Recombinant Human Angiotensin-converting Enzyme 2 (rhACE2) as a Treatment for Patients With COVID-19
Phase: PHASE2
Conditions: COVID-19
Sponsor: Apeiron Biologics

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STUDY PROTOCOL 
1 
Title Page 
Recombinant human angiotensin-converting enzyme 2 (rhACE2) as a treat-
ment for patients with COVID-19 
EudraCT No. 
2020-001172-15 
IND 
151312 
Protocol No. 
APN01-01-COVID19 
Version/Date 
Version 7.0, 10 AUG 2020 
Sponsor 
APEIRON Biologics AG 
Campus-Vienna-Biocenter 5 
1030 Vienna, 
Austria 
 
 
Coordinating Inves-
tigator 
 
 
Prof. Dr. med. Henning Bundgaard 
The Capital Region's Unit of Inherited Cardiac Diseases 
Faculty of Health and Medical Sciences 
University of Copenhagen 
Rigshospitalet, University of Copenhagen 
Department of Cardiology 
The Heart Centre 
Blegdamsvej 9 
2100 Copenhagen Ø, Denmark 
Telephone:  
+45 3545 0512 
 
CONFIDENTIALITY STATEMENT 
The information provided in the following document is confidential and is only available for 
review to Principal Investigator, the Ethics Committee and the Competent Authorities. No 
disclosure should take place without the written authorization from the Sponsor, except to 
the extent necessary to obtain informed consent from potential patients or to obtain approval 
of this protocol by an Ethics Committee or Regulatory Authorities. 
 
 

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SIGNATURES 
 
Sponsor Signature  
This protocol has been approved by APEIRON Biologics AG. 
 
 
Sponsor Signature 
 
Date 
 
 
 
 
Sponsor Name 
 
 
 
 
 
Coordinating Investigator Signature  
I hereby confirm that I have acknowledged the protocol and agree to conduct the clinical trial 
in compliance with the protocol. 
 
 
Coordinating Investigator Signature 
 
Date 
 
 
 
 
Coordinating Investigator Name 
 
 
 
 
 
Statistician Signature  
I hereby confirm that I have acknowledged the protocol and agree to conduct the clinical trial 
in compliance with the protocol. 
 
 
Statistician Signature 
 
Date 
 
 
 
 
Statistician Name 
 
 

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SUMMARY OF CHANGES 
 
Summary of changes since last version of the protocol (protocol version 1.0 to version 2.0) 
Amendment Number 
Date of Amend-
ment 
Section Affected  
by Change 
01 
27 Mar 2020 
Study schedule & Section 9.5.2.2.6 
Brief description of change: 
Clinical laboratory parameter (HIV, HBV and HBC serology) entered for screening. 
01 
27 Mar 2020 
Section 9.4.6. 
Brief description of change: 
Unblinding process was described in more detail. 
01 
27 Mar 2020 
Section 9.5.2.1.2 
Brief description of change: 
Wording regarding re-screening was corrected. 
01 
27 Mar 2020 
Synopsis & Section 9.3.2 
Brief description of change: 
Exclusion criterion 1 was specified. 
01 
27 Mar 2020 
Section 9.3.3.3 
Brief description of change: 
Holding rules were amended for a discontinuation criterion regarding renal impairment. 
01 
27 Mar 2020 
Section 7.4 
Brief description of change: 
Information about Figure 1 added. 
01 
27 Mar 2020 
Section 9.4.5 
Brief description of change: 
Detailed information for the chosen dose and dose regimen was added.   
01 
27 Mar 2020 
Study schedule 
Brief description of change: 
“Other exploratory indicators: specific exploratory indicators will be determined as needed” 
in the footnote deleted. 
01 
27 Mar 2020 
Section 13 
Brief description of change: 
References were updated 
Summary of changes since last version of the protocol (protocol version 2.0 to version 3.0) 
02 
05 APR 2020 
Title page, Signature Page & Study structure 
Brief description of change: 
Sponsor name changed  
02 
05 APR 2020 
Synopsis 
Brief description of change: 
Study purpose: Administrative correction “respiratory tract specimen” deleted as only blood 
samples re drawn and sign > corrected to ≥ 
02 
05 APR 2020 
Study schedule 
Brief description of change: 
Detection of viral nucleic acid or viral gene sequencing corrected and deleted on Day 2,4,6 
and 10 (same timepoints as biomarkers) 
02 
05 APR 2020 
Synopsis & Section 9.1, & 9.4.2.1. & 9.4.2.2  
Brief description of change: 

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Time for dose application corrected from 30 minutes to “3 to 30 minutes” 
02 
05 APR 2020 
9.4.3 
Brief description of change: 
For clarification sentence added that randomization is via the eCRF. 
02 
05 APR 2020 
9.5.2.2.6 
Brief description of change: 
“serum” deleted 
02 
05 APR 2020 
9.4.2.4&5 
Brief description of change: 
“unblinded member of study team” added 
02 
05 APR 2020 
9.5.2.2.13.2.1 
Brief description of change: 
“fax” deleted 
02 
05 APR 2020 
Study schedule, 8.2.1 & 9.5.2.2.6 
Brief description of change: 
Parameters for Immune function and Biomarker adapted 
02 
05 APR 2020 
Synopsis, 9.1, 9.4.1.1 & 9.4.1.4 
Brief description of change: 
Time window for dose application added. 
02 
05 APR 2020 
9.5.2.2.9 
Brief description of change: 
Reference to Investigator Manual added 
02 
05 APR 2020 
Study schedule & 9.5.2.2.6 
Brief description of change: 
eGFR added 
Summary of changes since last version of the protocol (protocol version 3.0 to version 4.0) 
03 
22 APR 2020 
Study synopsis & 8.3.1 
Brief description of change: 
Inclusion criterion 4 was deleted 
03 
22 APR 2020 
Study schedule & 8.5.2.1 
Brief description of change: 
Clarification regarding time period between screening and randomization added.  
03 
22 APR 2020 
8.5.2.2.7 
Brief description of change: 
Collection tube for individual Biomarkers changed and harmonized with the Lab Manual.  
  
Summary of changes since last version of the protocol (protocol version 4.0 to version 5.0) 
04 
04 MAY 2020 
Synopsis  
Brief description of change: 
Number of planned study sites increased to 16, US added as possible country 
04 
04 MAY 2020 
Synopsis & 8.3.1 
Brief description of change: 
Inclusion criterion body weight increased 
04 
04 MAY 2020 
Synopsis & 8.3.2 
Brief description of change: 
Exclusion criterion 1 redefined and exclusion criteria 2 modified.   
04 
04 MAY 2020 
Study schedule 
Brief description of change: 

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Clarification regarding serology and vital signs 
04 
04 MAY 2020 
8.4.2.3, & 8.4.2.4 
Brief description of change: 
Wording from reconstitution changed to preparation of study drug 
04 
04 MAY 2020 
8.4.6 
Brief description of change: 
Unblinded team added for clarification and harmonization. 
04 
04 MAY 2020 
Study schedule & 8.5.2.2.4 
Brief description of change: 
Clarification regarding physical examination 
04 
04 MAY 2020 
8.1 
Brief description of change: 
Clarification regarding randomization and standard of care treatment 
04 
04 MAY 2020 
6.1 
Brief description of change: 
Rational updated 
04 
04 MAY 2020 
Study schedule & 8.4.1.1 
Brief description of change: 
Clarification regarding 1st dose administration 
04 
04 MAY 2020 
8.5.2.2.11 
Brief description of change: 
SOFA score changed to mSOFA score 
Summary of changes since last version of the protocol (protocol version 5.0 to version 6.0) 
05 
08 JUN 2020 
Synopsis & 8.3.1 & 8.3.2 
Brief description of change: 
Inclusion criterion 1 modified,  
Inclusion criterion 5 deleted, Inclusion criterion 7 deleted for US, Exclusion criterion 10 
deleted, Exclusion criterion 18: clarified that it refers only to clinical trials 
05 
08 JUN 2020 
Study schedule & 8.5.2.1 
Brief description of change: 
Detection of viral nucleic acid or viral gene sequencing (PCR) modified (quantitative and 
qualitative analyses allowed) 
05 
08 JUN 2020 
Study schedule & 8.5.2.9 
Brief description of change: 
PCR test results up to 5 days before screening 
05 
08 JUN 2020 
Synopsis 
Brief description of change: 
Timelines, number of sites and countries updated 
05 
08 JUN 2020 
Study schedule & 8.5.2.2.9 
Brief description of change: 
Assessment of respiratory condition can also be performed by pulse oximetry 
05 
08 JUN 2020 
Study schedule & 8.5.2.2 
Brief description of change: 
Follow-up Visits may be performed as phone visit or in-home visit (in Russia). 
05 
08 JUN 2020 
8.5.2.2.13 
Brief description of change: 
Clarification regarding pre-treatment adverse events 
05 
08 JUN 2020 
8.5.2.2.13.1.4 
Brief description of change: 
Clarification regarding clinically significant laboratory changes to be reported as an ad-
verse event 

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05 
08 JUN 2020 
Synopsis & 8.1 
Brief description of change: 
Factor “presence of one co-morbid condition” is now excluded as stratification factor from 
randomization 
05 
08 JUN 2020 
Annex 2 
Brief description of change: 
Remote/Video Monitoring strategy during COVID-19 pandemic added 
Summary of changes since last version of the protocol (protocol version 6.0 to version 7.0) 
06 
10 AUG 2020 
Synopsis & 8.3.1  
Brief description of change: 
Inclusion criterion 6 deleted 
06 
10 AUG 2020 
 Synopsis & 7.2.1 & 8.7.1.2.5 
Brief description of change: 
Additional Endpoint (change of viral RNA) added 
06 
10 AUG 2020 
Synopsis & 8.1 & 8.3.3.2 & 8.4.1.1 & 8.4.1.4 
Brief description of change: 
If a patient will be discharged before day 7 IMP treatment can be stopped earlier.  
06 
10 AUG 2020 
6.7 & 8.2 
Brief description of change: 
“no available cure/treatment of COVID-19” deleted 
06 
10 AUG 2020 
8.1 
Brief description of change: 
Remdesivir as potential standard of care treatment added 
06 
10 AUG 2020 
8.5.2.2.6 
Brief description of change: 
Clarification of number of samples 
06 
10 AUG 2020 
8.2.1.1 & 8.5.2.1.2 
Brief description of change: 
Clarification of wording regarding screening failures 
06 
10 AUG 2020 
Study schedule 
Brief description of change: 
Correction of biomarkers regarding tubes  
06 
10 AUG 2020 
Synopsis & 8.7.1.2.5 
Brief description of change: 
Adaption of secondary endpoint 28-day mortality 
06 
10 AUG 2020 
Study schedule & 8.4.1.3 
Brief description of change: 
Follow-up visits may be performed as outpatients/phone visits 
06 
10 AUG 2020 
8.4.2.2 
Brief description of change: 
10 ml as strength for placebo added 
06 
10 AUG 2020 
8.4.6 
Brief description of change: 
Wording adapted 
06 
10 AUG 2020 
4.1 
Brief description of change: 
EMA & FDA COVID-19 Guidelines added 
06 
10 AUG 2020 
10 
Brief description of change: 
DSMB review adapted for overall options for COVID-19 patients and consequential adaption of 
study design if necessary.  
 

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SYNOPSIS 
Title 
Recombinant human angiotensin-converting enzyme 2 (rhACE2) as a 
treatment for patients with COVID-19  
Short Title  
APN01-COVID-19 
Protocol Identifier  
APN01-01-COVID19, EudraCT Number: 2020-001172-15, IND: 151312 
Drug development phase 
Phase II  
Planned Study Period  
FPI: Anticipated Q2 2020 
LPO: Anticipated Q4 2020 
Study Duration 
Up to 29 days per patient. Total study duration (FPI until LPO) up to 5 
months, with 2-4 months recruitment period per country 
Targeted Accrual 
200 patients, patient accrual planned as follows: 
Approximately 40 sites planned in Europe, Russia and US, hence for a 
1:1 (APN01: Placebo) randomization scheme. 
Study Rationale 
• 
SARS-CoV-2 spike uses the ACE2 receptor for entry into vari-
ous cells including alveolar epithelial cells and other cells in mul-
tiple organs 
• 
SARS-CoV-2 has been found in a number of ACE2 expressing 
tissues  
• 
Competitive binding by exogenous ACE2 may block viral entry 
and decrease viral replication in ACE2 expressing organs and 
protect the lung and distal organ from injury induced by SARS-
CoV-2 
• 
Preliminary studies in cell culture and multiple organoids have 
shown that ACE2 can decrease viral replication 
Study Purpose  
• 
To evaluate the clinical efficacy and safety of APN01 in patients 
with severe COVID-19, defined as those with hypoxemia and 
tachypnea  
• 
To monitor the biomarker changes (e.g. IL-6, Ang II) in respira-
tory tract specimen in patients with severe COVID-19 treated 
with APN01 
 
Primary Objective  
To assess clinical efficacy of APN01 using a composite outcome of all 
cause-death or need of invasive mechanical ventilation up to 28 days 
Secondary Objectives 
• 
To assess efficacy of APN01using log transformed levels of 
Lactate dehydrogenase (LDH) as a surrogate marker for organ 
damage. 
• 
To evaluate the safety of APN01 in patients with severe 
COVID-19  
• 
To monitor other biomarker changes (e.g. IL-6, Ang II) in pa-
tient with severe COVID-19 treated with APN01  
 
Study design  
Randomized, double blind, placebo-controlled trial 
The study is a parallel-group, randomized, double blind, placebo-con-
trolled study on top of best standard of care. 
The study will comprise two treatment groups as follows:  

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• 
Group A (active): APN01 (5 mg/ml, 4 ml/vial) 
• 
Group B (placebo control): sterile, 0.9% sodium chloride 
Eligible patients will be centrally allocated using a dynamic randomiza-
tion (1:1) to Group A or B to receive the treatment or placebo. Dynamic 
randomization factors will be age in years (continuous) and center. In-
vestigators and patients will be blinded to the treatment administered.  
After screening at day -1 and randomization at day -1 or 1, patients will 
be treated with APN01 or Placebo intravenously twice daily (BID) every 
12 hours ±1 hour over 3 to 30 minutes (morning and the evening) for 14 
doses (until day 7). If a patient will be discharged from hospital before 
day 7 treatment can be stopped at day of discharge. 
 
Follow up visits will be done at a daily basis for the first seven days and 
then on day 10, 14 and 28 to asses efficacy and safety. The study as-
sessments will be performed according to the study schedule (Table 1).  
Inclusion Criteria 
A patient will be eligible for inclusion in this study only if all the following 
criteria apply: 
 
Inclusion: 
1. Hospitalized male or female, ≥ 18 to ≤ 80 years of age  
2. Diagnosed to be COVID-19 POSITIVE（SARS-CoV-2 nucleic 
acid – qPCR） 
3. Oxygenation criterion: 
• 
Oxygen saturation ≤93% (either on Room Air or while 
the patient is on supplement oxygen) 
4. ALT < 5xULN; bilirubin ≤ 1.5xULN 
5. Signed Inform Consent Form 
 
Exclusion Criteria 
A patient will not be eligible for inclusion in this study if any of the follow-
ing criteria apply: 
1. Any patient for whom the investigator does not consider there is 
a reasonable expectation that they will be able to complete the 
study. 
2. Known history of positive Hepatitis B surface antigen, Hepatitis 
C antibody or HIV antibody. 
3. Current or chronic history of liver disease (Child Pugh score 
≥ 10), or known hepatic or biliary abnormalities (with the excep-
tion of Gilbert's syndrome or asymptomatic gallstones). 
4. The patient has participated in a clinical trial and has received 
an investigational product within the following time period prior 
to the first dosing day in the current study: 5 half-lives or twice 
the duration of the biological effect of the investigational product 
(whichever is longer). 
5. Patients requiring high doses of loop diuretics (i.e. > 240 mg fu-
rosemide daily) with significant intravascular volume depletion, 
as assessed clinically. 
6. History of sensitivity to any of the study medications, or compo-
nents thereof or a history of drug or other allergy that, in the 
opinion of the investigator or Medical Monitor, contraindicates 
their participation. 
7. Pregnant females as determined by positive serum or urine hCG 
test prior to dosing. 

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8. Lactating females. 
9. Unwillingness or inability to follow the procedures outlined in the 
protocol. 
10. Unstable Hemoglobin (Hb < 7) at time of drug infusion (i.e. Hb 
must be > 7 mg/dL at the time of drug infusion. Transfusion is 
permitted to increase Hb levels to allow entry into the study. 
11. Malignancy or other irreversible condition for which 6-month 
mortality is estimated to be >50%. 
12. Arterial blood pH less than 7.2 or serum HCO3- <15 (if ABG not 
available) before infusion is started. 
13. Known severe chronic pulmonary disease: 
• 
known FEV1/FVC less than 45% predicted, or 
• 
known chronic hypercapnia (PaCO2 > 45 mmHg) or 
chronic hypoxemia [(PaO2<55 mmHg) on FiO2 =0.21, 
or supplemental oxygen therapy prior to this admission], 
or 
• 
known FEV1 <15 ml/kg (e.g. 1L for 70 kg person), or 
• 
known radiographic evidence of chronic interstitial infil-
tration, or 
• 
known hospitalization within the past six months for res-
piratory failure (PaCO2 > 50 mmHg or PaO2 < 55 
mmHg, or oxygen saturation <88% on FiO2 = 0.21), 
• 
known chronic restrictive, obstructive, neuromuscular, 
chest wall, or pulmonary vascular disease resulting in 
severe exercise restriction (i.e. unable to climb stairs or 
perform household duties), known secondary polycy-
themia, severe pulmonary hypertension, or ventilator 
dependency 
14. Known vasculitis with diffuse alveolar hemorrhage 
15. Lung transplantation 
16. Pre-existing renal failure, i.e. requiring renal replacement ther-
apy with hemodialysis or peritoneal dialysis  
17. There are other uncontrolled co-morbidities that increase the 
risks associated with the study drug administration, that are as-
sessed by the medical expert team as unsuitable 
18. Patient in clinical trials with an IMP for COVID-19 within 30 days 
before ICF 
19. Unstable hemodynamics in the preceding 4 hours (MAP 
≤ 65 mmHg, or SAP < 90 mmHg, DAP < 60 mmHg, and vaso-
active agents required) 
20. Immunocompromised patients (chemotherapy, HIV, organ 
transplants, stem cell transplants), 
21. Receive any Angiotensin-Converting-Enzyme inhibitor (ACEi) or 
renin inhibitor treatment within 7 days before ICF 
Primary endpoint 
The primary endpoint is a composite endpoint of all cause-death or in-
vasive mechanical ventilation up to 28 days or hospital discharge. 
Secondary endpoints 
1. Log transformed levels of Lactate dehydrogenase (LDH) at 
day 5 as a surrogate marker for organ damage (powered sec-
ondary endpoint) 
2. 28-day mortality (all cause-death) 
3. Ventilator-free days (VFD) up to 28 days or hospital discharge  
4. Proportion of responders, defined as ≥2 improvement in 
WHO’s 11-Point Score system at day 7, 10, 14 and 28 
5. Time to death (all cause) 

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6. Proportion of patients with any use of invasive mechanical ven-
tilation up to 28 days or hospital discharge 
7. Time to first use of invasive mechanical ventilation up to 28 
days or hospital discharge 
8. Absolute values and absolute change in P/F ratio over time 
9. Absolute values and absolute change in the modified Sequen-
tial Organ Failure Assessment score (mSOFA score) over time 
10. Time to a 2-point decrease in WHO scoring scheme 
11. Absolute values and absolute change in lymphocyte counts 
over time  
12. Absolute values and absolute change in C-reactive protein lev-
els over time  
13. Absolute values and absolute change in D-dimer over time  
14. Absolute values and absolute change in log transformed levels 
of LDH over time 
15. Time to hospital discharge   
16. Change in viral RNA over time 
 
Biomarker endpoints: Absolute values and absolute changes in rele-
vant biomarkers over time: 
 
1. Angiotensin II (Ang II), Angiotensin 1-7 (Ang 1-7), Angiotensin 1-
5 (Ang 1-5), renin and aldosterone, Angiotensin-converting en-
zyme (ACE), Angiotensin-converting enzyme 2 (ACE2), Angio-
tensin I (Ang I), Angiotensin 1-9 (Ang 1-9) 
2. Cytokines: Interleukin 6 (IL-6), Interleukin 8 (IL-8), soluble Tu-
mor Necrosis Factor receptor type II (sTNFrII), Plasminogen Ac-
tivator Inhibitor type-1 (PAI-1), von Willebrand Factor (vWF), Tu-
mor necrosis factor-α (TNF-α) 
3. Alveolar epithelial markers: soluble Receptor for Advanced Gly-
cation End products (sRAGE), Surfactant protein-D(SP-D) 
4. Endothelial markers: Angiopoietin-2 
5. Change in clinical laboratory markers associated with poor out-
come over time (e.g., lymphocyte counts, hsTnI (high sensitivity 
troponin)) 
6. NT-proBNP, Ferritin  
 
Safety endpoints:   
Frequency of adverse events (AEs) and serious adverse events (SAEs) 
in vital signs, clinical laboratory assessments and in ECG parameters 
Study drug 
• 
Recombinant 
human 
angiotensin-converting 
enzyme 
2 
(rhACE2) – APN01* 
• 
Control Group: Placebo (physiological saline solution) 
 
*In other study documents (e.g. IB) APN01 is also referred to as 
GSK2586881 
 
Study drug dosage 
• 
0.4 mg/kg IV BID (for seven days)  
Intravenous administration of undiluted IMP using a polypropyl-
ene syringe with a 0.22 micron filter 
Statistical analysis plan 
Continuous variables will be summarized with means, standard devia-
tions, medians, lower and upper quartiles, minimums and maximums. 
Frequencies and percentages will be used to summarize categorical 

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variables. 
For time-to-event analyses censoring information will be used. 
It is assumed that no patients will discontinue the study early prior to 
day 28 or hospital discharge in this Covid-19 setting. It is also as-
sumed, that only very few missing values will arise due to not done 
evaluations. No imputation of missing values (e.g., no last observation 
carried forward (LOCF)) is planned, unless stated otherwise. 
 
Analysis sets: 
Safety Analysis Set (SAF): 
All randomized patients who received study medication (independent 
of whether it is APN01 or placebo) will be valid for the SAF. The SAF 
will be used for the evaluation of the safety assessments (as treated). 
 
Full Analysis Set (FAS): 
The FAS includes all randomized subjects. The FAS serves as the pri-
mary efficacy analysis set (as randomized). 
 
Per-protocol Analysis Set (PP): 
The PP includes all subjects included in the SAF who had no signifi-
cant protocol deviations and completed through Day 28 or until dis-
charge from the hospital (end of study follow-up). The PP will only be 
analyzed for main efficacy outcome measures (as treated). 
 
Analysis of primary efficacy endpoint 
The primary endpoint of this trial is a composite of all cause-death or 
any use of invasive mechanical ventilation up to 28 days or hospital 
discharge. Invasive mechanical ventilation is defined as patients who 
are intubated or have a tracheostomy tube and are receiving positive 
pressure ventilation. Patients discharged from hospital before day 28 
will be considered as non-event after confirmation by telephone inter-
view that they are alive at day 28.  Patients who will be discharged 
from hospital or early terminated before Day 28 will be considered hav-
ing an event on the day of discharge or early termination, if a telephone 
interview was not possible and/or no information about alive/death sta-
tus is known. 
Hypothesis to be tested: 
H0: pAPN01 = pPlacebo  
H1: pAPN01 ≠ pPlacebo 
H0 will be tested using a Chi-squared test. The level of significance is 
5% (two-sided). In addition, logistic regression analyses will be con-
ducted considering additional co-factors (will be detailed in the statisti-
cal analysis plan).   
 
Analysis of secondary efficacy endpoints 
Secondary efficacy variables will be tested descriptively and in an ex-
ploratory manner. 
 
1. Log transformed levels of Lactate dehydrogenase (LDH) at 
day 5 as a surrogate marker for organ damage. 
 
Log transformed levels of LDH will be analyzed using linear re-
gression adjusted for baseline log levels of LDH, centre and 
minimization factors. 
 

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95% confidence intervals will be calculated. 
Statistical procedures to check on a normal distribution of data, 
to be applied in case of non-normally distributed data, and to 
verify and handle minimization factors will be described in the 
statistical analysis plan, which will be finalized prior to unblind-
ing.   
 
2. 28-day mortality (all cause death)  
The percentage of patients who have died at day 28 will be 
presented by treatment group.  Patients who will be discharged 
from hospital or early terminated before Day 28 will be consid-
ered having an event on the day of discharge or early termina-
tion, if a telephone interview was not possible and/or no infor-
mation about alive/death status is known. The Chi-squared or 
Fisher’s exact test will be used to compare proportions. 95% 
CIs will be additionally calculated. Logistic regression analyses 
will be conducted considering additional co-factors (will be de-
tailed in the statistical analysis plan). 
 
3. Ventilator-free days (VFD) up to 28 days or hospital discharge 
VFD will be analyzed for both all patients as well as for the 
subgroup of patients who were alive at day 28 or hospital dis-
charge. For the analysis of all patients separate analyses will 
be conducted for patients who died: a) VFD will be set to 0, b) 
the observed VFD until death will be considered. Summary ta-
bles will be generated the VFD will be compared using Wil-
coxon rank sum test. In addition, bootstrap methods will be ap-
plied to calculate 95% confidence intervals and two-sided p-
values for the difference in means.   
 
4. Proportion of responders, defined as ≥2 improvement in 
WHO’s 11-Point Score system at day 7, 10, 14 and 28 
Similar analyses as for 28-day mortality will be conducted. 
 
5. Time to death (all cause) will be analyzed using Kaplan-Meier 
estimates and plots, log-rank test, and Cox proportional haz-
ards model (adjusted for minimization factors to derive hazard 
ratios and corresponding 95% confidence intervals). Patients 
who will be alive at day 28, or who will be discharged from hos-
pital before day 28 will be censored at discharge if they cannot 
be reached at or after day 28 by means of a telephone inter-
view. Further details will be described in the statistical analysis 
plan.  
 
6. Proportion of patients with any use of invasive mechanical ven-
tilation up to 28 days or hospital discharge. 
Similar analyses as for 28-day mortality will be conducted. 
 
7. Time to first use of invasive mechanical ventilation up to 28 
days or hospital discharge. 
Similar analyses as for time to death will be conducted. 
 
8. Absolute values and absolute change in P/F ratio over time 
The PF ratio is defined as PaO2 [mmHg] divided by FiO2 in 
[%] and will be evaluated on each visit. Summary statistics for 
the PF ratio for both the absolute values and the absolute 
change from Baseline (day 1) will be tabulated. 
 
9. Absolute values and absolute change in the modified Sequen-
tial organ failure assessment score (mSOFA score) over time 
Similar analyses as for the PF ratio will be conducted. 

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10. Time to a 2-point decrease in the WHO scale. Similar analyses 
as for time to death will be conducted. 
 
11. Absolute values and absolute change in lymphocyte counts 
over time 
Summary statistics for both the absolute values and the abso-
lute change from Baseline (day 1) will be tabulated. 
 
12. Absolute values and absolute change in C-reactive protein lev-
els over time  
Summary statistics for both the absolute values and the abso-
lute change from Baseline (day 1) will be tabulated. 
 
13. Absolute values and absolute change in D-dimer over time  
Summary statistics for both the absolute values and the abso-
lute change from Baseline (day 1) will be tabulated (prognostic 
information: Zhou et al. Lancet 2020). 
 
14. Absolute values and absolute change in log transformed levels 
of LDH over time  
Summary statistics for both the absolute values and the abso-
lute change from Baseline (day 1) will be tabulated. 
 
15. Time to hospital discharge   
Similar analyses as for time to death will be conducted. 
 
16. Change in viral RNA over time  
Summary statistics for both the absolute values and the abso-
lute change from Base-line (day 1) will be tabulated. 
 
 
Other biomarker endpoints 
Other biomarker endpoints will be analyzed using descriptive statistics.  
 
Sample size 
186 patients (93 per group) will yield 80% power to detect a 20% abso-
lute risk reduction in the primary composite endpoint, from 50% in the 
placebo group to 30% in the APN01 group at a two-sided alpha of 0.05. 
To consider patients who will be randomized but not treated a total of 
200 patients (100 per group) will be enrolled. 
Data Safety Monitoring 
Board (DSMB) 
The study will be monitored by a DSMB. 

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1 STUDY SCHEME 
 
 
 

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2 STUDY SCHEDULES 
Table 1: 
  
Screening 
period 
Treatment period 20 
Follow up period 
Procedures and assess-
ments 
Day -1* 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 10  
(±1 day)16 
Day 14  
(± 1 day)16 
Day 28 
End of Study 
Visit (or early 
termination 
visit) 
(± 1 day)15 
Informed consent  
X 
 
 
 
 
 
 
 
 
 
 
Inclusion and exclusion 
criteria  
X 
X ※** 
 
 
 
 
 
 
 
 
 
Demographics 1 
X 
 
 
 
 
 
 
 
 
 
 
Medical history 2 
X 
 
 
 
 
 
 
 
 
 
 
Randomization* 
 
X ※* 
 
 
 
 
 
 
 
 
 
Treatment 
 
X14 
X 
X 
X 
X 
X 
X 
 
 
 
Score Assessment of 
WHO`s 11-point scale 
X 
X ※** 
X 
X 
X 
X 
X 
X 
X 
X 
X19 
PCR (quantitative or 
qualitative) 3  
X 
X ※** 
 
X 
 
X 
 
X 
 
X 
X17 
Vital signs 4 
X 
X ※ 
X 
X 
X 
X 
X 
X 
X 
X 
X17, 18,19 
Physical examination5 
X 
X ※** 
X 
X 
X 
X 
X 
X 
X 
X 
X17, 19 
Serum or urine preg-
nancy test 6 
X 
 
 
 
 
 
 
 
 
 
X17, 19 
Clinical laboratory as-
sessments 7 
X 
X ※** 
X 
X 
  
X 
  
X 
X 
X 
X17, 19 

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Screening 
period 
Treatment period 20 
Follow up period 
Procedures and assess-
ments 
Day -1* 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 10  
(±1 day)16 
Day 14  
(± 1 day)16 
Day 28 
End of Study 
Visit (or early 
termination 
visit) 
(± 1 day)15 
HIV/HBV/HCV Serology8 
X 
 
 
 
 
 
 
 
 
 
 
ECG 9 
X 
X ※** 
X 
X 
  
X 
  
X 
X 
X 
X17, 19 
Assessment of Respira-
tory condition 10 
X 
X ※** 
X 
X 
X 
X 
X 
X 
X 
X 
X17 
mSOFA score 
X 
X ※** 
X 
X 
X 
X 
X 
X 
X 
X 
X17 
Assessment of Immune 
function 11 
  
X ※** 
X 
X 
  
X 
  
X 
X 
X 
X17, 19 
Biomarker 12 
  
X ※ 
 
X 
 
X 
 
X 
 
X 
X17, 19 
Patient status assess-
ment 13 
  
  
X 
X 
X 
X 
X 
X 
X 
X 
X17 
Adverse Events  
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Concomitant Medica-
tion  
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
* In case the required screening procedures take less time, randomization and start of treatment could be performed also on the same day then screening. The 
time period between start of screening procedures and start of treatment must not exceed 24 hours. 
** Events do not need to be done if randomization is on the same day as Screening  
※:  prior dosing  
mSOFA score: modified Sequential Organ Failure Estimated Score  
 
1 Demographic data: gender, age, ethnicity, height, history of allergies, history of smoking and alcohol use, weight, body mass index. 
2 Medical history: Medical history for the least 4 weeks. 
 
3 If PCR was performed within 5 days before the screening visit, the test does not need to be repeated at screening and the available test results can be used. 

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4 Vital signs include temperature, heart rate, respiration, blood pressure, and oxygen saturation. Vital signs need to be tested before and after each dose 
(within 30 min before/after IMP administration). 
5 physical examination could also be documented in the context of the general visit/health status assessment e.g. during a general clinical review 
6 Pregnancy Test: for FOCP only 
7 Laboratory tests include the following: in case a local lab cannot perform any of these parameters it should be reported as missing value  
• 
Inflammatory indicators: C- reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin. 
• 
Blood routines include: red blood cell (RBC) count, hematocrit (HCT) or hematocrit total, and classification of white blood cells (WBC), hemoglobin (Hb), 
platelet (PLT) count. 
• 
Urine routine includes: glucose (GLU), pH (PH), urinary protein (PRO), red blood cells (BLD), and white blood cells (LEU). 
• 
Stool routine + occult blood: red blood cells (BLD), white blood cells (LEU), occult blood. 
• 
Blood biochemistry includes: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (AKP), total bilirubin (TBl), total 
protein (ALB), albumin (ALB), urea nitrogen (BUN), Creatinine (Cr), uric acid (UA), potassium (K), sodium (Na), eGFR (assessment is calculated accord-
ing to the formula used in local laboratory). 
• 
Myocardial enzymes: creatine kinase (CK) and isoenzyme (CKMB), lactate dehydrogenase (of LDH), [alpha] - hydroxybutyrate dehydrogenase ([alpha] -
HBD), troponin (of cTnI). 
• 
Coagulation functions include: prothrombin time (PT), activated partial thromboplastin time (APTT), D- dimer, FIB  
8 results do not need to be available before randomization, results up to 4 weeks old are acceptable 
9 12- lead ECG: within 30 min after IMP administration  
10 Respiration: blood gas analysis (oxygenation index, blood lactic acid) or pulse oximetry. 
11 Immune function: immunoglobulin (Ig A, Ig M, Ig G) 
12 Biomarkers comprising (per collection of whole blood 10-12 ml) 
  
1 Li-Heparin blood collection tube (5-6 ml): 
1. Plasma equilibrium angiotensin levels: Angiotensin II (Ang II), Angiotensin 1-7 (Ang. 1 -7), Angiotensin 1-5 (Ang 1-5), Angiotensin I (Ang I), Angi-
otensin 1-9 (Ang 1-9) 
2. Aldosterone 
3. ACE2 Activity and ACE2 concentration 
4. Other exploratory RAAS Biomarkers indicators: specific exploratory indicators will be determined as needed 
 
1 EDTA blood collection tube (5-6 ml): 
1. Plasma-Renin-Concentration (PRC) 
2. Cytokines: interleukin- 6 (IL-6), interleukin- 8 (IL-8), soluble tumor necrosis factor receptor II (sTNFrII), PAI-1, vWF, tumor necrosis factor - α 
3. Alveolar epithelial markers: soluble advanced glycation product receptor (sRAGE), surface-active protein- D (SP-D) 
4. endothelial markers: angiopoietin -2 (Angiopoietin-2) 
5.   
6. COVID-19 antibodies, viral load  
13 Patient status assessments includes: no change, discharge from hospital, transition to critical illness, and death. 
14 1st dosing could also be on the evening of Day -1 in case randomization is on the same day as screening. 
15 Follow-up Visits (Day 28) may be performed as phone visit or in-home visit where applicable. . 

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16 If a patient is already discharged from the hospital, the follow-up visits could be performed on an out-patient basis or at patient's home provided the patient 
agrees to that. 
 
17 Assessments do not have to be performed in case of a phone visit 
18 Targeted Physical examination by phone interview 
19 The following assessments will be performed during in home-visits (Clinical Laboratory assessment, ECG, Assessment of immune function and Biomarker, if 
possible)  
20 If a patient will be discharged from hospital before day 7 treatment can be stopped at day of discharge. 
 
 

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3 
TABLE OF CONTENTS 
 
TITLE PAGE .......................................................................................................................... 1 
SUMMARY OF CHANGES .................................................................................................... 3 
SYNOPSIS ............................................................................................................................ 7 
1 
STUDY SCHEME ......................................................................................................... 14 
2 
STUDY SCHEDULES ................................................................................................... 15 
3 
TABLE OF CONTENTS ................................................................................................ 19 
3 
LIST OF ABBREVIATIONS........................................................................................... 21 
4 
ETHICS AND LEGAL ASPECTS .................................................................................. 24 
4.1 
Independent Ethics Committee (IEC) or Institutional Review Board ...................... 24 
4.2 
Ethical Conduct of the Clinical Trial ...................................................................... 24 
4.3 
Patient Information and Consent .......................................................................... 24 
4.4 
Confidentiality ....................................................................................................... 24 
4.5 
Insurance ............................................................................................................. 24 
4.6 
Publication Policy ................................................................................................. 25 
4.7 
Qualification of the Investigator ............................................................................ 25 
5 
INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE .............................. 26 
6 
INTRODUCTION .......................................................................................................... 28 
6.1 
Rationale .............................................................................................................. 28 
6.2 
Pharmacological Classification ............................................................................. 29 
6.3 
Clinical Use .......................................................................................................... 29 
6.4 
Human Pharmacokinetics ..................................................................................... 29 
6.5 
Preclinical Results ................................................................................................ 32 
6.6 
Cautions and Tolerability ...................................................................................... 33 
6.6.1 
Contraindications .............................................................................................. 33 
6.6.2 
Special Warnings and Preventive Measures for the Treatment ......................... 33 
6.6.3 
Use during Pregnancy and Lactation ................................................................ 33 
6.6.4 
Overdose .......................................................................................................... 33 
6.6.5 
Drug Abuse and Dependency ........................................................................... 33 
6.6.6 
Side Effects ...................................................................................................... 34 
6.7 
Risk-Benefit Considerations ................................................................................. 34 
7 
STUDY OBJECTIVES .................................................................................................. 35 
7.1 
Primary Objective ................................................................................................. 35 
7.1.1 
Primary Endpoint .............................................................................................. 35 
7.2 
Secondary Objectives ........................................................................................... 35 
7.2.1 
Secondary Endpoints........................................................................................ 35 
8 
INVESTIGATIONAL PLAN ........................................................................................... 36 
8.1 
Overall Study Design and Plan-Description .......................................................... 36 
8.2 
Discussion of Study Design, including the Choice of Control Groups ................... 37 
8.3 
Selection of Study Population ............................................................................... 37 
8.3.1 
Inclusion Criteria ............................................................................................... 37 
8.3.2 
Exclusion Criteria .............................................................................................. 38 
8.3.3 
Removal of Patients from Therapy or Assessment ........................................... 40 
8.4 
Treatments ........................................................................................................... 41 
8.4.1 
Treatments Administered .................................................................................. 41 
8.4.2 
Identity of Investigational Medicinal Products ................................................... 42 
8.4.3 
Method of Assigning Patient to Treatment Groups ............................................ 44 
8.4.4 
Selection of Doses in the Clinical Trial .............................................................. 44 
8.4.5 
Dose selection is based on previous clinical experience. .................................. 44 
8.4.6 
Blinding and Unblinding .................................................................................... 45 
8.4.7 
Prior and Concomitant Therapy ........................................................................ 45 

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8.4.8 
Treatment Compliance ..................................................................................... 45 
8.5 
Efficacy and Safety Variables ............................................................................... 46 
8.5.1 
Efficacy and Safety Measurements Assessed and Flow Chart ......................... 46 
8.5.2 
Appropriateness of Measurements ................................................................... 46 
8.5.3 
Primary Efficacy Variable(s).............................................................................. 56 
8.6 
Data Quality Assurance ........................................................................................ 56 
8.6.1 
Quality Assurance System ................................................................................ 56 
8.6.2 
Monitoring ......................................................................................................... 57 
8.6.3 
Documentation and Data Collection .................................................................. 57 
8.6.4 
Data Management ............................................................................................ 57 
8.6.5 
Archival of Documents ...................................................................................... 58 
8.7 
Statistical Methods Planned in the Protocol and Determination of Sample Size ... 58 
8.7.1 
Statistical and Analytical Plan ........................................................................... 58 
8.7.2 
Determination of Sample Size .......................................................................... 62 
9 
CHANGES IN THE CONDUCT OF THE CLINICAL TRIAL OR PLANNED ANALYSIS . 62 
9.1 
Protocol Deviations .............................................................................................. 62 
10 DSMB ........................................................................................................................... 63 
11 REPORTS .................................................................................................................... 63 
11.1.1 
Clinical Study Report .................................................................................... 63 
11.1.2 
Additional Reports ........................................................................................ 64 
12 REFERENCES ............................................................................................................. 65 
13 ANNEX 1 ...................................................................................................................... 66 
14 ANNEX 2 ...................................................................................................................... 67 
 
 

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3 
LIST OF ABBREVIATIONS 
 
ACE2 
Angiotensin-Converting Enzyme 2 
ABG 
Arterial blood gas 
ACE 
Angiotensin-converting enzyme 
ACEi 
Angiotensin-Converting-Enzyme inhibitor 
AE 
Adverse event 
AKP 
Alkaline phosphatase 
ALB 
Albumin 
ALT 
Alanine aminotransferase 
Ang 
Angiotensin 
ARDS 
Acute respiratory distress syndrome 
AST 
Aspartate aminotransferase 
AUC 
Area under the curve 
BID 
taken two times a day 
BLD 
Red blood cells 
BMI 
Body mass index 
BUN 
Urea nitrogen 
CA 
Competent authority 
CI 
Confidence interval 
CoV 
Coronavirus 
COVID-19 
Corona-virus-disease 2019 
Cr 
Creatinine 
CRO 
Contract research organization 
CRP 
C-reactive protein 
CS 
Clinically significant 
CSR 
Clinical study report 
cTnI 
Troponin 
DAP 
Diastolic arterial pressure 
DMP 
Data Management Plan 
DRM 
Data review meeting 
DSMB 
Data Safety Monitoring Board 
DVP 
Data Validation Plan 
EC 
Ethics committee 
ECG 
Electrocardiogram 
eCRF 
Electronic Case Report Form 
EDTA 
Ethylene Diamine Tetra-acetic Acid 
ELISA 
Enzyme-linked immunosorbent assay 
eGFR 
Estimated Glomerular filtration rate 
ESR 
Erythrocyte Sedimentation Rate 
EU 
European Union 
FAS 
Full Analysis Set 
FEV1 
Forced Expiratory Pressure in 1 Second 
FIH 
First in Human 
FOCP 
Female of Child-bearing Potential 
FU 
Follow-up 
FVC 
Forced Vital Capacity 
GCP 
Good Clinical Practice 

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GCS 
Glasgow coma score 
GEO 
Geometric 
GLU 
Glucose 
HCT 
Hematocrit 
HLA-DR 
Human Leukocyte Antigen- DR isotype 
hsTnI 
high sensitivity troponin 
i.v. 
intravenous 
IB 
Investigators brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation of Technical Require-
ments for Registration of Pharmaceuticals for Human Use 
IL 
Interleukin  
IMP 
Investigational Medicinal Product 
ISF 
Investigator site file 
IUD 
Intrauterine device 
IUS 
Intrauterine hormone-releasing system 
K 
Potassium 
LDH 
Lactate Dehydrogenase 
LEU 
White blood cells 
LOCF 
last observation carried forward 
LPLV 
Last patient last visit 
MAP 
Mean Arterial Pressure 
MedDRA 
Medical Dictionary for Regulatory Activities 
Min 
Minute 
mSOFA 
Modified Sequential Organ Failure Assessment 
N 
Number 
Na 
Sodium 
NCS 
Not clinically significant 
NOAEL 
No Observed Adverse Effect Level 
NSVT 
Non-sustained ventricular tachycardia 
PAH 
Pulmonary Arterial Hypertension 
PAI-1 
Plasminogen activator inhibitor type-1 
PI 
Principal Investigator 
PK 
Pharmacokinetic 
PLT 
Platelet 
PP 
Per-protocol Analysis Set 
PRO 
Urinary protein 
PT 
Prothrombin time 
QAU 
Quality Assurance Unit 
QC 
Quality Control 
QP 
Qualified Person 
qPCR 
quantitative polymerase chain reaction 
RBC 
Red blood cell count 
rhACE2 
Recombinant human angiotensin-converting enzyme 2 
SAE 
Serious Adverse Event 
SAF 
Safety Analysis Set 
SAP 
Systolic arterial pressure 
SAR 
Severe adverse reaction 

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SARS-CoV-2 
Severe acute respiratory syndrome coronavirus 2 
SDV 
Source Data Verification 
SHR 
Spontaneously hypertensive rats 
SmPC 
Summary of Product Characteristics 
SOC 
Standard of Care 
SOP 
Standard Operating Procedure 
SP-D 
Surfactant protein-D 
sRAGE 
soluble Receptor for Advanced Glycation End products 
sTNFrII 
Soluble tumor necrosis factor receptor type II 
SUSAR 
Suspected unexpected Serious Adverse Reaction 
TBI 
Total bilirubin 
TMF 
Trial Master File 
TP 
Total protein 
UA 
Uric acid 
ULN 
Upper limits of normal 
VFD 
Ventilator-free days 
VPC 
Ventricular Premature Complexes 
vWF 
von Willebrand Factor 
WBC 
White blood cell 
WHO 
World Health Organization 
WHO-CPS 
WHO Clinical Progression Scale 

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4 ETHICS AND LEGAL ASPECTS 
4.1 
Independent Ethics Committee (IEC) or Institutional Review Board 
This clinical trial will be planned and performed in accordance with  
• The Declaration of Helsinki in its version of Fortaleza, 2013; 
• The EU Clinical Trial Directive 2001/20/EC; 
• The EU Clinical Trial Directive 2001/83/EC; 
• ICH Guideline for Good Clinical Practice E6(R2), of 9 November 2016; 
• Code of Federal Regulations Title 21 – Part 312 EMA Guidance on the Management of 
Clinical Trials during the COVID-19 (Coronavirus) pandemic in its most current version 
• FDA Guidance on Conduct of Clinical Trials of Medical Products during COVID-19 Public 
Health Emergency in its most current versionApplicable national laws 
 
4.2 
Ethical Conduct of the Clinical Trial  
The sponsor or a designee will submit, among other documents, the study protocol, the patient 
information and the informed consent form to all involved ethics committees (EC) and request 
approval (favorable opinion). The sponsor or a designee will provide the clinical trial application 
to all involved national competent authorities (CA). The approval of both, the Ethics Committee 
and the Competent Authority must be obtained prior to the start of any study related interven-
tion in a country. 
4.3 
Patient Information and Consent 
Before any study specific procedures can take place, an investigator will explain to the patients 
the nature, significance and implications of the clinical trial. He/she will explain all methods, 
rules of conduct, and any restrictions which may apply. Possible effects and side effects will 
be discussed. Patients will be informed that they are free to withdraw from the clinical trial at 
any time, without giving any reason for doing so. They must be able to understand the full 
implications of their decision.  
All participants will date and sign an informed consent form as evidence of consent. The in-
vestigator will also date and sign the informed consent form. The patient information sheet and 
the informed consent form of each participant will be filed in the investigator site file (ISF). A 
copy of the dated and signed consent form and the information sheet will be handed to patients 
after signature and before enrollment.  
4.4 
Confidentiality 
The Principal Investigator (PI) at each study site must assure that patients’ anonymity will be 
strictly maintained and that their identities are protected from unauthorized parties. Only an 
identification code (i.e., consisting of an identification number, sex and year of birth) should be 
recorded on any form or biological sample submitted to the laboratory, Sponsor or EC. The PI 
must keep a patient identification log showing codes and names for all patients screened and 
for all patients enrolled in the trial.  
4.5 
Insurance 
The Sponsor is responsible for the appropriate insurance coverage for the patients in accord-
ance with all applicable national laws and provisions.  

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4.6 
Publication Policy 
The Sponsor has to publish the results of this study considering applicable legal requirements. 
Besides, it is in the sole discretion of the Sponsor whether to publish the results of this clinical 
trial. 
4.7 
Qualification of the Investigator 
The PI and the deputy (only for Germany) fulfill the requirements of applicable national law. 
Curriculum vitae of both will be filed in the trial maser file (TMF). 
For conducting the clinical trial, the PI may delegate tasks to investigators (or other qualified 
staff). This is to be documented properly. The PI is responsible for the adequate training and 
supervision of all delegates. No clinical trial related procedure must be performed by personnel 
which is not properly trained and delegated. 
In the present document the mere term “Investigator” refers to the PI or the deputy (only for 
Germany). 
 
 

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5 INVESTIGATORS AND STUDY ADMINISTRATIVE STRUCTURE 
 
 
Sponsor: 
 
 
APEIRON Biologics AG 
Campus-Vienna-Biocenter 5 
1030 Vienna, Austria 
 
Coordinating Investigator: Prof. Henning Bundgaard, MD 
 
 
 
 
Faculty of Health and Medical Sciences 
 
 
 
 
University of Copenhagen 
 
 
 
 
Rigshospitalet, University of Copenhagen 
 
 
 
 
Department of Cardiology, B 2141 
 
 
 
 
The Heart Centre, Blegdamsvej 9  
 
 
 
 
2100 Copenhagen Ø, Denmark 
 
 
 
 
Phone: 
+45 3545 0512 
 
 
 
 
 
Email:   
Henning.Bundgaard@Regionh.DK 
 
National Coordinating 
Investigator:  
For each country a national Coordinating Investigator is ap-
pointed. Names and contact details are filed in the TMF. 
 
Medical Monitor: 
 
Dr. Edgar Fenzl, MD 
 
 
 
 
FGK Clinical Research GmbH 
 
 
 
 
Heimeranstrasse 35, 80339 Munich, Germany 
 
 
 
 
Phone: 
+49 89 893 119 22 
 
 
 
 
Email:   
edgar.fenzl@fgk-cro.com 
 
 
Lead Clinical CRO:  
CTC North GmbH & Co. KG 
 
 
 
 
at the University Medical Center Hamburg-Eppendorf  
 
 
 
 
Martinistr. 64, 20251 Hamburg, Germany 
 
Responsibilities: 
Overall Project Management, Regulatory (Denmark, Austria, 
Germany, UK), Safety Management, 
 
Overall Monitoring, Data Management, Medical Writing 
 
Overall Project Lead  
CTC North GmbH & Co. KG 
 
 
 
 
Dr. Saskia Borregaard 
 
 
 
 
Phone: 
+49 40 524719 200 
 
 
 
 
Email:  
s.borregaard@ctc-north.com 
 
 
 
 
 
Dr. Katharina Bartsch 
 
 
 
 
Phone: 
+49 40 524719 218 
 
 
 
 
Email:  
k.bartsch@ctc-north.com 
 
Clinical CRO Russia  
IPHARMA LLC (ChemRar group)  
 
 
 
 
7, Nobel street 
 
 
 
 
Skolkovo Innovative Centre 
 
 
 
 
Moscow, 143026, Russia 

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Clinical CRO US 
PRC Clinical 
 
1350 Old Bayshore Highway, Ste. 125 
 
Burlingame, CA 94010, US 
 
Statistics: 
 FGK Clinical Research GmbH 
 
Heimeranstrasse 35, 80339 Munich, Germany 
 
 Olaf Böhm 
 
 Phone: 
+49 89 893 119 29 
 
Email:  
olaf.boehm@fgk-cro.com 

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6 INTRODUCTION 
6.1 
Rationale 
The contagious coronavirus, named SARS-CoV-2 (formerly 2019-nCoV), which broke out at 
the end of 2019, has led to a medical emergency across the world, with the World Health 
Organization (WHO) officially declaring the novel coronavirus a pandemic on 11 March 2020 
[1]. 
Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common 
cold to more severe diseases such as MERS-CoV and SARS-CoV.  
To determine the urgent need for new drugs and vaccines data obtained for Italy as a seriously 
and in comparison to other European country’s precocious effected country can be used.  
The percentage of patients in intensive care reported daily in Italy between March 1 and 
March 11, 2020, was consistently between 9% and 11% of patients who are actively infected. 
The number of patients infected since February 21, 2020 in Italy closely follows an exponential 
trend. Italy has had 12.462 confirmed cases according to the Istituto Superiore di Sanità as of 
March 11, and 827 deaths [2]. 
Assuming the exponential progression of infected patients along with 9 % and 11 % of patients 
with the need of admission to intensive care units developing acute respiratory distress syn-
drome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 
pneumonia, the number of people infected in Italy will probably impose a major strain on critical 
care facilities [3].  
A prospective observational cohort study with rapid data gathering and near real-time analysis, 
using a pre-approved questionnaire adopted by the WHO, performed in 166 UK hospitals be-
tween 6th February and 18th April 2020 included 16,749 people with COVID-19. The median 
age was 72 years [IQR 57, 82; range 0, 104], the commonest comorbidities were chronic car-
diac disease (29%), uncomplicated diabetes (19%), non-asthmatic chronic pulmonary disease 
(19%) and asthma (14%); 47% had no documented reported comorbidity. Increased age and 
comorbidities including obesity were associated with a higher probability of mortality. Distinct 
clusters of symptoms were found: 1. respiratory (cough, sputum, sore throat, runny nose, ear 
pain, wheeze, and chest pain); 2. systemic (myalgia, joint pain and fatigue); 3. enteric (ab-
dominal pain, vomiting and diarrhoea). Overall, 49% of patients were discharged alive, 33% 
have died and 17% continued to receive care at date of reporting. 17% required admission to 
High Dependency or Intensive Care Units; of these, 31% were discharged alive, 45% died and 
24% continued to receive care at the reporting date. Of those receiving mechanical ventilation, 
20% were discharged alive, 53% died and 27% remained in hospital. 
This description of COVID-19 demonstrates the importance of pandemic preparedness and 
the need to maintain readiness to launch research studies in response to outbreaks [4] 
Current data for the participating countries regarding the coronavirus according to the John 
Hopkins University are for Great Britain 187.842 confirmed with SARS-CoV-2 infected inhab-
itants (cumulated inclusive decedents and convalescents) and an average daily increase of 
4800 new daily infected over the last 7 days. 28.520 inhabitants died thereof with an average 
daily increase of 630 over the last 7 days.  
 

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The situation in Germany are: 165.664 confirmed with SARS-CoV-2 infected inhabitants (cu-
mulated inclusive decedents and convalescents) and an average daily increase of 1100 new 
daily infected over the last 7 days. 6866 inhabitants died thereof with an average daily increase 
of 130 over the last 7 days. 
In Denmark there are 9868 confirmed with SARS-CoV-2 infected inhabitants (cumulated in-
clusive decedents and convalescents) and an average daily increase of 140 new daily infect-
ed over the last 7 days. 484 inhabitants died thereof with an average daily increase of 9 over 
the last 7 days. 
In Austria there are 15.597 confirmed with SARS-CoV-2 infected inhabitants (cumulated in-
clusive decedents and convalescents) and an average daily increase of 53 new daily infected 
over the last 7 days. 598 inhabitants died thereof with an average daily increase of 8 over the 
last 7 days. 
Although the progression of SARS-CoV-2 within the mentioned countries seems to have a 
different dynamic nevertheless the situation described may be volatile and proofs the need for 
a possible treatment option and therefore justifies this clinical study [5]. 
6.2 
Pharmacological Classification 
The investigational medicinal product (IMP) APN01 is a recombinant human (rh) soluble angi-
otensin converting enzyme 2 (ACE2).  
Mode of action: APN01 is believed to be the cleavage of Angiotensin II of the renin angiotensin 
system to Angiotensin 1-7. Competitive binding by exogenous ACE2 may block viral entry and 
decrease viral replication in ACE2 expressing organs and protect the lung and distal organ 
from injury induced by SARS-CoV-2. Furthermore, preliminary studies in cell culture and mul-
tiple organoids have shown that ACE2 can decrease viral replication [6]. 
6.3 
Clinical Use 
The following clinical studies were performed with APN01: a placebo-controlled, Phase I, sin-
gle dose escalating and repeat-dose study in healthy volunteers; a Phase IIa study in patients 
with acute respiratory distress syndrome (ARDS); a Phase IIb single dose escalation investi-
gator sponsored study in patients with pulmonary arterial hypertension; a Phase I study exam-
ining the effects of APN01 on responses to acute hypoxia and exercise in healthy subjects; an 
ongoing Phase IIa, open-label, dose escalation study in patients with pulmonary arterial hy-
pertension. APN01 is also referred in other study documents as GSK2586881. 
In this study APN01 will be used for treatment of COVID 19 infected and hospitalized patients. 
6.4 
Human Pharmacokinetics 
Following pharmacokinetic (PK) data were obtained from a placebo-controlled, Phase I, single 
dose escalating and repeat-dose study in healthy volunteers and a Phase IIa study in patients 
with acute respiratory distress syndrome (ARDS). For further information please see Investi-
gators brochure chapter 5 [6]. 
Placebo-controlled, Phase I, single dose escalating and repeat-dose study in healthy volun-
teers:  

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Systemic ACE2 enzymatic activity was measured in plasma, and this measure was used to 
describe the exposure of GSK2586881 (APN01). Determination of rhACE2 content in plasma 
samples using a “sandwich” enzyme-linked immunosorbent assay (ELISA) was also con-
ducted and the results showed good correlation, and yield similar results up to about 10 μg/ml. 
There was however a slight difference at higher values, where the ELISA figures become 
smaller than ACE2 enzymatic activity, but the difference was relatively small with approxi-
mately 20 % lower at around 20 μg/ml range. The summary of systemic exposure of APN01 
as measured by ACE2 enzymatic activity assay following single dose of APN01 from 0.1 mg/kg 
to 1.2 mg/kg, is shown in Table 2. 
 
Table 2: Summary of systemic PK in healthy volunteers following single dose of 
GSK2586881 (APN01-1-01) 
Cohort 
1 
2 
3 
4 
7 
Dose 
0.1mg/k
0.2mg/
0.4mg/k
0.8mg/k
1.2mg/k
N 
3 
3 
3 
3 
3 
AUC1 
Geometric (GEO) Mean 
17.27 
26.60 
67.84 
81.80 
141.70 
CI 95% Lower GEO Mean 
7.84 
17.41 
53.81 
57.45 
75.55 
CI 95% Upper GEO Mean 
38.04 
40.65 
85.52 
116.48 
265.78 
Cmax 2 
Geometric Mean 
2.01 
2.85 
6.30 
12.72 
21.03 
CI 95% Lower GEO Mean 
1.42 
1.85 
5.58 
7.00 
16.76 
CI 95% Upper GEO Mean 
2.86 
4.39 
7.12 
23.13 
26.40 
1. Area under the curve (AUC) for each subject was taken from Apeiron APN01CSR 
(Apeiron Biologics AG) and summarized in house 
2. Cmax was calculated and summarized in house from raw data; Note: Cmax was 
not reported in Apeiron APN01 CSR 
 
Systemic exposure of GSK2586881 appeared to increase with increasing dose, and the 
increase was approximately dose proportional. GSK2586881 cleared quickly from sys-
temic, with median clearance of 589 mL/h and median half-life of 9.8 hours. 
Exploration of PK profiles indicated that GSK2586881 showed a bi-exponential decline, with 
an initial quick distribution phase followed by a relatively slower elimination phase. 
Six healthy volunteers received multiple dosage of GSK2586881 at 0.4 mg/kg once daily 
for three (3 subjects in cohort 5) and six (3 subjects in cohort 6) consecutive days [6]. 
 
Figure 1 shows the systemic ACE2 enzymatic activity of the healthy volunteers following 
repeated dosing of 0.4 mg/kg GSK2586881 (green and blue curves) in comparison to the 
respective values found in cohort 3, in which volunteers were treated only once at the same 
dosage (red curve): 
1. Single dose cohort (0.4 mg / kg) (red curve) 
2. Multiple dose cohort over 3 days (0.4 mg / kg) (green curve) 
3. Multiple dose cohort over 6 days (0.4 mg / kg) (blue curve) 

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Different infusion time points applied between the two multiple dose cohorts resulting in 
different curves during the first three days: 
Multiple dose- cohort 5 (3d) green curve: 
D1-3: 6 time points: prior + end of infusion, 1, 2, 4 and 8h after, D4: 24h after, D5: 48h after, 
D6: 72h after 
Multiple dose- cohort 6 (6d) blue: 
D1: 6 time points: prior + end of infusion, 1, 2, 4 and 8h after, D2 to D5: 1 time point prior 
D6: 6 time points: prior + end of infusion, 1, 2, 4 and 8h after, D7: 24h after, D8: 48h after, 
D9: 72h after 
Sampling at different times (before and after infusion) explains the difference between the 
two curves of the multiple dose cohorts on day 2 and day 3. Sampling on day 6 of the blue 
curve was performed again after infusion and showed once again the increase in the 
GSK2586881 (APN01) concentration (comparable to the measured concentration of the 
green curve at the same time of taking the samples on days 2 and 3). 
The shapes including the peaks and slopes of the curves were very similar indicating no 
changes in systemic PK following repeated dosing, and there was no marked accumulation 
of rhACE2 by repeated dosing for three and six consecutive days. 
 
Figure 1 
Systemic ACE2 activity measured in plasma samples of healthy sub-
jects with daily administrations of 0.4mg/kg GSK2586881 on three 
(green triangles) and six (blue squares) consecutive days, comparison 
to healthy subjects treated once with the same dosage (APN01-1-01) 
 
Phase IIa study in patients with acute respiratory distress syndrome (ARDS): 

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GSK2586881 concentrations were determined in plasma using a qualified analytical method 
based on sample dilution, followed by immunoassay analysis, and analyzed using population 
non-linear mixed effects modelling methods. Based on the population PK analysis the plasma 
GSK2586881 concentration time profile from n=24 ARDS patients (Parts A and B combined) 
was best described by a 1-compartment model with 1st order elimination. The only covariate 
found to be significant was study PART (Part A or B) on clearance. Population PK model 
parameters are described in Table 3. 
Table 3: Final Population PK Model (ACE114622) 
Parameter 
Esti-
SE 
Relative SE 
CL(L/h) – Part A 
0.384 
0.088
23.1 
CL (L/h) – Part B 
0.698 
0.060
8.7 
V (L) 
5.79 
0.521 
9.0 
IIV CL 
0.094 
0.030
32.7 
IIV V 
0 Fix 
- 
- 
Residual Error 
0.0596 
0.013
22.8 
IIV: Inter-occasion variability 
 
Based on the optimal model, the population mean estimate in Part A was lower (approxi-
mately 2-fold) than population mean estimate for Part B. However, the significance of this 
finding is unclear given the small subjects numbers in Part A (n=5). 
Individual AUC(0-24) values, derived from individual post-hoc estimates of CL, are summarized 
by PART (Part A and Part B) in Table 4. 
 
Table 4: Model Predicted CL and Systemic Exposure and Total Administered Dose 
(Geometric Mean [95% CI]) following administration of GSK2586881to ARDS 
subjects (ACE114622 Parts A and B) 
PAR
N 
Total GSK2586881 Dose 
CL (L/h) 
AUC(0-24) 
A 
5 
141 [118, 167] 
0.391 [0.281, 
359 [283, 456] 
B 
1
199 [184, 216] 
0.703 [0.624, 
284 [252, 320] 
 
Based on visual inspection, concentrations of GSK2586881 (APN01) determined by immu-
noassay (ng/mL) generally reflected enzymatic activity measurements (ng/mL) [6]. 
6.5 
Preclinical Results 
In a pharmacology study, GSK2586881 (APN01) (IV at 1 mg/kg) when administered alone or 
co-administered with angiotensin type 1 receptor blocker losartan (10 mg/kg/d, p.o. via chow) 
or an ACE inhibitor, captopril (10 mg/kg/d, p.o.), to male spontaneously hypertensive rats 
(SHR) resulted in a decrease in BP of 7.92 mmHg when compared with rats treated with 
vehicle alone. 
Minimal toxicity has been found in animal studies to date as shown in the Table 5 below. 
In the 14-day repeated dose study in cynomolgus monkeys, one female monkey receiving the 
highest dose, 20.8 mg/kg/day, on Day 12 had 6 Ventricular Premature Complexes (VPCs) 
including an episode of non-sustained ventricular tachycardia (NSVT) consisting of 3 VPCs 
(triplet). This finding was considered adverse, and therefore the no observed adverse effect 
level (NOAEL) for this study was determined to be 8 mg/kg/day. 
 

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Table 5: Summarized NOAEL of the toxicology and safety-pharmacology studies 
Model 
Species 
NOAEL 
(mg/kg/day) 
Repeated dose toxicology (2 weeks) 
HW rats 
20.8 
(highest dose tested) 
Repeated dose toxicology (4 weeks) 
Rhesus monkey 
2.5 
(highest dose tested) 
Repeated dose toxicology (2 weeks) 
Cynomolgus mon-
key 
8.0 
Cardiovascular & respiratory safety pharma-
cology 
Cynomolgus mon-
key 
8.0 
Acute dose toxicology 
CD rats 
40 
CNS interaction study (Irwin test) 
CD rats 
40 
 
Further information can be found in the investigator's brochure [6]. 
6.6 
Cautions and Tolerability 
6.6.1 Contraindications 
There are no specific disease-related contraindications known for the administration of 
APN01. However, APN01 should not be administered to pregnant women or nursing 
mothers. APN01 is contraindicated in subjects who are hypersensitive to APN01 or any 
of the excipients used. 
6.6.2 Special Warnings and Preventive Measures for the Treatment 
Patients receiving any Angiotensin-Converting-Enzyme inhibitor (ACEi) or Renin inhibitor 
within 7 days before giving informed consent are excluded from participating in this clinical trial 
with APN01.  
6.6.3 Use during Pregnancy and Lactation 
There is no clinical experience with the use of APN01 during pregnancy or lactation. Em-
bryofetal developmental toxicity studies with the compound have not been performed. There-
fore, APN01 may not be administered to pregnant or lactating females at this time. Women 
of childbearing potential may be included in clinical studies if they are enrolled under circum-
stances that would preclude the possibility of becoming pregnant during dosing. 
6.6.4 Overdose  
No specific antidote for APN01 is known. Patients should be observed and supported ap-
propriately. 
6.6.5 Drug Abuse and Dependency 
No studies have been conducted to evaluate the potential for abuse and dependence. The 
mechanism of action and pharmacological activity provide no basis to suggest that APN01 has 
potential for abuse or dependence. 

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6.6.6 Side Effects 
Adverse Reactions 
In a study of critically ill patients with ARDS, serious adverse events (SAEs) and safety find-
ings were consistent with a critically ill patient population with a wide range of underlying 
disease processes. More adverse events (AEs) of rash, hypernatremia, dysphagia and 
pneumonia were reported in patients on APN011 compared with placebo, although many of 
these events were reported in the follow-up period. 
No adverse systemic hemodynamic effects have been observed in patients with pulmonary 
arterial hypertension (PAH), but clinical experience is limited to single doses. 
No evidence of immunogenicity was found in the clinical studies to date, but further studies 
are needed to provide definitive information. 
Further information can be found in the IB, Chapter 5.3 [6]. 
6.7 
Risk-Benefit Considerations 
Based on available information and the design of the clinical trial, the Sponsor considers the 
trial to be ethically acceptable.  
In general, the adverse events in the first in human (FIH) Study (APN01-1-01) occurred with 
similar frequency between active and placebo treated subjects, without apparent dose-relat-
edness. In the Phase I-Study 204987 (Effects on the Response to Acute Hypoxia and Exer-
cise) of APN01 with healthy subjects there were no serious adverse events, deaths or other 
significant adverse events. In the Phase Ib Study 204696 in patients with PAH, there were no 
SAEs associated with the infusion of GSK2586881 (APN01) or reported within the 2-week 
period of study observation [6]. 
In the ongoing open-labeled Phase II a-206246-Study with Patients with PAH there were no 
SAEs and no anti-ACE2 binding antibodies detected. 
The hypernatremia reported with GSK258688 (APN01) in the Phase IIa-ACE114622-Study 
with patients with acute respiratory distress syndrome was mild and consistent with sodium 
levels in the placebo group, and a number of events occurred after discontinuation of drug. 
The episodes of pneumonia in subjects receiving GSK2586881 (APN01) in the same study 
were all considered nosocomial in origin and occurred between 5-36 days after the last dose 
of study drug. 
During Part A of the Phase IIa-ACE114622-Study 3 subjects experienced a total of 9 SAEs 
that resulted in death, only one of which (acute renal failure), was considered to be related to 
study drug, and was reported 4 days after the last dose of study drug. 
None of the fatal events in during Part B (3 fatal AEs - 2 in the placebo group due to multiple 
organ failure and septic shock and one in GSK2586881 (APN01) 0.4 mg/kg BID) was consid-
ered to be related to study treatment by the reporting investigator. 
In general, the safety findings were consistent with a critically ill patient population with a wide 
range of underlying disease processes. 
Fei Zhou et al. reported age, comorbidities, lymphocytopenia and elevated alanine aminotrans-
ferase, d-dimer, creatine kinase, high-sensitivity cardiac troponin I, prothrombin time, and dis-
ease severity to be associated with intensive care unit admission. In addition, angiotensin con-
verting enzyme 2, the receptor for SARS-CoV-2, is expressed on myocytes and vascular en-
dothelial cells, so there is at least theoretical potential possibility of direct cardiac involvement 
by the virus [7]. 

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The maximum blood volume of approximately 215 mL (female) and 200 mL (male) is consid-
ered adequate and no undue risk for the patients especially as some of the laboratory analyses 
are within the clinical routine. 
Giving the urgent need in the light of progression of infected people worldwide in comparison 
to so far known adverse events reported adverse events in study subjects on GSK2586881 
like rash, hypernatremia, dysphagia and pneumonia the PI and Sponsor still consider the trial 
to be ethically acceptable. 
7 STUDY OBJECTIVES 
7.1 
Primary Objective 
To assess clinical efficacy of APN01 using a composite outcome of all cause-death or need of 
invasive mechanical ventilation up to 28 days. 
7.1.1 Primary Endpoint 
The primary endpoint is a composite endpoint of all cause-death or invasive mechanical ven-
tilation up to 28 days or hospital discharge. 
7.2 
Secondary Objectives 
• 
To assess efficacy of APN01 using log transformed levels of Lactate dehydrogenase 
(LDH) as a surrogate marker for organ damage. 
• 
To evaluate the safety of APN01 in patients with severe COVID-19  
• 
To monitor other biomarker changes (e.g. IL-6, Ang II) in patient with severe COVID-
19 treated with APN01 
7.2.1 Secondary Endpoints 
1. Log transformed levels of Lactate dehydrogenase (LDH) at day 5 as a surrogate marker 
for organ damage (powered secondary endpoint) 
2. 28-day mortality (all cause death) 
3. Ventilator-free days (VFD) up to 28 days or hospital discharge  
4. Proportion of responders, defined as ≥2 improvement in WHO’s 11-Point Score system 
at day 7, 10,14 and 28 
5. Time to death (all cause) 
6. Proportion of patients with any use of invasive mechanical ventilation up to 28 days or 
hospital discharge 
7. Time to first use of invasive mechanical ventilation up to 28 days or hospital discharge 
8. Absolute values and absolute change in P/F ratio over time 
9. Absolute values and absolute change in the modified Sequential organ failure assess-
ment score (mSOFA score) over time   
10. Time to a 2-point decrease in WHO scoring schema 
11. Absolute values and absolute change in lymphocyte counts over time  
12. Absolute values and absolute change in C-reactive protein levels over time  

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13. Absolute values and absolute change in D-dimer over time  
14. Absolute values and absolute change in log transformed levels of LDH over time 
15. Time to hospital discharge   
16. Change in virus RNA over time 
Biomarker endpoints: Absolute values and absolute changes in relevant biomarkers over 
time: 
1. Angiotensin II (Ang II), Angiotensin 1-7 (Ang 1-7), Angiotensin 1-5 (Ang 1-5), renin and 
aldosterone, Angiotensin-converting enzyme (ACE), Angiotensin-converting enzyme 2 
(ACE2); Angiotensin I (Ang I), Angiotensin 1-9 (Ang 1-9) 
2. Cytokines: Interleukin 6 (IL-6), Interleukin 8 (IL-8), soluble Tumor Necrosis Factor re-
ceptor type II (sTNFrII), Plasminogen Activator Inhibitor type-1 (PAI-1), von Willebrand 
factor (vWF), Tumor necrosis factor-α (TNF-α); 
3. Alveolar epithelial markers: soluble Receptor for Advanced Glycation End products 
(sRAGE), Surfactant protein-D(SP-D); 
4. Endothelial markers: Angiopoietin-2 
5. Change in clinical laboratory markers associated with poor outcome over time (e.g., 
lymphocyte counts, D-Dimer, CRP, hsTnI (high sensitivity troponin)) 
6. NT-proBNP, Ferritin 
 
Safety endpoints: 
Frequency of AEs and SAEs, in vital signs, clinical laboratory assessments and in ECG pa-
rameters. 
8 INVESTIGATIONAL PLAN 
8.1 
Overall Study Design and Plan-Description  
The clinical trial is designed as a prospective, multi-centre, double-blind, randomized, placebo-
controlled, interventional trial to assess clinical safety, tolerability, and efficacy of APN01 on 
top of best standard of care (SOC) in patients with severe COVID-19 and to evaluate if treat-
ment with APN01 on top of SOC is superior to placebo (NaCl 0.9%) on top of SOC.  
SOC treatment (such as Concomitant medication, remdesivir (if approved and available) and 
ventilation techniques) will be documented in the eCRF and considered for evaluation for study 
data. SOC treatment follows the national guidelines (https://www.ersnet.org/covid-19-guide-
lines-and-recommendations-directory). 
The study will comprise two treatment groups as follows: 
• 
Group A (active):  
 
APN01 (5 mg/ml, 4 ml/vial) 
• 
Group B (placebo control):  sterile, 0.9% sodium chloride 

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Eligible patients are centrally allocated using a dynamic randomization (1:1) to Group A or B 
to receive the treatment or placebo. Dynamic randomization factors will be age in years (con-
tinuous) and center. The entire study team will be blinded expect for an unblinded pharmacist 
or an unblinded study team member (including team members involved in the IMP preparation, 
unblinded statisticians and DSMB members involved in DSMB, unblinded data managers in-
volved in generation and the upload of treatment listings to eCRF). .  Randomization will be 
carried out centrally using the electronic case report form (eCRF). 
After screening at day -1 and randomization at day -1 or 1, the patients will be treated with 
APN01 or Placebo intravenously twice daily (BID) every 12 hours (± 1 hour) over 3 to 30 
minutes in the morning and the evening until day 7. Preparation of APN01 (0.4mg/kg BID for 
seven calendar days) and placebo (normal saline) will be carried out according to the Phar-
macy Manual. The IMP will be administered in a double-blind manner (investigators, study 
team and patients will be blinded to the treatment administered).  
In the treatment period (day 1 to day 7) daily visits will be performed. If a patient will be dis-
charged from hospital before day 7 treatment can be stopped at day of discharge. After seven 
days of treatment or early discharge before day 7 the follow-up (FU) period starts. Three FU 
visits (day 10, 14 and 28) will be conducted to asses efficacy and safety. The study assess-
ments will be performed according to the study schedule (Table 1).   
8.2 
Discussion of Study Design, including the Choice of Control Groups  
The contagious coronavirus, named SARS-CoV-2 (formerly 2019-nCoV), which broke out at 
the end of 2019, has led to a medical emergency across the world, with the WHO officially 
declaring the novel coronavirus a pandemic on 11 March 2020 [1]. 
Whether or not the treatment with APN01 on top of SOC as approved in each country leads to 
a better outcome (assessed by using a composite outcome of all cause-death or invasive me-
chanical ventilation up to 28 days) is unclear. Therefore, this trial is of utmost importance.  
To this end APN01 (on top of SOC) will be compared with placebo (NaCl 0.9%) therapy (on 
top of SOC) in a double-blind clinical trial setting. This is scientifically the strongest possible 
design and ethically appropriate given the limited evidence for therapeutic options in the treat-
ment of patients with severe COVID-19. 
8.3 
Selection of Study Population 
The treatment is symptomatic and oxygen therapy represents the major treatment intervention 
for patients with severe infection. Therefore, effective therapies are needed to treat patients 
with severe COVID-19.  
Approximately 200 patients diagnosed to be COVID-19 POSITIVE will be enrolled in this study. 
Patients will be male or female and between ≥ 18 to ≤ 80 years of age. 
The patients must not be treated before all inclusion criteria (including test results) and none 
of the exclusion criteria are confirmed. Patients meeting all of the inclusion criteria and no 
exclusion criteria listed below will be included in the study: 
8.3.1 Inclusion Criteria 
1. Hospitalised male or female, ≥ 18 to ≤ 80 years of age at the time of consent. The date 
of signing informed consent is defined as the beginning of the screening period. This 
inclusion criterion will only be assessed at the first screening visit. 
2. Diagnosed to be COVID-19 POSITIVE (SARS-CoV-2 nucleic acid – qPCR)  
3. Oxygenation criterion 

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• Oxygen saturation ≤93 % (either on Room Air or while the patient is on supple-
ment oxygen) 
4. ALT < 5xULN; bilirubin ≤ 1.5xULN 
5. Signed informed consent form 
8.3.2 Exclusion Criteria 
1. Any patient for whom the investigator does not consider there is a reasonable expec-
tation that they will be able to complete the study. 
2. Known history of positive Hepatitis B surface antigen, Hepatitis C antibody or HIV anti-
body. 
3. Current or chronic history of liver disease (Child Pugh score ≥ 10), or known hepatic or 
biliary abnormalities (with the exception of Gilbert's syndrome or asymptomatic gall-
stones). 
4. The patient has participated in a clinical trial and has received an investigational prod-
uct within the following time period prior to the first dosing day in the current study: 
5 half-lives or twice the duration of the biological effect of the investigational product 
(whichever is longer). 
5. Patients requiring high doses of loop diuretics (i.e. > 240 mg furosemide daily) with 
significant intravascular volume depletion, as assessed clinically. 
6. History of sensitivity to any of the study medications, or components thereof or a history 
of drug or other allergy that, in the opinion of the investigator or Medical Monitor, con-
traindicates their participation. 
7. Pregnant females as determined by positive serum or urine hCG test prior to dosing. 
8. Lactating females. 
9. Unwillingness or inability to follow the procedures outlined in the protocol. 
10. Unstable Hemoglobin (Hb < 7) at time of drug infusion (i.e. Hb must be > 7 mg/dL at 
the time of drug infusion. Transfusion is permitted to increase Hb levels to allow entry 
into the study. 
11. Malignancy or other irreversible condition for which 6-month mortality is estimated to 
be >50% 
12. Arterial blood pH less than 7.2 or serum HCO3- <15 (if arterial blood gas (ABG) not 
available) before infusion is started. 
13. Known severe chronic pulmonary disease: 
• 
known FEV1/FVC less than 45% predicted, or 
• 
known chronic hypercapnia (PaCO2 > 45 mmHg) or chronic hypoxemia 
[(PaO2<55 mmHg) on FiO2 =0.21, or supplemental oxygen therapy prior to this 
admission], or 
• 
known FEV1 <15 ml/kg (e.g. 1L for 70 kg person), or 
• 
known radiographic evidence of chronic interstitial infiltration, or 
• 
known hospitalization within the past six months for respiratory failure (PaCO2 
> 50 mmHg or PaO2 < 55 mmHg, or oxygen saturation <88% on FiO2 = 0.21),  

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• 
known chronic restrictive, obstructive, neuromuscular, chest wall, or pulmonary 
vascular disease resulting in severe exercise restriction (i.e. unable to climb 
stairs or perform household duties), known secondary polycythemia, severe 
pulmonary hypertension, or ventilator dependency 
14. Known vasculitis with diffuse alveolar haemorrhage 
15. Lung transplantation 
16. Pre-existing renal failure, i.e. requiring renal replacement therapy with hemodialysis or 
peritoneal dialysis  
17. There are other uncontrolled comorbidities that increase the risks associated with the 
study drug administration, that are assessed by the medical expert team as unsuitable 
18. Patient in clinical trials with an IMP for COVID-19 within 30 days before signing in-
formed consent form (ICF) 
19. Unstable hemodynamics in the preceding 4 hours (MAP ≤ 65 mmHg, or 
SAP <90 mmHg, DAP < 60 mmHg, and vasoactive agents required) 
20. Immunocompromised patients (chemotherapy, HIV, organ transplants, stem cell trans-
plants) 
21. Receive any Angiotensin-Converting-Enzyme inhibitor (ACEi) or Renin inhibitor treat-
ment within 7 days before ICF  
8.3.2.1 Reproductive Potential 
The study population includes females of child-bearing potential (FOCP). A female is consid-
ered of childbearing potential, i.e. fertile, following menarche and until be-coming post-meno-
pausal unless permanently sterile. Permanent sterilisation methods include hysterectomy, bi-
lateral salpingectomy and bilateral oophorectomy. FOCP have to agree to comply with the 
applicable contraceptive requirements of the protocol as named below for the duration of the 
study or having post-menopausal status or be permanently sterilised (at least 6 weeks post-
sterilisation). 
Highly effective contraception is defined as a contraceptive method with failure rate of less 
than 1% per year when used consistently and correctly and when applicable, in accordance 
with the product label for example: 
• 
combined (estrogen and progestogen containing) hormonal contraception associated 
with inhibition of ovulation (oral, intravaginal, transdermal) 
• 
progestogen-only hormonal contraception associated with inhibition of ovulation (oral, 
injectable, implantable) 
• 
intrauterine device (IUD) 
• 
intrauterine hormone-releasing system (IUS) 
• 
bilateral tubal occlusion  
• 
vasectomized partner  
• 
sexual abstinence 
Condoms are to be used with the mentioned acceptable contraceptives. 
Male study participants need to comply with the contraceptive requirements given above as 
well. 

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FOCP with exclusively same-sex sex partners do not have to use highly effective/ acceptable 
birth control methods. 
8.3.3 Removal of Patients from Therapy or Assessment  
The study in its entirety may be discontinued prematurely by the Coordinating Investigator or 
Sponsor at any time (see below), and/or individual patients may terminate their participation 
prematurely, or have their participation be terminated by an Investigator. 
8.3.3.1 Withdrawal of Patients from the Clinical Trial 
The following circumstances may lead to discontinuation of the study by an individual patient 
who will then be recorded as a drop-out, include but are not limited to the following: 
• Withdrawal for personal reasons 
• AEs necessitating withdrawal from the clinical trial 
• Occurrence of a severe adverse reaction (SAR)  
• Sudden incidence of diseases 
• Circumstances in which the health of the patient would be endangered upon continued 
participation in the clinical trial 
• Lost to follow-up 
• Other (must be specified) 
If a patient withdraws from the study at any time either at his or her request or at the investi-
gator’s discretion, an “End-of-Study/Early Termination” visit should be performed and the “End 
of Study” eCRF section should be used to collect the relevant information. The visit may also 
be performed as a phone visit or in-home visit (in Russia). The reason(s) for withdrawal must 
be recorded on the relevant page of the patient’s eCRF and the patient’s source data. Patients 
discharged from hospital before day 28 will be contacted by telephone to asses if they are alive 
at day 28. 
It is vital to obtain follow-up data for any patient withdrawn from the study because of an AE. 
Every effort must be made to undertake protocol-specific safety follow-up procedures. If a pa-
tient is discontinued due to an AE, the event should be followed up until resolution or until the 
event becomes chronic.  
The Data Safety Monitoring Board may also recommend withdrawal of patients. 
8.3.3.2 Premature Treatment Discontinuation 
Patients must stop the IMP if the patient experiences any kind of hypersensitivity reaction. The 
patient may remain in the study and continue to attend study visits. 
Patients may be withdrawn from the IMP after initiation of infusion if in the opinion of the inves-
tigator or of the Medical Monitor there is a risk to the patient’s safety if they further receive IMP. 
If the patients are withdrawn from IMP, they may remain in the study and continue to attend 
study visits.  
IMP treatment can be stopped early if a patient will be discharged before day 7. 
8.3.3.3 Criteria for Termination of the Clinical Trial (Holding Rules) 
The trial will be supervised by an independent Data Safety Monitoring Board (DSMB). All final 
decisions, however, regarding study termination or modification will be decided by the Sponsor 
and in agreement with the independent DSMB. 

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The clinical trial will be terminated if  
• The DSMB requests termination of the clinical trial based on review of all clinical and 
laboratory data 
• The Sponsor, Regulatory Agency or an EC requests the termination of the clinical trial 
• 50% reduction in eGFR is observed. In addition, assessment of this parameter will be 
performed at the DSMB.  
8.3.3.4 Study Termination 
Individual study completion is defined as patients having finished the treatment period without 
early termination and reached the last visit within the specified window per the study schedule 
(Day 28; Table 1). 
Overall End of Study is defined as the date of last patient last visit (LPLV). Within 90 days after 
the End of Study the Coordinating Investigator and the Sponsor must inform regulatory author-
ities and ethics committees about the completion of the trial. 
The Sponsor may terminate the trial at any time for any reason and in particular if serious 
safety concerns rise for the patients. In the case of study termination, participating sites will be 
informed of the procedures to be followed to ensure that adequate consideration is given to 
the protection of the patient’s safety. 
The Sponsor has to inform the CAs and the ECs within 15 days. 
8.4 
Treatments 
8.4.1 Treatments Administered 
8.4.1.1 Experimental Intervention 
Administration of APN01 (on top of SOC) will be carried out according to investigators brochure 
(IB) and Pharmacy Manual. Dosing will be 0.4mg/kg twice a day (BID), administered for seven 
days, every 12 hours (± 1 hour). First dosing could either be in the morning of Day 1 or in the 
evening of Day -1. If a patient will be discharged before day 7, treatment can be stopped early 
at day of discharge. 
The IMP should only be administered if the staff, trained to evaluate and manage anaphylactic 
reactions, is immediately available, and in an environment where full resuscitation facilities can 
be assured. Each patient should be observed for adverse effects following APN01 administra-
tion. If hypersensitivity reactions or signs of intolerance occur during administration, the treat-
ment must be stopped immediately. Facilities for cardio-respiratory resuscitation and equip-
ment for handling acute anaphylactic/ anaphylactoid reactions should be available. Additional 
treatment with antihistamines and/or corticosteroids should be given as appropriate. 
8.4.1.2 Control Intervention 
Administration of Placebo (0.9% NaCl on top of SOC) is according to the dosing rules for 
APN01. 
8.4.1.3 Follow-up per patient 
After the treatment period of seven days or early discharge before day 7, a follow up period 
starts with visits on day 10, 14 and 28 to assess efficacy and safety. The study assessments 
will be performed according to the study schedule (Section 1, Table 1).   
For patients who are unable to attend regular study visits within the set time frame, unsched-
uled visits can additionally be planned outside of the visit time frame. 

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If a patient is already discharged from the hospital, the follow-up visits could be performed on 
an out-patient basis or at patient's home provided the patient agrees to that. 
8.4.1.4 Duration of Intervention per Patient 
The patients will be randomized in a 1:1 ratio to the following groups:  
• 
Group A (Test):  
APN01 (5 mg/ml, 4 ml/vial) 
• 
Group B (Placebo): 0.9% sodium chloride, sterile 
The treatment will be performed according to protocol and will be administered for seven days, 
BID every 12 hours (± 1 hour). In case patients will be discharged before day 7 treatment can 
be stopped early at day of discharge. 
8.4.2 Identity of Investigational Medicinal Products 
The IMP will be supplied by ABF Pharmaceutical Services GmbH, Austria. 
8.4.2.1 Test Product 
Active substances: 
Recombinant human angiotensin-converting enzyme 2 (rhACE2) 
APN01 
Strength 
Injection, 5 mg/mL, 4.0 mL/vial, supplied as a frozen liquid 
Dosage: 
 
0.4 mg/kg IV BID (every 12 hours ±1 hour for seven days) 
Route:  
 
intravenous (i.v.) over 3 to 30 minutes  
Administration: 
Intravenously of undiluted IMP using a polypropylene syringe with a 0.22 
micron filter, slow infusion 
Storage: 
 
-20°C (-15°C to -35°C), protected from light 
EU QP Release 
ABF Pharmaceutical Services GmbH 
Brunner Strasse 63/18-19 
1230 Vienna, Austria 
Additional information can be found in the IB. 
8.4.2.2 Placebo 
Active substance: 
NaCl 0.9% (normal/ physiological saline) 
Strength: 
 
10 or 100 mL container with 10 or 100 mL physiological saline 
Route:  
 
intravenous (i.v.) over 3 to 30 minutes  
Administration: 
 Intravenously of undiluted IMP using a polypropylene syringe with a 0.22 
micron filter 
Storage: 
 
As indicated on the label 
 
Additional information can be found in the Summary of Product Characteristics (SmPC) and 
the pharmacy manual. 

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8.4.2.3 Packaging & Labeling 
ABF Pharmaceutical Services GmbH will supply the IMP for the study. Test product is labeled 
in accordance with the applicable laws and GCP guidelines. Syringe with infusion solution for 
dose application will be labeled according to the instruction in the pharmacy manual. The phar-
macy manual contains detailed information about the necessary steps for preparation for indi-
vidual dose preparation. 
8.4.2.4 Dose preparation 
A pharmacist or unblinded member of the study team will be responsible for preparation of the 
treatment infusions. IMP will be withdrawn from the vial for individual dose preparation. The 
prepared dose in the syringe is stable for 8 hours at room temperature or 24 hours at refriger-
ated conditions (2-8°C). Detailed information about preparation of IMP can be found in the 
pharmacy manual. 
8.4.2.5 Storage 
The PI at each study site has the responsibility for ensuring that the IMP is stored under ap-
propriate conditions in a secure, limited-access location. IMP is distributed by the pharmacy or 
unblinded member of the study to a designed member of the study team. 
Study medication must be stored in accordance with labeled storage conditions -20°C (-15°C 
to -35°C), protected from light. Temperature monitoring is required at the storage location to 
ensure that the study medication is maintained within an established temperature range.  
8.4.2.6 Shipment 
The IMPs will be provided by ABF, Austria and or designee.  
8.4.2.7 Drug Accountability 
The PI at each study site has the overall responsibility for administering the IMPs.  
The investigator or a designee at the study sites will acknowledge receipt of the study medica-
tion documenting shipment content and condition. Damaged supplies will be replaced. Accu-
rate records of all study medication received, dispensed, used, returned or destroyed must be 
maintained. No study medication may be destroyed or returned from the investigational site 
without prior knowledge and written consent by the Sponsor. If such transfer is authorized by 
the Sponsor, all applicable local, state and national laws must be adhered to for the transfer. 
The PI, an investigator or a trained delegated member of the study team will administer the 
IMPs. All administrations will be documented in the site’s drug accountability log or other study 
drug record. The PI at the study site is responsible for assuring the retrieval of all dispensed 
study supplies from patients. 
At the end of the clinical trial or as instructed by the Sponsor all unused stock and empty used 
boxes are sent to a nominated contractor on behalf of the Sponsor. Study medication being 
returned to the Sponsor must be counted and verified by clinical investigational site personnel 
and the Sponsor or deputy. All certificates of delivery/drug receipts should be signed by the 
site representative to confirm contents of shipment. Shipment return forms must be signed 
prior to shipment by study site. Returned study medication must be packed in a tamper-evident 
manner to ensure product integrity. The Sponsor must give authorization to return any study 
medication prior to shipment. Shipment of all returned study medication must comply with local, 
state, and national laws. 

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Based on the entries in the site drug accountability logs, it must be possible to reconcile study 
medication delivered with those used and returned. One hundred percent of the study medi-
cation must be accounted for and all discrepancies investigated and documented. 
8.4.2.8 Patient Compliance 
Compliance must be assessed by an investigator 
For study medication administration at study site, compliance must be assessed by observa-
tion of dosing. Designated members of the study team will record details on the drug account-
ability log or other appropriate source documents. 
8.4.3 Method of Assigning Patient to Treatment Groups 
Randomization will be performed based on a variance minimization algorithm (dynamic ran-
domization). Patients will be assigned to a given treatment arm with a probability that takes in 
consideration the current arm assignments (8.4.8.1). Randomization will be done via the 
eCRF. Patients will be assigned a sequential randomization number by the eCRF.  
8.4.4 Selection of Doses in the Clinical Trial 
8.4.5 Dose selection is based on previous clinical experience.  
In the Phase IIa-ACE114622-Study with patients with acute respiratory distress syndrome (not 
in patients with COVID-19) dosing was 0.4 mg/kg BID over three consecutive days. The dose 
of APN01 in that study was sufficient to observe biological effect in enrolled patients, as evi-
denced by decreased plasma ang‐II and increased plasma ang1‐7 and ang1‐5. Moreover, de-
creases in plasma IL6 and increased SP‐D and a trend to lower plasma IL-6 were observed in 
patients assigned to the study drug, further indicating effect on biological endpoints potentially 
relevant to ARDS. Regarding the dosing schedule, the half‐life of rhACE2 is thought to be 9.6 
hours, such that twice daily dosing seems reasonable. 
The dose selected was largely based on previous experience with the drug, and more pre-
cisely on the study performed by Khan et al [8]. In addition, based on previous study findings 
no drug accumulation was observed with repeated dose administrations (either for 3 or 6 days; 
(Figure 15 of IB v 11.0). On this basis it seemed rational and safe to extend treatment duration 
to 7 days, as it appears that 7 days is the critical period for a potential recovery of lung func-
tions in ARDS patients [9,10, 11] 
The study by Khan gave drug for only 3 days because the goal of the study was different; 3 
days of dosing was felt to be sufficient to assess the basic pharmacology of the compound, 
initial safety in patients with ARDS, and possibly demonstrate a physiological effect. In this 
study, our goal is longer term outcomes. 
Looking to the antiviral activity described in Monteil et al (Cell, In Press) the virus can infect 
and replicate in human capillaries, and kidneys which likely explains shedding of the virus in 
these organs, potentially leading to multi-organ failure. While, it might be possible that a higher 
dose would be more effective in antiviral drug activity, the drug will be given to patients with 
varying degrees of viral load. In clinical practice during this pandemic, it is not possible to 
quickly measure the viremic viral load, and in fact many patients are not viremic. As such, we 
thought that from a safety perspective the dose given in the previous clinical trial would be the 
most appropriate for this Phase 2 trial. 

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8.4.6 Blinding and Unblinding 
The entire study team will be blinded expect for an unblinded pharmacist or an unblinded team 
member (including team members involved in the IMP preparation, unblinded statisticians and 
DSMB members involved in DSMB, unblinded data managers involved in generation and the 
upload of treatment listings to eCRF). IMP will be provided to the pharmacy or unblinded team 
in an unblinded manner. The PI will inform the pharmacist or unblinded member of the study 
team about the randomization of a new subject. The pharmacist or unblinded member of the 
study team will ascertain the treatment arm from the eCRF and provide the PI with the blinded 
treatment. In case of an emergency, patient treatment may be unblinded directly in the eCRF. 
The right to unblind treatment in the eCRF assigned to a given user role. Unblinding is per-
formed by opening the patient in the eCRF and clicking the “Emergency unblinding” link to 
activate the unblinding workflow. The time, date and reason for unblinding are captured in the 
eCRF. In addition, the unblinding will be documented in the respective “unblinding form”. Un-
blinding should be restricted to cases of emergency where knowledge of thy type of treatment 
is considered necessary for adequate treatment of the patient. The sponsor must be notified 
about any patient unblinded immediately. Breaking of the emergency code leads to the exclu-
sion of the respective patient.  
The randomization list will be exported and provided to statistician as part of the final data 
transfer. The randomization list will be archived as part of the final database archival package. 
8.4.7 Prior and Concomitant Therapy 
Prohibited treatment:  
Patients receiving ACE inhibitors, or renin inhibitors  
NOTE: angiotensin receptor blockers are not prohibited.  
Concomitant treatment:  
Any concomitant treatment given for any reason during the 
course of the study must be recorded on the eCRF and in the 
patient’s medical records, including dosage, start and stop dates 
and reason for use. 
8.4.8 Treatment Compliance  
8.4.8.1 Enrolment to the Clinical Trial 
A patient will only be enrolled in the trial if all inclusion and none of the exclusion criteria are 
met. A patient will only be admitted to the clinical trial if the ICF has been signed and all inclu-
sion and none of the exclusion criteria are met. Should there be any doubts as to the state of 
health, a patient will not be admitted to the clinical trial. 
8.4.8.2 Patient Identification 
The PI of each site will keep a record relating the patient numbers and the names of all patient 
that have given their informed consent, to allow easy checking of data in patient files, when 
required. This record will also include the date of the patient’s enrolment and completion, as 
well as patients who could not be included in the study for whatever reason. 
8.4.8.3 Early Termination 
All enrolled patients who discontinue early, or withdraw from the clinical trial will have the fol-
low-up assessments and procedures completed for their safety as outlined in Table 1. Patients 
who discontinue early or withdraw from the clinical trial will not be replaced as long as 200 
patients complete the study according to the protocol. 

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In some cases, it may be necessary for patients to return to the study site or will be contacted 
for a phone visit or in-home visit (in Russia) for additional care, confinement, and/or follow-up. 
Circumstances in which this may be necessary are:  
• 
Follow-up on abnormal laboratory evaluations 
• 
Follow-up on an ongoing AE at the final visit (day 28) and or final phone visit 
All additional safety follow-up visits will be at the discretion of the investigator, the PI and the 
Sponsor. 
8.4.8.4 Unscheduled Visits 
Unscheduled visits may be performed at any time during the clinical trial. Depending on the 
reason for the unscheduled visit (e.g., AE, abnormal laboratory values, ECG), appropriate as-
sessments will be performed based on the judgment of the investigator. Results of the assess-
ment and any changes in concomitant treatment will be recorded in the eCRF. After an un-
scheduled visit, the regular scheduled visits must continue according to the planned visit and 
assessment schedule. 
8.5 
Efficacy and Safety Variables 
8.5.1 Efficacy and Safety Measurements Assessed and Flow Chart 
Details regarding scheduled assessments and procedures to be conducted in this clinical trial 
are provided below. For detailed assessment schedules refer to Table 1. 
8.5.2 Appropriateness of Measurements 
8.5.2.1 Screening Procedures 
Written, signed, and dated informed consent from the patients prior to the performance of any 
clinical trial related procedures must be obtained by an investigator. A copy of the signed con-
sent form and the information sheet must be given to the patient for their records after signature 
and before enrollment. 
The time period between start of screening procedures and start of treatment must not exceed 
24 hours. In case the required screening procedures take less time, randomization and start 
of treatment could be performed also on the same day then screening.  Pre-dose events other 
than biomarker sampling and vital signs do not need to be performed if randomization and 
screening are on the same day. The following events will be performed: check of inclusion and 
exclusion criteria, obtaining medical history and demographics, score assessment of WHO’s 
11-point scale, PCR analysis, vital signs, physical examination, serum or urine pregnancy test, 
lab assessments, ECG, assessment of respiratory condition, mSOFA-score.  
See Table 1 for a complete list of screening procedures to be performed. 
Only an authorized and trained investigator may decide on the eligibility of the patient. 
8.5.2.1.1 Screening Failure  
A screening failure is defined as a patient who has given informed consent and failed to meet 
at least one inclusion or exclusion criteria or has not been administered IMP as defined by the 
protocol. 
8.5.2.1.2 Re-Screening of Patients 
Patients who fail to meet all inclusion/exclusion criteria will permitted to be re-screened once 
at a later timepoint.  

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8.5.2.2 Study Examinations 
Assessments are to be performed according to the schedule shown in Table 1. 
On Day -1/1 of the study schedule the assessments have to be performed prior dosing.  
Follow-up visit on Day 28 may be performed as a phone visit or in-home visit , where applicable 
. If a patient is already discharged from the hospital, the follow-up visits could be performed on 
an out-patient basis or at patient's home provided the patient agrees to that. 
8.5.2.2.1 Safety 
Safety will be evaluated by collecting reported AEs at regular intervals throughout the clinical 
trial and by the assessment of physical examination findings, vital signs, clinical laboratory 
parameters, and ECGs.  
 
8.5.2.2.2 Medical and Medication History 
A complete medical and medication history as well as demographic information will be as-
sessed at Screening. The medical history will be reviewed and recorded, including: 
Medical and Medication History for the least 4 weeks 
• 
Relevant recent ingestion of medication  
• 
History of respiratory, cardiovascular, renal, gastrointestinal, hepatic, endocrine, hema-
tological, neurological, psychiatric, musculoskeletal and other diseases 
Demographic information 
• 
Date of Birth 
• 
Sex 
• 
Height and weight 
• 
History of allergies  
• 
History of smoking and alcohol use 
• 
Body mass index (BMI) 
• 
Ethnicity 
8.5.2.2.3 Vital Signs 
The vital signs will be reviewed and recorded, including: 
• 
Temperature 
• 
Heart rate 
• 
Respiration 
• 
Blood pressure 
• 
Oxygen saturation.  
Vital signs need to be tested before and after each dose. 
All measurements of vital signs must be recorded in the appropriate source documents. 
8.5.2.2.4 Physical Examination  
A complete physical examination will be performed at the time points described in Table 1. 

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The physical examination will include a review of the following body systems:  
• 
General appearance 
• 
Skin 
• 
Head, Eyes, Ears, Nose and Throat  
• 
Spine/Neck/Thyroid 
• 
Musculoskeletal 
• 
Respiratory 
• 
Cardiovascular 
• 
Neurological 
• 
Abdomen (including liver and kidneys). 
• 
Relevant Co-Morbidities 
Any abnormalities or changes in intensity from the screening visit noted during the review of 
body systems should be documented in the medical record. If a new clinically significant ab-
normal finding (i.e. not noted at baseline) occurs after screening has been completed, it must 
be captured as an AE and documented on the source documents. In addition, resolution of 
any abnormal findings during the clinical trial will be noted in the medical record if clinically 
significant. 
Physical examination could also be documented in the context of the general visit/health status 
e.g. during a general clinical review assessment. 
8.5.2.2.5 Pregnancy test 
Appropriately performed using blood (serum) or urine test. 
8.5.2.2.6 Clinical Laboratory Assessments 
All laboratory assays will be performed according to the laboratory’s normal procedures. Ref-
erence ranges will be supplied by the laboratory and used to assess the laboratory data for 
clinical significance and out-of-range pathological changes. The physician should assess 
out-of-range laboratory values for clinical significance, indicating if the value(s) is/are not clin-
ically significant (NCS) or clinically significant (CS). Abnormal laboratory values that are unex-
pected or not explained by the patient’s clinical condition may be, at the discretion of the in-
vestigator, PI or Sponsor, repeated until confirmed, explained, or resolved as soon as possible.  
Details are defined in the Laboratory Manual. The following laboratory assessments will be 
performed:  
Bio-Chemistry 
Blood samples for biochemistry will be collected at the time points described in Table 1. The 
following parameters will be assessed:  
Aspartate aminotransferase (AST)  
Potassium (K)  
Alanine aminotransferase (ALT)  
Sodium (Na) 
Alkaline phosphatase (AKP)  
Albumin (ALB) 
Total bilirubin (TBl) 
Urea nitrogen (BUN)  
Total protein (TP)  
Creatinine (Cr) 

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Uric acid (UA)  
eGFR (assessment is calculated according 
to the formula used in local laboratory) 
Hematology / Blood Routine 
Blood will be drawn at the time points described in Table 1. The following parameters will be 
assessed: 
Red blood cell (RBC) count 
Hemoglobin (Hb)  
Hematocrit (HCT) or hematocrit total 
Platelet (PLT) count  
Classification of white blood cells (WBC)  
 
Inflammatory Indicators 
Blood will be drawn at the time points described in Table 1. The following parameters will be 
assessed: 
C- reactive protein (CRP)  
ESR  
Procalcitonin 
Urinalysis 
pH (PH) 
 
Urinary Protein (PRO) 
Blood (red blood cells (BLD) and white blood cells (LEU)) 
Glucose (GLU) 
Microscopic examination (if blood or protein is abnormal) 
Stool routine and occult blood 
The following parameters will be analyzed in fresh stool: 
 
Red blood cells (RBC) 
Occult blood 
White blood cells (LEU) 
 
Myocardial enzymes 
The following parameters will be analyzed: 
 
creatine kinase (CK)  
[alpha] - hydroxybutyrate dehydrogenase ([alpha]-HBD) 
and isoenzyme (CKMB) 
Troponin (cTnI) 
lactate dehydrogenase (LDH) 
 
Coagulation function 
To assess the coagulation function, the following parameter will be analyzed: 
 
Prothrombin time (PT)  
D-dimer 
Activated partial thromboplastin time (APTT)  
FIB 
Assessment of Immune function 
To assess the immune function the following parameter will be analyzed: 

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 COVID-19 Antibodies  
Immunoglobulin (IgG, IgA, IgM) 
Serology 
During the screening period only, 1 or 2 blood samples will be drawn to test for the presence 
of HIV, HBsAg, and HCV antibody. 
HIV testing (HIV I and HIV II) 
HCV antibody screen 
HBV testing (HBsAg) 
 
8.5.2.2.7 Biomarker 
Per collection of whole blood, the following biomarkers will be analyzed (12 ml):  
One Li-Heparin blood collection tube (5-6 ml): 
Plasma equilibrium angiotensin levels: 
 
 
Angiotensin II (Ang II) 
 
Angiotensin 1-7 (Ang. 1-7)  
 
Angiotensin 1-5 (Ang 1-5) 
 
Angiotensin I (Ang I) 
 
Angiotensin 1-9 (Ang 1-9) 
 
Aldosterone 
 
ACE2 Activity and ACE2 concentration 
 
Cardiac pump function markers: NT-proBNP, 
Ferritin  
 
Other exploratory indicators: specific exploratory indicators will be determined as needed. 
One EDTA blood collection tube (5-6 ml): 
Plasma-Renin-Concentration (PRC) 
 
Cytokines: 
 
 
Interleukin- 6 (IL-6) 
 
Interleukin- 8 (IL-8) 
 
Soluble tumor necrosis factor receptor II (sTNFrII) 
 
PAI-1 
 
vWF   
 
Tumor necrosis factor - α 
 
Alveolar epithelial markers: 
 
Soluble advanced glycation product receptor (sRAGE) 
 
Surface-active protein-D (SP-D) 
 
Endothelial markers: 
 
Angiopoietin-2 
 
Viral load 
 

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8.5.2.2.8 Electrocardiogram 
A 12-lead ECG will be performed within 30 min after IMP administration (Table 1). Actual ECG 
assessment times will be monitored. 
At a minimum, the date and time of when the event was performed, the investigator’s assess-
ment and the heart rate, RR, PR, QT, and QRS intervals are to be collected. All clinically 
significant abnormalities will be recorded on the appropriate source documents. 
8.5.2.2.9 Assessment of Respiratory Condition  
To assess the respiration of the patient a blood gas analysis (oxygenation index, blood lactic 
acid) or pulse oximetry will be performed (Table 1). 
Detailed information is provided in the Investigator Manual. 
8.5.2.2.10 WHO 11-point scale 
The WHO Clinical Progression Scale (WHO-CPS) measures patient illness by tracking pro-
gress through the healthcare system. The WHO-CPS incorporates a number of explicit fea-
tures that are advantageous for its use in in emerging infectious disease epidemic. It provides 
a measure of illness severity across an 11 point range from 0 (not infected) to 10 (dead) (Annex 
1). 
8.5.2.2.11 Modified Sequential Organ Failure Assessment (mSOFA) score 
The mSOFA score [12] is made up of the following components: 
• 
SpO2/FiO2 (mmHg) 
• 
Central Nervous System: Glasgow coma score (GCS) 
• 
Cardiovascular 
• 
Liver 
• 
Platelets 
• 
Renal: Creatinine  
Detailed information is provided in the Investigator Manual. 
8.5.2.2.12 Patient status assessment 
Patient status assessments includes the documentation of the following: no change, dis-
charge from hospital, transition to critical illness, and death. 
8.5.2.2.13 Adverse and Serious Adverse Events Assessments 
The investigator is responsible for ensuring that all adverse events observed by the investiga-
tor or reported by patient are properly captured in the patients' medical records. 
Adverse events will be recorded in the AE page of the eCRF using a recognized medical term 
or diagnosis that accurately reflects the event. 
All AEs will be reviewed, confirmed, and classified (causality and seriousness) by a qualified, 
designated physician. 
Pre-existing conditions that are present at screening are not defined as adverse events. These 
should be documented as medical history. Nevertheless, an AE will be documented in case of 
a worsening of severity of a pre-existing condition. AEs reported between screening and IMP 
application are defined as pre-treatment AE. 

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8.5.2.2.13.1 Definition of Adverse Events, Period of Observation, Recording of Adverse 
Events  
An AE is any untoward medical occurrence in a clinical investigation patient administered a 
pharmaceutical product and that does not necessarily have a causal relationship with this treat-
ment. An AE can therefore be any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom, disease or exacerbation of a pre-existing condition temporally 
associated with the use of a medicinal (test) product, whether or not considered related to the 
medicinal product (ICH Guidance E2A 1995). 
All AEs, including those associated with the IMP, are collected from the time of first dose ad-
ministration, regardless of the relationship to the IMP. All AEs are to be recorded on the ap-
propriate source documents and subsequently will be entered into the AE module of the eCRF. 
All AEs have to be recorded until the last trial day according to the clinical trial protocol. If the 
investigator becomes aware of a serious AE considered related to the IMP, it has to be reported 
(pharmacovigilance@ctc-north.com) even if it occurs after finalization of the clinical trial.  
All AEs must be followed to closure (i.e. the patient’s health has returned to his/her baseline 
status or all variables have returned to normal), an outcome is reached, stabilization (the in-
vestigator does not expect any further improvement or worsening of the event), or the event is 
otherwise explained regardless of whether the patient is still participating in the clinical trial and 
clinical judgment indicates that further follow-up is not warranted. When appropriate, medical 
tests and examinations are performed so that resolution of event(s) can be documented. 
Moreover, elective procedures (planned at time of randomization, e.g. catheter intervention of 
a coronary stenosis) will be determined as expected AE. 
8.5.2.2.13.1.1 
Severity Categorization 
The severity of AEs must be recorded. If the severity of an AE/SAE changes, or if there are 
any other changes they must be made within the same AE record. Also, only the highest se-
verity needs to be recorded. Worsening of pre-treatment events from the medical history, after 
initiation of IMP treatment, must be recorded as new AEs. 
The medical assessment of severity is determined by using the following definitions: 
Mild: 
Symptom barely noticeable to patient; does not influence performance or function-
ing. Prescription drug not ordinarily needed for relief of symptom but may be given 
because of personality of patient. 
Moderate: Symptom of a sufficient severity to make patient uncomfortable; performance of 
daily activities influenced: patient is able to continue in clinical trial; treatment for 
symptoms may be needed. 
Severe: 
Symptom causes severe discomfort. May be of such severity that patient cannot 
continue in clinical trial: Severity may cause cessation of treatment with test drug; 
treatment for symptom may be given and/or patient hospitalized. 
The term “severe” is here used to describe the severity/intensity of the specific event; it is not 
the same as “serious”, which is based on patient/event outcome or action criteria. 
8.5.2.2.13.1.2 
Relationship Categorization 
An investigator assesses each AE for its relationship to the IMP. 

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The assessment of the relationship of an AE to the administration of IMP is a clinical decision 
based on all available information at the time of and after the occurrence of the event. The 
factors which may be considered when evaluating the relationship of an AE to the IMP include: 
time from exposure to IMP until onset of the event; recovery or improvement on discontinuation 
of IMP; availability of alternative explanations such as underlying or intercurrent diseases; con-
comitant medications or treatments; pharmacology of the IMPs; known response pattern for 
this class of drug; recurrence on reintroduction of the IMP. 
If there is no reasonable possibility for suggesting a relationship, then the AE should be clas-
sified as ‘not related’. The adverse event should be classified as related if a reasonable possi-
bility of a causal relationship between the event and IMP exists. This means that there are 
facts (evidence) or arguments to suggest a causal relationship. The causality must be docu-
mented in the source document and eCRF. 
The following additional guidance may be helpful: 
Term 
Relationship 
Definition 
Related – 
Reasonable 
possibility  
Yes 
The temporal relationship between the event and the 
administration of the IMP is compelling and/or follows a 
known or suspected response pattern to that product, 
and the event cannot be explained by the patient’s med-
ical condition, other therapies, or accident. 
Not Related – 
No reasonable 
possibility  
No 
The event can be readily explained by other factors 
such as the patient’s underlying medical condition, con-
comitant therapy, or accident and no plausible temporal 
or biologic relationship exists between the IMP and the 
event. 
 
8.5.2.2.13.1.3 
Outcome Categorization 
The outcome of AEs must be recorded during the course of the clinical trial in the eCRF. Out-
comes are as follows: 
• 
Recovered/Resolved 
• 
Recovering/Resolving 
• 
Not recovered/Not resolved/ongoing 
• 
Recovered/Resolved with sequelae 
• 
Fatal 
• 
Unknown 
8.5.2.2.13.1.4 
Clinical Laboratory Evaluations 
A change in the value of a safety laboratory investigation can represent an AE if the change is 
clinically relevant or if, during treatment with the IMP, a shift of a parameter is observed from 
a normal value to an abnormal value, or a further worsening of an already abnormal value. 
When evaluating such changes, the extent of deviation from the reference range, the duration 
until return to the reference range, either while continuing treatment or after the end of treat-
ment with the IMP, and the range of variation of the respective parameter within its reference 
range, must be taken into consideration. 

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If, at the end of the treatment phase, there are abnormal laboratory values which were not 
present at baseline, further clinical or laboratory investigations should be performed until the 
values return to within reference range or until a plausible explanation (e.g., concomitant dis-
ease) is found for the pathological laboratory values. 
Changes in laboratory values that are clinically significant (cs) and are specific for COVID-19 
do not need to be documented as adverse events (AE). Clinically significant changes in labor-
atory values that are not due to COVID-19 need to be documented as AEs. 
 
The physician should decide, based on the above criteria and the clinical condition of a pa-
tient, whether a change in a laboratory parameter is clinically significant and therefore repre-
sents an AE.  
8.5.2.2.13.1.5 
Overdose and Medication Error  
Overdose, or medication error (as defined below) must be reported to the Sponsor according 
to the SAE reporting procedure whether or not they result in an AE/SAE.  
Overdose - Intentional or unintentional administration of a dose of study medication higher 
than the protocol prescribed dose for each patient. 
Medication Error - A mistake made in administration, and/or use of the study medication. For 
studies, medication errors are reportable only as defined below. 
Administration of an expired product should be considered as a reportable medication error 
when associated with an AE, or if otherwise appropriate. 
Cases of patients missing doses of study medication are not considered reportable as medi-
cation errors. 
8.5.2.2.13.2 
Serious Adverse Event (SAE) Procedures 
8.5.2.2.13.2.1 
Reporting Procedures 
All initial SAE reports must be reported by the investigator to the Sponsor’s Pharmacovigilance 
Department immediately, without undue delay, under no circumstances later than 24 hours 
following the first awareness of the event. All SAE follow-up reports must be reported in a 
timely manner. The investigator must complete, sign, and date the SAE form and verify the 
accuracy of the information recorded on the form with the corresponding source documents 
(Note: source documents are not to be sent unless requested) and e-mail the form to the 
Sponsor’s Qualified Person for Pharmacovigilance: 
Name:  
 
 
CTC North Safety Desk 
Phone: 
 
 
+49 40 524719-225 
Email:  
 
 
pharmacovigilance@ctc-north.com  
8.5.2.2.13.2.2 
Serious Adverse Event Definition 
A SAE is any untoward medical occurrence (whether considered to be related to IMP or not) 
that follows the first IMP administration at any dose: 
• Results in death 
• Is life-threatening 
NOTE: The term ‘life-threatening’ in the definition of ‘serious’ refers to an event in 
which the patient was at risk of death at the time of the event; it does not refer to an 
event which hypothetically might have caused death if was more severe. 

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• Requires inpatient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability/incapacity 
• Is a congenital abnormality/birth defect 
• Is an Important Medical Event; 
NOTE: Medical and scientific judgement should be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the patient 
or may require intervention to prevent one of the other outcomes listed in the definition above. 
These should also usually be considered serious. 
8.5.2.2.13.2.3 
Pregnancy 
Any report of pregnancy recorded for any female patient or for a female partner of a male 
patient should be reported to the Sponsor within the same timelines as an SAE, i.e. immedi-
ately (without undue delay, under no circumstances later than 24 hours following the first 
awareness/ within 30 days of IMP administration), but a separate form should be used. Preg-
nancy should be followed up at least until the birth or abort. 
8.5.2.2.13.2.4 
SAE Onset and SAE Stop Dates 
The onset date of the SAE is defined as the date the event meets serious criteria. The stop 
date is the date the event no longer meets serious criteria, the date the symptoms resolve, or 
the event is considered chronic. In the case of hospitalizations, the hospital admission and 
discharge dates are considered the onset and SAE resolution dates, respectively.  
8.5.2.2.13.2.5 
Fatal Outcome 
Any SAE that results in the patient’s death (i.e. the SAE was noted as the primary cause of 
death) should have Outcome „Fatal” and the date of death recorded as the stop date of the 
SAE. 
For all other events ongoing at time of death that did not contribute to the patient’s death, the 
outcome should be considered unknown, with the SAE stop date (date of death) recorded. 
For any SAE that results in the patient’s death or any ongoing events at the time of death, the 
action taken with the IMP should be recorded as “dose not changed” or “not applicable” (if the 
patient never received IMP). 
8.5.2.2.13.2.6 
Regulatory Agency, Ethics Committee, and Investigative Site Report-
ing 
The Sponsor is responsible for Suspected Unexpected Serious Adverse Reaction (SUSAR) 
reporting to the relevant Regulatory Authorities/European Union (EU), central Ethics Commit-
tees and investigators participating in the clinical trial in compliance with the legal reporting 
obligations.  
The expedited reporting will occur not later than 15 days after the Sponsor has first knowledge 
of the adverse reactions. For fatal or life-threatening cases the term will be maximal 7 days for 
a preliminary report with another 8 days for completion of the report.  

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8.5.3 Primary Efficacy Variable(s) 
8.5.3.1 Outcome Measures 
For the primary outcome a composite outcome of all cause-death or need of invasive mechan-
ical ventilation up to 28 days is used. For the secondary outcome (powered secondary end-
point) log transformed levels of Lactate dehydrogenase (LDH) as a surrogate marker for organ 
damage are used.  
8.5.3.2 Safety Variables  
Assessment of safety is performed for the safety set. Safety data include: 
• 
AEs (including changes from baseline in physical examination findings)  
• 
Clinical laboratory results  
• 
Vital signs  
• 
12-lead ECGs  
The safety evaluation will be based upon the review of the individual values (potentially clini-
cally important abnormalities) and descriptive statistics (summary tables, graphics).  
8.5.3.2.1 Adverse Events 
The AEs will be listed per patient using MedDRA terminology (lower level term, preferred term 
and system organ class) and will be reported in tables summarizing the frequency of patients 
with AEs and AEs by treatment and body system, the number of AEs and patients with AEs by 
treatments and the characteristics of AEs. 
For the hematology, clinical laboratory and the urine analysis deviations from the reference 
ranges will be summarized in frequency tables. 
8.5.3.2.2 Clinical Laboratory 
All relevant clinical variables obtained during screening, final examination or the clinical trial 
periods will be reported in appropriate tables together with descriptive statistics. Clinical labor-
atory findings outside of the reference range will be flagged. 
8.5.3.2.3 Vital Signs 
For blood pressure and pulse rate descriptive statistics will be listed by sampling times (screen-
ing and follow-up) according to the data reported in the source documents. 
8.5.3.2.4 ECG 
The results of the 12-lead ECG will be listed by sampling times (screening and follow-up) ac-
cording to the data reported in the source documents. 
8.6 
Data Quality Assurance 
8.6.1 Quality Assurance System 
Clinical trial management activities including medical writing, regulatory submission and com-
munication, monitoring, data management and eCRF development and safety management 
will follow the Standard Operating Procedures (SOP) of the CTC North or CTC North subcon-
tractors. Statistical analysis and clinical study report writing will follow the SOPs of FGK. 
The quality management system of the CTC North and FGK has been repeatedly audited by 
sponsors as well as by local authorities.  

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Standard phases of the study may be subject to audits by the quality assurance unit (QAU) of 
the Sponsor or CTC North.  
8.6.2 Monitoring 
CTC North is responsible for the overall monitoring of the clinical trial. Local partners will be 
subcontracted to ensure source data verification in local languages (Denmark and UK). Local 
CROs will be responsible for the monitoring in the US and Russia. Site qualification and site 
initiation visits will be performed as phone visits. A combination of remote monitoring and reg-
ular on-site visits will be performed depending on the possibility for on-site visits due to the 
current COVID-19 pandemic. Close-out visits are planned as on-site visits. The frequency and 
kind of monitoring visits will depend on the study site’s recruitment rate and current situation 
in each country/study site. The detailed extent of the monitoring and the risk based approach 
considering the COVID-pandemic situation and its influence on the daily life and the health 
system will be defined in the overall monitoring plan applicable for all countries and in Annex 
2. 
8.6.3 Documentation and Data Collection 
An eCRF will be prepared to report all data required by the protocol.  
Site staff will transfer the study data from the source documents into the eCRF and will check 
eCRF entries for completeness. Completed eCRF modules will be electronically signed by an 
Investigator in order to ensure data entry accuracy. 
Corrections to source data documents will be dated and initialed. Reasons for the corrections 
should be given. Corrections to eCRF entries must be electronically signed and reasons for 
the corrections must be provided. The date on which the correction was performed is automat-
ically recorded by the system's audit trail.  
A study monitor will review source data and the eCRF data for completeness and accuracy 
during the monitoring visits (source data verification (SDV)). The study monitor will point out 
discrepancies between source data and the data captured in the eCRF. The monitor will issue 
electronic queries to site staff in order to initiate discrepancy resolution. Discrepancies which 
require eCRF data corrections have to be resolved by authorized site personnel by answering 
the queries and changing the respective eCRF entries. These query management and query 
resolution activities are also automatically recorded by the system’s audit trail.  
8.6.4 Data Management 
Data management will check predefined eCRF entries as defined in the data management 
plan (DMP) and data validation plan (DVP). 
Quality control (QC) and data validation procedures such as programmed automatic edit and 
consistency checks ensure data validity and accuracy immediately at the point of entry into the 
clinical database. The database application which is used to capture electronic clinical trial 
data is fully CFR part 11 compliant. Thus, it is access restricted, requires electronic signatures, 
maintains an electronic audit trail and provides appropriate back-up functionalities. Details of 
the application and eCRF configuration and all further data management procedures will be 
described in the DMP. 
The database will only be locked after all queries and discrepancies have been resolved. 
After database lock, the data in the study database will be exported and transferred electroni-
cally to the responsible biometrician for statistical analysis. The export will be used to generate 
the patient listings, tabulations, and analyses. 

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Upon request safety and other reports will be generated and provided by DM to the respective 
members of the DSMB. 
8.6.5 Archival of Documents 
Sponsor will maintain the trial documents as specified in the ICH-GCP guideline and take 
measures to prevent accidental or premature destruction of these documents. 
All documents related to the clinical trial will be retained until at least 15 years after the end of 
the clinical trial.  
8.7 
Statistical Methods Planned in the Protocol and Determination of Sample Size 
8.7.1 Statistical and Analytical Plan 
Details for the statistical evaluation of the results will be given in a separate statistical analysis 
plan. 
8.7.1.1 Software to be used 
All statistical calculations will be carried out using SAS language and procedures (SAS 8.2 or 
higher version SAS-Institute, Cary NC, USA). 
8.7.1.2 Eligibility for Statistical Evaluation 
Eligibility of patients will be determined within the data review meeting (blind data review meet-
ing, DRM). 
8.7.1.2.1 Safety Analysis Set (SAF) 
All randomized patients who received study medication (independent of whether it is APN01 
or placebo) will be valid for the SAF. The SAF will be used for the evaluation of the safety 
assessments (as treated). 
8.7.1.2.2 Full Analysis Set (FAS) 
The FAS includes all randomized subjects. The FAS serves as the primary efficacy analysis 
set (as randomized). 
8.7.1.2.3 Per-Protocol Analysis Set (PP) 
The PP includes all subjects included in the SAF who had no significant protocol deviations 
and completed through Day 28 or until discharge from the hospital (end of study follow-up). 
The PP will only be analyzed for main efficacy outcome measures (as treated). 
8.7.1.2.4 Statistical Analysis 
Continuous variables will be summarized with means, standard deviations, medians, lower and 
upper quartiles, minimums and maximums. Frequencies and percentages will be used to sum-
marize categorical variables. 
For time-to-event analyses censoring information will be used. 
It is assumed that no patients will discontinue the study early prior to day 28 or hospital dis-
charge in this Covid-19 setting. It is also assumed, that only very few missing values will arise 
due to not done evaluations. No imputation of missing values (e.g., no last observation carried 
forward (LOCF)) is planned, unless stated otherwise. 
8.7.1.2.5 Primary and Secondary Endpoints 
Analysis of primary efficacy endpoint 

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The primary endpoint of this trial is a composite of all cause-death or any use of invasive 
mechanical ventilation up to 28 days or hospital discharge. 
Invasive mechanical ventilation is defined as patients who are intubated or have a tracheost-
omy tube and are receiving positive pressure ventilation. Patients who will be discharged from 
hospital before day 28 will be considered as non-event after confirmation by telephone inter-
view that they are alive at day 28. Patients who will be discharged from hospital or early termi-
nated before Day 28 will be considered having an event on the day of discharge or early ter-
mination, if a telephone interview was not possible and/or no information about alive/death 
status is known. 
Hypothesis to be tested: 
H0: pAPN01 = pPlacebo  
H1: pAPN01 ≠ pPlacebo 
H0 will be tested using a Chi-squared test. The level of significance is 5% (two-sided). In ad-
dition, logistic regression analyses will be conducted considering additional co-factors (will be 
detailed in the statistical analysis plan).   
Analysis of secondary efficacy endpoints 
Secondary efficacy variables will be tested descriptively and in an exploratory manner. 
1. Log transformed levels of Lactate dehydrogenase (LDH) at day 5 as a surrogate marker 
for organ damage 
Log transformed levels of LDH will be analyzed using linear regression adjusted for 
baseline log levels of LDH, center and minimization factors. 
95% confidence intervals will be additionally calculated. 
Statistical procedures to check on a normal distributed of data, to be applied in case of 
non-normally distributed data, and to verify and handle minimization factors will be de-
scribed in the statistical analysis plan, which will be finalized prior to unblinding.   
2. 28-day mortality (all cause death) 
The percentage of patients who have died at Day 28 will be presented by treatment 
group. Patients who will be discharged from hospital or early terminated before Day 28 
will be considered having an event on the day of discharge or early termination, if a 
telephone interview was not possible and/or no information about alive/death status is 
known. The Chi-squared or Fisher’s exact test will be used to compare proportions. 
95% CIs will be additionally calculated. Logistic regression analyses will be conducted 
considering additional co-factors (will be detailed in the statistical analysis plan). 
3. Ventilator-free days (VFD) up to 28 days or hospital discharge 
VFD will be analyzed for both all patients as well as for the subgroup of patients who 
were alive at Day 28 or hospital discharge. For the analysis of all patients separate 
analyses will be conducted for patients who died: a) VFD will be set to 0, b) the ob-
served VFD until death will be considered. Summary tables will be generated the VFD 
will be compared using Wilcoxon rank sum test. In addition, bootstrap methods will be 
applied to calculate 95% confidence intervals and two-sided p-values for the difference 
in means. 
4. Proportion of responders, defined as ≥2 improvement in WHO’s 11-Point Score system 
at day 7, 10, 14 and 28 

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Similar analyses as for 28-day mortality will be conducted. 
5. Time to death (all cause) will be analyzed using Kaplan-Meier estimates and plots, log-
rank test, and Cox proportional hazards model (adjusted for minimization factors to 
derive hazard ratios and corresponding 95% confidence intervals). Patients who will be 
alive at Day 28, or who will be discharged from hospital before day 28 with no infor-
mation on death until day 28, will be censored at discharge if they cannot be reached 
at or after day 28 by means of a telephone interview. Further details will be described 
in the statistical analysis plan.  
6. Proportion of patients with any use of invasive mechanical ventilation up to 28 days or 
hospital discharge 
Similar analyses as for 28-day mortality will be conducted. 
7. Time to first use of invasive mechanical ventilation up to 28 days or hospital discharge 
Similar analyses as for time to death will be conducted. Patients without invasive me-
chanical ventilation will be censored on the last day of evaluation. For patients who died 
the observed time to first use of invasive mechanical ventilation will be considered; if a 
patient who died did not receive any mechanical ventilation, the patient will be censored 
on time of death. 
8. Absolute values and absolute change in P/F ratio over time 
The PF ratio is defined as PaO2 [mmHg] divided by FiO2 in [%] and will be evaluated 
on each visit. Summary statistics for the PF ratio for both the absolute values and the 
absolute change from Baseline (day 1) will be tabulated. 
9. Absolute values and absolute change in the modified Sequential organ failure assess-
ment score (mSOFA score) over time 
Similar analyses as for the PF ratio will be conducted. 
10. Time to a 2-point decrease in WHO scoring scheme.  
Similar analyzes as for 28-day mortality will be conducted. Patients without ≥2 improve-
ment in WHO’s 11-Point Score system will be censored on the last day of WHO scoring 
evaluation. For patients who died the observed time to a 2-point decrease until death 
will be considered; if a patient who died no 2-point decrease was observed, the patient 
will be censored on time of death. 
11. Absolute values and absolute change in lymphocyte counts over time 
Summary statistics for both the absolute values and the absolute change from Baseline 
(day 1) will be tabulated. 
12. Absolute values and absolute change in C-reactive protein levels over time  
Summary statistics for both the absolute values and the absolute change from Baseline 
(day 1) will be tabulated. 
13. Absolute values and absolute change in D-dimer over time  
Summary statistics for both the absolute values and the absolute change from Baseline 
(day 1) will be tabulated (prognostic information: Zhou et al. Lancet 2020). 
14. Absolute values and absolute change in log transformed levels of LDH over time  
Summary statistics for both the absolute values and the absolute change from Baseline 
(day 1) will be tabulated. 
15. Time to hospital discharge   

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Similar analyses as for time to death will be conducted. Patients without hospital dis-
charge will be censored on the last of hospital stay. Patients who died in the hospital 
will be censored on the day of death. 
16. Change in viral RNA over time  
Summary statistics for both the absolute values and the absolute change from Baseline 
(day 1) will be tabulated. 
8.7.1.2.6 Biomarker Endpoints 
Biomarker endpoints will be analyzed using summary statistics at each scheduled measuring 
time point for absolute values and for absolute change from baseline values. No statistical 
testing procedures will be applied to Biomarker analyses. 
1. Angiotensin II (Ang II), Angiotensin 1-7 (Ang 1-7), Angiotensin 1-5 (Ang 1-5), renin 
and aldosterone, Angiotensin-converting enzyme (ACE), Angiotensin-converting en-
zyme 2 (ACE2), Angiotensin I (Ang I), Angiotensin 1-9 (Ang 1-9), 
2. Cytokines: Interleukin 6 (IL-6), Interleukin 8 (IL-8), Soluble tumor necrosis factor re-
ceptor type II (sTNFrII), Plasminogen activator inhibitor type-1 (PAI-1), von Willebrand 
factor (vWF), Tumor necrosis factor-α (TNF-α) 
3. Alveolar epithelial markers: Soluble receptor for advanced glycation end products 
(sRAGE), Surfactant protein-D(SP-D) 
4. Endothelial markers: Angiopoietin-2 
5. Change in clinical laboratory markers associated with poor outcome over time (e.g., 
lymphocyte counts, CRP, D-dimers, hsTnI (high sensitivity troponin)) 
6. NT-proBNP 
8.7.1.2.7 Safety Endpoint 
The safety evaluations will include analyses of AEs and SAEs, changes in vital signs, clinical 
laboratory assessments and in ECG parameters. The analysis of safety will be based on the 
SAF. 
AEs 
Pre-treatment AEs will be analyzed separately based on all patients included into the trial. AEs 
will be summarized by system organ class and preferred term according to Medical Dictionary 
for Regulatory Activities (MedDRA). The number of events, as well as the number and rate of 
affected subjects will be reported. AEs (system organ class and preferred term) will also be 
summarized by seriousness, by severity and by relationship to study medication. No statistical 
testing procedures will be applied to the analysis of AEs.  
Individual patient data listings will be provided for all deaths, patients with other SAEs, unex-
pected adverse drug reactions (as confirmed by the sponsor’s drug safety manager), discon-
tinuation of IMP due to AEs, or premature trial termination due to AEs. 
Vital signs 
For vital signs, body temperature and body weight standard descriptive summary statistics will 
be calculated at each scheduled time point 
Furthermore, standard descriptive summary statistics will be computed for the absolute change 
from baseline to each scheduled visit up to the last individual time point  
Laboratory measurements 

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Laboratory data will be subjected to both a quantitative analysis (descriptive summary statis-
tics) and qualitative analysis where frequencies of normal, above normal and below normal 
values will be computed. 
The following analyses will be performed: 
• 
Standard descriptive summary statistics will be calculated at each scheduled measur-
ing time point  
• 
Standard descriptive summary statistics will be calculated for the absolute change from 
baseline to each scheduled visit  
• 
Frequencies of normal, above normal, and below normal values will be computed at 
each scheduled measuring time point  
• 
Shift tables displaying changes with respect to the normal range between baseline and 
each scheduled visit will be provided 
• 
A listing of all patients with abnormal (above normal or below normal) values at any 
time point will be given 
Findings from ECG (12-lead) 
Frequencies for the respective categories of (ab)normality will be tabulated. 
A patient data listing of all clinically significant abnormal ECG values will be provided. 
8.7.2 Determination of Sample Size 
186 patients (93 per group) will yield 80% power to detect a 20% absolute risk reduction in the 
primary composite endpoint, from 50% in the placebo group to 30% in the APN01 group at a 
two-sided alpha of 0.05 when applying a two group Chi-Squares test. To consider patients who 
will be randomized but not treated a total of 200 patients (100 per group) will be enrolled. 
9 
CHANGES IN THE CONDUCT OF THE CLINICAL TRIAL OR PLANNED ANALYSIS 
Modifications of the protocol are permitted only if they are authorized by the Sponsor and the 
PI in writing.  
Deviations and changes to the study protocol will be classified by the Sponsor and the clinical 
trial center as: 
Note-to-File: This refers to clarifications which are not considered changes of the protocol. 
Study protocol amendment: This refers to changes of the protocol. If they fulfill the criteria as 
set out in the appropriate law, they need to be approved by the Ethics Committee(s) or the 
Competent Authority(ies) or both of them. Changes to the study protocol may also induce re-
vision of the patient information sheet/informed consent form. Accordingly, patients undergoing 
trial assessment procedures at the time of implementation of the change have to be given the 
amended version and have to be asked for consent to continue in this amended trial.  
9.1 
Protocol Deviations 
All protocol deviations will be tracked and actions will be defined, as feasible. All protocol de-
viations will be reviewed and classified in the DRM before data base lock and unblinding for 
the final analysis for assessment of their influence on the quality of the study analysis. 
Protocol deviations (PD) are defined as follows: 

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Major PD: 
• 
Informed consent procedure: ICF not signed and dated by patient/investigator 
• 
Violation of an in- or exclusion criterion 
• 
Randomization procedure 
• 
Incorrect use of IMP (storage, preparation and administration) 
• 
Use of forbidden concomitant medication 
• 
Delayed reporting of serious adverse events 
10 DSMB 
A Data and Safety Monitoring Board (DSMB) will be established to protect the safety of study 
participants.  
The DSMB will receive blinded CRF data in the form of tables and listings (prepared by an 
independent statistician), and adjudicate on patient status changes. Where appropriate, the 
DSMB may receive unblinded data (on a patient level) that should be reviewed in a closed 
session. 
The data should include, but is not limited to, demographics, patient enrolment, baseline char-
acteristics, AE data, SAE data (by severity and causality), laboratory data, protocol adherence, 
and patient withdrawals. 
The DSMB will assess data quality and timeliness and patient’s risk versus benefit. In addition, 
the DSMB will monitor external factors relevant to the trial, for example scientific and thera-
peutic developments that may affect participant safety or ethical status. Based on the observed 
benefits or adverse effects, the DSMB will make recommendations to the Sponsor concerning 
continuation, termination or modifications of the trial. Trial modifications may apply to an ad-
justment of dose and treatment duration, to the included trial population by adaptation of inclu-
sion and/or exclusion criteria, to modifications on allowed or prohibited concomitant medica-
tions and medications to be considered for standard of care. The DSMB shall review overall 
diagnostic and therapeutic options available for COVID-19 patients and make recommenda-
tions whether the trial design needs to reflect these options through modifications in this trial. 
The Sponsor will establish a DSMB charter document explaining the working procedures for 
the DSMB. 
In addition, a DSMB meeting will be conducted whenever safety relevant data occur that might 
have an influence on the trial. 
11 REPORTS  
All reports to the Sponsor will be in English. The Sponsor will receive an electronic copy of all 
versions of the electronic CRFs. 
11.1.1 Clinical Study Report 
All clinical, analytical and statistical results will be presented in a clinical study report (CSR). 
The outline of this report will accord to the ICH-GCP E3 document "Structure and Content of 
Clinical Study Reports" of July 17, 1996. 
The Sponsor will receive the original CSR. 

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All reports are the property of the Sponsor. Publication of the report or of part of it may only be 
allowed when authorized by the Sponsor in consultation with the clinical trial center. 
11.1.2 Additional Reports 
Within a year upon completion of the clinical trial, a summary of the CSR will be sent to the 
Ethics Committee and Competent Authorities as required by appropriated law.  

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12 REFERENCES 
 
 
 
1  
Joint statement ICAO-WHO on COVID-19“ (https://www.icao.int/Security/COVID-
19/Pages/Statements.aspx from 11 March 2020  
2  
Johns Hopkins CSSE https://gisanddata.maps.arcgis.com/apps/opsdashboard/in-
dex.html#/bda7594740fd40299423467b48e9ecf6.[last accessed on March, 18 2020] 
3  
Andrea Remuzzi, Guiseppe Remuzzi: COVID-19 and Italy: what next? The Lancet. 
Published online March, 12 2020. 
4  
AB Docherty, EM Harrison, CA Green et al.: Features of 16.749 hospitalised UK pa-
tients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol. 
https://doi.org/10.1101/2020.04.23.20076042. Posted April 28, 2020. [last accessed 
on May 04, 2020]. 
5  
Johns Hopkins CSSE https://gisanddata.maps.arcgis.com/apps/opsdashboard/in-
dex.html#/bda7594740fd40299423467b48e9ecf6. [last accessed on May 04.2020] 
6  
Investigator's Brochure for GSK2586881 (formerly known as APN01) A Soluble Re-
combinant Human Angiotensin Converting Enzyme 2 (rhACE2), Version 11 dated 17 
Juni 2020. 
7  
Fei Zhou, Ting Yu, Ronghui Du at el.: Clinical course and risk factors for mortality of 
adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The 
Lancet. Published online March, 9,2020. 
8        Akram Khan, Cody Benthin, Brian Zeno et al.: A pilot clinical trial of recombinant hu-
man angiotensin-converting enzyme 2 in acute respiratory distress syndrome. Critical 
Care 21:234, 2017. 
9        B. Taylor Thompsons, Rachel C. Chamber, Kathleen D. Liu: Acute Respiratory Dis-
tress Syndrome. NEJM 377,6, August 10, 2017. 
10        Michael A. Matthay et al.: The acute respiratory distress syndrome. J Clin Invest, 
122 (8): 2731-2740, 2017. 
11        Rob Mac Sweeney & Daniel F. McAuley: Acute respiratory distress syndrome. Lan-
cet 388: 2416-30, 2016. 
12  
Colin K. Grissom, Samuel M. Brown, Kathryn G. Kuttler et al.: A Modified Sequential 
Organ Failure Assessment (MSOFA) Score for Critical Care Triage. Disaster Med 
Public Health Prep. 4(4), 27: 7.84, 2010. 
                                               

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13 ANNEX 1 
The WHO Working Group’s on the Clinical Characterization of COVID-19 infection Proposed 
Core Outcome Measure Set for Clinical Studies of COVID-19 Infection. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Notes: 
1. If hospitalized for isolation only, record status as for ambulatory patient 
2. If pO2 not available, use SpO2/FIO2 ratio with a cutoff of 200 
 
 

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14 ANNEX 2 
Remote/Video monitoring visit  
 
Due to the Corona-Pandemic on-site monitor and pharmacy visits may not be possible due to 
travel restrictions and/or access restrictions at the hospitals. For this reason, a combined re-
mote and video monitoring visits may be the only possibility to monitor the site for an indefinite 
period. 
The general goals of the remote/video on-site monitoring visits are the same as for the on-site 
monitor visits with the restriction that complete source data verification is not possible. For the 
remote/video monitoring a software certified for the use in the medical field and GDPR conform 
(i.e., CLICKDOC Videosprechstunde for Germany and Austria) is used. 
Monitoring will only be conducted within the limits of site personnel (availability, workload, time) 
and technical capabilities to ensure secure video monitoring. Furthermore, essential data have 
to be entered into the database (eCRF) which includes the upload of corresponding documents 
(e.g. laboratory, physician’s letter) in order to perform SDV remotely.  
Study sites need to agree with the remote and video monitoring. Therefore, a written confirma-
tion document will be provided to the sites and needs to be signed and collected by the CRA. 
 
The following data according to recommendations of the European authorities are to be 
checked via remote/video monitoring: 
• 
Verification of availability and correctness of signed informed consent forms 
• 
data relevant for the inclusion and exclusion (including medical history) 
• 
doses and dose regimens of IMP 
• 
recording of (serious) adverse events 
• 
concomitant medication 
Video Monitoring: documents will be shown to the CRA by videoconference. 
 
The following data should be checked during an on-site Visits.  
 
• 
For 100% of all randomized patients: verification of availability and correctness of 
signed informed consent  
• 
For 100% of all randomized patients:  
o data relevant for the inclusion and exclusion  
o data relevant for the primary objective  
o data relevant for the secondary objectives 
o IMP treatment  
o concomitant medication 
o safety-related data for AEs / SAEs  
 
Video Visits (blinded) 
 
The following documents will be reviewed per Video-Monitoring if available, i.e. the site 
needs to have documentation on paper. 
 
Categorie 
Document 
Informed Consent Form 
ICF 
Physician´s letter/ 
Source Data Worksheets 
In regard to I/E criteria, review of: 
- 
Medical History 
- 
Concomitant Medication  
- 
Age, Weight, 
- 
Oxygen Saturation 
Safety: 

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AE/SAE Documentation 
Laboratory values 
In regard to I/E criteria review of: 
ALT, bilirubin, Hb, Hepatitis B+C, HIV 
COVID positive testing 
 
In case one of the listed documents is only available as an electronic patient file, it cannot be 
reviewed per video-monitoring. 
 
Documents listed below for remote monitoring will also be checked within the frame of video 
monitoring visit. 
 
Remote Visits: 
 
General requirements for provision of scanned documents for remote monitoring: 
 
- 
Quality of scans should have at least minimum 200 dpi. 
- 
Completeness of documents will be guaranteed by on the cover page of the docu-
ment the complete number of pages of the document is indicated (for example 1-12), 
with initials and actual date.  
- 
No scans of documents including personal data or data which can lead to the identity 
of the patients will be provided. 
- 
Study personnel will be instructed to send the scans as a response to an email of the 
CRA and to just respond to the email without adding another recipient to the email to 
avoid that documents will be sent to unauthorized third parties by mistake. 
- 
Documents received by the study site will be documented in the monitoring report. 
 
Remote Visits (blinded) 
 
The following documents should be provided (in case of any changes to previous visit) by the 
sites upon request via email and checked by remote monitoring: 
 
- 
Patient enrolment log 
- 
Site delegation log 
- 
IMP handover form 
- 
IMP drug accountability form 
- 
Trainings logs 
- 
Acknowledgments (Protocol, IB) 
- 
Site Visit Log 
- 
Site staff documents (FD, GCP, CV) 
- 
Note to files 
 
Remote Visits (unblinded) 
 
The following documents should be provided (in case of any changes to previous visit) by the 
sites upon request via email and checked by remote monitoring: 
- 
Handover forms 
- 
IMP dispatch form 
- 
Preparation of trial medication (APN01 or Placebo) 
- 
IMP accountability logs (APN01 or Placebo) 
- 
Investigational product stock on site/ Pharmacy 
- 
Temperature Recording Log (APN01 or Placebo) 
- 
Training Logs 
- 
Note to files 
- 
Print out randomization confirmation eCRF