in the Pharmacy Procedures. 
 
3.4. Contraindicated medications 
There are no known contraindicated medications. There is a theoretical consideration about use of 
nitric oxide or prostanoid therapy, but there is no compelling data to date to suggest that such 
medication should be restricted. Use of pulmonary vasodilators will thus be tracked with concomitant 
medications. 
 
3.5. Precautionary medications 
The clinical site should have necessary equipment and medications for the management of any 
infusion reaction. These include capacity to monitor vital signs, ability to infuse and monitor 
vasopressor agents if necessary, and capacity to manage diarrhea and electrolyte loss. Unrelated to 
aviptadil but centrally related to COVID-19, sites must be able to manage progression of respiratory 
failure. 
 
4. Clinical and laboratory evaluations 
 
Clinical and laboratory evaluations will follow the master protocol schedule of assessments. 
 
4.1 Timing of Assessments 
All assessments are outlined in the relevant section of the master protocol.  
 
4.2. Pharmacokinetic Assessments 
Pharmacokinetic assessments are being performed in a Phase 2 trial performed by NeuroRX. 
 
5. Clinical management issues 
All participants should be monitored closely for hypotension and diarrhea and any additional adverse 
events, with special attention to treatment-emergent adverse events. 
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5.1. Symptoms and Signs 
Symptoms and signs that may occur as part of an infusion reaction, include, but are not limited to, 
decrease in mean arterial pressure, diarrhea, facial flushing.  Infusion-related reactions’ severity will 
be assessed and reported using the Division of AIDS (DAIDS) Table for Grading the Severity of Adult 
and Pediatric Adverse Events, Corrected version 2.1. Given the unique nature of the target population 
for this trial, hypotension will be graded according to the scale in Table 5 (Section 10) of the master 
protocol rather than the DAIDS AE Grading Table. 
 
5.2. Site Needs 
The clinical site should have necessary equipment, medications, adequately qualified and 
experienced staff with appropriate medical cover for the management of any infusion reaction, which 
may include, but is not limited to, hypotension and diarrhea. 
 
5.3. Management of Infusion Reactions including Discontinuation 
Infusion of aviptadil or its placebo will be guided by infusion management guidelines in the context of 
clinician judgment. If the complete infusion is not administered, all follow-up procedures and reporting 
outlined in the master protocol should be adhered to as indicated. 
 
6. Agent-specific safety monitoring activities 
 
Safety monitoring for aviptadil will be as specified in the master protocol. However, grade 3 or 4 
diarrhea in the peri-infusion period will only be included in the composite safety endpoint if the 
diarrhea is a serious adverse event, or results in discontinuation of the study drug infusion. “Peri-
infusion” refers to the time period during and up to 2 hours after an infusion.   
 
The primary safety outcome was modified in order to avoid mistaken inferences regarding safety, 
because diarrhea is common with aviptadil and is generally well managed with loperamide in prior 
clinical experience. For example, diarrhea treated with loperamide would generally be classified as a 
grade 3 adverse event.  All grade 3 or 4 diarrhea that occurs outside the peri-infusion time period will 
still be included in the primary safety outcome, as part of incident grade 3 or 4 AEs.  Also, all peri-
infusion diarrhea events will be reported to the DSMB as part of the infusion reaction summaries. 
 
Specific to aviptadil study drug, there is one change to the safety monitoring schedule displayed in 
Table 3 of the master protocol: hypotension of any grade will be recorded daily through Day 28. 
 
Note that as part of the oversight of this trial, the DSMB will review unblinded safety data regularly 
during the trial. 
 
Hypotension is defined as a lower arterial blood pressure or low arterial blood pressure/perfusion 
leading to (1) initiation or clinically meaningful increase in vasopressor therapy, (2) administration of 
an intravenous fluid bolus (≥500 ml of crystalloid solution or equivalent volume of colloid), or (3) 
modification or discontinuation of study drug infusion. Specific grading of hypotension will be 
according to Section 10, Table 5 of the master protocol. Specific to the aviptadil vs. placebo 
comparison, in addition to standard data summaries for hypotension AEs, hypotension associated 
with organ dysfunction within the first 5 days after study entry will also be compared between aviptadil 
and its placebo. Hypotension associated with organ dysfunction is defined as hypotension plus 
concomitant or subsequent organ dysfunction. Organ dysfunction in this setting is a composite 
outcome consisting of items 5a-5f (excluding item 5b4) of the secondary outcome of clinical organ 
failure and serious infections (section 4.1.2 of the TESICO master protocol). 
 
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For regulatory reporting purposes, including identification and potential expedited reporting of 
‘SUSAR’ events, the following serious and/or non-serious Adverse Events/Reactions are considered 
expected for this study as applies to the aviptadil factor. 
• Hypotension* 
• Diarrhea 
 
* For regulatory reporting purposes, hypotension up to Grade 3 is considered expected for aviptadil in 
this specific study, population, disease and setting.  Hypotension occurring at Grade 4 or higher as 
described in Table 5 in the main protocol document is not considered expected. 
 
In addition, the following adverse events/reactions are considered expected unless serious: 
• Bradycardia 
• Tachycardia 
• Flushing 
 
The DSMB reviews safety data on an ongoing and unblinded manner.  If a pattern, frequency, or 
other characteristic of concern becomes evident to the DSMB with regard to the ‘expected’ events 
listed above, the study team and sponsor will be promptly notified and action will be taken as may be 
indicated for subject protection and/or reporting purposes. 
 
 
 
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34. 
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