A Single-site, Randomised, Controlled, Parallel Design, Open-label Investigation of an Approved Nebulised Recombinant Human DNase Enzyme (Dornase Alfa) to Reduce Hyperinflammation in Hospitalised Participants With COVID-19
Phase: PHASE2
Conditions: COVID-19 (Coronavirus Disease 2019), Hypoxia
Sponsor: University College, London

Dornase alfa in COVID-19:   Sponsor code: 132333 
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Full title of trial 
 
A single-site, randomised, controlled, parallel design, 
open-label investigation of an approved nebulised 
recombinant human DNase enzyme (dornase alfa) to 
reduce 
hyperinflammation 
in 
hospitalised 
participants with COVID-19 (The COVASE trial) 
Short title 
 
Dornase alfa in COVID-19 
Version and date of protocol 
 
V2.0, 25 April 2020 
  
Sponsor: 
University College London (UCL) 
 
Sponsor protocol number 
132333 
NCT 04359654 
 
Funder (s): 
  
EudraCT no  
 
2020-001937-11 
ISRCTN / Clinicaltrials.gov no:  
[Insert ISRCTN or Clinicaltrials.gov reference no] 
 
 
Active treatment 
Dornase alfa (Pulmozyme: recombinant human 
DNAse I) 
PLACEBO IMP(s): 
None  
Phase of trial 
Phase IIa 
Sites(s) 
UCLH  
Chief investigator: 
Prof Joanna Porter 
UCL Respiratory  
The Rayne Building 
5 University Street 
London WC1E 6JF  
 
Sponsor Representative: 
Joint Research Office, UCL, 1st Floor Maple House, 
149 Tottenham Court Road, 
London W1T 7NF 
Postal address: 
Joint Research Office, UCL 
Gower Street,  
London WC1E 6BT 
 
 
 
 

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Protocol Version History 
 
Version Number 
Date 
Protocol Update Finalised By (insert name of 
person):  
Reasons for 
Update 
2.0 
25 
April 
2020 
 
Response to 
REC/MHRA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1 
Signatures 
The Chief Investigator and the JRO have discussed this protocol. The investigator agrees to perform the 
investigations and to abide by this protocol  
The investigator agrees to conduct the trial in compliance with the approved protocol, EU GCP and UK 
Regulations for CTIMPs (SI 2004/1031; as amended), the UK Data Protection Act (1998), the Trust 
Information Governance Policy (or other local equivalent), the current UK Policy Framework for Health 
and Social Care Research , the Sponsor’s SOPs and other regulatory requirements as amended. 
 
Chief investigator 
Professor Joanna Porter 
UCL Respiratory 
 
 
 
Signature 
Date 
Sponsor  
Dr Nick McNally  
 
 
UCL 
Signature 
Date 
 
 
 
 
 

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1.1 Contents 
 
Protocol Version History .................................................................................................... 2 
1 
Signatures ................................................................................................................... 3 
1.1 
Contents ............................................................................................................ 4 
1.3 
Trial personnel ................................................................................................ 10 
2 
Summary .................................................................................................................. 11 
3 
Background and rationale ........................................................................................ 14 
3.1 
Assessment and management of risk .............................................................. 18 
4 
Objectives and endpoints ........................................................................................ 20 
5 
Trial design ............................................................................................................... 21 
5.1 
Overall design ................................................................................................. 21 
6 
Off-label use of an Approved Medicinal Product (Pulmozyme) .............................. 24 
6.1 
Recombinant Human DNase (dornase alfa) ................................................... 24 
6.2 
Source of dornase alfa, manufacture and distribution .................................... 24 
6.3 
Storage and handling of dornase alfa .............................................................. 24 
6.4 
Accountability of dornase alfa ........................................................................ 25 
6.5 
Concomitant medication ................................................................................. 25 
6.6 
Post-trial IMP arrangements ........................................................................... 25 
7 
Selection of participants .......................................................................................... 25 
7.1 
Eligibility of trial participants ......................................................................... 25 
7.1.1 
Trial participant inclusion criteria .............................................................. 25 
7.1.3 
Trial participant exclusion criteria ............................................................. 26 
7.2 
Recruitment ..................................................................................................... 26 
7.3 
Informed consent procedure ........................................................................... 26 
8 
Trial procedures ....................................................................................................... 27 
8.1 
Pre-treatment Assessments ............................................................................. 27 
8.2 
Randomisation Procedures ............................................................................. 27 
8.3 
Treatment Schedule ........................................................................................ 28 
8.3.1 
Dose modifications .................................................................................. 28 
8.4 
Subsequent assessments and procedures ........................................................ 28 
8.4.1 
Schedule of assessments ........................................................................ 28 

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8.5 
Laboratory Assessments and Procedures ........................................................ 30 
8.6 
Clinical Procedures and Data Collection ........................................................ 31 
8.7 
Assessment of dornase alfa compliance ......................................................... 32 
8.8 
Discontinuation/withdrawal of participants .................................................... 32 
8.9 
Replacements .................................................................................................. 32 
8.10 
Stopping rules ................................................................................................. 33 
8.11 
Definition of end of trial ................................................................................. 33 
9 
Recording and reporting of adverse events and reactions ...................................... 33 
9.1 
Definitions ...................................................................................................... 33 
9.2 
Recording adverse events ............................................................................... 34 
9.3 
Assessments of Adverse Events ..................................................................... 35 
9.3.1 
Severity ................................................................................................... 35 
9.3.2 
Causality .................................................................................................. 35 
9.3.3 
Expectedness .......................................................................................... 35 
9.3.4 
Seriousness ............................................................................................. 36 
9.4 
Procedures for recording and reporting Serious Adverse Events ................... 36 
9.5 
Serious Adverse Events which do not require immediate reporting .............. 38 
9.6 
Reporting SUSARs ......................................................................................... 38 
9.7 
Development Safety Update Reports .............................................................. 38 
9.8 
Pregnancy ....................................................................................................... 38 
9.9 
Overdose ......................................................................................................... 39 
9.10 
Reporting urgent safety measures and other safety events ............................. 39 
9.11 
Notification of serious breaches to GCP and/or the protocol (SPON/S15) .... 39 
10 
Data management and quality assurance ............................................................... 40 
10.1 
Confidentiality ................................................................................................ 40 
10.2 
Data collection tools and source document identification .............................. 40 
10.3 
Completing Case Report Forms...................................................................... 40 
10.4 
Data handling and analysis ............................................................................. 40 
11 
Statistical Considerations ......................................................................................... 41 
11.1 
Outcomes ........................................................................................................ 41 
11.1.1 
Primary outcomes .................................................................................... 41 
11.1.2 
Secondary outcomes ............................................................................... 41 

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11.2 
Sample size and recruitment ........................................................................... 42 
11.2.1 
Sample size calculation ........................................................................... 42 
11.2.2 
Planned recruitment rate .......................................................................... 42 
11.3 
Statistical analysis plan ................................................................................... 42 
11.3.1 
Summary of baseline data and flow of participants .................................. 42 
11.3.2 
Primary outcome analysis ........................................................................ 43 
11.3.3 
Secondary outcome analysis ................................................................... 44 
11.3.4 
Sensitivity and other planned analyses .................................................... 44 
11.4 
Interim analysis ............................................................................................... 45 
11.5 
Other statistical considerations ....................................................................... 45 
12 
Record keeping and archiving .................................................................................. 45 
13 
Oversight committees .............................................................................................. 45 
13.1 
Data Monitoring Committee (DMC) .............................................................. 45 
14 
Direct Access to Source Data/Documents ............................................................... 45 
15 
Ethics and regulatory requirements ........................................................................ 46 
16 
Monitoring requirement for the trial ....................................................................... 46 
17 
Finance ..................................................................................................................... 46 
18 
Insurance .................................................................................................................. 47 
19 
Publication policy ..................................................................................................... 47 
20 
References................................................................................................................ 47 
21 
Appendix 1 - Schedule of Assessments .................................................................... 49 
 
 
 

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1.2  List of abbreviations 
AE                                    
Adverse Event 
AR                                    
Adverse Reaction 
ARDS                               
Acute respiratory distress syndrome 
BAC                                  
Best Available Care 
BID                                   
Twice per day 
CA                                    
Competent Authority      
CF                                     
Cystic Fibrosis 
cfDNA                              
Cell-free DNA    
CI                                      
Chief Investigator 
Conmeds                        
Concomitant medications         
CoV                                  
Coronavirus 
CRF                                  
Case Report Form 
CRO                                 
Contract Research Organisation 
CRP            
C-reactive protein   
CT            
Computer tomography   
CTA                                  
Clinical Trial Authorisation 
CTIMP                             
Clinical Trial of Investigational Medicinal Product          
DI                                     
Designated Individual         
DMC                                
Data Monitoring Committee       
DNA                                 
Deoxyribonucleic acid 
DNase                             
Deoxyribonuclease 
DSUR                               
Development Safety Update Report 
EC                                     
European Commission 
EMA                                 
European Medicines Agency 
EU                                    
European Union 
EUCTD                             
European Clinical Trials Directive 
EudraCT                          
European Clinical Trials Database 
EudraVigilance              
European database for Pharmacovigilance 
FDA                                  
Federal drug administration 
FVC                                  
Forced vital capacity 
GAfREC                           
Governance Arrangements for NHS Research Ethics 

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GCP                                  
Good Clinical Practice 
GMP                                
Good Manufacturing Practice  
H3                                    
Histone 3 
HTA                                  
Human Tissue Authority 
ICF                                    
Informed Consent Form 
ICU                                   
Intensive care unit 
IL-1 β                               
Interleukin -1 beta 
IL-6                                  
Interleukin-6 
IL-8                                  
Interleukin-8 
ISARIC 
International Severe Acute Respiratory and Emerging 
Infection Consortium 
ISF                                    
Investigator Site File 
ISRCTN                            
International Standard Randomised   
MA                                   
Marketing Authorisation 
MHRA                              
Medicines and Healthcare products Regulatory Agency 
MPO                                
Myeloperoxidase 
MS                                   
Member State 
MV                                   
Mechanical Ventilation 
NIHR                                
National Institute for health research 
NHS R&D                        
National Health Service Research & Development    
NETs                                
Neutrophil extracellular traps 
NOCRI                             
NIHR Office for Clinical Research Infrastructure 
PCR                                  
Polymerase chain reaction 
PCT                                  
ProCalcitonin 
PD                                    
Pharmacodynamics 
PI                                      
Principal Investigator 
PO                                    
Purchase order 
PIS                                    
Participant Information Sheet 
PL                                     
Product License 
QD                                   
Once per day 
QA                                    
Quality Assurance 
QC                                    
Quality Control 

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RECOVERY                      
Randomised evaluation of COVID-19 therapy 
RCT                                  
Randomised Controlled Trial 
REC                                  
Research Ethics Committee 
RSI                                    
Reference Safety Information 
SAP                                  
Statistical Analysis Plan 
SAR                                  
Serious Adverse Reaction 
SAE                                  
Serious Adverse Event 
SDV                                  
Source Document Verification 
SOFA                                
Sepsis-related Organ Failure Assessment 
SOP                                  
Standard Operating Procedure  
SMPC                               
Summary of Product Characteristics  
SUSAR                             
Suspected Unexpected Serious Adverse Reaction  
TNFα                                
Tumour necrosis factor alpha 
TRC                                  
Translational Research Collaboration 
UCL                                  
University College London 
UCLH                               
University College London hospital 
WHO                               
World health organisation 
 
 

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1.3 Trial personnel 
See protocol cover page for Chief Investigator and Sponsor contact details. 
 
Statistician 
Aiden Flynn 
Exploristics Ltd 
20 Rosemount Road 
Northern Ireland 
BT24 8SY 
e-mail: aiden.flynn@exploristics.com 
fax: 07971 529973 
External laboratory 
The Francis Crik Institute 
Dr Veni Papayannopoulos 
1 Midland Rd 
London NW1 1AT 
 
 

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2 Summary 
 
The clinical spectrum of SARS-CoV-2 infection (COVID-19) appears to be 
wide, encompassing asymptomatic infection, mild upper respiratory tract 
illness (majority of cases) and severe viral pneumonia with respiratory 
failure and even death in the minority of subjects. In severe viral 
pneumonia excessive and inappropriate activation of neutrophils can 
result in the formation of neutrophil extracellular traps (NETs) which 
exacerbate the clinical course of the pneumonia. These NETs consist of 
DNA, histones and other components of neutrophils (e.g. 
myeloperoxidase (MPO)). These NETs are found in the lungs and in the 
circulation and contribute to organ damage. A treatment that reduces 
NET formation is likely to reduce the exuberant inflammatory response 
and thereby improve the clinical course of viral pneumonia and save lives. 
 NETs have been shown to drive disease in influenza pneumonia as well 
as in subjects with cystic fibrosis. In addition, their role has been explored 
in various pre-clinical models of viral infection (mouse and bovine) and 
shown that reduction of the NETs improves symptoms and increases 
survival. High neutrophil infiltration is prominent in the lungs of COVID-19 
patients and evidence of NET components in the circulation and lung 
biopsies has been reported in clinical study of COVID-19 patients.  
Dornase alfa is a recombinant human DNase I that has been approved 
since 1994 for the treatment of cystic fibrosis (CF). It is delivered directly 
to the lungs by nebulisation and has been shown to: 
• 
reduce NETs and inflammation  
• 
reduce the relative risk of developing a respiratory tract infection 
• 
improve pulmonary function in both chronic and acute 
exacerbation of inflammatory CF 
Dornase alfa is safe and well-tolerated in children and adults with CF at 
doses ranging from 2.5mg QD up to a maximum of 10mg BID. 
This study proposes to treat hospitalised subjects with COVID-19 by 
administration of 2.5mg Dornase alfa BID for 7 days. The effect on NETs, 
inflammation and clinical course will be closely monitored. We expect to 
see a reduction in circulating NETS and inflammatory biomarkers that will 
result in clinical benefit. Historic controls will be derived from an existing 
database of 120 subjects with COVID-19 that have been admitted to UCL 
since the beginning of the outbreak. 
It is worth noting that dornase alfa can be self-administered at home. 
Therefore, dornase alfa has the potential to provide benefit in subjects 
with COVID-19 who have mild disease and are self-isolating and in those 
discharged from hospital to recuperate at home. 

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Objectives: 
Primary objective: to assess the effect of nebulised dornase alfa 
on C-reactive Protein (CRP) in hospitalised participants with 
COVID-19. 
Secondary objective: to assess the effect of nebulised dornase 
alfa on clinical responses in hospitalised participants with COVID-
19.  
Exploratory objective: to assess the effect of nebulised dornase 
alfa on inflammation, biomarkers of NETs, coagulation, 
complement activation and haemolysis in hospitalised 
participants with COVID-19. 
Type of trial: 
A single-site, randomised, controlled, parallel design, open-label 
trial of an approved nebulised recombinant human DNase enzyme 
(dornase alfa) to reduce hyperinflammation in hospitalised 
participants with COVID-19 (The COVASE Trial). 
Trial design and methods: 
An open-label, randomised, Best-Available-Care (BAC) and 
historic-controlled trial of nebulised dornase alfa [2.5 mg BID] for 
7 days in participants with COVID-19 who are admitted to 
hospital and are at risk of ventilatory failure (the COVASE study). 
Controls will include a randomised arm to receive BAC, historic 
data from UCLH patients with COVID-19 and biobanked samples 
will be used to demonstrate an effect of dornase alfa. CRP will be 
measured to assess the effect of dornase alfa on inflammation. 
Clinical endpoints and biomarkers (e.g. d-dimer) will be used to 
assess the clinical response. Exploratory endpoints will explore 
the effects of dornase alfa on features of neutrophil extracellular 
traps (NETs). 
Trial duration per 
participant: 
Six weeks from consent to last trial assessment. 
Estimated total trial 
duration: 
Four - five months from when first participant enrolled to last 
participant follow-up. 
Planned trial sites: 
Single site  
Total number of 
participants planned: 
40 participants will be enrolled. A sample size re-estimation is 
planned to occur approximately one third of the way through the 
study (e.g. when 12 participants have been randomised). At this 
point, the decision may be made to randomise additional 
participants if the variability of the primary endpoint is higher than 
anticipated. 
Main inclusion/exclusion 
criteria: 
Participants who are hospitalised for COVID-19 will be recruited 
into the study. 
 

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Inclusion criteria:  
1. 
Male and female participants, aged ≥ 18 years.  
2. 
Participants who are hospitalised for suspected 
Coronavirus (SARS-CoV)-2 infection confirmed by 
polymerase chain reaction (PCR) test or radiological 
confirmation with chest CT scan   
3. 
Participants with stable oxygen saturation (>=94%) on 
supplementary oxygen 
4. 
CRP >= 30 mg/L. 
5. 
Participants will have given their written informed 
consent to participate in the study and are able to comply 
with instructions and nebuliser. 
Exclusion criteria 
1. 
Females who are pregnant, planning pregnancy or 
breastfeeding. 
2. 
Concurrent and/or recent involvement in other research or 
use of another experimental investigational medicinal 
product that is likely to interfere with the study medication 
within the last 3 months before study enrolment. 
3. 
Serious condition meeting one of the following:  
I. 
respiratory distress with respiratory rate 
>=40 breaths/min 
II. 
oxygen saturation <=93% on high-flow 
oxygen 
4. 
Require mechanical invasive or non-invasive ventilation at 
screening 
5. 
Concurrent severe respiratory disease such as asthma, 
COPD and/or ILD. 
6. 
Any major disorder that in the opinion of the Investigator 
would interfere with the evaluation of the results or 
constitute a health risk for the study participant. 
7. 
Terminal disease and life expectancy <12 months without 
COVID-19. 
8. 
Known allergies to the dornase alfa and excipients. 
9. 
Participants who are unable to inhale or exhale orally 
throughout the entire nebulisation period. 
Statistical methodology 
and analysis: 
Full details of the planned statistical analysis will be presented in 
the Statistical Analysis Plan (SAP).  All baseline data, 
demographics, endpoints, safety and tolerability will be 
summarised overall and by treatment group and by day. In 
general, continuous data will be summarised using the mean 
(standard deviation), median (1st and 3rd quartiles), minimum 

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and maximum, and categorical data will be represented as 
frequency counts (percentages).  
For analyses relating to the primary objective, group comparisons 
will be performed using a repeated measures mixed model, 
adjusted for baseline factors and with treatment as the main 
effect.  Prior to analysis, all endpoints will be assessed for 
conformance to normality assumptions and the appropriate 
transformation will be conducted if necessary.  Some exploratory 
endpoints may only be available in the active treatment group.  In 
this case, a within group analysis will be conducted to compare 
baseline and post-baseline measurements. 
An interim analysis will be conducted when 12 participants have 
been randomised.  The results of the interim analysis will be used 
to re-estimate the sample size if necessary. 
3 Background and rationale 
Clinical background 
COVID-19 is a heterogeneous disease caused by infection with SARS-CoV-2 and although the majority of 
patients (80%) have mild disease, 15% will require oxygen and of these 25% will require ICU, of which 47 
– 71% require ventilatory support. Risk factors for severe disease include older age, male sex, obesity and 
comorbid disease. There are no specific cures for COVID-19 and current care is supportive. A key challenge 
is to intercept patients early in the course of their disease to prevent deterioration and reduce the 
numbers that need ventilatory support, a life-saving treatment that is currently only available for a 
minority of patients. 
SARS-CoV-2 is able to directly infect nasal, bronchiolar and alveolar epithelial cells resulting in lung 
inflammation, characterised, in severe cases, by an over-exuberant inflammatory response, shortness of 
breath and hypoxaemia.  Once SARS-CoV-2 infection progresses to the stage of pneumonia, key 
pathogenic drivers result in symptoms characteristic of the acute respiratory distress syndrome (ARDS) 
with a high mortality.   
In patients with confirmed COVID-19 pneumonia, 50% developed dyspnoea at 8 days after illness onset 
(range: 5–13 days). Mortality of these patients is around 4-15%, as a result of ARDS, coagulation 
dysfunction, and secondary infection that may result in septic shock and multi-organ failure (Zhou et al., 
Lancet 2020). Cytokines are thought to be key drivers of these pathological events and in particular levels 
of IL-6 are found to be raised in COVID-19 patients and to correlate with mortality (Gong et al., medRχiv 
2020). Anti-IL-6 is seen as a potential therapy in COVID-19 following favourable reports from a clinical 
study in China.    
There is an urgent need to intervene and reduce the inflammatory response of patients with COVID-19 
early in the course of their disease and so prevent progression to ICU.  
 
 

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Scientific background 
Our hypothesis is that in the COVID-19 lung, the release of neutrophil extracellular traps (NETs) by 
neutrophils promotes lung damage and the induction of pathogenic pro-inflammatory cytokines, such as 
IL-6 and IL-1. This inflammatory cascade recruits additional neutrophils leading to a pathogenic feedback 
amplification loop. High neutrophil infiltration is prominent in the lungs of COVID-19 patients and 
evidence of NET components in the circulation and lung biopsies has been reported in clinical study of 
COVID-19 patients (Betsy J. Barnes et al., JEM 2020l; Zuo et al. medRxiv preprint 
doi:https://doi.org/10.1101/2020.04.09.20059626). Based on this evidence, blocking or clearing NETs to 
treat severe COVID-19 symptoms has now been proposed by an international consortium (Betsy J. Barnes 
et al., JEM 2020). 
NETs are composed of a backbone of decondensed chromatin fibres coated with antimicrobial granular 
and cytoplasmic proteins, such as myeloperoxidase, neutrophil elastase (NE) and α- defensins. Double-
stranded DNA is a major component of NETs, which prevents their degradation. This extracellular DNA is 
normally broken down by endogenous deoxyribonucleases (DNases) but in severe inflammation these 
DNases may become overwhelmed by a massive release of NETs and are unable to completely degrade 
NETs. Our recent work suggest incomplete NET degradation would lead to amplification rather than 
reduction of inflammation.   
While sensing of microbes and viruses promotes inflammation, the release of endogenous host molecules 
during infection, known as damage-associated molecular patterns (DAMPs), can amplify cytokine 
induction. Work in Dr Venizelos Papayannopoulos’ lab at the Francis Crick institute has identified specific 
DAMPs that are critical for the induction of pathogenic hyperinflammation during infection. Free 
circulating histones are key pathogenic factors in microbial sepsis. We recently found that extracellular 
chromatin acts as a potent pro-inflammatory signal, allowing extracellular chromatin structures called 
neutrophil extracellular traps (NETs) to induce IL-1β and IL-6, via Toll-like receptor 4 (TLR4) 
(Tsourouktsoglou et al. in press).  
Consistently, NET-mediated pathology causes death in murine models of severe pulmonary Influenza 
infection (Pillai et al., Science 2016) and the presence of NETs correlates with flu severity in humans (Zhu 
et al., J. Infect. Dis. 2018). DNase treatment significantly delayed mortality in severe flu in immune-
compromised mice (Pillai et al., Science 2016) and cleared NETs and lowered airway obstruction in severe 
bovine respiratory syncytial virus (RSV) infection (Cortjens et al., Thorax 2018). Finally, mice that are 
genetically pre-disposed to NET overproduction following pulmonary infection with a virulent fungal 
mutant strains can be rescued from lethality with NET formation inhibitors (Papayannopoulos, Nat. Rev. 
Immunol. 2018).  NETs are major drivers of coagulation during sepsis, particularly in the absence of 
endogenous DNAses, and are regulated by the complement cascade (Jimenez-Alcazar et al., Science 
2017).  
Rationale for the trial 
Dornase alfa is a recombinant human DNase enzyme indicated in conjunction with standard therapies for 
the management of cystic fibrosis (CF) to improve pulmonary function. Dornase alfa degrades 
extracellular DNA, and so promotes the clearance of NETs and lead to a significant improvement in lung 
function for treated CF patients by facilitating mucus clearance in the lung. Dornase alfa is approved 
worldwide as a nebulised formulation, with an excellent safety profile and is well tolerated. The most 

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common side effect is a hoarse voice. Moreover, dornase alfa could be administered in addition to 
effective antiviral therapy and should not interfere with antiviral drugs that could be used for COVID-19. 
By facilitating the clearance of NETs, dornase alfa not only facilitates sputum clearance in CF patients, but 
has additional anti-inflammatory activity. Dornase alfa has been shown to reduce NETs in the 
bronchoalveolar lavage (BAL) and sputum of participants with CF (Konstan et al 2012). In the 
Bronchoalveolar Lavage for the Evaluation of Anti-inflammatory Treatment (BEAT) study, the percentage 
of neutrophils in bronchoalveolar lavage fluid significantly increased in untreated CF patients (P<0.02) 
while remaining constant in the dornase alfa-treated group. Levels of elastase and IL-8 also significantly 
increased from baseline in the untreated group (P<0.007 and P<0.02 for elastase and IL-8, respectively), 
but remained stable in patients receiving dornase alfa (Konstan and Ratjen, J. Cyst. Fibros. 2012).  
There is scientific evidence to support the potential benefits of dornase alfa in COVID-19 infection. Viral 
sepsis driven by a hyperinflammation is thought to be a major cause of mortality in COVID-19 infection. 
Interleukin-1β (IL-1β), IL-6 and TNFα are key cytokines in microbial sepsis. Positive outcomes with Roche’s 
Actemra (tocilizumab), an antibody that blocks the pro-inflammatory cytokine interleukin-6 (IL-6), in 
COVID-19 treatment has led to several anti-inflammatory trials. 
Our hypothesis is that nebulised dornase alfa will break down the DNA backbone of NETs in the COVID-
19 lung which will promote the degradation of pro-inflammatory extracellular histones and prevent the 
amplification of the inflammatory response and the resultant lung damage. 
Positive data will enable rapid testing into a large clinical trial in the UK and prevent ICU capacity issues 
faced today. Dornase alfa is a cost-effective drug and is currently available for prescription.  
We propose to test this hypothesis with this COVASE Phase IIa trial. We propose that all people with 
COVID-19 who are admitted to hospital for supplementary oxygen, who showed evidence of systemic 
inflammation but did not immediately require intubation and ventilation, would be eligible for nebulised 
dornase alfa, a safe and cost-effective treatment, twice daily for 7 days.  
The hypothesis to be tested is illustrated in Figure 1.  
 

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Potential Real-World evidence 
It is theoretically possible that the CF population could provide Real-World evidence on the effect of 
dornase alfa on COVID-19. Some participants with CF may develop COVID-19 and may or may not be on 
dornase alfa. An epidemiological study could determine outcomes in the two groups (CF + COVID-19 not 
taking dornase alfa and CF + COVID-19 taking dornase alfa). However, currently, the numbers are too low. 
Considering participants with CF across London, there are a few adults with COVID-19, none of whom 
have severe disease or have been admitted to ITU. However, they are likely to have been ‘shielding’ since 
before the term was coined. So far, no paediatric cases have been reported. However, given that much of 
the infected paediatric age group elsewhere is asymptomatic or mild, they may not be effectively 
documented. Therefore, it is not possible at this stage to consider the effect of dornase alfa on the 
progression of COVID-19 in the setting of CF. All cases of COVID-19 infection in participants with CF will 
be captured through the national patient registry. This also identifies patients on dornase alfa, so 
retrospectively these cohorts can be assessed. Data will not be available in high enough numbers for this 
to be useful during the current pandemic.  
Dornase alfa dosing rational 
The dose to be administered in this trial is 2.5 mg dornase alfa BID (approved) administered with the 
eRapid nebuliser (or equivalent jet nebuliser connected to an air compressor with an adequate air flow 
and equipped with a mouthpiece as recommended for dornase alfa-see section 8.3 Table 1). This is twice 
the standard daily dose (2.5mg QD) and is recommended for older/refractory people with CF. It has been 
shown to be safe and well tolerated in children and adults with CF. Doses of 2.5mg QD have been 
Figure 1: Schematic Representation of the Hypothesis to be tested in the COVASE trial 

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administered for years (since 1994) to thousands of people with CF. Higher doses up to 10mg BID have 
been used in short-term studies with a similar safety and tolerability profile. Dornase alfa has been shown 
to be safe and well-tolerated during acute exacerbations of CF. Dornase alfa is administered in addition 
to other treatments for CF (FDA label and EMA SmPC). 
Thus, dornase alfa at 2.5 mg BID for seven days is expected to be safe and well-tolerated in hospitalised 
participants with COVID-19. It is well tolerated and has the potential to block the production of not one 
but several pro-inflammatory cytokines and acts enzymatically. Moreover, it has been shown not to 
interfere with anti-viral immune defence (Cortjens et al., Thorax 2018). 
3.1 Assessment and management of risk  
The table below summarises the risks, frequencies and mitigations of COVASE trial 
Name of 
treatment  
Recombinant 
human DNase  
1 (dornase 
alfa) 
administered 
by 
nebulisation 
Potential risk 
voice alteration 
pharyngitis 
rash 
laryngitis 
chest pain 
 conjunctivitis 
Risk Frequency 
≥3% 
Risk Management 
DMC configured to mitigate participant 
safety and data integrity risks 
Recombinant 
human DNase  
1 (dornase 
alfa) 
administered 
by 
nebulisation 
rhinitis 
decrease in FVC of 
≥10%* 
fever 
dyspnoea 
less than 3% 
DMC configured to mitigate participant 
safety and data integrity risks 
Recombinant 
human DNase  
1 (dornase 
alfa) 
administered 
by 
nebulisation 
There is a low potential 
immunogenicity 
risk 
and 
antibodies 
to 
dornase alfa will not be 
measured in this study 
Low (2-4%) 
There have been no reports of 
anaphylaxis attributed to the 
administration of dornase alfa. Urticaria, 
mild to moderate, and mild skin rash 
have been observed and have been 
transient. Within all of the studies, a 
small percentage (average of 2-4%) of 
people treated with dornase alfa 
developed serum antibodies to dornase 
alfa. None of these people developed 
anaphylaxis, and the clinical significance 
of serum antibodies to dornase alfa is 
unknown. 

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Failure 
to 
recruit 
patients 
 
unlikely 
Feasibility data suggests that sufficient 
participants can be recruited over the 
time specified. However, additional sites 
are available through the NOCRI 
respiratory TRP that represents 10 of the 
UK BRCs 
 
Delay in dornase alfa  
supply  
 
unlikely 
UCLH pharmacy to check and put a PO as 
soon as the grant is awarded and 
REC/MHRA approval received. 
 
Delay in eRapid supply 
in the UK  
 
unlikely 
UCLH pharmacy to check and put a PO as 
soon as the grant is awarded and 
MHRA/REC approval received. 
 
Competing clinical 
trials 
unlikely 
There are trials currently ongoing at UCLH 
that will compete. Trials at UCLH are 
prioritised and overseen by the COVID-19 
committee to ensure equitable 
recruitment of hospitalised participants 
to all ongoing trials. Deliverability of trials 
is also under their management.  
 
Staff sickness due to 
COVID-19 
unlikely 
Additional nursing support is available to 
cover levels of 25-50% due to COVID-19 
infection and time off work. 
*Single measurement only, does not reflect overall FVC changes. 
The table below summarise the risks and mitigations of all test above standard care that are being 
performed in the COVASE Trial: 
Intervention  
Nebulisation of dornase 
alfa to participants with 
COVID-19 
 
Potential risk 
As dornase alfa is approved for 
the treatment of children and 
adults with CF, we will be using 
the drug ‘off-label’ for the first 
time in participants with COVID-
19. There is a low risk that the 
safety and tolerability in this 
population may be different to 
that expected from CF 
Risk Management 
We will therefore use ‘sentinel’ 
dosing for the first three participants 
enrolled. This means that the three 
sentinel participants will each 
commence dosing and safely 
complete 2 days of treatment 
individually, before another 
participant is dosed. Thereafter 
(participant 4 and onwards) 
enrolment and dosing may occur in 
parallel. 

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Blood draws 
Complications that can arise from 
venepuncture include 
haematoma formation, nerve 
damage, pain, haema-
concentration, extravasation, 
iatrogenic anaemia, arterial 
puncture, petechiae, allergies, 
fear and phobia, infection, 
syncope and fainting, excessive 
bleeding, oedema and thrombus 
Experienced hospital staff will be 
drawing the blood and will minimise 
these potential risks 
 
In accordance with the MRC/DH/MHRA Joint Project Risk-adapted Approaches to the 
Management of Clinical Trials of Investigational Medicinal Products, this trial is categorised as:  
Type B = Somewhat higher than the risk of standard medical care  
4 Objectives and endpoints 
Primary objective: to assess the effect of nebulised dornase alfa on the inflammatory/immune 
responses in hospitalised participants with COVID-19 
• 
Primary endpoint:  
▪ 
Changes in acute phase reactant (C-Reactive Protein (CRP)) 
 Secondary objective: to assess the effect of nebulised dornase alfa on clinical responses in 
hospitalised participants with COVID-19 compared to control group. 
• 
Secondary endpoints: 
▪ 
Physical exam and vital signs 
▪ 
Whole blood count and differential count 
▪ 
Incidence of Mechanical Ventilation (MV) 
▪ 
Time on MV 
▪ 
ProCalcitonin (PCT) 
▪ 
D-dimer 
▪ 
Oxygen requirement (oxygen flow or oxygenation index) 
▪ 
Length of ICU stay [hours] 
▪ 
Length of stay in the hospital [days) 
▪ 
Incidence of multi-organ failure according to SOFA (Sepsis-related Organ Failure 
Assessment)  
▪ 
Incidence of Ventilator-Associated Pneumonia (VAP) or hospital acquired 
pneumonia 
▪ 
Acute physiology score + age points + chronic health points (APACHE score) 
▪ 
Ordinal score (WHO scoring tool) 
▪ 
Survival at Day35 

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Exploratory objective: to assess the effect of nebulised dornase alfa on inflammation, 
biomarkers of NETs, coagulation, complement activation and haemolysis in hospitalised 
participants with COVID-19  
• 
Exploratory endpoints may be measured in the circulation (blood) and, when these are 
available, in bronchial secretions (spontaneous expectorant or routine bronchoscopy 
during MV). They may include, but are not limited to:  
▪ 
Circulating pro-inflammatory cytokines (e.g. IL-6, TNFα, IL-1β, IL-8)  
▪ 
Cell-free DNA (cfDNA) 
▪ 
Circulating histone 
▪ 
Citrullinated H3 
▪ 
NET Elisa assay 
▪ 
NET formation assay 
▪ 
Coagulation (e.g fibrin, tissue factor, Von Willebrand factor, thrombin, 
thromboxane A2)  
▪ 
Complement cascade (e.g C1q) 
▪ 
Haemolysis (e.g RBC lysis) 
▪ 
Expression profiling of white blood cells by RNA seq 
5 Trial design 
5.1 
Overall design 
A single-site, randomised, controlled, parallel design, open-label investigation of an approved 
nebulised recombinant human DNase enzyme (dornase alfa) to reduce hyperinflammation in 
hospitalised participants with COVID-19 (the COVASE Trial: Figure 2). 
Participants will be screened, consented, enrolled and randomised up to 3 days after they are 
admitted to the hospital. They will be randomised in a 3:1 ratio to receive BAC + dornase alfa or 
Figure 2: COVASE Trial Schematic 

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BAC alone. A total of 40 participants will be enrolled (30 to receive BAC plus dornase alfa and 10 
to receive BAC). On Day1 to Day7 of the trial, participants randomised to the active arm, will 
receive 2.5mg BID nebulised dornase alfa in addition to BAC. On Day1, Day3, Day5 and Day7, 
blood samples will be drawn in both trial arms in order to test pharmacodynamic endpoints 
(PD), biomarkers and clin labs. Clinical assessments will be undertaken daily (as per UCLH clinical 
guidelines). Participants will be followed until discharge or death or a maximum of 28 days 
follow-up.  
A sample size re-estimation is planned when 12 participants have been randomised. This 
analysis will ensure that the assumptions made in the sample size calculation remain valid. 
However, if the variability is higher than expected then up to an additional 10 participants will 
be enrolled and treated with dornase alfa (up to 50 participants in total).  
CRP has been chosen as the Primary Endpoint because it is a clinically important marker of 
inflammation and is used to make clinical treatment decisions. In addition, it is induced by the 
over-exuberant inflammation mediated by the NETs and inflammatory histones. CRP is a 
prognostic marker and correlates with clinical symptoms and response to therapy. Thus, CRP is 
at the centre of the COVID-19 disease pathway: from NETS to CRP to clinical disease 
progression.  
Based on clinical judgement, it may be decided to keep some participants on treatment for up to 
14 days. In particular, if participants have significant benefits from therapy, but show relapses of 
the COVID-19 inflammatory state (rising CRP and increasing oxygen requirements in the absence 
of bacterial infection), on completing 7 days of treatment, then the medical team have the 
choice of reinstating  dornase alfa treatment  for up to 7 further days (14 days in total). Blood 
sampling, as specified, will continue until the last day of dosing with dornase alfa. 
Study controls 
Due to the evolving situation with hospitalised COVID-19 participants, the burden on the NHS 
and the availability of other COVID-19 trials, it is considered inappropriate to conduct a placebo-
controlled study. Therefore, a randomised, controlled, open-label approach where dornase alfa 
is administered on top of BAC and compared to BAC alone has been adopted.  
The data derived from the 10 participants who are randomised to the BAC arm of the study who 
do not receive dornase alfa will provide control data for all of the study endpoints. 

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The 30 participants randomized to BAC + dornase alfa will be compared to 10 randomised 
controls from the COVASE study. In addition, 10 participants in other clinical trials on BAC (bio-
banked samples) and 60 participants from a historic database of the first 120 people with 
COVID-19 treated at UCLH will also be used as comparator data. 
However, to enhance the control group, a hybrid approach will be applied such that additional 
data will be combined with the randomised controls, illustrated in Figure 3. The sample size 
calculation indicates that 90 evaluable participants are required (60 control:30 active). These 
control data may include: data from the randomised BAC arm, historic COVID-19 UCLH 
database, biobanked samples from other ongoing trials and observational trials in COVID-19.  
This hybrid strategy allows two things:  
• 
provides comparators for all of the study objectives (including limited data for the 
exploratory objectives)  
• 
demonstrates that the historic controls are representative/similar to the study population 
Comparator data from UCLH is available as historic controls for the Primary and Secondary 
Endpoints. A database of the first 120 participants with COVID-19 admitted to UCLH is available 
and being analysed currently. CRP is routinely measured daily (or on alternate days) in all 
participants admitted to UCLH and will be used to control for the Primary Endpoint. All of the 
Secondary Endpoints are also routinely measured and will be available in the database. 
Participants in the database will be selected to act as controls as follows: 
1. 
Apply the inclusion and exclusion criteria of the COVASE study 
2. 
Additional selection to identify closest matches using a propensity score based on age, 
gender, BMI, baseline CRP, oxygen requirements and the number of comorbidities. 
At least 60 control participants are expected to be available to act as controls. 
Other ongoing and planned trials may be a source of cytokine data as well as biobanked samples 
that could be used to provide control information on the exploratory endpoints (e.g. ISARIC and 
RECOVER Trials) assuming suitable consent is available.   
   Figure 3 Comparator Data.  

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6 Off-label use of an Approved Medicinal Product (Pulmozyme) 
6.1  Recombinant Human DNase (dornase alfa) 
Genentech (a wholly owned subsidiary of Roche) and Chugai Pharmaceutical developed and 
launched an inhalation solution (Pulmozyme) of dornase alfa, a highly purified recombinant 
human deoxyribonuclease (dornase alfa), for daily administration in conjunction with standard 
therapies. The product is indicated for the management of people with cystic fibrosis (CF) to 
improve pulmonary function. Dornase alfa is safe and well tolerated in adults and children. 
Dornase alfa was launched in the US for the management of mild-to-moderate CF in 
conjunction with standard therapies in January 1994; in December 1996, the FDA expanded 
approval for use in CF participants with advanced CF. In April 1994, the drug was launched in 
the UK and Ireland, and by October 1994, it had been launched in France and Germany. In June 
2012, dornase alfa was launched in Japan for the improvement of pulmonary function in 
participants with CF. 
In December 2014, the FDA approved the eRapid Nebuliser System from PARI to deliver 
dornase alfa and to reduce treatment times (three minutes to deliver 2.5mg). 
The recommended dosage is one 2.5 mg single-use ampule inhaled once daily using a 
recommended nebuliser jet nebuliser/compressor system or eRapid™ Nebuliser System. Some 
participants (older/refractory) benefit from twice daily administration. (FDA label and EMA 
SmPC). 
The most common adverse reactions (occurring in ≥ 3% of participants treated with dornase 
alfa over placebo) seen in clinical trials in CF participants were: voice alteration, pharyngitis, 
rash, laryngitis, chest pain, conjunctivitis, rhinitis, decrease in FVC of ≥10%, fever, and 
dyspnoea. 
6.2 Source of dornase alfa, manufacture and distribution 
Dornase alfa inhalation solution is a sterile, clear, colourless solution supplied in 30 unit cartons 
containing 5 foil pouches of 6 single-use ampules. Each 2.5 mL ampule contains 2.5mg of 
dornase alfa (1 mg/mL): NDC 50242-100-40. 
Dornase alfa will be prescribed by the CI (or designee) and dispensed to patients via hospital stock. 
Alternatively, dornase alfa will be supplied directly from the manufacturer (Roche) as required. 
Handling and management of dornase alfa will be subject to standard procedures of the 
pharmacy. The dornase alfa will not be modified in any way, but administered as approved.  
6.3 Storage and handling of dornase alfa 
Dornase alfa is stored under refrigeration (2°C to 8°C/36°F to 46°F) in their protective foil to 
protect from light. Dornase alfa should not be used beyond the expiration date stamped on the 
ampule. Unused ampules must be stored in their protective foil pouch under refrigeration. 
Dornase alfa must be refrigerated during transport and not exposed to room temperatures for a 
total time of 24 hours. 

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6.4 Accountability of dornase alfa 
The Drug Accountability Log must be completed to record each dose of dornase alfa dispensed 
for each trial participant.  This log must be retained in the relevant section of the Pharmacy Site 
File, and a copy must be submitted to the sponsor upon request. It is the responsibility of the 
Pharmacy Lead to maintain drug accountability records.  
All used/unused ampules maybe returned to site pharmacy, to be then updated in the drug 
accountability log in the pharmacy site file. Following authorisation by the sponsor, drug 
destruction will be conducted in accordance to local practice, and this will be documented in the 
drug destruction log in the hospital pharmacy file. 
Detailed instructions are contained in the summary of drug arrangements. 
6.5 Concomitant medication 
Participants in the COVASE trial will continue to receive best available care (BAC) per UCLH 
guidelines. Dornase alfa will be administered in addition to BAC.  
BAC currently consists of symptomatic relief: antipyretics, analgesics and intravenous fluids if 
needed. In addition, patients may need supplemental oxygen and/or mechanical ventilation. 
There is no basis to support a drug-drug interaction risk, as this is a recombinant human protein 
that is administered directly to the lungs. Systemic exposure is very low and dornase alfa is 
cleared by proteinases present in the lungs. 
There is a potential risk that other medications administered as BAC may affect the endpoints in 
the study e.g. decrease CRP. However, this cannot be avoided and will be considered in the 
analysis plan for the data. Furthermore, a sample-size re-estimation is planned in order to take 
this potential source of unexpected variability into account. 
Concomitant medications will be recorded in the participant’s medical records/CRF. 
6.6 Post-trial IMP arrangements 
No specific arrangements required. 
7 Selection of participants 
People who are at high probability of COVID-19 and admitted to hospital will be identified from 
inpatient lists and approached, pending COVID PCR results (12 hours). They will be given a 
patient information sheet (PIS) with details of the clinical trial to read before deciding on entry 
into the COVASE trial. 
7.1 Eligibility of trial participants 
7.1.1 Trial participant inclusion criteria 
1. 
Male and female participants, aged ≥ 18 years  

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2. 
Participants who are hospitalised for suspected Coronavirus (SARS-CoV)-2 infection 
confirmed by polymerase chain reaction (PCR) test or radiological confirmation with 
chest CT    
3. 
Participants with stable oxygen saturation (>=94%) on supplementary oxygen  
4. 
CRP >= 30 mg/L 
5. 
Participants will have given their written informed consent to participate in the study 
and are able to comply with instructions and nebuliser 
7.1.3 Trial participant exclusion criteria 
1. 
Females who are pregnant, planning pregnancy or breastfeeding 
2. 
Concurrent and/or recent involvement in other research or use of another experimental 
investigational medicinal product that is likely to interfere with the study medication 
within (specify time period e.g. last 3 months) of study enrolment 
3. 
Serious condition meeting one of the following:  
i. Respiratory distress with respiratory rate >=40 breaths/min  
ii. oxygen saturation<=93% on high-flow oxygen 
4. 
Require mechanical invasive or non-invasive ventilation at screening  
5. 
Concurrent severe respiratory disease such as asthma, COPD and/or ILD 
6. 
Any major disorder that in the opinion of the Investigator would interfere with the 
evaluation of the results or constitute a health risk for the trial participant 
7. 
Terminal disease and life expectancy <12 months without COVID-19  
8. 
Known allergies to dornase alfa and excipients  
9. 
Participants who are unable to inhale or exhale orally throughout the entire nebulisation 
period 
7.2 Recruitment 
Participants will be recruited from inpatients at UCLH. 
Participant recruitment will only commence when the trial has been issued with the ‘Open to 
Recruitment’ letter by the Sponsor. 
Recruitment rate is estimated to range from 3 to 6 participants per week. Recruitment is 
estimated to take 12-15 weeks. 
7.3 Informed consent procedure 
It is the responsibility of the Investigator, or a person delegated by the Investigator to obtain 
written informed consent from each participant prior to participation in the trial, following 
adequate explanation of the aims, methods, anticipated benefits and potential hazards of the 
trial.  
The person taking consent will be GCP trained, suitably qualified and experienced, and will have 
been delegated this duty by the CI/ PI on the Staff Signature and Delegation of Tasks. 
“Adequate time” must be given for consideration by the participant before taking part. Due to 
the rapidly escalating situation, consent will be sought after giving the participant adequate time 

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to consider their decision after being given the study documentation. Patients will be given 
additional time up to 18 hours if needed. It must be recorded in the medical notes when the 
participant information sheet (PIS) has been given to the participant.  
The Investigator or designee will explain that participants are under no obligation to enter the 
trial and that they can withdraw at any time during the trial, without having to give a reason. 
No clinical trial procedures will be conducted prior to the participant giving consent by signing the 
Consent form. Consent will not denote enrolment into trial.  
A copy of the signed informed consent form will be given to the participant.  The original signed 
form will be retained in the trial file at site and a copy placed in the medical notes. 
The PIS and consent form will be reviewed and updated if necessary, throughout the trial (e.g. 
where new safety information becomes available) and participants will be re-consented as 
appropriate.  
8 Trial procedures  
8.1 Pre-treatment Assessments  
The following trial specific procedures will be carried out after consent and within 3 days of 
treatment to assess the participant’s eligibility:  
• 
Informed consent 
• 
Medical history  
• 
Physical examination  
• 
Vital signs  
• 
Pregnancy test (urine) 
• 
Whole blood count and differential 
• 
Oxygen saturation and record oxygen delivery device if applicable (can be repeated if 
necessary) 
• 
Oxygen requirement 
• 
Blood draw for PD 
• 
Blood draw for biomarkers 
• 
Clinical Laboratory assessments including CRP, d-dimer and PCT (can be repeated if 
necessary) 
• 
Concomitant medications 
All pre-treatment procedures will be carried out as specified in the schedule of assessments 
(Appendix 1). 
8.2 Randomisation Procedures  
Participant randomisation will be undertaken centrally by an  independent statistician (ie not 
the trial statistician) using SAS PROC PLAN according to SOPs. The randomisation schedule will 
be maintained in a secure, password protected environment, inaccessible to others supporting 
the trial. 
 

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Following participant consent, and confirmation of eligibility (see section 8.1 for pre-treatment 
assessments) the randomisation procedure described below will be carried out.  
Participants are considered to be enrolled into the trial following: consent, pre-treatment 
assessments (see section 8.1), confirmation of eligibility, completion of the randomisation 
process, allocation of the participant trial number and treatment by the central coordinating 
team.  
8.3 Treatment Schedule 
Dornase alfa will be nebulised at 2.5mg twice per day (12 ± 3 hours apart) for seven days using 
either: 
• 
the recommended eRapid Nebuliser System, consisting of the eRapid™ Nebuliser Handset 
with eBase™ Controller OR 
• 
a jet nebuliser connected to an air compressor with an adequate air flow and equipped 
with a mouthpiece (Table 1). 
Table1 Recommended Jet Nebulisers/Compressors 
Jet nebuliser 
Compressor 
Hudson T Up-draft II with  
Marquest Acorn II with  
PARI LC Plus with  
Durable Sidestream with  
Durable Sidestream with  
Pulmo-Aide  
Pulmo-Aide  
PARI PRONEB  
MOBILAIRE™  
Porta-Neb 
8.3.1 Dose modifications 
Based on clinical judgement, it may be decided to extend the dosing period for some 
participants. For example, a change from 2.5mg BID for 7 days to 2.5mg BID for up to 14 days. 
In particular, if participants have significant benefits from therapy, but show relapses of the 
COVID-19 inflammatory state (rising CRP and increasing oxygen requirements in the absence of 
bacterial infection), on completing 7 days of treatment, then the medical team have the choice 
of reinstating dornase alfa treatment for up to 7 further days (14 days in total) at 2.5mg BID. 
Blood sampling will continue until the last day of dosing with dornase alfa. 
8.4 Subsequent assessments and procedures 
8.4.1 Schedule of assessments 
The following assessments and procedures will take place on Day1, Day3, Day5 and Day7 of 
dosing. In participants who remain on treatment beyond Day7, assessments will occur on Day9, 
Day11 and Day14 of dosing. 
o Eligibility confirmation (at Day1 only) 
o Physical examination  

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o Vital signs (Blood pressure, heart rate, temperature, respiration rate) 
o Whole blood count and differential 
o Oxygen saturation and record oxygen delivery device if applicable 
o Oxygen requirement (oxygen flow or oxygenation index) 
o Blood draw and bronchial secretions (when available) for PD 
o Blood draw and bronchial secretions (when available) for biomarkers 
o Clinical Laboratory assessments including CRP, d-dimer and PCT (can be 
repeated if necessary) 
o Multi-organ failure according to SOFA (Sepsis-related Organ Failure 
Assessment) 
o Acute physiology score + age points + chronic health points (APACHE score) data 
that has been collected to calculate this score. 
o Ordinal score (WHO scoring tool) 
o Adverse Events review 
o Concomitant Medication review 
Other assessments to be recorded if/when they occur: 
• 
Length of ICU stay (hours) 
• 
Length of stay in the hospital (days) 
• 
Length of time on mechanical ventilation (days) 
• 
Ventilator-associated pneumonia (VAP) or hospital-acquired pneumonia 
• 
Survival (days) 
Assessments/procedures at follow-up. These assessments and procedures will occur before the 
participant is discharged from the hospital or Day35, whichever comes first.  
o Physical examination  
o Vital signs (Blood pressure, heart rate, temperature, respiration rate) 
o Pregnancy test (urine) 
o Whole blood count and differential 
o Oxygen saturation and record oxygen delivery device if applicable 
o Oxygen requirement (oxygen flow or oxygenation index) 
o Blood draw for PD 
o Blood draw for biomarkers 
o Clinical Laboratory assessments including CRP, d-dimer and PCT (can be 
repeated if necessary) 
o Multi-organ failure according to SOFA (Sepsis-related Organ Failure 
Assessment) 
o Acute physiology score + age points + chronic health points (APACHE score) data 
that has been collected to calculate this score. 
o Ordinal score (WHO scoring tool) 
o Adverse Events review (daily) 
o Concomitant Medication review 
Other assessments to be recorded if/when they occur: 
• 
Length of ICU stay (hours) 
• 
Length of stay in the hospital (days) 
• 
Length of time on mechanical ventilation (days) 
• 
Ventilator-associated pneumonia (VAP) or hospital-acquired pneumonia 

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• 
Survival (days) 
In participants who are discharged before Day35, a telephone call will occur at Day35 to ask them 
about their breathing e.g. Are you short of breath? Has your breathing returned to the same level 
as previously? 
A schedule of all trial assessments and procedures is set out in Appendix 1. 
8.5 Laboratory Assessments and Procedures 
Local laboratories will be used for the primary and secondary assessments and procedures.  These 
include  CRP, whole blood count and differential count, proCalcitonin (PCT), and D-Dimer. The 
samples will be taken as per hospital standard procedures as part of routine clinical care. 
The following tests will be carried out at Local Laboratories:  
Laboratory test 
Parameters 
BLOOD 
Haematology 
 
leukocytes, erythrocytes, haemoglobin, haematocrit, mean 
corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), 
platelets, neutrophils, eosinophils, basophils, lymphocytes, 
monocytes 
 
Serum chemistry 
 
glutamate pyruvate transaminase (GPT / ALAT), glutamic-
oxaloacetic transaminase (GOT / ASAT), gamma-glutamyl 
transferase (gamma-GT), alkaline phosphatase, total bilirubin, 
creatinine, chloride, potassium, sodium, total protein, albumin, 
Lactate, Renal function: (Creatinine, Urea and Na, K, Cl), Clotting 
screen including Prothrombin time, Bone profile (ca2+), High-
sensitivity troponin, Ferritin, LDH, Creatinine   
Biomarkers 
CRP, PCT, D-dimer 
 
PD and biomarkers (exploratory) samples 
The volume of blood required for PD and biomarkers exploratory endpoints is 10ml.  
When it is available, bronchial secretions may be collected to measure PD and biomarkers. The 
bronchial secretion will be obtained due to spontaneous expectoration or route clinical 
bronchoscopy during MV. 
All samples for exploratory endpoints (biomarkers and PD) will be labelled with the unique 
identifying number (UIN) prior to transfer to The Francis Crick Institute. Samples will be stored 
in secure UCL research facilities with restricted access under the custodianship of the Chief 
Investigator or designee until the samples are shipped by courier. 
Transfer of samples for exploratory endpoints (biomarkers and PD)  to The Francis Crick 
Institute will be subject to a laboratory agreement in which the Francis Crick Institute will be 
responsible for restricting use of the samples and data to agreed purposes, maintenance of 
confidentiality and data security, reporting publications and other outputs to the chief 
investigator of this trial and restricting onward transfer of samples to a third party.  

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PD and biomarker samples will be collected under the supervision of the Chief Investigator (or 
designee) and send to The Francis Crick Institute with courier to a dedicated person in the 
laboratory of Dr Veni Papayannopoulos. Blood (up to 10 mL – vacutainers- heparin or EDTA) 
and bronchial secretions will be transferred to The Francis Crick institute.  Samples will be 
processed and stored for further analysis in the Francis Crick Institute Freezer Farm. Tracking 
of samples will be done with Freezerpro data base. Research samples will be processed in the 
Crick laboratories by designated research staff within an SOP (COVASE SOP) under the 
supervision of Dr Veni Papayannopoulos.  
Exploratory samples (blood draw and bronchial secretion for PD and biomarkers – Appendix I)  
Sample processing:  
1) Leukocyte pelleting for RNA extraction and sequencing (biomarker). 
2) Plasma collected for: Haemolysis (biomarker); cytokine analysis by ELISA and multiplex panel 
for 67 markers of inflammation ( biomarker); coagulation  markers such fibrin, tissue factor, 
Von Willebrand factor, thrombin, thromboxane A2 (biomarker),  complement cascade markers 
such as C1q, (biomarker), quantification of NETs  by NET ELISA ( PD) , quantification of cell-free 
DNA (PD) and in vitro NET formation assays (biomarker). 
3) Plasma samples denatured and boiled in SDS for Western immunoblotting to assess 
neutrophil markers such as neutrophil elastase; myeloperoxidase; histones; citrullinated H3. 
(PD). 
4) Bronchial secretions will be processed according to local procedures for the measurement 
of biomarkers. 
These samples will be handled at containment level 2 according to local guidelines. 
 Total blood draw/participant 
treatment arm 
blood at each 
timepoint 
number of blood 
draw timepoints 
Number of days 
in the trial 
total blood over 
the trial 
BAC for 7 days 
30mL 
6 
35 days 
180mL 
Dornase alfa for 7 
days 
30mL 
6 
35 days 
180mL 
Dornase alfa for 
14 days 
30mL 
 9 
35 days 
up to 270mL 
8.6 Clinical Procedures and Data Collection 
All study procedures will be carried out by UCLH medical staff in the hospital and as specified in 
UCLH guidelines. 
Medical examination:   The following sites will be examined:  head, neck, ears, nose, throat, eyes, 
chest, lungs, heart, abdomen, skin, and lymph nodes; and the following systems will be assessed:  
musculoskeletal and neurological. 

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8.7 Assessment of dornase alfa compliance 
Monitoring (e.g. watching participant inhale dornase alfa) and recording this appropriately. 
8.8 Discontinuation/withdrawal of participants 
In consenting to participate in the trial, participants are consenting to trial treatment, 
assessments, follow-up and data collection.  
Discontinuation of trial treatment for clinical reasons 
A participant may be withdrawn from trial treatment whenever continued participation is no 
longer in the participant’s best interests, but the reasons for doing so must be recorded.  Reasons 
for discontinuing treatment may include: 
• 
Alternative clinical diagnosis emerges (no longer considered to have primary COVID-19 
lung disease).  
• 
Disease progression whilst on therapy. 
• 
Unacceptable toxicity. 
• 
Intercurrent illness which prevents further treatment. 
• 
Patients withdrawing consent to further trial treatment. 
• 
Any alterations in the participant’s condition which justifies the discontinuation of 
treatment in the CI’s or designee’s opinion. 
• 
Persistent non-compliance to protocol requirements. 
• 
Participant is put on end of life pathway and dies prior to dosing. 
The decision to withdraw a participant from treatment must be recorded in the CRF and medical 
notes, and the sponsor when required should be notified in writing. 
Participant withdrawal from trial treatment or follow-up 
If a participant expresses their wish to withdraw from trial treatment or follow-up, sites should 
explain the importance of remaining on trial follow-up and seek permission to allow use of routine 
follow-up data to be used for trial purposes.  The importance of safety follow-up should be 
emphasised to the participant in the Participant Information Sheet. 
The decision of the participant to withdraw from treatment or follow-up must be recorded in the 
CRF and medical notes. 
The participant may withhold their reason for withdrawal however, if the participant gives a 
reason for their withdrawal, this should be recorded. 
Withdrawal of consent to data collection  
If a participant explicitly states that they do not wish to contribute further data to the trial their 
decision will be respected and recorded in the CRF and medical notes.  
8.9 Replacements 
40 evaluable participants are required to meet the primary endpoint, Therefore, if a participant 
withdraws or is withdrawn, a replacement participant may be enrolled to the same treatment 
arm. 

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8.10 Stopping rules  
The trial may be stopped before completion on the recommendation of the sponsor and CI and 
following guidance from the DMC following an interim analysis or at any stage during the study. 
8.11 Definition of end of trial 
Recruitment rate is estimated to range from 3 to 6 participants per week. Recruitment is 
estimated to take 12-15 weeks. 
The expected duration of the trial is 3 – 4 months from recruitment of the first participant to last 
follow-up visit. 
The end of trial is the date of the last visit of the last participant. 
9 Recording and reporting of adverse events and reactions 
Collection, recording and reporting of adverse events (including serious and non-serious events 
and reactions) to the sponsor will be completed according to the sponsor’s SOP (INV/S05). 
9.1 Definitions 
 
Term 
Definition 
Adverse Event (AE) 
Any untoward medical occurrence in a participant administered 
dornase alfa and which does not necessarily have a causal relationship 
with this treatment. Therefore, an AE can be any unfavourable or 
unintended change in the structure (signs), function (symptoms) or 
chemistry (laboratory data) in a participant to whom dornase alfa has 
been administered, including occurrences which are not necessarily 
caused by or related to that product. 
Adverse Reaction (AR) 
Any untoward and unintended response in a participant to dornase alfa 
which is related to any dose administered to that participant.  
This includes medication errors, uses outside of protocol (including 
misuse and abuse of product) 
Serious Adverse Event 
(SAE), Serious Adverse 
Reaction (SAR) or 
Unexpected Serious 
Adverse Reaction  
Any adverse event, adverse reaction or unexpected adverse reaction, 
respectively, that: 
• 
results in death, 
• 
is life-threatening*, 
• 
requires prolongation of existing hospitalisation**, 
• 
results in persistent or significant disability or incapacity, or 
• 
consists of a congenital anomaly or birth defect 

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* A life-threatening event, this refers to an event in which the 
participant was at risk of death at the time of the event; it does not refer 
to an event which hypothetically might have caused death if it were 
more severe. 
** Hospitalisation is defined as an in-patient admission, regardless of 
length of stay. Hospitalisation for pre-existing conditions, including 
elective procedures do not constitute an SAE. 
Some medical events may jeopardise the subject or may require an 
intervention to prevent one of the above characteristics/consequences. 
Such important medical events should also be considered as serious. 
The term “severe” is often used to describe the intensity of an event or 
reaction (e.g. mild, moderate or severe) and should not be confused or 
interchanged with the term “serious”. 
Suspected Unexpected 
Serious Adverse 
Reaction (SUSAR) 
 A serious adverse reaction, the nature, severity or outcome of which is 
not consistent with the Reference Safety Information. 
Reference Safety 
Information (RSI) 
A list of medical events that defines which reactions are expected for 
the IMP being administered to clinical trial subjects, and so do not 
require expedited reporting to the Competent Authority. It is contained 
in a specific section in the Summary of product characteristics (SmPC) 
or the Investigator Brochure (IB). 
 
9.2 Recording adverse events 
All adverse events will be assessed every day and recorded in the medical records in the first 
instance.  
All adverse events will be recorded with clinical symptoms and accompanied with a simple, brief 
description of the event, including dates as appropriate.  
Non-serious Adverse Events (AEs) and Serious Adverse Events (SAEs) related to COVID-19 will not 
be collected in the CRFs or reported to Sponsor for this trial.  
The following events listed below describe anticipated Covid-19 related AEs: 
Worsening respiratory failure, fever, venous thrombo-embolic disease, worsening respiratory 
failure, hospital-acquired secondary infection, organ-failure, lymphopenia, rising CRP, death. 
 

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9.3 Assessments of Adverse Events 
Each adverse event will be assessed for severity, causality, seriousness and expectedness as 
described below. 
9.3.1 Severity  
Category 
Definition 
Mild 
 The adverse event does not interfere with the participant’s daily routine, and 
does not require intervention; it causes slight discomfort 
Moderate 
 The adverse event interferes with some aspects of the participant’s routine, or 
requires intervention, but is not damaging to health; it causes moderate 
discomfort 
Severe 
 The adverse event results in alteration, discomfort or disability which is clearly 
damaging to health 
 
9.3.2  Causality 
The assessment of relationship of adverse events to the administration of dornase alfa is a clinical 
decision based on all available information at the time of the completion of the case report form.   
The differentiated causality assessments will be captured in the trial specific CRF/AE Log and/or 
SAE form.  
The following categories will be used to define the causality of the adverse event: 
 
Category 
Definition 
Related 
A causal relationship between an IMP/investigational treatment and an 
adverse event is at least a reasonable possibility, i.e., the relationship cannot 
be ruled out. 
Not related 
There is no reasonable possibility of a causal relationship between an 
IMP/investigational treatment and an adverse event. 
 
9.3.3 Expectedness 
Category 
Definition 
Expected 
An adverse event which is consistent with the information about dornase alfa 
listed in the  current approved Reference Safety Information (RSI) for the trial. 
Unexpected 
An adverse event which is not consistent with the information about dornase alfa 
listed in the  current approved Reference Safety Information (RSI) for the trial. 

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* This includes listed events that are more frequently reported or more severe than previously reported 
The RSI to be used to assess expectedness is section 4.8 of the SmPC for Pulmozyme (dornase alfa).  
9.3.4 Seriousness 
All events are assessed for seriousness as defined for an SAE in section 9.1.  
9.4 Procedures for recording and reporting Serious Adverse Events 
All serious adverse events (SAEs/SARs/SUSARs) will be recorded in the medical records in the first 
instance. Serious Adverse Events (SAEs) related to COVID-19 will not be collected in the CRFs or 
reported to Sponsor for this trial.  
All other SAEs will be recorded in the CRF, and the sponsor’s SAE Recording Log and SAE Reporting 
Form.  
All SAEs will be recorded from randomisation until 24h after last study dose. 
All SAEs (except Covid-19 related SAEs specified in section as not requiring reporting to the 
Sponsor), must be recorded on a serious adverse event (SAE) Reporting Form. The CI/PI or 
designated individual will complete the sponsor’s SAE form and email to the Sponsor at 
SAE@ucl.ac.uk, within 24 h of his/her becoming aware of the event. The Chief or Principal 
Investigator or designee will respond to any SAE queries raised by the sponsor as soon as possible.  
 
 
 
 
Completed SAE forms must be sent within 24 hours of becoming 
aware of the event to the Sponsor  
Email forms to SAE@ucl.ac.uk  
 

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Flow Chart for SAE reporting 
 

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9.5 Serious Adverse Events which do not require immediate reporting  
The following events listed below describe anticipated COVID-19 related AEs: 
Worsening respiratory failure, fever, venous thrombo-embolic disease, worsening respiratory 
failure, hospital-acquired secondary infection, organ-failure, lymphopenia, rising CRP, death. 
These SAEs will be RECORDED in the participants’ medical notes.  They will not be recorded in the 
CRF or SAE Recording Log and SAE Reporting Forms will not be completed and sent to the sponsor.  
If the frequency or severity of these events is not consistent with the COVID-19 , the event must 
be reported to the sponsor as an SAE in the normal way. 
9.6 Reporting SUSARs 
The sponsor will notify the main REC and MHRA of all SUSARs.  SUSARs that are fatal or life-
threatening must be notified to the MHRA and REC within 7 days after the sponsor has learned of 
them.  Other SUSARs must be reported to the REC and MHRA within 15 days after the sponsor 
has learned of them.   
9.7 Development Safety Update Reports 
The sponsor will provide the main REC and the MHRA with Development Safety Update Reports 
(DSUR) which will be written in conjunction with the trial team and the Sponsor’s office. The 
report will be submitted within 60 days of the Developmental International Birth Date (DIBD) of 
the trial each year until the trial is declared ended. 
9.8 Pregnancy 
Pregnancy is considered to be highly unlikely during the study as participants are hospitalised for 
the duration of the trial. 
There are no adequate and well-controlled studies with dornase alfa in pregnant women. 
However, animal reproduction studies have been conducted with dornase alfa. In these studies, 
no evidence of foetal harm was observed in rats and rabbits at doses of dornase alfa up to 
approximately 600 times the maximum recommended human dose (MRHD). 
It is not known whether dornase alfa is present in human milk. In a pharmacokinetic study in 
Cynomolgus monkeys, levels of dornase alfa detected in milk were less than 0.1% of the maternal 
serum concentration at 24 hours after dosing [intravenous bolus dose (0.1 mg/kg) of dornase alfa 
followed by an intravenous infusion (0.080 mg/kg/hr) over a 6-hour period] on post-partum day 
14.  
Dornase alfa is not contra-indicated in pregnancy or lactation. 
In the unlikely event that a female participant or the female partner of a male participant becomes 
pregnant at any point during the trial, a completed trial specific Pregnancy Reporting Form will be 
preferably emailed to the Sponsor SAE@ucl.ac.uk, within 24 hours of his / her becoming aware 

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of the event in line with the Sponsors SOP (JRO/INV/S05). The Chief or Principal Investigator or 
designee will respond to any queries raised by the sponsor as soon as possible.   
 
 
The Sponsor must be kept informed of any new developments involving the pregnancy through 
the completion of a follow-up Pregnancy Reporting Form. Any pregnancy that occurs in a female 
trial subject during a clinical trial should be followed to termination or to term. 
Consent to report information regarding the pregnancy must be obtained from the pregnant 
participant.  A trial-specific pregnancy monitoring information sheet and informed consent form 
for trial participants and the partners of trial participants must be used for this purpose.   
With consent additional information regarding the pregnancy will be collected and reported to 
the Sponsor, the Sponsor will advise on the length of follow up of the pregnancy/child on a case 
by case basis. 
9.9 Overdose  
Overdose is unlikely as dornase alfa will be administered by hospital staff.  
Cystic fibrosis participants have received up to 20mg BID for up to 6 days and 10mg BID 
intermittently (2 weeks on/2 weeks off drug) for 168 days. These doses were well tolerated. 
Prescribing information 
https://www.gene.com/download/pdf/pulmozyme_prescribing.pdf 
9.10 Reporting urgent safety measures and other safety events 
If any urgent safety measures are taken the CI/PI or designee shall immediately and in any event 
no later than 3 days from the date the measures are taken, give written notice to the MHRA, the 
relevant REC and Sponsor of the measures taken and the circumstances giving rise to those 
measures. 
9.11 Notification of serious breaches to GCP and/or the protocol (SPON/S15)  
 A “serious breach” is a breach which is likely to affect to a significant degree: 
(a) the safety or physical or mental integrity of the participants of the trial, or 
(b) the scientific value of the trial. 
The sponsor of a clinical trial shall notify the licensing authority in writing of any serious breach 
of: 
(a) the conditions and principles of GCP in connection with that trial, or  
Completed Pregnancy Reporting Forms must be sent within 24 
hours of becoming aware of the event to the Sponsor  
Email forms to SAE@ucl.ac.uk  

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(b) the protocol relating to that trial, as amended from time to time, within 7 days of becoming 
aware of that breach. 
The sponsor will be notified immediately of any case where the above definition applies during 
the trial conduct phase.  The sponsor’s SOP on the ‘Notification of violations, urgent safety 
measures and serious breaches’ will be followed.  
10 Data management and quality assurance 
10.1 Confidentiality 
All data will be handled in accordance with the UK Data Protection Act 2018. 
The Case Report Forms (CRFs) will bear the participant’s initials and UIN.  All reports and other 
results are strictly confidential and access is restricted to relevant healthcare professionals. All of 
the participant’s data will be pseudo-anonymised (according to standard operating procedures) 
prior to sending data externally for analysis. This will be clearly explained to the participant in the 
Patient information sheet.   
Patient consent for this will be sought. 
10.2 Data collection tools and source document identification 
Data will be collected on Trial specific case report forms (CRFs) or data collection tools such as 
CRFs.   
Source data are contained in source documents and must be accurately transcribed on to the CRF. 
Examples of source documents are medical records which include laboratory and other clinical 
reports etc. 
A source document list will be implemented prior to the start of the trial to identify: 
which data is to be recorded directly onto the CRF;  
which data is recorded firstly into source documents, such as medical notes, and then transcribed 
into the CRF; and   
which data is not to be recorded in the CRF, but only recorded in source documents, e.g., 
participant questionnaires and diary cards.  
10.3 Completing Case Report Forms  
All CRFs must be completed and signed by staff that are listed on the site staff delegation log and 
authorised by the CI/PI or designee to perform this duty.  The CI/PI or designee is responsible for 
the accuracy of all data reported in the CRF. 
10.4 Data handling and analysis 
A trial specific data management SOP will be in place for the trial. This will contain details of the 
software to be used for the database, the process of database design, data entry, data quality 
checks, data queries, data security, database lock and data transfer. 

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Where data are transferred electronically this will be in accordance with the UK Data Protection 
Act 1998 as well as UCL Information Security Policy and Trust Information Governance Policy.  
There will be a documented record of data transfer and measures in place for the recovery of 
original information after transfer. 
11 Statistical Considerations  
11.1 Outcomes 
11.1.1 Primary outcomes 
The primary endpoint is the change from baseline in acute phase reactant (C-Reactive Protein 
(CRP)).  This will be measured according to the assessment schedule in section 8.4.1.  This 
endpoint is on a continuous scale.   
11.1.2 Secondary outcomes 
There are multiple secondary endpoints which will be measured according to the assessment 
schedule in 8.4.1. 
Some of these endpoints are based on change from baseline and are repeated, continuous 
measures: 
• 
Whole blood count and differential count 
• 
ProCalcitonin (PCT) 
• 
D-dimer 
• 
Oxygen requirement (oxygen flow or oxygenation index) 
There is one survival endpoint which is censored/truncated time to event data. 
Other secondary endpoints are continuous, absolute measures that are derived only at the end 
of the assessment period:   
• 
Time on MV 
• 
Length of ICU stay [hours] 
• 
Length of stay in the hospital [days). 
The remaining endpoints are on a binary or ordinal scale:  
• 
Incidence of MV 
• 
Incidence of multi-organ failure according to SOFA (Sepsis-related Organ Failure 
Assessment)  
• 
Incidence of Ventilator-Associated Pneumonia (VAP) or hospital acquired pneumonia 
• 
Ordinal score (WHO scoring tool). 

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11.2 Sample size and recruitment 
11.2.1  Sample size calculation 
Sample size calculations were produced using the proc power function in SAS Version 9.4. These 
were conducted to achieve 80% power to detect difference in the active arm versus the control 
group at the 5% level of significance.  Based on a mean of 99mg/L in the control group and a 
common standard deviation of 62mg/L derived from the literature (Han et al., 2020; Zhou, 
2020), a total sample size of 90 participants would provide sufficient power to detect a greater 
than a 40% relative difference for  CRP in the dornase alfa group compared to the control group.  
Given the reported average values in severe and non-severe participants and on clinical 
observations from COVID-19 patients, this difference would be achievable and clinically 
relevant.   
   
This study will use existing data collected at UCLH from participants admitted with COVID-19 as a 
comparator group.  Participants in the database will be selected to act as controls as follows: 
• 
Apply the inclusion and exclusion criteria of the COVASE study 
• 
Additional selection to identify closest matches  
 
This will give the correct ratio of active versus comparator (ratio of 1:2).  To achieve the required 
power, this would result in 30 participants in the active treatment group and at least 60 in the 
control.  An additional 10 participants will be recruited as a control for the exploratory 
objectives and to compare the characteristics of enrolled participants with the historical 
controls.  This gives a total of 40 participants enrolled in the study and 60 historical controls. 
 
Participants who drop out of the study will be replaced so the sample size relates to the number 
of evaluable participants required.    
A re-estimation of the sample size will be carried following an interim analysis when 12 
participants have been randomised.   
11.2.2 Planned recruitment rate 
The anticipated recruitment rate is 3-5 participants per week at UCLH.  To obtain 40 participants, 
the recruitment period is likely to last between 8 and 14 weeks.  Given the paucity of treatment 
options and the observed number of cases, the sample size should be easily attainable. 
Randomisation methods 
Subjects will be allocated to dornase alfa or BAC in a 3:1 ratio in accordance with the 
randomisation schedule. The randomisation schedule will be based on permuted block 
randomisation produced using SAS PROC PLAN.  Block sizes will vary in multiples of 4.   
11.3 Statistical analysis plan 
11.3.1 Summary of baseline data and flow of participants 
All subjects enrolled in the study will be accounted for in a CONSORT diagram. There will be 
multiple analysis populations: 

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1 Primary analysis population - all evaluable patients randomised to dornase alfa + matched 
historical comparators. 
2 Per protocol population - as above but excluding protocol violations. 
3 Safety population - all enrolled patients receiving at least one dose of dornase alfa and the 
comparator groups. 
4 Comparator population - the matched historical controls, patients randomised to BAC and 
historical records linked to biobanked samples. 
5 Exploratory analysis population - all evaluable patients randomised to dornase alfa or to BAC 
plus historical patient data from biobanked samples. 
The primary analysis will be conducted using the primary analysis population and is based on the 
ITT principle.  Details on subjects enrolled but not included in the analysis populations will be 
presented as part of the CONSORT diagram. 
The key baseline data that will be used to compare the groups and the analysis populations are 
age, gender, BMI, baseline CRP, oxygen requirements and the number of comorbidities.  In 
general, continuous data will be summarised using the mean, standard deviation, median, 
minimum and maximum and categorical data will be represented as frequency counts and 
percentages. 
11.3.2 Primary outcome analysis 
The primary outcome analysis will involve the primary endpoint and the primary analysis 
population.  The endpoint will be summarised overall, by treatment group and by day. Data will 
be summarised using the mean (standard deviation), median (1st and 3rd quartiles), minimum 
and maximum, and 95% confidence intervals.  
The primary endpoint will be compared between groups using a repeated measures mixed model, 
adjusted for age, gender, BMI, baseline value, oxygen requirements, time from baseline, and the 
number of comorbidities and with treatment as the main effect and treatment by time as an 
interaction effect.  Prior to analysis, the primary endpoint will be assessed for conformance to 
normality assumptions and the appropriate transformation will be conducted if necessary.   This 
model-based approach is likely to be more robust to missing or spurious data.  Treatment effect 
will be declared significant at the 5% level of significance.   
The primary analysis population comprises the active treatment group and historical matched 
controls.  The matching procedure will include an initial application of the study inclusion and 
exclusion criteria to identify the subjects that meet the criteria within the database.  Further 
matching will involve the use of propensity scores to select the 60 controls that most closely 
match with participants in the active treatment group.  The propensity score model will include 
age, gender, BMI, baseline CRP, oxygen requirements and the number of comorbidities and two 
controls will be matched for each participant in the active group.  

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11.3.3 Secondary outcome analysis 
This study was not powered to detect any effects relating to secondary endpoints.  Therefore, the 
secondary analysis will involve descriptive statistics.  In general, continuous data will be 
summarised using the mean (standard deviation), median (1st and 3rd quartiles), minimum and 
maximum, and categorical data will be represented as frequency counts (percentages). 
A further comparison of the secondary endpoints will involve the appropriate general linear 
models for binary, continuous or ordinal data with age, gender, BMI, baseline value, oxygen 
requirements and the number of comorbidities as covariates and treatment as a main effect.  This 
will provide the adjusted means and 95% confidence intervals for the endpoint in the active and 
control groups.  The same model will be used to estimate the difference between the groups and 
the associated confidence interval.  
Continuous endpoints will be assessed for conformance to normality assumptions and the 
appropriate transformation will be conducted if necessary.   
A survival analysis will be conducted on the time to event data.  The Kaplan-Meier method will be 
used to estimate the median survival times and the associated 95% confidence intervals.  The time 
to event data will be censored at 28 days post last dose (Day35) for the randomised participants 
and at the date of the last electronic record for the historical control group.  The survival model 
will include treatment as a stratification variable.  A cox proportional hazards model will be used 
to generate a hazard ratio and associated confidence intervals, adjusting for age, gender, BMI, 
baseline value, oxygen requirements and the number of comorbidities as covariates and 
treatment as a main effect. 
The secondary outcome analysis will use the primary analysis population. 
11.3.4 Sensitivity and other planned analyses 
All primary and secondary analyses will be repeated using the primary analysis population and 
the per protocol population.  The use of the per protocol population is only as a sensitivity 
analysis to understand the impact of non-compliance. 
This study utilises a combination of enrolled and randomised participants, historical controls and 
banked biosamples.  Descriptive statistics will be produced for key baseline variables for all data 
sources within the comparator population.  These will be used to evaluate the comparability of 
the source data. 
There are planned subgroup analyses that relate to secondary objectives.  A comparison of the 
secondary endpoint, time on MV, between treatment groups will be conducted only in 
participants that received MV.  Other subgroup analyses may be performed but these are 
considered to be exploratory. 
Further exploratory analyses are planned for the exploratory endpoints in the study.  These 
analyses will follow the same principles and considerations with regards to the application of 
statistical approaches for specific data types and data structures.  The exploratory analyses will 
use the exploratory analysis population.    

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Full details of the planned statistical analysis will be presented in a separate Statistical Analysis 
Plan (SAP).  This will be finalised prior to database lock.  The results from all analyses will be 
presented in the form of tables, figures and listings. 
11.4 Interim analysis 
An interim analysis will be conducted when 12 participants have been randomised.  The results 
of the interim analysis will be used to re-estimate the sample size if necessary. The interim 
analysis will be conducted by an independent statistician in a secure, password protected 
environment.  The analysis will involve the production of descriptive statistics for the primary 
endpoint, AEs and baseline characteristics by study population and by treatment.  No formal 
statistical comparison between the treatment groups will be performed.  The sample size re-
estimation may result in the recruitment of more subjects than originally planned but not less. 
11.5 Other statistical considerations 
Any deviation from the original statistical plan will be described and justified in the final report, 
as appropriate. 
12 Record keeping and archiving 
At the end of the trial, all essential documentation will be archived securely by the CI and trial 
sites for a minimum of 25 years from the declaration of end of trial.  
Essential documents are those which enable both the conduct of the trial and the quality of the 
data produced to be evaluated and show whether the site complied with the principles of Good 
Clinical Practice and all applicable regulatory requirements.  
The sponsor will notify sites when trial documentation can be archived. All archived documents 
must continue to be available for inspection by appropriate authorities upon request.  
13 Oversight committees  
13.1 Data Monitoring Committee (DMC) 
The role of the DMC is to provide advice on data and safety aspects of the trial but not all members 
are independent.  The members consist of the CI, a sponsor physician and a statistician or their 
respective designees. Meetings of the Committee will be held weekly to review emerging data as 
well as the results of the interim analysis (Interim Analysis section 11.4), or as necessary to address 
any issues.  The DMC may recommend stopping the study at the interim analysis (or at any stage 
of the study). 
14 Direct Access to Source Data/Documents 
The investigator(s)/institution(s) will permit trial-related monitoring, audits, REC review, and 
regulatory inspection(s), providing direct access to source data/documents.  Trial participants are 
informed of this during the informed consent discussion.  Participants will consent to provide 
access to their medical notes. 

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15 Ethics and regulatory requirements 
The sponsor will ensure that the trial protocol, participant information sheet, consent form, GP 
letter and submitted supporting documents have been approved by the appropriate regulatory 
body (MHRA in UK) and an appropriate research ethics committee, prior to any participant 
recruitment. The protocol, all other supporting documents including and agreed amendments, 
will be documented and submitted for ethical and regulatory approval as required. Amendments 
will not be implemented prior to receipt of the required approval(s).  
Before the site may be opened to recruit participants, the Chief Investigator/Principal Investigator 
or designee must receive NHS permission in writing from the Trust Research & Development 
(R&D).  It is the responsibility of the CI/ PI or designee at each site to ensure that all subsequent 
amendments gain the necessary approvals, including NHS Permission (where required) at the site.  
This does not affect the individual clinician’s responsibility to take immediate action if thought 
necessary to protect the health and interest of individual participants (see section 9.10 for 
reporting urgent safety measures). 
An annual progress report (APR) will be submitted to the REC within 30 days of the anniversary 
date on which the favourable opinion was given, and annually until the trial is declared ended. 
The chief investigator will prepare the APR. 
Within 90 days after the end of the trial, the CI/Sponsor will ensure that the main REC and the 
MHRA are notified that the trial has finished.  If the trial is terminated prematurely, those reports 
will be made within 15 days after the end of the trial. 
The CI will supply the Sponsor with a report of the clinical trial which complies with the format as 
defined by the EMA. This will then be uploaded to EudraCT for availability to the MHRA and a copy 
of the report will be submitted to the main REC, within 1 year after the end of the trial (the 
exploratory endpoints will be reported separately).  
16 Monitoring requirement for the trial 
The sponsor will determine the appropriate level and nature of monitoring required for the trial.  
Risk will be assessed on an ongoing basis and adjustments made accordingly. 
The degree of monitoring will be proportionate to the objective, purpose, phase, design, size, 
complexity, blinding, endpoints and risks associated with the trial. 
A trial specific oversight and monitoring plan will be established. The trial will be monitored in 
accordance with the agreed plan. 
17 Finance 
Funding has been sought from LifeArc and outcome is pending. 
There are no financial interests by CI, PIs or trial management members in dornase alfa or the 
eRapid nebuliser. 

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18 Insurance 
University College London holds insurance against claims from participants for injury caused by 
their participation in the clinical trial. Participants may be able to claim compensation if they can 
prove that UCL has been negligent. However, as this clinical trial is being carried out in a hospital, 
the hospital continues to have a duty of care to the participant of the clinical trial.  University 
College London does not accept liability for any breach in the hospital’s duty of care, or any 
negligence on the part of hospital employees. This applies whether the hospital is an NHS Trust 
or otherwise.   
Participants may also be able to claim compensation for injury caused by participation in this 
clinical trial without the need to prove negligence on the part of University College London or 
another party.  Participants who sustain injury and wish to make a claim for compensation should 
do so in writing in the first instance to the Chief Investigator, who will pass the claim to the 
Sponsor’s Insurers, via the Sponsor’s office. 
Hospitals selected to participate in this clinical trial shall provide clinical negligence insurance 
cover for harm caused by their employees and a copy of the relevant insurance policy or summary 
shall be provided to University College London, upon request. 
Indemnity arrangements for the eRapid nebuliser will be in place, with the manufacturer, to cover 
the malfunction and breakdown of the device. 
19 Publication policy 
There will be weekly team meetings for the staff working on the project.  Data generated will be 
disseminated through medRxiv and bioRxiv and through the Breathing Matters newsletters and 
website (www.breathingmatters.co.uk and twitter feed @breathingmatter).  
20 References 
1. Barnes, Betsy J., Jose M. Adrover, Amelia Baxter-Stoltzfus, Alain Borczuk, Jonathan Cools-Lartigue, 
James M. Crawford, Juliane Daßler-Plenker, Philippe Guerci, Caroline Huynh, Jason S. Knight, 
Massimo Loda, Mark R. Looney, Florencia McAllister, Roni Rayes, Stephane Renaud, Simon 
Rousseau, Steven Salvatore, Robert E. Schwartz, Jonathan D. Spicer, Christian C. Yost, Andrew 
Weber, Yu Zuo, and Mikala Egeblad. 2020. 'Targeting potential drivers of COVID-19: Neutrophil 
extracellular traps', Journal of Experimental Medicine, 217. 
2. Cortjens, B., de Jong, R., Bonsing, J.G., van Woensel, J.B.M., Antonis, A.F.G., and Bem, R.A. (2018). 
Local dornase alfa treatment reduces NETs-induced airway obstruction during severe RSV infection. 
Thorax 73, 578-580. 
3. Gong, J., Dong, H., Xia, S.Q., Huang, Y.Z., Wang, D., Zhao, Y., Liu, W., Tu, S., Zhang, M., Wang, Q., et 
al. (2020). Correlation Analysis Between Disease Severity and Inflammation-related Parameters in 
Participants with COVID-19 Pneumonia. medRχiv. 
4. Konstan, M.W., and Ratjen, F. (2012). Effect of dornase alfa on inflammation and lung function: 
potential role in the early treatment of cystic fibrosis. J Cyst Fibros 11, 78-83. 
5. Papayannopoulos, V. (2018). Neutrophil extracellular traps in immunity and disease. Nature reviews 
Immunology 18, 134-147. 

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6. Pillai, P.S., Molony, R.D., Martinod, K., Dong, H., Pang, I.K., Tal, M.C., Solis, A.G., Bielecki, P., 
Mohanty, S., Trentalange, M., et al. (2016). Mx1 reveals innate pathways to antiviral resistance and 
lethal influenza disease. Science 352, 463-466. 
7. Zhou, F., Yu, T., Du, R., Fan, G., Liu, Y., Liu, Z., Xiang, J., Wang, Y., Song, B., Gu, X., et al. (2020). 
Clinical course and risk factors for mortality of adult inparticipants with COVID-19 in Wuhan, China: 
a retrospective cohort study. Lancet 395, 1054-1062. 
8. Zhu, L., Liu, L., Zhang, Y., Pu, L., Liu, J., Li, X., Chen, Z., Hao, Y., Wang, B., Han, J., et al. (2018). High 
Level of Neutrophil Extracellular Traps Correlates With Poor Prognosis of Severe Influenza A 
Infection. J Infect Dis 217, 428-437. 

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21 Appendix 1 - Schedule of Assessments    
Visit No. 
1 
2 
3 
4 
5 
6 to 8 
Final  
visit 8,10 
  
Day-
1 
Day1 
Day3 
Day5 
Day7 
Day9, 
Day11, 
Day14 10 
Day35 or 
discharge 11 
Window of flexibility for timing 
of visits 
±2 
days 
  
±1 
day 
±1 
day 
±1 
day 
±1 day 
±2 day 
Informed Consent 
X 
  
  
  
  
  
  
Medical History 
X 
  
  
  
  
  
  
Physical Examination 
X 
X 
X 
X 
X 
X 
X 
Vital Signs 
X 
X 
X 
X 
X 
X 
X 
Pregnancy test 1 
X 
  
  
  
  
  
X 
Clinical Laboratory assessments 
2 
X 
X 
X 
X 
X 
X 
X 
Eligibility confirmation 
  
X 
  
  
  
  
  
CRP 3 
X 
X 
X 
X 
X 
X 
X 
Whole blood count and 
differential count  4 
X 
X 
X 
X 
X 
X 
X 
ProCalcitonin (PCT) 3 
X 
X 
X 
X 
X 
X 
X 
D-Dimer 3 
X 
X 
X 
X 
X 
X 
X 
Oxygen requirement (oxygen 
flow or oxygenation index) 
X 
X 
X 
X 
X 
X 
X 
Length of ICU stay (hours) 
  
X 
X 
X 
X 
X 
X 
Length of stay in the hospital 
(days) 
  
X 
X 
X 
X 
X 
X 
Length of time on mechanical 
ventilation (days) 
  
X 
X 
X 
X 
X 
X 
Survival (days) 
  
X 
X 
X 
X 
X 
X 

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Ventilator-Associated 
Pneumonia (VAP) or hospital 
acquired pneumonia 
  
X 
X 
X 
X 
X 
X 
Acute physiology score + age 
points + chronic health points 
(APACHE score) 
  
X 
X 
X 
X 
X 
X 
Ordinal score (WHO scoring 
tool) 
  
X 
X 
X 
X 
X 
X 
Blood draw for 
pharmacodynamics (PD) 5 
X 
X 
X 
X 
X 
X 
X 
Blood draw for biomarkers 6 
X 
X 
X 
X 
X 
X 
X 
Bronchial secretion for PD and 
biomarkers 5,6, 7 
  
X 
X 
X 
X 
X 
X 
nebulised dornase alfa 
administration 8 
  
X 
X 
X 
X 
X  
 
Adverse Events review 12 
  
X 
X 
X 
X 
X 
X 
Concomitant Medication review 
X 
X 
X 
X 
X 
X 
X 
Questions about breathing 9 
  
  
  
  
  
  
X 
1. A urine pregnancy test 
2. Clinical Laboratory assessments include: glutamate pyruvate transaminase (GPT / ALAT), glutamic-
oxaloacetic transaminase (GOT / ASAT), gamma-glutamyl transferase (gamma-GT), alkaline 
phosphatase, total bilirubin, creatinine, chloride, potassium, sodium, total protein, albumin, Lactate, 
Renal function: (Creatinine, Urea and Na, K, Cl), Clotting screen including Prothrombin time, Bone 
profile (ca2+), High-sensitivity troponin, Ferritin, LDH, Creatinine   
3. CRP, PCT and D-Dimer are measured in the clinical laboratory sample 
4. Full Blood Count: leukocytes, erythrocytes, haemoglobin, haematocrit, mean corpuscular volume 
(MCV), mean corpuscular haemoglobin (MCH), platelets, neutrophils, eosinophils, basophils, 
lymphocytes, monocytes 
5. Pharmacodynamics: may include but is not limited to Cell-free DNA (cfDNA), Circulating histone, 
Citrullinated H3, NET Elisa assay 
6. Biomarkers: may include but is not limited to Circulating pro-inflammatory cytokines (e.g. IL-6, TNFα, 
IL-1β, IL-8), Markers of activation of the coagulation (e.g. fibrin, tissue factor, Von Willebrand factor, 

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thrombin, thromboxane A2) and complement cascade (e.g. C1q), haemolysis (e.g. red blood cell lysis), 
NET formation  
7. Bronchial secretions will be collected as appropriate for clinical reasons only (e.g. spontaneous 
expectorant or bronchoscopy during MV) 
8. Dornase alfa administered daily at 2.5mg BID by nebuliser 
9. In participants who are discharged prior to Day35, a follow-up telephone call will take place to ask 
about their breathing. 
10. In participants who receive dornase alfa (2.5mg BID ) beyond Day7, additional blood draws and 
procedures will take place on Day9, Day11, Day14 
11. Final study visit is at discharge or Day35 whichever comes first 
12. Adverse events will be recorded every day and not just on study visit days