A Phase 2, Open Label, Randomized Study of the Efficacy and Safety of Acalabrutinib With Best Supportive Care Versus Best Supportive Care in Subjects Hospitalized With COVID-19
Phase: PHASE2
Conditions: COVID-19
Sponsor: AstraZeneca

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Clinical Study Protocol 
Drug Substance
Acalabrutinib
Study Code
D822FC00003
Version
5.0
Date
24Jul2020
A Phase 2, Open Label, Randomized Study of the Efficacy and Safety of 
Acalabrutinib with Best Supportive Care Versus Best Supportive Care in 
Subjects Hospitalized with COVID-19
Sponsor:
Acerta Pharma B.V., a Dutch limited liability company, whose registered office is at 
Kloosterstraat 9, 5349 AB, Oss, The Netherlands, a member of the AstraZeneca group 
(“Company”)
IND Number 149513

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PROTOCOL AMENDMENT SUMMARY OF CHANGES TABLE
DOCUMENT HISTORY
Document
Date
Amendment 4 (Version 5.0)
24Jul2020
Amendment 3 (Version 4.0)
23Jun2020
Amendment 2 (Version 3.0)
13May2020
Amendment 1 (Version 2.0)
08May2020 
Original Protocol (Version 1.0)
01May2020
Amendment 4 (24Jul2020) 
The overall rationale for this amendment was to address feedback from study sites that are 
managing patient care during the COVID-19 pandemic.
In addition to the amendment changes summarized below, a few minor errors and typos were 
corrected.
Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
1.1 Schedule of 
Activities (Table 1 and 
Table 2)
Removed Day 1 column from 
both Tables 1 and 2. Made 
changes to “Daily until hospital 
discharge” column to adjust for 
this change.
Clarification
Non-substantial
1.1 Schedule of 
Activities (Table 1)
Substantial
1.1 Schedule of 
Activities (Table 2)
Substantial
1.1 Schedule of 
Activities (Table 1 and 
Table 2),
8.3 On-study 
Procedures
Added nasal swab sample 
collection for SARS-CoV-2 viral 
load/viral shedding
To clarify method of sample 
collection for SARS-CoV-2 
viral load/viral shedding
Substantial
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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
1.1 Schedule of 
Activities (Table 1),
9.6.3 Pharmacokinetic 
and Pharmacodynamic 
Analyses
Added footnote t to Table 1 and 
text to Section 9.6.3 to indicate 
that PK assessments will be 
conducted in up to 15 evaluable 
subjects and PD assessments in 
up to 15 evaluable subjects 
randomized to Arm 1 
(acalabrutinib + BSC)
Assessment in up to 
15 evaluable subjects each are
considered adequate to 
characterize the PK/active 
metabolite and PD, 
respectively, of acalabrutinib 
in the COVID-19 population
Non-substantial
1.2 Synopsis,
6.1.1 Dosing and 
Duration of Treatment,
6.1.3.1 Drug-drug 
Interactions,
6.5.4 Acalabrutinib 
Drug-drug Interaction 
Guidance in the 
Presence of Life-
threatening COVID-19 
Infection,
6.5.4.2 Active 
Substances That May 
Decrease Acalabrutinib 
Plasma Concentrations
For subjects not on PPIs, 
removed volume (240 mL) of 
water and just stated that it 
should be taken with water. For 
subjects who are on PPIs, 
changed volume of COCA-
COLA from 240 mL to “at least 
100 mL”. 
Based on in-vitro data, 
administering acalabrutinib 
100 mg oral capsules (in the 
presence of PPIs) with at least 
a 100 mL of COCA-COLA is 
considered to be adequate for 
mitigating the effect of PPIs 
on acalabrutinib PK/PD
Non-substantial
1.2 Synopsis,
4.4 Internal DMC
Added text to indicate that the 
iDMC will review safety and 
efficacy data. In addition, the 
iDMC may support any health 
authority interactions or internal 
discussions based on their 
review, and the study team will 
remain blinded to the data that 
the iDMC will review.
For transparency and to 
preserve the trial integrity
Substantial
5.2 Exclusion Criteria
Removed the cutoffs for oxygen 
flow rates from Exclusion 
Criterion 1 and indicated that 
subjects should be considered 
for eligibility in part based on 
their ability to swallow pills
Clarified which patients with 
respiratory failure are eligible 
for enrollment
Substantial

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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
Added an exception to Exclusion 
Criterion 8 to indicate that AST 
and/or ALT can be up to 5 ×
ULN if considered due to 
underlying COVID-19, but 
cannot be associated with 
concurrent elevated bilirubin (up 
to 2 × ULN)
Hepatotoxicity and ALT/AST 
are not currently adverse drug 
reactions for acalabrutinib and 
there is evidence for 
ALT/AST increases associated 
with COVID-19 (Cai et al 
2020, Guan et al 2020)
Substantial
8.1 Screening 
Assessments,
8.1.1 Informed Consent
Moved second paragraph under 
Section 8.1.1 to Section 8.1
Paragraph relates to all 
screening visits
Non-substantial
9.6. Statistical Analyses 
Added a description of the 
timing of the primary analysis of 
the study and the updated 
analysis
For clarity 
Non-substantial
ALT = alanine aminotransferase; AST = aspartate aminotransferase; BSC = best supportive care; COVID-19 = coronavirus 
disease 2019; iDMC = internal Data Monitoring Committee; PD = pharmacodynamics; PK = pharmacokinetics; PPI = proton-
pump inhibitor; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; ULN = upper limit of normal.

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TABLE OF CONTENTS
TITLE PAGE........................................................................................................................1
PROTOCOL AMENDMENT SUMMARY OF CHANGES TABLE....................................2
TABLE OF CONTENTS......................................................................................................5
1.
PROTOCOL SUMMARY ..................................................................................9
1.1
Schedule of Activities (SoA)...............................................................................9
1.2
Synopsis ...........................................................................................................17
1.3
Schema .............................................................................................................22
2.
INTRODUCTION ............................................................................................24
2.1
Background and Study Rationale ......................................................................24
2.2
Benefit/Risk Assessment...................................................................................25
3.
OBJECTIVES AND ENDPOINTS...................................................................26
4.
STUDY DESIGN .............................................................................................28
4.1
Overall Design..................................................................................................28
4.2
Scientific Rationale for Study Design................................................................29
4.3
Justification for Dose ........................................................................................29
4.4
Internal DMC....................................................................................................30
4.5
End of Study Definition ....................................................................................30
5.
STUDY POPULATION ...................................................................................31
5.1
Inclusion Criteria ..............................................................................................31
5.2
Exclusion Criteria .............................................................................................31
5.3
Screen Failures .................................................................................................34
6.
STUDY TREATMENTS..................................................................................34
6.1
Treatments Administered ..................................................................................34
6.1.1
Dosing and Duration of Treatment ....................................................................34
6.1.2
Missed Dosing Windows and Doses..................................................................34
6.1.3
Special Considerations......................................................................................35
6.1.3.1
Drug-drug Interactions......................................................................................35
6.1.3.2
Subjects With Respiratory Failure and Who Can Still Swallow Pills .................35
6.1.3.3
Subjects No Longer Able to Swallow Pills........................................................35
6.1.3.4
Vomiting After Acalabrutinib Treatment...........................................................36
6.1.3.5
Discharged From Hospital Before Treatment Completion .................................36
6.2
Acalabrutinib Preparation/Handling/Storage/Accountability .............................36
6.3
Measures to Minimise Bias: Randomisation and Blinding.................................36
6.3.1
Subject Enrollment and Randomization.............................................................37
6.3.1.1
Procedures for Handling Incorrectly Enrolled or Randomized Subjects.............37
6.3.1.2
Methods for Assigning Treatment Groups.........................................................38
6.3.1.3
Methods for Ensuring Blinding .........................................................................38

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6.4
Treatment Compliance......................................................................................38
6.5
Concomitant Therapy........................................................................................38
6.5.1
Premedications..................................................................................................38
6.5.2
Permitted Concomitant Therapy........................................................................38
6.5.3
Prohibited or Restricted Concomitant Therapy..................................................39
6.5.4
Acalabrutinib Drug-drug Interaction Guidance in the Presence of Life-threatening 
COVID-19 Infection .........................................................................................40
6.5.4.1
Active Substances That May Increase Acalabrutinib Plasma Concentrations.....40
6.5.4.2
Active Substances That May Decrease Acalabrutinib Plasma Concentrations....41
6.6
Risks Associated with Acalabrutinib.................................................................41
6.6.1
Hemorrhage ......................................................................................................42
6.6.2
Infections..........................................................................................................42
6.6.3
Hepatitis B Reactivation....................................................................................43
6.6.4
Progressive Multifocal Leukoencephalopathy ...................................................43
6.6.5
Cytopenias........................................................................................................43
6.6.6
Second Primary Malignancies...........................................................................43
6.6.7
Atrial Fibrillation..............................................................................................43
6.6.8
Reference Safety Information............................................................................44
6.7
Dose Modification and Toxicity Management...................................................44
6.7.1
Renal Impairment .............................................................................................46
6.7.2
Hepatic Impairment ..........................................................................................46
6.8
Treatment After the End of Study......................................................................46
7.
DISCONTINUATION OF TREATMENT AND SUBJECT WITHDRAWAL .47
7.1
Discontinuation of Study Treatment..................................................................47
7.2
Subject Withdrawal from the Study...................................................................47
7.3
Lost to Follow-Up.............................................................................................48
8.
STUDY ASSESSMENTS AND PROCEDURES..............................................48
8.1
Screening Assessments .....................................................................................49
8.1.1
Informed Consent .............................................................................................49
8.1.2
Demographics...................................................................................................49
8.1.3
Confirmation of Eligibility................................................................................49
8.1.4
Medical History ................................................................................................49
8.1.5
Physical Examinations and Chest Imaging, Electrocardiogram, and 
Echocardiogram................................................................................................49
8.1.6
Vital Signs ........................................................................................................50
8.1.7
Urine or Serum Pregnancy ................................................................................50
8.1.8
Laboratory Tests ...............................................................................................50
8.2
Concomitant Medications .................................................................................51
8.3
On-study Procedures.........................................................................................51
8.4
Clinical Assessments During Hospitalization ....................................................53
8.4.1
Oxygen Treatments and Ventilator Use.............................................................53
8.4.2
Modified Sequential Organ Failure Assessment (SOFA) Scores........................53
8.4.3
Assessment of Number of Days in ICU.............................................................53

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8.5
Follow Up Procedures.......................................................................................54
8.6
Collection of Adverse Events............................................................................54
8.6.1
Method of Detecting AEs and SAEs .................................................................55
8.6.2
Time Period and Frequency for Collecting AE and SAE Information................55
8.6.3
Follow-up of AEs and SAEs .............................................................................55
8.6.4
Adverse Event Data Collection .........................................................................56
8.6.5
Causality Collection..........................................................................................56
8.6.6
Adverse Events Based on Signs and Symptoms ................................................57
8.6.7
Adverse Events Based on Examinations and Tests ............................................57
8.6.8
Hy’s Law..........................................................................................................57
8.6.9
Disease Under Study.........................................................................................58
8.6.10
Disease Progression ..........................................................................................58
8.6.11
Deaths...............................................................................................................58
8.6.12
Adverse Events of Special Interest ....................................................................58
8.7
Safety Reporting and Medical Management......................................................59
8.7.1
Reporting of Serious Adverse Events................................................................59
8.7.2
Pregnancy.........................................................................................................60
8.7.2.1
Maternal Exposure............................................................................................60
8.7.2.2
Paternal Exposure .............................................................................................61
8.7.3
Overdose...........................................................................................................61
8.7.4
Medication Error...............................................................................................61
8.8
Efficacy Assessments........................................................................................62
8.8.1
Improvements on the 9-Point Ordinal Scale ......................................................62
9.
STATISTICAL CONSIDERATIONS...............................................................62
9.1
Statistical Hypotheses .......................................................................................62
9.2
Sample Size Determination...............................................................................63
9.3
Populations for Analyses...................................................................................63
9.4
Interim Analysis................................................................................................64
9.5
Missing Data Handling .....................................................................................64
9.6
Statistical Analyses ...........................................................................................64
9.6.1
Safety Analyses ................................................................................................65
9.6.2
Efficacy Analyses .............................................................................................65
9.6.3
Pharmacokinetic and Pharmacodynamic Analyses ............................................66
10.
REFERENCES .................................................................................................67
LIST OF TABLES
Table 1
Schedule of Activities - Arm 1 (Acalabrutinib + BSC).............................10
Table 2
Schedule of Activities - Arm 2 (BSC Only) .............................................14
Table 3
Protocol Objectives and Endpoints...........................................................26

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Table 4
Acalabrutinib Use with Moderate CYP3A Inhibitors and Gastric Acid 
Reducing Agents......................................................................................40
Table 5
Risks Associated with Acalabrutinib Monotherapy in Subjects With 
Hematologic Malignancies (N = 1040).....................................................42
Table 6
Analysis Populations................................................................................63
Table 7
IATA Dangerous Goods Regulations Classification of Infectious 
Substances ...............................................................................................81
Table 8
CYP3A Inhibitors ....................................................................................87
Table 9
CYP3A Inducers......................................................................................88
Table 10
Other Drugs Needing Additional Considerations......................................88
Table 11
Highly Effective Methods of Contraception (<1% Failure Rate)...............90
Table 12
Child-Pugh Classification of Cirrhosis Severity .......................................91
LIST OF FIGURES
Figure 1
Study Design ...........................................................................................23
LIST OF APPENDICES
Appendix A
Regulatory, Ethical and Study Oversight Considerations..........................70
Appendix B
Adverse Event Definitions and Additional Safety Information .................75
Appendix C
Handling of Human Biological Samples ..................................................79
Appendix D
Actions Required in Cases of Increases in Liver Biochemistry and 
Evaluation of Hy’s Law ...........................................................................82
Appendix E
Examples of Coadministered Drugs That Need Additional Consideration 87
Appendix F
Contraception Requirements....................................................................89
Appendix G
Child-Pugh Score.....................................................................................91
Appendix H
Abbreviations ..........................................................................................92
Appendix I
Protocol Amendment History...................................................................95

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1.
PROTOCOL SUMMARY
1.1
Schedule of Activities (SoA)
The SoAs for Arm 1 (acalabrutinib + best supportive care [BSC]) and Arm 2 (BSC only) are 
presented in Table 1 and Table 2, respectively.

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Table 1
Schedule of Activities - Arm 1 (Acalabrutinib + BSC)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
28 (±3) days 
after last dose 
of acala-
brutinib i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
Informed consent
X
8.1.1
Demography
X
8.1.2
Determine eligibility
X
5.1, 5.2
Medical history and COVID-19 
epidemiology
X
8.1.4
Physical examination (symptom 
driven, including lung 
auscultation, height, weight)
X
8.1.5
Chest imaging
X r
As clinically indicated
8.1.5, 8.3
Electrocardiogram
X l
As clinically indicated
X
8.1.5, 8.3
Echocardiogram
As clinically 
indicated
As clinically indicated
8.1.5, 8.3
Vital signs (blood pressure, 
respiratory rate, oximetry, pulse 
and body temperature)
X s
X
X
X
X
8.1.6, 8.3
Local laboratory assessments:
Urine or serum pregnancy test 
(for WOCBP only)
X
X
X
8.1.7, 8.3
Hematology b
X
X
X
X
X
X
8.1.8, 8.3
Serum or plasma chemistry c
X
X
X
X
X
X
8.1.8, 8.3
Arterial blood gases (if 
available) n
X
X
X
X
8.1.6, 8.1.8, 
8.3, 8.4.1
Hepatitis B and C testing d
X
As clinically indicated
As clinically 
indicated
6.6.3, 8.1.8, 
8.3
Serum ferritin m
X
qod 
(starting from Day 1)
X
X
X
8.1.8, 8.3
Fibrinogen m
X
qod
8.1.8, 8.3
PT, aPTT, and INR m
X
qod
8.1.8, 8.3

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Table 1
Schedule of Activities - Arm 1 (Acalabrutinib + BSC)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
28 (±3) days 
after last dose 
of acala-
brutinib i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
D-dimer m
X
qod
X
X
8.1.8, 8.3
CRP
X
X
X
X
X
8.1.8, 8.3
Procalcitonin (if available) m
X
qod
X
X
8.1.8, 8.3
Cardiac troponin I m
X
Day 5
X
8.1.8, 8.3
SARS-CoV-2 RT-PCR virus 
testing for eligibility e
Within 
7 days prior 
to randomi-
zation
8.1.8, 5.1
Clinical assessments
As applicable until hospital discharge
8.4
9-point ordinal scale
X
X
X
X
8.8.1
Central laboratory assessments q
Correlative samples a,o
Days 1 a, 3, and 7
X
X
X
-
8.3
Immunophenotyping a,g
Days 1 a, 3, and 7
X
X
X
8.3
Serum and nasal swab samples 
for SARS-CoV-2 viral 
load/viral shedding a
Days 1 a, 3, and 7
X
X
X
8.3
Acalabrutinib PK p,t
0.5 and 2 hours 
postdose on Day 3;
1 and 4 hours postdose 
on Day 7
8.3
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Table 1
Schedule of Activities - Arm 1 (Acalabrutinib + BSC)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
28 (±3) days 
after last dose 
of acala-
brutinib i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
Acalabrutinib administration
The first dose of 
acalabrutinib should 
be administered 
within 6 hours of 
randomization
100 mg bid (q12h) × 
10 days (maximum)
6.1
Adverse events
X k
X
X
X
X
Xj
8.6
Concomitant medications
X
X
X
X
X
Xj
8.2
Survival status
X
X
Xj
Xj
4.5
anti-HBc = hepatitis B core antibody; aPTT = activated partial thromboplastin time, bid = twice daily; BSC = best supportive care; CD = cluster of differentiation; 
CRP = C-reactive protein; CT = computed tomography; ECG = electrocardiogram; FU = follow-up; COVID-19 = coronavirus disease 2019; CSP = Clinical Study Protocol; 
HBsAg = hepatitis B surface antigen; HCV = hepatitis C virus; ICF = Informed Consent Form; ICU = intensive care unit; INR = international normalized ratio; 
PBMC = peripheral blood mononuclear cell; PD = pharmacodynamics; PK = pharmacokinetics; PT = prothrombin time; q12h = every 12 hours; qod = every other day; 
RT-PCR = reverse transcriptase-polymerase chain reaction; SAE = serious adverse event; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; WOCBP = women of 
childbearing potential.
a
Predose.
b
Hematology: complete blood count with differential includes, but not limited to white blood cell count, hemoglobin, platelet count, absolute neutrophil count (ANC) or 
percentage, red blood cell count, absolute monocyte count or percentage, and absolute lymphocyte count (ALC) or percentage. 
c
Serum or plasma chemistry: albumin, alkaline phosphatase, alanine transaminase (ALT), aspartate aminotransferase (AST), bicarbonate, blood urea nitrogen (BUN), 
calcium, chloride, creatinine, glucose, lactate dehydrogenase (LDH), magnesium, phosphate/phosphorus, potassium, sodium, total bilirubin (direct and indirect bilirubin, if 
available), total protein and uric acid. 
d
Hepatitis serology must include, at a minimum, HBsAg, anti-HBc, and HCV antibody. If additional hepatitis serology is collected per institutional guidelines, it should be 
recorded in the database. Additional testing information is provided in Section 6.6.3 and Section 8.1.8.
e
COVID-19 infection must be confirmed according to the World Health Organization criteria (including positive nucleic acid test of any specimen [eg, respiratory, blood, 
urine, stool, or other bodily fluid]) within 7 days prior to randomization. If test has already been documented within 7 days prior to randomization, no need to repeat the 
testing again.
f
g
Flow cytometry testing of peripheral blood will include, but is not limited to, CD3+, CD4+, CD8+, CD14+, CD19+, and CD16+/56+ cells.
h
If a subject is discharged prior to Day 7, he/she needs to visit the site for an assessment 2 to 4 days after discharge. Assessments should match those for Day 10.
i
Telemedicine is recommended for capturing adverse events concomitant medications, and survival. Safety laboratory tests can be done at the hospital or a local laboratory 
provided the results are ultimately captured in the clinical database for the study.
j
All subjects will be followed for survival for 90 (± 7) days.
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Table 1
Schedule of Activities - Arm 1 (Acalabrutinib + BSC)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
28 (±3) days 
after last dose 
of acala-
brutinib i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
k
After signing the ICF, but prior to randomization, only SAEs should be reported (see Section 8.6.2).
l
Screening can be performed within 1 to 3 days prior to dosing, depending on the local requirements for laboratory turn-around times; ECG can be collected at any time 
during this screening window.
m
Serum ferritin, fibrinogen, PT, aPTT, INR, D-dimer, procalcitonin, and cardiac troponin I should be performed more frequently if clinically indicated.
n
Arterial gases should be collected from subjects if the sample is easily accessible and the procedure will not be painful to subjects (ie, subject is in ICU or has arterial port). 
All available data from the arterial gases should be entered into the database. If the collection of arterial gases is not clinically indicated, the test should not be performed.
o
p
All blood samples for PK assessment (ie, 0.5, 1, 2, and 4 hours postdose) can also be collected during a single visit on Day 3 or after.
q
For all central laboratory assessments, sample collection windows of ± 1 day will be allowed for each of Days 3 and 7.
r
Per standard of care, chest imaging can be done by chest x-ray or CT scan with contrast, or any other appropriate means to confirm pneumonia prior to or upon 
hospitalization (within 7 days of randomization).
s
During screening, vital signs should be collected as close as possible to randomization on Day 1. If more than one value is obtained for vital signs during screening, the value 
closest to randomization should be used.
t
PK assessments will be conducted in up to 15 evaluable subjects and PD assessments in up to 15 evaluable subjects randomized to Arm 1 (acalabrutinib + BSC).
CCI

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Table 2
Schedule of Activities - Arm 2 (BSC Only)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
38 (±3) days 
after randomi-
zation i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
Informed consent
X
8.1.1
Demography
X
8.1.2
Determine eligibility
X
5.1, 5.2
Medical history and COVID-19 
epidemiology
X
8.1.4
Physical examination (symptom 
driven, including lung auscultation, 
height, weight)
X
8.1.5
Chest imaging
X q
As clinically 
indicated
8.1.5, 8.3
Electrocardiogram
X l
As clinically 
indicated
X
8.1.5, 8.3
Echocardiogram
As clinically 
indicated
As clinically 
indicated
8.1.5, 8.3
Vital signs (blood pressure, 
respiratory rate, oximetry, pulse 
and body temperature)
X r
X
X
X
X
8.1.6, 8.3
Local laboratory assessments:
Urine or serum pregnancy test 
(for WOCBP only)
X
X
X
8.1.7, 8.3
Hematology b
X
X
X
X
X
X
8.1.8, 8.3
Serum or plasma chemistry c
X
X
X
X
X
X
8.1.8, 8.3
Arterial blood gases (if 
available) n
X
X
X
X
8.1.6, 8.1.8, 
8.3, 8.4.1
Hepatitis B and C testing d
X
As clinically 
indicated
As clinically 
indicated
6.6.3, 8.1.8, 
8.3
Serum ferritin m
X
qod 
(starting from Day 1)
X
X
X
8.1.8, 8.3
Fibrinogen m
X
qod
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Table 2
Schedule of Activities - Arm 2 (BSC Only)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
38 (±3) days 
after randomi-
zation i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
PT, aPTT, and INR m
X
qod
8.1.8, 8.3
D-dimer m
X
qod
X
X
8.1.8, 8.3
CRP
X
X
X
X
X
8.1.8, 8.3
Procalcitonin (if available) m
X
qod
X
X
8.1.8, 8.3
Cardiac troponin I m
X
Day 5
X
8.1.8, 8.3
SARS-CoV-2 RT-PCR virus 
testing for eligibility e
Within 
7 days prior 
to randomi-
zation
8.1.8, 5.1
Clinical assessments
As applicable until hospital discharge
8.4
9-point ordinal scale
X
X
X
X
8.8.1
Central laboratory assessments p
Correlative samples a,o
Days 1 a, 3, and 7
X
X
X
-
8.3
Immunophenotyping a,g
Days 1 a, 3, and 7
X
X
X
8.3
Serum and nasal swab samples 
for SARS-CoV-2 viral load/viral 
shedding a
Days 1 a, 3, and 7
X
X
X
8.3
Adverse events
X k
X
X
X
X
Xj
8.6
Concomitant medications
X
X
X
X
X
Xj
8.2
Survival status
X
X
Xj
Xj
4.5
anti-HBc = hepatitis B core antibody; aPTT = activated partial thromboplastin time, BSC = best supportive care; CD = cluster of differentiation; CT = computed tomography; 
ECG = electrocardiogram; FU = follow-up; COVID-19 = coronavirus disease 2019; CRP = C-reactive protein; CSP = Clinical Study Protocol; HBsAg = hepatitis B surface 
antigen; HCV = hepatitis C virus; ICF = Informed Consent Form; ICU = intensive care unit; INR = international normalized ratio; PBMC = peripheral blood mononuclear cell; 
PT = prothrombin time; qod = every other day; RT-PCR = reverse transcriptase-polymerase chain reaction; SAE = serious adverse event; SARS-CoV-2 = severe acute respiratory 
syndrome coronavirus 2; WOCBP = women of childbearing potential.
a
Predose.
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Table 2
Schedule of Activities - Arm 2 (BSC Only)
Assessments
Screening
(Day -3 to 
Day -1 l)
Daily until hospital 
discharge
Day 10 or 
discharge h
Day 14
(±2 days) 
after 
randomi-
zation
Day 28
(±3 days) 
after 
randomi-
zation
Safety FU
38 (±3) days 
after randomi-
zation i
Long-term 
FU 90 (±7) 
days after 
randomi-
zation i,j
CSP 
section
b
Hematology: complete blood count with differential includes, but not limited to white blood cell count, hemoglobin, platelet count, absolute neutrophil count (ANC) or 
percentage, red blood cell count, absolute monocyte count or percentage, and absolute lymphocyte count (ALC) or percentage. 
c
Serum or plasma chemistry: albumin, alkaline phosphatase, alanine transaminase (ALT), aspartate aminotransferase (AST), bicarbonate, blood urea nitrogen (BUN), 
calcium, chloride, creatinine, glucose, lactate dehydrogenase (LDH), magnesium, phosphate/phosphorus, potassium, sodium, total bilirubin (direct and indirect bilirubin, if 
available), total protein and uric acid. 
d
Hepatitis serology must include, at a minimum, HBsAg, anti-HBc, and HCV antibody. If additional hepatitis serology is collected per institutional guidelines, it should be 
recorded in the database. Additional testing information is provided in Section 6.6.3 and Section 8.1.8.
e
COVID-19 infection must be confirmed according to the World Health Organization criteria (including positive nucleic acid test of any specimen [eg, respiratory, blood, 
urine, stool, or other bodily fluid]) within 7 days prior to randomization. If test has already been documented within 7 days prior to randomization, no need to repeat the 
testing again.
f
g
Flow cytometry testing of peripheral blood will include, but is not limited to, CD3+, CD4+, CD8+, CD14+, CD19+, and CD16+/56+ cells.
h
If a subject is discharged prior to Day 7, he/she needs to visit the site for an assessment 2 to 4 days after discharge. Assessments should match those for Day 10.
i
Telemedicine is recommended for capturing adverse events concomitant medications, and survival. Safety laboratory tests can be done at the hospital or a local laboratory 
provided the results are ultimately captured in the clinical database for the study.
j
All subjects will be followed for survival for 90 (± 7) days.
k
After signing the ICF, but prior to randomization, only SAEs should be reported (see Section 8.6.2).
l
Screening can be performed within 1 to 3 days prior to dosing, depending on the local requirements for laboratory turn-around times; ECG can be collected at any time 
during this screening window.
m
Serum ferritin, fibrinogen, PT, aPTT, INR, D-dimer, procalcitonin, and cardiac troponin I should be performed more frequently if clinically indicated.
n
Arterial gases should be collected from subjects if the sample is easily accessible and the procedure will not be painful to subjects (ie, subject is in ICU or has arterial port). 
All available data from the arterial gases should be entered into the database. If the collection of arterial gases is not clinically indicated, the test should not be performed.
o
p
For all central laboratory assessments, sample collection windows of ± 1 day will be allowed for each of Days 3 and 7.
q
Per standard of care, chest imaging can be done by chest x-ray or CT scan with contrast, or any other appropriate means to confirm pneumonia prior to or upon 
hospitalization (within 7 days of randomization).
r
During screening, vital signs should be collected as close as possible to randomization on Day 1. If more than one value is obtained for vital signs during screening, the value 
closest to randomization should be used.
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1.2
Synopsis
International Co-ordinating Investigators:
Wyndham Wilson, MD PhD
Center for Cancer Research
National Cancer Institute
Building 10, Room 12C-442
Bethesda, MD 20892
Protocol Title: 
A Phase 2, Open-Label, Randomized Study of the Efficacy and Safety of Acalabrutinib with 
Best Supportive Care Versus Best Supportive Care in Subjects Hospitalized with COVID-19
Rationale: 
Coronavirus disease 2019 (COVID-19) is a new pandemic disease caused by the severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2). Most COVID-19 cases (~80%) are mild 
respiratory illnesses. However, the some require hospitalization (mostly due to pneumonia) 
and can progress quickly to severe acute lung injury and acute respiratory distress syndrome 
(ARDS) (Huang et al 2020, Wu and McGoogan 2020, Zhou et al 2020), which is associated 
with high mortality. A viral-induced cytokine storm or “hyperimmune response” is 
hypothesized to be a major pathogenic mechanism of ARDS in these patients through 
modulation of pulmonary macrophages and dendritic cells (Channappanavar et al 2016, 
Huang et al 2005, Wong et al 2004, Yoshikawa et al 2009) and/or neutrophils (Herold et al 
2015). Putative inflammatory mediators include interleukin (IL)-1β, IL-6, IL-8, IL-10, tumor 
necrosis factor alpha (TNFα), and monocyte chemoattractant protein-1 (MCP-1) (Chen et al 
2020, Herold et al 2015, Yoshikawa et al 2009).
Bruton’s tyrosine kinase (Btk) is a Tec family non-receptor protein kinase, expressed in B 
cells, myeloid cells, osteoclasts, mast cells and platelets. The function of Btk in signaling 
pathways activated by the engagement of the B-cell receptor has been well established (Buggy 
and Elias 2012). Btk is also involved in the following biologic processes: Fc gamma receptor 
signaling in myeloid cells, mast cell degranulation, osteoclast differentiation, and signaling 
through Toll-like receptors (TLRs) in macrophages and neutrophils. Btk inhibition is 
associated with a decrease in proinflammatory cytokines in patients with hematologic 
malignancies.
Acalabrutinib is a covalent Btk inhibitor with greater selectivity and better physiochemical 
properties than ibrutinib and other Btk inhibitors currently in development. Acalabrutinib is 
currently approved in the United States for the treatment of patients with mantle cell 
lymphoma or chronic lymphocytic leukemia/small lymphocytic lymphoma [Calquence® 
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have shown statistically significant decreases in the following cytokines: TNFα (p<0.001), 
IL-10 (p<0.001), and MCP-1 (p<0.01) (Byrd et al 2016) and IL-6 (p<0.05) (data on file). 
Decreasing these immunomodulating cytokines in patients with COVID-19 may mitigate the 
pathophysiologic response that leads to the most severe morbidity and mortality associated 
with viral infection. Recently, encouraging results were reported in a case series of patients 
hospitalized with severe COVID-19 and treated with acalabrutinib led by investigators at the 
National Institutes of Health (Roschewski 2020). Similarly, other BTK inhibitors have shown 
promise in COVID-19 patients with hematologic malignancies (Thibaud et al 2020, Treon et 
al 2020).
The purpose of this Phase 2 study is to evaluate the safety and preliminary efficacy of adding 
acalabrutinib to best supportive care (BSC) for subjects with life-threatening COVID-19 
symptoms.
Objectives and Endpoints:
Primary Objectives
Primary Endpoints/Variables

To evaluate the safety of acalabrutinib in 
subjects with COVID-19 when administered 
with BSC

To evaluate the efficacy of adding 
acalabrutinib to BSC for the treatment of 
COVID-19
Safety

Type, frequency, severity, and relationship to 
study treatment of any treatment-emergent 
adverse events (TEAEs) or abnormalities of 
laboratory tests, serious adverse events 
(SAEs), or adverse events (AEs) leading to 
discontinuation of study treatment.
Efficacy

Proportion of subjects alive and free of 
respiratory failure at Day 28
For the purpose of this study, respiratory 
failure is defined based on resource 
utilization of any of the following modalities:
o
Endotracheal intubation and mechanical 
ventilation
o
Oxygen delivered by high-flow nasal 
cannula (heated, humidified, oxygen 
delivered via reinforced nasal cannula at 
flow rates >20 L/min with fraction of 
delivered oxygen ≥0.5)
o
Noninvasive positive pressure ventilation 
or continuous positive airway pressure 
o
Extracorporeal membrane oxygenation 
Secondary Efficacy Objectives
Secondary Efficacy Endpoints/Variables
To evaluate the efficacy of adding acalabrutinib 
to BSC for the treatment of COVID-19

Proportion of subjects alive and free of 
respiratory failure (defined above) at Day 14

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
Percent change from baseline in C-reactive 
protein (CRP; time frame: baseline, Days 3, 
5, 7, 10, 14, 28)

Change from baseline in ferritin (time frame: 
baseline, Days 3, 5, 7, 10, 14, 28)

Change from baseline in absolute 
lymphocyte counts (time frame: baseline, 
Days 3, 5, 7, 10, 14, 28)

All-cause mortality at Day 90

Proportion of subjects alive and discharged 
from the intensive care unit (ICU) at Days 14
and 28

Time from randomization to first occurrence 
of respiratory failure or death on study (up to 
28 days after randomization) due to any 
cause

Number of days alive and free of respiratory 
failure from randomization to 28 days after 
randomization

Number of days with respiratory failure from 
randomization to 28 days after randomization

Number of days hospitalized from 
randomization to 28 days after randomization

Number of days in ICU (length of stay) from 
randomization to 90 days after randomization

Number of days alive outside of hospital 
from randomization to 28 days after 
randomization

Number of days alive outside of hospital 
from randomization to 90 days after 
randomization

Relative change from baseline in 
oxygenation index (SpO2/FiO2) to Days 3, 5, 
7, and 10

Time to clinical improvement of at least 2 
points (from randomization) on a 9-point 
category ordinal scale through Day 28 (see 
Section 8.8.1)

Time to SpO2 > 94% on room air

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Pharmacokinetic (PK) Objective
PK Endpoint/Variable
To assess PK of acalabrutinib and its active 
metabolite in subjects with COVID-19 when 
administered with BSC
Summarized plasma concentrations of 
acalabrutinib and ACP-5862 at specified time 
points. PK parameters (eg, area under the 
concentration-time curve [AUC] and maximum 
observed concentration [Cmax]) estimated, as 
appropriate.
Exploratory Objectives
Exploratory Endpoints/Variables
Overall Design:
This is a multicenter, randomized, open-label, Phase 2 study that will evaluate acalabrutinib 
plus BSC versus BSC in subjects with COVID-19 who are hospitalized.
Subjects will be randomly assigned (1:1) to receive one of the following 2 treatments:

Arm 1: Acalabrutinib 100 mg twice daily (bid) × 10 days + BSC (n=30)

Arm 2: BSC alone (n=30)
For the purpose of this study, BSC is per discretion of the Investigator and institutional 
guidelines. However, refer to Section 5.2 and Section 6.5.3 for prohibited or restricted 
concomitant therapy. Subjects will be randomized based on the following stratification 
factors, which are considered prognostic factors for poor outcome:

Age (≥ 65 vs < 65 years)

Comorbidities (present vs absent).  “Present” is defined as having at least 1 of the
following comorbidities:

Cardiovascular disease, as defined by either heart failure New York Heart
Association class ≥2 or hypertension requiring treatment

Diabetes mellitus requiring treatment

Chronic obstructive pulmonary disease or asthma requiring treatment

Current active solid tumor or hematologic malignancy
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Inclusion/exclusion criteria are provided in Section 5. Assessments are provided in 
Section 1.1.
Study Period:
Estimated date of first subject enrolled Q2 2020.
Estimated date of last subject completed is Q3 2020.
Number of Subjects:
The total number of subjects to be randomized in this study is 60.
Treatments and Treatment Duration:
Acalabrutinib treatment should be administered within 6 hours of randomization on Day 1.
Subjects will take acalabrutinib 100 mg capsules by mouth bid for 10 days (a maximum of 
20 doses). Capsules will be taken with water. The capsules should be swallowed intact and 
subjects should not attempt to open capsules or dissolve them in water.
Subjects on concomitant proton-pump inhibitors (PPIs) must take acalabrutinib with at least
100 mL of COCA-COLA® at room temperature. Other cola beverages (eg, Diet Coke®, 
COCA-COLA Zero Sugar) or juices are not permitted. The capsules should be swallowed 
intact and subjects should not attempt to open capsules or dissolve them in COCA-COLA. 
NOTE: COCA-COLA contains glucose (5 g per 100 mL). Blood glucose levels of diabetic 
subjects must be monitored as clinically indicated and blood glucose-lowering medications 
adjusted accordingly.
Acalabrutinib can be taken with or without food.
Retreatment with acalabrutinib is not allowed.
BSC will be administered in both arms per Investigator’s discretion and institutional 
guidelines. 
Refer to Section 6.1 for additional information on treatments administered.
Internal Data Monitoring Committee:
This study will have an internal Data Monitoring Committee (iDMC), independent from the 
Sponsor’s study team. Details of the roles and responsibilities of the iDMC and the safety and 
efficacy review will be provided in a separate iDMC charter. The iDMC will be responsible 
for reviewing the safety data periodically, enable early identification of safety signals in the 
study, minimize risk to subjects during the study, and make recommendations according to 

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prespecified stopping rules for safety, and as to the future conduct of this study in accordance 
with the iDMC charter (refer to Section 4.4 for details). 
Statistical Methods:
In general, continuous data will be summarized using descriptive statistics (number of 
observations, mean, standard deviation, median, minimum, and maximum). Frequencies and 
percentages will be used for summarizing categorical (discrete) data.
Safety will be summarized for the treated population (Safety population) and will be based on 
the treatment they actually received. In this study, treatment is either acalabrutinib + BSC or 
BSC only. If a subject receives at least 1 dose of acalabrutinib, the subject is considered as
acalabrutinib-treated, regardless to which arm the subject was randomized. Safety assessments 
will consist of monitoring and recording AEs, SAEs, and AEs leading to discontinuation of 
study treatment; measurements of protocol-specified hematology, clinical chemistry, and other 
laboratory variables; measurement of protocol-specified vital signs; and other 
protocol-specified tests that are deemed critical to the safety evaluation of the study treatment.
For subjects randomized to Arms 1 or 2, efficacy will be summarized for the intent-to-treat 
(ITT) population, which is defined as all subjects who were randomized, to be analyzed 
according to the arm to which they are randomly assigned, following “intent-to-treat” 
principle. An estimate of the primary endpoint, the proportion of subjects who are alive and 
free of respiratory failure at Day 28 and its 90% confidence interval (CI; using Wald method 
with continuity correction) will be calculated for each treatment arm. The Cochran-Mantel-
Haenszel χ2 test stratified by age (≥ 65 vs < 65 years) and comorbidities (present vs absent) 
will be used to compare the proportion of subjects who are alive and free of respiratory failure 
at Day 28 between the two treatment arms. An unstratified analysis will also be performed. 
Finally, the difference in the proportion of subjects who are alive and free of respiratory 
failure at Day 28 will also be provided with 90% CIs. The treatment difference will be also 
estimated using a logistic regression (Ge 2011) with indicators for treatment and the 
randomization stratification factors (2 × 2) as well as baseline respiratory failure (with vs 
without).
Refer to Section 9 for additional details. 
1.3
Schema
The general study design is summarised in Figure 1.

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Figure 1
Study Design
bid = twice per day; BSC = best supportive care (for COVID-19 symptoms); SARS-CoV-2+ = severe acute 
respiratory syndrome coronavirus 2 positive.

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2.
INTRODUCTION
2.1
Background and Study Rationale
Coronavirus disease 2019 (COVID-19) is a new pandemic disease caused by the severe acute 
respiratory syndrome coronavirus 2 (SARS-CoV-2). In a retrospective study of 191 patients 
with COVID-19, sepsis was the most frequently observed complication, followed by 
respiratory failure, acute respiratory distress syndrome (ARDS), heart failure, and septic 
shock. While sepsis might be directly caused by SARS-CoV-2 infection, further research is 
needed to investigate the pathogenesis of COVID-19 illness. Most COVID-19 cases (~80%) 
are mild respiratory illnesses. 5% to 15% of these respiratory illnesses require hospitalization 
(mostly due to pneumonia) and can progress quickly to severe acute lung injury and ARDS 
(Huang et al 2020, Wu and McGoogan 2020, Zhou et al 2020), which is associated with high 
mortality.
Normally, human coronaviruses are detected and cleared by the immune system, but a subset 
of patients experience increased severity of symptoms (Channappanavar and Perlman 2017, 
Zhou et al 2020). These symptoms have been associated with the loss of control of the virally 
induced immune response (Li et al 2020). In these cases, the inflammatory response is 
hypothesized to be a major pathogenic mechanism of ARDS through modulation of 
pulmonary macrophages and dendritic cells (Channappanavar et al 2016, Huang et al 2005, 
Wong et al 2004, Yoshikawa et al 2009) and/or neutrophils (Herold et al 2015). Putative 
inflammatory mediators include interleukin (IL)-1β, IL-6, IL-8, IL-10, tumor necrosis factor 
alpha (TNFα), and monocyte chemoattractant protein-1 (MCP-1) (Chen et al 2020, Herold et 
al 2015, Yoshikawa et al 2009). During the acute phase of coronavirus infection, T cells are 
the critical mediators of clearance of infection, while B cells generate a protective humoral 
response (Zhao et al 2009, Zhao et al 2014). Generation of antibodies against coronaviruses is 
not always protective. In a mouse model, an anti-spike immunoglobulins (specific to 
SARS-COV) could skew the inflammation-resolving response which lead to severe acute lung 
injury in mice (Liu et al 2019).
Bruton’s tyrosine kinase (Btk) is a Tec family nonreceptor protein kinase, expressed in 
B cells, myeloid cells, osteoclasts, mast cells, and platelets. The function of Btk in signaling 
pathways activated by the engagement of the B-cell receptor has been well established (Buggy 
and Elias 2012). Btk is also involved in the following biologic processes: Fc gamma receptor
signaling in myeloid cells, mast cell degranulation, and signaling through Toll-like receptors 
(TLRs) in macrophages and neutrophils. Specifically, Btk is required for TLR 7/8 signaling, 
which recognize single strand RNA viruses such as coronaviruses, signal through Btk in 
macrophages (Page et al 2018).

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Recently, Btk inhibition has shown to rescue mice from lethal influenza A-virus induced acute 
lung injury by significantly decreasing lung inflammation and macrophage/monocyte 
mediated cytokines/chemokines (TNFα, IL-1β, IL-6, MCP-1, etc) in the lung homogenates. 
These results suggest that Btk inhibition may represent a new immunomodulatory treatment 
for virally induced lung damage driven by excessive inflammation (Florence et al 2018). 
Additionally, in a murine model of sepsis, acalabrutinib has shown to ameliorate the cardiac 
dysfunction by suppressing pro-inflammatory cytokines/chemokines associated with sepsis
(O'Riordan et al 2019). Patients with hematologic malignancies treated with acalabrutinib 
(Calquence®) have shown significant reduction of several cytokines/chemokines including 
pro-inflammatory markers such as: TNFα (p<0.001), IL-10 (p<0.001), MCP-1 (p<0.01), 
MIP-1β (p<0.001), MIP-1α (p<0.001), IL-16 (p<0.001), TARC (p<0.001), CXCL13 
(p<0.001), Granzyme A (p<0.001) (Byrd et al 2016, Covey 2017), and IL-6 (p<0.05) (data on 
file). Several of these cytokines/chemokines have been shown to be associated with more 
severe illness in COVID-19 patients. We hypothesize that acalabrutinib treatment will inhibit 
cells that produce pro-inflammatory cytokines/chemokines, will lead to reduced inflammation 
of the lungs in patients with COVID-19, and mitigate the pathophysiologic response that leads 
to the most severe morbidity and mortality associated with viral infection. Recently, 
encouraging results were reported in a case series of patients hospitalized with severe COVID-
19 and treated with acalabrutinib led by investigators at the National Institutes of Health 
(Roschewski 2020). Similarly, other BTK inhibitors have shown promise in COVID-19 
patients with hematologic malignancies (Thibaud et al 2020, Treon et al 2020).
Together, strong scientific evidence justifies a clinical trial in this patient population. The 
purpose of this study is to evaluate the safety and preliminary efficacy of adding acalabrutinib 
to best supportive care (BSC) for subjects hospitalized due to COVID-19 symptoms.
2.2
Benefit/Risk Assessment
The lack of established treatments and vaccines for the novel SARS-CoV-2 virus has driven 
major medical centers to an unprecedented overload, which has undoubtedly contributed to 
the mortality observed with this disease. While vaccines and antiviral therapies are urgently 
needed, drugs that can address the pathophysiology of the disease to decrease the morbidity 
and mortality and reduce hospital admissions and intensive care unit (ICU) use are also 
needed without delay.
Btk inhibition may serve as an important addition to the COVID-19 armamentarium by 
reducing the viral-induced hyperimmune response, which leads to lung destruction. 
Acalabrutinib is currently approved in the United States for the treatment of patients with 
mantle cell lymphoma or chronic lymphocytic leukemia/small lymphocytic lymphoma. As of 
30Oct2019, acalabrutinib has been administered to over 3300 participants in clinical studies, 
including subjects with hematologic malignancies, solid tumors, or rheumatoid arthritis, and 
participants who are healthy subjects or those with mild to moderate hepatic impairment. No 

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serious adverse events (SAEs) have been reported in the hepatic impairment trial or in the 
healthy volunteer trials. Some subjects with chronic lymphocytic leukemia have been 
receiving acalabrutinib therapy for more than 5 years. Acalabrutinib has been administered 
alone and in combination with other kinase inhibitors, anti-CD20 antibodies, 
chemoimmunotherapy (eg, bendamustine/rituximab), and an anti-programmed cell death 1 
(PD-1) receptor antibody. No dose-limiting toxicities (DLTs) have been identified for 
acalabrutinib monotherapy or when administered in combination with the aforementioned 
agents. Current clinical safety data supports combining acalabrutinib with other agents.
Refer to the acalabrutinib Investigator’s Brochure for the most up to date safety and efficacy 
information. Identified risks for acalabrutinib are summarized in Section 6.6 and are based on 
events observed in subjects with cancer who have been on long-term treatment with 
acalabrutinib 100 mg twice daily (bid).
Based on the safety profile of acalabrutinib to date, no overt toxicities have been identified 
that would preclude acute treatment for subjects with moderate to severe COVID-19 
symptoms.
Precautionary safety measures, in addition to regular monitoring of safety by an internal Data 
Monitoring Committee (iDMC) and the Sponsor, are included in the study design to enable 
early identification of safety signals in the study and minimize the risk to subjects.
3.
OBJECTIVES AND ENDPOINTS
Table 3
Protocol Objectives and Endpoints
Primary Objectives
Primary Endpoints/Variables

To evaluate the safety of acalabrutinib in 
subjects with COVID-19 when administered 
with BSC

To evaluate the efficacy of adding 
acalabrutinib to BSC for the treatment of 
COVID-19
Safety

Type, frequency, severity, and relationship to 
study treatment of any TEAEs or 
abnormalities of laboratory tests, SAEs, or 
AEs leading to discontinuation of study 
treatment.
Efficacy

Proportion of subjects alive and free of 
respiratory failure at Day 28
For the purpose of this study, respiratory 
failure, is defined based on resource 
utilization of any of the following modalities:
(a) Endotracheal intubation and mechanical 
ventilation
(b) Oxygen delivered by high-flow nasal 
cannula (heated, humidified, oxygen 

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delivered via reinforced nasal cannula at 
flow rates >20 L/min with fraction of 
delivered oxygen ≥0.5)
(c) Noninvasive positive pressure ventilation 
or continuous positive airway pressure 
(d) Extracorporeal membrane oxygenation 
Secondary Efficacy Objective
Secondary Efficacy Endpoints/Variables:
To evaluate the efficacy of adding acalabrutinib 
to BSC for the treatment of COVID-19

Proportion of subjects alive and free of 
respiratory failure (as defined above) at 
Day 14

Percent change from baseline in CRP (time 
frame: baseline, Days 3, 5, 7, 10, 14, 28)

Change from baseline in ferritin (time frame: 
baseline, Days 3, 5, 7, 10, 14, 28)

Change from baseline in absolute 
lymphocyte counts (time frame: baseline, 
Days 3, 5, 7, 10, 14, 28)

All-cause mortality at Day 90

Proportion of subjects alive and discharged 
from the ICU at Days 14 and 28

Time from randomization to first occurrence 
of respiratory failure or death on study (up to 
28 days after randomization) due to any 
cause

Number of days alive and free of respiratory 
failure from randomization to 28 days after 
randomization

Number of days with respiratory failure from 
randomization to 28 days after randomization

Number of days hospitalized from 
randomization to 28 days after randomization

Number of days in ICU (length of stay) from 
randomization to 90 days after randomization

Number of days alive outside of hospital 
from randomization to 28 days after 
randomization

Number of days alive outside of hospital 
from randomization to 90 days after 
randomization

Relative change from baseline in 
oxygenation index (SpO2/FiO2) to Days 3, 5, 
7, and 10

Time to clinical improvement of at least 2 
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category ordinal scale through Day 28 (see
Section 8.8.1)

Time to SpO2 > 94% on room air
PK Objective
PK Endpoints/Variables
To assess PK of acalabrutinib and its active 
metabolite in subjects with COVID-19 when 
administered with BSC
Summarized plasma concentrations of 
acalabrutinib and ACP-5862 at specified time 
points. PK parameters (eg, AUC and Cmax) 
estimated, as appropriate.
Exploratory Objectives
Exploratory Endpoints/Variables
AE = adverse event; AUC = area under the concentration-time curve; BSC = best supportive care; 
 CL/F = apparent clearance; Cmax = maximum observed concentration; 
COVID-19 = coronavirus disease 2019; CRP = C-reactive protein; FiO2 = fraction of inspired oxygen; 
ICU = intensive care unit; 
 
 PK = pharmacokinetics; SAE = serious adverse event; SARS-CoV-2 = severe acute respiratory 
syndrome coronavirus 2; SpO2 = oxygen saturation; t1/2 = half-life; TEAE = treatment-emergent adverse 
event; tmax = time to maximum observed concentration; 
 Vdss/F = apparent 
volume of distribution at steady-state.
4.
STUDY DESIGN
4.1
Overall Design
This is a multicenter, randomized, open-label, Phase 2 study that will evaluate acalabrutinib 
plus BSC versus BSC in subjects with COVID-19 who are hospitalized.
Subjects will be randomly assigned (1:1) to receive one of the following 2 treatments:

Arm 1:  Acalabrutinib 100 mg bid × 10 days + BSC (n=30)

Arm 2:  BSC alone (n=30)
For the purpose of this study, BSC is per discretion of the Investigator and institutional 
guidelines. However, refer to Section 5.2 and Section 6.5.3 for prohibited or restricted 
concomitant therapy. Subjects will be randomized based on the following stratification 
factors, which are considered prognostic factors for poor outcome:
CCI
CCI
CCI
CCI

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
Age (≥ 65 vs < 65 years)

Comorbidities (present vs absent). “Present” is defined as having at least 1 of the 
following comorbidities: 

Cardiovascular disease, as defined by either heart failure New York Heart 
Association (NYHA) class ≥2 or hypertension requiring treatment

Diabetes mellitus requiring treatment

Chronic obstructive pulmonary disease or asthma requiring treatment

Current active solid tumor or hematologic malignancy
Inclusion/exclusion criteria are provided in Section 5. Assessments are provided in 
Section 1.1.
4.2
Scientific Rationale for Study Design
The immune system is required to clear viral infections and generate protective immunity 
from viral pathogens like SARS-CoV-2. There is significant evidence that in patients with 
severe respiratory problems, the immune system and inflammation contribute to the severity 
of the disease. Macrophages and neutrophils are key to producing cytokines driving this 
inflammation. The hypothesis being evaluated in this trial is whether Btk inhibition of the 
viral-induced macrophage and neutrophil immune response can decrease inflammation and 
reduce respiratory failure or death. Given the various covariates that contribute to these 
outcomes (eg, lack of consensus on standard of care, actively changing local treatment 
practices, and patients’ comorbid conditions), a single-arm study will likely not be informative 
as data from historical controls are changing almost daily. Hence, this will be a randomized 
study. Subjects who are hospitalized for COVID-19 disease and meet the eligibility criteria 
will be randomized 1:1 to receive acalabrutinib plus BSC (n=30) versus BSC (n=30).
Stratification by age and comorbidities will be applied to randomization as these are expected 
to be important covariates.
4.3
Justification for Dose
Acalabrutinib 100 mg bid has been evaluated in various indications (ie, B-cell malignancies 
and solid tumours) alone and in combination with anti-CD20 antibodies, chemotherapy, a 
phosphatidylinositol-3-kinase (PI3K) inhibitor, and an anti-PD-1 antibody. No DLTs have 
been identified for acalabrutinib alone or when given in combination with these agents. For all 
of these indications, acalabrutinib was administered daily until disease progression; some 
subjects have been receiving acalabrutinib for > 5 years. The long-term safety experience of 
chronic administration of acalabrutinib 100 mg bid monotherapy and in combination with 
other agents, supports the proposed dosage of acalabrutinib is 100 mg bid for acute treatment. 
In addition, correlative studies—in subjects with chronic lymphocytic leukemia treated with 
acalabrutinib 200 mg once daily (qd) or 100 mg bid—show bid dosing maintained higher Btk 

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occupancy and achieved more potent NF-kappaB pathway inhibition compared with qd dosing 
(Sun et al 2020). Activation of NF-kappaB occurs in the lungs of patients with ARDS and 
may contribute to the increased expression of proinflammatory mediators (Moine et al 2000). 
Therefore, 100 mg bid dosing is proposed for this study to ensure maximum target 
engagement. 
4.4
Internal DMC
This study will have an iDMC. Details of the roles and responsibilities of the iDMC and the 
safety and efficacy review will be provided in a separate iDMC charter. The iDMC will be 
responsible for reviewing the safety data periodically. 
The iDMC will review the cumulative safety data approximately 28 days after the first 
30 subjects (approximately 15 subjects per arm) are randomized. 
In addition, if at any time during the conduct of the study either of the criteria below are met, 
enrollment of additional subjects will be paused such that the iDMC would convene and 
conduct a full safety review.

Any death due to acalabrutinib (per Investigator)

≥20% treatment discontinuation rate due to toxicity attributed to acalabrutinib (per
Investigator), when 10 or more acalabrutinib subjects have been treated

Any Grade 4 hemorrhage due to acalabrutinib (per Investigator)
During the safety review, the iDMC with compare the known adverse event (AE) profile 
associated with acalabrutinib with comprehensive safety data from the current study. The 
iDMC will determine if an unacceptable increase in Grade 3 or higher AEs known to be 
associated with acalabrutinib occurred in the study. After the review, the iDMC will make a 
recommendation regarding study continuation, hold, or termination.
At the time of the safety review the iDMC will also review all available efficacy data and will 
support any health authority interactions or internal discussions based on their review. The 
study team will remain blinded to the data that the iDMC will review.
4.5
End of Study Definition
The end of study is defined as the last expected visit/contact of the last subject undergoing the 
study.
A subject is considered to have completed the study when he/she has completed his/her last 
scheduled procedure shown in the Schedule of Activities (SoA; Section 1.1). All randomized 
subjects will be followed for survival through 90 (± 7) days after randomization.

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All subjects who discontinue the investigational study treatment for any reason other than 
withdrawal of consent, loss to follow-up, or death will have a safety follow up assessment 
28 (± 3) days after the last dose of acalabrutinib (Arm 1), or 38 (± 3 days) after randomization 
for those subjects randomized to the BSC arm (Arm 2), as outlined in Section 1.1.
The study may be stopped if, in the judgment of the Sponsor, study subjects are placed at 
undue risk because of clinically significant findings.
See Appendix A 6 for guidelines for the dissemination of study results.
5.
STUDY POPULATION
Prospective approval of protocol deviations to recruitment and enrollment criteria, also known 
as protocol waivers or exemptions, is not permitted.
Each subject should meet all the inclusion criteria and none of the exclusion criteria for this 
study to be assigned to a study intervention. Under no circumstances can there be exceptions 
to this rule. Subjects who do not meet the entry requirements are screen failures, refer to 
Section 5.3.
5.1
Inclusion Criteria 
Subjects are eligible to be included in the study only if all of the criteria below apply.
1.
Ability to understand the purpose and risks of the study and provide signed and dated 
informed consent or have a legal representative provide consent and authorization to use 
protected health information (in accordance with national and local patient privacy 
regulations).
2.
Men and women ≥18 years of age at the time of signing the Informed Consent Form 
(ICF).
3.
SARS-CoV-2 confirmed per World Health Organization criteria (including positive 
nucleic acid test of any specimen [eg, respiratory, blood, urine, stool, or other bodily 
fluid]) within 7 days of randomization.
4.
COVID-19 pneumonia (documented radiographically) requiring hospitalization and 
oxygen saturation <94% on room air or requires supplemental oxygen.
5.
Able to swallow pills.
6.
Willing to follow contraception guidelines (refer to Appendix F).
5.2
Exclusion Criteria 
Subjects are excluded from the study if any of the criteria below apply.

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COVID-19 Related Medical Conditions
1.
Respiratory failure at the time of screening (see Section 3 for definition of respiratory 
failure) due to COVID-19 pneumonia that impedes the ability to swallow pills, or in the 
opinion of the treating physician, the subject is likely to require mechanical ventilation 
within the immediate 24 hours and therefore unable to swallow pills.
2.
Known medical resuscitation within 14 days of randomization.
3.
Any serious medical condition or abnormality of clinical laboratory tests that, in the 
Investigator’s judgment, precludes the subject’s safe participation in and completion of 
the study.
4.
Suspected uncontrolled active bacterial, fungal, viral, or other infection (besides 
infection with SARS-CoV-2).
5.
In the opinion of the Investigator, progression to death is imminent and inevitable within 
the next 24 hours, irrespective of the provision of treatments.
Medical Conditions
6.
Not expected to survive 28 days given their preexisting, uncorrectable medical 
condition, for example, subjects with, or suspected to have, the following conditions: 
multiorgan failure, poorly controlled neoplasms; endstage cardiac disease; cardiac arrest 
requiring cardiopulmonary resuscitation or with pulseless electrical activity or asystole 
within past 30 days; endstage lung disease; endstage liver disease; or human 
immunodeficiency virus (HIV)/acquired immunodeficiency syndrome with known 
endstage process.
7.
Pregnant or breast feeding.
8.
Alanine aminotransferase (ALT), aspartate aminotransferase (AST) and/or bilirubin 
≥3 × upper limit of normal (ULN) and/or severe hepatic impairment (Child-Pugh 
class C; see Appendix G) detected during the screening period (per local laboratory).
Exception: AST and/or ALT can be up to 5 × ULN if considered due to underlying 
COVID-19 disease, but cannot be associated with concurrent elevated bilirubin (up to 
2 × ULN).
9.
Absolute neutrophil count (ANC) < 500/µL at screening (per local laboratory).
10.
Platelet count < 50,000/µL at screening (per local laboratory).
11.
Estimated creatinine clearance of <30 mL/min calculated using the Cockcroft-Gault 
formula [(140age) × mass (kg)/(72 × creatinine mg/dL) multiply by 0.85 if female].
12.
Uncontrolled or untreated symptomatic arrhythmias, myocardial infarction within the 
last 6 weeks, or congestive heart failure (NYHA Grade 3 or 4). 
Exception: Subjects with controlled, asymptomatic atrial fibrillation during screening are 
allowed to enroll on study.
13.
History of chronic hypercarbia, respiratory failure in past 6 months, or use of home 
oxygen in the setting of severe chronic respiratory disease.

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14.
Quadriplegia.
15.
History of primary immunodeficiency, tuberculosis, progressive multifocal 
leukoencephalopathy (PML), aspergillus or other invasive mold/fungal infection, or 
received organ or bone marrow transplantation within 6 months of randomization.
16.
Serology status reflecting active hepatitis B or C infection.
a)
Subjects who are hepatitis B core antibody (anti-HBc) positive and who are 
hepatitis B surface antigen (HBsAg) negative will need to have a negative or 
undetectable hepatitis B viral load by quantitative polymerase chain reaction (PCR) 
result before randomization. Those who are HBsAg positive or have detectable 
hepatitis B viral load by PCR will be excluded.
b)
Subjects who are hepatitis C virus (HCV) antibody positive will need to have a 
negative PCR result before randomization. Those who are hepatitis C PCR positive 
will be excluded.
17.
Known active HIV with detectable viral load or CD4 counts < 500 cells/mm3.
Prior/Concomitant Therapy
18.
Treatment with a strong cytochrome P450 (CYP)3A inhibitor (within 7 days before first 
dose of study drug) or inducer (within 14 days before first dose of study drug).
19.
Subjects are excluded who have already received prior immunomodulatory/ 
immunosuppressive treatment intended as specific treatment for COVID-19 (after 
randomization these agents may be permitted – see Section 6.5.2). Note: Steroids are 
permitted prior to randomization and on study..
20.
Active participation in other drug clinical trials or received treatment with an 
investigational drug within 5 half-lives or 30 days (whichever is longer) of 
randomization/enrollment. 
Exception: Subjects may receive COVID-19-specific antiviral drugs (eg, remdesivir, 
hydroxychloroquine).
21.
Requires or is receiving specific anticoagulation with warfarin or equivalent vitamin K 
antagonists (eg, phenprocoumon) within 7 days prior to randomization. Other 
anticoagulants are permitted.
22.
Subjects on dual antiplatelet and therapeutic anticoagulant therapy (eg, aspirin and
therapeutic doses of low molecular weight heparin).
23.
History of hypersensitivity (ie, allergic response) to active or inactive excipients of 
acalabrutinib or other Btk inhibitors.
24.
Known cytoreductive chemotherapy treatment within 14 days of randomization.
25.
Major surgery (as defined by the Investigator) within 4 weeks prior to randomization or 
still recovering from prior surgery.

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5.3
Screen Failures
Screen failures are defined as subjects who consent to participate in the clinical study but are 
not subsequently randomized. A minimal set of screen failure information is required to 
ensure transparent reporting of screen failure subjects to meet the Consolidated Standards of 
Reporting Trials (CONSORT) publishing requirements and to respond to queries from 
regulatory authorities. Minimal information includes demography, screen failure details, 
eligibility criteria, and any SAE unrelated to the disease under investigation.
Individuals who do not meet the criteria for participation in this study (screen failure) may be
rescreened. Rescreened subjects should be assigned the same subject number as for the initial 
screening.
6.
STUDY TREATMENTS
Study treatment is defined as any investigational product(s) (including marketed product 
comparator and placebo) or medical device(s) intended to be administered to a study subject 
according to the study protocol. Study treatment in this study refers to acalabrutinib.
6.1
Treatments Administered
6.1.1
Dosing and Duration of Treatment
Acalabrutinib treatment should be administered within 6 hours of randomization on Day 1. 
Subjects will take acalabrutinib 100 mg capsules by mouth bid for 10 days (a maximum of 
20 doses). Capsules will be taken with water. The capsules should be swallowed intact and 
subjects should not attempt to open capsules or dissolve them in water. For subjects requiring 
a proton-pump inhibitor (PPI), acalabrutinib must be administered as described in 
Section 6.1.3.1.
Acalabrutinib can be taken with or without food. 
Retreatment with acalabrutinib is not allowed.
BSC will be administered in both arms per Investigator’s discretion and institutional 
guidelines.
6.1.2
Missed Dosing Windows and Doses
The bid doses should be scheduled approximately 12 hours apart. It is recommended that 
acalabrutinib be taken as close to the scheduled time as possible (within ±1 hour). However, if 
the scheduled time is missed, it can be taken up to 3 hours after the scheduled time, with a 
return to the normal schedule upon the following dose for 10 days (a maximum of 20 doses).

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If the 3-hour dosing window is missed, the dose must be skipped on that day. Study drug may 
be held for a maximum of 3 consecutive days (6 consecutive doses) from expected dose due to 
toxicity. If a dose is missed due to an adverse event (AE) or for any other reason, missed 
doses should be completed so the subject receives a maximum of 20 doses of study drug, even 
if this is beyond the 10-day dosing period.
6.1.3
Special Considerations
6.1.3.1
Drug-drug Interactions
Drug-drug interactions may occur with some of the drugs being used as BSC (eg, drugs that 
are moderate inhibitor of CYP3A, gastric acid reducing agents), and dosing of acalabrutinib 
may need to be adjusted. Please refer to Section 6.5.4 for detailed information and guidance.
Subjects on concomitant PPIs must take acalabrutinib with at least 100 mL of COCA-COLA®
at room temperature. Other cola beverages (eg, Diet Coke®, COCA-COLA Zero Sugar) or 
juices are not permitted. The capsules should be swallowed intact and subjects should not 
attempt to open capsules or dissolve them in COCA-COLA. NOTE: COCA-COLA contains 
glucose (5 g per 100 mL). Blood glucose levels of diabetic subjects must be monitored as 
clinically indicated and blood glucose-lowering medications adjusted accordingly.
Administration of acalabrutinib with COCA-COLA mitigates the effect of PPIs. Several 
acidic beverages with pH similar to COCA-COLA were assessed (eg, orange drink, lemonade, 
COCA-COLA Zero Sugar, cranberry juice, and grapefruit juice) but not found to be optimal. 
In healthy subjects, pharmacokinetic (PK) exposure following 100-mg acalabrutinib 
suspension in COCA-COLA (nasogastric delivery) is similar in the presence or absence of 
PPIs, and comparable to that of the 100-mg acalabrutinib capsule. In addition, based on a 
verified physiologically-based biopharmaceutics model (Pepin et al 2019), acalabrutinib 
exposure is predicted to be similar between the administration of 100-mg acalabrutinib 
capsule with 100 mL COCA-COLA in the presence of PPIs and the 100-mg acalabrutinib 
capsule taken with water. Overall, these data support the use of acalabrutinib in subjects who 
need to take PPIs for the management of various acid-related disorders.
6.1.3.2
Subjects With Respiratory Failure and Who Can Still Swallow Pills
Subjects who have respiratory failure before completing the maximum of 20 doses and who 
are still able to swallow pills, will be permitted to continue treatment with acalabrutinib for 
the maximum of 20 doses, according to the Investigator’s clinical judgment.
6.1.3.3
Subjects No Longer Able to Swallow Pills
Subjects who can no longer swallow pills will not be eligible to continue acalabrutinib 
treatment.

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6.1.3.4
Vomiting After Acalabrutinib Treatment
If vomiting occurs after taking acalabrutinib, the subject should not retake acalabrutinib until 
the next scheduled dose.
6.1.3.5
Discharged From Hospital Before Treatment Completion
Subjects who are discharged from the hospital before they have completed 10 days (20 doses) 
of acalabrutinib therapy will be required to complete the remaining dosing at home. They 
should adhere to their established dosing schedule and treatment guidelines, including in cases 
where subjects remain on PPIs. These subjects must complete a drug dosing diary to be faxed 
or mailed back to the study site.
6.2
Acalabrutinib Preparation/Handling/Storage/Accountability
Acalabrutinib should be stored according to the instructions on the label affixed to the 
package of the drug product.
If a drug shipment arrives damaged or if there are any other drug complaints, a Product 
Complaint Form should be completed and emailed to the Sponsor or the Sponsor’s 
representative. Refer to the pharmacy manual and the Investigator’s Brochure for additional 
information regarding the drug product to be used in this study.
The Investigator or designee (eg, pharmacist) must confirm appropriate temperature 
conditions have been maintained during transit for all study treatment received and any 
discrepancies are reported and resolved before use of the study treatment.
Only subjects enrolled in the study may receive study treatment and only authorized site staff 
may supply or administer study treatment. All study treatments must be stored in a secure, 
environmentally controlled, and monitored (manual or automated) area in accordance with the 
labeled storage conditions with access limited to the Investigator and authorized site staff.
The Investigator, institution, or the head of the medical institution (where applicable) is 
responsible for study treatment accountability, reconciliation, and record maintenance (ie, 
receipt, reconciliation, and final disposition records).
Further guidance and information for the final disposition of unused study treatment are 
provided in the Clinical Study Agreement.
6.3
Measures to Minimise Bias: Randomisation and Blinding
Given the urgent nature of the COVID-19 pandemic, this will be an open-label study. 
However, the study is randomized and include stratification factors as outlined in Section 4.1.

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6.3.1
Subject Enrollment and Randomization
All eligible subjects will be centrally randomized using an interactive response technology 
(IRT) that will assign the subjects to either acalabrutinib plus BSC versus BSC, stratified by 
the stratification factors defined in Section 4.1. Before the study is initiated, log-in 
information and directions for the IRT will be provided to each site. 
Investigators should keep a record (ie, the subject screening log) of subjects who entered 
screening. 
At screening, the Investigators or suitably trained delegate will:

Obtain informed consent before any study specific procedures are performed.

Obtain a unique 7-digit enrollment number (E-code), through the IRT the following 
format (ECCNNXXX: CC being the country code, NN being the center number, and 
XXX being the subject enrollment code at the center). This number is the subject’s unique 
identifier and is used to identify the subject on the electronic case report forms (eCRFs).

Determine subject eligibility (see Section 5.1 and Section 5.2).
At randomization, once the subject is confirmed to be eligible, the Investigator or suitably 
trained delegate will:

Log the E-code and stratification factors (age [≥ 65 vs < 65 years] and comorbidities 
[present vs absent]) in the IRT system and the system will sequentially randomize the 
eligible subject to 1 of the 2 treatment arms. 

If the subject is ineligible and not randomized, the IRT should be contacted to terminate 
the subject in the system. 

Subjects will begin treatment on Day 1. Treatment should start no more than 6 hours after 
being randomized. Subjects must not be randomized and treated unless all eligibility 
criteria have been met. 
If a subject withdraws from participation in the study, then his/her enrollment/randomization 
code cannot be reused. A withdrawn subject will not be replaced.
6.3.1.1
Procedures for Handling Incorrectly Enrolled or Randomized Subjects
Subjects who fail to meet the eligibility criteria should not, under any circumstances, be 
enrolled or receive study medication. There can be no exceptions to this rule. Subjects who are 
enrolled, but subsequently found not to meet all the eligibility criteria must not be randomized 
or initiated on treatment and must be withdrawn from the study.
Where a subject does not meet all the eligibility criteria but is randomized in error, or 
incorrectly started on treatment, the Investigator should inform the study physician 
immediately, and a discussion should occur between the study physician and the Investigator

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regarding whether to continue or discontinue the subject from treatment. The study physician 
must ensure all decisions are appropriately documented and that the potential benefit:risk 
profile remains positive for the subject.
6.3.1.2
Methods for Assigning Treatment Groups
The actual treatment assigned to subjects will be determined by the randomization scheme in 
the IRT. A stratified permuted block randomization scheme will be used, with the 
stratification factors defined in Section 4.1. The randomization scheme will be produced by a 
computer software program that incorporates a standard procedure for generating 
randomization numbers. 
Randomization codes will be assigned strictly sequentially, within each stratum, as subjects 
become eligible for randomization. 
6.3.1.3
Methods for Ensuring Blinding
This is an open-label study for the personnel at study sites. Specific treatment to be taken by a 
subject will be assigned using an IRT. The site will contact the IRT prior to the start of study 
treatment administration for each subject. The site will record the treatment assignment on the 
applicable case report form, if required. To maintain the integrity of the study, the Sponsor’s 
personnel directly involved in the study conduct will, under no circumstances, view data 
aggregated by treatment arm during the course of the study.
6.4
Treatment Compliance
The study treatment should only be used as directed in this protocol. Details of treatment with 
the study treatment, including change from the dosing schedule, dose interruptions, dose 
reductions, and dose discontinuations, should be recorded in the eCRF. The investigational 
product will not be distributed to the study site until the contract is concluded between the 
study site and the Sponsor. The Investigator or designee is responsible for managing the 
investigational product from time of receipt by the study site until the destruction of all unused 
investigational product at that site. The Investigator(s) is responsible for ensuring that all 
unused investigational product is returned to the site by the subject(s).
6.5
Concomitant Therapy
6.5.1 
Premedications
No specific premedications or supporting medications are required in conjunction with 
acalabrutinib administration.
6.5.2 
Permitted Concomitant Therapy
BSC for COVID-19 is required for all subjects in this study except as listed in Section 5.2 
and Section 6.5.3. Given the rapid emergence of new data related to COVID-19, BSC could 

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change during the duration of the study. The use of therapies such as remdesivir, therapeutic 
plasma, corticosteroids, or other immunomodulatory agents (eg, tocilizumab) is permitted if 
recommended by local authorities and part of institutional policies or guidelines. The 
concomitant administration of immunosuppressive agents with acalabrutinib may require 
additional safety monitoring as determined by the treating clinician. Investigators should 
maintain prohibitions of certain concurrent medications for other reasons as listed in 
Section 6.5.3.
6.5.3
Prohibited or Restricted Concomitant Therapy
The medications listed below are prohibited for all randomized subjects.
Medications Prohibited for All Subjects in Both Treatment Arms Through Day 28
Immunomodulatory drugs, intended as treatment for COVID-19 but not considered standard 
of care according to local institutional guidelines, are prohibited for all randomized subjects in 
the study through Day 28. Subjects who are taking immunomodulatory drugs for other 
medical conditions (eg, tocilizumab for rheumatoid arthritis) may continue with treatment 
upon discussion with the Medical Monitor. 
Medications Prohibited for All Subjects in Both Treatment Arms Through Day 10
Strong CYP3A inhibitors or inducers: Drug-drug interactions may occur with some of the 
drugs being used as BSC (eg, drugs that are strong inducers or strong inhibitors of CYP3A). 
The concomitant use of strong inhibitors of CYP3A (see Appendix E) should be avoided by 
all subjects on the study. If a subject requires a strong CYP3A inhibitor while on treatment 
with acalabrutinib, discontinue acalabrutinib treatment. Conversely, concomitant 
administration of a strong inducer of CYP3A has the potential to decrease exposure of 
acalabrutinib and could reduce efficacy. Therefore, the concomitant use of strong CYP3A 
inducers should be avoided by all subjects in the study. If a subject requires a strong CYP3A 
inducer while on treatment with acalabrutinib, discontinue acalabrutinib. For additional 
information on drugs with potential drug-drug interactions, refer to Section 6.5.4.
Certain anticoagulants: Warfarin or equivalent vitamin K antagonists (eg, phenprocoumon) 
are prohibited for all subjects in the study. Subjects who require prophylaxis or therapeutic 
anticoagulation for thrombosis (deep vein thrombosis or pulmonary embolism) will be 
allowed to receive therapeutic anticoagulation with a non-vitamin K inhibitor class of 
anticoagulants (eg, heparin or low-molecular-weight heparin).
Refer to Section 5.2 for additional restrictions on concomitant therapy. 

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6.5.4
Acalabrutinib Drug-drug Interaction Guidance in the Presence of 
Life-threatening COVID-19 Infection
Drug-drug interaction recommendations provided for acalabrutinib in this protocol are made 
with respect to the presence of life-threatening COVID-19 infection and ability to achieve 
pharmacodynamic (PD) Btk receptor occupancy steady-state in target B-cell and monocytic 
populations. Therefore, the Sponsor recommends that all eligible subjects with COVID-19 
begin dosing with acalabrutinib 100 mg bid. The duration of acalabrutinib therapy will be 
limited to 10 days (a maximum of 20 doses). Table 4 provides moderate CYP3A inhibitors
and acid reducing agent guidance for subjects with COVID-19. Refer to Appendix E for a list 
of common CYP3A inhibitors/inducers and gastric acid reducing medicines.
Table 4
Acalabrutinib Use with Moderate CYP3A Inhibitors and Gastric Acid 
Reducing Agents
Co-administered 
Medicines
Recommended Acalabrutinib Use
CYP3A 
Inhibitor
Moderate CYP3A 
inhibitor 
Monitor subjects closely for adverse reactions if taking 
moderate CYP3A inhibitors. For subjects who 
experience an intolerable adverse event (ie, Grade 3-4) 
attributed to acalabrutinib therapy, reduce the dose to 
100 mg once daily.
Gastric Acid 
Reducing 
Medicines
Proton-pump inhibitors 
(PPIs)
Avoid concomitant use. If PPI concomitant use cannot 
be avoided, dose modification of acalabrutinib is not 
necessary; however, acalabrutinib must be 
administered with at least 100 mL of COCA-COLA to 
improve acalabrutinib absorption (refer to 
Section 6.1.3.1). Other cola beverages are not 
permitted.
H2-receptor antagonists
Take acalabrutinib 2 hours before taking a H2-receptor 
antagonist. 
Antacids 
Separate dosing by at least 2 hours.
6.5.4.1
Active Substances That May Increase Acalabrutinib Plasma Concentrations
CYP3A Inhibitors
Co-administration with a strong CYP3A inhibitor (200 mg itraconazole qd for 5 days) 
increased acalabrutinib maximum observed concentration (Cmax) and area under the 
concentration-time curve (AUC) by 3.7- and 5.1-fold in healthy subjects (N=17), respectively.

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Consider alternative therapies that do not strongly inhibit CYP3A activity. In subjects 
requiring strong CYP3A inhibitors (eg, ketoconazole, conivaptan, clarithromycin, indinavir, 
itraconazole, ritonavir, telaprevir, posaconazole, voriconazole), discontinue acalabrutinib
treatment. 
6.5.4.2
Active Substances That May Decrease Acalabrutinib Plasma Concentrations
CYP3A Inducers 
Co-administration of a strong CYP3A inducer (600 mg rifampin qd for 9 days) decreased 
acalabrutinib Cmax and AUC by 68% and 77% in healthy subjects (N=24), respectively.
Consider alternative therapies to strong inducers of CYP3A activity (eg, phenytoin, rifampin, 
carbamazepine). Avoid St. John’s wort which may unpredictably decrease acalabrutinib 
plasma concentrations. If these inducers cannot be avoided, discontinue acalabrutinib 
treatment.
Gastric Acid Reducing Medications
Acalabrutinib solubility decreases with increasing pH. Co-administration of acalabrutinib with 
an antacid (1 g calcium carbonate) decreased acalabrutinib AUC by 53% in healthy subjects. 
Co-administration with a PPI (40 mg omeprazole for 5 days), decreased acalabrutinib AUC by 
43%.
If treatment with an acid reducing agent is required, consider using an antacid (eg, calcium 
carbonate), or an H2-receptor antagonist (eg, famotidine). For use with antacids, separate 
dosing by at least 2 hours. For H2-receptor antagonists, take acalabrutinib 2 hours before 
taking the H2-receptor antagonist.
Due to the long-lasting effect of PPIs, separation of doses with PPIs may not eliminate the 
interaction with acalabrutinib. In subjects requiring treatment with PPIs (eg, omeprazole, 
esomeprazole, lansoprazole, dexlansoprazole, rabeprazole, or pantoprazole) during the study, 
acalabrutinib must be administered with at least 100 mL COCA-COLA at room temperature 
to improve acalabrutinib absorption (see Section 6.1.3.1). Other cola beverages are not 
permitted. 
Dose modification of acalabrutinib is not necessary when co-administered with gastric acid 
reducing medications.
6.6
Risks Associated with Acalabrutinib
The safety profile of acalabrutinib in patients with COVID-19 is not yet established. The 
COVID-19 population is distinct from patients with hematologic malignancies, the population 
for which acalabrutinib is indicated, and the duration of acalabrutinib treatment for COVID-19 
is much shorter than for the indicated population with hematologic malignancies. Therefore, 

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the safety profile of acalabrutinib in the COVID-19 population may differ from that 
established in the cancer population.
The experience with chronic administration of acalabrutinib in hematologic cancer studies is 
described below. Table 5 summarizes the risks associated with acalabrutinib (any grade, 
≥Grade 3, and mean time to first onset) based on 1040 subjects with hematologic 
malignancies who received acalabrutinib monotherapy (data on file).
For more detailed information on treatment-emergent adverse events (TEAEs), refer to the 
acalabrutinib Investigator’s Brochure. Full details regarding the clinical safety of acalabrutinib 
are presented in Sections 5 and 6 of the acalabrutinib Investigator’s Brochure.
Table 5
Risks Associated with Acalabrutinib Monotherapy in Subjects With 
Hematologic Malignancies (N = 1040)
Event category
Number (%) of subjects
Median (min, max), months
Any grade
≥Grade 3
Time to first onset
Hemorrhage
482 (46.3)
28 (2.7)
1.2 (0, 53)
Major hemorrhage
37 (3.6)
28 (2.7)
9.8 (0, 44)
Infections
694 (66.7)
183 (17.6)
3.2 (0, 45)
Anemia
144 (13.8)
81 (7.8)
0.7 (0, 41)
Neutropenia
163 (15.7)
148 (14.2)
3.1 (0, 44)
Thrombocytopenia
93 (8.9)
50 (4.8)
1.7 (0, 39)
Second primary malignancy
127 (12.2)
43 (4.1)
9.5 (0, 50)
Atrial fibrillation
46 (4.4)
13 (1.3)
17.4 (0, 43)
max = maximum; min = minimum.
6.6.1
Hemorrhage
Bleeding events, some fatal, including central nervous system, respiratory, and gastrointestinal 
hemorrhage, have been reported in subjects treated with acalabrutinib. 
Please refer to Section 6.7 for study drug modification guidance.
6.6.2
Infections
Serious infections, including fatal events, have been reported in subjects treated with 
acalabrutinib (eg, aspergillosis). Subjects should be monitored for signs and symptoms of 
infection and treated as medically appropriate. Please refer to Section 6.7 for study drug 
modification guidance.

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6.6.3
Hepatitis B Reactivation
Across the acalabrutinib clinical development program, 9 subjects had hepatitis B virus 
(HBV) reactivation. Seven of the 9 subjects developed HBV reactivation after receiving 
acalabrutinib, and 2 subjects had HBV reactivation prior to receiving (crossover) 
acalabrutinib. One subject experienced a serious Grade 4 event that subsequently resulted in 
liver failure and death. Subjects who are anti-HBc positive or have a known history of HBV 
infection may be monitored monthly with a quantitative PCR test for HBV DNA, when 
clinically indicated. Any subject with a rising viral load (above lower limit of detection) 
should discontinue study treatment and have antiviral therapy instituted and a consultation 
with a physician with expertise in managing hepatitis B. Insufficient data exist regarding the 
safety of resuming acalabrutinib in subjects who develop HBV reactivation.
6.6.4
Progressive Multifocal Leukoencephalopathy 
Across the acalabrutinib clinical development program, 2 subjects had events of PML (both 
serious) after receiving acalabrutinib. Signs and symptoms of PML may include cognitive and 
behavioral changes, language disturbances, visual disturbances, sensory deficits, weakness, 
and coordination and gait difficulties. Please refer to Section 6.7 for study drug modification 
guidance.
6.6.5
Cytopenias
Grade 3 or 4 events of cytopenias, including anemia, neutropenia, and thrombocytopenia have 
occurred in subjects treated with acalabrutinib. Monitor blood counts as specified in the SoA 
and as medically appropriate. Please refer to Section 6.7 for study drug modification guidance. 
6.6.6
Second Primary Malignancies 
Second primary malignancies, including non-skin carcinomas solid tumors and skin cancers, 
have been reported in subjects with B-cell malignancies treated with acalabrutinib. The most 
frequent second primary malignancy was skin cancer (squamous basal cell carcinoma of the 
skin). Subjects should be monitored for signs and symptoms of malignancy. Subjects who 
develop a malignancy should be managed according to institutional guidelines with diagnostic 
evaluations or as clinically indicated, and it may be necessary for subjects to permanently 
discontinue study treatment. Continuation of acalabrutinib treatment should be discussed with 
the Medical Monitor.
6.6.7
Atrial Fibrillation 
Monitor for symptoms of atrial fibrillation and atrial flutter (eg, palpitations, dizziness, 
syncope, chest pain, dyspnea), and obtain an electrocardiogram (ECG) as clinically indicated. 
Subjects with atrial fibrillation should be managed per institutional guidelines with supportive 
care and diagnostic evaluations or as clinically indicated. Please refer to Section 6.7 for study 
drug modification guidance.

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6.6.8
Reference Safety Information
See the Reference Safety Information in the acalabrutinib Investigator’s Brochure for 
assessment of expectedness of serious adverse reactions.
6.7
Dose Modification and Toxicity Management
In general, no acalabrutinib dose modification is required if a subject experiences a Grade 1 or 
Grade 2 AE. Acalabrutinib therapy should be modified or discontinued, however, for the 
following AEs:
Event
Acalabrutinib Dose Modification/Discontinuation
Hematological
Grade 4 neutrophil count decrease 
(ANC < 500/μL)
•
Hold acalabrutinib, and consider introducing
growth factors (eg, G-CSF) and continue to 
monitor ANC
•
If neutropenia has improved to Grade 1 or 
baseline within 3 days of event onset, restart 
acalabrutinib
•
If neutropenia has not improved to Grade 1 or 
baseline within 3 days of event onset, discontinue 
acalabrutinib
Any grade febrile neutropenia lasting more 
than 2 days
•
Discontinue acalabrutinib
•
Consider introducing growth factors (eg, G-CSF), 
evaluate subject for infection, and begin 
antibiotic treatment per institutional guidelines
Presence of significant bleeding events 
with or without thrombocytopenia, such as:
•
Grade 3 or 4 hemorrhage
•
Any grade serious hemorrhage event
•
Any grade intracranial hemorrhage or 
hematoma
Discontinue acalabrutinib
Grade 4 platelet count decrease
(< 25,000/mm3)
•
Hold acalabrutinib and consider platelet 
transfusions, as clinically indicated
•
If thrombocytopenia has improved to ≤Grade 2 
within 3 days of event onset, restart acalabrutinib
•
If thrombocytopenia has not improved to 
≤Grade 2 within 3 days of event onset, 
discontinue acalabrutinib
Gastrointestinal/hepatic
Grade 3 or 4 nausea, vomiting, or diarrhea, 
if persistent despite optimal antiemetic 
and/or antidiarrheal therapy
Discontinue acalabrutinib

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Event
Acalabrutinib Dose Modification/Discontinuation
Acute hepatic toxicity or hepatic failure, 
which is of such severity that after 
evaluation by a hepatologist, would 
consider appropriate to stop all non-
essential medications
Discontinue acalabrutinib
Cardiovascular
Grade 3 or 4 hypertension, if persistent 
despite optimal antihypertensive therapy
Discontinue acalabrutinib
Grade 3 or 4 arrhythmias that are sustained
or associated with cardiovascular 
instability
Discontinue acalabrutinib
Infections
Severe opportunistic infection (such as 
Pneumocystis jirovecii pneumonia, 
toxoplasmosis, disseminated 
Mycobacterium avium complex, PML)
Discontinue acalabrutinib
Grade 3 confirmed bacterial infections 
•
Hold acalabrutinib
•
If infection does not respond to appropriate 
antimicrobial therapy within 48-72 hours, 
discontinue acalabrutinib
Grade 4 confirmed bacterial infections
Discontinue acalabrutinib
Other
Any non-COVID-19-related Grade 4 AE
Discontinue acalabrutinib
Any other Grade 3 or Grade 4 toxicity that 
persists despite optimal medical 
management
Discontinue acalabrutinib
AE = adverse event; ALT = alanine aminotransferase; ANC = absolute neutrophil count; ALP = alkaline 
phosphatase; AST = aspartate aminotransferase; G-CSF = granulocyte colony-stimulating factor; 
PML = progressive multifocal leukoencephalopathy.
Clinical judgment should be used to determine appropriate management of the subject during 
any AE. 
Acalabrutinib may be held for a maximum of 3 consecutive days (6 consecutive doses) from 
expected dose due to toxicity. Any other clinically important events where dose delays may be 
considered appropriate by the Investigator, as well as continuation of therapy after a dose is 
held beyond 3 days, must be discussed with the Medical Monitor. If a dose is missed due to an 
AE or for any other reason, missed doses should be completed so the subject receives a 
maximum of 20 doses of study drug, even if this is beyond the 10-day dosing period.

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6.7.1
Renal Impairment
After administration of a single 100 mg radiolabeled acalabrutinib dose in healthy subjects, 
84% of the dose was recovered in the feces and 12% of the dose was recovered in the urine 
(2% acalabrutinib). No clinically relevant PK difference was observed in subjects with mild or 
moderate renal impairment (estimated glomerular filtration rate [eGFR] ≥30 mL/min/1.73 m2, 
as estimated by Modification of Diet in Renal Disease [MDRD] equation). Acalabrutinib PK 
and clinical safety has not been evaluated in subjects with severe renal impairment (eGFR 
<29 mL/min/1.73 m2, MDRD) or renal impairment requiring dialysis. 
The effect of dialysis on acalabrutinib plasma concentrations has not been studied. 
Acalabrutinib is rapidly absorbed, metabolised and distributed. The plasma protein binding is 
97.5% and is noncovalent (potentially dialyzable). 
 
 
 If subjects with 
COVID-19 enrolled in this study require acute hemodialysis, it is recommended to dose 
acalabrutinib 100 mg and pause hemodialysis for 2 to 4 hours after acalabrutinib 
administration to allow for absorption and distribution to target cell populations.
6.7.2
Hepatic Impairment
Acalabrutinib clinical safety has not been evaluated in patients with severe hepatic 
impairment. If acalabrutinib is administered to subjects with hepatic impairment, monitor 
subjects carefully for AEs and follow recommendation dose modifications in Section 6.7.
The PK acalabrutinib in subjects with hepatic impairment has been studied. Briefly, the AUC 
of acalabrutinib increased 1.9-fold in subjects with mild hepatic impairment (Child-Pugh 
class A), 1.5-fold in subjects with moderate hepatic impairment (Child-Pugh class B) and 
5.3-fold in subjects with severe hepatic impairment (Child-Pugh class C) compared with 
subjects with normal liver function. No clinically relevant PK difference in ACP-5862 was 
observed in subjects with severe hepatic impairment (Child-Pugh class C) compared with 
subjects with normal liver function. No clinically relevant PK differences in acalabrutinib and 
ACP-5862 were observed in subjects with mild or moderate hepatic impairment (total 
bilirubin less and equal to ULN and AST greater than ULN, or total bilirubin greater than 
ULN and any AST) relative to subjects with normal hepatic function (total bilirubin and AST 
within ULN).
6.8
Treatment After the End of Study
Not applicable.
CCI

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7.
DISCONTINUATION OF TREATMENT AND SUBJECT 
WITHDRAWAL 
7.1
Discontinuation of Study Treatment 
Subjects may discontinue study treatment for the following reasons:

Unable to swallow pills

Completed treatment

Pregnancy

AE

Investigator’s decision

Subject’s withdrawal of consent from study

Decision by the Sponsor to terminate the study

Lost to follow-up

Death

Other
The Investigator should instruct the subject to contact the site before or at the time if study 
treatment is stopped. A subject that decides to discontinue study treatment will always be 
asked about the reason(s) and the presence of any AEs. The date of last intake of study 
treatment should be documented in the eCRF. Refer to the guidance in Section 6.5.3.
All subjects will be followed through 90 (± 7) days after randomization.
Subjects who receive acalabrutinib should have follow up assessments for safety 28 (± 3) days 
after the last dose of acalabrutinib (whether due to discontinuation or completion of dosing). 
Subjects who have been randomized to the BSC arm should have a follow up assessment for 
safety 38 (± 3) days after randomization.
For the safety and survival follow-up visits, telemedicine is recommended for capturing AEs 
and concomitant medications. Safety laboratory tests can be done at the hospital or a local 
laboratory provided the results are ultimately captured in the clinical database for the study.
7.2
Subject Withdrawal from the Study
A subject may withdraw from the study (eg, withdraw consent), at any time (investigational 
product and assessments) at his/her own request, without prejudice to further treatment.
A subject who considers withdrawing from the study must be informed by the Investigator 
about modified follow-up options (eg, telephone contact, a contact with a relative or treating 
physician, or information from medical records).

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If the subject withdraws consent for disclosure of future information, the Sponsor may retain 
and continue to use any data collected before such a withdrawal of consent.
If a subject withdraws from the study, he/she may request destruction of any samples taken, 
and the Investigator must document this in the site study records.  
A subject who withdraws consent will always be asked about the reason(s) and the presence of 
any AE. The Investigator will follow up subjects as medically indicated. 
7.3
Lost to Follow-Up
A subject will be considered lost to follow-up if he/she fails to return for scheduled visits or is 
unable to be contacted by the study site.
In the case a subject is lost to follow-up, every possible effort must be made by the study site 
personnel to contact the subject and determine the reason for discontinuation. Site personnel 
should check hospital records and a publicly available death registry (if available), as well as 
checking with the subject’s current physician, to obtain a current survival status. The measures 
taken to follow up must be documented (the applicable eCRF modules will be updated).
When a subject withdraws before completing the study, the reason for withdrawal must be 
documented in the eCRF and in the source documents. Subjects who withdraw consent should 
still be encouraged to complete the SFU assessments before withdrawing consent, but these 
assessments cannot be mandated once consent is withdrawn.
Subjects who are withdrawn or removed from study treatment will not be replaced.
8.
STUDY ASSESSMENTS AND PROCEDURES
Study procedures and their timing are summarised in the SoA in Section 1.1.
The Investigator will ensure that data are recorded on the eCRF. 
The Investigator ensures the accuracy, completeness, and timeliness of the data recorded and 
of the provision of answers to data queries per the Clinical Study Agreement. The Investigator
will sign the completed eCRF. A copy of the completed eCRF will be archived at the study 
site.
Immediate safety concerns should be discussed with the Medical Monitor upon occurrence or 
awareness to determine if the subject should continue or discontinue study treatment.
Adherence to the study design requirements, including those specified in the SoA, is essential 
and required for study conduct.

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All screening evaluations must be completed and reviewed to confirm that potential subjects 
meet all eligibility criteria. The Investigator will maintain a screening log to record details of 
all subjects screened and to confirm eligibility or record reasons for screening failure, as 
applicable.
8.1
Screening Assessments
Procedures conducted as part of the subject’s clinical management of COVID-19 symptoms 
and obtained before signing of the ICF may be used for screening or baseline purposes 
provided the procedures met the protocol-specified criteria and were performed within 
24 hours of signing the informed consent.
8.1.1
Informed Consent
The informed consent process must be followed per local and institutional guidelines 
(Appendix A 3).
8.1.2
Demographics
The following subject demographics will be collected: age, sex, race, ethnicity, and history of 
substance abuse (cigarettes [yes/no; if yes, specify packs per day], vaping [yes/no], 
recreational drugs [yes/no; if yes, specify name], alcohol [yes/no; if yes, specify amount]).
8.1.3
Confirmation of Eligibility
Subject eligibility for enrollment will be assessed per Section 5.
8.1.4
Medical History
Collect and record the subject’s relevant medical history through review of medical records 
and by interview. Concurrent medical signs and symptoms must be documented to establish 
baseline severities. Information on COVID-19 epidemiology will also be collected.
8.1.5
Physical Examinations and Chest Imaging, Electrocardiogram, and 
Echocardiogram
The screening physical examination will be symptom-directed and include height, weight and 
lung auscultation.
Per standard of care, chest imaging can be done by chest x-ray or CT scan with contrast, or 
any other appropriate means to confirm pneumonia prior to or upon hospitalization (within 
7 days of randomization). Post treatment assessment will continue as clinically indicated.
A single 12-lead ECG and will be done during the screening period and at Day 10 or upon 
discharge from the hospital. ECG should be collected during the treatment period, as clinically 

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indicated. For all ECGs, details of rhythm, ECG intervals, and an overall evaluation will be 
recorded.
An echocardiogram should be collected at baseline or during the treatment period, as 
clinically indicated per SoA.  Percentage left ventricular ejection fraction should be recorded. 
If the Investigator considers an abnormal ECG or echocardiogram finding at screening or 
baseline to be clinically significant, that finding should be reported as a concurrent condition. 
Any clinically significant abnormal ECG or echocardiogram findings during the treatment 
period should be recorded in the source document and the AE section of eCRF, according to 
standard AE collection and reporting processes.
8.1.6
Vital Signs
The vital signs to be collected are blood pressure, respiratory rate, oximetry, pulse, and body 
temperature.
During screening, vital signs should be collected as close as possible to randomization on 
Day 1. If more than one value is obtained for vital signs during screening, the value closest to 
randomization should be used. The oxygen-haemoglobin saturation of the blood will be 
assessed using standard pulse oximetry or by arterial blood gas for those subjects who have an 
arterial blood gas obtained.
8.1.7
Urine or Serum Pregnancy 
Screening pregnancy testing will be done on women of childbearing potential only (refer to 
Appendix F).
8.1.8
Laboratory Tests
The screening period should occur immediately prior to randomization and dosing. Screening 
can be performed within 1 to 3 days prior to dosing, depending on the local requirements for 
laboratory turn-around times. The following laboratory tests will be done during screening as 
specified in the SoA (Section 1.1) using the sites local laboratories:

Urine or serum pregnancy test (women of childbearing potential only)

Hematology studies must include complete blood count (CBC) with differential 
including, but not limited to white blood cell count, hemoglobin, platelet count, ANC or 
percentage, red blood cell count, absolute monocyte count or percentage, and absolute 
lymphocyte count (ALC) or percentage. 

Chemistry will include albumin, alkaline phosphatase, ALT, AST, bicarbonate, blood 
urea nitrogen (BUN), calcium, chloride, creatinine, glucose, lactate dehydrogenase 
(LDH), magnesium, phosphate/phosphorus, potassium, sodium, total bilirubin (direct and 
indirect bilirubin, if available), total protein, and uric acid.  

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
Arterial blood gases (if available; see Section 8.4.1)

C-reactive protein (CRP)

Serum ferritin, fibrinogen, D-dimer, procalcitonin

Prothrombin time (PT), activated partial thromboplastin time (aPTT), international 
normalized ratio (INR)

Cardiac troponin I

Hepatitis serology must include, at a minimum, HBsAg, anti-HBc, and HCV antibody (if 
additional hepatitis serology is collected per institutional guidelines, it should be collected 
in the database)

SARS-CoV-2 reverse transcriptase-polymerase chain reaction viral test. Sites should 
report this as positive/negative.
Refer to the laboratory manual for instructions on processing and shipping. Additional 
handling information provided in Appendix C.
8.2
Concomitant Medications
Document all concomitant medications and procedures from the start of screening procedures 
through the end of participation on the study (refer to Section 1.1). Reason for treatment 
should be captured as “disease under study”.
Medications used as BSC should be captured as concomitant medications.
8.3
On-study Procedures 
Planned time points for all on-study procedures are provided in the SoA (Section 1.1). While 
the subject remains hospitalized, assessments should be performed per SoA until discharge. 
The date of admission and discharge will be collected for all subjects. If a subject is 
discharged prior to Day 10, the subject should continue to take acalabrutinib at home. If the 
subject was discharged prior to Day 7, the subject should return to the clinic 2 to 4 days after 
discharge and complete the Day 10 assessment as outlined in the SoA.
The following laboratory evaluations will be done at the local laboratories while on study:

Urine or serum pregnancy test (women of childbearing potential only)

Hematology studies must include complete blood count (CBC) with differential 
including, but not limited to white blood cell count, hemoglobin, platelet count, ANC or 
percentage, red blood cell count, absolute monocyte count or percentage, and absolute 
lymphocyte count (ALC) or percentage.

Chemistry will include albumin, alkaline phosphatase, ALT, AST, bicarbonate, BUN, 
calcium, chloride, creatinine, glucose, LDH, magnesium, phosphate/phosphorus, 
potassium, sodium, total bilirubin (direct and indirect bilirubin, if available), total protein, 
and uric acid.

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
Arterial blood gases (if available; see Section 8.4.1)

CRP

Serum ferritin, fibrinogen, D-dimer, procalcitonin*

PT, aPTT, INR*

Cardiac troponin I*

Hepatitis B serology will be collected as clinically indicated for subjects with a known 
history of hepatitis B exposure (see Section 6.6.3)
*These laboratory tests should be performed more frequently than described in the SoA 
(Section 1.1) if clinically indicated.
Samples (peripheral blood samples for mononuclear cells, serum/plasma, and RNA) will be 
collected per the timepoints delineated in the SoA (Section 1.1) and sent to respective central 
laboratories for the following tests:


 

Immunophenotyping: Flow cytometry testing of peripheral blood will include, but is not 
limited to, CD3+, CD4+, CD8+, CD14+, CD19+ and CD16+/56+ cells

Serum and nasal swab samples for SARS-CoV-2 viral load/viral shedding 

 

Plasma samples for acalabrutinib/ACP-5862 PK (subjects on acalabrutinib arm only)

NOTE: Safety, CRP, PK, PD, and correlative laboratory tests are considered Tier 1 and 
should not be missed. The site must follow the SoA.
Refer to the laboratory manual for instructions on processing and shipping. Additional 
handling information provided in Appendix C.
Other procedures to be performed while on study include:

Chest imaging

ECG

Echocardiogram

Vital signs
CCI
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8.4
Clinical Assessments During Hospitalization
8.4.1
Oxygen Treatments and Ventilator Use
If a subject requires oxygen supplementation, data will be recorded, including method of 
oxygen supplementation, maximum daily flow rate and fraction of inspired oxygen (FiO2).
If a subject requires mechanical ventilation, data will be recorded regarding whether ventilator 
weaning was attempted. 
For subjects on mechanical ventilation the following ventilator settings will be recorded: tidal 
volume, FiO2, peak airway pressure over the last 24 hours, plateau pressure, positive end 
expiratory pressure, and respiratory rate. The data will be recorded qd, and the worst value of 
the day will be entered
For subjects on mechanical ventilation, an arterial blood gas (pH, partial pressure of oxygen 
[PaO2], partial pressure of carbon dioxide [PaCO2], and FiO2 at the time the sample was 
obtained), will be recorded qd. If more than one value is obtained for the arterial blood gases, 
the value closest to 08:00 will be used.
Arterial gasses should be collected from subjects if the sample is easily accessible and the 
procedure will not be painful to subjects (ie, subject is in the ICU or has arterial port). All 
available data from the arterial gases should be entered into the database. If the collection of 
arterial gases is not clinically indicated, the test should not be performed.
Predicted body weight will be recorded on the ventilator eCRF for assessment of tidal volume.
8.4.2
Modified Sequential Organ Failure Assessment (SOFA) Scores
A modified SOFA score will be calculated. For each of the following routine assessments, the 
worst value of the day will be recorded in the eCRF: PaO2/FiO2 (mmHg) or oxygen saturation 
by pulse oximetry (SpO2)/FiO2 (mmHg), platelet count, bilirubin, vasopressor use (μg/kg/min, 
mmHg), and creatinine ([or urine output]). For laboratory values, use last available (if within 
48 hours). On days when laboratory results are unavailable, values will be extrapolated from 
the previously available values.
8.4.3
Assessment of Number of Days in ICU
Assessment of ICU length of stay will be obtained by asking the Investigator to determine if 
the subject is receiving ICU standard care (or equivalent) on each day during hospitalization 
up to Day 90. In the event of an affirmative response, a further question will be asked to 
determine if this ICU care is considered necessary (rather than being due to logistical reasons).
Only days in the ICU (or equivalent), which the Investigator considers necessary, will be 
regarded as ICU days.

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8.5
Follow Up Procedures
Follow up procedures are outlined in Section 1.1
8.6
Collection of Adverse Events
The Principal Investigator is responsible for ensuring that all staff involved in the study are 
familiar with the content of this section.
The definitions of an AE or SAE can be found in Appendix B.
The following are NOT considered an AE:

Pre-existing condition that has not worsened: A pre-existing condition (documented on 
the medical history eCRF) is not considered an AE unless the severity, frequency, or 
character of the event worsens during the study period.

Diagnostic testing and procedures: Testing and procedures should not be reported as 
AEs or SAEs, but rather the cause for the test or procedure should be reported. If a test or 
procedure is done to rule out a diagnosis, the sign or symptom leading to the 
test/procedure should be the event term, and the event term should only be updated to the 
diagnosis if/when the diagnosis is confirmed. Testing and procedures performed solely as 
screening measures (eg, routine screening mammography or colonoscopy) should not be 
reported as AEs or SAEs.

Abnormal laboratory results: Abnormal laboratory results are not AEs unless they are 
clinically significant. For example, a clinically significant laboratory result is one that 
requires treatment (for example a blood transfusion for low haemoglobin) or requires a 
change in study drug (eg, lowering the dose or withholding study drug while the 
laboratory finding resolves or stabilizes).

Progression of underlying disease: Progression of underlying disease unequivocally 
related to COVID-19 pneumonia (such as worsening of respiratory status or
complications associated with pneumonia) will not be reported as an AE if it is clearly 
consistent with the suspected progression of the underlying disease. Clinical symptoms of 
progression may be reported as AEs if the symptoms cannot be determined as exclusively 
due to the progression of the underlying disease, or if they do not fit the expected pattern 
of progression for the disease under study.
Symptomatic deterioration may occur in some subjects. Symptomatic deterioration is when 
progression is evident in the subject’s clinical symptoms and the Investigator may elect not to 
perform further disease assessments. 
If there is any uncertainty about an AE being due only to the disease under study, it should be 
reported as an AE or SAE.
AE will be reported by the subject (or, when appropriate, by a caregiver, surrogate, or the 
subject's legally authorized representative).

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The Investigator and any designees are responsible for detecting, documenting, and recording 
events that meet the definition of an AE or SAE. For information on how to follow up AEs,
see Section 8.6.3.
8.6.1
Method of Detecting AEs and SAEs
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and 
non-leading verbal questioning of the subject is the preferred method to inquire about 
AE occurrences.  
8.6.2
Time Period and Frequency for Collecting AE and SAE Information 
After the signing of the ICF, all SAEs must be reported. After randomization, all AEs/SAEs, 
irrespective of attribution of causality, must be reported. 
AE reporting, irrespective of seriousness, ends 28 (± 3) days after the last dose of study 
treatments(s) for those on acalabrutinib + BSC (Arm 1) and 38 (± 3) days from randomization 
for those on BSC only (Arm 2).
SAEs considered related to study treatments(s) or study procedures occurring after the end of 
the AE reporting period (as defined above) must be reported.  Information on concomitant 
medications at the time of the treatment-related SAE will also be collected.
All SAEs will be recorded and reported to the Sponsor or designee within 1 day (ie, 
immediately but no later than 24 hours from when he or she becomes aware of it), as 
indicated in Appendix B. The Investigator will submit any updated SAE data to the Sponsor
within 24 hours of it being available.
The method of recording, evaluating, and assessing causality of AE and SAE and the 
procedures for reporting SAEs are provided in Section 8.7.1.
8.6.3
Follow-up of AEs and SAEs
After the initial AE/SAE report, the Investigator is required to proactively follow each subject 
at subsequent visits/contacts. All SAEs/non-SAEs/AEs of special interest (AESIs; as defined 
in Section 8.6.12), will be followed until resolution, stabilization, the event is otherwise 
explained, or the subject is lost to follow-up. 
Any AEs that are unresolved at the subject’s last AE assessment or other assessment/visit as 
appropriate in the study are followed up by the Investigator for as long as medically indicated, 
but without further recording in the eCRF. The Sponsor retains the right to request additional 
information for any subject with ongoing AE(s)/SAE(s) at the end of the study, if judged 
necessary.

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8.6.4
Adverse Event Data Collection
The following variables will be collected for each AE:

AE diagnosis/description

The date when the AE started and stopped

Maximum Common Terminology Criteria for Adverse Events (CTCAE) grade

Whether the AE is serious or not

Investigator causality rating against the investigational product (yes or no)

Action taken regarding investigational product

Administration of treatment for the AE 

Outcome
In addition, the following variables will be collected for SAEs:

Date AE met criteria for SAE

Date Investigator became aware of SAE

Seriousness criteria

Date of hospitalisation

Date of discharge

Probable cause of death

Date of death

Autopsy performed

Causality assessment in relation to study procedure(s)

Causality assessment to other medications

Description of SAE
The grading scales found in the revised NCI CTCAE Version 5.0 will be utilized for all events 
with an assigned CTCAE grading. For those events without assigned CTCAE grades, the 
recommendation in the CTCAE criteria that converts mild, moderate, and severe events into 
CTCAE grades should be used. A copy of the CTCAE Version 5.0 can be downloaded from 
the Cancer Therapy Evaluation Program website 
(https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quic
k_Reference_8.5x11.pdf).
8.6.5
Causality Collection
The Investigator will assess causal relationship between investigational product and each AE, 
and answer ‘yes’ or ‘no’ to the question ‘Do you consider that there is a reasonable possibility 
that the event may have been caused by the investigational product?’

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For SAEs, causal relationship will also be assessed for other medication and study procedures. 
Note that for SAEs that could be associated with any study procedure the causal relationship is 
implied as ‘yes’.
A guide to the interpretation of the causality question is found in Appendix B of this protocol.
8.6.6
Adverse Events Based on Signs and Symptoms
All AEs spontaneously reported by the subject or reported in response to the open question 
from the study site staff: ‘Have you had any health problems since the previous visit/you were
last asked?’, or revealed by observation will be collected and recorded in the eCRF. When 
collecting AEs, the recording of diagnoses is preferred (when possible) to recording a list of 
signs and symptoms. However, if a diagnosis is known and there are other signs or symptoms 
that are not generally part of the diagnosis, the diagnosis and each sign or symptom will be 
recorded separately.
8.6.7
Adverse Events Based on Examinations and Tests
The results from the protocol-mandated laboratory tests and vital signs will be summarised in 
the Clinical Study Report. Deterioration as compared to baseline in protocol-mandated 
procedures (eg, safety laboratory tests and vital signs) should therefore only be reported as 
AEs if they fulfil any of the SAE criteria or are the reason for discontinuation of treatment 
with the investigational product.
If deterioration in a laboratory value/vital sign is associated with clinical signs and symptoms, 
the sign or symptom will be reported as an AE and the associated laboratory result/vital sign 
will be considered as additional information. Wherever possible the reporting Investigator
uses the clinical, rather than the laboratory term (eg, anemia versus low hemoglobin value). In 
the absence of clinical signs or symptoms, clinically relevant deteriorations in non-mandated 
parameters should be reported as AE(s).
Deterioration of a laboratory value, which is unequivocally due to disease progression, should 
not be reported as an AE/SAE.
Any new or aggravated clinically relevant abnormal medical finding at a physical examination 
as compared with the baseline assessment will be reported as an AE unless unequivocally 
related to the disease under study, see Section 8.6.9 and Section 8.6.10.
8.6.8
Hy’s Law
Cases where a subject shows elevations in liver biochemistry may require further evaluation, 
and occurrences of AST or ALT ≥3×ULN together with total bilirubin ≥2×ULN may need to 
be reported as SAEs. Please refer to Appendix D for further instruction on cases of increases 
in liver biochemistry and evaluation of Hy’s law.

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8.6.9
Disease Under Study 
Systemic symptoms of the disease under study are those which might be expected to occur as 
a direct result of the clinical presentation associated with COVID-19 pneumonia and 
respiratory illness. Events which are unequivocally due to disease under study should not be 
reported as an AE during the study unless they meet SAE criteria or lead to discontinuation of 
the investigational product.
8.6.10
Disease Progression
Disease progression can be considered as a worsening of a subject’s condition attributable to 
COVID-19 pneumonia for which the investigational product is being studied.  It may be an 
increase in the severity of the disease under study and/or increases in the symptoms of the 
disease. Events, which are unequivocally due to COVID-19 pneumonia, should not be 
reported as an AE or SAE during the study. Events attributable to disease progression of 
COVID-19 include pulmonary failure, ARDS, sepsis, shock, multiorgan failure and death.
8.6.11
Deaths
All deaths that occur during the study treatment period, or within the protocol-defined follow 
up period after the administration of the last dose of study treatment, must be reported as 
follows:

Death clearly resulting from disease progression should be documented in the eCRF in 
the Death page. It should not be reported as an SAE.

Where death is not due (or not clearly due) to progression of the disease under study, the 
AE causing the death must be reported as an SAE within 24 hours. It should also be 
documented in the Death page in the eCRF. The report should contain a comment 
regarding the co-involvement of disease progression, if appropriate, and should assign the 
main and contributory causes of death.

Deaths with an unknown cause should always be reported as an SAE and documented in 
the Death page in the eCRF, but every effort should be made to determine a cause of 
death. A post-mortem may be helpful in the assessment of the cause of death, and if 
performed, a copy of the post-mortem results should be forwarded to Sponsor Patient 
Safety or its representative within the usual time frames.
Deaths occurring after the protocol-defined follow-up period after the administration of the 
last dose of study treatment should be documented in the Death page. If the death occurred as 
a result of an event that started after the defined follow-up period and the event is considered 
to be due to a late-onset toxicity to study treatment, then it should also be reported as an SAE.
8.6.12
Adverse Events of Special Interest
AESIs are events of scientific and medical interest specific to the further understanding of the 
acalabrutinib safety profile and require close monitoring and rapid communication by the 

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Investigators to the Sponsor. An AESI can be serious or non-serious. All AESIs will be 
recorded in the eCRF. Serious AESIs will be recorded and reported as per Section 8.7.1.
The following events are AESIs for subjects receiving acalabrutinib and must be reported to 
the Sponsor expeditiously (see Section 8.7.1 for reporting instructions), irrespective of 
regulatory seriousness criteria or causality:

Ventricular arrhythmias (eg, ventricular extrasystoles, ventricular tachycardia, 
ventricular arrhythmia, ventricular fibrillation)
8.7
Safety Reporting and Medical Management
8.7.1
Reporting of Serious Adverse Events 
All SAEs have to be reported to the Sponsor, whether or not considered causally related to the 
investigational product, or to the study procedure(s). All SAEs will be recorded in the eCRF. 
Prompt notification by the Investigator to the Sponsor of an SAE is essential so that legal 
obligations and ethical responsibilities towards the safety of subjects and the safety of a study 
treatment under clinical investigation are met. 
The Sponsor has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a study treatment under clinical investigation.  The 
Sponsor will comply with country-specific regulatory requirements relating to safety reporting 
to the regulatory authority, the Institutional Review Board (IRB)/Independent Ethics 
Committee (IEC), and Investigators.
If any SAE occurs in the course of the study, then Investigators or other site personnel inform 
the appropriate Sponsor representatives within 1 day (ie, immediately but no later than 
24 hours from when he or she becomes aware of it).
The designated Sponsor representative works with the Investigator to ensure that all the 
necessary information is provided to the Sponsor Patient Safety data entry site within 
1 calendar day of initial receipt for fatal and life-threatening events and within 5 calendar 
days of initial receipt for all other SAEs.
For fatal or life-threatening AEs where important or relevant information is missing, active 
follow-up is undertaken immediately. Investigators or other site personnel inform Sponsor
representatives of any follow-up information on a previously reported SAE within 1 calendar 
day (ie, immediately but no later than 24 hours from when he or she becomes aware of it).
For all studies except those utilizing medical devices, Investigator safety reports must be 
prepared for suspected unexpected serious adverse reactions (SUSAR) according to local 
regulatory requirements and Sponsor policy and forwarded to Investigators as necessary.

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An Investigator who receives an Investigator safety report describing an SAE or other specific 
safety information (eg, summary or listing of SAEs) from the Sponsor will review and file the 
report/information with the Investigator’s Brochure and will notify the IRB/IEC according to 
local requirements, if appropriate.
For further guidance on the definition of a SAE, see Appendix B.
8.7.2
Pregnancy
All pregnancies, partner pregnancies, and outcomes of pregnancy/partner pregnancy should be 
reported to the Sponsor, with the exception of any pregnancy that is discovered before the 
subject has received any study treatment.
If a pregnancy is reported, the Investigator should inform the Sponsor within 1 day (ie, 
immediately but no later than 24 hours of when he/she becomes aware of the pregnancy).
Abnormal pregnancy outcomes (eg, spontaneous abortion, fetal death, stillbirth, congenital 
anomalies, ectopic pregnancy) are considered SAEs.
8.7.2.1
Maternal Exposure
If a subject becomes pregnant during the course of the study, investigational product should be 
discontinued immediately.
Pregnancy itself is not regarded as an AE unless there is a suspicion that the investigational 
product under study may have interfered with the effectiveness of a contraceptive medication. 
Congenital abnormalities/birth defects and spontaneous miscarriages should be reported and 
handled as SAEs. Elective abortions without complications should not be handled as AEs. The 
outcome of all pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, 
normal birth, or congenital abnormality) should be followed up and documented even if the 
subject was discontinued from the study.
If any pregnancy occurs in the course of the study, then the Investigator or other site personnel 
informs the appropriate Sponsor representatives within 1 day (ie, immediately but no later 
than 24 hours of when he/she becomes aware of the pregnancy).
The designated Sponsor representative works with the Investigator to ensure that all relevant 
information is provided to the Sponsor subject safety data entry site within either 1 day or 
5 calendar days for SAEs (see Section 8.7.1), and within 30 days for all other pregnancies.
The same timelines apply when outcome information is available.

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8.7.2.2
Paternal Exposure 
Male subjects should refrain from fathering a child or donating sperm during the study and for 
2 days after the last dose of acalabrutinib.
Pregnancy of a subject’s partner is not considered to be an AE. However, the outcome of all 
pregnancies (spontaneous miscarriage, elective termination, ectopic pregnancy, normal birth, 
or congenital abnormality), occurring from the date of the first dose until 2 days after the last 
dose of acalabrutinib, should, if possible, be followed up and documented in the Pregnancy 
Report Form. Consent from the partner must be obtained before the Pregnancy Report Form is 
completed.
Where a report of pregnancy is received, prior to obtaining information about the pregnancy, 
the Investigator must obtain the consent of the subject’s partner. The local study team should 
adopt the Master Pregnant Partner Form in line with local procedures/requirements and submit 
it to the relevant regulatory authority/IRB/ethics committee prior to use.
8.7.3
Overdose
Study drug overdose is the accidental or intentional use of the drug in an amount higher than 
the dose being studied. An overdose or incorrect administration of study treatment is not an 
AE unless it results in untoward medical effects. Any study treatment overdose or incorrect 
administration of study treatment should be noted on the Overdose eCRF.
All AEs associated with an overdose or incorrect administration of study treatment should be 
recorded on the Adverse Event eCRF. If the associated AE fulfils serious criteria, the event 
should be reported to the Sponsor immediately (ie, no later than 24 hours after learning of the 
event). 
For overdoses associated with a SAE, the standard reporting timelines apply; see 
Section 8.6.2. For other overdoses, reporting must occur within 30 days.
The designated Sponsor representative works with the Investigator to ensure that all relevant 
information is provided to the Sponsor Patient Safety data entry site.
8.7.4
Medication Error
If a medication error occurs in the course of the study, then the Investigator (or other site 
personnel) informs the appropriate Sponsor representatives within 1 day (ie, immediately but 
no later than 24 hours of when the Investigator (or other site personnel) becomes aware of the 
error.
The designated Sponsor representative works with the Investigator to ensure that all relevant 
information is completed within 1 calendar day (in the event of initial fatal/life-threatening 
errors or follow-up fatal/life-threatening errors) or 5 calendar days (in the event of other 

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serious initial and follow-up errors) if there is an SAE associated with the medication error 
(see Section 8.7.1), and within 30 days for all other medication errors.
The definition of a Medication Error can be found in Appendix B.
8.8
Efficacy Assessments
8.8.1
Improvements on the 9-Point Ordinal Scale
For the purposes of this study, the condition of each potential subject in the study will be 
assessed using a 9-point category ordinal scale below. Assessments will be performed as 
described in the SoA.
0.*
Uninfected, no clinical or virological evidence of infection 
1. 
Ambulatory, no limitation of activities 
2. 
Ambulatory, limitation of activities 
3. 
Hospitalized – mild disease, no oxygen therapy 
4. 
Hospitalized – mild disease, oxygen by mask or nasal prongs 
5. 
Hospitalized – severe disease, non-invasive ventilation or high flow oxygen 
6. 
Hospitalised – severe disease, intubation and mechanical ventilation 
7.
Hospitalized – severe disease, ventilation and additional organ support, such 
as pressors, renal replacement therapy, extracorporeal membrane 
oxygenation 
8.
Death 
*Score of zero on 9-point category ordinal scale will not be evaluated in this study.
To be considered a “responder” to treatment with a target candidate, a subject needs to show 
an improvement of at least 2 points (from randomization) on this scale. The time to clinical 
improvement of 2 points will be assessed as a secondary endpoint.
9.
STATISTICAL CONSIDERATIONS 
9.1
Statistical Hypotheses
Overall study design is described in Section 4.1 of the protocol. Subjects who are hospitalized 
for COVID-19 symptoms and meet the eligibility criteria will be randomized 1:1 to receive 
acalabrutinib plus BSC (Arm 1: n=30) vs BSC (Arm 2: n=30).
Stratification by age (≥65 vs <65 years) and comorbidities (present vs absent) will be applied
to randomization. 

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The primary objective of the study is to evaluate the safety and preliminary efficacy of 
acalabrutinib plus BSC (Arm 1) vs BSC (Arm 2). There is no formal hypothesis testing for the 
safety and efficacy endpoints. The primary focus for the efficacy is to estimate the treatment 
effect as measured by the difference between treatment arms in the proportion of subjects who 
are alive and free of respiratory failure.
9.2
Sample Size Determination 
The planned total number of subjects in this study is 60.  
Based on the reported rate of deaths and need for ICU admission (a surrogate for respiratory 
failure) in subjects who are hospitalized for COVID-19 (Arentz et al 2020, Bhatraju et al 
2020, CDC 2020, Grasselli et al 2020), it assumed that the proportion of subjects who are 
alive and free of respiratory failure at Day 28 is 70% under BSC. A targeted difference of 
20% between two treatment arms (ie, 90% for acalabrutinib + BSC) is of clinical interest. 
With a total sample size of 60, the half-width of the 2-sided 90% confidence interval for the
observed treatment difference is 16.4% using unpooled estimate for variance. It has 
approximately 64% power, with a 2-sided type I error of 0.1, to detect a difference of 20% 
between the 2 arms. 
9.3
Populations for Analyses
The analysis populations are defined as shown in Table 6.
Table 6
Analysis Populations
Population/ Analysis set
Description
Full analysis set (ITT population)
The full analysis set will include all subjects who 
are randomized and will be used for all efficacy 
analyses. Treatment arms will be compared on the 
basis of randomized study treatment, regardless of 
the treatment actually received. Subjects who 
were randomized but did not subsequently go on 
to receive study treatment will be included in the 
analysis in the treatment arm to which they were 
randomized, following the “intent-to-treat” 
principle.
Per-protocol analysis set
The per-protocol analysis set will be a subset of 
the ITT population including only subjects 
without important detected protocol deviations 
affecting the efficacy endpoints. Subjects will be 
summarized according to the actual treatment first 
received. The primary endpoint of the study will 
also be summarized for this population.

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Table 6
Analysis Populations
Population/ Analysis set
Description
Safety analysis set
The safety analysis set (Safety population) is 
based on the treatment subjects actually received.  
In this study, the treatment is either acalabrutinib 
+ BSC or BSC only. If a subject receives at least 1 
dose of acalabrutinib, the subject is considered as 
acalabrutinib-treated, regardless which arm the 
subject was randomized to. Subjects who are 
randomized to acalabrutinib + BSC but do not 
receive any acalabrutinib will be summarized in 
the BSC group. 
PK analysis set
The PK analysis set will include all subjects who 
receive ≥1 dose of acalabrutinib and had ≥1 post-
dose evaluable PK data point for acalabrutinib. 
The population will be defined by AstraZeneca, 
the pharmacokineticist and the statistician prior to 
any analyses being performed.
BSC = best supportive care; ITT = Intent-to-treat; PK = pharmacokinetic.
9.4
Interim Analysis
There are no formal interim futility and interim efficacy analyses in this Phase 2 study.
9.5
Missing Data Handling
No imputation of values for missing data will be performed except that missing or partial start 
and end dates for AEs and concomitant medication will be imputed per prespecified, 
conservative imputation rules.
The specification for handling death in the analysis of endpoints that do not contain mortality as a 
component will be provided in the Statistical Analysis Plan (SAP).
9.6
Statistical Analyses
A comprehensive SAP will be developed and finalized before database lock and will describe 
the subject populations to be included in the analyses, and procedures for accounting for 
missing, unused, and spurious data. Any deviations from the SAP will be reported in the 
Clinical Study Report.
The primary analysis of the study will take place when all randomized subjects have been 
followed for 38 (± 3) days from randomization.
An updated analysis for those endpoints requiring 90-day assessments will take place after the 
last randomized subject has had 90 days follow up from randomization. 

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9.6.1
Safety Analyses
Safety assessments will consist of monitoring and recording AEs, SAEs and AEs leading to 
discontinuation of study treatment; measurements of protocol-specified hematology, clinical 
chemistry, and other laboratory variables; measurement of protocol-specified vital signs; and 
other protocol-specified tests that are deemed critical to the safety evaluation of the study 
treatment. All safety analyses will be performed on the safety analysis set as defined in 
Section 9.3.
Verbatim descriptions of AEs will be mapped per the most recent version of Medical 
Dictionary for Regulatory Activities (MedDRA) thesaurus terms and graded per National 
Cancer Institute (NCI) CTCAE, v5.0 or higher. Extent of exposure to study treatment, all AEs, 
SAEs, any AEs leading to study treatment discontinuation, and study treatment related AEs 
will be summarized. The frequency of AEs will be summarized by system organ class and 
preferred terms per MedDRA by the worst reported NCI CTCAE grade. TEAEs will be 
summarized, unless otherwise specified. In this study, for Arm 1 (acalabrutinib + BSC), 
TEAEs are defined as AEs starting or ongoing AEs worsening after the first dose of study 
treatment and AEs with start date up to the last dose of study treatment plus 28 (± 3) days; for 
Arm 2 (BSC only), TEAEs are defined as AEs starting or ongoing AEs worsening after the 
date of randomization and AEs with start date up to 38 (± 3) days from randomization.
Laboratory abnormalities will be defined based on laboratory normal ranges (universal normal 
ranges, if central laboratory). Selected laboratory parameters may be analysed with shift tables 
and summaries of changes from baseline to worst post-treatment value.
Vital sign and all other safety assessments will be tabulated and summarized.
Full details of AE, laboratory assessments, vital sign assessments and all other safety 
assessments will be provided in the SAP.
9.6.2
Efficacy Analyses
Primary Endpoint
The primary endpoint is the proportion of subjects who are alive and free of respiratory failure 
at Day 28 (see Section 3 for a definition of respiratory failure). The point estimate and its 
90% confidence interval (CI; using Wald method with continuity correction) will be 
calculated for each treatment arm. The Cochran-Mantel-Haenszel χ2 test stratified by age 
(≥65 vs < 65 years) and comorbidities (present vs absent) will be used to compare the 
proportion of subjects who are alive and free of respiratory failure at Day 28 between the two 
treatment arms. An unstratified analysis will also be performed. Finally, the difference in the 
proportion of subjects who are alive and free of respiratory failure at Day 28 will also be 

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provided with 90% CIs. The treatment difference will be also estimated using a logistic 
regression (Ge 2011) with indicators for treatment and the randomization stratification factors 
(2 × 2) as well as baseline respiratory failure (with vs without).
The primary endpoint of the study will be summarized by subgroups that include age group, 
sex, race, ethnicity, comorbidities, baseline respiratory failure, and history of substance abuse.
The primary endpoint will be summarized and analysed as per the methods above for the full 
analysis set (ITT population) as well as the per-protocol analysis set.
Additional sensitivity analyses and subgroup analyses of the primary endpoint may be 
performed as appropriate.
Secondary Endpoints
The proportion of subjects alive and free of respiratory failure at Day 14 will be summarized 
using the full analysis set.
Summary statistics (n, mean, median, standard deviation, minimum, and maximum) will be 
presented by treatment arm for continuous secondary efficacy endpoints (refer to Section 3).
Summary statistics for the number of days hospitalized from randomization to 28 days after 
randomization and the number of days in ICU from randomization to 90 days after 
randomization will be summarized.
Time from randomization to first occurrence of respiratory failure or death on study (up to 
28 days after randomization) due to any cause will be analysed using Kaplan-Meier method; 
hazard ratio and corresponding 90% CIs will be estimated using Cox proportional hazards 
models, stratified by randomization stratification factors. If a subject did not have an event 
and did not drop out prior to Day 28, the data will be censored at Day 28; if a subject did not 
have an event but dropped out prior to Day 28, the data will be censored at the last date known 
to be alive and free of respiratory failure.
Similarly, time to clinical improvement of at least 2 points (from randomization) on a 9-point 
category ordinal scale through Day 28 will be analysed using Kaplan-Meier method.
The statistical analysis plan will provide the further details.
9.6.3
Pharmacokinetic and Pharmacodynamic Analyses 
PK assessments will be conducted in up to 15 evaluable subjects and PD assessments in up to 
15 evaluable subjects randomized to Arm 1 (acalabrutinib + BSC). Subjects are considered 
evaluable if they have an evaluable PK/PD profile, ie, (1) receive acalabrutinib treatment and 
(2) do not have data that are unavailable or incomplete (ie, provide data from all PK/PD visits 
indicated in the SoA).

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The statistical analysis and reporting of PK and PD parameters will be provided in the SAP. 
10.
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Appendix A
Regulatory, Ethical and Study Oversight Considerations
A 1
Regulatory and Ethical Considerations
This study will be conducted in accordance with the protocol and with the following:

Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki and Council for International Organizations of Medical Sciences 
(CIOMS) International Ethical Guidelines

Applicable International Council for Harmonisation (ICH) GCP Guidelines

Applicable laws and regulations
The protocol, protocol amendments, ICF, Investigator’s Brochure, and other relevant 
documents (eg, advertisements) must be submitted to an IRB/IEC by the Investigator, and 
reviewed and approved by the IRB/IEC, before the study is initiated.  
Any amendments to the protocol will require IRB/IEC approval before implementation of 
changes made to the study design, except for changes necessary to eliminate an immediate 
hazard to study subjects.  
The Investigator will be responsible for the following:

Providing written summaries of the status of the study to the IRB/IEC annually or more 
frequently in accordance with the requirements, policies, and procedures established by 
the IRB/IEC

Notifying the IRB/IEC of SAEs or other significant safety findings as required by 
IRB/IEC procedures

Providing oversight of the conduct of the study at the site and adherence to requirements 
of 21 CFR, ICH guidelines, the IRB/IEC, European regulation 536/2014 for clinical 
studies (if applicable), and all other applicable local regulations
The study will be performed in accordance with the Sponsor policy on Bioethics and Human 
Biological Samples.
A 2
Financial Disclosure
Investigators and sub-investigators will provide the Sponsor with sufficient, accurate financial 
information as requested to allow the Sponsor to submit complete and accurate financial 
certification or disclosure statements to the appropriate regulatory authorities.  Investigators 
are responsible for providing information on financial interests during the course of the study 
and for 1 year after completion of the study.

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A 3
Informed Consent Process
The Investigator or his/her representative will explain the nature of the study to the subject or 
his/her legally authorised representative and answer all questions regarding the study.  
Subjects must be informed that their participation is voluntary. Subjects or their legally 
authorised representative will be required to sign a statement of informed consent that meets 
the requirements of 21 CFR 50, local regulations, ICH guidelines, Health Insurance Portability 
and Accountability Act (HIPAA) requirements, where applicable, and the IRB/IEC or study 
center.  
The medical record must include a statement that written informed consent was obtained 
before the subject was enrolled in the study and the date and time the written consent was 
obtained. The authorised person obtaining the informed consent must also sign the ICF.
Subjects must be re-consented to the most current version of the ICF(s) during their 
participation in the study.  
A copy of the ICF(s) must be provided to the subject or the subject’s legally authorized 
representative.
Subjects will be told that they are free to refuse to participate and may withdraw their consent 
at any time and for any reason during the sample storage period. If a subject withdraws 
consent to the use of donated biological samples, the samples will be disposed of/destroyed, 
and the action documented. If samples already have been analysed at the time of the request, 
the Sponsor will not be obliged to destroy the results of this research.
A 4
Data Protection
Each subject will be assigned a unique identifier by the Sponsor. Any subject records or data 
sets transferred to the Sponsor will contain only the identifier; subject names or any 
information which would make the subject identifiable will not be transferred.  
The subject must be informed that his/her personal study-related data will be used by the 
Sponsor in accordance with local data protection law. The level of disclosure must also be 
explained to the subject.  
The subject must be informed that his/her medical records may be examined by Clinical 
Quality Assurance auditors or other authorised personnel appointed by the Sponsor, by 
appropriate IRB/IEC members, and by inspectors from regulatory authorities.

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A 5
Committee Structures
An iDMC will be formed. Detailed information regarding the composition of the iDMC and 
detailed iDMC procedures will be provided in a separate charter. The iDMC will be 
responsible for reviewing the safety data periodically and provide recommendations according 
to the charter.
The safety of all Sponsor clinical studies is closely monitored on an ongoing basis by Sponsor
representatives in consultation with Patient Safety. Issues identified will be addressed; for 
example, this could involve amendments to the CSP and letters to Investigators.
A 6
Dissemination of Clinical Study Data
A description of this clinical trial will be available on http://astrazenecaclinicaltrials.com and 
http://www.clinicaltrials.gov as will the summary of the main study results when they are 
available. The clinical trial and/or summary of main study results may also be available on 
other websites according to the regulations of the countries in which the main study is 
conducted.
A 7
Data Quality Assurance
All subject data relating to the study will be recorded on printed CRF or eCRF unless 
transmitted to the Sponsor or designee electronically (eg, laboratory data). The Investigator is 
responsible for verifying that data entries are accurate and correct by physically or 
electronically signing the CRF/eCRF.
The Investigator must maintain accurate documentation (source data) that supports the 
information entered in the CRF/eCRF.
The Investigator must permit study-related monitoring, audits, IRB/IEC review, and 
regulatory agency inspections and provide direct access to source data documents.
The Sponsor or designee is responsible for the data management of this study including 
quality checking of the data.
Study monitors will perform ongoing source data review to confirm that data entered into the 
CRF/eCRF by authorized site personnel are accurate, complete, and verifiable from source 
documents; that the safety and rights of subjects are being protected; and that the study is 
being conducted in accordance with the currently approved protocol and any other study 
agreements, ICH GCP, and all applicable regulatory requirements.
Records and documents, including signed ICFs, pertaining to the conduct of this study must 
be retained by the Investigator for 15 years after study completion unless local regulations or 
institutional policies require a longer retention period. No records may be destroyed during the 

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retention period without the written approval of the Sponsor. No records may be transferred to 
another location or party without written notification to the Sponsor.
A 8
Source Documents
Source documents provide evidence for the existence of the subject and substantiate the 
integrity of the data collected.  Source documents are filed at the Investigator’s site.
Data reported on the CRF/eCRF that are transcribed from source documents must be 
consistent with the source documents or the discrepancies must be explained. The Investigator
may need to request previous medical records or transfer records, depending on the study. 
Also, current medical records must be available.
Definitions of what constitutes source data can be found in the Clinical Study Agreement.
A 9
Study and Site Closure
The Sponsor designee reserves the right to close the study site or terminate the study at any 
time for any reason at the sole discretion of the Sponsor. The study may be stopped if, in the 
judgment of the Sponsor, trial subjects are placed at undue risk because of clinically 
significant findings that:

Meet individual stopping criteria or are otherwise considered significant 

Are assessed as causally related to study treatment, 

Are not considered to be consistent with continuation of the study
Regardless of the reason for termination, all data available for the subject at the time of 
discontinuation of follow-up must be recorded in the CRF/eCRF. All reasons for 
discontinuation of treatment must be documented.
In terminating the study, the Sponsor will ensure that adequate consideration is given to the 
protection of the subjects’ interests.
Study sites will be closed upon study completion. A study site is considered closed when all 
required documents and study supplies have been collected and a study-site closure visit has 
been performed.
The Investigator may initiate study-site closure at any time, provided there is reasonable cause 
and sufficient notice is given in advance of the intended termination.

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Reasons for the early closure of a study site by the Sponsor or Investigator may include but 
are not limited to:

Failure of the Investigator to comply with the protocol, the requirements of the IRB/IEC 
or local health authorities, the Sponsor's procedures, or GCP guidelines

Inadequate recruitment of subjects by the Investigator

Discontinuation of further study treatment development
A 10
Publication Policy
The results of this study may be published or presented at scientific meetings once the primary 
analysis is completed and the study is unblinded. No other publications prior to that timepoint 
is allowed.
The Sponsor will comply with the requirements for publication of study results. In accordance 
with standard editorial and ethical practice, the Sponsor will generally support publication of 
multicenter studies only in their entirety and not as individual site data.  In this case, a 
coordinating Investigator will be designated by mutual agreement.
Authorship will be determined by mutual agreement and in line with International Committee 
of Medical Journal Editors authorship requirements.
Subsequent to the primary publication, if an Investigator plans to publish any subset of data, 
or case report, the Investigator agrees to submit all manuscripts or abstracts to the Sponsor 
before submission. This allows the Sponsor to protect proprietary information and to provide 
comments.

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Appendix B
Adverse Event Definitions and Additional Safety 
Information
B 1
Definition of Adverse Events
An AE is the development of any untoward medical occurrence (other than progression of the 
disease under evaluation) in a patient or clinical study subject administered a medicinal 
product and which does not necessarily have a causal relationship with this treatment. An AE 
can therefore be any unfavourable and unintended sign (eg, an abnormal laboratory finding), 
symptom (eg, nausea, chest pain), or disease temporally associated with the use of a medicinal 
product, whether or not considered related to the medicinal product.  
The term AE is used to include both serious and non-serious AEs and can include a 
deterioration of a pre-existing medical occurrence. An AE may occur at any time, including 
run-in or washout periods, even if no study treatment has been administered.
B 2
Definition of Serious Adverse Events
A SAE is an AE occurring during any study phase (ie, run-in, treatment, washout, follow-up), 
that fulfils one or more of the following criteria:

Results in death

Is immediately life-threatening

Requires in-patient hospitalization or prolongation of existing hospitalization 

Results in persistent or significant disability or incapacity

Is a congenital abnormality or birth defect

Is an important medical event that may jeopardize the subject or may require medical 
treatment to prevent one of the outcomes listed above.
B 3
Life-threatening
‘Life-threatening’ means that the subject was at immediate risk of death from the AE as it 
occurred, or it is suspected that use or continued use of the product would result in the 
subject’s death. ‘Life-threatening’ does not mean that, had an AE occurred in a more severe 
form, it might have caused death (eg, hepatitis that resolved without hepatic failure).
B 4
Hospitalization
Outpatient treatment in an emergency room is not in itself a serious AE, although the reasons 
for it may be (eg, bronchospasm, laryngeal oedema). Hospital admissions and/or surgical 
operations planned before or during a study are not considered AEs if the illness or disease 
existed before the subject was enrolled in the study, provided that it did not deteriorate in an 
unexpected way during the study.

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B 5
Important Medical Event or Medical Treatment
Medical and scientific judgement should be exercised in deciding whether a case is serious in 
situations where important medical events may not be immediately life threatening or result in 
death, hospitalization, disability or incapacity but may jeopardize the subject or may require 
medical treatment to prevent one or more outcomes listed in the definition of serious. These
should usually be considered as serious.
Simply stopping the suspect drug does not mean that it is an important medical event; medical 
judgement must be used.

Angioedema not severe enough to require intubation but requiring intravenous 
hydrocortisone treatment

Hepatotoxicity caused by paracetamol (acetaminophen) overdose requiring treatment with 
N-acetylcysteine

Intensive treatment in an emergency room or at home for allergic bronchospasm

Blood dyscrasias (eg, neutropenia or anemia requiring blood transfusion, etc.) or 
convulsions that do not result in hospitalization

Development of drug dependency or drug abuse
B 6
Intensity Rating Scale
The grading scales found in the revised NCI CTCAE v5.0 will be utilized for all events with 
an assigned CTCAE grading. For those events without assigned CTCAE grades, the 
recommendation in the CTCAE criteria that converts mild, moderate and severe events into 
CTCAE grades should be used. A copy of the CTCAE can be downloaded from the Cancer 
Therapy Evaluation Program website 
(https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_Quic
k_Reference_8.5x11.pdf).
It is important to distinguish between serious and severe AEs. Severity is a measure of 
intensity whereas seriousness is defined by the criteria in Appendix B 2. An AE of severe 
intensity need not necessarily be considered serious. For example, nausea that persists for 
several hours may be considered severe nausea, but not a SAE unless it meets the criteria 
shown in Appendix B 2. On the other hand, a stroke that results in only a limited degree of 
disability may be considered a mild stroke but would be a SAE when it satisfies the criteria 
shown in Appendix B 2.

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B 7
A Guide to Interpreting the Causality Question
When assessing causality consider the following factors when deciding if there is a 
‘reasonable possibility’ that an AE may have been caused by the drug.

Time Course. Exposure to suspect drug. Has the subject actually received the suspect 
drug?  Did the AE occur in a reasonable temporal relationship to the administration of the 
suspect drug?

Consistency with known drug profile. Was the AE consistent with the previous 
knowledge of the suspect drug (pharmacology and toxicology) or drugs of the same 
pharmacological class? Or could the AE be anticipated from its pharmacological 
properties?

De-challenge experience. Did the AE resolve or improve on stopping or reducing the dose 
of the suspect drug?

No alternative cause. The AE cannot be reasonably explained by another aetiology such 
as the underlying disease, other drugs, other host or environmental factors.

Re-challenge experience. The Sponsor would not normally recommend or support a 
re-challenge.

Laboratory tests. A specific laboratory investigation (if performed) has confirmed the 
relationship.
In difficult cases, other factors could be considered such as:

Is this a recognized feature of overdose of the drug?

Is there a known mechanism?
Causality of ‘related’ is made if following a review of the relevant data, there is evidence for a 
‘reasonable possibility’ of a causal relationship for the individual case. The expression 
‘reasonable possibility’ of a causal relationship is meant to convey, in general, that there are 
facts (evidence) or arguments to suggest a causal relationship.
The causality assessment is performed based on the available data including enough 
information to make an informed judgment. With limited or insufficient information in the 
case, it is likely that the event(s) will be assessed as ‘not related’.
Causal relationship in cases where the disease under study has deteriorated due to lack of 
effect should be classified as no reasonable possibility.
B 8
Medication Error
For the purposes of this clinical study a medication error is an unintended failure or mistake in 
the treatment process for a Sponsor study treatment that either causes harm to the subject or 
has the potential to cause harm to the subject.  

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A medication error is not lack of efficacy of the drug, but rather a human or process related 
failure while the drug is in control of the study site staff or subject.
Medication error includes situations where an error:  

Occurred

Was identified and intercepted before the subject received the drug

Did not occur, but circumstances were recognized that could have led to an error
Examples of events to be reported in clinical studies as medication errors:

Drug name confusion

Dispensing error, eg, medication prepared incorrectly, even if it was not actually given to 
the subject

Drug not administered as indicated, for example, wrong route or wrong site of 
administration

Drug not taken as indicated, eg, tablet dissolved in water when it should be taken as a 
solid tablet 

Drug not stored as instructed, eg, kept in the fridge when it should be at room temperature 

Wrong subject received the medication (excluding IRT errors)

Wrong drug administered to subject (excluding IRT errors)
Examples of events that do not require reporting as medication errors in clinical studies:

Errors related to or resulting from IRT - including those which lead to one of the above 
listed events that would otherwise have been a medication error 

Subject accidentally missed drug dose(s), eg, forgot to take medication

Accidental overdose (will be captured as an overdose)

Subject failed to return unused medication or empty packaging

Errors related to background and rescue medication, or standard of care medication in 
open label studies, even if an AstraZeneca product 
Medication errors are not regarded as AEs, but AEs may occur as a consequence of the 
medication error.

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Appendix C
Handling of Human Biological Samples
C 1
Chain of Custody of Biological Samples
A full chain of custody is maintained for all samples throughout their lifecycle.
The Investigator at each center keeps full traceability of collected biological samples from the 
subjects while in storage at the centre until shipment or disposal (where appropriate).
The sample receiver keeps full traceability of the samples while in storage and during use until 
used or disposed of or until further shipment and keeps documentation of receipt of arrival.
The Sponsor will keep oversight of the entire life cycle through internal procedures, 
monitoring of study sites, auditing or process checks, and contractual requirements of external 
laboratory providers.
Samples retained for further use will be stored in the Sponsor-assigned biobanks and will be 
registered by the Sponsor Biobank Team during the entire lifecycle. 
If required, the Sponsor will ensure that remaining biological samples are returned to the site 
according to local regulations or at the end of the retention period, whichever is the sooner.
C 2
Withdrawal of Informed Consent for Donated Biological Samples
If a subject withdraws consent specifically to the subsequent use of donated biological 
samples, the samples will be disposed of/destroyed, and the action documented. If samples are 
already analyzed, the Sponsor is not obliged to destroy the results of this research. A general 
withdrawal of consent to study treatment does not imply a withdrawal of consent to 
subsequent analyses of biological samples. In case a subject withdraws the general informed 
consent and additionally wants to withdraw consent for further analyses of his/her biological 
samples, the subject is required to sign an opt-out.
As collection of the biological sample(s) is an integral part of the study, then the subject is 
withdrawn from further study participation.
The Investigator:

Ensures subjects’ withdrawal of informed consent to the use of donated samples is 
notified immediately to Sponsor

Ensures that biological samples from that subject, if stored at the study site, are 
immediately identified, disposed of /destroyed, and the action documented

Ensures the organization(s) holding the samples is/are informed about the withdrawn 
consent immediately and that samples are disposed of/destroyed, the action documented, 
and the signed document returned to the study site

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
Ensures that the subject and Sponsor are informed about the sample disposal.
The Sponsor ensures the organization(s) holding the samples is/are informed about the 
withdrawn consent immediately and that samples are disposed of/destroyed and the action 
documented and returned to the study site.
C 3
International Airline Transportation Association Regulations on 
Labeling and Shipment of Biological Samples
Air transportation of biological samples (including biohazardous materials and potentially 
biohazardous materials) is regulated under International Airline Transportation Association 
(IATA) Dangerous Goods Regulations (DGR; 61st edition [2020]) Division 6.2—Infectious 
Substances. The IATA DGR definition of infectious substances includes any substance that is 
known or reasonably expected to contain pathogens, ie, microorganisms (including bacteria, 
viruses, rickettsiae, parasites, fungi) or other agent, such as a proteinaceous infectious particle 
(prion), that can cause disease in humans or animals.
As Division 6.2 infectious substances, biological samples transported by air must be classified 
as Category A, Category B, or Exempt; secured in IATA-compliant packaging; and identified 
using the appropriate United Nations shipping number and label requirements corresponding 
to the species, sample type, and infectious nature of material being shipped. See Table 7 for 
details.
Under IATA regulations, subject specimens from clinical trials will fall into Category B or 
Exempt. Clinical trial samples can often be packed and transported at ambient temperature.  
However, in cases where biological samples must be refrigerated or frozen for transport (eg, 
using dry ice or liquid nitrogen), additional dangerous goods specifications will apply; refer to 
DGR Section 3.6.2.2.3.8 (e). IATA-compliant couriers and materials should be used for 
transportation and packaging, and where applicable, packing should be done by 
IATA-certified personnel. 
Transportation of biological samples by road or rail is routinely subject to local regulations 
requiring shipment in safe, appropriate packaging materials to contain any risk of infection or 
contamination at all times, in addition to the use of approved couriers. Wherever possible, 
compliance with IATA Instruction 650 standards for biological sample containment are 
encouraged for road or rail transport of subject specimens. 

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Table 7
IATA Dangerous Goods Regulations Classification of Infectious 
Substances
Category a
Description
Shipping instructions 
UN number and labeling
Category A 
infectious 
substances
Any infectious substance 
transported in a form that, 
when exposure occurs, b is 
capable of causing permanent 
disability, life threatening 
disease, or fatal disease in 
otherwise healthy humans or 
animals.  
(Examples include Ebola and 
Lassa fever virus.)
Category A pathogens must 
be: 
Packed and shipped in 
accordance with IATA 
Instruction 620 
Identified using the 
appropriate UN shipping 
number and label 
information
UN 2814
“Infectious substances 
affecting humans or both 
humans and animals”
UN 2900
“Infectious substances 
affecting animals only”
Category B 
infectious 
substances
Any infectious substance that 
does not meet the criteria for 
inclusion in Category A.  
Category B infectious 
substances are not in a form 
capable of causing permanent 
disability, life threatening 
disease, or fatal disease in 
otherwise healthy humans or 
animals when exposure 
occurs. b
(Examples include hepatitis A, B, 
C, D, and E viruses, and HIV 
types 1 and 2.)
Category B pathogens must 
be: 
Packed and shipped in 
accordance with IATA 
Instruction 650 
Identified using the 
appropriate UN shipping 
number and label 
information
UN 3373 
“Biological substance, 
Category B”
Exempt 
substances
Subject specimens for which 
there is minimal likelihood 
that pathogens are present. 
(Examples may include 
blood-based samples, tissue 
cultures, or other biological 
samples.)
Exempt substances must be: 
Packed and shipped in 
accordance with 
requirements specified in 
Division 6.2, 
Section 3.6.2.2.3.8 of the 
IATA DGR a
Identified using the 
appropriate label 
information
“Exempt human specimen”
“Exempt animal specimen”
DGR = Dangerous Goods Regulation; IATA = International Airline Transportation Association; UN = United Nations.
Note:  IATA Dangerous Goods Regulations, 61st Edition. 01 January 2020. International Air Transport Association. 
Available at: https://www.iata.org/en/programs/cargo/dgr/download/.
a
For transport purposes, the classification of infectious substances according to risk groups was removed in the DGR 
46th edition (2005).  There is no direct relationship between risk groups and Categories A and B.
b
Exposure occurs when an infectious substance is released outside of the protective packaging, resulting in physical 
contact with humans or animals.

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Appendix D
Actions Required in Cases of Increases in Liver 
Biochemistry and Evaluation of Hy’s Law
D 1
Introduction
This Appendix describes the process to be followed in order to identify and appropriately 
report Potential Hy’s Law (PHL) cases and Hy’s Law (HL) cases.  It is not intended to be a 
comprehensive guide to the management of elevated liver biochemistries. 
During the course of the study the Investigator will remain vigilant for increases in liver 
biochemistry.  The Investigator is responsible for determining whether a subject meets 
potential PHL criteria at any point during the study.
All sources of laboratory data are appropriate for the determination of PHL and HL events; 
this includes samples taken at scheduled study visits and other visits including central and all 
local laboratory evaluations even if collected outside of the study visits; for example, PHL 
criteria could be met by an elevated ALT from a central laboratory and/or elevated TBL from 
a local laboratory. 
The Investigator will also review AE data (for example, for AEs that may indicate elevations 
in liver biochemistry) for possible PHL events.
The Investigator participates, together with AstraZeneca clinical project representatives, in 
review and assessment of cases meeting PHL criteria to agree whether HL criteria are met.  
HL criteria are met if there is no alternative explanation for the elevations in liver 
biochemistry other than Drug Induced Liver Injury (DILI) caused by the Investigational 
Medicinal Product (IMP). 
The Investigator is responsible for recording data pertaining to PHL/HL cases and for 
reporting SAEs and AEs according to the outcome of the review and assessment in line with 
standard safety reporting processes.
D 2
Definitions
Potential Hy’s Law
AST or ALT ≥ 3x ULN together with Total Bilirubin (TBL) ≥ 2x ULN at any point during 
the study following the start of study medication irrespective of an increase in alkaline 
phosphatase (ALP).
Hy’s Law
AST or ALT ≥ 3x ULN together with TBL ≥ 2x ULN, where no other reason, other than the 
IMP, can be found to explain the combination of increases, eg, elevated ALP indicating 
cholestasis, viral hepatitis, another drug.  

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For PHL and HL the elevation in transaminases must precede or be coincident with (i.e. on the 
same day) the elevation in TBL, but there is no specified timeframe within which the 
elevations in transaminases and TBL must occur.
D 3
Identification of Potential Hy’s Law Cases
In order to identify cases of PHL it is important to perform a comprehensive review of 
laboratory data for any subject who meets any of the following identification criteria in 
isolation or in combination:

ALT ≥ 3xULN

AST ≥ 3xULN

TBL ≥ 2xULN
Central laboratories being used:
When a subject meets any of the PHL identification criteria, in isolation or in combination, the 
central laboratory will immediately send an alert to the Investigator (also sent to AstraZeneca 
representative). 
The Investigator will also remain vigilant for any local laboratory reports where the PHL 
identification criteria are met, where this is the case the Investigator will:

Notify the AstraZeneca representative 

Request a repeat of the test (new blood draw) by the central laboratory without delay

Complete the appropriate unscheduled laboratory CRF module(s) with the original local 
laboratory test result
When the identification criteria are met from central or local laboratory results the Investigator 
will without delay:

Determine whether the subject meets PHL criteria (see Section D 2 within this Appendix 
for definition) by reviewing laboratory reports from all previous visits (including both 
central and local laboratory results)
Local laboratories being used:
The Investigator will without delay review each new laboratory report and if the identification 
criteria are met will:

Notify the AstraZeneca representative 

Determine whether the subject meets PHL criteria (see Section D 2 within this Appendix 
for definition) by reviewing laboratory reports from all previous visits

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
Promptly enter the laboratory data into the laboratory CRF
D 4
Follow-up
D 4.1
Potential Hy’s Law Criteria not met
If the subject does not meet PHL criteria the Investigator will:

Inform the AstraZeneca representative that the subject has not met PHL criteria.

Perform follow-up on subsequent laboratory results according to the guidance provided in 
the Clinical Study Protocol.
D 4.2
Potential Hy’s Law Criteria met
If the subject does meet PHL criteria the Investigator will:

Determine whether PHL criteria were met at any study visit prior to starting study 
treatment

Notify the AstraZeneca representative who will then inform the central Study Team 

Within 1 day of PHL criteria being met, the Investigator will report the case as an SAE of 
Potential Hy’s Law; serious criteria ‘Important medical event’ and causality assessment 
‘yes/related’ according to CSP process for SAE reporting.

For subjects that met PHL criteria prior to starting IMP, the investigator is not required to 
submit a PHL SAE unless there is a significant change# in the subject’s condition

The Study Physician contacts the Investigator, to provide guidance, discuss and agree an 
approach for the study subjects’ follow-up (including any further laboratory testing) and 
the continuous review of data

Subsequent to this contact the Investigator will:

Monitor the subject until liver biochemistry parameters and appropriate clinical 
symptoms and signs return to normal or baseline levels, or as long as medically 
indicated. Completes follow-up SAE Form as required.

Investigate the aetiology of the event and perform diagnostic investigations as 
discussed with the Study Physician. This includes deciding which the tests available 
in the Hy’s law lab kit should be used 

Complete the three Liver CRF Modules as information becomes available 
# A ‘significant’ change in the subject’s condition refers to a clinically relevant change in 
any of the individual liver biochemistry parameters (ALT, AST or total bilirubin) in 
isolation or in combination, or a clinically relevant change in associated symptoms.  The 
determination of whether there has been a significant change will be at the discretion of
the Investigator; this may be in consultation with the Study Physician if there is any 
uncertainty.

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D 5
Review and Assessment of Potential Hy’s Law Cases
The instructions in this section should be followed for all cases where PHL criteria are met.
As soon as possible after the biochemistry abnormality was initially detected, the Study 
Physician contacts the Investigator in order to review available data and agree on whether 
there is an alternative explanation for meeting PHL criteria other than DILI caused by the 
IMP, to ensure timely analysis and reporting to health authorities within 15 calendar days 
from date PHL criteria was met.  The AstraZeneca Global Clinical Lead or equivalent and 
Global Safety Physician will also be involved in this review together with other subject matter 
experts as appropriate.  
According to the outcome of the review and assessment, the Investigator will follow the 
instructions below.
Where there is an agreed alternative explanation for the ALT or AST and TBL elevations, 
a determination of whether the alternative explanation is an AE will be made and 
subsequently whether the AE meets the criteria for a SAE:

If the alternative explanation is not an AE, record the alternative explanation on the 
appropriate CRF

If the alternative explanation is an AE/SAE: update the previously submitted Potential 
Hy’s Law SAE and AE CRFs accordingly with the new information (reassessing event 
term; causality and seriousness criteria) following the AZ standard processes.
If it is agreed that there is no explanation that would explain the ALT or AST and TBL 
elevations other than the IMP:

Send updated SAE (report term ‘Hy’s Law’) according to AstraZeneca standard 
processes. 

The ‘Medically Important’ serious criterion should be used if no other serious 
criteria apply

As there is no alternative explanation for the HL case, a causality assessment of 
‘related’ should be assigned.
If, there is an unavoidable delay, of over 15 calendar days in obtaining the information 
necessary to assess whether or not the case meets the criteria for HL, then it is assumed that 
there is no alternative explanation until such time as an informed decision can be made:

Provides any further update to the previously submitted SAE of Potential Hy’s Law, 
(report term now ‘Hy’s Law case’) ensuring causality assessment is related to IMP and 
seriousness criteria is medically important, according to Clinical Study Protocol (CSP)
process for SAE reporting.

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
Continue follow-up and review according to agreed plan.  Once the necessary 
supplementary information is obtained, repeat the review and assessment to determine 
whether HL criteria are still met.  Update the previously submitted PHL SAE report 
following CSP process for SAE reporting, according to the outcome of the review and 
amending the reported term if an alternative explanation for the liver biochemistry 
elevations is determined.
D 6
Laboratory tests
Hy’s Law Laboratory Kit for Central Laboratories
Additional standard chemistry and coagulation 
tests
GGT
LDH
Prothrombin time
INR
Viral hepatitis
IgM anti-HAV 
IgM and IgG anti-HBc
HBsAg
HBV DNA
IgG anti-HCV
HCV RNA* 
IgM anti-HEV
HEV RNA
Other viral infections
IgM & IgG anti-CMV
IgM & IgG anti-HSV
IgM & IgG anti-EBV
Alcoholic hepatitis
Carbohydrate deficient transferrin (CD-
transferrin)**
Autoimmune hepatitis
Antinuclear antibody (ANA)
Anti-Liver/Kidney Microsomal Ab (Anti-LKM)
Anti-Smooth Muscle Ab (ASMA)
Metabolic diseases
alpha-1-antitrypsin
Ceruloplasmin
Iron
Ferritin
Transferrin
Transferrin saturation
* HCV RNA is only tested when IgG anti-HCV is positive or inconclusive
** Carbohydrate deficient transferrin (CD-transferrin) is not available in China. Study teams should amend this 
list accordingly
Reference
Aithal et al 2011, Clinical Pharmacology and Therapeutics 89(6):806-815. 
http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances
/UCM174090.pdf.

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Appendix E
Examples of Coadministered Drugs That Need Additional 
Consideration
The lists of drugs in these tables are not exhaustive. Any questions about drugs not on this list 
should be addressed to the Medical Monitor of this study.
Table 8
CYP3A Inhibitors
Strong inhibitors of CYP3A
Moderate inhibitors of CYP3A
Boceprevir
aprepitant
clarithromycin a
cimetidine
cobicistat a
ciprofloxacin
conivaptan a
clotrimazole
danoprevir and ritonavir b
crizotinib
diltiazem a
cyclosporine
elvitegravir and ritonavir b
dronedarone a
grapefruit juice
erythromycin
Idelalisib
fluconazole
indinavir and ritonavir b
fluvoxamine
itraconazole a
imatinib
Ketoconazole
tofisopam
lopinavir and ritonavir a,b
verapamil a
Nefazodone
nelfinavir a
paritaprevir and ritonavir and (ombitasvir and/or dasabuvir) b
Posaconazole
ritonavir a,b
saquinavir and ritonavir a,b
telaprevir a
tipranavir and ritonavir a,b
Troleandomycin
Voriconazole
a
Inhibitor of P-glycoprotein.
b
Ritonavir is usually given in combination with other anti-HIV or anti-HCV drugs in clinical practice. Caution should 
be used when extrapolating the observed effect of ritonavir alone to the effect of combination regimens on CYP3A 
activities.

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Table 9
CYP3A Inducers
Strong inducers of CYP3A
Moderate inducers of CYP3A
Carbamazepine
bosentan
Enzalutamide
efavirenz
Mitotane
etravirine
Phenytoin
modafinil
Rifampin
St. John’s wort a
a
The effect of St. John’s wort varies widely and is preparation-dependent.
Source: US FDA. Drug development and drug interactions: table of substrates, inhibitors and inducers. 
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.h
tm#inVivo. Accessed 23 July 2019.
Table 10
Other Drugs Needing Additional Considerations
Proton pump inhibitors
H2-receptor antagonists
Dexlansoprazole
cimetidine
Esomeprazole
famotidine
Lansoprazole
nizatidine
Omeprazole
Rabeprazole
Pantoprazole
Source: US FDA. Established pharmacologic class text phrase. https://www.fda.gov/downloads/drugs/
guidancecomplianceregulatoryinformation/lawsactsandrules/ucm428333.pdf. Accessed 23 July 2019.  

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Appendix F
Contraception Requirements
Contraception requirements for this study are as follows.
F 1
Female Subjects of Childbearing Potential
Please note, females of childbearing potential are defined as those who are post-menarche, not 
surgically sterile (ie, bilateral salpingectomy, bilateral oophorectomy, or complete 
hysterectomy) or post-menopausal.
Women will be considered post-menopausal if they have been amenorrheic for 12 months 
without an alternative medical cause.  The following age-specific requirements apply:

Women <50 years of age would be considered post-menopausal if they have been 
amenorrheic for 12 months or more following cessation of all hormonal replacement 
therapy and if they have luteinizing hormone and follicle-stimulating hormone levels in 
the post-menopausal range for the institution.

Women ≥50 years of age would be considered post-menopausal if they have been 
amenorrheic for 12 months or more following cessation of all hormonal replacement 
therapy, had radiation-induced menopause with last menses >1 year ago, had 
chemotherapy-induced menopause with last menses >1 year ago.
Female subjects of childbearing potential who are not totally sexually abstinent (ie, refraining 
from heterosexual intercourse during the entire period of risk associated with study 
treatments), and who intend to be sexually active with a nonsterilized male partner, must use 
at least one highly effective method of contraception (see Table 11) consistent with local 
regulations regarding the use of contraception for subjects participating in clinical trials, from 
the time of signing the ICF throughout the total duration of the drug treatment and the drug 
washout period (2 days after the last dose of acalabrutinib). 
Non-sterilized male partners of a female subject of childbearing potential must use a male 
condom plus spermicide (condom alone in countries where spermicides are not approved) 
throughout this period. Cessation of birth control after this point should be discussed with a 
responsible physician. Periodic abstinence, the rhythm method, and the withdrawal method 
are not acceptable methods of contraception. The reliability of total sexual abstinence should 
be evaluated in relation to the duration of the clinical trial and the preferred and usual lifestyle 
of the subject. Female subjects should refrain from breastfeeding throughout this period.  
F 2
Male Subjects with a Female Partner of Childbearing Potential
Non-sterilized male subjects (including males sterilized by a method other than bilateral 
orchidectomy, eg, vasectomy) who are not abstinent and intend to be sexually active with a 
female partner of childbearing potential must use a male condom plus spermicide (condom 
alone in countries where spermicides are not approved) from the time of screening throughout 

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the total duration of the drug treatment and the drug washout period (2 days after the last dose 
of acalabrutinib). Periodic abstinence, the rhythm method, and the withdrawal method are not 
acceptable methods of contraception. Male subjects should refrain from sperm donation 
throughout this period.
Vasectomized (ie, sterile) males are considered fertile and should still use a male condom plus 
spermicide as indicated above during the clinical trial.
Even if the female partner is pregnant, male subjects should still use a condom, as indicated 
above during the clinical trial, if there is a concern about damaging the developing fetus from 
drug in ejaculate.
Female partners (of childbearing potential) of male subjects must also use a highly effective 
method of contraception throughout this period (see Table 11).
F 3
Highly Effective Methods of Contraception
Highly effective methods of contraception, defined as one that results in a low failure rate 
(ie, less than 1% per year) when used consistently and correctly, are described in Table 11. 
Note that some contraception methods are not considered highly effective (eg, male or female 
condom with or without spermicide; female cap, diaphragm, or sponge with or without 
spermicide; non copper containing intrauterine device; progestogen-only oral hormonal 
contraceptive pills where inhibition of ovulation is not the primary mode of action [excluding 
Cerazette/desogestrel which is considered highly effective]; and triphasic combined oral 
contraceptive pills).
Table 11
Highly Effective Methods of Contraception (<1% Failure Rate)
Barrier/intrauterine methods
Hormonal methods
•
Copper T intrauterine device
•
Levonorgestrel-releasing intrauterine system 
(eg, Mirena®) a
•
Implants: Etonogestrel-releasing implants 
(eg, Implanon® or Norplant®)
•
Intravaginal devices: 
Ethinylestradiol/etonogestrel-releasing 
intravaginal devices (eg, NuvaRing®) 
•
Injection: Medroxyprogesterone injection 
(eg, Depo-Provera®)
•
Combined pill: Normal and low dose combined 
oral contraceptive pill
•
Patch: Norelgestromin/ethinylestradiol-releasing 
transdermal system (eg, Ortho Evra®)
•
Minipill: Progesterone based oral contraceptive 
pill using desogestrel: Cerazette® is currently the 
only highly effective progesterone-based pill
a
This is also considered a hormonal method.

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Appendix G
Child-Pugh Score
Cirrhosis severity, as determined by the Child-Pugh score (Pugh 1973), will be recorded in the 
eCRF as specified in the SoAs.
The modified Child-Pugh classification of liver disease severity according to the degree of 
ascites by clinical exam, serum concentrations of bilirubin and albumin, prothrombin time, 
and degree of encephalopathy is shown in Table 12. The severity of cirrhosis is classified as 
follows:

Child-Pugh class A (well-compensated disease): score of 5 to 6

Child-Pugh class B (significant functional compromise): score of 7 to 9

Child-Pugh class C (decompensated disease): score of 10 to 15
Table 12
Child-Pugh Classification of Cirrhosis Severity
Parameter
Points assigned
1
2
3
Ascites
Absent
Slight
Moderate
Bilirubin
<2 mg/dL
(<34.2 μmol/L)
2 to 3 mg/dL
(34.2 to 51.3 μmol/L)
>3 mg/dL
(>51.3 μmol/L)
Albumin
>3.5 g/dL
(35 g/L)
2.8 to 3.5 g/dL
(28 to 35 g/L)
<2.8 g/dL
(28 g/L)
Prothrombin time
Seconds over control
<4
4 to 6
>6
INR
<1.7
1.7 to 2.3
>2.3
Encephalopathy
None
Grade 1 to 2
Grade 3 to 4
INR = international normalized ratio.

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Appendix H
Abbreviations
Abbreviation or 
special term
Explanation
AE
Adverse event
AESI
Adverse event of special interest
ALC
Absolute lymphocyte count
ALT
Alanine aminotransferase
ANC
Absolute neutrophil count
anti-HBc
Hepatitis B core antibody
aPTT
Activated partial thromboplastin time
AST
Aspartate aminotransferase
ARDS
Acute respiratory distress syndrome
AUC
Area under the concentration-time curve
bid
Twice daily
BSC
Best supportive care
Btk
Bruton’s tyrosine kinase
BUN
Blood urea nitrogen
CBC
Complete blood count
CI
Confidence interval
Cmax
Maximum observed concentration
COVID-19
Coronavirus disease 2019
CRF
Case report form (electronic/paper)
CRP
C-reactive protein
CSP
Clinical Study Protocol
CT
Computed tomography
CTCAE
Common Terminology Criteria for Adverse Events
CYP
Cytochrome P450
DGR
Dangerous Good Regulation
DILI
Drug-induced liver injury
DLT
Dose-limiting toxicity
ECG
Electrocardiogram
eCRF
Electronic case report form
eGFR
Estimated glomerular filtration rate
FiO2
Fraction of inspired oxygen
GCP
Good Clinical Practice
HBsAg
Hepatitis B surface antigen
HBV
Hepatitis B virus
HCV
Hepatitis C virus
HL
Hy’s law

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Abbreviation or 
special term
Explanation
IATA
International Airline Transportation Association
ICF
Informed consent form
ICH
International Council for Harmonisation
ICU
Intensive care unit
iDMC
Internal Data Monitoring Committee
IEC
Independent Ethics Committee
IL
Interleukin
INR
International normalized ratio
IRB
Institutional Review Board
IRT
Interactive response technology
LDH
Lactate dehydrogenase
MCP-1
Monocyte chemoattractant protein-1
MDRD
Modification of Diet in Renal Disease
MedDRA
Medical Dictionary for Regulatory Activities
MRI
Magnetic resonance imaging
NCI
National Cancer Institute
NG
Nasogastric
NYHA
New York Heart Association
PaCO2
Partial pressure of carbon dioxide
PaO2
Partial pressure of oxygen
PCR
Polymerase chain reaction
PD
Pharmacodynamic(s)
PD-1
Programmed cell death 1
PHL
Potential Hy’s law
PI3K
Phosphatidylinositol-3-kinase
PK
Pharmacokinetic(s)
PML
Progressive multifocal leukoencephalopathy
PPI
Proton-pump inhibitor
PT
Prothrombin time
qd
Once daily
SAE
Serious adverse event
SAP
Statistical Analysis Plan
SARS-CoV-2
Severe acute respiratory syndrome coronavirus 2
SoA
Schedule of Activities
SOFA
Sequential Organ Failure Assessment
SpO2
Oxygen saturation
SUSAR
Suspected unexpected serious adverse reaction

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Abbreviation or 
special term
Explanation
TEAE
Treatment-emergent adverse event
TLR
Toll-like receptor
TNFα
Tumor necrosis factor alpha
ULN
Upper limit of normal

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Appendix I
Protocol Amendment History
The Protocol Amendment Summary of Changes Table for the current amendment is located 
directly before the Table of Contents.
Amendment 3 (23Jun2020) 
The overall rationale for the amendment was to address feedback from study sites that are 
managing local challenges during the COVID-19 pandemic.
Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
1.1 Schedule of 
Activities (Table 1)
Added footnote l to indicate that 
screening can be performed within 
1-3 days prior to dosing
Allow flexibility around 
timing of screening 
Non-substantial
Added footnote o to indicate that 
 
 
 
Clarification
Non-substantial
Added footnote q to indicate that for 
all central laboratory assessments, 
sample collection windows of ± 1 
day will be allowed for each of 
Days 3 and 7.
Clarification
Non-substantial
Added a separate column for Day 1
Clarification 
Non-substantial
Specified in title that Table 1 only 
applies to Arm 1 (acalabrutinib + 
BSC)
Clarification 
Non-substantial
1.1 Schedule of 
Activities (Table 2)
Added Table 2 for Arm 2 (BSC 
only) assessments
Clarification
Non-substantial
1.1 Schedule of 
Activities (Table 1);
6.1 Treatments 
Administered
Revised the statement 
“Acalabrutinib must be 
administered within 6 hours of 
randomization” to “Acalabrutinib 
should be administered within 6 
hours of randomization”
Patient centricity
Non-substantial
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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
1.1 Schedule of 
Activities (Table 1);
8.1.5 Physical 
Examinations and 
Chest Imaging, 
Electrocardiogram, and 
Echocardiogram
Added footnote r in Table 1 and text 
in Section 8.1.5 to indicate that per 
standard of care, chest imaging can 
be done by chest x-ray or CT scan 
with contrast, or any other 
appropriate means to confirm 
pneumonia prior to or upon 
hospitalization (within 7 days of 
randomization).
Clarification
Non-substantial
1.1 Schedule of 
Activities (Table 1);
8.1.6 Vital Signs
Added footnote s in Table 1 and text 
in Section 8.1.6 to indicate that 
during screening, vital signs should 
be collected as close as possible to 
the dosing on Day 1. If more than 
one value is obtained for vital signs 
during screening, the value closest 
to the first dose of study drug 
should be used.
Clarification
Non-substantial
1.1 Schedule of 
Activities (Table 1);
8.1.8 Laboratory Tests
Revised footnote d in Table 1 and 
text in Section 8.1.8 to indicate that 
hepatitis serology should include, at 
a minimum, HBsAg, anti-HBc, and 
HCV antibody. Also, stated that if 
additional hepatitis serology is 
collected per institutional 
guidelines, it should be recorded in 
the database.
Clarification
Non-substantial
1.1 Schedule of 
Activities (Table 1);
8.1.8 Laboratory Tests;
8.3 On-study 
Procedures
Revised Table 1 and Sections 8.1.8 
and 8.3 so that collection of ferritin, 
D-dimer, fibrinogen, PT, aPTT, 
INR, and procalcitonin to occur 
every other day while in the 
hospital, and cardiac troponin I to 
be collected on Day 5 while in the 
hospital. Added footnote m to 
specify that these laboratory tests 
should be collected more frequently 
if clinically indicated. Removed 
BNP assessment.
Also, stated in Section 8.3 that 
“Safety, CRP, PK, 
pharmacodynamic, and correlative 
laboratory tests are considered 
Tier 1 and should not be missed. 
The site must follow the SoA.”
Patient centricity; reduce 
amount of blood 
collection
Substantial

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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
1.1 Schedule of 
Activities (Table 1);
8.3 On-study 
Procedures
Revised footnote h in Table 1 and 
text in Section 8.3 to indicate that if 
a subject is discharged prior to 
Day 7 (+ 3 days) (instead of 
Day 10), he/she needs to visit the 
site for an assessment 2 to 4 days 
after discharge
Patient centricity
Non-substantial
Revised Table 1 to indicate that PK 
will be collected 0.5 and 2 hours 
postdose on Day 3, and 1 and 4 
hours postdose on Day 7. Added 
footnote p to clarify that these PK 
assessments can also be collected 
during a single visit on Day 3 or 
after. 
Patient centricity and 
understanding the 
complexities of multiple 
blood draws of a subject 
in isolation due to 
COVID-19
Non-substantial
1.1 Schedule of 
Activities (Table 1);
8.4.1 Oxygen 
Treatments and 
Ventilator Use
Added footnote n to Table 1 and 
text to Section 8.4.1 to clarify that 
arterial gases should be collected 
from subjects if the sample is easily 
accessible and the procedure will 
not be painful to subjects. Also 
stated that if collection of arterial 
gases is not clinically indicated, the 
test should not be performed.
Patient centricity, since 
taking arterial gases is 
painful 
Non-substantial
1.2 Synopsis;
2.1 Background and 
Study Rationale
Cited recent publications reporting 
activity of acalabrutinib and other 
Btk inhibitors in COVID-19 
Clarification
Non-substantial
1.2 Synopsis;
3 Objectives and 
Endpoints
Reduced the number of PK 
parameters to be assessed for the PK 
endpoint
Given the reduced 
number of plasma 
samples for PK
Non-substantial
1.2 Synopsis;
6.1 Treatments 
administered
Revised Section 6.1 and 
restructured with sub-headers for 
clarity. Aligned Sections 1.2 and 
6.1.
Clarification
Non-substantial
Added text to Section 6.1.3.1 to 
indicate that subjects on 
concomitant PPIs must take 
acalabrutinib with 8 ounces 
(approximately 240 mL) of COCA-
COLA at room temperature. Other 
cola beverages are not permitted. 
Based on new data 
generated by Sponsor 
supporting use of 
acalabrutinib with 
concomitant PPIs
Substantial

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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
4.5 End of Study 
Definition;
7.1 Discontinuation of 
Study Treatment;
8.6.2 Time Period and 
Frequency for 
Collecting AE and 
SAE Information;
9.6.1 Safety Analyses
Specified that safety follow-up will 
occur 38 (± 3 days) after 
randomization for those subjects 
randomized to the BSC arm
Clarification
Non-substantial
5.1 Inclusion Criteria
Inclusion Criterion 3: Revised to 
indicate that SARS-CoV-2 infection 
must be confirmed within 7 days 
(instead of 3 days) prior to 
randomization
Patient centricity and 
given lack of RT-PCR 
resources in local 
hospitals during the 
pandemic
Non-substantial
5.2 Exclusion Criteria
Exclusion Criterion 8: Changed 
“within 24 hours at screening” to 
“during the screening period”
To align with revised 
screening period of 1 to 3 
days
Non-substantial
Exclusion Criterion 16: Revised 
hepatitis serology criteria
Clarification
Non-substantial
Exclusion Criterion 19: Removed 
PPI restriction
Based on new data 
generated by Sponsor 
supporting removal of 
exclusion
Substantial
Exclusion Criterion 19: Revised 
immunomodulatory/ 
immunosuppressive treatment 
exclusion 
Clarification
Non-substantial
Exclusion Criterion 21: Removed 
steroid restriction
Align with global 
treatment practices
Substantial
6.1 Treatments 
Administered;
6.7 Dose Modification 
and Toxicity 
Management
Added text to allow participants to 
make up missed doses 
Allow participants to 
receive the full dosing of 
acalabrutinib (total of 
20 doses)
Substantial
6.3.1.2 Methods for 
Assigning Treatment 
Groups
Removed the sentence, “Subjects 
will be identified to the IRT per 
country regulations.”
Not applicable as only 
year of birth and gender 
are collected in the IRT 
(no full date of birth or 
initials)
Non-substantial
6.5.2 Permitted 
Concomitant Therapy
Clarified BSC agents that will be 
permitted in this study
Align with global 
treatment practices
Substantial

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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
6.5.3 Prohibited or 
Restricted 
Concomitant Therapy
Clarified that certain anticoagulants 
such as warfarin or equivalent 
vitamin K antagonists (eg, 
phenprocoumon) are prohibited for 
all subjects treated with 
acalabrutinib
Clarification
Non-substantial
Removed PPIs as a prohibited 
concomitant medication
Based on new data 
generated by Sponsor 
supporting removal of 
PPIs as a prohibited 
concomitant medication
Substantial
Removed steroid treatment 
language
Align with global 
treatment practices
Substantial
Clarified that immunomodulatory 
drugs, intended as treatment for 
COVID-19 but not considered
standard of care according to local 
institutional guidelines, are 
prohibited for all randomized 
subjects in the study through Day 
28. Subjects who are taking 
immunomodulatory drugs for other 
medical conditions (eg, tocilizumab 
for rheumatoid arthritis) may 
continue with treatment upon 
discussion with the Medical 
Monitor.
Clarification
Non-substantial
6.5.4 Acalabrutinib 
Drug-drug Interaction 
Guidance in the 
Presence of Life-
threatening COVID-19 
Infection;
6.5.4.2 Active 
Substances That May 
Decrease Acalabrutinib 
Plasma Concentrations
Added PPIs to Table 3 and specified 
that concomitant use of PPIs should 
be avoided. However, if PPI 
concomitant use cannot be avoided, 
dose modification of acalabrutinib is 
not necessary, but acalabrutinib 
must be administered with 240 mL 
of COCA-COLA to improve 
acalabrutinib absorption.
Based on new data 
generated by Sponsor 
supporting removal of 
PPIs as a prohibited 
concomitant medication
Substantial
6.5.4.2 Active 
Substances That May 
Decrease Acalabrutinib 
Plasma 
Concentrations;
Appendix E Examples 
of Coadministered 
Removed ranitidine
Removed from market
Non-substantial

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Section number and 
name
Description of change
Brief rationale
Substantial/ 
non-substantial
Drugs That Need 
Additional 
Consideration 
(Table 8)
6.6 Risks Associated 
with Acalabrutinib
Clarified the risks associated with 
acalabrutinib and added a table 
showing frequency and time to 
onset of risks associated with 
acalabrutinib
Clarification
Non-substantial
8.1.8 Laboratory Tests;
8.3 On-study 
Procedures
Removed wording “(at select 
centers only)” and “(at ALL 
centers)” for the exploratory 
samples. 
Made additional changes to these 
sections for clarity and to align with 
the SoA.
Clarification; all centers 
must collect the samples
Non-substantial
8.6.4 Adverse Event 
Data Collection;
B6 Intensity Rating 
Scale
Provided full URL for CTCAE 
V5.0
Correction
Non-substantial
10 References
Updated references using EndNote
Consistency with 
protocol template
Non-substantial
A7 Data Quality 
Assurance
Changed “source data verification” 
to “source data review”
Correction
Non-substantial
AE = adverse event; anti-HBc = hepatitis B core antibody; aPTT = activated partial thromboplastin time; BNP = brain 
natriuretic peptide; BSC = best supportive care; COVID-19 = coronavirus disease 2019; CRP = C-reactive protein; 
CTCAE = Common Terminology Criteria for Adverse Events; FDA = Food and Drug Administration; HBsAg = hepatitis 
B surface antigen; HCV = hepatitis C virus; ICU = intensive care unit; INR = international normalized ratio; IRT = 
interactive response technology; PBMC = peripheral blood mononuclear cell; PK = pharmacokinetics; PPI = proton-pump 
inhibitor; PT = prothrombin; RT-PCR = reverse transcriptase-polymerase chain reaction; SARS-CoV-2 = severe acute 
respiratory syndrome coronavirus 2; SoA = Schedule of Activities; WHO = World Health Organization.
Amendment 2 (13May2020) 
Changes were implemented in the protocol amendment to address the FDA comments.
Section # and Name
Description of Change
Brief Rationale
5.2 Exclusion Criteria
Revised Exclusion Criterion 23 to 
indicate that subjects who require or are 
receiving anticoagulation with warfarin 
or equivalent vitamin K antagonists (eg, 
phenprocoumon) within 7 days prior to 
randomization are excluded. Also, added 
that other anticoagulants are permitted.
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Section # and Name
Description of Change
Brief Rationale
Revised Exclusion Criterion 24 to 
indicate that subjects on combined 
antiplatelet and therapeutic anticoagulant 
therapy (eg, aspirin and therapeutic doses 
of low molecular weight heparin) at study 
entry will be excluded
6.5.3 Prohibited or Restricted 
Concomitant Therapy
Revised this section to reflect prohibition 
of anticoagulants for all subjects in both 
treatment arms. Also, clarified that 
subjects who require prophylaxis or 
therapeutic anticoagulation for 
thrombosis (deep vein thrombosis or 
pulmonary embolism) will be allowed to 
receive therapeutic anticoagulation with a 
non-vitamin K inhibitor class of 
anticoagulants. Should subjects require 
either a vitamin K antagonist or 
combined administration of antiplatelet 
and therapeutic anticoagulation while on 
study, acalabrutinib treatment must be 
discontinued.
Revised based on FDA feedback
Amendment 1 (08May2020) 
Changes were implemented in the protocol amendment to address the FDA comments.
Section # and Name
Description of Change
Brief Rationale
1.1 Schedule of Activities
Added serum ferritin and CRP 
assessments at “Day 10 or discharge”
To align with endpoints
1.1 Schedule of Activities;
1.2 Synopsis;
3 Objectives and Endpoints;
8.8.1 Improvements on the 
9-Point Ordinal Scale
Added secondary efficacy endpoint of
time to clinical improvement of at 
least 2 points (from randomization) on 
a 9-point ordinal scale through Day 28
To collect additional data
1.2 Synopsis;
3 Objectives and Endpoints;
9.2 Sample Size 
Determination;
9.6.2 Efficacy Analyses
Revised the primary efficacy endpoint 
of respiratory failure from Day 14 to 
Day 28, and revised the secondary 
efficacy endpoint of respiratory failure 
from Day 28 to Day 14
Revised based on FDA feedback
1.2 Synopsis;
9.6.2 Efficacy Analyses;
10 References
Changed method for calculating 
confidence intervals from Blyth-Still-
Casella to Wald method with 
continuity correction
Revised based on FDA feedback
4.4 Internal DMC
Specified that enrollment also be 
paused and safety reviewed upon the 
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Section # and Name
Description of Change
Brief Rationale
occurrence of any Grade 4 
hemorrhage due to acalabrutinib (per 
Investigator)
5.2 Exclusion Criteria
Exclusion Criterion 17: Added a new 
criterion to exclude subjects with 
known active HIV with detectable 
viral load or CD4 count of 
<500 cells/mm3 
Added based on FDA feedback
Exclusion Criterion 18: Revised to 
exclude subjects on CYP3A inhibitor 
within 7 days (instead of 14 days) and 
inducer within 14 days (instead of 7 
days) before first dose of study drug
Corrected error
Exclusion Criterion 24: Added a new 
criterion to exclude subjects on 
combined antiplatelet and 
anticoagulant therapy
Added based on FDA feedback

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Section # and Name
Description of Change
Brief Rationale
6.5.3 Prohibited or Restricted 
Concomitant Therapy
Moved paragraphs for strong CYP3A 
inhibitors/inducers and proton-pump 
inhibitors from Section 6.5.3.1 
(Medications Prohibited for Subjects 
Treated with Acalabrutinib) to 
Section 6.5.3.2 (Medications 
Prohibited for All Randomized 
Subject)
Revised based FDA feedback that 
SoC be consistent across the 
treatment arms 
6.5.3.2 Medications 
Prohibited for All 
Randomized Subjects
Clarified in Section 6.5.3.2 that 
immunomodulatory drugs are 
prohibited for all subjects in both 
treatment arms through Day 28 and 
strong CYP3A inhibitors or inducers, 
PPIs, and steroids are prohibited for 
all subjects in both treatment arms 
through Day 10
Revised based on FDA feedback
In the steroids paragraph, specified 
that if corticosteroids exceeding 7.5 
mg/day or active inhaled 
corticosteroids are required for 
clinical care, acalabrutinib treatment 
must be discontinued
Revised based on FDA feedback
6.6 Risks Associated with 
Acalabrutinib
Revised to align with updated 
Section 6.7
Consistency
6.7 Dose Modification and 
Toxicity Management
In the table, revised event criteria and 
dose modification/discontinuation 
guidelines. 
Revised based on FDA feedback 
and for clarity
8.1.8 Laboratory Tests;
8.3 On-study Procedures
Removed reference to “(at select 
centers only)” and “(at all centers)” 
from central laboratory tests
Revised so that all these tests are 
required at all sites
9.6.2 Efficacy Analyses
Included baseline respiratory failure 
(with vs without) in the subgroup 
analysis
Added based on FDA feedback
Revised to indicate number of days in 
ICU from randomization to 90 days 
(instead of 28 days) after 
randomization
Corrected error
F1 Female Subjects of 
Childbearing Potential
Removed prednisone, vincristine, 
doxorubicin, rituximab, and 
cyclophosphamide from the drug 
washout period 
Not relevant to this study