ACTIV-6: COVID-19 Outpatient Randomized Trial to Evaluate Efficacy of Repurposed Medications
Phase: PHASE3
Conditions: Covid19
Sponsor: Susanna Naggie, MD

ACTIV-6: COVID-19 Study of Repurposed Medications - Arm B (Fluvoxamine)  
NCT05890586 
Protocol [v3.0] date Jul 06, 2021 
 

CONFIDENTIAL 
ACTIV-6 Protocol [v3.0] 
 
 
1 
 
 
 
ACTIV-6: COVID-19 Outpatient Randomized Trial to Evaluate Efficacy of Repurposed 
Medications 
 
 
 
 
Protocol Number:  
 
Pending 
PIND Number: 
 
155481 
Principal Investigator: 
Adrian Hernandez, MD, MHS 
Duke Clinical Research Institute 
200 Morris St. 
Durham, NC 27701 
Phone: 919-668-7515 
Email: adrian.hernandez@duke.edu 
Co-Principal 
Investigator/IND 
Sponsor: 
Susanna Naggie, MD, MHS 
Duke Clinical Research Institute 
200 Morris St. 
Durham, NC 27701 
Phone: 919-684-2584 
Email: susanna.naggie@duke.edu 
Data Coordinating 
Center Investigator 
Chris Lindsell, PhD 
Vanderbilt University School of Medicine 
2525 West End Avenue 
Suite 1100, Rm 11129 
Nashville, TN 37203 
Phone: 615-343-9867 
Email: chris.lindsell@vumc.org 
Lead 
 
Funding Agency: 
 
National Center for Advancing Translational Sciences  
Version: 
 
3.0 
Date: 
06JUL2021 
 
 

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ACTIV-6 Protocol [v3.0] 
 
 
2 
Statement of Compliance 
 
This trial will be conducted in compliance with the International Council for Harmonisation 
(ICH) E6 (R2) guideline for Good Clinical Practice (GCP), and the applicable regulatory 
requirements from the United States (US) Code of Federal Regulations (CFR), including 45 CFR 
46 (Human Subjects Protection); 21 CFR 312 (Investigational New Drug); 21 CFR 50 (Informed 
Consent), and 21 CFR 56 (Institutional Review Board). 
All individuals who are responsible for the conduct, management, or oversight of this study have 
completed Human Subjects Protection and ICH GCP Training. 
 
 
 
 

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ACTIV-6 Protocol [v3.0] 
 
 
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Site Principal Investigator Statement 
 
I have read the protocol, including all appendices, and the package insert(s)/product label(s), and 
I agree that the protocol contains all necessary details for my staff and me to conduct this study 
as described. I will personally oversee the conduct of this study as outlined herein and will make 
a reasonable effort to complete the study within the time designated. I agree to make all 
reasonable efforts to adhere to the attached protocol. 
I will provide all study personnel under my supervision with copies of the protocol and access to 
all information provided by the sponsor or the sponsor’s representative. I will discuss this 
material with study personnel to ensure that they are fully informed about the efficacy and safety 
parameters and the conduct of the study in general. I am aware that, before beginning this study, 
the IRB, or equivalent oversite entity must approve this protocol in the clinical facility where it 
will be conducted. 
I agree to obtain informed consent from participants, as required by the IRB of record and 
according to government regulations and ICH guidelines. I further agree to report to the sponsor 
or its representative any adverse events in accordance with the terms of this protocol and the US 
CFR, Title 21, part 312.64, ICH GCP 4.11. I further agree to ensure the study is conducted in 
accordance with the provisions as stated and will comply with the prevailing local laws and 
customs. 
 
 
 
 
 
Site Principal Investigator Name (Print) 
 
 
 
 
 
 
 
Site Principal Investigator Signature 
 
Date 

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ACTIV-6 Protocol [v3.0] 
 
 
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Table of Contents 
1. 
Protocol Summary................................................................................................. 12 
1.1. 
Synopsis .................................................................................................................. 12 
1.2. 
Schema .................................................................................................................... 18 
2. 
Introduction .......................................................................................................... 19 
2.1. 
Study Rationale ........................................................................................................ 19 
2.2. 
Background.............................................................................................................. 19 
2.3. 
Benefit/Risk Assessment .......................................................................................... 20 
2.3.1. 
Risk Assessment....................................................................................................... 20 
2.3.2. 
Benefit Assessment .................................................................................................. 20 
3. 
Objectives and Endpoints...................................................................................... 21 
4. 
Study Design.......................................................................................................... 23 
4.1. 
Overall Design ......................................................................................................... 23 
4.2. 
End of Study Definition............................................................................................ 23 
5. 
Study Population ................................................................................................... 24 
5.1. 
Inclusion Criteria...................................................................................................... 24 
5.2. 
Exclusion Criteria .................................................................................................... 24 
5.3. 
Recruitment and Engagement ................................................................................... 24 
5.3.1. 
Participant Recruitment ............................................................................................ 24 
5.3.2. 
Participant Engagement ............................................................................................ 24 
5.3.3. 
Participant Randomization Process............................................................................ 25 
5.4. 
Screen Failures......................................................................................................... 25 
5.5. 
Enrollment ............................................................................................................... 25 
6. 
Study Drug(s) ........................................................................................................ 26 
6.1. 
Repurposed Medication Treatments .......................................................................... 26 
6.2. 
Placebo .................................................................................................................... 26 
6.3. 
Study Drug Accountability ....................................................................................... 26 
6.4. 
Concomitant Therapy ............................................................................................... 26 
6.5. 
Intervention After the End of the Study ..................................................................... 26 
7. 
Participant Withdrawal/Termination and Study Termination............................. 27 
7.1. 
Participant Withdrawal/Termination ......................................................................... 27 
7.2. 
Premature Termination or Suspension of the Study.................................................... 27 
7.3. 
Lost to Follow-up ..................................................................................................... 27 
8. 
Study Assessments and Procedures....................................................................... 29 
8.1. 
Schedule of Events ................................................................................................... 30 
8.1.1. 
Screening ................................................................................................................. 31 
8.1.2. 
Intervention Period ................................................................................................... 31 
8.1.3. 
Follow-up Period ...................................................................................................... 32 
8.1.4. 
Final Visit ................................................................................................................ 32 
8.2. 
Clinical Assessments ................................................................................................ 33 
8.3. 
Quality of Life Questionnaires .................................................................................. 34 
9. 
Safety Assessments ................................................................................................ 35 

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9.1. 
Adverse Events and Serious Adverse Events ............................................................. 35 
9.1.1. 
Adverse Device Effect (ADE) and Unanticipated Adverse 
Device Effect (UADE).............................................................................................. 35 
9.1.2. 
Collection Period for AE and SAE Information ......................................................... 36 
9.1.3. 
Assessing Causality of a Serious Adverse Event ........................................................ 37 
9.1.4. 
Reporting and Monitoring of SAEs ........................................................................... 37 
9.1.5. 
Events of Special Interest.......................................................................................... 38 
9.2. 
Unanticipated Problem (UP) and Terminations.......................................................... 39 
9.2.1. 
Definition of Unanticipated Problem ......................................................................... 39 
9.2.2. 
Reporting of an Unanticipated Problem ..................................................................... 39 
10. 
Statistical Considerations ...................................................................................... 40 
10.1. 
Statistical Hypotheses............................................................................................... 40 
10.1.1. 
Primary Hypothesis .................................................................................................. 40 
10.2. 
Sample Size Determination....................................................................................... 40 
10.3. 
Randomization ......................................................................................................... 40 
10.4. 
Blinding................................................................................................................... 40 
10.5. 
Populations for Analyses .......................................................................................... 41 
10.6. 
Statistical Analyses .................................................................................................. 41 
10.6.1. 
General Considerations ............................................................................................. 41 
10.6.2. 
Statistical modeling .................................................................................................. 42 
10.6.3. 
Model priors............................................................................................................. 43 
10.6.4. 
Assessing Effectiveness ............................................................................................ 44 
10.6.5. 
Planned Interim Analyses, Early Stopping, and Type-I Error 
Control..................................................................................................................... 44 
10.6.6. 
Sensitivity and Supplementary Analyses ................................................................... 45 
10.6.7. 
Differential Treatment Effects and Subgroup Analyses .............................................. 46 
10.6.8. 
Secondary Clinical Endpoint ..................................................................................... 46 
10.6.9. 
Exploratory Analysis ................................................................................................ 46 
10.6.10. Adherence and Retention Analysis ............................................................................ 47 
10.7. 
Interim Reporting ..................................................................................................... 47 
10.8. 
Independent Data Monitoring Committee (IDMC) .................................................... 47 
10.9. 
Adjudication Committee........................................................................................... 48 
11. 
Ethical Standards .................................................................................................. 49 
11.1. 
Institutional Review Board (IRB).............................................................................. 49 
11.2. 
Informed Consent Process ........................................................................................ 49 
11.3. 
Participant and Data Confidentiality.......................................................................... 49 
11.4. 
Site Management and Quality Assurance .................................................................. 50 
11.5. 
Site Monitoring ........................................................................................................ 50 
12. 
Data Handling and Record Keeping ..................................................................... 51 
12.1. 
Data Collection and Management Responsibilities .................................................... 51 
12.2. 
Study Records Retention .......................................................................................... 51 
12.3. 
Protocol Deviations .................................................................................................. 51 
12.4. 
Publication and Data Sharing Policy ......................................................................... 51 
13. 
Study Leadership .................................................................................................. 53 

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14. 
Summary of Changes ............................................................................................ 54 
15. 
References ............................................................................................................. 56 
16. 
Appendix A – Ivermectin ...................................................................................... 61 
16.1. 
Risk Assessment ...................................................................................................... 61 
16.2. 
Additional Appendix-Level Exclusion Criteria .......................................................... 62 
16.2.1. 
Precautions............................................................................................................... 62 
16.3. 
Ivermectin Information ............................................................................................. 63 
16.3.1. 
Formulation, Appearance, Packaging, and Labeling ................................................... 63 
16.3.2. 
Drug Dispensing, Storage, and Stability .................................................................... 63 
16.3.3. 
Dosing and Administration ....................................................................................... 63 
16.3.4. 
Rationale for Selection of Dose ................................................................................. 63 
16.4. 
Placebo Information ................................................................................................. 65 
16.4.1. 
Formulation, Appearance, Packaging, and Labeling ................................................... 65 
16.4.2. 
Drug Dispensing, Storage, and Stability .................................................................... 65 
16.4.3. 
Dosing and Administration ....................................................................................... 65 
16.5. 
Events of Special Interest ......................................................................................... 65 
17. 
Appendix B – Fluvoxamine Maleate ..................................................................... 66 
17.1. 
Risk Assessment ...................................................................................................... 66 
17.2. 
Additional Appendix-Level Exclusion Criteria .......................................................... 67 
17.2.1. 
Precautions............................................................................................................... 68 
17.3. 
Fluvoxamine Information ......................................................................................... 68 
17.3.1. 
Formulation, Appearance, Packaging, and Labeling ................................................... 68 
17.3.2. 
Drug Dispensing, Storage, and Stability .................................................................... 69 
17.3.3. 
Dosing and Administration ....................................................................................... 69 
17.3.4. 
Rationale for Selection of Dose ................................................................................. 69 
17.4. 
Placebo Information ................................................................................................. 72 
17.4.1. 
Formulation, Appearance, Packaging, and Labeling ................................................... 72 
17.4.2. 
Drug Dispensing, Storage, and Stability .................................................................... 72 
17.4.3. 
Dosing and Administration ....................................................................................... 72 
17.5. 
Events of Special Interest ......................................................................................... 72 
18. 
Appendix C –Fluticasone Furoate ......................................................................... 73 
18.1. 
Risk Assessment ...................................................................................................... 73 
18.2. 
Additional Appendix-Level Exclusion Criteria .......................................................... 74 
18.2.1. 
Precautions............................................................................................................... 74 
18.3. 
Fluticasone Furoate Information ............................................................................... 75 
18.3.1. 
Formulation, Appearance, Packaging, and Labeling ................................................... 75 
18.3.2. 
Drug Dispensing, Storage, and Stability .................................................................... 75 
18.3.3. 
Dosing and Administration ....................................................................................... 75 
18.3.4. 
Rationale for Selection of Dose ................................................................................. 75 
18.4. 
Placebo Information ................................................................................................. 76 
18.4.1. 
Formulation, Appearance, Packaging, and Labeling ................................................... 76 
18.4.2. 
Drug Dispensing, Storage, and Stability .................................................................... 77 
18.4.3. 
Dosing and Administration ....................................................................................... 77 
18.5. 
Events of Special Interest ......................................................................................... 77 

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18.6. 
Safety Reporting for Fluticasone Furoate .................................................................. 77 
 

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Abbreviations 
ACE 
Angiotensin-converting Enzyme 
ADE 
Adverse Device Effect 
AE 
Adverse Event 
ARB 
Angiotensin II Receptor Blockers 
ARNI 
Angiotensin Receptor Neprilysin Inhibitor 
BiPAP 
Bilevel Positive Airway Pressure 
BMD 
Bone Mineral Density 
BMI 
Body Mass Index 
CCC 
Clinical Coordinating Center 
CEA 
Clinical Event Ascertainment  
CFR 
Code of Federal Regulations 
CONSORT 
Consolidated Standards of Reporting Trials 
COPD 
Chronic Obstructive Pulmonary Disease 
COVID-19 
Coronavirus Disease 2019 
CPAP 
Continuous Positive Airway Pressure 
DCC 
Data Coordinating Center 
DIC 
Disseminated Intravascular Coagulation 
DUA 
Data Use Agreement 
ECMO 
Extracorporeal Membrane Oxygenation 
EDC 
Electronic Data Capture 
ESI 
Event of Special Interest 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
Human Immunodeficiency Virus 
IC50 
Half-Maximal Inhibitory Concentration 
ICF 
Informed Consent Form 
ICH 
International Council for Harmonisation 
ICMJE 
International Committee of Medical Journal Editors 
ICS 
Inhaled Corticosteroid 
ICU 
Intensive Care Unit 
IDMC 
 
IDS 
Investigational Drug Service 
IRB 
Institutional Review Board 
KO 
Knockout 
LPS 
Lipopolysaccharide  
MAOI 
Monoamine Oxidase Inhibitors 
mITT 
Modified Intention to Treat 
MOP 
Manual of Procedures 
NCATS 
National Center for Advancing Translational Sciences 
NIH 
National Institute of Health 
OCD 
Obsessive Compulsive Disorder 
OHRP 
Office for Human Research Protections 
OR 
Odds Ratio 
PCORI 
Patient-Centered Outcomes Research Institute 

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PCR 
Polymerase Chain Reaction 
PHI 
Personal Health Information 
PHQ 
Patient Health Questionnaire 
PPOS 
Predicted Probability of Success 
PROMIS 
Patient-reported Outcomes Measurement Information System 
QOL 
Quality of Life 
RRT 
Renal Replacement Therapy  
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SARS-CoV-1/2 
Severe Acute Respiratory Syndrome Coronavirus 1/2 
SD 
Standard Deviation 
SNRI 
Selective Norepinephrine Reuptake Inhibitor 
SSRI 
Selective Serotonin Norepinephrine Reuptake Inhibitor  
SUSAR 
Serious Unexpected Suspected Adverse Reaction 
UADE 
Unanticipated Adverse Device Effect 
UP 
Unanticipated Problems 
US 
United States 
WT 
Wildtype 
 
 

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Table of Figures 
Figure 1: ACTIV-6 Study Schema ..........................................................................................18 
Figure 2: Operational Structure Diagram .................................................................................53 
Figure 3: Survival curve of WT and S1R KO mice ..................................................................70 
Figure 4: Summary of JAMA Randomization Clinical Trial of Fluvoxamine for Early COVID-
19. .........................................................................................................................................71 
Figure 5: Summary of study results for the prospective, nonrandomized observational cohort 
study with fluvoxamine in participants diagnosed with COVID-19...........................................71 
 

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List of Tables 
Table 1: Schedule of Events ....................................................................................................30 
Table 2: ACTIV-6 Sample Size Estimates and Power ..............................................................40 
Table 3: Ivermectin Adverse Event Table for Doses ≥ 300 µg/kg .............................................61 
Table 4: Ivermectin Dosing Schedule ......................................................................................63 
Table 5. Fluvoxamine Adverse events occurring in 10-week studies of adult OCD or depression
 ..............................................................................................................................................66 
Table 6. Fluvoxamine Adverse events that occurred in COVID-19 study participants receiving 
300 mg/day for 15 days...........................................................................................................67 
Table 7. Fluticasone Adverse reactions that occurred in ≥3% of adults and adolescents with 
asthma in a 24-week trial. .......................................................................................................73 
 
 

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1. 
Protocol Summary 
1.1. 
Synopsis 
 
Title 
ACTIV-6: COVID-19 Outpatient Randomized Trial to Evaluate 
Efficacy of Repurposed Medications 
Clinical study phase 
III 
Rationale 
Coronavirus Disease 2019 (COVID-19) is caused by a novel 
coronavirus, severe acute respiratory syndrome coronavirus 2 
(SARS-CoV-2), that first emerged in December 2019 and has since 
resulted in a global pandemic unseen in almost a century in cases 
and mortality. Over 2020, advances were made for treatment of 
COVID-19 and several vaccinations for prevention of SARS-CoV-
2 infection have received emergency use authorization. However, 
the pandemic continues to evolve with new variants and surges of 
infections in different regions of the world, requiring an ongoing 
evidence-generating clinical trial platform, in particular for the 
treatment of COVID-19 in the outpatient setting. This platform 
protocol can serve as an evidence generation system for prioritized 
drugs, repurposed from other Food and Drug Administration (FDA) 
indications with an established safety record in humans and 
preliminary data of efficacy. The ultimate goal is to evaluate if 
repurposed medications can make participants feel better faster and 
reduce death and hospitalization. 
Primary Objective 
 
To evaluate the effectiveness of repurposed medications [(study 
drug(s)] in reducing symptoms of nonhospitalized participants 
with mild to moderate COVID-19 
Secondary 
Objectives 
 
To evaluate the clinical outcomes (e.g. hospitalization and 
death) in participants in a study drug arm versus those in the 
placebo arm 
 
To describe symptom resolution in participants in a study drug 
arm versus those in the placebo arm 
 
To describe the quality of life (QOL) in participants in a study 
drug arm versus those in the placebo arm 
Exploratory 
Objectives 
 
To describe long-term COVID-19-related symptoms in 
participants in a study drug arm versus those in the placebo 
arm  

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Intervention 
All interventions will occur in addition to standard of care. Each 
study drug appendix describes a different study drug and 
matching placebo. The following arms will be included in each 
study appendix: 
 Study Drug Arm: repurposed medications (see 
Appendices) 
 Placebo Arm: placebo control 
While each appendix describes the placebo that matches the 
study drug, for comparative analysis the control group will 
comprise eligible, concurrently enrolled participants from all 
placebo arms.  
Study Design 
This study is a platform protocol designed to be flexible so that 
it is suitable for a wide range of settings within healthcare 
systems and in community settings where it can be integrated 
into routine COVID-19 testing programs and subsequent 
treatment plans. This platform protocol will enroll participants in 
an outpatient setting with a confirmed polymerase chain reaction 
(PCR) or antigen test for SARS-CoV-2. Each appendix will 
describe a repurposed medication (study drug) to meet the 
protocol objectives. 
When only one study drug/appendix is under study, allocation 
between study drug and placebo will be 1:1. If multiple study 
drugs/appendices are under study, participants will also be 
randomized among the study drugs for which eligibility is 
confirmed. Since the route of administration of each study drug 
may differ, the placebos may also differ. To achieve blinding 
and an equitable randomization probability, a two step 
randomization process will be used. 
In the first step, the participant will be randomized m:1 active 
study drug to placebo, where m is the number of active study 
drugs for which the participant is eligible. Then, participants will 
be randomized among the m study drugs for which they are 
eligible. Participants will carry their ‘study drug’ versus 
‘placebo’ randomization with them into the study drug appendix. 
In this way, a participant allocated to placebo who is randomized 
to study drug A will be given the placebo that matches study 
drug A. This achieves equal probability of exposure to a placebo 
or an active study drug, and equitable distribution among all 
study arms for which a participant is eligible. Sites will be 
informed to which study drug appendix the participant is 
randomized, but not whether they are allocated to the study drug 
arm or placebo arm within that appendix.  

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For analysis, concurrent placebo participants who were eligible 
for the study drug appendix will be pooled. This will result in 
approximately a 1:1 allocation ratio for any study drug to 
placebo. If a study drug appendix is stopped for efficacy and 
becomes standard of care, the active study drug arm may serve 
as a concurrent placebo for other study drugs.  
Participants will receive complete supply of repurposed 
medication (study drug) or placebo with length of treatment and 
amount of study drug/placebo depending on the study drug 
appendix and arm to which they are randomized. 
This study is designed so that it can be done completely 
remotely. However, screening and enrollment may occur in 
person at sites and unplanned study visits may occur in-person 
or remotely, as deemed appropriate by an investigator for safety 
purposes. Participants will be on-study for 90 days, during which 
they will complete various questionnaires. 
Population 
Up to 15,000 adults   
Study Duration 
24 months 
Study Location 
Up to 280 sites  
Inclusion Criteria 
1. Completed Informed Consent 
2. Age ≥30 years old 
3. Confirmed SARS-CoV-2 infection by any authorized or 
approved PCR or antigen test collected within 10 days of 
screening 
4. Two or more current symptoms of acute infection for ≤7 days. 
Symptoms include the following: fatigue, dyspnea, fever, cough, 
nausea, vomiting, diarrhea, body aches, chills, headache, sore 
throat, nasal symptoms, new loss of sense of taste or smell 
Exclusion Criteria 
1. Prior diagnosis of COVID-19 infection (> 10 days from 
screening) 
2. Current or recent (within 10 days of screening) hospitalization 
3. Current use of study drug or study drug/device combination*  
4. Known allergy/sensitivity or any hypersensitivity to 
components of the study drug or placebo* 
5. Known contraindication to study drug including prohibited 
concomitant medications (see Appendices)* 

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*If only one study drug appendix is open at the time of enrollment. 
If multiple study drug appendices are open, a participant may opt-
out of any study drug appendix or be excluded from any study drug 
appendix based on contraindications listed in the study drug 
appendix, current use of study drug, or known 
allergy/sensitivity/hypersensitivity and still remain eligible for the 
remaining study drug appendices. 
Sample Size 
Considerations 
An estimated sample size of ~600 participants per study drug 
appendix is needed to have >85% power to determine whether 
there is evidence of meaningful benefit. This will involve 300 
participants in the active study drug arm and 300 concurrent 
placebo controls. Moreover, when a study drug demonstrates 
overall effectiveness, the planned adaptations to increase accrual 
up to 1200 participants (600 receiving the active study drug and 
600 receiving the placebo) for the purpose of demonstrating 
benefit on clinical events is a reasonable extension within the 
context of this platform. This study will enroll up to 15,000 
adults, depending on the number of study drug appendices that 
are added and adjustments to sample size depending on the data. 
General Statistical 
Consideration for 
Primary Analysis 
The primary outcome of interest for this platform is symptoms, 
collected using a web-assisted symptom diary according to Table 1. 
Symptoms will be counted on an ordinal scale.  
The overall effect of each study drug versus matching placebo will 
be quantified using the common odds ratio (OR) from the 
proportional odds model (primary estimand). Evidence for efficacy 
will be quantified as the posterior probability that the OR is less 
than 0.9. This is denoted as the “posterior probability for efficacy” 
or 𝑃(𝑂𝑅< 0.9|Data). Similarly, the risk difference in 
hospitalization or death will be used to draw conclusions about 
clinical efficacy. Regardless of whether there is an efficacy signal, 
the following quantities from the model will be reported: 
 Mean and median time to symptom resolution (for quantifying 
benefit on symptoms) 
 Mean and median time to hospitalization or death (secondary 
outcomes) 
The primary analysis will be implemented separately for each study 
drug, where the matching placebo arm will consist of concurrently 
randomized participants that meet the inclusion and exclusion 
criteria for that study drug appendix. A modified intention to treat 
(mITT) approach will be used for primary analyses; all participants 
who receive study drug will be included as assigned. It is possible 
that the delivery of medications (placebo or study drug) does not 

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occur; this will result in exclusion of the participant for the mITT 
analysis. All available data will be used to compare each study drug 
versus placebo control, regardless of post-randomization adherence 
to study protocols.  
Independent Data 
Monitoring 
Committee (IDMC)  
Frequent IDMC reviews will be conducted to ensure the safety of 
study participants and evaluate the accumulating endpoint data by 
treatment group. Regular IDMC meetings will monitor the 
following parameters at a minimum: 
 Recruitment progress 
 Enrollment overall and by subgroups 
 Adherence, retention, and status of data collection 
 Serious adverse events  
 Assessment for futility  
 Probability for benefit across endpoints 
Interim Analysis 
Interim analyses will be performed per study drug appendix, after 
approximately every 200 participants (100 in study drug arm and 
100 in placebo arm) have completed the Day 14 Visit. Placebo 
control participants contributing to this count will be drawn from 
across study drug appendices, and will include participants who 
were eligible for the study drug appendix of interest regardless of 
final study drug arm allocation. The following decision thresholds 
will be checked at each interim analysis: 
i) 
The study drug is found to have benefit (efficacy): A 
posterior probability of meaningful benefit (e.g. OR < 
0.9) for a study drug in comparison to the placebo 
control of > 0.95 will result in a declaration of overall 
superiority.  
a. If a study drug arm is declared superior, a futility 
analysis will be conducted on observing clinical 
efficacy (reduction in hospitalizations or death) if the 
study drug arm were to continue for an additional 
one year. Accrual will be projected based on actual 
trial accrual and projected case rates. Stopping for 
futility will be strongly encouraged if the predicted 
probability of success (PPOS) is low (e.g. <0.1) and 
will be discouraged if the PPOS is high (e.g. >0.7).   
ii) 
The study drug is found to be substantially similar to the 
placebo control (inefficacy): A posterior probability of 
>0.95 that there is no more than trivial benefit (e.g. OR 

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> 0.9) or harm of an arm will result in termination of 
that arm.  
iii) 
The study drug is found to cause harm (inferiority): A 
posterior probability of >0.85 for worse adverse clinical 
outcomes (hospitalization or death) for a study drug 
relative to the placebo control (e.g. a risk difference > 
0.01) will result in termination of that arm. 
iv) 
The predicted probability of success of any study drug 
given expected accrual at a prespecified point in time 
will be provided to the IDMC. Stopping for futility will 
be strongly encouraged if the PPOS is low (e.g. <0.1) 
and will be discouraged if the PPOS is high (e.g. >0.7).  
Note that unlike the probability of inefficacy, PPOS 
involves Bayesian posterior predictive distributions. 
Futility is a low probability of achieving any conclusions within a 
reasonable time frame or with available resources. Prior to each 
interim analysis, the target date for study completion will be 
specified, and accrual will be projected by that target date. A 
statistical model may be used to predict accrual. Futility assessment 
will use the lowest of either the planned accrual or predicted 
accrual at study closure. 
The combination of decision thresholds and effect sizes have been 
selected to balance the ability to observe a meaningful effect on 
symptoms, to observe the potential for an effect on clinical 
outcomes, and to maximize power. In making decisions, power will 
be balanced with the Type 1 error rate. For each study drug, 
simulations will be used to demonstrate that the operating 
characteristics are consistent with a Type I error control of at least 
5%. 
 
 
 
 
 
 
 
 
 

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1.2. 
Schema 
 
 
Figure 1: ACTIV-6 Study Schema 

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2. 
Introduction 
2.1. 
Study Rationale 
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel betacoronavirus that 
first emerged in December 2019 and has since caused a global pandemic unseen in almost a 
century with respect to the number of cases and overall mortality. [1, 2] The clinical disease 
related to SARS-CoV-2 is referred to as Coronavirus Disease 2019 (COVID-19). Over 2020, 
advances were made for treatment of COVID-19 and several vaccinations have received 
emergency use authorization for prevention of SARS-CoV-2 infections. [3-8] However, the 
pandemic continues to evolve with new variants and surges of infections in different regions of 
the world, requiring an ongoing evidence-generating platform, in particular for the treatment of 
COVID-19 infection in the outpatient setting. This platform protocol can serve as an evidence 
generating system for prioritized drugs repurposed from other indications with an established 
safety record and preliminary evidence of clinical efficacy for the treatment of COVID-19. The 
ultimate goal is to evaluate if repurposed medications can make participants feel better faster and 
reduce death and hospitalization. 
2.2. 
Background 
In December 2019, numerous patients in Wuhan, China were diagnosed with pneumonia caused 
by an unknown virus. By January 7, 2020, Chinese scientists had isolated SARS-CoV-2. This is 
a novel betacoronavirus closely related to severe acute respiratory syndrome coronavirus 1 
(SARS-CoV-1). [2]  In the subsequent months the spread of the virus led to a global pandemic. 
As of February 10, 2021 there were approximately 107,002,486 confirmed COVID-19 cases 
resulting in 2,343,477 deaths worldwide. [1] 
The virus continues to spread despite social distancing measures and travel restrictions. COVID-
19 vaccinations are actively being distributed and administered in some countries; however, new 
SARS-CoV-2 strains continue to emerge, with early reports of potential for reduced monoclonal 
antibody therapeutic and vaccine efficacy. [9] Additionally, data regarding transmission after 
vaccination is pending, highlighting the need to establish treatment regimens despite vaccination 
availability. Finally, while vaccine roll-out is occurring, sufficient immune coverage to reach 
herd immunity across the globe is unlikely in the next year. Thus, there remains a need to 
identify safe and efficacious treatments that can be administered in the outpatient setting.  
As of February 2021, multiple clinical trials have been reported, providing early guidance to 
clinical providers on management of COVID-19, particularly in the hospital setting. One drug 
has been approved by the FDA for use in the inpatient setting (remdesivir) and one has been 
FDA approved for years (dexamethasone); both have been reported to improve clinical disease 
and in the case of dexamethasone, mortality. [10, 11] Numerous medications are currently under 
investigation including monoclonal antibodies to spike protein and numerous 
immunomodulatory agents, including tocilizumab. No therapies have been approved for pre- or 
post-exposure prophylaxis nor for therapy of outpatients, although there are several 
investigational agents authorized for emergency use by the FDA, including bamlanivimab, 
bamlanivimab + etesevimab in combination, and casirivimab + imdevimab in combination. [12, 
13]   

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2.3. 
Benefit/Risk Assessment 
The risks for participation in this study include taking study drug (see Appendices) and loss of 
confidentiality. There may be some benefit to the participant if the therapy is effective against 
COVID-19. 
2.3.1. 
Risk Assessment 
Loss of confidentiality risks: There is a potential risk of loss of confidentiality. Every effort will 
be made to protect the participant’s confidential medical information, but this cannot be 
guaranteed. Clinical information will not be released without written permission of the 
participant, except as necessary for monitoring by the IRB, FDA, National Institutes of Health 
(NIH), Office for Human Research Protections (OHRP), other local, US, and international 
regulatory authorities/entities as part of their duties. 
Risk lowering measures: Study procedures to manage and minimize risks include careful 
selection of the participants and monitoring over time to check on participants’ health. 
Additional guidance to manage any risks or any change to the risk to the participant based on 
emerging data will be provided to the study teams, as needed. In addition, an independent 
Independent Data Monitoring Committee (IDMC) will monitor safety of the participants 
throughout the study. 
2.3.2. Benefit Assessment 
Participants who randomize to a study drug arm may benefit from study drug administration.  
There is no direct benefit to participants randomized to the placebo arm apart from participating 
in generating evidence that may ultimately support treatment for SARS-CoV-2 infection. In 
addition, they will benefit from involvement with the team following their health status during 
the study. The knowledge gained will be a benefit to others in the future.  

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3. 
Objectives and Endpoints 
Objectives 
Outcome Measurements 
Reported Endpoints 
Primary 
 
 
To evaluate the 
effectiveness of repurposed 
medications [(study drug(s)] 
in reducing symptoms in 
nonhospitalized participants 
with mild to moderate 
COVID-19 
The following will be evaluated 
from baseline through Day 14: 
 Hospitalization  
 Death 
 Symptom count 
The following model-
assisted endpoints will be 
reported for the primary 
objective: 
 The odds ratio (OR) 
describing the overall 
difference in symptoms and 
clinical events over the 14 
days 
 The overall risk difference 
for hospitalization and 
death 
 Mean and median time to 
symptom resolution 
Secondary 
 
 
To evaluate the clinical 
outcomes (e.g. 
hospitalization and death) in 
participants in a study drug 
arm versus those in the 
placebo arm 
 COVID Clinical Progression 
Scale on Day 7, Day 14, and 
Day 28 (see Section 8.2) 
 Hospitalization or death 
through Day 28 
 Mortality through Day 28 
 Hospitalization, urgent care 
visit, emergency room visit 
through Day 28 
The following model-
assisted endpoints will be 
reported for the COVID 
Clinical Progression Scale: 
 The OR describing the 
overall difference in 
clinical progression  
 The OR describing the 
difference in clinical 
progression at each 
measured time point 
 The overall risk difference 
for hospitalization or death 
The following endpoints for 
the composite of 
unscheduled medically 
assisted care will be 
estimated: 

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 The overall risk difference 
for any of urgent care, 
emergency care, 
hospitalization or death 
 Time to first urgent care, 
emergency care, 
hospitalization or death  
 Risk and time to event for 
each component of the 
composite  
To describe symptom 
resolution in participants in 
a study drug arm versus 
those in the placebo arm 
Symptom resolution, defined as 
first of at least three consecutive 
days without symptoms 
Directly measured mean and 
median time to symptom 
resolution 
To describe the quality of 
life (QOL) in participants in 
a study drug arm versus 
those in the placebo arm 
Modified Patient-Reported 
Outcomes Measurement 
Information System (PROMIS)-
29 at baseline, Day 7, Day 14, 
Day 28, and Day 90 Follow-up 
Model-assisted endpoints 
will be reported for QOL 
scores: 
 Overall OR  
 Odds ratios (ORs) specific 
to days 7, 14, 28 and 90 
 Mean difference in QOL 
scores at each time point 
Exploratory 
 
 
To describe long-term 
COVID-19-related 
symptoms in participants in 
a study drug arm versus 
those in the placebo arm 
Symptom occurrence, type, and 
severity at Day 90 Follow-up 
 
Directly measured mean and 
median symptom count and 
QOL score at Day 90 in 
study drug arm(s) versus 
placebo. 

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4. 
Study Design 
Refer to Section 1.2 for the Study Schema. 
4.1. 
Overall Design 
This study is a platform protocol designed to be flexible so that it is suitable for a wide range of 
settings within healthcare systems and in community settings where it can be integrated into 
routine COVID-19 testing programs and subsequent treatment plans. The platform protocol will 
enroll participants with mild to moderate COVID-19 in an outpatient setting with a confirmed 
PCR or antigen test for SARS-CoV-2 infection. Each appendix will describe a repurposed 
medication (study drug arm) that is sized to meet the master protocol objectives. 
Participants will be randomized based on the study drug appendices that are actively enrolling at 
the time of randomization. Study drug appendices may be added or removed according to 
adaptive design and/or emerging evidence. When there are multiple study drug appendices 
available, randomization will occur based on appropriateness of each drug for the participant as 
determined by the study protocol and investigator and participant equipoise. Each participant 
will be required to randomize to at least one study drug versus placebo. The probability of 
placebo to treatment will remain the same regardless of eligibility decisions.  
Eligible participants will be randomized (1:1), in a blinded fashion, to either the study drug 
arm or placebo arm in addition to standard of care. As additional study drug appendices are 
added, the randomization will be altered to leverage placebo data across arms. Participants 
will receive a complete supply of repurposed medication (study drug) or placebo with the 
quantity depending on the study drug/placebo to which they are randomized. 
All study visits are designed to be remote. However, screening and enrollment may occur in-
person at sites and unplanned study visits may occur in-person or remotely, as deemed 
appropriate by the site investigator for safety purposes. Participants will be asked to complete 
questionnaires and report safety events during the study, according to Table 1. Participants will 
be prompted by the online system to report safety events and these will be reviewed and 
confirmed via medical records and site staff, as necessary.  
4.2. 
End of Study Definition 
A participant is considered to have completed the study if he/she has completed the Long-term 
Follow-up assessments at 90 days. 
The end of the study is defined as the date of the last follow-up of the last participant in the 
study. Data from interim analyses or recommendations by the IDMC may result in protocol 
modifications or early termination of the study.  
 

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5. 
Study Population 
All Eligibility Criteria will be obtained per participant.   
5.1. 
Inclusion Criteria 
1. Completed Informed Consent 
2. Age ≥ 30 years old 
3.   Confirmed SARS-CoV-2 infection by any authorized or approved polymerase chain 
reaction (PCR) or antigen test collected within 10 days of screening 
4. Two or more current symptoms of acute infection for ≤7 days. Symptoms include the 
following: fatigue, dyspnea, fever, cough, nausea, vomiting, diarrhea, body aches, chills, 
headache, sore throat, nasal symptoms, new loss of sense of taste or smell  
5.2. 
Exclusion Criteria  
1. Prior diagnosis of COVID-19 infection (> 10 days from screening) 
2. Current or recent (within 10 days of screening) hospitalization 
3. Current use of study drug or study drug/device combination*  
4. Known allergy/sensitivity or any hypersensitivity to components of the study drug or 
placebo* 
5. Known contraindication(s) to study drug including prohibited concomitant medications 
(see Appendices)* 
*If only one study drug appendix is open at the time of enrollment. If multiple study drug 
appendices are open, a participant may opt-out of any study drug appendix or be 
excluded from any study drug appendix based on contraindications listed in the study 
drug appendix, current use of study drug, or known allergy/sensitivity/hypersensitivity 
and still remain eligible for the remaining study drug appendices. 
5.3. 
Recruitment and Engagement 
5.3.1. 
Participant Recruitment 
Participants who are eligible based on positive SARS-CoV-2 PCR or antigen test will be 
identified by participating sites or will self-identify to a central study hotline(s) and be referred to 
the closest site. Site investigators, or their designee, may contact eligible participants to introduce 
the study and discuss study participation.  
5.3.2. 
Participant Engagement 
Participants will be engaged in the study through multiple channels. This includes, but is not 
limited to, ongoing participation in other registries partnering with ACTIV or healthcare systems.  
Additionally, participant engagement will include:  
 compensation for participants who complete the Day 90 Final Visit;  
 creating a study-wide ACTIV-6 Advisory Group;  

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 developing participant-centered approaches that recognize the needs and preferences of 
COVID-19 survivors locally and nationally; and 
 multifaceted approaches that combine engagement tools, leverage the online system, use 
of social media, and representative COVID-Participants. 
5.3.3. 
Participant Randomization Process 
This trial is a double-blind, placebo-controlled trial. Participants and investigators will be 
blinded. A participant who is eligible for m study drug arms/appendices will be randomized m:1 
study drug to placebo (Figure 1). The participant will then be randomized with 1/m probability to 
each of the study drug appendices. A participant entering a study drug appendix carries their 
study drug or placebo designation with them and will get either the study drug or matching 
placebo. Participants who receive placebo will be pooled across study drug arms for those study 
drug arms/appendices that the participant is eligible. This reduces overall sample size by 
facilitating sharing of data from concurrent controls while maintaining a 1:1 allocation to study 
drug or placebo. Randomization sequences will not be pre-generated. Given the adaptive nature 
of the trial and the unknown number of study drug appendices, arm assignment will be 
implemented at the time of confirming eligibility for randomization using a random number 
generator. The participant eligibility criteria will be checked for each study drug appendix, and 
the randomization probabilities will be set. The two step procedure will then occur, and the 
assignment to both study drug appendix and study drug versus placebo will be made. The 
participant and study teams will know which study drug appendix the participant is allocated to, 
but will be blinded to study drug versus placebo because they will be matching.  
The participant, treating clinicians, and study personnel will remain blinded to study drug versus 
placebo assignment until after the database is locked and blinded analysis is completed. Only the 
biostatistical team who is preparing closed IDMC interim reports will be unblinded. Specifically, 
study drug/placebo will be dispensed with packaging and labelling that would blind treatment 
assignment. Unblinding will occur only if required for participant safety or treatment at the 
request of the treating clinician. Refer to the Manual of Procedures (MOP) for further details. 
5.4. 
Screen Failures 
Screen failures are defined as participants who consent to participate in the clinical study, who 
fulfill inclusion and exclusion criteria, but are not subsequently randomized. A minimal set of 
screen failure information is required to ensure transparent reporting of screen failure 
participants to meet the Consolidated Standards of Reporting Trials (CONSORT) publishing 
requirements and to respond to queries from regulatory authorities.  
Individuals who are considered screen failures may not be re-screened. 
5.5. 
Enrollment 
Participants who are randomized and receive study drug/placebo will be considered enrolled. 
Participants who are randomized, but do not receive study drug/placebo for any reason (e.g. 
study drug lost in the mail), will not be considered enrolled on the study and will be identified as 
consented not enrolled. 

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6. 
Study Drug(s) 
6.1. 
Repurposed Medication Treatments 
See Appendices 
6.2. 
Placebo 
See Appendices 
6.3. 
Study Drug Accountability  
Use of study drug will be tracked via the online system, call center, or sites. Participants will 
dispose of any unused study drug as they would normally when stopping a medication. 
6.4. 
Concomitant Therapy 
Select concomitant medications of interest that the participant is receiving at the time of 
enrollment or receives during the course of the study will be recorded along with dosing 
information. Select concomitant medications of interest include the following and will be 
verified at each remote visit by designated study personnel: 
 Any therapeutics that is thought to have potential or purported COVID activity including 
hydroxychloroquine  
 Antibiotics  
 Antifungals  
 Antiparasitic 
 Antivirals including HIV protease inhibitors and ribavirin 
 Immunosuppressants including steroids  
 Angiotensin-converting-enzyme (ACE)/angiotensin II receptor blockers 
(ARB)/angiotensin receptor neprilysin inhibitor (ARNI) 
 Statin 
 Anticoagulants and antiplatelets 
 COVID-19 vaccine (before, during, or after study intervention) 
Refer to the MOP for more details on concomitant therapy. Refer to the appendices for 
contraindicated medications for each of the study drugs. 
6.5. 
Intervention After the End of the Study 
No additional study drug will be provided to the participant following completion of the study.   

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7. 
Participant Withdrawal/Termination and Study Termination 
7.1. 
Participant Withdrawal/Termination 
Participants will be followed until participant closeout, withdrawal of consent, or death. 
A participant may withdraw from the study at any time at his/her own request, or may be 
withdrawn at any time at the discretion of the investigator for safety, behavioral, compliance, or 
administrative reasons. This is expected to be uncommon. 
Those who request withdrawal from the study will be asked to continue on study follow-up with 
limited participation through the Final Visit (Section 8.1.4). Limited participation may include a 
call(s) to assess safety at study visits following withdrawal. 
If the participant withdraws consent for disclosure of future information, the sponsor may retain 
and continue to use any data collected before such a withdrawal of consent. 
7.2. 
Premature Termination or Suspension of the Study 
The study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. Written notification will be provided documenting reason for study suspension 
or termination to the investigators, funding agency, and regulatory authorities, as appropriate. 
Circumstances that may warrant termination or suspension include, but are not limited to: 
 Determination of unexpected, significant, or unacceptable risk to participants 
 Insufficient compliance to protocol requirements 
 Data that are not sufficiently complete and/or evaluable 
 Determination of futility after a sufficient time has passed for accrual of the primary and 
secondary outcomes 
 Recommendation by the IDMC 
7.3. 
Lost to Follow-up 
Participants will be asked for proxy contacts to assess vital status and/or other clinical events, 
including safety, if a participant fails to provide the information. Provision of proxy information 
is not required for study participation. A participant will be considered lost to follow-up if he or 
she repeatedly fails to complete study assessments/procedures as outlined below and neither the 
participant nor the participant’s proxy can be contacted by the study site. 
The following actions must be taken if a participant fails to provide baseline information, if they 
fail to complete daily symptom reporting by midnight the day after receiving the first dose of 
study drug/placebo (Day 2), if they miss two consecutive daily symptom reportings during Days 
3 to 14, if they miss either the Day 14 or Day 28 Remote Visits, and/or they fail to complete the 
Day 90 assessments: 
 
The site or call center must attempt to contact the participant and counsel the participant 
on the importance of completing study assessments/procedures. 
 
The site or call center will contact the participant’s proxy to assess vital status and/or 
other clinical or safety events. 
 
The site or call center will attempt to collect all missing survey responses. 

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 
Before a participant is deemed lost to follow-up, the investigator or designee must make 
every effort to regain contact with the participant (where possible, three telephone calls 
and, if necessary, a certified letter to the participant’s last known mailing address or 
local equivalent methods). These contact attempts should be documented in the 
participant’s research record. 
 
Online obituary search.    
 
Should the participant continue to be unreachable, they will be considered lost to 
follow-up.  
 

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8. 
Study Assessments and Procedures 
Screening and eligibility confirmation will be participant-reported. A positive SARS-CoV-2 test 
result must be verified prior to randomization (refer to the MOP for details). Sites will be 
responsible for notifying the coordinating center for participant withdrawals, lost to follow-up, 
permanent cessation of study drug, study drug dose modifications (if allowed, per Appendix), or 
change in vital status. Data will be collected directly from the participant and supported by 
medical records, as needed. 
 
 

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8.1. 
Schedule of Events  
 
Table 1: Schedule of Events 
 
                                              
 
 
 
1 Refer to study drug appendix for length of study drug administration. 
2 Only for enrollment in Study Drug Appendices that have pregnancy listed as a contraindication for females of 
childbearing potential. Participants will self-report pregnancy using the Pregnancy Reasonably Excluded Guide. 
3 Review only during study drug/placebo administration if contraindicated medications provided for the study drug 
arm, per Appendix. 
4 Day 14 only. 
5 Daily symptom reporting; continued daily beyond day 14 through day 28 until symptoms resolve for > 3 
consecutive days. 
6 Day 7 and 14 only. 
7 Day 3, 7, and 14 only. 
8 Participant’s medical record will be reviewed to confirm Serious Adverse Events (SAEs), Unanticipated Adverse 
Device Events (UADEs) [as applicable], and Events of Special Interest (ESIs). 
 
Screening Intervention 
Period 
Follow-up Period 
Final 
Visit 
Unplanned 
Study Visit 
Day 
Within 2 days 
of Day 1 
Day 1 
Days 2-14 
Day 15-
20 
Day 21 
± 2 days 
Day 22-
27 
Day 28 
+ 5 
days 
Day 90 
+ 5 days 
ACTIV-6 Trial 
 
 
 
 
 
 
 
 
 
Consent 
X 
 
 
 
 
 
 
 
 
Demographic Information 
X 
 
 
 
 
 
 
 
 
Eligibility criteria confirmed 
X 
 
 
 
 
 
 
 
 
Randomization 
X 
 
 
 
 
 
 
 
 
Receipt of study drug or placebo 
 
X 
 
 
 
 
 
 
 
Continued use study drug  
 
Continuous1 
 
 
 
 
 
 
Clinical Assessments 
 
 
 
 
 
 
 
 
 
Abbreviated medical history 
X 
 
 
 
 
 
 
 
 
Self-reported Pregnancy 
X2 
 
 
 
 
 
 
 
 
Concomitant Therapy 
X 
X3 
X3 
 
 
 
 
 
 
Remote Visit 
 
 
X4 
 
 
 
X 
 
 
Drug Adherence 
 
X 
X 
 
 
 
 
 
 
COVID-19 Outcomes 
 
X 
X6 
 
X 
 
X 
X 
 
Symptom Reporting 
X5 
X 
X5 
X5 
X5 
X5 
X5 
X 
 
QOL Questionnaire 
X 
 
X6 
 
 
 
X 
X 
 
At-home pulse oximetry 
 
 
X7 
 
 
 
 
 
 
Safety Assessment8 
 
Continuous via online system and medical record review 
X 

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8.1.1. 
Screening 
The following events will occur at Screening: 
 Consent: Participants will be consented either via an e-consent process or paper process. 
The consent process should be done in accordance with local and central IRB regulations. 
Phone consenting may be facilitated through the e-consent or paper process. 
 Demographic information will be collected including, but not limited to, age, sex, race, 
ethnicity, and occupation  
 Eligibility criteria confirmation by the participant via the online system or by site staff via 
a paper process 
 Abbreviated medical history  
 Self-reported pregnancy, for women of childbearing potential (only for enrollment in 
Study Drug Appendices that include pregnancy as a contraindication)  
 Concomitant therapy  
 Symptom reporting, daily during screening period 
 QOL questionnaire 
 Randomization (see Section 5.3.3) 
8.1.2. 
Intervention Period 
The following events will occur during the Intervention Period, starting with receipt of study 
drug/placebo: 
Day 1: 
 Receipt of study drug or placebo 
 Study drug self-administration (see Appendices for specific study drug/placebo 
administration) 
 Concomitant therapy  
 Drug adherence questionnaire 
 COVID-19 Outcomes 
 Symptom reporting 
 SAE, UADE (as applicable), and ESI collection 
Days 2-14: 
 Study drug self-administration (see Appendices for specific study drug/placebo 
administration) 
 Concomitant therapy, including contraindicated medications provided for the study drug 
arm, per Appendix, during study drug/placebo administration. 
 Remote visit (Day 14 only) 
 Drug adherence questionnaire, daily 
 COVID-19 Outcomes (Day 7 and 14 only) 
 Symptom reporting, daily 
 QOL questionnaire (Day 7 and 14 only) 
 At-home pulse oximetry readings (Day 3, 7, and 14 only)  

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 SAE, UADE (as applicable), and ESI collection 
8.1.3. 
Follow-up Period 
Day 15-20:  
 Symptom reporting, daily from Day 14 for participants who have not yet reported three 
consecutive days of no symptoms. Participants who experience three days of 
improvement before Day 14 but who then experience symptoms again will not be 
followed daily. 
 SAE, UADE (as applicable), and ESI collection 
Day 21 ± 2 days: 
 COVID-19 Outcomes 
 Symptom reporting, daily from Day 14 for participants who have not yet reported three 
consecutive days of no symptoms. Participants who experience three days of 
improvement before Day 14 but who then experience symptoms again will not be 
followed daily. 
 SAE, UADE (as applicable), and ESI collection 
Day 22-27:  
 Symptom reporting, daily from Day 14 for participants who have not yet reported three 
consecutive days of no symptoms. Participants who experience three days of 
improvement before Day 14 but who then experience symptoms again will not be 
followed daily. 
 SAE, UADE (as applicable), and ESI collection 
Day 28 + 5 days: 
 Remote visit 
 COVID-19 Outcomes 
 Symptom reporting, daily from Day 14 for participants who have not reported three 
consecutive days of no symptoms. Participants who experience three days of 
improvement before Day 14 but who then experience symptoms again will not be 
followed daily. 
 QOL questionnaire 
 SAE, UADE (as applicable), and ESI collection 
8.1.4. 
Final Visit 
Day 90 + 5 days:  
 COVID-19 Outcomes 
 Symptom reporting 
 QOL questionnaire 
 SAE, UADE (as applicable), and ESI collection 

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8.2. 
Clinical Assessments 
Abbreviated Medical History: smoking status, estimated body mass index (BMI)/obesity, pre-
existing underlying lung disease (e.g. chronic obstructive pulmonary disease, asthma, idiopathic 
pulmonary fibrosis), underlying immunosuppression (transplant, malignancy, human 
immunodeficiency virus (HIV), autoimmune disease), medical conditions that may increase risk 
of COVID-19 infections or complications (e.g., diabetes, cardiovascular disease, hypertension, 
chronic kidney disease), venous thromboembolism, chronic liver disease 
Concomitant Medications of Interest: Concomitant medications of interest, including study drug 
specific contraindicated medications, will be collected. Refer to Section 6.4 for concomitant 
medications of interest and to the study drug specific appendices for contraindicated 
medications. 
Self-reported Pregnancy: Participants will be asked to self-report pregnancy, as needed, per 
Study Drug Appendix. The 3-item “Pregnancy Reasonably Excluded Guide” will be used to 
assess pregnancy at screening. The “Pregnancy Reasonably Excluded Guide” uses traditional and 
World Health Organization criteria to exclude pregnancy via participant self-report [14]. Refer to 
the MOP for details.  
Remote Visit: Designated study personnel will contact the participant directly via a phone call or 
other form of direct contact (e.g. text or e-mail survey) in order to conduct study assessments, 
including, but not limited to, COVID-19 outcomes, drug adherence (at Day 14), and safety 
events. A missed remote visit will be considered a protocol deviation (non-major). If a 
participant misses a remote visit, site study staff should take immediate action to contact the 
participant, per Section 7.3 follow-up processes. Refer to the MOP for details.  
Drug Adherence: Adherence to the study drug administration schedule will be collected via the 
online system and confirmed at the Day 14 remote visit. 
COVID-19 Outcomes: The COVID-19 outcomes for this trial are based on the World Health 
Organization’s Ordinal Scale for Clinical Improvement and will be collected via the online 
system and from the medical record. [15] The following outcomes will be assessed as part of the 
COVID Clinical Progression Scale:   
0. No clinical or virological evidence of infection 
1. No limitation of activities 
2. Limitation of activities 
3. Hospitalized, no oxygen therapy 
4. Hospitalized, on oxygen by mask or nasal prongs 
5. Hospitalized, on non-invasive ventilation or high-flow oxygen 
6. Hospitalized, on intubation and mechanical ventilation 
7. Hospitalized, on ventilation + additional organ support – pressors, RRT, ECMO 
8. Death 
Symptom Reporting: Symptoms and symptom-related responses will be reported by the 
participant via the online system. Additional symptom reporting may occur from the sites, as 
available. Each of pre-defined symptoms will be assessed on an ordinal severity scale of none, 
mild, moderate, and severe. The following symptoms will be collected:  

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 Fatigue 
 Dyspnea - shortness of breath or difficulty breathing at rest or with activity 
 Fever 
 Cough  
 Nausea  
 Vomiting 
 Diarrhea 
 Body aches 
 Sore throat 
 Headache 
 Chills 
 Nasal symptoms 
 New loss of sense of taste or smell 
 Other COVID-related symptom  
At-home pulse oximetry measurements: Participants will provide pulse oximetry readings using 
a study-provided FDA-approved pulse oximeter. Two consecutive pulse oximetry readings must 
be reported at each required timepoint. Day 3, 7, and Day 14 are study-required timepoints for 
pulse oximetry readings. Participants can report pulse oximetry readings at other times 
throughout the study, at their own discretion.   
8.3. 
Quality of Life Questionnaires 
The following QOL questionnaire will be used in this study: 
 Modified PROMIS-29: PROMIS measures were developed through a collaborative 
process funded by the NIH. [16] The PROMIS-29 consists of seven health domains with 
four 5-level items associated with each and a pain intensity assessment using a 0-10 
numeric rank. The seven health domains include physical function, fatigue, pain 
interference, depressive symptoms, anxiety, ability to participate in social roles and 
activities, and sleep disturbance. [17] The PROMIS-29 measures will be modified for this 
study and will include select questions from each of the seven health domains, refer to the 
MOP for details. 

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9. 
Safety Assessments 
9.1. 
Adverse Events and Serious Adverse Events 
An AE is any untoward medical occurrence in humans, whether or not considered drug-related, 
which occurs during the conduct of a clinical trial. An AE can therefore be any change in clinical 
status, routine labs, x-rays, physical examinations, etc., that is considered clinically significant by 
the study investigator.  
An SAE or serious suspected adverse reaction or serious adverse reaction as determined by the 
investigator or the sponsor is an AE that results in any of the following serious outcomes:  
 Death  
 Life-threatening AE (“life-threatening” means that the study participant was, in the 
opinion of the investigator or sponsor, at immediate risk of death from the reaction as it 
occurred and required immediate intervention)  
 Persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions  
 Inpatient hospitalization or prolongation of existing hospitalization  
 Congenital abnormality or birth defect  
 Important medical event that may not result in one of the above outcomes, but may 
jeopardize the health of the study participant or require medical or surgical intervention 
to prevent one of the outcomes listed in the above definition of serious event 
Hospitalization for elective treatment of a preexisting condition that did not worsen from 
baseline does not meet the definition of an SAE. Hospitalization is defined as a stay in the 
hospital exceeding 24 hours.  
An unexpected AE is defined as any AE, the specificity or severity of which is not consistent 
with the package insert. 
9.1.1. 
Adverse Device Effect (ADE) and Unanticipated Adverse Device Effect (UADE) 
For those repurposed medications that are a part of a combination product, which includes a drug 
and a device, the following additional definitions will apply. 
An ADE is an AE related to the use of an investigational medical device. This includes any AE 
resulting from insufficiencies or inadequacies in the instructions for use, the deployment, the 
implantation, the installation, the operation, or any malfunction of the repurposed medical 
device. This also includes any event that is a result of a use error or intentional misuse. 
 Device malfunction – the failure of a device to perform in accordance with the 
instructions for use or clinical investigative plan. 
 User error or intentional misuse - A device is used in a manner that is an act or omission 
of an act that results in a different medical device response than intended by the 
manufacturer or expected by the user. 
A UADE is any SAE 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 or applications (including a supplemental plan or application), or any other unanticipated 

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serious problem associated with a device that relates to the rights, safety, or welfare of 
participants. 
Unanticipated Adverse Device Effects (UADEs) will include events meeting either A or B as 
stated below: 
A. Events meeting ALL of the following criteria: 
 Not included in the relevant appendices or Product Label 
 Related to the device per site PI and/or IND sponsor 
 Serious (meets any of the following criteria): 
o Is life-threatening illness or injury 
o Results in permanent impairment of a body function or a body structure 
o Necessitates medical or surgical intervention to prevent permanent 
impairment of a body function or a body structure 
o Results in hospitalization 
o Led to fetal distress, fetal death, or congenital abnormality or birth defect 
o Led to death 
(Permanent means irreversible impairment or damage to a body structure or function, excluding 
trivial impairment or damage). 
B. Any other unanticipated serious problem associated with the device that relates to the 
rights, safety, or welfare of participants. 
9.1.2. 
Collection Period for AE and SAE Information 
Study participants (and their designated emergency proxies) will be instructed to report ESIs, 
SAEs, and UADEs through their access to the study’s online system. Each day for 14 days, the 
participant will be asked to report on their symptoms and health state, including hospitalization 
and/or other change in health condition. The assessments include specific questions pertaining to 
ESIs, as well as symptoms and severity, health care visits, medications and a notification to the 
participant to contact the study team with any concerns or questions. If the participant is still 
reporting symptoms at Day 14, they will continue to be assessed until they have experienced 
three consecutive days without symptoms, or until Day 28, whichever is shorter. At Day 28 and 
at Day 90, participants will complete assessments. Safety reporting will be available to the 
participant continuously throughout the study, but will only be required at the aforementioned 
collection points.   
The daily and follow-up assessments, as described in the paragraph above, will be monitored and 
sites will be actively notified of events requiring review, including for reporting that meets 
criteria for ESIs, SAEs, or UADEs. Refer to the MOP for details. In addition, participants will be 
invited during assessments to request contact from the study team, or to report any unusual 
circumstances that might be relevant, if they so wish. Failure to complete daily assessments is 
also a trigger for review of a possible SAE. A missed assessment on the day after receiving the 

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first dose of study medication (Day 2) or any two consecutive days of missed assessments up to 
Day 14 will prompt a notification to the site to contact the participant. 
All participants will be instructed to self-report concerns either via an online event reporting 
system, by calling the site, or by calling a 24-hour hotline. Participants will have access to event 
reporting via the online system from the signing of the informed consent form (ICF) until the 
Final Visit (Day 90). 
Events of special interest (ESIs) and SAEs will be extracted by site personnel from the 
participant’s medical record if the participant seeks medical care or if hospitalization occurs, 
each of which notifies the site to conduct follow up.  
Medical occurrences that begin before the start of study drug/placebo, but after obtaining 
informed consent, will not be considered an AE. 
Non-serious AEs (or ADEs, as applicable) may be reported by the participant, but will not be 
further assessed by the site or study personnel unless the event meets the criteria of an ESI.  
Events of Special Interest (ESIs), SAEs, and UADEs (as applicable) will be collected from the 
start of study drug/device combination until the Final Visit (Day 90) or until 30 days after the 
last dose/use of device if participant terminates the study early. 
9.1.3. 
Assessing Causality of a Serious Adverse Event 
If an SAE occurs, the site investigator or medical monitor will assess the relationship to study 
drug by using the following criteria: 
 Related:  
o Study drug - there is a temporal relationship between study drug and event onset 
or the event abates when study drug is discontinued or known to occur with study 
drug. 
o Device – an event is due to the use of the device and cannot be reasonably 
explained by an alternative cause. 
 Not related: The event has no temporal relationship to study drug (or study device, as 
applicable) or the AE (or ADE, as applicable) has a much more likely alternate etiology 
or is due to an underlying or concurrent illness or effect of another drug (or device, as 
applicable). 
9.1.4. 
Reporting and Monitoring of SAEs 
All of the study drugs used in this platform protocol are repurposed medications that are 
approved for marketing in the US for another medical condition. However, their investigational 
use for treatment of COVID-19 infection is not an approved indication and will be under an IND 
and subject to IND regulations in 21 CFR 312. The IND sponsor or designee will review SAEs 
weekly, and will perform aggregate reviews of SAEs every two weeks. The IND sponsor or her 
designee will be responsible for determining if the safety reporting criteria are met per 21 CFR 
312.32(c)(1)(i)(C) and 21 CFR 312.32(c)(1)(iv) and will notify the Data Coordinating Center 
(DCC) to prepare an aggregate report for submission to the FDA. An aggregate safety report will 
be submitted to FDA as soon as possible, but in no case later than 15 calendar days after the IND 

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sponsor determination. If the IND sponsor determines that an unexpected fatal or life-threatening 
suspected adverse reaction occurs markedly more frequently in a study drug arm than in the 
placebo arm, an aggregate safety report will be submitted to the FDA as soon as possible, but in 
no case later than 7 calendar days after the IND sponsor determination. Information on 
individual SAEs will be available upon request from the Agency following the submission of any 
aggregate reports. 
Any UADE(s) that the IND sponsor determines is/are reportable will be submitted to the FDA, 
manufacturer, all reviewing IRBs, and all participating investigators within 10 working days of 
when the sponsor makes that determination. 
If the IND sponsor determines that a UADE presents an unreasonable risk to participants, all 
investigations or parts of investigations presenting that risk shall be terminated as soon as 
possible. Termination shall occur not later than 5 working days after the sponsor makes this 
determination and no later than 15 working days after the sponsor first received notice of the 
effect. 
All hospitalization and death events will be adjudicated (see Section 10.9), any event that is 
determined to be COVID-19-related will not be reportable as an expedited SAE, with the 
exception of events that are related to study drug and unexpected, which will be reportable 
regardless of relatedness to COVID-19. All events that are not COVID-19-related per the 
adjudication process will be reviewed by the DCRI Safety Medical Monitor to determine if the 
event is a reportable SAE. 
Individual SAEs and UADEs must be entered into the data system within 24 hours of site 
awareness. The DCRI Safety Surveillance team will notify pharmaceutical partners of SAEs 
within 1 business day of their receipt that occur involving the specific appendix of the supplied 
study drug/placebo, as required. Serious Adverse Events that are related and confirmed unlisted 
by the DCRI Safety Medical Monitor will be reported to the FDA as SUSARs; as 7-day reports 
for unexpected fatal or life-threatening adverse reactions and 15-day reports for serious and 
unexpected adverse reactions. If the IND sponsor, IDMC, or FDA note a clinically important 
increase in the rate of a SUSAR, the IND sponsor or her designee will notify investigators no 
later than 15 calendar days after determining that the information qualifies for reporting. The 
investigator will follow all reportable events until resolution, stabilization or the event is 
otherwise explained. The DCRI Safety Surveillance Team will follow all SAEs until resolution, 
stabilization, until otherwise explained. 
Pregnancies that occur while on-study will be collected and will not be followed to outcome if 
outcome occurs beyond the participant’s Final Study Visit, however, any associated ESI or SAE 
should be reported if information can be collected and entered into the EDC. The DCRI Safety 
Surveillance team will notify pharmaceutical partners of a pregnancy within 1 business day of 
receipt that occur involving the specific appendix of the supplied study drug/placebo, as 
required. 
9.1.5. Events of Special Interest  
The following are also considered ESIs to the study and will be collected by study personnel via 
medical record review when concern for ESIs are observed for hospitalized participants:  
 Hypoxia, defined as two consecutive pulse oximetry readings ≤ 93% 

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Each study drug may have a unique list of possible related ESIs. Refer to the relevant 
appendices. 
9.2. 
Unanticipated Problem (UP) and Terminations 
9.2.1. Definition of Unanticipated Problem  
The OHRP considers UPs involving risks to participants or others to include, in general, any 
incident, experience, or outcome that meets all of the following criteria: 
 Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the IRB-approved research 
protocol and informed consent document; and (b) the characteristics of the participant 
population being studied. 
 Related or possibly related to participation in the research (“possibly related” means there 
is a reasonable possibility that the incident, experience, or outcome may have been 
caused by the procedures involved in the research). 
 Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
9.2.2. Reporting of an Unanticipated Problem  
The site investigator will report UPs for their participants to the DCC. The site may also be 
required to inform their reviewing IRB about a UP occurring at the local institution. The UP 
report to the DCC will include the following: 
 A detailed description of the event, incident, experience, or outcome  
 An explanation of the basis for determining that the event, incident, experience, or 
outcome represents an UP  
 A description of any changes to the protocol or other corrective actions that have been 
taken or are proposed in response to the UP 
 The DCC will document and review all UPs.  Details of the UP reporting process will be 
located in the MOP. 

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10. 
Statistical Considerations 
10.1. 
Statistical Hypotheses 
10.1.1. 
Primary Hypothesis 
The primary hypothesis in this trial is that participants who receive study drug will have 
improved COVID-19 symptoms as compared to those who receive placebo. 
10.2. 
Sample Size Determination 
This study is designed to be analyzed using a Bayesian approach, accepting the possibility of 
adding and dropping of arms as the trial progresses. There is also the potential for extending 
accrual in a study drug appendix if there is the potential to demonstrate benefit on clinical 
events. Detailed simulations will be used to demonstrate the operating characteristics of each 
study drug appendix. Decision thresholds will be set to balance overall power with control of 
the Type I error rate. To aid planning for this trial, symptom count and clinical event data were 
estimated from participants in a clinical trial with similar inclusion criteria. Data were not 
collected daily in that study, but evaluations were completed on Day 10 after randomization, 
which is considered a clinically meaningful point in time. Based on the observed distribution, it 
is estimated that studies of about n=600 (300 study drug and 300 placebo) will be sufficiently 
sized to determine whether there is evidence of meaningful benefit with >85% power (Table 2). 
Moreover, when a study drug demonstrates overall effectiveness, the planned adaptations to 
increase targeted accrual for the purpose of demonstrating benefit on clinical events is a 
reasonable extension within the context of this platform. This study will enroll up to 15,000 
adults, depending on the number of study drug appendices that are added and adjustments to 
sample size depending on the data. [18]  
Table 2: ACTIV-6 Sample Size Estimates and Power 
OR 
Corresponding 
difference in mean 
symptom burden 
Power 
Corresponding Risk 
Difference in clinical 
events 
Power 
80% 
85% 
90% 
80% 
85% 
90% 
0.4 
2.10 
75 
86 
101 
0.025 
343 
392 
459 
0.5 
1.98 
132 
150 
176 
0.021 
455 
520 
608 
0.6 
1.86 
242 
277 
324 
0.017 
675 
772 
903 
0.7 
1.74 
496 
567 
664 
0.012 
1004 
1148 
1343 
0.8 
1.61 
1267 
1449 
1696 
0.009 
1652 
1889 
2211 
The sample sizes given are the sample size for the study drug arm only. Placebos will be borrowed across study drug 
appendices. The total size of the placebo arm will be equal to the size of the study drug arm. The total number of 
placebos in the trial will depend on eligibility of participants among the study drug appendices and the number of study 
drugs. The calculations are based on symptom burden, hospitalization, and death at Day 10. 
10.3. 
Randomization 
See Section 5.3.3 for additional details.  
10.4. 
Blinding 
The investigators, treating clinicians, and study participants will all remain blinded to study drug 
versus placebo assignment until after the database is locked and blinded analysis is completed. 

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Only the Investigational Drug Service (IDS) and staff who are handling randomization codes and 
unblinded members of the biostatistical team who are preparing closed IDMC interim reports 
will be unblinded. The statistical staff responsible for preparing IDMC reports will not directly 
interact with the clinical team that delivers care to the study participants. Specifically, study 
medication will be dispensed with packaging and labelling that would blind treatment 
assignment. Unblinding will occur only if required for participant safety or treatment at the 
request of the treating clinician.  
The web-based randomization system will include blind-breaking instructions. Participant safety 
must always be the first consideration in making an unblinding determination. If the investigator 
decides that unblinding is warranted, the investigator should contact the IDS that shipped study 
drug/placebo for unblinding a participant’s intervention assignment.  
10.5. 
Populations for Analyses 
Modified Intention to Treat (mITT) Population:  
● All participants who receive study drug/placebo. 
● Participants who do not receive study drug, for any reason, will be excluded; while this 
modifies the intention to treat principle, the failure of delivery of medications from site to 
participant is not under the control of either investigator nor participants and is expected 
to occur infrequently and randomly. All other participants will be included, and they will 
be analyzed according to which arm they were assigned. Thus, the mITT analysis set 
includes all participants who were randomized and received the study drug. 
Safety Population: 
● The safety population will include those persons in the mITT population who report 
taking at least one dose of study drug or matching placebo. In the unlikely case a 
participant receives the incorrect study drug, participants will be grouped according to the 
treatments that they received.  
10.6. 
Statistical Analyses 
The Statistical Analysis Plan (SAP) for a study drug appendix will be finalized prior to the first 
interim analysis. It will include a more technical and detailed description of the statistical 
analyses outlined in this section, including detailed simulations used to inform the sample size 
estimates. This section is a summary of the planned statistical analyses of the most important 
endpoints including primary and secondary endpoints. 
10.6.1. General Considerations 
Baseline demographic and clinical variables will be summarized for each randomized arm of the 
study. Descriptive summaries of the distribution of continuous variables will be presented in 
terms of percentiles (e.g., median, 25th and 75th percentiles) along with means and standard 
deviations. Categorical variables will be summarized in terms of frequencies and percentages. 
Histograms and boxplots may be used to visualize the data. 
The primary analysis for this study will use a covariate adjusted statistical model. The primary 
outcome is an ordinal variable, which is the count of symptoms with hospitalization added as the 

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count of symptoms plus one, and death as the count of symptoms plus two. The outcome is 
measured daily for 14 days. The outcome is compared between participants receiving study drug 
and participants receiving placebo each of the 14 days using a longitudinal statistical model that 
takes into account the repeated measurements on each participant. The statistical model produces 
a common OR, which is directly associated with the concordance probability or the Wilcoxon-
Mann-Whitney U-statistic. This is the main quantity, or estimand, that will be used to make an 
overall claim of effectiveness in this trial.  
10.6.2. Statistical modeling 
Estimation and inferences about the effect of each study drug versus matching placebo will be 
made using Bayesian proportional odds logistic regression methods. For each study drug, the 
matching placebo arm will consist of concurrently randomized participants that meet the 
inclusion and exclusion criteria for that study drug. 
The general form of the Proportional Odds - model can be stated in terms of covariates X and an 
outcome variable Y, where probabilities of outcome value y or greater are given by 
Pr(𝑌≥𝑦|𝑋) = expit(α𝑦+ 𝑋β) where α𝑦 is the intercept for outcome value y and expit is the 
logistic (inverse logit) transformation. X contains baseline covariates and treatment. The 
coefficients β represent the log OR associated with the effects of each adjustment variable, 
including arm assignment. Specifically, the OR represents the relative effect of study drug versus 
placebo on the odds Pr(𝑌≥𝑦|𝑋) (1 −Pr(𝑌≥𝑦|𝑋))
⁄
, for any value y. 
The proportional odds is attractive for the analysis of ordinal and quantitative response variables, 
such as the primary outcome, because they directly model the cumulative distribution function 
from which the many summaries of the primary outcome in each study drug arm are easily 
derived. Example summaries are the probability of a participant being symptom free, and the 
probability of being hospitalized or worse.  
The proportional odds model can be extended to accommodate repeated measures over time for 
individual participants. A longitudinal framework allows one to model the course of disease. 
There are several approaches to taking into account repeated measurements, among which a first-
order Markov state transition model for ordinal outcome provided the best fit to the correlation 
structure found in data from the ORCHID trial. While these participants had more severe disease 
and the outcome was clinical in nature, the same considerations apply to the within-participant 
correlation structure for symptoms, hospitalization or death. The longitudinal ordinal 
proportional odds model will be fit using a Markov state transition model.  
With a first-order Markov process, the outcome on one day of measurement becomes the 
predictor for the next day of measurement. The model will also take absolute time (days from 
first dose of study drug) into account because the mix of outcomes changes over time in a way 
that simple transition odds ratios cannot capture. The selected approach allows the correlation 
between states on two successive days to be high within participant, and it handles absorbing 
states such as death. It also allows the consideration of different time intervals between 
measurements (if measurement days are missed).  
Markov models typically assume that the outcome variable is also assessed at baseline (time 
zero). This the case for ACTIV-6. Participants cannot inhabit the extremes of the scale at 
enrollment, and that is of no consequence. The main obstacle to using transition models is that 

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the primary model parameters (for the proportional odds model) at one time are conditioned on 
the previous state. The model will be restated to obtain probabilities of being in state y or worse 
(“state occupancy probabilities”) through recursive (through time) matrix multiplications to 
“uncondition” the transition probabilities. Thus, the OR and the probability of being in any given 
state (or worse) can be provided for any day. The probabilities will be leveraged for quantifying 
the effect of study drugs on symptom burden, hospitalization, and death. For example, it is 
possible to state the probability of having more than 5 symptoms, the probability of being 
symptom free, or the probability of being hospitalized or having died. These quantities are 
readily comparable between study drug and placebo participants to place the OR from the 
proportional odds model in context. In preliminary data used to explore observable effect sizes 
(Table 2), an OR of 0.6 would be observed as an absolute difference in the probability of being 
hospitalized or dying of 0.017 (1.7%). 
State occupancy probabilities are functions of all model parameters. Because of that it is difficult 
to get confidence intervals and statistical tests using frequentist methods. The Bayesian approach 
will be used to provide exact inferences, taking all uncertainties into account. Graphical methods 
will be used to show the probability of a participant being either symptom free, or of being 
hospitalized or worse, as a function of time and treatment (these figures are sometimes referred 
to as funnel plots). Various ways of restating the model results are also possible. For example, if 
considering the state occupancy probabilities for mortality, this would approximate a Cox 
proportional hazards model.  
The common OR will be used as the primary estimand for claims of effectiveness in reducing 
symptoms. The probability of hospitalization or death will be used as the primary estimand for 
clinical efficacy. These are the primary estimands for decision making in this trial, and both they 
and their posterior distribution are readily computed using standard Bayesian methods. Mean and 
median time to symptom resolution will be used to quantify the clinical benefit of symptom 
improvement. 
In the modeling, the proportional odds assumption will be checked. While the model is generally 
robust, a check will be done for the possibility of a different treatment effect on clinical events 
than on symptoms and a partially proportional model will be used if it does differ. The time by 
treatment interaction will also be checked to determine whether the OR changes during the 14-
day observation window. If it does, the decision making in this trial will be anchored to the OR 
observed on Day 14. 
10.6.3. 
Model priors 
Prior distributions will be specified as follows: 
- 
Intercepts  are derived parameters from the multinomial outcome cell probabilities 
having a Dirichlet distribution with concentration parameter 1 (
⁄ 0.80 + 0.35 max (𝑘, 3)), 
found to have excellent properties (here k = total number of outcome categories) 
- 
The covariate X is an indicator variable for being in the study drug arm (versus matching 
placebo), and the study drug effect 
 (negative values indicate benefit) has a skeptical 
prior which is a normal distribution having mean zero and small standard deviation [SD] 
(concentrating the treatment effect towards zero) provided below. 

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The mean zero prior for the study drug effect 
 implies an equal chance of harm of the treatment 
as of benefit, consistent with equipoise.  The choice of the SD  of the prior distribution for 
 
further defines the skepticism of this effect in the following way. Assume that the investigational 
study drug is not a cure but is rather an incremental therapy. This implies that the odds ratio OR 
  for the study drug cannot be near zero (values < 1.0 indicate benefit).  Assume that the 
probability of a large benefit on the outcome severity, with large meaning an OR < 0.5, is only 
0.025, and to be symmetric the chance of large harm (OR > 2) is also 0.025.  Thus, the prior 
probability that the OR is in [0.5, 2] is 0.95. The prior SD  that achieves this level of skepticism 
is log (0.5) Φ−1(0.025)
⁄
 where  denotes the standard normal cumulative distribution function. 
10.6.4. 
Assessing Effectiveness 
The overall effect of each study drug versus matching placebo will be quantified using the 
common OR from the proportional odds model (primary estimand). Evidence for efficacy will be 
quantified as the posterior probability that the OR is less than 0.9. This is denoted the “posterior 
probability for efficacy” or 𝑃(𝑂𝑅< 0.9|Data). Similarly, the risk difference in hospitalization 
or death will be used to draw conclusions about clinical efficacy. Regardless of whether there is 
an efficacy signal, the following quantities will be reported from the model: 
 Mean and median time to symptom resolution (for quantifying benefit on symptoms) 
 Mean and median time to hospitalization or death (secondary outcomes) 
The primary analysis will be implemented separately for each study drug, where the matching 
placebo arm will consist of concurrently randomized participants that meet the inclusion and 
exclusion criteria for that study drug. An mITT approach will be used for primary analyses. All 
available data will be used to compare each study drug versus placebo control, regardless of 
post-randomization adherence to study protocols.  
10.6.5. 
Planned Interim Analyses, Early Stopping, and Type-I Error Control 
Individual study drugs may require different sample sizes, and the sample sizes may be adjusted 
based on the results of interim analyses. Therefore, fixed enrollment triggers will be used for 
interim analyses. An interim analysis will occur after enrollment and completion of 14 day 
follow up of approximately every 200 participants in a study arm (100 in study drug arm and 100 
in placebo arm). At each interim analysis, the study drug appendix may be stopped early for 
efficacy or futility. Thresholds have been established to guide stopping of the trial if there is 
clear evidence of clinical benefit, there is evidence of equivalence, there is evidence of symptom 
benefit but pursuing clinical benefit is futile, or if the study drug is harmful. The following 
decision thresholds will be checked at each interim analysis: 
i) 
The Study Drug is found to have benefit (efficacy): A posterior probability of 
meaningful benefit (e.g. OR < 0.9) for a study drug in comparison to the placebo control 
of > 0.95 will result in a declaration of overall superiority.  
a. 
If a study drug arm is declared superior, a futility analysis will be 
conducted on observing clinical efficacy (reduction in hospitalizations or death) if 
the study drug arm were to continue for an additional one year. Accrual will be 
projected based on actual trial accrual and projected case rates. Stopping for 

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futility will be strongly encouraged if the predicted probability of success (PPOS) 
is low (e.g. <0.1) and will be discouraged if the PPOS is high (e.g.>0.7).   
ii) 
The study drug is found to be substantially similar to the placebo control 
(inefficacy): A posterior probability of >0.95 that there is no more than trivial benefit 
(e.g. OR > 0.9) or harm of an arm will result in termination of that arm.  
iii) 
The study drug is found to cause harm (inferiority): A posterior probability of 
>0.85 for worse adverse clinical outcomes (hospitalization or death) for a study drug 
relative to the placebo control (e.g. a risk difference >0.01) will result in termination of 
that arm. 
iv) 
The predicted probability of success of any study drug given expected accrual at a 
prespecified point in time will be provided to the IDMC. Stopping for futility will be 
strongly encouraged if the PPOS is low (e.g. <0.1) and will be discouraged if the PPOS is 
high (e.g. >0.7).  Note that unlike the probability of inefficacy, PPOS involves Bayesian 
posterior predictive distributions. 
Futility is a low probability of achieving any conclusions within a reasonable time frame or with 
available resources. Prior to each interim analysis, the target date for study completion will be 
specified, and accrual will be projected by that target date. A statistical model may be used to 
predict accrual. Futility assessment will use the lowest of either the planned accrual or predicted 
accrual at study closure. 
The combination of decision thresholds and effect sizes have been selected to balance the ability 
to observe a meaningful effect on symptoms, to observe the potential for an effect on clinical 
outcomes, and to maximize power. In making decisions, power will be balanced with the Type 1 
error rate. For each study drug, simulations will be used to demonstrate that the operating 
characteristics are consistent with a Type I error control of at least 5%.   
10.6.6. 
Sensitivity and Supplementary Analyses 
The proportional odds assumption of the model requires that the effect of treatment on the odds 
that Y ≥ 3 (measured as an OR versus placebo) is the same relative effect as for Y ≥ 4. Even 
when the proportional odds assumption is strongly violated, the estimated OR remains a simple 
function of the Wilcoxon-Mann-Whitney U-statistic, namely the probability that a randomly 
chosen participant on treatment B has a higher response than a randomly chosen participant on 
treatment A,45 the probability index or concordance probability. Thus, the proportional odds 
assumption is not necessary for the proportional odds model to provide a reasonable global 
assessment of treatment effectiveness, when the primary estimand is the OR. However, derived 
quantities such as the difference in medians may be more sensitive to violations of the 
proportional odds assumption. To assess the robustness of inferences about the primary estimand 
with respect to the proportional odds assumption. This assumption will be relaxed using a 
partially proportional odds model as necessary. 
In addition to checking assumptions about the modeling approach, association of adherence with 
outcomes will also be ascertained. In the main statistical model, the number of doses of study 
drug consumed will be added as a covariate. 

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10.6.7. 
Differential Treatment Effects and Subgroup Analyses 
Differential treatment effect, also referred to as heterogeneity of treatment effect, refers to 
differences in treatment efficacy as a function of pre-existing participant characteristics such as 
baseline variables. This is often assessed by forming subgroups. However, these subgroups do 
not inherit the baseline covariate adjustment of the full participant outcome model, and are 
problematic because of improper subgrouping when a continuous variable is used. For example, 
dichotomizing age at 65 years is arbitrary and it is very unlikely that any study drug effect has a 
discontinuity in effect at 65 years old. Also, subgroup estimates and statistical assessments of 
them are unreliable and are often taken out of context when a more systematic analysis does not 
find evidence for an interaction between the covariate and study drug.  
For these reasons, analysis of differential study drug effect will be prespecified and model based.  
For example, effectiveness variability can be estimated with continuous age by adding a smooth 
age by study drug interaction into the model and using this model and using this model to 
estimate treatment contrast and their uncertainties across age = 10, 11, …, 100. Differential 
treatment effects by sex, body mass index, and age will be examined.  
Studies under this master protocol will be sized only for assessing overall study drug effects. 
Thus, there may be inadequate power to (1) examine interactions and to (2) estimate covariate-
specific treatment effects (e.g., odds ratio at age 70 or for females). 
10.6.8. 
Secondary Clinical Endpoint 
The COVID Clinical Progression Scale score on Day 14 will be compared between participants 
in each study drug arm and the placebo arm using a covariate adjusted proportional odds model. 
A similar approach will be used for QOL outcomes. Covariates will be prespecified and will 
include at a minimum: age, baseline severity, and duration of illness. The proportional odds 
assumption will mainly be examined using graphical methods—e.g., the logit of the empirical 
cumulative distribution function of the ordinal scale should be parallel among categories of 
covariates. If proportionality is clearly violated, a partial proportional odds or non-proportional 
odds models will be considered. As before, a Bayesian approach to model interpretation will be 
used. For estimating time to symptom resolution based on the definition of at least three 
consecutive days without symptoms, a proportional hazards model will be used. Since death is a 
competing risk, cause-specific hazards will be estimated. Observations will be censored at 28 
days. 
10.6.9. 
Exploratory Analysis 
Exploratory analyses involve the same outcome variables, measured at 90 days. Exploratory 
analysis will focus on describing long term outcomes, particularly symptoms and severity, 
clinical status, and QOL. Statistical models will use a similar form as for the main analysis. As 
well as simple analysis that consider the effect of treatment on long term outcomes, the SAP will 
describe how participant state during the intervention period will be used to inform longer term 
outcomes.  

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10.6.10. 
Adherence and Retention Analysis 
Withdrawals from study drug and consent withdrawals will be tracked via the online system.  
Participants will be asked about their use of study drug. Those reporting discontinuation or 
switching will be asked about the reasons for discontinuation/switching.   
Measures of study retention to inform follow-up time will be based on several measures, 
including web-based check-ins for symptoms and COVID-19 outcome reporting. 
10.7. 
Interim Reporting  
In addition to routine evaluation of decision thresholds pursuant to the statistical design of this 
study, regular IDMC reviews will be conducted to ensure the safety of study participants.  
Regular IDMC meetings will monitor the following parameters at a minimum: 
 Recruitment progress 
 Enrollment overall and by subgroups 
 Adherence, retention, and status of data collection 
 Events of special interest (ESIs) 
 Unanticipated problems 
 Serious adverse events (SAEs) 
Interim examination of clinical endpoints will be based on the accrual of primary endpoint data.  
It is expected that reviews of the data will occur approximately after each 200 participants are 
enrolled in each study drug appendix (100 in study drug arm and 100 in placebo arm).  
For ethical reasons, interim examinations of key safety and process data will be performed at 
regular intervals during the course of the trial. The DCC will create reports to track participant 
enrollment, rates of adherence with the assigned treatment strategy, and frequency of protocol 
violations. Prior to each meeting, the DCC will conduct any requested statistical analyses and 
prepare a summary report along with the following information: participant enrollment reports, 
rates of adherence with the assigned treatment, and description of SAEs.  
Safety reports will be prepared for the IDMC approximately weekly once enrollment begins. The 
prespecified stopping thresholds are intended to guide the interpretation of interim analyses and 
are not a strict rule for early termination. It is expected that both internal and external factors will 
influence the decisions of the IDMC. The SAP will describe the planned interim analyses and 
futility monitoring in detail. 
10.8. 
Independent Data Monitoring Committee (IDMC) 
The IDMC will monitor participant safety and study performance. An IDMC charter that outlines 
the operating guidelines for the committee and the procedures for the interim evaluations of 
study data will be developed and agreed upon by the IDMC. Reports will be prepared by the 
DCC in accordance with the plan outlined in the charter, or as requested by the IDMC chair, and 
will include interim analyses of primary and secondary endpoints, additional safety events, and 
other information as requested by the committee. After each scheduled closed meeting, the 
IDMC will send a recommendation to the IND sponsor to continue, modify, or terminate the 
study. After approval, the recommendations will be forwarded by the clinical coordinating center 

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(CCC) to investigators for submission to their local, regional and national IRB/Ethic 
Committees, as applicable. Please refer to the IDMC Charter for further details. 
10.9. 
Adjudication Committee 
The medical records will be requested for all participants reporting a hospitalization and/or death 
at any point during the study. For each participant-reported hospitalization or death event, the 
DCRI Clinical Event Ascertainment (CEA) group will review the medical records and confirm 
the occurrence and root cause of the event as part of an adjudication process. The CEA group 
includes specialists relevant to the hospitalization or death events of interest, additional details 
about review procedures will be provided in an adjudication charter.  
 

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11. 
Ethical Standards 
11.1. 
Institutional Review Board (IRB) 
The protocol, ICF(s), recruitment materials, and all participant materials will be submitted to the 
IRB(s) of record for review and approval. This approval must be obtained before any participant 
is enrolled. Any amendment to the protocol will require review and approval by the IRB(s) 
before being implemented in the study. All changes to the consent form will also be IRB-
approved and a determination will be made regarding whether previously consented participants 
need to be re-consented. 
11.2. 
Informed Consent Process 
All consenting will occur either via an electronic consent process or a paper process. Consent 
forms describing in detail the study drug/placebo, study procedures, and risks will be given to the 
participant and documentation of informed consent is required prior to starting study procedures. 
Informed consent is a process that is initiated prior to the individual’s agreement to participate in 
the study and continues throughout the individual’s study participation. A description of risks 
and possible benefits of participation will be provided to the participants. Consent forms will be 
IRB-approved and the participant will be asked to read and review the document. The participant 
will be provided a phone number and email in the event they have questions about study 
participation. This will allow them to communicate with the investigators (or their delegate), for 
further explanation of the research study and to answer any questions that may arise, as 
necessary. Participants will have the opportunity to carefully review the consent form and ask 
questions prior to signing. 
The participants should have the opportunity to discuss the study and think about it prior to 
agreeing to participate. The participant will sign the informed consent document prior to any 
procedures being done specifically for the study. The participants may withdraw consent at any 
time throughout the course of the study. A copy of the informed consent document will be 
provided to the participants for their records. The rights and welfare of the participants will be 
protected by emphasizing to them that the quality of their medical care will not be adversely 
affected if they decline to participate in this study. 
The study team will distinguish between the desire to discontinue study drug and the desire to 
withdraw consent for study follow-up. In the event that a participant withdraws consent, the 
investigator or his/her designee will clarify with the participant and document whether the 
withdrawal is temporary or permanent, and if a full or partial withdrawal. 
11.3. 
Participant and Data Confidentiality 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, 
and the sponsor(s) and their agents. This confidentiality is extended to cover testing of biological 
samples in addition to the clinical and private information relating to participants. Therefore, the 
study protocol, documentation, data, and all other information generated will be held in strict 
confidence. No information concerning the study or the data will be released to any unauthorized 
third party without prior written approval of the sponsor. The study participant’s contact 
information will be securely stored in the clinical study database. 

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Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, will be transmitted to and stored at the DCC. The study data entry and study 
management systems used by clinical sites and by research staff will be secured and password 
protected. At the end of the study, all study-related data storage systems will be archived 
according to local processes. 
11.4. 
Site Management and Quality Assurance 
The study team will work in tandem to ensure that the data collected in this study are as complete 
and correct as possible. A four-step, multi-functional approach to quality control will be 
implemented: 
 Training: Prior to the start of enrollment, the clinician investigators and key study 
personnel at each site will be trained with the clinical protocol and data collection 
procedures, including how to use the Electronic Data Capture (EDC) system. Follow-up 
training and training for new study personnel or new versions of the protocol will be 
conducted as needed. 
 Monitoring: The CCC, along with the DCC, will ensure that data collection is handled 
properly, will provide in-service training, and will address questions from site investigators 
and coordinators. Electronic review of data quality and completeness will occur on a 
regular and ongoing basis. Any issues will be addressed. At a minimum, source document 
verification will occur, as needed, for confirmation of COVID-19 diagnosis and 
hospitalization(s). 
 Managing data: After the data have been transferred for statistical summarization, data 
description, and data analysis, further crosschecking of the data will be performed with 
discrepant observations being flagged and appropriately resolved through a data query 
system. 
 Reviewing data: Data regarding events of interest will be reviewed to ensure appropriate 
documents are collected for DSMB review. The DCC will monitor standardized 
classification of symptoms and contact site study teams when events comprising the 
primary endpoint are not complete. 
11.5. 
Site Monitoring 
This study will employ a centralized risk-based approach to monitoring with routine and periodic 
review of participant-submitted data to validate the informed consent process, select eligibility 
criteria, hospitalization, identify and follow-up on missing data, inconsistent data, data outliers, 
etc. and ensure completion of administrative and regulatory processes. The study team will 
facilitate regular communication through training sessions, teleconferences, videoconferencing, 
email, etc. Using quality-by-design principles, steps will be taken at the study design stage to 
foresee and limit problems that might occur during the study conduct. Follow-up from the online 
system and call center is expected to keep participants engaged. Minimal levels of intervention 
and a focus on observing rather than influencing the study participants greatly increases the 
likelihood that Good Clinical Practices will be followed. Central statistical monitoring is 
particularly useful for identifying unusual patterns in data. An integrated approach to quality 
surveillance will be deployed, which will be detailed in the appropriate study management plans. 

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12. 
Data Handling and Record Keeping 
12.1. 
Data Collection and Management Responsibilities 
Minimizing research activities and conducting the trial in a pragmatic manner will increase the 
ability to complete the trial in the face of strained clinical and research resources during the 
COVID-19 pandemic. Data will be collected by electronic methods, supplemented by telephone 
or videophone follow-up and from the electronic health record.  
Data will be collected directly from participants using REDCap through text messaging or email 
with a survey link, or phone call as back up. The process for using text messaging is Health 
Insurance Portability and Accountability Act (HIPAA) compliant.  
Site personnel or participants will enter study data into a secure online database. Data will be 
maintained in a secure online database until the time of study publication. At the time of 
publication, the DCC will generate a de-identified version of the database for archiving (see 
Section 12.4). 
12.2. 
Study Records Retention 
Study documents should be retained for a minimum of six years after the study has ended. 
However, if required by local regulations, these documents should be retained for a longer 
period. No records will be destroyed without the written consent of the sponsor, if applicable. It 
is the responsibility of the sponsor to inform the investigator when these documents no longer 
need to be retained. 
12.3. 
Protocol Deviations 
A protocol deviation is defined as non-compliance with the clinical study protocol, GCP, or 
MOP requirements. The non-compliance may be on the part of the participant, site investigator, 
or the site staff.  
A major protocol deviation is a significant divergence from the protocol that may have 
significant effect on the participant’s safety, rights, or welfare and/or on the integrity of the study 
data. Major protocol deviations must be sent to the study IRB and local IRB per their guidelines, 
recorded in source documents, and reported to the coordinating center. Major protocol deviations 
will be tracked. For this study, any missed or delayed survey completion will not be considered a 
major protocol deviation. Refer to the MOP for details. 
12.4. 
Publication and Data Sharing Policy 
This study will comply with the NIH Public Access Policy, which ensures that the public has 
access to the results of NIH-funded research. Methods of data sharing will include 1) archiving 
de-identified data in a data repository and 2) sharing of limited datasets under a Data Use 
Agreement (DUA) and IRB approval. Data will be made available to qualified investigators by 
archiving a fully de-identified dataset in a platform to be determined at the end of the trial. Both 
repositories allow users to search, view study information, and then submit an application to 
receive data. Prior to archiving study data, the DCC will produce a final dataset that will be 
stripped of all personal health information (PHI), including full date elements, in compliance 

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with the HIPAA privacy rule. The relative timing of an event will be retained in the dataset 
converting to study days instead of dates.  
The study result will be returned, including some participant specific results, to enhance value from 
participation. Study results will be disseminated to the public and the medical community through 
presentations at scientific meetings and publishing manuscripts in high impact peer-reviewed 
journals. The International Committee of Medical Journal Editors (ICMJE) member journals have 
adopted a clinical studies registration policy as a condition for publication. The ICMJE defines a 
clinical study as any research project that prospectively assigns human participants to 
intervention or concurrent comparison or control groups to study the cause-and-effect 
relationship between a medical intervention and a health outcome. The ICMJE policy, and the 
Section 801 of the Food and Drug Administration Amendments Act of 2007, requires that all 
clinical studies be registered in a public registry such as ClinicalTrials.gov, which is sponsored 
by the National Library of Medicine. For interventional clinical trials performed under NIH IC 
grants and cooperative agreements, it is the grantee’s responsibility to register the study in an 
acceptable registry, so the research results may be considered for publication in ICMJE member 
journals.  

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13. 
Study Leadership 
The Steering Committee is a multi-stakeholder committee that oversees the study and includes 
representatives from clinical sites, the trial coordinating center, the NIH, PCORI, Operation 
Warp Speed, the FDA, National Center for Advancing Translational Sciences (NCATS), ACTIV 
representatives with no conflict of interest, and academic and industry advocates.  
The CCC and DCC are each overseen by principal investigator(s). The CCC is responsible for 
study coordination, site management, communication, and financial administration. The DCC is 
responsible for treatment allocations, receipt and processing of data, quality control programs, 
and statistical analysis and reporting.   
An independent IDMC will oversee the safety and welfare of trial participants as well as provide 
recommendations for continuation, discontinuation or revision of the trial. 
 
 
Figure 2: Operational Structure Diagram 

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14. 
Summary of Changes 
Protocol Version (version #, date) 
Summary of Changes 
Version 1.0, 01APR2021 
N/A, Version 1.0 
Version 2.0, 25MAY2021 
 Added current use of study drug or 
study drug/device combination as an 
exclusion criteria (Sections 1.1 and 
5.2); 
 Added a phone call follow-up the day 
after first study drug dose, clarified 
that follow-up will occur if two 
consecutive days of reporting are 
missed during Days 3-14, and added 
that sites/call center will collect 
missing survey information during 
follow-up calls (Section 7.3); 
 Added at-home pulse oximetry 
readings and description of at-home 
pulse oximetry reading collection 
(Table 1 and Section 8.2); 
 Added symptom severity scale 
(Section 8.2); 
 Added Adverse Device Effect and 
Unanticipated Adverse Device Effects 
definitions, collection/reporting period 
details, and causality assessment 
details (Sections 9.1.1, 9.1.2, 9.1.3, 
9.1.4); 
 Clarified that hypoxia ESI will only be 
collected from hospitalized 
participants (Section 9.1.5); 
 Clarified that any missing or delayed 
survey completion will not be 
considered a major protocol deviation 
(Section 12.3); 
 Updated Ivermectin and matched 
placebo information and packaging 
(Sections 16.3, 16.3.1, 16.3.3, 16.4.1); 
 Added Appendix B – Fluvoxamine 
maleate (Section 17); 

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 Added Appendix C – Fluticasone 
Furoate (Section 18); 
 Changed symptom freedom to 
symptom resolution for consistency 
throughout; 
 Other administrative changes 
throughout. 
Version 3.0, 06JUL2021 
 Clarified that the sample size increase 
will included 1:1 active study drug to 
placebo (Section 1.1); 
 Added footnote 6 to COVID-19 
Outcomes during Intervention Period 
to clarify that these will be assessed on 
Day 7 and 14 (Table 1); 
 Added that events that are COVID-19 
related AND study drug related and 
unexpected will be considered 
reportable (Section 9.1.4); 
 Updates made to fluvoxamine 
appendix: excluded linezolid, use of 
fluoxetine within 45 days of consent, 
and bipolar disorder per FDA 
feedback (Section 17.2); added 
precautions of additional drugs 
including tramadol, buspirone, 
fentanyl, lithium, amphetamines, St. 
John’s Wart, carbamazepine, 
quinidine, and tacrine per FDA 
feedback (Section 17.2.1); 
 Updates made to fluticasone furoate 
appendix: brand name Arnuity Ellipta 
replaced with fluticasone furoate 
throughout (Section 18); changed liver 
failure exclusion criteria to “moderate 
to severe hepatic impairment, defined 
as Child-Pugh B or C” (Section 18.2); 
removed hepatic impairment 
precautions as it was added to 
exclusion criteria (Section 18.2.1); 
 Other minor administrative changes 
throughout. 

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19: A Pilot Randomised, Controlled, Open Label, Multicentre Trial. 2020, SSRN. 
51. 
Podder, C.S., et al., Outcome of ivermectin treated mild to moderate COVID-19 cases: a 
single-centre, open-label, randomised controlled study. IMC Journal of Medical Science, 
2020. 14(2). 
52. 
Ravikirti, et al., Ivermectin as a potential treatment for mild to moderate COVID-19 – A 
double blind randomized placebo-controlled trial. medRxiv, 2021: p. 
2021.01.05.21249310. 
53. 
Morteza Shakhsi, N., et al., Research Square, 2021. 
54. 
Espitia-Hernandez, G., et al., Effects of Ivermectin-azithromycin-cholecalciferol 
combined therapy on COVID-19 infected patients: A proof of concept study. Biomedical 
Research, 2020. 
55. 
Babalola, O., et al., Ivermectin shows clinical benefits in mild to moderate COVID19: A 
randomised controlled double blind dose response study in Lagos. medRxiv, 2021: p. 
2021.01.05.21249131. 
56. 
NIH. COVID-19 Treatment Guidelines Fluvoxamine. 2021  [cited 2021 April 23]; 
Available from: 
https://www.covid19treatmentguidelines.nih.gov/immunomodulators/fluvoxamine/. 
57. 
Apotex, Higlights of Fluvoxamine Maleate Tablets Prescribing Information. 
58. 
Lenze, E.J., et al., Fluvoxamine vs Placebo and Clinical Deterioration in Outpatients 
With Symptomatic COVID-19: A Randomized Clinical Trial. JAMA, 2020. 324(22): p. 
2292-2300. 
59. 
Rosen, D.A., et al., Modulation of the sigma-1 receptor–IRE1 pathway is beneficial in 
preclinical models of inflammation and sepsis. Science Translational Medicine, 2019. 
11(478): p. eaau5266. 
60. 
Rafiee, L., V. Hajhashemi, and S.H. Javanmard, Fluvoxamine inhibits some inflammatory 
genes expression in LPS/stimulated human endothelial cells, U937 macrophages, and 
carrageenan-induced paw edema in rat. Iran J Basic Med Sci, 2016. 19(9): p. 977-984. 
61. 
Seftel, D. and D.R. Boulware, Prospective Cohort of Fluvoxamine for Early Treatment of 
Coronavirus Disease 19. Open Forum Infectious Diseases, 2021. 8(2). 
62. 
GlaxoSmithKline, Highlights of Prescribing Information for Arnuity Ellipta. 2018: 
Online. 
63. 
Yamaya, M., et al., Inhibitory effects of glycopyrronium, formoterol, and budesonide on 
coronavirus HCoV-229E replication and cytokine production by primary cultures of 
human nasal and tracheal epithelial cells. Respir Investig, 2020. 58(3): p. 155-168. 
64. 
Peters, M.C., et al., COVID-19-related Genes in Sputum Cells in Asthma. Relationship to 
Demographic Features and Corticosteroids. Am J Respir Crit Care Med, 2020. 202(1): p. 
83-90. 

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65. 
Finney, L.J., et al., Inhaled corticosteroids downregulate the SARS-CoV-2 receptor ACE2 
in COPD through suppression of type I interferon. J Allergy Clin Immunol, 2021. 147(2): 
p. 510-519.e5. 
 
 
 

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16. 
Appendix A – Ivermectin  
16.1. 
Risk Assessment 
The most commonly reported adverse events for ivermectin are pruritus (25.3%), headache 
(13.9%), and dizziness (7.5%) (ICH working group, 2003). Since the 1980s, the use of 
ivermectin in humans for the treatment of filariasis, especially onchocerciasis, has been 
associated with SAEs, including coma, seizure and death only when administered in regions 
where onchocerciasis and loiasis are co-endemic. [19] 
The issue of SAEs due to ivermectin is a threat to adherence to mass drug administration and the 
control and elimination of disease in communities co-endemic with O. volvulus and Loa loa. 
Mass drug administration were suspended from 2004 to 2006 in some health zones in the 
Equateur, Bas Congo, and Oriental provinces in the Democratic Republic of the Congo because 
of ivermectin-associated SAEs in the Bas Congo and Oriental provinces in 2003. [20] It has been 
thought that co-infection with L. loa is a risk factor for the development of these reactions. [21] 
Additionally, a study investigating escalating high doses of ivermectin in healthy adults was 
performed to explore the safety of its use in the treatment of head lice. The authors documented 
no evidence of CNS toxicity in doses up to 10 times the highest FDA-approved dose of 200 
µg/kg. [22] 
Table 3 shows safety events that occurred in greater than 5% of the clinical trial population who 
received ≥ 300 µg/kg of ivermectin. [23]  For a detailed list of the adverse reactions that occurred 
during clinical trials with ivermectin, refer to the product label and the Investigator’s Brochure. 
Ivermectin is pregnancy category C and is not contraindicated per FDA. Analyses of outcomes 
of pregnancies in women inadvertently exposed to ivermectin through mass administration 
campaigns show no evidence of increased birth defects, neonatal deaths, maternal morbidity, 
preterm births, or low birthweight over baseline rates. [24, 25] 
Table 3: Ivermectin Adverse Event Table for Doses ≥ 300 µg/kg 
Indication (dose) 
Wuchererua bancrofti 
(200-400 µg/kg) [26] 
Wuchererua bancrofti 
(200 µg/kg, then 400 
µg/kg on day 4) [27] 
Stage II or III tungiasis 
lesions (300 µg/kg, 
days 1 & 2) [28]  
Loa loa infection (300 
or 400 µg/kg) [29] 
Symptomatic 
Plasmodium 
falciparum malaria 
(600 µg/kg) [30] 
Adverse Reactions 
Abdominal Pain 
 
 
7% 
 
 
Cough 
42% 
 
 
 
 
Diarrhea 
 
 
 
6.5% 
 
Eye disorders 
 
 
 
 
9% 

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Fever 
69% 
46% 
 
8% 
 
Gastrointestinal  
 
18% 
 
 
 
Headache 
75% 
 
11% 
16% 
 
Local Inflammation 
 
9% 
 
 
 
Local Pain 
 
9% 
 
 
 
Lumber myalgia 
 
 
 
6.5% 
 
Malaise 
 
27% 
 
 
 
Myalgia 
37% 
 
 
 
 
Neurological 
 
15% 
 
 
 
Pneumonia 
 
 
 
 
9% 
Pruritus 
 
 
 
60% 
 
Renal 
 
33% 
 
 
 
Respiratory 
 
33% 
 
 
 
16.2. 
Additional Appendix-Level Exclusion Criteria 
1. End-stage renal disease on renal replacement therapy 
2. Liver failure or decompensated cirrhosis 
3. Use of warfarin, CYP3A4, P-gp inhibitor drugs, or CYP3A4 substrates (see Section 
16.2.1) 
4. Nursing mothers 
5. Pregnancy*  
*Participants must agree to use an effective method of contraception during study drug 
administration and for at least 3 days after their final dose of study drug. Effective methods 
include any of the following: abstinence, partner vasectomy, bilateral tubal ligation, intrauterine 
device, progestin implants, or barrier (condom, diaphragm, cervical cap) plus spermicide. 
16.2.1. 
Precautions 
While rare, post-marketing reports indicate an increased International Normalized Ratio (INR) 
when ivermectin was co-administered with warfarin. With a 3-day dosing period this is unlikely 
to be a significant issue, but INR monitoring can be recommended to the care provider if felt 
warranted by site investigator.   
Use of CYP3A4 inducers and inhibitors and P-gp inhibitor are contraindicated for use with 
ivermectin. 

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16.3. 
Ivermectin Information  
Ivermectin is a semisynthetic oral agent used primarily as an anti-parasitic agent. It is derived 
from highly active, broad-spectrum, anti-parasitic agents isolated from Streptomyces avermitilis 
fermentation products. It binds selectively, and with high affinity, to glutamate-gated chloride 
ion channels, therefore increasing cell membrane permeability to chloride ions resulting in death 
of the parasite. [31] It is currently FDA-approved for the following indications: strongyloidiasis 
of the intestinal tract due to the nematode parasite Strongyloides stercoralis and onchocerciasis 
due to the nematode parasite Onchocerca volvulus. [23] Per the FDA-approved labelling of 
ivermectin, the recommended dose is 200 µg/kg/day to treat strongyloidiases and 150 µg/kg/day 
to treat onchocerciasis in the form of a 3 mg tablet.   
16.3.1. 
Formulation, Appearance, Packaging, and Labeling 
Ivermectin is a white to yellowish-white, nonhygroscopic, crystalline powder. For this study, 
ivermectin will be supplied as fifteen 7-mg tablets in a bottle with a single panel label. The 
tablets are white, round, biconvex tablets with “123” over the scoring on one side. All packaging 
will be labeled to indicate that the product is for investigational use. 
16.3.2. 
Drug Dispensing, Storage, and Stability 
Ivermectin will be supplied as 7-mg tablets and must be stored at temperatures below 30°C. 
16.3.3. 
Dosing and Administration 
Ivermectin should be taken on an empty stomach with water (30 minutes before a meal or 2 
hours after a meal). Each participant will receive a bottle of fifteen 7-mg tablets and will be 
instructed to take a pre-specified number of tablets for 3 consecutive days based on their weight 
(see Table 4) for a daily dose of approximately 300-400 µg/kg. 
Table 4: Ivermectin Dosing Schedule 
Weight (kg) 
Day 1 (# of 7-
mg tablets) 
Day 2 (# of 7-
mg tablets) 
Day 3 (# of 7-
mg tablets) 
Daily Dose 
(µg/kg) 
35-52 
2 
2 
2 
269-400 
53-69 
3 
3 
3 
304 -396 
70-89 
4 
4 
4 
315-400 
>90 
5 
5 
5 
≤389 
16.3.4. 
Rationale for Selection of Dose 
Pre-clinical studies: 
Reports from in vitro studies suggest that ivermectin acts against RNA viruses such as SARS-
CoV-2 by inhibiting the host importin α/β-mediated nuclear transport that prevent viral proteins 
from entering the nucleus to alter host cell function. [32] A single dose addition of ivermectin to 
Vero-hSLAM cells 2 hours post infection with SARS-CoV-2 was able to effect a 5000-fold 

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reduction in viral RNA at 48 hours and may interfere with the attachment of SARS-CoV-2 spike 
protein to the human cell membrane. [33, 34] 
Ivermectin has been shown to inhibit the replication of SARS-CoV-2 in cell culture. However, 
pharmacokinetic and pharmacodynamic studies suggest that ivermectin doses up to 100-fold 
higher than those approved for use in humans would be required to achieve the plasma 
concentrations necessary to duplicate the drug’s antiviral efficacy in vitro. [35, 36] Even though 
ivermectin appears to accumulate in lung tissue, with the doses used in most clinical trials, 
predicted systemic plasma and lung tissue concentrations are much lower than 2 µM, the half-
maximal inhibitory concentration (IC50) against SARS-CoV-2 in vitro. [37, 38] 
Ivermectin demonstrates potential anti-inflammatory properties in some in vitro 
studies, properties which have been postulated to be beneficial in the treatment of COVID-19. 
[39-41] The dose range for an anti-inflammatory effect may be lower than for the anti-viral 
effects. [41]   
Clinical studies: 
A number of retrospective cohort studies and the results of several randomized trials of 
ivermectin use in patients with COVID-19 have been published in peer-reviewed journals or 
made available as preliminary, non-peer-reviewed reports. Some clinical studies showed no 
benefits after ivermectin use, whereas others reported shorter time to resolution of disease 
manifestations attributed to COVID-19, greater reduction in inflammatory markers, shorter time 
to viral clearance, or lower mortality rates in patients who received ivermectin than in patients 
who received comparator drugs or placebo. [42-48] 
Most of the studies reported to date are limited by their small sample size, varying dosing 
schedules and the adjunctive use of various concomitant medications (e.g., doxycycline, 
hydroxychloroquine, azithromycin, zinc, corticosteroids), confounding assessment of the true 
efficacy or safety of ivermectin. Clinical studies in outpatients with COVID-19 did not always 
describe the severity of COVID-19 and the study outcome measures were not always defined. 
Nonetheless, while some have shown no difference, most clinical trials of outpatients with 
mild/moderate COVID-19 have shown clinical improvement with even a single dose or a short 
two to five-day course of ivermectin given orally shortly after symptom onset. [36, 46, 49, 50]  
There is a dose-dependent relationship between ivermectin dose and clinical efficacy. Trials 
using lower doses of ivermectin tend to show no or minimal clinical benefit in COVID-19 
patients treated in the outpatient or hospital setting. [51, 52] Higher doses, at least 0.4 mg/kg, 
particularly when administered in multiple doses, have been shown to significantly reduce time 
to recovery and mortality as compared with lower doses or placebo/standard care. [49, 53-55] 
There is a concentration-dependent virologic response seen using higher-than-usual doses of 
ivermectin (600 μg/kg vs. 200 μg/kg once daily for 5 days) that have been shown to significantly 
reduce the time to PCR viral positivity over standard doses with minimal associated toxicities. 
[50]  
The safety, tolerability, and pharmacokinetics of escalating high doses of ivermectin was tested 
in healthy adult subjects. [35] Doses from 30 mg/day (347-571 µg/kg) to 120 mg/day (1404-
2000 µg/kg) given for 3 days were all well tolerated. [35] These data coupled with evidence of 

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superior clinical efficacy of doses in the lower of this range provide the rationale for the 300-400 
µg/kg dose given for 3 days in the proposed trial. 
16.4. 
Placebo Information  
16.4.1. 
Formulation, Appearance, Packaging, and Labeling 
Placebo will match the appearance of the 7-mg ivermectin tablets: white, round, biconvex tablets 
with “123” over the scoring on one side. A total of fifteen tablets will be provided in a bottle 
with a single panel label. The placebo formulation includes the following ingredients in a 210 mg 
tablet: microcrystalline cellulose, NF (MC-102; pregelatinized starch, NF (Starch 1500); 
croscarmellose sodium, NF (Vivasol, GF Grade); colloidal silicon dioxide, NF (Aerosil 200) and 
magnesium stearate, NF (2257). All packaging will be labeled to indicate that the product is for 
investigational use. 
16.4.2. 
Drug Dispensing, Storage, and Stability 
Placebo must be stored at temperatures below 30°C. 
16.4.3. 
Dosing and Administration 
Dosing and administration will occur according to Section 16.3.3 in order to maintain blinding. 
16.5. 
Events of Special Interest 
None 

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17. 
Appendix B – Fluvoxamine Maleate  
17.1. 
Risk Assessment 
The most common adverse effects of fluvoxamine described in the setting of treatment of 
psychiatric conditions include gastrointestinal effects, neurological effects, dermatological 
reactions, and in rare cases suicidal ideation. [56] In two 10-week controlled trials in Obsessive 
Compulsive Disorder (OCD) and depression at doses ranging from 100-300 mg/day, the most 
commonly observed adverse reactions associated with the use of fluvoxamine maleate tablets 
(incidence of 5% or greater and at least twice that for placebo) were nausea, somnolence, 
insomnia, asthenia, nervousness, dyspepsia, abnormal ejaculation, sweating, anorexia, tremor, 
and vomiting (see Table 5). [57]   
Table 6 lists the complete set of adverse events identified in a randomized clinical trial of 
fluvoxamine (300 mg/day for 15 days) versus placebo in 152 COVID-19 participants. [58] 
Adverse events and serious adverse events were more common in the placebo arm and the single 
SAE in the fluvoxamine arm was dehydration and the study medication was not interrupted. [58]  
Table 5. Fluvoxamine Adverse events occurring in 10-week studies of adult OCD or 
depression 
 *Table shows events that occurred in ≥ 5% of adult OCD and depression study 
participants receiving 100-300 mg/day for 10 weeks of fluvoxamine maleate versus 
placebo.[57] 
Adverse Reaction 
Fluvoxamine, 
n=892 (%) 
Placebo, 
n=778 (%) 
Headache 
22 
20 
Asthenia 
14 
6 
Nausea 
40 
14 
Diarrhea 
11 
7 
Constipation 
10 
8 
Dyspepsia 
10 
5 
Anorexia 
6 
2 
Vomiting 
5 
2 
Somnolence 
22 
8 
Insomnia 
21 
10 
Dry Mouth 
14 
10 
Nervousness 
12 
5 
Dizziness 
11 
6 
Tremor 
5 
1 

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Anxiety 
5 
3 
 
Table 6. Fluvoxamine Adverse events that occurred in COVID-19 study participants 
receiving 300 mg/day for 15 days. 
Adverse Reaction [58] 
 
Fluvoxamine, n=80 
(%) 
Placebo, n=72 
(%) 
Pneumonia 
3.8 
8.3 
Shortness of breath 
2.5 
5.6 
Headache or head pain 
2.5 
1.4 
Gastroenteritis, nausea, or vomiting 
1.3 
6.9 
Muscle aches 
1.3 
0 
Bacterial infection 
1.3 
0 
Vasovagal syncope 
1.3 
0 
Teeth chattering 
1.3 
0 
Dehydration 
1.3 
0 
Low oxygen saturation or hypoxia 
0 
8.3 
Chest pain or tightness 
0 
2.8 
Fever 
0 
2.8 
Acute respiratory failure 
0 
1.4 
Serious adverse events 
1.3 
6.9 
Other adverse events 
13.8 
8.3 
17.2. 
Additional Appendix-Level Exclusion Criteria 
1. Use of selective serotonin (or norepinephrine) reuptake inhibitors (SSRIs/SNRIs), 
including fluvoxamine, or monoamine oxidase inhibitors (MAOIs) within 2 
weeks of consent including triptans and tryptophan. Use of fluoxetine within 45 
days of consent.  
2. Co-administration of tizanidine, thioridazine, alosetron, pimozide, diazepam, 
ramelteon, linezolid 
3. Bipolar Disorder 
4. Nursing mothers 
5. Pregnancy* 

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*Participants must agree to use an effective method of contraception during study drug 
administration and for at least 3 days after their final dose of study drug. Effective methods 
include any of the following: abstinence, partner vasectomy, bilateral tubal ligation, intrauterine 
device, progestin implants, or barrier (condom, diaphragm, cervical cap) plus spermicide.  
17.2.1. 
Precautions 
Fluvoxamine is a potent inhibitor of CYP1A2 and 2C19 and a moderate inhibitor of CYP2C9, 
2D6, and 3A4, as such, it may enhance anticoagulant effects of antiplatelets and anticoagulants 
as well as other medications. It is recommended that concomitant medications listed below be 
discussed with participants and potential effects of increased drug exposure reviewed and 
monitored by the participant and/or their prescribing clinician. 
 Tricyclic antidepressants: monitor for side effects with amitriptyline, clomipramine, 
imipramine 
 Antipsychotic drugs: neuroleptic malignant syndrome or similar; particularly 
clozapine (hypotension, seizure) 
 Benzodiazepines: particularly alprazolam; recommend dose reduction  
 Tramadol, buspirone, fentanyl, lithium, amphetamines, St. John’s Wart, 
carbamazepine, quinidine, and tacrine 
 Methadone: opioid intoxication 
 Mexiletine: monitor for side effects 
 Theophylline: recommend dose reduction and monitor for side effects 
 Warfarin: monitor INR 
 NSAIDS or aspirin: monitor for signs of bleeding 
 Diltiazem, propranolol, metoprolol: monitor for bradycardia 
Participants should be warned about fluvoxamine inhibition of caffeine metabolism. A 
description is 1 cup of coffee has the effects of 4 cups while taking fluvoxamine.  
Caution should be used in participants with hepatic dysfunction due to approximately 30% 
increase in exposures.  
17.3. 
Fluvoxamine Information  
Fluvoxamine is an FDA-approved SSRI for the treatment of OCD. Clinically it is also used for 
other conditions such as depression.[56] The active ingredient in fluvoxamine is fluvoxamine 
maleate.  
17.3.1. 
Formulation, Appearance, Packaging, and Labeling 
Fluvoxamine is a round golden 50 mg tablet that is scored on both sides - one side has “APO” 
and the other side has “F50” with a partial bisect. All packaging will be labeled to indicate that 
the product is for investigational use. 

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17.3.2. 
Drug Dispensing, Storage, and Stability 
Drug will be supplied by Apotex and distributed by Belmar Pharmacy. Study drug should be 
stored in controlled room temperature (20°C to 25°C); excursions are permitted to 15°C to 30°C. 
17.3.3. 
Dosing and Administration 
Fluvoxamine will be self-administered orally by each participant at a dose of 50 mg BID for 10 
days. 
17.3.4. 
Rationale for Selection of Dose 
The recommended starting dose of fluvoxamine for OCD in adults is 50 mg daily dose to be 
titrated up to a maximum of 300 mg/day divided into BID doses. Clinical data from the placebo-
controlled, randomized trial in nonhospitalized adults with mild COVID-19 demonstrated that a 
50 mg BID fluvoxamine dose was well-tolerated and effective (see Figure 4).[58] In the same 
study, doses of 100 mg BID in COVID-19 participants resulted in additional side effects over a 
14-day period. The 300 mg daily dose is for serotonin receptor activity, whereas the postulated 
dose for sigma-1 receptor activity as an anti-inflammatory is lower. Therefore, the proposed 
dosing regimen of 50 mg BID for 10 days will use the anticipated minimal effective dose to 
maximize efficacy and minimize toxicity. 
Pre-Clinical Studies: 
Pre-clinical studies have indicated that the anti-inflammatory effects of fluvoxamine may support 
its use for treating COVID-19. Systemic inflammation as a result of infection can damage 
vasculature which may lead to tissue hypoperfusion and multiple organ failure.[59] Reducing 
systemic inflammation thereby may avoid or mitigate the aforementioned serious clinical 
outcomes. In murine studies, administration of fluvoxamine significantly increased survival of 
S1R wildtype (WT) mice and S1R knockout (KO) mice challenged with ligand 
lipopolysaccharide (LPS) as compared to mice that received saline (Figure 3).[59] Fluvoxamine 
also reduced production of inflammatory cytokines in ex vivo and in vitro murine and human 
cells (HEK293mTLR4/MD2/CD14, primary lung fibroblasts, and mouse bone marrow-derived 
macrophages) and inflammatory genes in human endothelial cells.[59, 60] 

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Figure 3: Survival curve of WT and S1R KO mice  
Figure note: Mice were treated with vehicle (33% Kolliphor in saline) or STF (30 mg/kg) after 
administration of LPS (2 mg/kg) as indicated in (B) (n = 15 to 16 mice per group; **P < 0.01, 
***P < 0.001, log-rank test).[59] 
Clinical Studies: 
A placebo-controlled, randomized trial in nonhospitalized adults with mild COVID-19 tested the 
efficacy and safety of fluvoxamine (50 mg oral one-time dose, followed by 100 mg orally twice 
daily for 2 days, followed by 100 mg orally three times daily through day 15) versus placebo 
[58]. Results of the study reported that 8.3% (6/72) of participants who received placebo 
experienced clinical deterioration within 15 days of randomization, as opposed to 0% (0/80) in 
the fluvoxamine arm (absolute difference 8.7%; 95% CI, 1.8% to 16.5%; P = 0.009).[58]  
Clinical deterioration was defined as shortness of breath/pneumonia with hypoxia (Figure 4). 
Concomitant SSRI/SNRI dosing was not allowed per the trial protocol thus the participant’s 
SSRI/SNRI was held for the study dosing period if reported at baseline.  

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Figure 4: Summary of JAMA Randomization Clinical Trial of Fluvoxamine for Early 
COVID-19.  
A prospective, nonrandomized observational cohort study that evaluated fluvoxamine showed 
that on Day 14, 0/65 participants had persistent symptoms as opposed to 19/48 participants who 
did not receive fluvoxamine (P < 0.001) [61]. Additionally, by Day 14, none of the participants 
who received fluvoxamine were hospitalized as compared to 6 participants who were 
hospitalized who did not receive the drug (see Figure 5). In this study, all participants were 
offered fluvoxamine and decided whether or not to take the study drug. Participants who chose to 
receive the study drug received 50 mg of fluvoxamine two times a day following an upfront 100 
mg loading dose.[61]  
 
Figure 5: Summary of study results for the prospective, nonrandomized observational 
cohort study with fluvoxamine in participants diagnosed with COVID-19.  

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17.4. 
Placebo Information  
The placebo will be a fluvoxamine-matched placebo containing mannitol, magnesium stearate, 
hydroxyethyl cellulose, polyethylene glycol, titanium dioxide, yellow ferric oxide, and purified 
water. The appearance and packaging will match that of the study drug (as described in Section 
17.3.1). All packaging will be labeled to indicate that the product is for investigational use.  
17.4.1. 
Formulation, Appearance, Packaging, and Labeling 
Placebo will match the appearance of the fluvoxamine tablets: round golden 50 mg tablet that is 
scored on both sides - one side has “APO” and the other side has “F50” with a partial bisect. All 
packaging will be labeled to indicate that the product is for investigational use. 
17.4.2. 
Drug Dispensing, Storage, and Stability 
Placebo will be supplied by Apotex and distributed by Belmar Pharmacy. Placebo should be 
stored in controlled room temperature (20°C to 25°C). 
17.4.3. 
Dosing and Administration 
Participants will self-administer one placebo tablet orally, twice daily for 10 days. 
17.5. 
Events of Special Interest 
None 
 

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18. 
Appendix C –Fluticasone Furoate 
18.1. 
Risk Assessment 
The most common adverse reactions reported in ≥ 5% of adults and adolescents with lung 
disease include nasopharyngitis, bronchitis, upper respiratory tract infection, and headache. 
Long-term use of systemic and local corticosteroids may also result in the following side effects: 
Candida albicans infection, immunosuppression, hypercorticism and adrenal suppression, 
reduction in bone mineral density (BMD), or glaucoma and cataracts. [62] 
There are insufficient data on the use of fluticasone furoate in pregnant women. There are 
clinical considerations with use of fluticasone furoate in pregnant women to inform drug-
associated risk and benefit. In animal reproduction studies, fluticasone furoate administered by 
inhalation to rats and rabbits during the period of organogenesis produced no fetal structural 
abnormalities. The highest fluticasone furoate doses in the rat and rabbit studies were 4 times and 
1 times the maximum recommended human daily inhalation dose, respectively. The estimated 
risk of major birth defects and miscarriage for the indicated populations is unknown. In the US 
general population, the estimated risk of major birth defects and miscarriage in clinically 
recognized pregnancies is 2% to 4% and 15% to 20%, respectively. [62] 
Disease-Associated Maternal and/or Embryofetal Risk: In women with poorly or moderately 
controlled asthma, there is an increased risk of several perinatal outcomes such as pre-eclampsia 
in the mother and prematurity, low birth weight, and small for gestational age in the neonate. 
[62]  
Table 7. Fluticasone Adverse reactions that occurred in ≥3% of adults and adolescents 
with asthma in a 24-week trial.  
Adverse Reaction [62] 
Fluticasone furoate,  
fluticasone 200 µg, n=119 
(%) 
Fluticasone furoate, 
fluticasone 100 µg, 
n=119 (%) 
Nasopharyngitis 
13 
12 
Headache  
13 
10 
Bronchitis 
7 
12 
Influenza 
7 
4 
Upper Respiratory tract infection 
6 
2 
Sinusitis 
4 
7 
Oropharyngeal pain  
4 
3 
Pharyngitis 
3 
6 

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Back pain 
3 
3 
Dysphonia 
3 
2 
Oral candidiasis 
3 
<1 
Procedural pain 
3 
<1 
Rhinitis 
3 
<1 
Throat irritation 
3 
<1 
Abdominal pain 
3 
0 
Cough 
3 
0 
18.2. 
Additional Appendix-Level Exclusion Criteria 
1. Severe hypersensitivity to milk proteins  
2. Currently prescribed or use within 30 days of inhaled or systemic steroids 
3. Moderate to severe hepatic impairment, defined as Child-Pugh B or C 
4. Nursing mothers 
5. Pregnancy* 
*Participants must agree to use an effective method of contraception during study drug 
administration and for at least 3 days after their final dose of study drug. Effective methods 
include any of the following: abstinence, partner vasectomy, bilateral tubal ligation, intrauterine 
device, progestin implants, or barrier (condom, diaphragm, cervical cap) plus spermicide.  
18.2.1. 
Precautions 
While not contraindicated, the following should be considered while taking fluticasone furoate: 
 Strong cytochrome P450 3A4 inhibitors (e.g. ketoconazole, ritonavir, clarithromycin, 
conivaptan, indinavir, itraconazole, lopinavir, nefazodone, nelfinavir, saquinavir, 
telithromycin, troleandomycin, voriconazole) should be used with caution as 
increased systemic corticosteroid adverse effects may occur in combination with 
fluticasone furoate. Generally, due to the limited study drug administration length, 
clinically significant interactions are unlikely.  
 Paradoxical Bronchospasm may occur with an immediate increase in wheezing after 
dosing. Fluticasone furoate should be discontinued immediately if this occurs.  
 

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18.3. 
Fluticasone Furoate Information  
Inhaled fluticasone furoate will be provided by GlaxoSmithKline. It is a synthetic trifluorinated 
inhaled corticosteroid (ICS) with anti-inflammatory activity. In vitro and in vivo models have 
shown that fluticasone furoate demonstrates anti-inflammatory actions by activating the 
glucocorticoid response element, inhibiting pre-inflammatory transcription factors such as 
NFkB, and inhibiting antigen-induced lung eosinophilia, which may contribute to its efficacy in 
the approved indications. It is FDA-approved for once-daily maintenance treatment of asthma as 
prophylactic therapy in patients 5 years and older. [62]  
18.3.1. 
Formulation, Appearance, Packaging, and Labeling 
Fluticasone furoate is an inhaled powder drug product. It is a synthetic trifluorinated 
corticosteroid that is insoluble in water. Fluticasone furoate is a white powder. Fluticasone 
furoate will be provided in a two tone grey inhaler with a mouthpiece cover and separate foil 
blister strips. The blister strips used for this study will contain a white powder mix with a 
mixture of 200 µg micronized fluticasone furoate and lactose monohydrate. The inhaler will be 
packaged in a moisture-protective foil tray with a desiccant and a peelable lid. [62] All 
packaging will be labeled to indicate that the product is for investigational use. 
18.3.2. 
Drug Dispensing, Storage, and Stability 
The study drug should be stored at room temperature (20°C to 25°C) with excursions permitted 
from 15°C to 30°C. It should be stored in a dry environment away from direct heat or sunlight. 
Unopened fluticasone furoate should be stored inside the unopened moisture-protective foil tray 
and only removed immediately before use. Any unused study product should be discarded 6 
weeks after opening the foil tray or when the counter reads “0” (after all blisters have been used), 
whichever comes first. The inhaler is not reusable.[62] The study product has a shelf life of 24 
months when stored at ≤ 25°C. After removal of the secondary package and the desiccant packet 
from the inhaler, the product may be stored up to 6 weeks at ≤ 25°C.  
18.3.3. 
Dosing and Administration 
Fluticasone furoate is a self-administered inhaled drug. Participants will self-administer 200 µg 
(1 blister) of fluticasone furoate once daily for 14 days. After inhaler activation, the powder 
within the blister is exposed and the participant inhales the study drug through the mouthpiece.  
18.3.4. 
Rationale for Selection of Dose 
Inhaled corticosteroids (ICS) have been shown to be effective in improving asthma and as a 
combination therapy in chronic obstructive pulmonary disease (COPD) and thus are commonly 
prescribed medications world-wide. Corticosteroids have been shown to have a broad range of 
pharmacologic activity on multiple cell types including mast cells, eosinophils, neutrophils, 
macrophages and lymphocytes, as well as other mediators of inflammation such as histamine, 
eicosanoids, and leukotrienes. In addition to the anti-inflammatory role of ICS, there is also 
potential for regulation of gene transcription in epithelial cells.[63-65] This regulation of gene 
transcription may result in inhibition of SARS-CoV-2 replication. Furthermore, in asthmatic 
patients, ICS may lower gene expression of ACE2 and TMPRSS2. The ACE2 receptor is 
expressed on epithelial cells and binds SARS-CoV-2 for entry and the serine protease TMPRSS2 

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primes the SARS-CoV-2 spike protein for binding. Lowering gene expression of ACE2 and 
TMPRSS2 may reduce binding and entry into cells therefore reducing or preventing infection.  
Clinical Studies: 
The PRINCIPLE (Platform Randomized trial of Interventions against COVID-19 in Older 
People) trial is a multicenter, open-label, multi-arm, adaptive randomized, platform trial. The 
trial is ongoing and released an interim analysis after the Trial Steering Committee advised the 
Trial Management Group that the pre-specified superiority criterion was met on the time to 
recovery in the overall study population and the subgroup of participants with confirmed positive 
SARS-CoV-2 testing. Participants were eligible if aged >65 years, or >50 years with 
comorbidities and had ongoing symptoms from PCR confirmed or suspected COVID-19 with 
symptoms starting within the past 14 days. Participants were randomized to any open active 
intervention arm including inhaled budesonide and usual care. Participants were followed 
through an online, daily symptom diary for 28 days. Participants received usual care plus inhaled 
budesonide 800 µg daily for 14 days or usual care alone. The primary outcome of the trial at the 
start was hospitalization or death within 28 days; however, the rate of hospitalization was lower 
than initially expected thus the Trial Management Group and the Trial Steering Committee 
recommended amending the primary outcome to include a measure of illness duration. The trial 
was completed with two co-primary endpoints measured within 28 days of randomization: 1) 
time to first reported recovery defined as the first day that a participant reported feeling 
recovered; and 2) hospitalization or death related to COVID-19.  
The interim analysis included eligible SARS-CoV-2 positive participants who were randomized 
to inhaled budesonide (N=751) or usual care alone (N=1028). The mean age was 62.8 years and 
83% of participants had co-morbidities. The median days from symptom onset to enrollment was 
6 days. There was evidence of a benefit in time-to-first-recovery in the budesonide arm with an 
estimated median benefit of 3 days. The point estimate of the proportion of COVID-19 related 
hospitalizations or deaths was lower in the budesonide group (8.5%) versus usual care (10.3%), 
but this did not meet statistical significance (95% BCI -0.7 – 4.8%). There were two SAEs for 
hospitalization unrelated to COVID-19, both in the budesonide group.  
A smaller trial of 146 nonhospitalized adults with mild COVID-19 reported that inhaled 
budesonide at the same dose reduced COVID-19 related emergency assessments and 
hospitalization.  
The dose of ICS studied is PRINCIPLE is consistent with a high dose of inhaled steroid. The 
equivalent high dose of fluticasone furoate is 200 µg/day. Inhaled fluticasone furoate has a 
greater anti-inflammatory potency per microgram than budesonide, thus fluticasone furoate is 
administered at a lower daily dose and used only once daily to achieve a similar high dose.  
18.4. 
Placebo Information  
18.4.1. 
Formulation, Appearance, Packaging, and Labeling 
The placebo will be an fluticasone furoate-matched placebo containing lactose for inhalation in 
the same two tone grey inhaler that is used for the study drug. The appearance and packaging 
will match that of the study drug (as described in Section 18.3.1). All packaging will be labeled 
to indicate that the product is for investigational use. 

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18.4.2. 
Drug Dispensing, Storage, and Stability 
Placebo will be stored in the same conditions as study drug, room temperature (20°C to 25°C) 
with excursions permitted from 15°C to 30°C in a dry environment away from direct heat or 
sunlight. The placebo has a shelf life of up to 36 months when stored at ≤ 30°C. 
18.4.3. 
Dosing and Administration 
Participants will self-administer one blister of placebo via inhalation from the inhaler once daily 
for 14 days.  
18.5. 
Events of Special Interest 
None 
18.6. 
Safety Reporting for Fluticasone Furoate 
Sponsor will promptly notify GlaxoSmithKline of all SAEs, UADEs, and pregnancies (if 
applicable), and medical device deficiencies that have occurred for participants enrolled in this 
Study Drug Appendix, in accordance with the timelines and procedures specified in the 
Protocol/appendix. In addition, the sponsor will reasonably obtain and provide follow-up 
information as available, to GSK upon request.