Clinical Trial on the Safety and Efficacy of Regadenoson for Moderate to Severe COVID-19 Adult Patients
Phase: PHASE1
Conditions: COVID-19, Lung Inflammation
Sponsor: University of Maryland, Baltimore

 
CLINICAL TRIAL ON THE 
SAFETY AND EFFICACY OF 
REGADENOSON FOR 
MODERATE TO SEVERE 
COVID-19 ADULT PATIENTS. 
IND149635 Application 
 
 
 
NOVEMBER 11, 2022 
CHRISTINE L LAU 
University of Maryland, Baltimore 

1 
 
Table of Contents 
Volume 1: Detailed Draft Protocol Synopsis .................................................................... 4 
Primary Objectives ....................................................................................................... 4 
Primary Endpoint ...................................................................................................... 4 
Secondary Endpoints ................................................................................................ 4 
Study Design ................................................................................................................ 5 
Eligibility Criteria .......................................................................................................... 6 
Inclusion Criteria ....................................................................................................... 6 
Exclusion Criteria ...................................................................................................... 6 
Safety Assessments .................................................................................................... 7 
Sample Size and Statistical Analysis ........................................................................... 8 
Study Centers ............................................................................................................ 10 
References................................................................................................................. 10 
Volume 2: Detailed Information for IND 149635 Application ......................................... 11 
Drug Name................................................................................................................. 11 
A Description of The drug Substance ........................................................................ 11 
The Active Pharmaceutical Ingredient (API) and Formulation for Clinical Study ........ 11 
Dosage Form, Formulation and Route of Administration ........................................ 11 
The Known or Suspected Mechanism of Action of The Drug ................................. 11 
A Summary of The Available Pharmacokinetic Information .................................... 11 
The Renal and Hepatic Function Criteria ................................................................ 12 
Data and Literature Supporting The Proposed Use of The Drug in COVID-19 .......... 13 
Literatures .................................................................................................................. 17 
FDA-Approved Labeling and Existing IND for Regadenoson ..................................... 19 
Results For In Vitro and In Vivo Toxicology ............................................................... 19 
Brief Assay Descriptions ............................................................................................ 20 
A Detailed Justification for The Proposed Dose, Dosing range, Number of Doses, and 
Dose Interval .............................................................................................................. 20 
Trial Timeline ............................................................................................................. 20 
Timeline .................................................................................................................. 20 
Our Retention and Follow Up Plans........................................................................ 21 

2 
 
The End of Study .................................................................................................... 21 
Volume 3: Detailed DSMB Plan (Regadenoson trial on COVID-19) .............................. 22 
Introduction ................................................................................................................ 22 
Responsibilities of the DSMB ..................................................................................... 22 
Protections Against Risk and Loss of Confidentiality .............................................. 22 
Monitoring Plan ....................................................................................................... 22 
STUDY CONDUCT AND ETHICAL CONSIDERATIONS .......................................... 23 
Consent Forms and the Consenting Process ......................................................... 23 
Maintenance of Study Documents .......................................................................... 24 
Organization and Interactions .................................................................................... 24 
DSMB Members and NHLBI Program Staff ............................................................... 24 
Roles of NHLBI staff in DSMB Meetings .................................................................... 24 
Scheduling, Timing, and Organization of Meetings .................................................... 25 
Discussion of Confidential Material ............................................................................ 26 
Reports of DSMB Deliberations ................................................................................. 27 
Reports to the DSMB ................................................................................................. 28 
Statistical Monitoring Guidelines ................................................................................ 28 
ADVERSE EVENTS AND REPORTING .................................................................... 28 
Definitions ............................................................................................................... 28 
Adverse Event ........................................................................................................ 28 
Serious Adverse Event ........................................................................................... 29 
Attribution Assessment ........................................................................................... 30 
Severity ................................................................................................................... 30 
Adverse Event Recording .......................................................................................... 31 
Reporting Requirements ............................................................................................ 31 
Reporting to the UMB HSR-IRB and DSMB ........................................................... 31 
Reporting to the FDA .............................................................................................. 32 
Appendix A................................................................................................................. 34 
Appendix B................................................................................................................. 35 
Volume 4: Appendix ...................................................................................................... 36 
APPENDIX A: NIAID 8-Point Ordinal Scale for COVID-19 ............................................ 36 

3 
 
Table 1, Detailed Grading Scales of Toxicity of Regadenoson .................................. 37 
Table 2: Detailed Projected Timeline for Each Subject .............................................. 41 
 
 
 

4 
 
Volume 1: Detailed Draft Protocol Synopsis 
Title: Clinical Trial on the Safety and Efficacy of Regadenoson for Moderate to Severe 
COVID-19 Adult Patients. 
Short Title: Regadenoson Trial on COVID-19 Patients 
Disease: Moderate to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-
2), aka Coronavirus Disease 2019 (COVID-19). 
Target Population: Moderate to Severe adult patients with COVID-19. 
Phase of Development: Phase 2 
Primary Objectives:  
The primary objective of this study is to evaluate the safety, tolerability, and efficacy of 
Regadenoson in moderate to severe adults with COVID-19. Moderate illness is 
defined as individuals who have evidence of lower respiratory disease by clinical 
assessment or imaging and a saturation of oxygen (SpO2) >93% on room air at sea 
level. Severe Illness is defined as individuals who have respiratory frequency >30 
breaths per minute, SpO2 ≤ 93% on room air at sea level, ratio of arterial partial 
pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) <300, or lung 
infiltrates >50% 
Primary Endpoint: 
Proportion of patients alive and free of respiratory failure through the 30-day trial.  
Respiratory failure is defined based on resource utilization requiring at least 1 of the 
following modalities: 
a. Endotracheal intubation and mechanical ventilation 
b. Oxygen delivered by high-flow nasal cannula (heated, humidified, oxygen delivered 
via reinforced nasal cannula at flow rates >20L/min with fraction of delivered oxygen 
≥0.5) 
c. Noninvasive positive pressure ventilation or CPAP 
d. ECMO 
Secondary Endpoints: 
1.   A 2-point improvement from baseline using the National Institutes of Allergy and 
Infectious Diseases (NIAID) 8-point ordinal scale for COVID-19 (see APPENDIX A). All-
cause mortality at Day 30. 

5 
 
2. Proportion of participants with at least 2-point improvement at Day 15 and Day 30 
using the NIAID 8-point ordinal scale. 
3. ICU length of stay 
4. Hospital length of stay 
In addition: The data on 1) Physical Exam; 2) Clinical Laboratory Values 3) Arterial 
Blood Gas; and 4) Vital Signs, including heart rate, blood pressure and oxygen 
saturation, at the different time-points prior, during and post the study drug 
administration will be collected to evaluate the effects of Regadenoson on these 
patients. The data on the ventilator parameters, the length of stay on ventilator, and the 
length of stay in ICU and/or hospital will also be collected during the post follow up to 
evaluate the efficacy of Regadenoson in these moderate to severe Covid-19 patients.  
Due to the mixture of the moderate and severe COVID-19 patients with various baseline 
severity levels, we will record pertinent patient information, such as age, sex, race, 
symptoms, signs, saturation of oxygen, medications, treatments, days of illness, 
comorbidities, chest X-ray imaging, and baseline severity (such as, on oxygen, on 
ventilator, on ECMO etc.) prior to Regadenoson infusion. We will also record whether 
each participated patient is treated with additional COVID-19 therapies. When we 
analyze the effects of Regadenoson on COVID-19, we can subgroup these patients and 
conduct primary efficacy analysis and propose appropriate methods of covariate 
adjustment. 
Study Design:  
This is a single center, randomized, phase 2 study to evaluate the safety, tolerability, 
and efficacy of Regadenoson for the treatment of moderate to severe adults with 
COVID-19.  Patients will be followed up for 30 days from the start of study drug 
administration.  
Estimated sample size: 40 
Estimated accrual period: 18 months 
Allocation: Randomized 
Masking: Double-blind, placebo-controlled 
Study Duration for each subject: 30 days  
Study Treatments: 
Regadenoson will be given intravenously as a 5µg/kg loading dose (a dose less than 
400µg) over 30 minutes, followed by a continuous slow infusion (1.44µg/kg/hour) with 

6 
 
the use of a pediatric infusion pump for 6 hours. The saline will be used as placebo 
controls.  
 
Eligibility Criteria 
Inclusion Criteria: 
1. 
18 years of age or older 
2. 
Laboratory-confirmed COVID-19+ by RT-PCR  
3. 
Moderate to Severe COVID-19 patients according to FDA's COVID-19 
treatment guideline on Management of Persons with COVID-19: 
4. 
Verbal or written informed consent must be obtained from patient or LAR 
(Legally Authorized Representative) before any study procedure is performed. 
Exclusion Criteria: 
1. Pregnant or breastfeeding women 
2. Subject has signs or symptoms of acute myocardial ischemia or has required a 
cardiac intervention within the past 90 days. 
3. Subject with chronic cardiac conditions including non-vascularized coronary 
artery disease, heart failure, valvular disease, and cardiomyopathy. 
4. Subject has an acute or chronic cardiac arrhythmia such as Sinoatrial (SA) or 
Atrioventricular (AV) Nodal Block/dysfunction, bradycardia, a permanent 
pacemaker, an internal defibrillator, or Atrial Fibrillation/Atrial Flutter requiring 
treatment or observation. 
5. Subject has history of hypotension (sustained systolic blood pressure < 80 
mmHg) 
6. Subject has a history of severe hypertension not adequately controlled with anti-
hypertensive medications (Systolic blood pressure ≥ 200 mmHg and/or Diastolic 
blood pressure ≥ 110 mmHg)  
7. Subject has moderate or severe renal impairment as well as subject with end 
stage renal disease (defined as GFR < 60 mL/min/1.73 m2) 
8. Subject has a history of clinically overt stroke within the past 3 years  
9. Subject with a history of seizure disorder  
10. Subject has pre-existing respiratory conditions, most notably asthma or chronic 
obstructive pulmonary disease or emphysema. 
11. Subject with respiratory failure for greater than 72 hours. Defined as the 
continuous use of mechanical ventilation, HFNC >20L/min, CPAP, and/or ECMO. 
(CPAP use due to obstructive sleep apnea is acceptable). 
12. Subject who is being treated with chronic anti-coagulation or anti-platelet therapy 
(prophylactic aspirin is acceptable)  
13. Subject who is receiving or has received within 30 days any other investigational 
agents as part of a research study. 

7 
 
14. Subject who has received theophylline or aminophylline within 12 hours of study 
dosing  
15. Subjects who are currently taking or have taken Persantine and/or Aggrenox 
within 5 days  
16. Subjects who have any other clinical conditions that in the opinion of the 
investigator would make the subject unsuitable for the study.  
Safety Assessments:  
This study will be conducted in 2 cohorts.  Our ongoing phase 1 trial with slow infusion 
of Regadenoson (1.44micrograms/kg/hour) in lung transplant patients study showed no 
obvious dose limiting toxicity.  Safety assessments (vital signs, Pulse oximetry and 
Arterial Blood Gas, laboratory studies, electrocardiograms, etc.) will be performed on a 
schedule commensurate with the level of care and the identified potential risk of the 
study drug during Regadenoson infusion and 12 hours post infusion. Given the cardiac 
risk with Regadenoson, we will continue cardiac monitoring during the infusion of 
Regadenoson, and EKGs daily or as needed, and cardiac markers only if cardiac 
symptoms occur. To monitor potential platelet aggregation effects, labs (PT, PTT, INR, 
platelets, D-Dimer, and thromboelastography (TEG)) will be drawn prior to the infusion 
and on post infusion day 1. Patients who receive anti-clotting medications during 
Regadenoson infusion or within 6 hours of the end of infusion will be checked for 
clotting time and if necessary, anti-coagulant administration will be reduced or stopped. 
In addition, we will have a pregnancy test for patients who may have potential risk with a 
urine sample before study drug administration. Patients with a negative result will be 
enrolled. We will ensure that protections for women of childbearing potential align with 
International Council on Harmonization M3 R2 guidelines for highly effective methods of 
contraception. 
In cohort 1, we will enroll patients to test the safety, tolerability and toxicity in moderate 
to severe COVID-19 patients. Initial subjects in cohort 1 will receive a loading dose of 
5.0 µg/kg (not to exceed 400 µg) over 30 minutes followed by a low dose infusion of 
1.44 µg/kg/hr. Toxicity of Regadenoson treatment will be graded by using the Common 
Terminology Criteria for Adverse Events (CTCAE) Criteria version 4.03 in this trial. If 
two dose limiting toxicities occur at a loading dose of 5.0 µg/kg then the loading dose 
will be halved to 2.5 µg/kg and enrollment will continue. If two dose limiting toxicities 
occur at a loading dose of 2.5 µg/kg then the Data and Safety Monitoring Board (DSMB) 
will convene to determine if the study should continue and omitting the loading dose 
may be considered. Alternatively, the DSMB will convene after 5 out of 5 patients or 5 
out of 6 patients tolerate a given loading dose to make a determination on moving 
forward to cohort 2. Otherwise, the trial will be terminated. (please see the details in the 
Detailed DSMB Plan section) 
 
The sickle cell trial and our phase 1 trial in lung transplant patients did not show any 
renal/hepatic toxicity. Because COVID-19 itself may cause renal injury, we will closely 
monitor the renal and hepatic function of these patients per their standard of care. To 
assess safety of each subject, we will tabulate sequentially the number of participants 

8 
 
who unexpectedly experience serious cardiovascular side effects or persistent (> 30 
min) intolerable side effects. If at any point in the accrual, the posterior probability 
exceeds 90% that the risk of at least one serious side effect for participants in the 
Regadenoson arm is more than 10 percentage points greater than in the standard care 
arm, we will stop the trial. 
 
Adverse Event (AE) Recording and Reporting:  
 
All adverse events will be collected starting at time of consent through POD 30. Adverse 
events will be recorded on a case report form and will be assessed for seriousness, 
severity, attribution and expectedness by the site Principal Investigator. A serious 
cardiovascular side effect is defined as a sustained change (> 5 minutes) in 
systolic blood pressure >30 mm Hg or systolic blood pressure <75 mm Hg, 
tachycardia >130 bpm, or bradycardia <40 bpm. 
 
The COVID-19 patient population has increased risk for vascular events and these 
events are monitored as part of standard of care. Standard of care will be followed, and 
diagnostics may include lab values and imaging studies. Additionally, PT, PTT, INR, 
platelets, and TEG labs will be drawn before and after the infusion and the study team 
will monitor the study participants by observing their clinical progress/course for any 
such clinically significant vascular events that occur during the study period. These 
events will report them as adverse events as part of good clinical research practice. 
 
Reporting to the UMB HSR-IRB and DSMB:  
 
The Principal Investigator or designee is responsible for reporting SAEs and 
unanticipated problems to the site IRB according to the participating site institutional 
guidelines. (Please see the revised additional information form details)  
 
Reporting to the FDA:  
 
The PI for the study is responsible for providing safety updates to the FDA per the 
guidelines. The reporting times refer to the time the study team received knowledge of 
the AE. Please see the attached Table 1 for details. 
 
Sample Size and Statistical Analysis: 
The study aims to maximize knowledge on the use of Regadenoson to treat COVID-19 
in order to plan for a larger trial. Safety analysis will be prioritized to allow for the 
expansion to a multi-site trial. The study will enroll moderate and severely ill subjects to 
maximize enrollment at the single enrolling institution. Severity of illness and baseline 
respiratory failure will be delineated within the analysis to account for the variability in 
the patient population. This trial will provide estimates of outcome variability in the 
primary and secondary outcomes that will be valuable for planning a larger randomized 
trial. Additionally, in planning for a larger trial, exploratory analyses will adjust estimates 
of treatment differences by known risk factors. Although we recognize that these 

9 
 
analyses will be limited by the number of observed events, they will be useful for 
decisions on eligibility criteria or stratification factors in the larger trial.  The analyses will 
be carried out on data from all randomized participants.  
 
We will enroll 40 moderate to severe COVID-19 patients, which is defined in the 
inclusion criteria above. Following the recommendation of the FDA review of our IND 
application, the trial focuses on providing estimates of outcome variability in the primary 
and secondary outcomes that will be valuable for planning a larger randomized trial. 
Additionally, in planning for a larger trial, exploratory analyses will adjust estimates of 
treatment differences by known risk factors. Due to the mixture of the moderate to 
severe COVID-19 patients with various baseline severity levels, we will record 
information regarding each patient, such as age, sex, race, symptoms, vital signs, 
saturation of oxygen, medications, treatments, days of illness, comorbidities, chest X-
ray imaging, and baseline severity (such as, whether on oxygen, on ventilator, or on 
ECMO etc.) prior to Regadenoson infusion. When we analyze the effects of 
Regadenoson on COVID-19 patients, we can do exploratory analyses within subgroups 
of these patients and conduct primary efficacy analysis and propose appropriate 
methods of covariate adjustment. The prevention and treatment of respiratory failure will 
be analyzed within appropriate subgroups. For each subject, we will clearly document 
the reason for hospital admission, document the standard of care followed for each 
subject, and if care decisions are made based on resource limitation.  
 
The primary outcome is the proportion of patients alive and free of respiratory failure 
through the 30-day trial. The total sample size of 40 participants will be randomized 
equally between the usual care and Regadenoson groups, using a randomly permuted 
block design, with random block sizes of 2 and 4.  This plan will be generated by the 
study statistician.   Within each group, the primary outcome proportion can be estimated 
with a standard error of no more than 11 percentage points; the difference between the 
groups can be estimated with a standard error that is no more than 16 percentage 
points.  These calculations are based on the most conservative estimate in terms of 
standard error, using a proportion of 50% in each group.  If, as expected, the 
proportions in each group are greater, such as 80% in usual care and 90% in the 
Regadenoson group, the difference can be estimated with a standard error of 11 
percentage points.  While these are relatively large standard errors, they are adequate 
to meet the objective suggested by the IND review, providing estimates of outcome 
proportions to be used in a larger trial. 
 
To assess safety, the DSMB statistician will tabulate sequentially the proportion of 
participants in each group who unexpectedly experience serious cardiovascular side 
effects or persistent (> 30 min) intolerable side effects, based on clinical experience with 
Regadenoson. Intolerable side effects include headache or dyspnea.  If the lower bound 
of a one-sided 80% confidence interval for the difference in proportions exceeds 10%, 
we will pause the trial, examine the adverse event profiles, and consider modifying 
dosing.  With this rule, if the true proportion of patients who experience serious side 
effects is 20% in each group, there is a 16.5% chance that the trial will be paused; if the 

10 
 
true proportion with Regadenoson is 40%, there is a 58% chance the study will be 
paused.     
 
To plan for a future study, we will compute a 90% one-sided confidence interval (CI) for 
the difference in failure free survival (FFS) proportions at 30 days. The CI will use 
standard formulas for estimates and standard errors for the Kaplan-Meier estimate of 
the FFS distribution at a specific point in time (Klein et al, 2007). Censoring on the 
primary outcome will be unlikely since we will have follow-up at 30 days for FFS.  For 
the secondary outcome of time to improvement as well as for the length of stay 
outcomes, survival time will be used as a competing risk (see Brock et al, 2011 and 
Harhay et al, 2019). Both of these papers recommend the use of cumulative incidence 
curves (CIC) for competing risks, as described by Kleinbaum and Klein, 2012).  Group 
comparisons of the specific CIC can be made with the test of Grey (1988); with 
covariates, the method of Fine and Gray (1999) can be used to model the CIC.    
Study Centers: 
University of Maryland Medical Center, Baltimore, MD. 
References: 
Brock GN, Barnes C, Ramirez JA, Myers J. How to handle mortality when investigating 
length of hospital stay and time to clinical stability. BMC Med Res Methodol. 2011; 
11:144. Published 2011 Oct 26. doi:10.1186/1471-2288-11-144. PMC3269825 
Harhay MO, Ratcliffe SJ, Small DS, Suttner LH, Crowther MJ, and Halpern SD (2019). 
Measuring and Analyzing Length of Stay in Critical Care Trials Med Care. 2019 
Sep;57(9): e53-e59. doi: 10.1097/MLR.0000000000001059. 
Klein JP, Logan B, Harhoff M and Anderson PK (2007) Analyzing survival curves at a 
ﬁxed point in time. Statist. Med. 2007; 26:4505–4519 
Kleinbaum D and Klein M (2012) Survival Analysis, A Self-Learning Test, 3rd Edition. 
Springer Science:New York. 
Gray RJ (1988) A Class of k-sample tests for comparing the cumulative incidence of a 
competing risk. Annals of Statistics, 16 1141-1154. 
Fine J and Gray RJ (1999) A proportional hazards model for the subpopulation of a 
competing risk. Journal of the American Statistical Association, 94, 496-509.  
Field JJ et al. Randomized phase 2 trial of regadenoson for treatment of acute vaso-
occlusive crises in sickle cell disease. Blood Adv. 2017 Aug 28;1(20):1645-1649.  
Lau CL, Beller JP, Boys JA, Zhao Y, Phillips J, Cosner M, Conaway MR, Petroni G, 
Charles EJ, Mehaffey JH, Mannem HC, Kron IL, Krupnick AS, Linden J. Adenosine A2A 
receptor agonist (regadenoson) in human lung transplantation. J Heart Lung Transplant. 
2020 Jun;39(6):563-570. 

11 
 
Volume 2: Detailed Information for IND 149635 Application 
Drug Name: CVT3146, Generic Name: Regadenoson Injection, Trade Name: Lexiscan 
A Description of The drug Substance: Regadenoson is an A2A adenosine receptor 
agonist that is a coronary vasodilator [see Clinical Pharmacology (12.1)]. Regadenoson 
is chemically described as adenosine, 2-[4- [(methylamino)carbonyl]-1H-pyrazol-1-yl]-, 
monohydrate. Its structural formula is: 
 
The molecular formula for Regadenoson is C15H18N8O5 • H2O and its molecular 
weight is 408.37. LEXISCAN is a sterile, nonpyrogenic solution for intravenous injection. 
The solution is clear and colorless.  
 
The Active Pharmaceutical Ingredient (API) and Formulation for Clinical Study: Each 1 mL 
in the 5 mL pre-filled syringe contains 0.084 mg of Regadenoson monohydrate, 
corresponding to 0.08 mg Regadenoson on an anhydrous basis, 10.9 mg dibasic 
sodium phosphate dihydrate or 8.7 mg dibasic sodium phosphate anhydrous, 5.4 mg 
monobasic sodium phosphate monohydrate, 150 mg propylene glycol, 1 mg edetate 
disodium dihydrate, and Water for Injection, with pH between 6.3 and 7.7. 
 
Dosage Form, Formulation and Route of Administration: liquid, 400 micrograms/vial. The 
recommended dose of LEXISCAN is 5 mL (0.4 mg Regadenoson) administered as an 
intravenous injection within 10 seconds. 
 
The Known or Suspected Mechanism of Action of The Drug: Regadenoson is a low affinity 
agonist (Ki ≈ 1.3 μM) for the A2A adenosine receptor, with at least10-fold lower affinity 
for the A1 adenosine receptor (Ki > 16.5 μM), and weak, if any, affinity for the A2B and 
A3 adenosine receptors. Activation of the A2A adenosine receptor by Regadenoson 
produces coronary vasodilation and increases coronary blood flow (CBF). 
 
A Summary of The Available Pharmacokinetic Information: In healthy subjects, the 
Regadenoson plasma concentration-time profile is multi-exponential in nature and best 
characterized by 3-compartment model. The maximal plasma concentration of 
Regadenoson is achieved within 1 to 4 minutes after injection of LEXISCAN and 
parallels the onset of the pharmacodynamic response. The half-life of this initial phase 
is approximately 2 to 4 minutes. An intermediate phase follows, with a half-life on 
average of 30 minutes coinciding with loss of the pharmacodynamic effect. The terminal 

12 
 
phase consists of a decline in plasma concentration with a half-life of approximately 2 
hours [see Clinical Pharmacology (12.2)]. Within the dose range of 0.3–20 μg/kg in 
healthy subjects, clearance, terminal half-life or volume of distribution do not appear 
dependent upon the dose. 
 
According to the Lexiscan label description, in a randomized, placebo-controlled trial of 
504 patients (LEXISCAN n=334 and placebo n=170) with a diagnosis or risk factors for 
coronary artery disease and NKFK/DOQI Stage III or IV renal impairment (defined as 
GFR 15-59 mL/min/1.73 m2), no serious adverse events were reported through the 24-
hour follow-up period.  
 
Since the dose we will use in this trial is lower than the MPI trial, we anticipate that 
Regadenoson infusion may not impair renal function. Our phase I trial in lung transplant 
patients did not show any renal/hepatic toxicity. However, because COVID-19 itself may 
cause renal injury, plus standard of care treatments may also affect kidney function, 
these factors may impair renal or hepatic function.   
 
The Renal and Hepatic Function Criteria: 
 
The stages of Chronic Kidney Disease are classified as follows: 
 
• 
Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2) 
• 
Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m2) 
• 
Stage 3a: Moderate reduction in GFR (45-59 mL/min/1.73 m2) 
• 
Stage 3b: Moderate reduction in GFR (30-44 mL/min/1.73 m2) 
• 
Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m2) 
• 
Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m2 or dialysis) 
 
or  
 
• 
Acute kidney injury Grade scales:  
• 
Grade 1: Creatinine level increase of >0.3 mg/dL; creatinine 1.5 - 2.0 x above 
baseline  
• 
Grade 2: Creatinine 2 - 3 x above baseline  
• 
Grade 3: Creatinine >3 x baseline or >4.0 mg/dL; hospitalization indicated 
• 
Grade 4: Life-threatening consequences; dialysis indicated  
• 
Grade 5: Death  
 
 
 
 
The Child- Pugh classification is a means of assessing the severity of liver injury. 
 
Score 
1 
2 
3 
bilirubin (micromol/l) 
<34 
34-50 
>50 

13 
 
albumin (g/l) 
>35 
28-35 
<28 
PT (s prolonged) 
<4 
4-6 
>6 
encephalopathy 
none 
mild 
marked 
ascites 
none 
mild 
marked 
If there is primary biliary cirrhosis or sclerosing cholangitis, then bilirubin is classified as 
<68=1; 68-170=2; >170=3. 
The individual scores are summed and then grouped as: 
• 
<7 = A 
• 
7-9 = B 
• 
>9 = C 
If any participated patients developed renal or liver impairments as described above 
(Kidney: Stages 3 and 4 or Grade Scale>3, or Liver summed scores>B), we will stop the 
infusion of Regadenoson and take the following steps: All study activities will take place 
within the hospital setting with available physician, nurse, and facility support. Should a 
participant suffer any injury as a result of taking part in this research study, all needed 
facilities, emergency treatment and professional services will be available to them, just 
as they are to the community in general. Participants will be informed that there are no 
arrangements to provide free treatment of the injury or any other type of payment for the 
injury. These will be billed to the participant or his/her insurance and this information will 
be reviewed during the informed consent process. Any injuries will be reported to the 
clinical site PI. The PI contact information will be provided to the participant within the 
informed consent. The participant/LAR will also be informed that he/she (they) will not 
give up any legal rights by providing verbal consent or signing the consent form. 
 
Data and Literature Supporting The Proposed Use of The Drug in COVID-19: 
 
Activation of adenosine 2A receptors inhibits inflammation by directly targeting multiple 
inflammatory/immune cells. It is well established that the activity of inflammatory cells, 
including invariant natural killer T (iNKT), NKs, macrophages, DCs, monocytes, T-cells, 
platelets, and neutrophils, is inhibited by A2AR activation, resulting in reduced 
proinflammatory cytokines and decreased endothelial adhesion molecule expression 
during acute lung injury  in different animal models (mouse/rat acute lung injury models, 
pre-clinical porcine lung transplantation model) [1-4]. A2AR agonist inhibited 
inflammatory/immune cells (such as iNKT cells and neutrophil) activation and infiltration 
into the lungs, Therefore, A2A agonists reduce acute lung injury through inhibiting 
proinflammatory cytokine releasing (including IL-6, TNFα, IFN-γ. etc) [5-9]. Our 
unpublished data showed A2A agonists also have been found to reduce lethality to 
cytokine storm associated with bacterial sepsis (Figures 1 & 2). Our phase I trial  
in lung transplant patients showed that low dosage, slow infusion of Regadenoson 
inhibited IL-6 production when compared with a patient without Regadenoson treatment 
(Figure 3). Regadenoson also decreased matrix metalloproteinase -9 (MMP-9) levels, 
but not MMP-2 level, when compared with control patient (Figure 4). We demonstrated 

14 
 
that MMP-9, but not MMP-2, was significantly elevated in the acute injured lungs when 
compared with sham operated lungs [10]. The recent publications showed that MMP-9 
plays an important role in acute lung injury by increasing vascular permeability, 
promoting inflammatory cell infiltrating into the lungs and positively associating with IL-6, 
TNFα, and IL-8 [11-14]. In addition, our proteomic analysis data showed that 
Regadenoson treated lung transplantation patients increased tissue inhibitor of 
metalloproteinase -1 (TIMP-1) when compared with control patient at the same time 
points (Figure 5). TIMP-1 is an endogenous inhibitor of MMP-9. Therefore, 
Regadenoson not only down-regulated MMP-9, but also up-regulated it's inhibitor. The 
phase II trials of adult sickle cell patients showed that Regadenoson inhibited iNKT 
cells, which is a key immune cell involved in both innate and adaptive immune response 
[15]. The newly published data showed that respiratory failure from acute respiratory 
distress syndrome (ARDS) is the leading cause of mortality for severe COVID-19 
patients.  The severe COVID-19 patients might have a cytokine storm syndrome, as 
indicated by elevated levels of various proinflammatory cytokines, including IL-6, TNFα, 
IFN-γ and others [16-29]. These life-threatening cytokines impair pulmonary function. 
Therefore, there is an urgent need to identify and treat hyperinflammation using 
existing, approved therapies with proven safety profiles to address the immediate need 
to reduce the high 2-4% mortality of severe COVID-19 patients. We propose that 
Regadenoson be used for the treatment of patients with virally induced lung 
hyperinflammation.  We predict that A2AR agonist treatment will decrease the 
pulmonary cytokine storm evoked by viruses, reduce lung inflammation and enhance 
pulmonary function.  Based on our current phase 1 trial data and published evidence, 
we expect that Redadenoson may save lives of severe COVID-19 patients through 
several different mechanisms (inhibiting proinflammatory cytokine (IL-6) and MMP-9 
and increasing TIMP-1). 
 
 
 
 
 

15 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2. ATL-146e improves survival in a rat fibrin-thrombin clot model 
of gram-negative sepsis. Fisher 344 male rats (N=25) were treated with 5 
mg/kg gentamicin twice daily 2 hours post infection and ATL-146e at 2, 8 
12 and 20h post infection. (In collaboration with Dr. Peter DeMarsh, 
A 
Figure 1. ATL-146e improves survival in a mouse E. Coli model of 
sepsis and is synergistic with Ceftriaxone (N=8). (In collaboration 
with Dr. Mike Scheld, UVa). 

16 
 
 
Figure 3. Regadenoson inhibits IL-6 releasing post lung transplantation. All the patients 
underwent double lung transplantation. The data are collected from 8 Regadenoson treated 
patients and 1 control patient. The data are normalized to prior Regadenoson infusion.  
 
 
Figure 4. Plasma Levels of MMP-9 and MMP-2 in two Regadenoson infused patients (P022 
&P023) and 1 control patient (C4) at different time points. 1. Prior incision, 2. 15min prior 1st 
Lung reperfusion, 3. 30min post 1st Lung reperfusion, 4. 30min post 2nd Lung reperfusion, 5. 6 
hours post 1st Lung reperfusion. t-MMP-9, tetramer MMP-9; d-MMP-9, dimerized MMP-9 and 
TIMP-1, p-MMP-9, pro-MMP-9; a-MMP-9, active MMP-9; p-MMP-2, pro-MMP-2.    

17 
 
 
 
 
Figure 5. Tissue inhibitor of metalloproteinase -1(TIMP-1) protein in Regadenoson infused lung 
transplant patient (C011) and control patient (C4). TIMP-1 was detected with the LC-MS system 
consisted of a Thermo Electron Q Exactive HF mass spectrometer system. The data were 
analyzed by database searching using the Sequest search algorithm against a database of 
Uniprot Human. C011, Regadenoson infused patient; C4, non-Regadenoson treated patient. -1: 
Prior incision, -3: 30min post 1st Lung reperfusion, -5: 6 hours post 1st Lung reperfusion. 
 
 
Literatures:  
1. Reutershan J et al. Therapeutic anti-inflammatory effects of myeloid cell 
adenosine receptor A2a stimulation in lipopolysaccharide-induced lung injury. J 
Immunol, 2007. 179(2):1254-63.  
2. Ohta, A. and M. Sitkovsky, Role of G-protein-coupled adenosine receptors in 
downregulation of inflammation and protection from tissue damage. Nature, 
2001. 414(6866): 916-20.  
3. Lappas  CM et al. Adenosine A2A receptor activation reduces hepatic ischemia 
reperfusion injury by inhibiting CD1d-dependent NKT cell activation. J Exp Med, 
2006. 203(12):2639-48. 
4. LaPar DJ et al. Pretreatment strategy with adenosine A2A receptor agonist 
attenuates reperfusion injury in a preclinical porcine lung transplantation model. J 
Thorac Cardiovasc Surg, 2011. 142(4):887-94. 
5. Sharma AK et al. Adenosine A2A receptor activation on CD4+ T lymphocytes 
and neutrophils attenuates lung ischemia-reperfusion injury. J Thorac Cardiovasc 
Surg. 2010 Feb;139(2):474-82. 
6. Sharma AK et al. Natural Killer T Cell-derived IL-17 Mediates Lung Ischemia-
Reperfusion Injury. Am J Respir Crit Care Med. 2011 Jun; 183(11):1539-49. 

18 
 
7. Emaminia A et al. Adenosine A(2A) Agonist Improves Lung Function During Ex 
Vivo Lung Perfusion. Ann Thorac Surg. 2011 Nov;92(5):1840-6.  
8. Stone ML et al. Ex Vivo Perfusion With Adenosine A2A Receptor Agonist 
Enhances Rehabilitation of Murine Donor Lungs After Circulatory Death. 
Transplantation. 2015 Dec;99(12):2494-503.  
9. Sharma et al. NOX2 Activation of Natural Killer T Cells Is Blocked by the Adenosine 
A2A Receptor to Inhibit Lung Ischemia-Reperfusion Injury. Am J Respir Crit Care 
Med. 2016 May 1;193(9):988-99. 
10. Zhao Y et al. Depletion of Tissue Plasminogen Activator Attenuates Lung 
Ischemia-Reperfusion Injury via Inhibition of Neutrophil Extravasation. Am J 
Physiol Lung Cell Mol Physiol. 2011 May; 300(5):L718-29.  
11. Yano M et al. Increased matrix metalloproteinase 9 activity and mRNA 
expression in lung ischemia-reperfusion injury. J Heart Lung Transplant. 2001 
Jun;20(6):679-86. 
12. Shi Z et al. LipoxinA4 attenuates acute pancreatitis-associated acute lung injury 
by regulating AQP-5 and MMP-9 expression, anti-apoptosis and PKC/SSeCKS-
mediated F-actin activation. Mol Immunol. 2018 Nov;103:78-88. 
13. Liang Y et al. Elevated IL-33 promotes expression of MMP2 and MMP9 via 
activating STAT3 in alveolar macrophages during LPS-induced acute lung injury. 
Cell Mol Biol Lett.  2018 Oct 31;23:52. 
14. Chao W et al. 3, 4-dihydroxybenzalacetone attenuates lipopolysaccharide-
induced inflammation in acute lung injury via down-regulation of MMP-2 and 
MMP-9 activities through suppressing ROS-mediated MAPK and PI3K/AKT 
signaling pathways. Int Immunopharmacol. 2017 Sep;50:77-86. 
15. Field JJ et al. Randomized phase 2 trial of regadenoson for treatment of acute 
vaso-occlusive crises in sickle cell disease. Blood Adv. 2017 Aug 28;1(20):1645-
1649.  
16. Chen G et al. Clinical and immunologic features in severe and moderate 
Coronavirus Disease 2019. J Clin Invest. 2020 Mar 27. pii:137244. 
17. Sarzi-Puttini P et al. COVID-19, cytokines and immunosuppression: what can we 
learn from severe acute respiratory syndrome? Clin Exp Rheumatol. 2020 Mar-
Apr;38(2):337-342. 
18. McGonagle D et al.The Role of Cytokines including Interleukin-6 in COVID-
19 induced Pneumonia and Macrophage Activation Syndrome-Like Disease. 
Autoimmun Rev. 2020 Apr 3:102537. 
19. Tufan A et al. COVID-19, immune system response, hyperinflammation and 
repurposing antirheumatic drugs. Turk J Med Sci. 2020 Apr 21;50(SI-1):620-632. 
20. Lagunas-Rangel FA et al. High IL-6/IFN-γ ratio could be associated with severe 
disease in COVID-19 patients. J Med Virol. 2020 Apr 16. doi: 10.1002/jmv.25900.  
21. Wan S et al. Relationships among lymphocyte subsets, cytokines, and the 
pulmonary inflammation index in coronavirus (COVID-19) infected patients. Br J 
Haematol. 2020 Apr 16. doi: 10.1111/bjh.16659. 
22. Liu B et al. Can we use interleukin-6 (IL-6) blockade for coronavirus disease 2019 

19 
 
(COVID-19)-induced cytokine release syndrome (CRS)? J Autoimmun. 2020 Apr 
10:102452. doi: 10.1016/j.jaut.2020.102452. 
23. Mehta P et al. COVID-19: consider cytokine storm syndromes and 
immunosuppression. Lancet. 2020 Mar 28;395(10229):1033-1034. 
24. Zhao M. Cytokine storm and immunomodulatory therapy in COVID-19: role of 
chloroquine and anti-IL-6 monoclonal antibodies. Int J Antimicrob Agents. 2020 
Apr 16:105982. doi: 10.1016/j.ijantimicag.2020.105982 
25. J. B. Moore, C. H. June, Cytokine release syndrome in severe COVID-19. Science 
10.1126/science.abb8925 (2020) 
26. Lipworth B et al. Weathering the cytokine storm in susceptible patients with severe 
SARS-CoV-2 infection. J Allergy Clin Immunol Pract. 2020 Apr 17. pii: S2213-
2198(20)30365-2.  
27. Ye Q et al. The pathogenesis and treatment of the `Cytokine Storm' in COVID-19. 
28. J Infect. 2020 Apr 10. pii: S0163-4453(20)30165-1. 
29. Zhang C et al. The cytokine release syndrome (CRS) of severe COVID-19 and 
Interleukin-6 receptor (IL-6R) antagonist Tocilizumab may be the key to reduce the 
mortality. Int J Antimicrob Agents. 2020 Mar 29:105954.  
30. Beller JP,et al. First in Human Lung Transplantation: Adenosine A2A Receptor 
Agonist (Regadenoson) in Lung Transplantation. J Heart Lung Transplant. 2020 
Feb; Accepted for publication. 
FDA-Approved Labeling and Existing IND for Regadenoson:  
 
Regadenoson, the proposed drug in this proposal, is FDA approved agent for 1) 
Radionuclide myocardial perfusion imaging, 2) Phase II clinical trial in adult sickle cell 
disease patient (above reference #15), 3) Our phase I clinical trial in lung 
transplantation (IND# 062862, above reference #30). In the trial 1), Regadenoson (400 
micrograms) was given intravenously within 30 seconds. In trials 2) and 3), 
Regadenoson was administrated with low dose, slow infusion (1.44micrograms/kg/hour) 
for up to 12 hours.  No dose limiting toxicity was observed in these trials. Therefore, we 
anticipate the dose we are going to use in these moderate to severe COVID-19 patients 
in this proposal will be safe. The labeling of Regadenoson is attached.  
 
Results For In Vitro and In Vivo Toxicology: Regadenoson was negative in the Ames 
bacterial mutation assay, chromosomal aberration assay in Chinese hamster ovary 
(CHO) cells, and mouse bone marrow micronucleus assay. Long-term animal studies 
have not been conducted to evaluate LEXISCAN's carcinogenic potential or potential 
effects on fertility. Minimal cardiomyopathy (myocyte necrosis and inflammation) was 
observed in rats following single-dose administration of Regadenoson. Increased 
incidence of minimal cardiomyopathy was observed on day 2 in males at doses of 0.08, 
0.2 and 0.8 mg/kg (1/5, 2/5, and 5/5) and in females (2/5) at 0.8 mg/kg. In a separate 
study in male rats, the mean arterial pressure was decreased by 30 to 50% of baseline 
values for up to 90 minutes at Regadenoson doses of 0.2 and 0.8 mg/kg, respectively. 
No cardiomyopathy was noted in rats sacrificed 15 days following single administration 
of Regadenoson. The mechanism of the cardiomyopathy induced by Regadenoson was 
not elucidated in this study but was associated with the hypotensive effects of 

20 
 
Regadenoson. Profound hypotension induced by vasoactive drugs is known to cause 
cardiomyopathy in rats. 
Brief Assay Descriptions: The blood samples will be collected at different timepoints prior 
to, during, and after the Regadenoson infusion. Cytokines, biomarkers, and immune cell 
levels will be analyzed. The plasma level of Regadenoson in the participants will be 
measured according to our phase I trial in lung transplantation.  The samples (plasma) 
will be precipitated (150 µL) using 1350 µL of acetonitrile. Samples will be vortexed of 
15 seconds and spun for 10 minutes at max speed on a benchtop microfuge. 1400 µL of 
supernatant will be removed and dried. The samples will be reconstituted in 30 µL of 
50% methanol/0.1% formic acid – water. The LC-MS system consists of a Thermo 
Electron Orbitrap ID-X mass spectrometer with a HESI source interfaced to a Thermo 
Accucore Vanquish C18 1.5um, 2.1 x 100mm column. 10 µL of the extract will be 
injected and the compounds eluted from the column by a methanol/0.1% formic acid 
gradient at a flow rate of 250 µL/min over 0.12 hours (0.25 hours total time).  The 
nanospray ion source will be operated at 3.2 kV.  The sample will be analyzed by MS, 
MS/MS and PRM quantification.  
 
A Detailed Justification for The Proposed Dose, Dosing range, Number of Doses, and Dose 
Interval: Regadenoson will be given intravenously as 5 µg/kg loading dose over 30 mins 
(to avoid unpleasant side effects sometimes associated with the rapid bolus injection of 
Regadenoson), followed by a continuous slow infusion (1.44micrograms/kg/hour) with 
the use of a pediatric infusion pump for 6 hours. The initial high dose (5 µg/kg) infusion 
is based on: Regadenoson is a FDA approved drug for myocardial perfusion imaging 
with a bolus dosing (400 micrograms, in 10 seconds). The initial dose (5 µg/kg) is lower 
than the MPI dose (400 µg).  And it will be given slower as a bolus over 30 mins. The 
low dosage (1.44micrograms/kg/hour) slow infusion is based on the Sickle cell disease 
phase II clinical trial and our clinical phase I trial in lung transplant patients. Both trials 
have demonstrated that low dosage infusion(1.44micrograms/kg/hour) is safe with no 
dose limiting toxicities up to 12 hours (above reference #30). A loading dose is needed 
in the present study to get effective drug concentrations to the patients as soon as 
possible after diagnosis of cytokine storm syndrome. We will keep Aminophylline, a 
competitive adenosine receptor antagonist, on hand as a rescue medication for rare 
side effects of Regadenoson, such as bronchoconstriction.  Aminophylline has been 
used to terminate persistent pharmacodynamic effects. In such case, aminophylline 
may be administered in doses ranging from 50 mg to 250 mg by slow intravenous 
injection (50 mg to 100 mg over 30–60 seconds). 
 
Trial Timeline 
Timeline: Please see the attached for the detailed (Table 2) projected timeline for each 
patient.  A loading dose is needed in the present study to get effective drug 
concentrations to the patients as soon as possible after diagnosis of cytokine storm 
syndrome in hospitalized COVID-19 patients. We propose to treat a total of 40 
moderate to severe COVID-19 patients in this protocol. In this trial, the discontinuation 
from study drug is defined as any subject discontinuing Regadenoson treatment or 
discontinuing from the study post drug treatment for any reasons (such as, COVID-19 

21 
 
caused mortality, comorbidity caused serious injury). Because the study involves a 
single Regadenoson treatment with a duration less than 7 hours, the possibility of 
discontinuation from the study drug is very low. Withdraw from the study is defined as 
any subject or his/her LAR willingly withdrawing from the clinical trial for any reasons. 
The collected data from discontinued subjects may also be used in the outcome 
analysis.  
 
Our Retention and Follow Up Plans: Since study participation is 30 days, we anticipate 
that most participating subjects will remain either as an inpatient or will follow up 
frequently after COVID19 diagnosis and recovery. Patients will be monitored by study 
personnel according to the Post Infusion Procedures. We will try to minimize missing 
data in this trial by taking the following steps: We will encourage patients who 
discontinue therapy to remain in the study and to continue follow-up for all key safety 
and efficacy outcomes. Due to the pandemic, we will follow-up with these patients 
virtually via phone for all required timepoints post Regadenoson infusion that occur after 
discharge. We will record vital status for all patients. We will also take the following 
actions (1) the protocol and informed consent forms clearly differentiate treatment 
discontinuation from study withdrawal; (2) site investigators will be trained on the 
importance of retention and steps to prevent missing data; (3) the consent forms include 
a statement educating patients about the continued scientific importance of their data 
even if they discontinue study treatment early; and (4) take steps to be able to ascertain 
vital status in all randomized patients (e.g., with a vital records search).  
Infusion of Regadenoson will be added to current standard of care. We recognize that 
standard of care may change as the study progresses and these issues will be 
addressed as they arise. If not completed as standard of care, CRP will be collected at 
screening and on day 1,  
The End of Study: We anticipate the Regadenoson treatment will 1) enhance lung 
function by reducing hypoxia (as measured by pulse oximetry, ventilator parameters, 
ABGs as clinically indicated, and CXR findings), and 2) increase survival. At the end of 
this study, we will perform primary efficacy analyses and survival analyses.  If this 
statistical analysis proves that Regadenoson treatment enhanced lung function, 
shortened the length of staying in ICU and/or hospital, and increased survival when 
compared with the randomized placebo-control group, we will 1) pursue a large scale 
multiple sites phase III trial for the efficacy and long term safety of Regadenoson in 
moderate to severe COVID-19 patients, 2) will explore the mechanisms of its efficacy by 
measuring levels of pro- and anti- inflammatory cytokines (such as IL-1β, IL-4, IL-6, IL-
8, IL-10, IL-12, TNFα, IFN-γ etc) and levels of enzymes and their inhibitors (MMP-2, 
MMP-9, MPO, neutrophil elastase, TIMP-1, TIMP-2, etc) and activation of 
inflammatory/immune cells (such as macrophages, neutrophils, monocytes, invariant 

22 
 
NKT cells, etc).  
 
Volume 3: Detailed DSMB Plan (Regadenoson trial on COVID-19) 
 
Introduction 
 
This study will utilize a Data Safety Monitoring Board to be requested through the 
National Institute of Health.  The DSMB will follow the guidelines as described in the 
NIH issued policy on data and safety monitoring 
(http://www.nhlbi.nih.gov/research/funding/human-subjects/data-safety-monitoring-
policy).   Safety reports will include summary tables describing patient enrollment, 
baseline characteristics of patients, adverse events, serious adverse events and any 
other relevant data requested by the board.  The DSMB may pause or halt the trial at 
any time based on data from this or other trials.  The DSMB will determine the 
frequency of their meetings and establish a charter for this trial prior to the enrollment of 
the first subject in this study.   
 
Responsibilities of the DSMB 
 
Protections Against Risk and Loss of Confidentiality  
All research interventions will be administered by trained healthcare professionals at 
each site.  Resuscitation equipment and trained personnel will be immediately available 
during the infusion procedure.   
The federal regulation under the Health Insurance Portability and Accountability Act 
(HIPPA) governs the protection of individual identifiable health information.  The 
University of Maryland Baltimore Institutional Review Board for Health Sciences 
Research serves as the Privacy Board and oversees institutional compliance with and 
interpretation of the HIPPA Privacy Rule. Institutional policies contain best practices for 
activities such as secure email and written documentation regarding individual patients 
and provides resources for clinical staff and investigators on safeguards to protect 
patient rights.  Only approved investigators and research staff will have access to the 
data for this study.  Institutional Data Protections Standards will be followed for 
collection and storage of the research data which contains Protected Health Information 
(PHI).  HIPPA identifiers will be destroyed with the data after all retention requirements 
have been met. 
Monitoring Plan 
Study site monitoring will be conducted by the University of Maryland, Baltimore Office 
of Accountability and Compliance (UMB OAC).  For instances of remote monitoring, 
participating institutions will be required to forward de-identified copies of subjects’ 
medical record and source documents to the UMB OAC to aid in source documentation 
verification.  A complete documentation of the monitoring plan is found in the full Site 
Monitoring Plan. 
 

23 
 
 
STUDY CONDUCT AND ETHICAL CONSIDERATIONS 
This study will be conducted in accordance with the standards of Good Clinical Practice 
(GCP), all applicable federal, state, and local laws, and in accord with the ethical 
principles that originated in the Declaration of Helsinki.  The PI will ensure that staff are 
trained and carry out the study in accord with the protocol specifications.  The PI will 
ensure that all study site personnel are aware that the study protocol and all data 
generated are confidential and should not be disclosed to third parties (with the 
exception of local and national regulatory bodies which require access for oversight 
purposes). As part of our routine in clinical research at the University of Maryland, we 
collect all disparity data and report it to the IRB on an annual basis during the continuing 
review process. The study may not begin at each site until IRB approval has been 
obtained. 
All COVID-19 clinical research studies at the medical center are overseen by the 
institution’s COVID-19 task force committee that helps organize the screening of 
COVID-19 patients for study enrollment.  They have instituted a daily research huddle to 
facilitate this process and direct potential study subjects to the most appropriate clinical 
trials.  All active studies are invited to this meeting where the newly admitted/diagnosed 
COVID-19 patients are discussed and presented for consideration of enrollment in 
clinical trials. This group of clinicians and investigators has been conducting this 
meeting since the Spring 2020 and thus far it has been a very successful mechanism by 
which patients are enrolled into clinical trials in a fair and clinically relevant approach. 
We will have a representative from our study team attend this meeting each day and do 
not anticipate any barriers or conflicts related to competing clinical trials.   
Consent Forms and the Consenting Process 
Consent forms will be written in accord with 21 CFR 50 and will be reviewed and 
approved by each institutions IRB prior to use. Subjects or legally authorized 
representatives (LARs) should be educated separately about the risks associated with 
COVID-19.  Informed consent will be obtained from each participant or LAR prior to 
conducting any study-specific procedures. 
Since COVID19 positive patients are in isolation rooms, discussion of the study is more 
complicated.  
If the patient is alert and not intubated, the consent form could be presented to the 
patient in 2 ways; either physically by the nurse or electronically (patient can view via 
iPad). The PI will then call into the patient room and go over the study with the patient 
and answer any questions they may have. 
The patient will be evaluated to determine if they have the capacity to consent to the 
study. This evaluation will be documented. If the patient is intubated or otherwise 
incapacitated, the legally authorized representative (LAR) will be identified and their 
relationship to the patient documented. PI will call the LAR to discuss the study. The 
research staff will send the consent form electronically to the LAR, and the consent 

24 
 
process will occur over the phone, since there may be a no visitor policy in place for 
COVID patients. Verbal consent will be accepted. 
Maintenance of Study Documents 
Signed consent forms and other research records will be retained in a confidential 
manner.  Record retention will be in accord with 21 CFR 312.62 and HIPAA regulations. 
 
Organization and Interactions 
 
Communication with DSMB members will be primarily through the NHLBI Program 
Office.  It is expected that study investigators will not communicate with DSMB 
members about the study directly, except when making presentations or responding to 
questions at DSMB meetings or during conference calls.  
 
This charter may be sent, if requested, to an IRB or an outside party under a formal 
FOIA inquiry.   
 
DSMB Members and NHLBI Program Staff 
 
DSMB members and their expertise are listed in Appendix A.  NHLBI Program Staff 
involved in the study and their responsibilities are listed in Appendix B. Consistent with 
NHLBI policy, each DSMB is assigned an Executive Secretary (ES) to provide an 
unbiased staff interface between the DSMB members and other meeting participants, 
especially during closed and executive sessions.  The ES is responsible for assuring the 
accuracy and timely transmission of the final recommendations and DSMB minutes. 
 
Roles of NHLBI staff in DSMB Meetings 
 
• NHLBI program staff members involved in the day-to-day conduct of the study 
may attend the open sessions of DSMB meetings.  These Program staff may 
attend portions of a closed session as needed, but not when post-randomization 
outcome data by treatment group will be discussed.   
• NHLBI’s Office of Biostatistics Research has assigned a statistician to this 
DSMB. The NHLBI study statistician will also serve as a resource to the DSMB 
as needed.   
• The NHLBI ES will be a federal employee with appropriate expertise and training 
who has no other involvement in the conduct of the trial and does not report 
directly to the lead program official. 
• The ES is the only NHLBI staff member who can routinely be in the executive 
session.  The DSMB can opt to have an executive session without the ES, but 
then they will be responsible for minutes for that portion of the meeting.  The 
DSMB can request to have other staff members attend the executive session to 
provide additional information as needed. 
• The NHLBI ES and statistician are expected to report issues of substantive 
concern to the NHLBI Division Director responsible for the trial.  The NHLBI 

25 
 
Division Director will communicate with the Office of the Director, NHLBI. Under 
special circumstances, and with the concurrence of the DSMB Chair, the Division 
leadership and Director and Deputy Director of the NHLBI may see unmasked 
data presented at DSMB meetings.  
• There may be occasions when it is appropriate for new staff not involved in the 
study to attend a DSMB meeting as a training opportunity.  This will be discussed 
with the DSMB Chair before the meeting; the new staff member(s) would attend 
only the portions of the meeting outlined in the first bullet above. 
 
Scheduling, Timing, and Organization of Meetings 
 
DSMB meetings are usually held by conference call, or in the Washington, DC area 
when an in-person meeting is required.  
 
The purposes of the first meeting are to: 
 
• Convey NHLBI’s expectations for DSMB operations 
• Review this Charter 
• Provide an overview of study activities 
• Review and accept or make recommendations to the protocol, consent and the 
analysis plan before approving these documents to be sent to the IRB.  
 
Enrollment in the study cannot begin until the DSMB’s recommendations for approval 
has been accepted by the Director, NHLBI, and approval has been obtained from the 
IRB. 
 
Meetings will be scheduled based on enrollment. They will occur after the completion of 
cohort 1 as described in the safety assessment section. Meetings will also be scheduled 
after enrollment of 15, 25, and 40 subjects, with additional meetings or conference calls 
scheduled as needed to review SAEs or other issues. Meetings and conference calls 
will be scheduled by the CCC in collaboration with the NHLBI Program Office.   
 
The agenda for DSMB meetings and calls will be drafted by the DSMB chair in 
consultation with NHLBI staff.  The ES will finalize the agenda after consultation with the 
DSMB Chair.  The agenda and meeting materials should be distributed by the NHLBI 
two weeks before each meeting or call.   
 
At the time that the agenda is sent out, and again at the beginning of the meeting, the 
ES will ask all DSMB members to state whether they have developed any new conflicts 
of interest since the last formal annual report to NHLBI.  If a new conflict is reported, the 
Chair and staff will determine if the conflict limits the ability of the DSMB member to 
participate in the discussion.   
 
The DSMB will review adverse event data, other safety data, quality and completeness 
of study data, and enrollment data at each meeting to ensure proper trial conduct.  
Study personnel should provide any new literature particularly pertinent to the trial, 

26 
 
along with their recommendation as to whether it affects the trial conduct or design.  
The DSMB will review the informed consent form when it reviews the protocol. The 
DSMB will review the consent periodically and/or as needed and consider whether the 
consent form requires revision in light of any new findings or amendments.  At intervals, 
if included in the statistical analysis plan, the DSMB will also review formal interim 
analyses of the primary end point. 
 
In addition to regular meetings, it may be necessary to convene the DSMB urgently on 
an ad hoc basis to discuss new data or other information that raises questions about 
equipoise, safety, or anything else in the trial.   
 
It is expected that all DSMB members will attend every meeting and conference call.  
However, it is recognized that this may not always be possible. A quorum for voting is 
half of the standing members plus one. The Board may wish to decide if particular 
expertise is needed within the quorum for a particular meeting. All standing Monitoring 
Board members are voting members.  The Board may decide in advance whether ad 
hoc members can vote. 
 
Discussion of Confidential Material 
 
DSMB meetings and calls will be organized into open, closed, and executive sessions. 
 
• During the open sessions, information will be presented to the DSMB by the 
principal investigator or staff at UMB, study investigators, and NHLBI staff as 
appropriate, with time for discussion. 
 
• During the closed sessions, the DSMB, UVA statistician, and NHLBI statistician 
will discuss confidential data from the study, including information on efficacy and 
safety.  NHLBI’s expectation is that the DSMB will review unmasked data.  If the 
closed session occurs on a conference call, steps will be taken to ensure that 
only the appropriate participants are on the call, and to invite others to re-join the 
call only at the conclusion of the closed session. 
 
• The DSMB may hold an executive session in which only the DSMB members 
are present. The NHLBI ES may attend the executive session at the invitation of 
the DSMB Chair.  If the ES does not attend the executive session, the DSMB 
Chair will be responsible for summarizing the DSMB’s discussion and 
recommendations to the ES.   
 
Voting on recommendations will follow Robert’s Rules of Order. 
 
At the conclusion of the closed and executive sessions, the DSMB chair may provide a 
summary of the preliminary recommendations to the lead investigators and masked 
NHLBI staff to provide an opportunity for study investigators, the PI, and NHLBI to ask 

27 
 
questions to clarify the recommendations.  Recommendations that would unmask 
results, such as a recommendation to close a study prematurely, should not be 
disclosed until approved by NHLBI leadership.  The meeting is then adjourned. 
 
 
Reports of DSMB Deliberations 
 
• Formal minutes:  The NHLBI ES is responsible for preparation and transmission 
of the formal DSMB minutes to the Director of the applicable Division within 14 
calendar days of each meeting or call.  Minutes will document whether there is 
conflict of interest on the part of Board members and will summarize the key 
points of the discussion and debate, requests for additional information, response 
of the investigators to previous recommendations, and the recommendations 
from the current meeting.   
• Following division review, the minutes are sent to: 
 
o DSMB Chair, who approves them on behalf of the DSMB 
o Division of Lung Diseases Director, NHLBI, for final Institute approval 
 
• Once the Division of Lung Diseases Director, NHLBI has approved the minutes, 
they are considered final. 
• Recommendations of the Board are sent to the primary study investigator(s) and 
may be included in the materials for the subsequent DSMB meeting. 
• Reports to IRB:  The NHLBI program office will prepare a Summary Report and 
submit it to primary study investigators within 30 calendar days of each meeting.  
Primary study investigators will forward the Summary Report to the IRB. 
• If the DSMB does not identify any safety or other protocol-related concerns, the 
Summary Report will state that: 
 
o a review of outcome data, adverse events, and information relating to 
study 
performance (e.g., data timeliness, completeness, and quality) across all 
centers took place on a given date 
o the observed frequency of adverse events did not exceed what was 
expected and indicated in the informed consent; 
o a review of recent literature relevant to the research took place, and; 
o the DSMB recommended that the study continue without modification of 
the protocol or informed consent 
 
• If the DSMB does identify concerns, the NHLBI staff will distribute, as soon as 
feasible, preferably within 7 calendar days of the DSMB meeting, the Summary 
Report as outlined above, outlining the concerns and the basis for any 
recommendations that the DSMB has made in response to the concerns. 
Adverse event reporting will be consistent with NHLBI policy.   
 
 

28 
 
Reports to the DSMB  
 
For each meeting, unblinded analyses and reports will be prepared by the DSMB 
statistician as this is a double blinded study and the PI and study staff will not have 
access to the data required to prepare these reports. Reports will be prepared 
according to the DSMB’s recommendations regarding which data should be presented 
and the format of the data presentation. 
 
Statistical Monitoring Guidelines 
 
The DSMB will review the adequacy of the statistical monitoring plan.  The final plan, 
whether part of a research protocol or separate document, will be maintained as an 
appendix to this Charter. The DSMB should discuss the statistical monitoring 
procedures that will be followed to guide recommendations about termination or 
continuation of the trial.  These procedures could include guidelines for termination due 
to safety reasons.   
 
ADVERSE EVENTS AND REPORTING 
This section defines the types of safety data that will be collected under this protocol 
and outlines the procedures for appropriately collecting, recording and reporting those 
data.   
Definitions 
Adverse Event 
For the purposes of this protocol, an adverse event will be defined as any adverse 
medical change (i.e., de novo or increased severity in a preexisting condition) from the 
subject’s baseline condition, that occurs during the course of the clinical study, after 
receiving Regadenoson infusion through Day 30, whether considered device related or 
not and meeting the protocol requirements. 
Anticipated symptoms caused by the COVID-19 infection and standard care are 
expected to occur between time of Regadenoson infusion and Day 30. The following 
are examples of anticipated events caused by the COVID-19 infection and standard 
care are medications not considered AE’s: 
• Fever   
• Incubation related inflammation, sour throat   
• Shortness of breath   
• Pneumonia 
• Renal insufficiencies secondary to medications  
• Sleep issues (insomnia)  
• Gastrointestinal discomfort (i.e. constipation, decreased appetite, diarrhea)  
• Pulmonary observations (i.e. wheezing, cough)  
• Neurological observations (i.e. hallucinations, confusion)  
• Renal observations (i.e. urinary tract infections, urinary retention)  

29 
 
• There may be additional expected events not listed which may be documented in 
the patient’s medical record by the investigator.  
The events above are not considered adverse events for this study and will not be 
recorded. 
Serious Adverse Event  
• A Serious Adverse Event (SAE) is one that:  
• Leads to death; 
• Leads to serious deterioration in the health of the study patient that: 
o Results in life-threatening illness or injury; 
o Results in a permanent impairment of a body structure or a body function; 
o Requires in patient hospitalization or prolongation of existing 
hospitalization; 
o Results in medical or surgical intervention to prevent permanent 
impairment to body structure or a body function; 
• Results in congenital anomaly/birth defect 
• Significant medical event. 
NOTE: A planned hospitalization for a pre-existing condition, or anticipated procedures 
such as routine transplant related biopsy or elective surgery will not be considered 
serious adverse events.  
Note that seriousness and severity are separate concepts. The term “severe” refers to 
the intensity of a specific event; a severe event may be of minor medical significance 
(e.g., a severe leg cramp). The term “serious” is based on an outcome or action criteria 
that are usually associated with events that pose a threat to the patient’s life or 
functioning. An event that is mild in severity is serious if it leads to one of the outcomes 
defined above. 
Unanticipated problem involving risks to subjects or others (UP) - Any incident, 
experience or outcome that meets all the following criteria: 
• Unexpected (in terms of nature, severity, or frequency) given: 
• The research procedures that are described in the protocol related-documents, 
such the IRB-approved research protocol and the informed consent form 
document and, 
• The characteristics of the subject population being studied;  
• Related or possibly related to the subject participation in research; and 

30 
 
• Suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic, or social harm) related to the 
research than was previously known or recognized. 
Grading of Adverse Events – Events will be graded by using the Common Terminology 
Criteria for Adverse Events (CTCAE) Criteria version 4.03. 
Attribution Assessment 
Attribution – the determination and documentation of whether an adverse event is 
related to Regadenoson infusion. 
Attribution Categories: 
1. Not Related – Event clearly related to other factors (e.g., clinical state, 
other therapies; concomitant drugs) 
2. Possibly Related – Sequence of event is compatible with device, or 
procedure, but could have been produced by other factors 
3. Probably Related - Sequence of event is compatible with device, or 
procedure and cannot be explained by other factors without much 
doubt 
4. Definitely Related - Sequence of event is compatible with device or 
procedure and beyond doubt cannot be explained by other factors 
Severity 
The degree of severity of the AE to the subject’s health will be documented on the AE 
CRF.   
Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic 
observations only; intervention not indicated. 
Grade 2 Moderate; minimal, local or noninvasive intervention indicated; limiting 
age-appropriate instrumental ADL. 
Grade 3 Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-
care ADL. 
  
Grade 4 Life-threatening consequences; urgent intervention indicated. 
  
Grade 5 Death related to AE. 
Unanticipated Adverse Device Effect (UADE) 
A UADE is any serious adverse effect on health or safety, any life-threatening problem 
or death caused by, or associated with a device, if that effect, problem, or death was not 
previously identified in nature, severity, or degree of incidence in the investigational plan 
(e.g., ICF, Study Protocol, Instructions for Use (IFU), publications, etc.) or any other 

31 
 
unanticipated serious problem associated with a device that relates to the rights, safety, 
or welfare of subjects. 
Adverse Event Recording 
All adverse events will be collected starting at time of infusion through POD 30.  Events 
that meet the definition of “anticipated” (see section 8.1.1) will not be recorded as 
adverse events unless the event meets the criteria of a Serious Adverse Event.  
Adverse events should be recorded on a case report form and will be assessed for 
seriousness, severity, attribution and expectedness by the site Principal Investigator.    
Reporting Requirements 
Expedited Reporting 
The following events require expedited reporting, i.e., notification to the study 
monitoring team within 24 hours and DSMB and NHLBI within at least 7 calendar days 
of learning of the event’s occurrence:  
• All Serious Adverse Events that are at least possibly related/associated with the 
study device.  
• All unanticipated problems and unanticipated adverse device effects that occur 
within 30 days of Regadenoson infusion.  
• All (fatal) events within 30 days of Regadenoson infusion.  
Efforts should be made to report expedited events to the DSMB and NHLBI as soon as 
possible but within at least 7 days.  All other events will be recorded in the electronic 
data capture system. 
Events that require expedited reporting must be reported by email or telephone within 
24 hours to: 
Office of Accountability and Compliance 
University of Maryland, Baltimore 
410-706-2281 
oac@umaryland.edu 
Expedited reports will also be submitted to the DSMB and NHLBI (see Table 4) within 7 
calendar days of learning of the event’s occurrence. 
Reporting to the UMB HSR-IRB and DSMB  
The Principal Investigator or designee is responsible for reporting SAEs and 
unanticipated problems to the site IRB according to the participating site institutional 
guidelines. 
 
 

32 
 
 
   Table 4.  DSMB and NHLBI Reporting Requirements 
DSMB and NHLBI 
Type of Event 
To whom will 
it be 
reported: 
Time Frame for 
Reporting 
How reported? 
All Adverse Events  
DSMB and 
NHLBI 
30 calendar days 
prior to scheduled 
DSMB meetings 
DSMB report will include 
listing of all Adverse 
Events  
Reportable SAE’s and 
Unanticipated 
Problems  
DSMB and 
NHLBI 
7 calendar days 
of knowledge of 
the event 
Report to Designated 
DSMB member and NHLBI 
DSMB Reports 
IRB 
  
15 calendar days 
of the study team 
receiving the 
report 
Copy of DSMB report 
 
Reporting to the FDA 
The Sponsor for the study is responsible for providing safety updates to the FDA per the 
following guidelines (Table 5).  The reporting times refer to the time the study team received 
knowledge of the AE. 
Table 5.  FDA Reporting Requirements 
UMB PI HELD IDE 
Type of Event 
To whom 
will it be 
reported: 
Time Frame for 
Reporting 
How reported? 
Life-threatening and/or 
fatal unexpected events 
related or possibly 
related to the use of the 
investigational agent. 
FDA 
Within 7 calendar 
days of the study 
team learning of 
the event 
Form FDA 3500A 
(MedWatch) or narrative 
Serious, unexpected 
and related or possibly 
related adverse events 
FDA 
Within 15 
calendar days 
after the study 
team receives 
knowledge of the 
event 
Form FDA 3500A 
(MedWatch) or narrative 

33 
 
 
 
 
 
 
Unanticipated Adverse 
Device Effects 
FDA 
Within 10 working 
days of the study 
team learning of 
the event 
Form FDA 3500A 
(MedWatch) or narrative 
All adverse events 
FDA 
Annually 
IDE annual report 
 

34 
 
Appendix A 
 
Jason D. Christie, MD, MSCE (Chair) 
Hospital of the University of PA - Univ of PA School of 
Medicine 
Division of Pulmonary and Critical Care Medicine 
Center for Clinical Epidemiology and Biostatistics 
423 Guardian Drive 
717 Blockley Hall 
Philadelphia, PA 19104 
Phone: 212 573 3209 
Fax: 212 573-0198 
email: jchristi@mail.med.upenn.edu 
 
Robert Bies, Pharm.D., Ph.D. 
Associate Professor 
University of New York 
Department of Pharmaceutical Sciences 
372 Kapoor Hall 
Buffalo, NY 14214-8033 
Phone: (716) 645-7315 
email: robertbi@buffalo.edu 
 
Elisa J. Gordon, PhD, MPH 
Professor of Surgery, Division of Transplantation 
Northwestern Univ. Feinberg School of Medicine 
633 N. St. Clair, Suite 20th Floor 
Chicago, IL 60611 
Phone: 312 503-5563 
email: e-gordon@northwestern.edu 
 
Matthew G. Hartwig, MD 
Associate Professor of Surgery 
Duke University School of Medicine 
8664A Hafs Bldg 
DUMC Box 3863 Med Ctr 
Durham, NC 27710 
Phone: (919) 613-5635 
email: matthew.hartwig@duke.edu 
 
David J. Pinsky, MD 
Director, Frankel Cardiovascular Medicine 
University of Michigan 
1500 E Medical Center Dr SPC 5856 
Cardiovascular Center Floor 3 
2141 Cardiovascular Center 
Ann Arbor, MI 48109-5853 
Phone: 734 936-3500 
email: dpinsky@umich.edu 
 
Stephen R. Wisnieski, PhD 
Professor, Design, Biostatistics and Epidemiology 
University of Pittsburgh School of Public Health 
127 Parran Hall 
Pittsburgh, PA 15261 
Phone: 412 624 5218 
Fax: 412 624-3775 
email: wisniew@edc.pitt.edu 
 
 

35 
 
Appendix B 
Executive Secretary 
 
 
 
 
 
 
 
Marishka Brown, Ph.D. 
Executive Secretary, Regadenoson DSMB 
Director, National Center on Sleep Disorders Research 
Division of Lung Diseases 
National Heart, Lung, and Blood Institute 
National Institutes of Health 
Bethesda, MD 20892 
Phone: 301-435-0199 
 
 
Peyvand Ghofrani, MDE, CCRA 
Clinical Trial Specialist, Division of Lung Diseases 
National Heart, Lung and Blood Institute 
National Institutes of Health 
6701 Rockledge Drive, MSC 7952 
Bethesda, MD 20892 
Tel: (301) 435-0199 
Fax: (301) 480-3451 
Email: ghofranip@nhlbi.nih.gov 
 
Mario Stylianou, Ph.D. 
Mathematical Statistician 
National Heart, Lung and Blood Institute 
National Institutes of Health 
6701 Rockledge Dr., MSC 7913 
Bethesda, Maryland 20892 
Tel: (301) 435-0434 
Email: stylianm@nhlbi.nih.gov 
 
Matt Craig, Ph.D. 
Program Officer, Division of Lung Diseases 
National Heart, Lung and Blood Institute 
National Institutes of Health 
6701 Rockledge Drive, MSC 7952 
Bethesda, MD 20892 
Tel: (301) 435-0222 
Fax: (301) 480-3557 
Email: matt.craig@nih.gov 
 
Lisa Viviano, BSN 
Clinical Trial Specialist, Division of Lung Diseases 
National Heart, Lung and Blood Institute 
National Institutes of Health 
6701 Rockledge Drive, MSC 7952 
Bethesda, MD 20892 
Tel: (301) 435-0233 
Fax: (301) 480-3547 
Email: lisa.viviano@nih.gov 
 
 
 

36 
 
Volume 4: Appendix 
APPENDIX A: NIAID 8-Point Ordinal Scale for COVID-19 
The ordinal scale is an assessment of the clinical status at the first assessment of a given study 
day. The scale is as follows:  
1. Death;  
2. Hospitalized, on invasive mechanical ventilation or extracorporeal membrane oxygenation 
(ECMO);  
3. Hospitalized, on non-invasive ventilation or high flow oxygen devices;  
4. Hospitalized, requiring supplemental oxygen;  
5. Hospitalized, not requiring supplemental oxygen, requiring ongoing medical care (COVID-
19 or otherwise); 
6. Hospitalized, not requiring supplemental oxygen, and no longer requires ongoing medical 
care (e.g., patient still admitted for isolation purposes only). 
7. Not hospitalized, limitation on activities;  
8. Not hospitalized, no limitations on activities.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

37 
 
Table 1, Detailed Grading Scales of Toxicity of Regadenoson  
 
CTCAE v4.0 
Term 
Grade 1    
Grade 2    
Grade 3    
Grade 4    
Grade 
5    
1 
Acute 
coronary 
syndrome 
 - 
Symptomatic, 
progressive 
angina; cardiac 
enzymes 
normal; 
hemodynamicall
y stable 
Symptomatic, 
unstable angina 
and/or acute 
myocardial 
infarction, cardiac 
enzymes abnormal, 
hemodynamically 
stable 
Symptomatic, 
unstable angina 
and/or acute 
myocardial 
infarction, 
cardiac enzymes 
abnormal, 
hemodynamically 
unstable 
Death 
2 
Atrial 
fibrillation 
Asymptom
atic, 
interventio
n not 
indicated 
Non-urgent 
medical 
intervention 
indicated 
Symptomatic and 
incompletely 
controlled 
medically, or 
controlled with 
device (e.g., 
pacemaker), or 
ablation 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
3 
Atrial flutter 
Asymptom
atic, 
interventio
n not 
indicated 
Non-urgent 
medical 
intervention 
indicated 
Symptomatic and 
incompletely 
controlled 
medically, or 
controlled with 
device (e.g., 
pacemaker), or 
ablation 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
4 
Atrioventric
ular block 
complete 
 - 
Non-urgent 
intervention 
indicated 
Symptomatic and 
incompletely 
controlled 
medically, or 
controlled with 
device (e.g., 
pacemaker) 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
5 
Atrioventric
ular block 
first degree 
Asymptom
atic, 
interventio
n not 
indicated 
Non-urgent 
intervention 
indicated 
 - 
 - 
 - 
6 
Cardiac 
arrest 
 - 
 - 
 - 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
7 
Heart failure 
Asymptom
atic with 
Symptoms with 
mild to 
Severe with 
symptoms at rest 
Life-threatening 
consequences; 
Death 

38 
 
laboratory 
(e.g., BNP 
[B-
Natriuretic 
Peptide ]) 
or cardiac 
imaging 
abnormaliti
es 
moderate 
activity or 
exertion 
or with minimal 
activity or exertion; 
intervention 
indicated 
urgent 
intervention 
indicated (e.g., 
continuous IV 
therapy or 
mechanical 
hemodynamic 
support) 
8 
Mobitz 
(type) II 
atrioventric
ular block 
Asymptom
atic, 
interventio
n not 
indicated 
Symptomatic; 
medical 
intervention 
indicated 
Symptomatic and 
incompletely 
controlled 
medically, or 
controlled with 
device (e.g., 
pacemaker) 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
9 
Mobitz type 
I 
Asymptom
atic, 
interventio
n not 
indicated 
Symptomatic; 
medical 
intervention 
indicated 
Symptomatic and 
incompletely 
controlled 
medically, or 
controlled with 
device (e.g., 
pacemaker) 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
10 
Myocardial 
infarction 
 - 
Asymptomatic 
and cardiac 
enzymes 
minimally 
abnormal and 
no evidence of 
ischemic ECG 
changes 
Severe symptoms; 
cardiac enzymes 
abnormal; 
hemodynamically 
stable; ECG 
changes consistent 
with infarction 
Life-threatening 
consequences; 
hemodynamically 
unstable 
Death 
11 
Ventricular 
arrhythmia 
Asymptom
atic, 
interventio
n not 
indicated 
Non-urgent 
medical 
intervention 
indicated 
Medical 
intervention 
indicated 
Life-threatening 
consequences; 
hemodynamic 
compromise; 
urgent 
intervention 
indicated 
Death 
12 
Ventricular 
fibrillation 
 - 
 - 
 - 
Life-threatening 
consequences; 
hemodynamic 
compromise; 
urgent 
intervention 
indicated 
Death 
13 
Cardiac 
disorders - 
Asymptom
atic or mild 
Moderate; 
minimal, local or 
Severe or medically 
significant but not 
Life-threatening 
consequences; 
Death 

39 
 
Other, 
specify 
symptoms; 
clinical or 
diagnostic 
observatio
ns only; 
interventio
n not 
indicated 
noninvasive 
intervention 
indicated; 
limiting age-
appropriate 
instrumental 
ADL 
immediately life-
threatening; 
hospitalization or 
prolongation of 
existing 
hospitalization 
indicated; 
disabling;  limiting 
self care ADL 
urgent 
intervention 
indicated 
14 
Electrocardi
ogram QT 
corrected 
interval 
prolonged 
QTc 450 - 
480 ms 
QTc 481 - 500 
ms 
QTc >= 501 ms on 
at least two 
separate ECGs 
QTc >= 501 
or >60 ms change 
from baseline 
and Torsade de 
pointes or 
polymorphic 
ventricular 
tachycardia or 
signs/symptoms 
of serious 
arrhythmia 
 - 
15 
Headache 
Mild pain 
Moderate pain; 
limiting 
instrumental 
ADL 
Severe pain; 
limiting self care 
ADL 
 - 
 - 
16 
Stroke 
Asymptom
atic or mild 
neurologic 
deficit; 
radiographi
c findings 
only 
Moderate 
neurologic 
deficit 
Severe neurologic 
deficit 
Life-threatening 
consequences; 
urgent 
intervention 
indicated 
Death 
17 
Acute 
kidney injury 
Creatinine 
level 
increase 
of >0.3 
mg/dL; 
creatinine 
1.5 - 2.0 x 
above 
baseline 
Creatinine 2 - 3 
x above baseline 
Creatinine >3 x 
baseline or >4.0 
mg/dL; 
hospitalization 
indicated 
Life-threatening 
consequences; 
dialysis indicated 
Death 
18 
Bronchial 
obstruction 
Asymptom
atic; clinical 
or 
diagnostic 
observatio
ns only; 
interventio
Symptomatic 
(e.g., mild 
wheezing); 
endoscopic 
evaluation 
indicated; 
radiographic 
Shortness of breath 
with stridor; 
endoscopic 
intervention 
indicated (e.g., 
laser, stent 
placement) 
Life-threatening 
respiratory or 
hemodynamic 
compromise; 
intubation or 
urgent 
Death 

40 
 
n not 
indicated 
evidence of 
atelectasis/lobar 
collapse; 
medical 
management 
indicated (e.g., 
steroids, 
bronchodilators) 
intervention 
indicated 
19 
Bronchospas
m 
Mild 
symptoms; 
interventio
n not 
indicated 
Symptomatic; 
medical 
intervention 
indicated; 
limiting 
instrumental 
ADL 
Limiting self care 
ADL; oxygen 
saturation 
decreased 
Life-threatening 
respiratory or 
hemodynamic 
compromise; 
intubation or 
urgent 
intervention 
indicated 
Death 
  
 
 

41 
 
Table 2: Detailed Projected Timeline for Each Subject: 
 
Screening 
                                   Treatment/follow-up 
Observations 
D-3 to D1 
D1 
D3 
D7 ± 1 
D15 ± 2 D30 ± 2 
Confirm COVID-19 results 
X 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
Informed Consent 
X 
 
 
 
 
 
Confirm eligibility 
X 
 
 
 
 
 
Collect demographic data 
X 
 
 
 
 
 
Pregnancy Test 
X1 
 
 
 
 
 
Randomization  
X2 
 
 
 
 
 
Study Product administration 
 
X 
 
 
 
 
AE assessments 
 
X 
X 
X 
X 
X 
Physical Examination3 
X 
X 
X* 
X* 
X* 
X* 
Laboratory testing4 
X 
X 
X* 
X* 
X* 
X* 
Arterial blood gas5 
X 
X 
X* 
X* 
X* 
X* 
Chest imaging 
X 
X* 
X* 
X* 
X* 
X* 
Cardiac monitoring/EKG 
X 
X 
X* 
X* 
X* 
X* 
Vital/Respiratory Status 
X 
X 
X 
X 
X 
X 
Research labs and storage6 
X 
X 
 
 
 
 
Notes: 
Day 1 assessments are to occur within 24 hours of infusion end. 
* Not required, but to be recorded if available. 
1 If female and of childbearing age. 
2 If enrolled in the randomization arm. 
3 Record available medications and vital signs including heart rate, blood pressure, oxygen saturation, respiratory rate 
4 Laboratory tests includes CBC with differential count, chemistries with creatinine, ALT, AST, total bilirubin, ESR, LDH, CK 
when available. PT, PTT, INR, TEG, CRP, and D-Dimer are required prior to infusion and on post infusion day 1.  
5 Required at baseline and D1 if arterial line present. 
6 For open enrollment and Randomized subjects: blood samples will be collected prior to infusion, immediately after the 
load dose, 4 hours into the low dose infusion, and post infusion day 1.