A Randomized, Multicenter, Open-label Phase II Trial to Compare Prophylaxis of Graft Versus Host Disease With Tacrolimus and Mycophenolate Mofetil Versus Ruxolitinib After Post-transplant Cyclophosphamide
Phase: PHASE2
Conditions: Graft-versus-host-disease, Stem Cell Transplant Complications, Acute Myeloid Leukemia, Acute Lymphoid Leukemia
Sponsor: St. Petersburg State Pavlov Medical University

 
 
 
 
 
 
 
 
 
CLINICAL TRIAL PROTOCOL 
 
Title: 
A randomized, multicenter, open-label Phase II trial to compare 
prophylaxis of graft versus host disease with tacrolimus and 
mycophenolate mofetil versus ruxolitinib after post-transplant 
cyclophosphamide 
Short title: 
PTCy-Ruxo 
Version and date: 
Draft version 2.0 from 10.10.2019 
 
 
 
 
 

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STUDY PROTOCOL SYNOPSIS 
Title 
A randomized, multicenter, open-label Phase II trial to 
compare prophylaxis of graft versus host disease with 
tacrolimus and mycophenolate mofetil versus ruxolitinib after 
post-transplant cyclophosphamide 
Phase 
II 
Objectives 
 To compare the incidence of acute GVHD grade II-
IV; 
 To compare the non-relapse mortality (NRM); 
 To compare the incidence of relapse of the underlying 
disease; 
 To compare the incidence of chronic, moderate and 
severe GVHD according to NIH 2015 criteria; 
 To compare overall survival (OS); 
 To compare event-free survival (EFS); 
 To compare the toxicity of two regimens of 
prophylaxis based 
 To compare the cumulative incidence of primary graft 
failure and secondary rejection, not associated with 
the relapse of the disease; 
 To compare the incidence of infectious complications. 
Endpoints 
 Proportion of patients with acute GVHD II-IV grade 
(timeframe: 125 days); 
 NRM (timeframe: 2 years); 
 Proportion of patients with relapse (timeframe: 2 
years); 
 Proportion of patients with chronic, moderate and 
severe GVHD (timeframe: 2 years); 
 OS (timeframe: 2 years); 
 EFS (timeframe: 2 years); 
 Number of patients with hepatic toxicity (liver 
function tests), nephrotoxicity (creatinine), cytopenia 
after engraftment (platelets, white blood cells, 
neutrophils) are assessed, according to the treating 
physician 
neurotoxicity, 
hemorrhagic 
cystitis, 
thrombotic microangiopathy, veno-occlusive disease 
are assessed (timeframe: 6 months); 
 Proportion of patients with primary or secondary graft 
failure (timeframe: 6 months); 
 Number 
of 
patients 
with 
bacteremia 
before 
engraftment, bacteremia after engraftment, severe 
sepsis 
(presence 
of 
multiple 
organ 
failure), 
pneumonia, soft tissue infection, invasive mycosis 

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(probable 
or 
proven 
invasive 
aspergillosis, 
candidaemia, 
zygomycosis), 
reactivation 
of 
cytomegalovirus, other opportunistic viral infections 
(timeframe: 6 months). 
Study design 
This is multicenter investigator-initiated randomized open-
label phase II clinical trial to compare prophylaxis of graft 
versus 
host 
disease 
treated 
with 
tacrolimus 
and 
mycophenolate mofetil versus ruxolitinib after post-transplant 
cyclophosphamide. 
In total 128 patients will be included in the study. After 
inclusion into the study and performing of transplantation 
patients will be randomized in 1:1 proportion in two arms (64 
patients per arm): arm A will include patients who will be 
treated with cyclophosphamide and ruxolitinib for GVHD 
prophylaxis; arm B will include patients who will be treated 
with cyclophosphamide, tacrolimus and MMF for GVHD 
prophylaxis. After the end of the treatment patients will be 
followed-up during two years. 
Number of patients 
128 
Study population 
The study will include patients with ALL and AML with 
indications for transplantation. Indications for transplantation 
in the first remission for ALL are the presence of a high 
cytogenetic risk (t(4;11), t(9;22)) and the persistence of 
minimal residual disease after consolidation as part of 
program chemotherapy. For acute myeloid leukemia, the 
indications in the first remission are standard and high 
cytogenetic risk, patients with translocations t(16;16), 
t(15;17), t(8;21) are not included. These groups of patients 
have a 30% increase in relapse-free survival compared with 
patients without transplantation. All patients in the second 
remission of ALL and AML (with the exception of t(15;17)) 
are 
candidates 
for 
HSCT, 
because 
programmed 
chemotherapy, regardless of its options, can achieve no more 
than 10% of non-progressive survival. In this group of 
patients, the benefits of performing HSCT are at least 40%. 
Benefits from HSCT persist even with 15–20% mortality 
from complications. 
The highest failure rate of HSCT is associated with a relapse 
of the disease afterwards. For ALL and AML, methods that 

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reduce the risk of relapse are only currently being developed. 
There are no generally accepted approaches to post-transplant 
therapy. One of the objectives of this study is to reduce the 
likelihood of relapse of leukemia. 
Inclusion criteria 
All eligible patients must meet all the following inclusion 
criteria: 
1. Informed consent to participate in the study, signed by 
the patient; 
2. Diagnosis: acute lymphoblastic or acute myeloblastic 
leukemia; 
3. Morphological remission, defined as less than 5% of 
blasts by microscopy or flow cytometry with a 
peripheral leukocyte level of more than 1.500 μL. It is 
acceptable to include patients without restored 
platelets or erythrocytes; 
4. Indications for performing allogeneic hematopoietic 
stem 
cell 
transplantation, 
determined 
by 
the 
participating center in accordance with local medical 
practice; 
5. Unrelated or haploidentical donor; 
6. Age 18-70 years; 
7. Functional status according to ECOG scale 0-2 score. 
Exclusion criteria 
All eligible patient must not meet any following criteria: 
1. Repeated allogeneic transplantation, regardless of the 
indications for its implementation; 
2. Source of graft - umbilical cord stem cells; 
3. Any ex vivo modification of the graft with the 
exception of separation or washing of red blood cells; 
4. The presence of more than 5% of clonal tumor cells 
according to flow cytometry in the presence of 
morphological remission; 
5. Diagnosis: acute promyelocytic leukemia; 
6. Severe organ failure: creatinine more than 2 ULN; 

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ALT, AST more than 5 ULN; bilirubin more than 1.5 
ULN; respiratory failure more than 1 grade; 
7. Unstable hemodynamics, requiring the introduction of 
vasopressors; 
8. Uncontrolled bacterial or fungal infection at the time 
of randomization, determined by the level of CRP> 70 
mg/l with adequate antibacterial or antifungal therapy; 
9. Arhythmia 
that 
persist 
despite 
adequate 
antiarrhythmic therapy: a tachysystolic form of atrial 
fibrillation, ventricular arrhythmias V gradation 
according to Laun, AV block of III degree; 
10. Decrease 
in 
ejection 
fraction 
according 
to 
echocardiography less than 40%; 
11. Angina of more than II functional class or unstable 
angina; 
12. Another 
severe 
concomitant 
pathology, 
which 
according to the attending physician does not allow 
the patient to be included in the study; 
13. Pulmonary pathology with a decrease in FEV1 of less 
than 60% or pulmonary diffusion capacity of less than 
60%; 
14. Inability to quit smoking for a period of 6 months 
after transplantation; 
15. Pregnancy or refusal to perform highly effective 
contraception for 6 months after transplantation. 
16. Somatic or mental pathology not allowing to sign 
informed consent. 
Investigational 
medical 
product 
The therapy under investigation is the prophylaxis of GVHD 
using PTCy and ruxolitinib (PTCy + ruxolitinib). The 
comparison group is GVHD prophylaxis with the use of 
PTCy, CNI and MMF (PTCy + CNI + MMF). 
 

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TABLE OF CONTENTS 
PROTOCOL SIGNATURE PAGE ............................................................................................... 2 
STUDY PROTOCOL SYNOPSIS ................................................................................................ 3 
LIST OF ABBREVIATIONS ...................................................................................................... 10 
GLOSSARY OF TERMS ............................................................................................................ 11 
1 
GENERAL INFORMATION .......................................................................................... 12 
1.1 
Study title, protocol number, version and date .................................................... 12 
1.2 
Responsible parties............................................................................................... 12 
1.3 
Rationale .............................................................................................................. 12 
1.3.1 Investigational medical product ............................................................... 12 
1.3.2 Comparator ............................................................................................... 12 
1.3.3 Pre-clinical studies ................................................................................... 13 
1.3.4 Clinical studies ......................................................................................... 13 
1.3.5 Risk / benefit ............................................................................................ 13 
1.3.6 Regulatory ................................................................................................ 14 
1.3.7 Rationale for dose and regimen selection ................................................ 14 
1.3.8 Study population ...................................................................................... 15 
1.3.9 Study rationale ......................................................................................... 15 
2 
STUDY OBJECTIVES .................................................................................................... 19 
3 
STUDY DESIGN ............................................................................................................. 19 
3.1 
Investigational parameters (endpoints) ................................................................ 19 
3.2 
Overall study design ............................................................................................. 20 
3.3 
Randomization ..................................................................................................... 22 
3.4 
Masking ................................................................................................................ 22 
3.5 
Number of subjects .............................................................................................. 22 
3.6 
Methodology ........................................................................................................ 22 
3.6.1 Screening .................................................................................................. 24 
3.6.2 Biological samples cryopreservation ....................................................... 24 
3.6.3 Transplantation visit ................................................................................. 25 
3.6.4 Prophylaxis and Follow-up visits ............................................................. 25 
3.6.5 Early termination ...................................................................................... 25 
3.6.6 Subject withdrawal ................................................................................... 26 
3.7 
Study termination ................................................................................................. 26 
3.8 
Drug storage and accountability........................................................................... 27 
4 
STUDY POPULATION .................................................................................................. 27 
4.1 
Inclusion criteria................................................................................................... 27 
4.2 
Exclusion criteria ................................................................................................. 28 
5 
STUDY TREATMENTS ................................................................................................. 29 
5.1 
Allocation to treatment ......................................................................................... 29 
5.2 
Conditioning therapy ............................................................................................ 29 
5.3 
Prophylaxis of graft-versus-host disease .............................................................. 32 
5.3.1 PTCy + CNI + MMF ................................................................................ 32 

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5.3.2 RTCy + ruxolitinib ................................................................................... 33 
5.4 
Acute graft-versus-host disease treatment ........................................................... 33 
5.5 
Dose regimen and modification ........................................................................... 34 
5.6 
Drug supplies ....................................................................................................... 35 
5.7 
Other study treatments ......................................................................................... 35 
5.8 
Concomitant medications ..................................................................................... 35 
5.8.1 Permitted medications .............................................................................. 35 
5.8.2 Prohibited medications ............................................................................. 36 
6 
EFFICACY AND SAFETY ASSESMENTS .................................................................. 37 
6.1 
Efficacy assesments ............................................................................................. 38 
6.2 
Safety assessments ............................................................................................... 43 
6.3 
Adverse events ..................................................................................................... 43 
6.3.1 Definitions ................................................................................................ 43 
6.3.2 Seriousness criteria................................................................................... 44 
6.3.3 Reporting .................................................................................................. 45 
6.3.4 Pregnancy ................................................................................................. 46 
7 
DATA ANALYSIS AND STATISTICAL METHODS ................................................. 47 
8 
DIRECT ACCESS TO SOURCE DATA ........................................................................ 48 
9 
AUDITS AND INSPECTIONS / QUALITY CONTROL .............................................. 48 
10 
ETHICAL CONSIDERATIONS ..................................................................................... 49 
10.1 
Institutional review board / Independent ethics committee ................................. 49 
10.2 
Patient information and informed consent ........................................................... 49 
10.3 
Confidentiality ..................................................................................................... 49 
10.4 
Study discontinuation ........................................................................................... 49 
10.5 
Confidentiality ..................................................................................................... 50 
11 
DATA MANAGEMENT ................................................................................................. 50 
12 
AUDITS AND INSPECTIONS / QUALITY CONTROL .............................................. 50 
13 
FINANCIAL ASPECTS AND INSURANСE ................................................................ 50 
14 
STUDY RESULTS AND PUBLICATIONS .................................................................. 50 
15 
REFERENCES ................................................................................................................. 52 
16 
APPENDICES ................................................................................................................. 57 
16.1 
Appendix 1: Dose adjustment of calcineurin inhibitors ....................................... 57 
16.2 
Appendix 2: Clinical manifestations of the cytokine release syndrome and 
clinical intervention .............................................................................................. 59 
 
LIST OF TABLES 
Table 3-1: Study visits ................................................................................................................. 22 
Table 3-2: Cryopreservation schedule ......................................................................................... 24 
Table 5-1: Busulfan 8 mg/kg conditioning regime ...................................................................... 30 
Table 5-2: Busulfan 10 mg/kg conditioning regime .................................................................... 30 

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Table 5-3: Busulfan 12 mg/kg conditioning regime .................................................................... 30 
Table 5-4: Busulfan 14 mg/kg conditioning regime .................................................................... 31 
Table 5-5: Busulfan 16 mg/kg conditioning regime .................................................................... 31 
Table 6-1: GVHD staging ............................................................................................................ 38 
Table 6-2: Overall grade and organ involvement grade evaluation ............................................. 39 
Table 7-1: Sample size ................................................................................................................. 47 
 
LIST OF FIGURES 
Figure 3-1: Study design .............................................................................................................. 20 
Figure 5-1: Dose regimen and modifications ............................................................................... 35 
 
 
 

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LIST OF ABBREVIATIONS 
Abbreviation 
Definition 
AE 
adverse event 
ALL 
acute lymphoblastic leukemia 
AML 
acute myeloid leukemia 
CMV 
cytomegalovirus 
CNI 
calcineurin inhibitors 
CRS 
cytokine release syndrome 
CTCAE 
Common Terminology Criteria for Adverse Events 
DNA 
deoxyribonucleic acid 
EFS 
event-free survival 
GVHD 
«graft-versus-host» disease 
GVL 
«graft-versus-leukemia» effect 
HSCT 
allogeneic hematopoietic stem cell transplantation 
IMP 
investigational medical product 
MMF 
mycophenolate mofetil 
NRM 
non-relapse mortality 
PTCy 
post-transplant cyclophosphamide 
RNA 
ribonucleic acid 
SAE 
serious adverse event 
 

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GLOSSARY OF TERMS 
Term 
 
Definition 
Acute «graft-versus-
host» disease 
 
Develops from the time the transplant is engrafted and up to 100 
days after transplantation 
Chronic 
«graft-
versus-host» disease 
 
Develops after 100 days from transplantation. In the period from 
100-180, there may be an “overlap” syndrome, when GVHD has 
features of acute and chronic form. In this case, the diagnosis of 
acute or chronic GVHD is determined by the attending physician, 
depending on the prevailing clinical manifestations 
Disease relapse 
 
In this study, the recurrence of acute leukemia will be considered 
to be the presence of more than 5% blast cells according to 
cytology or flow cytometry during bone marrow aspiration after 
transplantation. Any positive test for minimal residual disease, for 
which any therapeutic intervention was carried out with the 
exception of reduction of immunosuppressive therapy, will also be 
equated with a relapse of the disease 
Event-free survival 
 
The time from the moment of transplantation to the moment of 
death or the end of the observation time, or the recurrence of the 
disease in accordance with the criteria above  
Non-relapse 
mortality 
 
Mortality from any cause in the absence of data for the relapse of 
the underlying disease 
Overall survival 
 
The time from the moment of transplantation to the time of death 
or the end of the observation time 
Survival 
without 
relapse and GVHD 
 
The time from the moment of transplantation to the time of death 
or the end of the observation period, or recurrence of the disease in 
accordance with the above criteria, or acute GVHD III-IV grade, 
or chronic GVHD moderate and severe 
 
 
 

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1 GENERAL INFORMATION 
1.1 Study title, protocol number, version and date 
Study title: A randomized, multicenter, open-label Phase II trial to compare prophylaxis of graft 
versus host disease with tacrolimus and mycophenolate mofetil versus ruxolitinib after post-
transplant cyclophosphamide 
Phase: II 
Protocol number: PTCy-Ruxo 
Protocol version: draft 2.0 
Protocol date: 10.10.2019 
1.2 Responsible parties 
Sponsor: Pavlov FSMU 
PI: Ivan Moiseev, MD 
1.3 Rationale 
1.3.1 Investigational medical product 
The therapy under investigation is the prophylaxis of GVHD using PTCy and ruxolitinib (PTCy 
+ ruxolitinib). The comparison group is GVHD prophylaxis with the use of PTCy, CNI and 
MMF (PTCy + CNI + MMF). 
1.3.2 Comparator 
To date, unrelated and haploidentical transplants prevail in the structure of HSCT (Passweg et 
al., 2018). However, during transplantation from alternative donors, there is a significant 
increase in the likelihood of acute and chronic GVHD, which is partially offset by a decrease in 
the likelihood of relapse. Therefore, overall patient survival is comparable to the results of 
related matched transplants for most malignant diseases. Anti-thymocyte globulin (ATG) is most 
often used to reduce the likelihood of lethal GVHD in transplantations from unrelated donors 
(Bacigalupo et al., 2001). Nevertheless, recent studies have demonstrated the superiority of 
prophylaxis with PTCy over ATG in unrelated HSCT (Moiseev et al., 2016). At the same time, 
PTCy is the most commonly used regimen in the world for haploidentical transplants (Luznik et 
al., 2008). Thus, today the combination of PTCy, CNI and MMF is the most effective 
prophylaxis in unrelated and haploidentical HSCT. The frequency of clinically significant acute 
and chronic GVHD usually does not exceed 20–25%, and the mortality rate of GVHD is 5%. 
Moreover, there are no significant differences in such prophylaxis with regard to GVHD between 
an unrelated and haploidentical donor (Moiseev et al., 2018). Thus, the best available therapy is 
used as the comparison group. 

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1.3.3 Pre-clinical studies 
Ruxolitinib was studied in preclinical studies of general pharmacology, safety pharmacology, 
repeated toxicity, genotoxicity, reproductive toxicity, phototoxicity and carcinogenicity. 
Detailed information related with pre-clinical studies described in Investigator’s Brochure. 
1.3.4 Clinical studies 
As of February 22, 2019, more than 9,400 participants in intervention studies have received 
ruxolitinib. This drug is currently registered in the Russian Federation according to the 
indications "myelofibrosis" and "polycythemia vera". Please see Investigator’s Brochure for 
detailed information about clinical studies of ruxolitinib. 
1.3.5 Risk / benefit 
When using the best available prophylaxis that will be used in the comparison group, the 
mortality from complications of HSCT is about 15%, the risk of relapse in transplantation of 
acute lymphoblastic leukemia (ALL) and acute myeloblastic leukemia (AML) in 1-2 remissions 
is 20%. Renal toxicity of grade 2-4 in the comparison group is expected to be at a level of 15%, 
veno-occlusive liver disease about 3%, thrombotic microangiopathy about 3%. A significant 
reduction in these complications, a comparable or lower incidence of transplant mortality, and a 
lower frequency of relapses are expected in the study group. Thus, a 5–10% increase in survival 
and a better safety profile in the PTCy-ruxolitinib group are expected compared to the best 
available therapy. 
The risks of using PTCy-ruxolinib prophylaxis are associated with a possible increase in the 
likelihood of severe acute GVHD and mortality associated with it. Based on the available data, it 
is possible to increase the frequency of acute GVHD II-IV degree by 10%. However, preliminary 
results suggest a greater likelihood of a response to starting therapy when using this prophylaxis, 
which eliminates the risk, associated with the greater frequency of this complication. Possible 
risks include the hematological toxicity of ruxolitinib, delayed engraftment, worse graft function, 
and a higher incidence of bacterial infections. According to registration studies (Harrison et al., 
2012) and the results of using ruxolitinib in the early period after transplantation (Zeiser et al., 
2015), hematologic toxicity is expected in 20–30% of patients; however, planned and 
interventional ruxolitinib dose reductions are prescribed in the protocol, and transplant centers 
have significant experience in managing patients with poor graft function and pancytopenia, 
since there are many reasons for poor graft function, including viral infections, antiviral agents 
toxicity, autoimmune conflicts. On average in the control group, poor graft function is expected 
in 15% of patients. Thus, even in the case of the development of the hematological toxicity of a 
number of patients, this is not expected to be accompanied by an increase in the probability of 
transplant mortality. 

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1.3.6 Regulatory 
The study will be conducted in accordance with this clinical trial protocol, the Helsinki 
Declaration of the World Medical Association “Ethical Principles for Medical Research with the 
Human Participation as a Subject” of 1964, with subsequent amendments and additions 
applicable to the sections of the Federal Law of the Russian Federation 61-FZ “On treatment 
medicines ”, the national standard of the Russian Federation“ Good Clinical Practice ”(GOST 
R52379-2005) dated 09/25/2005, order of the Ministry of Health of Russia dated 01.04.2006 No. 
200n“ On approval of the rules of clinical practice in the Russian Federation ”, RF PP No. 714“ 
On approval of standard rules for compulsory life and health insurance for a patient participating 
in clinical trials of a medicinal product ”, Agreement on Uniform Principles and Rules for the 
Treatment of Medicines in the Framework of the Eurasian Economic Union of 23 December 
2014, as well as the ICH GCP guidance documents. 
1.3.7 Rationale for dose and regimen selection 
Ruxolitinib 
[(R)-3-(4-(7H-pyrrolo[2,3-d]pyrimidin-4-yl)-1H-pyrazol-1-yl)-3-
cyclopentylpropannitrile phosphate] (INCB018424 phosphate, INC424, ruxolitinib phosphate) is 
a powerful new selective, suitable for oral administration inhibitor of Janus kinase-1 (JAK1) 
(inhibition concentration by 50% (IC50) = 3.3 ± 1.2 nmol/l) and Janus kinase-2 (JAK2) (IC50 = 
2.8 ± 1.2 nmol/l), which has a selective (moderate to profound) effect on Tyrosine kinase-2 
(TYK2) (IC50 = 19 ± 3.2 nmol/l) and Janus kinase-3 (JAK3) (IC50 = 428 ± 243 nmol/l), 
respectively. This drug is currently registered in the Russian Federation according to the 
indications "myelofibrosis" and "polycythemia vera". In these diseases, a significant component 
of the clinical manifestations is determined by a mutation in the JAK2 gene, therefore blocking 
this signaling pathway leads to a decrease in the symptoms of the disease. 
However, Janus kinases transmit signals from the main signaling pathways of T-lymphocyte 
activation, STAT3 and STAT5. It is the activation of these signaling pathways that is one of the 
main pathogenesis mechanisms of GVHD. In addition, JAK activity regulates antigen 
presentation by dendritic cells and a number of other immunological processes. Blocking the 
above mechanisms with ruxolitinib allows you to influence the main pathogenesis mechanisms 
of GVHD - antigen presentation and proliferation of alloreactive clones, so this drug is used to 
treat a steroid-refractory form of GVHD (Teshima T, 2016). 
To date, one large multicenter retrospective study of the use of ruxolitinib in steroid-refractory 
acute and chronic GVHD has been published, which showed 82% of the responses in the acute 
form and 85% of the responses in the chronic form. At the same time, this therapy did not cause 
a severe decrease in anti-infective immunity, and was accompanied by a relatively low frequency 
of bacterial and fungal infections. These factors determined extremely favorable overall survival 
rates for this difficult group of patients (79% and 97% for acute and chronic GVHD, 
respectively). Although there are currently no prospective comparative studies published with 
ruxolitinib, however, the results obtained are among the best for such severe complication of 

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HSCT as steroid-refractory GVHD (Zeiser R, 2015). Similar results were shown in a number of 
small single-center studies presented at the European Congress of Bone Marrow Transplantation 
(EBMT Annual Meeting, 2018). In Russian Federation from 2016 to 2018 in Pavlov First Saint 
Petersburg State Medical University, within the framework of the clinical testing protocol of the 
Ministry of Health of the Russian Federation (2016-29-1), we also investigated the activity and 
safety of ruxolitinib in steroid refractory acute and chronic GVHD. According to preliminary 
results, the response rate in the acute form of GVHD was 83%, and in the chronic form – 85%. 
The 2-year survival rate for acute GVHD was 58%, while for chronic GVHD – 89%. The data 
obtained in the protocol of clinical approbation correspond to the data of an international study, 
which indicates reproducibility of the results and the effectiveness of ruxolitinib in treatment of 
GVHD. 
1.3.8 Study population 
The study will include patients with ALL and AML with indications for transplantation. 
Indications for transplantation in the first remission for ALL are the presence of a high 
cytogenetic risk (t(4;11), t(9;22)) and the persistence of minimal residual disease after 
consolidation as part of programmed chemotherapy. For acute myeloid leukemia, the indications 
in the first remission are standard and high cytogenetic risk, patients with translocations t(16;16), 
t(15;17), t(8;21) are not included. These groups of patients have a 30% increase in relapse-free 
survival compared with patients without transplantation. All patients in the second remission of 
ALL and AML (with the exception of t(15;17)) are candidates for HSCT, because programmed 
chemotherapy, regardless of its options, can achieve no more than 10% of non-progressive 
survival. In this group of patients, the benefits of performing HSCT are at least 40%. Benefits 
from HSCT persist even with 15–20% mortality from complications. 
The highest failure rate of HSCT is associated with a relapse of the disease afterwards. For ALL 
and AML, methods that reduce the risk of relapse are only currently being developed. There are 
no generally accepted approaches to post-transplant therapy. One of the objectives of this study 
is to reduce the likelihood of relapse of leukemia. 
1.3.9 Study rationale 
Allogeneic hematopoietic stem cell transplantation (HSCT) was introduced into medical practice 
in the 1970s as a treatment of the blood system tumors (Thomas ED, 1975) and various marrow 
failure syndromes resistant to standard therapy (Thomas ED, 1972). The “graft-versus-host” 
disease (GVHD) is one of the most frequent and at the same time one of the most life-threatening 
complications of allogeneic hematopoietic stem cell transplantation (Afanasyev BV, 1997, 
Savchenko VG, 2007). The main obstacle to the widespread use of this method is transplantation 
mortality, reaching in some cases 20-30% (Gratwohl A, 2015). The main cause of transplant 
mortality is GVHD, which develops in 30–70% of patients (Ferrara J, 2004), depending on the 
type of donor and prophylaxis. In the case of the acute form, mortality can reach 40% (Saliba 
RM, 2012), and in case of chronic – 10% (Perez-Simon JA, 2008). Despite the emergence of 

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new methods of treatment, progress in improving the survival of patients with GVHD, especially 
with the acute form, has been moderate (Gratwohl A, 2015), therefore improving the GVHD 
prophylaxis protocols is the key to improving the results of transplantation. 
Prophylaxis approaches were developed at the Dana-Farber Cancer Center in the 1970s, and 
included the use of a calcineurin inhibitor, cyclosporin A, in combination with low doses of 
methotrexate (Storb R, 1989). Despite the introduction of such a scheme more than 40 years ago, 
a recent study showed that 73% of centers in Europe still use similar prophylaxis (Ruutu T, 
2012). Although this type of prophylaxis gives good results in related matched transplantation, 
allo-HSCT from alternative donors (unrelated and haploidentical) that prevail in the structure of 
transplantation is associated with a significant incidence of GVHD and high mortality (Beatty 
PG, 1991). For a long time, the standard for HSCT from alternative donors was the addition of 
antithymocyte globulin (ATG) to prevention (Bacigalupo, 2001). Nevertheless, in the Russian 
population of recipients of unrelated HSCT, even with the addition of ATG, the percentage of 
severe acute and chronic GVHD remained high (Afanasyev BV, 2007, Moiseev IS, 2019). 
Significant progress in the use of haploidentical or 50% matched donors has been made with the 
introduction of prophylaxis using post-transplant cyclophosphamide (PTCy) in combination with 
tacrolimus and mycophenolate mofetil (MMF) (Luznik, 2008). Today, it is the most commonly 
used in Europe technology of haploidentical transplantation, which allows obtaining clinical 
results comparable to related compatible transplantation, and is easily reproducible (Lorentino F, 
2018). The implementation of this protocol in case of unrelated transplantations in the Russian 
patient population showed a significant decrease in the incidence of GVHD and transplantation 
lethality compared with ATG (Moiseev IS, 2016). Thus, among the widely used methods, a 
combination of PTCy, a calcineurin inhibitor and MMF is currently the most effective 
prophylaxis of GVHD in unrelated and haploidentical transplantation. The frequency of 
clinically significant acute and chronic GVHD with its use does not exceed 20% in the Russian 
patient population (Moiseev IS, 2018). However, this method has several drawbacks: the 
significant suppression of the “graft-versus-leukemia” effect (GVL), nephrotoxicity observed in 
40-50% of patients, the presence of complications associated with calcineurin inhibitors 
(thrombotic microangiopathy, veno-occlusive liver disease) . In this study, it is planned to show 
that the combination of PTCy with ruxolitinib shows, at least, not the worse clinical results of 
HSCT, but reduces the incidence of the above complications. 
The profile of complications in patients with GVHD receiving ruxolitinib is extremely favorable. 
Out of the side effects in patients with acute GVHD, cytopenia was described in 53% of patients, 
reactivation of cytomegalovirus in 33%. However, cytopenia and viral reactivations are 
characteristic of this complication and in 51% cytopenia was present before the start of therapy. 
In chronic GVHD, for which cytopenia is not typical, severe cytopenia was observed in only 7% 
of patients, which corresponds to the results of the use of the drug in other conditions (Zeiser R, 
2016; Harrison C, 2012). Thus, high efficacy against GVHD and a favorable toxicity profile 
makes ruxolitinib an encouraging candidate to replace calcineurin inhibitors (tacrolimus and 

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cyclosporine) and MMF in prophylaxis regimens in order to reduce the number of complications 
and reduce transplant mortality. 
Another advantage of using ruxolitinib as opposed to classical immunosuppressants as 
prophylaxis is the selective suppression of GVHD, without suppressing the GVL, which is the 
basis of the antitumor effect of allogeneic HSCT (Choi, 2014). Since the majority of patients 
with HSCT are diagnosed with malignant diseases, and the relapse of the disease is the main 
cause of mortality after HSCT, maintaining GVHD is the key task of increasing the effectiveness 
of HSCT. All of the above prerequisites became the basis for Pavlov First Saint Petersburg State 
Medical University studies on the GVHD prophylaxis with PTCy and ruxolitinib in allogeneic 
HSCT regarding high-risk myelofibrosis (NCT02806375). A pilot study included 20 patients 
with myelofibrosis. The results of this study showed satisfactory control of acute GVHD; only 
10% of patients required the administration of systemic glucocorticosteroids. No cases of chronic 
severe GVHD were reported. Only mild nephrotoxicity was observed in 15% of patients and did 
not require therapy. Cases of veno-occlusive disease are also not recorded. At the same time, not 
a single case of recurrence of the underlying disease was recorded, although the usual frequency 
of recurrences of myelofibrosis after HSCT is about 20-30% (Morozova EV, 2017). Thus, the 
results of the pilot study are extremely encouraging: there is a pronounced antitumor activity of 
this prevention option and a favorable toxicity profile, which creates prerequisites for conducting 
a multicenter validation study. 
The choice of dose is based on the results of the pilot Pavlov First Saint Petersburg State Medical 
University study (NCT02806375) and clinical trials of the Ministry of Health of the Russian 
Federation (2016-29-1). In the NCT02806375 study, the starting dose of ruxolitinib was 15 mg, 
while 40% of patients required dose reduction after 30 days due to poor graft function. The 
pharmacokinetics in this study showed accumulation of ruxolitinib with daily intake and a 3-fold 
increase in the minimum concentration (C0) after 2 and 10 days of administration, respectively. 
Also in clinical trials using doses of 20 mg for the treatment of moderate GVHD, grade 3-4 
hematologic toxicity was observed in 30% of patients, which indicates the need to use doses less 
than 20 mg to ensure safe engraftment. Also, to prevent poor graft function and associated 
mortality, from the 21st day a dose reduction of up to 10 mg per day is planned. The results of 
the NCT02806375 study showed that reducing the dosage to 10 mg due to poor graft function 
did not lead to a decrease in the control of GVHD. In these patients, there were no episodes of 
acute GVHD after dose reduction. Also in this study, therapy with ruxolitinib was performed 
during the conditioning to control the manifestations of the underlying disease. However, it is 
known that ruxolitinib administration prior to HSCT reduces the likelihood of GVHD 
afterwards. It is possible that the favorable control of GVHD was also associated with the pre-
transplant administration of ruxolitinib (Kroeger et al., 2018), therefore, in this study, the use of 
ruxolitinib during the conditioning at a dose of 15 mg was left unchanged. Thus, on the basis of 
the available data, the optimal dosage regimen is the starting dosage of 5 mg 3 times a day 

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during the conditioning, then – from the day +5, followed by reduction to 5 mg 2 times a day by 
day +21 HSCT. 
The effect of PTCy is based on the activation of T cells in the absence of immunosuppression 
immediately after transplantation and selective apoptosis of activated alloreactive cells (Luznik 
L, 2012). It is known that using PTCy as the only component of GVHD prophylaxis may be 
sufficient to control GVHD with related matched bone marrow transplantation (Luznik L, 2010), 
however, with the use of peripheral blood stem cells (PBSC), transplantation from unrelated and 
haploidentical donors who make up a large part in the structure of transplantation activity, PTCy 
alone is not enough to prevent severe GVHD manifestations (Holtick U, 2016), therefore the 
combination of other immunosuppressive drugs should be used in such situations. Most centers 
use calcineurin inhibitors (CNIs) (cyclosporin A or tacrolimus) and MMF. This combination is 
planned as a control group in this study. This type of prophylaxis for unrelated and 
haploidentical transplants provides good control of acute GVHD (less than 20% has clinically 
significant manifestations) and only 15% of patients have symptoms of moderate to severe 
chronic GVHD. There is also a low level of non-relapse mortality, not exceeding 10% in the 
group of patients with standard risk. At the same time, there are no significant differences 
between unrelated and haploidentical donors. Nephrotoxicity in 40% of patients is a negative 
aspect of this prophylaxis regimen, and hemorrhagic cystitis rate is 15%. Also, it does not 
increase the incidence of GVHD compared with the classic prophylaxis regimens, and the 
relapse of the disease is the main cause of treatment failure (Moiseev IS, 2018). 
Considering the extremely high efficacy of GVHD control when using the PTCy-CNI-MMF 
regimen, with any realistic sample size, it will be impossible to demonstrate the advantages of 
the PTCy-ruxolitinib regimen in terms of control of acute and chronic GVHD. In addition, the 
results of a pilot study showed a similar incidence of acute and chronic GVHD with the PTCF-
CNI-MMF regimen. Therefore, the primary goal is to demonstrate the equivalence of PTCF-
CNI-MMF and PTCy-ruxolitinib in terms of GVHD control. Since GVHD, unlike nephrotoxicity 
and most cases of endothelial complications of CNI, is a potentially life-threatening event, it is 
first necessary to demonstrate equivalent GVHD control when using these two types of 
prophylaxis. 
The secondary tasks, first of all, include demonstration that the non-relapse mortality (NRM) 
using the PTCy-ruxolitinib mode will not be significantly worse. Considering that in a pilot 
study (Morozova EV, 2017) NRM in such a severe HSCT patient group as myelofibrosis was 
15%, it is expected that mortality will also be comparable when using these two protocols. The 
second important secondary point is the relapse rate. At present, there are no data in the literature 
on the frequency of relapses in the PTCy-ruxolitinib group, however, the probability of relapse 
of the underlying disease is expected to decrease at least two-fold. Other secondary points for 
which significant differences are expected are the frequency of nephrotoxicity and endothelial 
complications (veno-occlusive liver disease and thrombotic microangiopathy). The remaining 
rates of overall survival and event-free survival stem from the above objectives. Survival rates 

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are expected to be at least as good in the PTCy-ruxolitinib group as in the PTCy-CNI-MMF 
group. In case of a decrease in the frequency of relapses in the PTCy-ruxolitinib group, an 
improvement in survival without relapse is expected. 
2 STUDY OBJECTIVES 
The main study aim is to compare the efficacy and safety of GVHD prophylaxis with PTCy and 
ruxolitinib to control group where prophylaxis will be carried out with PTCy, CNI and MMF. 
Primary study objective is: 
 To compare the incidence of acute GVHD. 
Secondary study objectives are: 
 To compare the non-relapse mortality (NRM) 
 To compare the incidence of relapse of the underlying disease 
 To compare the incidence of chronic, moderate and severe GVHD according to NIH 
2015 criteria 
 To compare overall survival (OS) 
 To compare event-free survival (EFS) 
 To compare the toxicity of two regimens of prophylaxis based 
 To compare the cumulative incidence of primary graft failure and secondary rejection, 
not associated with the relapse of the disease 
 To compare the incidence of infectious complications 
3 STUDY DESIGN 
3.1 Investigational parameters (endpoints) 
Primary endpoint of this study is: 
 Proportion of patients with acute GVHD II-IV grade (timeframe: 125 days). 
Secondary endpoints of this study are: 
 NRM (timeframe: 2 years) 
 Proportion of patients with relapse (timeframe: 2 years) 
 Proportion of patients with chronic, moderate and severe GVHD (timeframe: 2 years) 
 OS (timeframe: 2 years) 
 EFS (timeframe: 2 years) 

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 Number of patients with hepatic toxicity (liver function tests), nephrotoxicity (creatinine), 
cytopenia after engraftment (platelets, white blood cells, neutrophils) are assessed, 
according to the treating physician neurotoxicity, hemorrhagic cystitis, thrombotic 
microangiopathy, veno-occlusive disease are assessed (timeframe: 6 months) 
 Proportion of patients with primary or secondary graft failure (timeframe: 6 months) 
 Number of patients with bacteremia before engraftment, bacteremia after engraftment, 
severe sepsis (presence of multiple organ failure), pneumonia, soft tissue infection, 
invasive mycosis (probable or proven invasive aspergillosis, candidaemia, zygomycosis), 
reactivation of cytomegalovirus, other opportunistic viral infections (timeframe: 6 
months) 
3.2 Overall study design 
This is multicenter investigator-initiated randomized open-label phase II clinical trial to compare 
prophylaxis of graft versus host disease treated with tacrolimus and mycophenolate mofetil 
versus ruxolitinib after post-transplant cyclophosphamide. 
Figure 3-1 summarizes the study design. 
Figure 3-1: Study design 

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3.3 Randomization 
After inclusion into the study and performing of transplantation patients will be randomized in 
1:1 proportion in two arms (64 patients per arm): arm A will include patients who will be treated 
with cyclophosphamide and ruxolitinib due to GVHD prophylaxis; arm B will include patients 
who will be treated with cyclophosphamide, tacrolimus and MMF due to GVHD prophylaxis. 
After the end of the treatment patients will be followed-up during two years. 
3.4 Masking 
Not applicable due to open-label desigh. 
3.5 Number of subjects 
128 patients will be included in the study. 
3.6 Methodology 
During the course of the study the allogeneic hemopoietic stem cell transplant procedure is 
performed for all participating patients. The transplant procedure includes the following stages:  
 Conditioning regimen consisting of fludarabin and busulfan performed from D-7 to D-1 
 The graft transfusion at D0 
 Post-transplant cyclophosphamide infusion as part of GVHD prophylaxis  
 Imunosuppressive therapy from D+5 to D+120 in control group and D+150 in study 
group 
The pre-engraftment stage is delivered in inpatient conditions in accordance with Russian Health 
Ministry regulation on healthcare delivery in patients with conditions, in which the bone marrow 
and hemopoietic stem cells transplantation are indicated as well as the updates to healthcare 
delivery Regulation in accordance with “surgery (human organs and/or tissues transplantation)”. 
The post-engraftment treatment may be delivered in inpatient, day hospital or outpatient 
conditions. The number of visits after the patient is discharged from the hospital is regulated by 
internal standard procedures of participating sites. The visits on day 100, day 180, 1 year, and 2 
years after the transplant (final visit) are mandatory. 
Table 3-1: Study visits 
Study visits / 
Study procedures 
SCR 
ASCT 
visit 
Prophylaxis 
visits 
Follow-up visits 
Visit: 
 
V1 
V2 
V3 
V4 
V5 
Day: 
 
D0 
D100 
D180 
Y1D5
15 
Y2D880 
Eligibility criteria 
× 
 
 
 
 
 

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Study visits / 
Study procedures 
SCR 
ASCT 
visit 
Prophylaxis 
visits 
Follow-up visits 
Visit: 
 
V1 
V2 
V3 
V4 
V5 
Day: 
 
D0 
D100 
D180 
Y1D5
15 
Y2D880 
ICF signing 
× 
 
 
 
 
 
Demographics / 
anthropometrics data 
× 
 
 
 
 
 
HIV, HCV, HBV test 
× 
 
 
 
 
 
Pregnancy test 
× 
 
 
 
 
 
Complete blood count 
× 
 
×c 
× 
 
 
Blood chemistry 
× 
 
× 
× 
 
 
Electrocardiography 
× 
 
 
 
 
 
Echocardiography 
× 
 
 
 
 
 
Microscopy or flow 
cytometry 
× 
 
 
 
 
 
CMV testa 
× 
 
 
 
 
 
Graft compositionb 
 
× 
 
 
 
 
Spirography 
× 
 
 
 
 
 
Physical examination / 
ECOG 
× 
 
× 
× 
× 
× 
Comorbidities 
× 
 
 
 
 
 
Disease risk index 
× 
 
 
 
 
 
HCT-CI 
× 
 
 
 
 
 
C-reactive protein test 
 
 
 
 
 
 
ASCT 
 
× 
 
 
 
 
Acute GVHD assessment 
 
 
× 
 
 
 
Chronic GVHD 
assessment 
 
 
 
× 
× 
× 
Serum EDTA 
× 
× 
× 
× 
 
 
Blood DNA and RNA 
× 
 
× 
 
 
 
Chimerism testd 
 
 
× 
×e 
× e 
× e 
Bone marrow biopsy 
 
 
× 
× 
 
 
Relapse assessment 
 
 
× 
× 
× 
× 
Adverse event collection 
 
 
× 
× 
× 
× 
Secondary malignancies 
 
 
 
 
× 
× 

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a 
for assessment of recipient / donor CMV serostatus; 
b 
Minimally CD34+, NC, CD3+; 
c 
for assessment of WBC, neutprophils and PLT engraftment; 
d 
by CRP or the relevant method; 
e             not mandatory 
3.6.1 Screening 
The following procedures will be performed on the screening visit: 
 Patient written informed consent for study participation must be obtained before any 
study-related procedures; 
 Check for eligibility criteria; 
 Collection of demographic and anthropometric data; 
 HIV, HCV, HBV test (may be performed during one month before screening); 
 Pregnancy test for woman patients; 
 Complete blood count; 
 Blood chemistry; 
 Echocardiography at rest; 
 Physical examination and patient condition according to ECOG scale. 
 Comorbidities; 
 DRI and HCT-CI calculation. 
3.6.2 Biological samples cryopreservation 
The current study involves blood ruxolitinib concentration and cytokines levels determination. 
Also there are plans for blood Janus kinases levels assessment. Table 3-2 summarizes the 
schedule for obtaining samples to be cryocopreserved. The collection is not mandatory and will 
be performed by the centers willing to participate in biologic research studies after the 
completion of the protocol. 
Table 3-2: Cryopreservation schedule 
Sample / Visit 
V1 
V8 
V10 
V11 
V12 
V13 
V14 
V15 
V17 
Day: 
D-7 
D0 
D7 
D14 
D21 
D30 
D60 
D100 
D180 
Serum EDTA 
× 
× 
× 
× 
× 
× 
× 
× 
× 
DNA and RNA 
peripheral blood 
× 
 
 
 
 
× 
× 
× 
× 
Plasma processing: the sample (it should not be taken from the first portion of blood) is obtained 
into EDTA-containing test tube from central venous catheter or peripheral vein. During 2-3 
hours after the sample was obtained it is centrifuged at 4⁰С and 1000g for 15 minutes. Plasma is 

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aliquoted as 1 ml portions into at least 2 separate samples. Aliquoted samples are frozen at -70-
80⁰С until the day the test is performed.  
DNA processing: the sample (it should not be taken from the first portion of blood) is obtained 
into EDTA-containing test tube from central venous catheter or peripheral vein. During the same 
day the DNA and RNA are purified using a standard method, then samples are frozen at -20-
40⁰С Ountil the day the test is performed. If DNA and RNA purification is impossible, then 
whole blood samples may be frozen in cryogenic test tube at -20-40⁰С for further study. 
3.6.3 Transplantation visit 
The following procedures will be performed during this visit: 
 Graft composition evaluation 
 ASCT. 
3.6.4 Prophylaxis and Follow-up visits 
The following procedures will be performed during follow-up visits: 
 Physical examination and patient condition according to ECOG scale. 
 Chimerism assessment 
 Relapse assessment by bone marrow or peripheral blood morphology, MRD testing will 
be performed only as part of the center routine clinical practice. 
 Acute GVHD staging on V2 (maximal clinical grades recorded)  
 Chronic GVHD assessment and staging if necessary 
 Adverse event collection 
 Secondary malignancies 
3.6.5 Early termination 
The patients may stop receiving study therapy at any time for any reason. If a patient decides to 
stop receiving study therapy, than the researcher should deploy reasonable efforts (i.e. making a 
phone call or sending a message/e-mail) to determine the main reason for this decision. If the 
patient informs of an intention to withdraw his consent, stops following visits schedule, or 
become lost to follow-up due to any other reason, than this should be considered leaving the 
study. 
The investigator may cease study therapy if he decides its continuation is harmful for a patient 
and may lead to deterioration of his condition. The study therapy cessation should also be 
considered in the following situations: 
 Development of a life-threatening complication (Gr.4 according to CTCAE 5.0) except 
hematological toxicity, which is related to study therapy according to researcher’s 
opinion  

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 Underlining condition relapse or progression  
 Signs of graft rejection requiring rapid immunosuppressive therapy withdrawal and an 
unplanned donor lymphocyte infusion, “boost” with donor stem cells or other anticancer 
therapy 
 Pregnancy  
 Protocol deviations possible compromising the patient’s safety including the intake of 
forbidden medications   
Patients, which cease study therapy are NOT considered leaving the study, they should continue 
visits for evaluation (see Section 5.1) to be transferred to long-term survival evaluation group. If 
the patients cease visits due to unknown reason, than the researcher should deploy reasonable 
efforts (i.e. making a phone call or sending a letter/e-mail) to contact patient. 
3.6.6 Subject withdrawal 
All patients may withdraw their consent for study participation at any time and for any reason. 
The only case, in which the consent is withdrawn, is when a patient clearly refuses to take part in 
the study further, declines any further evaluation or visits, as well as all contacts related to the 
study. 
The study sponsor will keep all records and study results, which were already obtained for 
evaluation. All biological samples collected may be kept for subsequent evaluation (or any other 
use corresponding to legal requirements). 
In case of consent withdrawal the researcher should deploy reasonable efforts (i.e. making a 
phone call or sending a letter/e-mail) to determine and document the main reason for this 
decision. In this case the study therapy should be stopped and an alternative GVHD prophylaxis 
regimen in accordance with standard operation procedures of this participating center should be 
offered. 
3.7 Study termination 
Intermediate results of the study are presented annually to the heads of transplant centers 
participating in the study. Based on the submissions, a decision is made on the safety of 
continuing the study. Recommended event thresholds in the study group for stopping the study 
after the first year of inclusion (20 patients in the study group: more than 50% acute GVHD II – 
IV degree requiring systemic glucocorticosteroid therapy, more than 50% chronic GVHD 
moderate and severe, more than 30% NRM). Recommended event thresholds in the study group 
for discontinuing the study after the second year of inclusion (40 patients in the study group): 
more than 40% acute GVHD grade II-IV requiring systemic glucocorticosteroid therapy, more 
than 40% of chronic GVHD is moderate to severe, more than 25% NRM. The decision to 
terminate the study should be adopted by the supervisory board collectively. In the case of the 

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decision to change the protocol instead of the termination of the study, the changes must be 
submitted for approval by the ethics committees of participating centers. 
The criterion for changing the dosing regimen of ruxolitinib is the presence of more than 30% of 
severe poor graft function during interim analysis. The decision to change the dosage is also 
made by supervisory board and is submitted by the ethical committees. 
The composition of the supervisory board of the study: 
 Pavlov First Saint Petersburg State Medical University: Afanasyev, Boris Vladimirovich, 
Director of the Scientific and Research Institute for Children's Oncology, Hematology 
and Transplantology named after R.M. Gorbacheva, MD, Honored Doctor of Russia; 
 National Research Center for Hematology: Elena Nikolayevna Parovichnikova, Head of 
the Department of Chemotherapy of Hemoblastosis, Hematopoietic Depression and 
BMT, Doctor of Medicine; 
 The Federal State-Financed Scientific Institution Kirov Research Institute of Hematology 
and Blood Transfusion under the Federal Medical Biological Agence (KRIHBT): 
Paramonov Igor Vladimirovich, Director of the Research Institute of Hematology and 
Blood Transfusion, MD. 
3.8 Drug storage and accountability 
The IMP must be kept in a secured location in storage conditions according to its SmPC. 
Investigator must keep all related drug supplies documentation. 
Quantity of IMP packages and its administration to patients must be fulfilled in IMP 
accountability log by responsible site person. 
Each patient must keep a IMP accountability diary. Patient’s IMP compliance will be assessed 
through each study visit by the investigator. 
4 STUDY POPULATION 
4.1 Inclusion criteria 
All eligible patients must meet all the following inclusion criteria: 
1. Informed consent to participate in the study, signed by the patient; 
2. Diagnosis: acute lymphoblastic or acute myeloblastic leukemia; 
3. Morphological remission, defined as less than 5% of blasts by microscopy or flow 
cytometry with a peripheral leukocyte level of more than 1.500 μL. It is acceptable to 
include patients without restored platelets or erythrocytes; 
4. Indications for performing allogeneic hematopoietic stem cell transplantation, determined 
by the participating center in accordance with local medical practice; 

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5. Unrelated or haploidentical donor; 
6. Age 18-70 years; 
7. Functional status according to ECOG scale 0-2 score. 
4.2 Exclusion criteria 
All eligible patient must not meet any following criteria: 
1. Repeated allogeneic transplantation, regardless of the indications for its implementation; 
2. Source of graft - umbilical cord stem cells; 
3. Any ex vivo modification of the graft with the exception of separation or washing of red 
blood cells; 
4. The presence of more than 5% of clonal tumor cells according to flow cytometry in the 
presence of morphological remission; 
5. Diagnosis: acute promyelocytic leukemia; 
6. Severe organ failure: creatinine more than 2 ULN; ALT, AST more than 5 ULN; 
bilirubin more than 1.5 ULN; respiratory failure more than 1 grade; 
7. Unstable hemodynamics, requiring the introduction of vasopressors; 
8. Uncontrolled bacterial or fungal infection at the time of randomization, determined by the 
level of CRP> 70 mg/l with adequate antibacterial or antifungal therapy; 
9. Rhythm disturbances that persist despite adequate antiarrhythmic therapy: a tachysystolic 
form of atrial fibrillation, ventricular arrhythmias V gradation according to Laun, AV 
block of III degree; 
10. Decrease in ejection fraction according to echocardiography less than 40%; 
11. Angina of more than II functional class or unstable angina; 
12. Another severe concomitant pathology, which according to the attending physician does 
not allow the patient to be included in the study; 
13. Pulmonary pathology with a decrease in FEV1 of less than 60% or pulmonary diffusion 
capacity of less than 60%; 
14. Inability to quit smoking for up to 6 months after transplantation; 
15. Pregnancy or refusal to perform highly effective contraception for 6 months after 
transplantation. 
Highly effective contraceptive methods include: 

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 
Total abstinence: if it corresponds to the preferred and customary way of life of 
the patient. Periodic abstinence (for example, calendar, ovulation, symptothermal, 
postovulation methods) and interrupted sexual intercourse are not considered acceptable 
methods of contraception; 
 
Female sterilization (surgical bilateral oophorectomy with or without 
hysterectomy), total hysterectomy or tubal ligation at least 6 weeks before the start of the 
therapy being studied. In the case of ovariectomy only, the reproductive status of the 
woman must be confirmed using a subsequent analysis of hormones; 
 
Sterilization of the male partner (at least 6 months before screening). For women 
participating in the study, the sexual partner after a vasectomy should be the only partner; 
 
Use of oral, injectable or implanted hormonal contraceptive drugs, intrauterine 
devices or contraceptive systems, or other forms of hormonal contraception with similar 
efficacy (failure rate less than 1%), for example, hormonal vaginal rings or transdermal 
hormonal contraceptives. 
16. Somatic or mental pathology not allowing to sign informed consent. 
5 STUDY TREATMENTS 
5.1 Allocation to treatment 
Patients will be randomized before the start of conditioning based on 2 strata – type of donor  
and a disease risk index (DRI). Detailed mathematical methods for randomization are described 
in Section 2.5, Statistical Methods. Stratification will be site-specific, that means each site will 
have an equal number of patients in the study arms. 
5.2 Conditioning therapy 
Mandatory for inclusion in this study is the conditioning therapy, which includes administration 
of two medications – fludarabine and busulfan. The total dose of fludarabine 180 mg/m2 during 6 
days, i.e. daily dose of 30 mg/m2. The dose and route of administration of busulfan are selected 
within the framework of the standard operating procedures of the investigational sites depending 
on the age, patient's somatic status, comorbidity, and tolerability of prior chemotherapy. 
Possible regimes conditioning therapy are summarized in Table 5-1, Table 5-2, Table 5-3, Table 
5-4 and Table 5-5. 

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Table 5-1: Busulfan 8 mg/kg conditioning regime 
Drug 
Dose 
Route of administration 
Days 
D -7 
D -6 
D -5 
D -4 
D -3 
D -2 
D -1 
SCT 
Fludarabine 
30 mg/m2/day 
iv 
days -7 to -2, 1-hour infusion 
× 
× 
× 
× 
× 
× 
 
 
Busulfan1 
4 mg/kg/day 
p/o 
days -4 to -3 p/o at 0600, 1200, 
1800 and 2400 
 
 
 
×××× ×××× 
 
 
 
Ruxolitinib 
15 mg/day 
iv 
days -7 to -2 from +5 p/o in 
three doses 
× 
× 
× 
× 
× 
× 
 
 
1 
Busulfan 8 mg/kg: 1 mg/kg per os 4 times a day, days -4 and -3 before transplantation 
Table 5-2: Busulfan 10 mg/kg conditioning regime 
Drug 
Dose 
Route of administration 
Days 
D -7 
D -6 
D -5 
D -4 
D -3 
D -2 
D -1 
SCT 
Fludarabine 
30 mg/m2/day 
iv 
days -7 to -2, 1-hour infusion 
× 
× 
× 
× 
× 
× 
 
 
Busulfan1 
4 mg/kg/day 
p/o 
day -5 p/o at 1800 and 2400; 
days -4 to -3 p/o at 0600, 1200, 
1800 and 2400 
 
 
×× 
×××× ×××× 
 
 
 
Ruxolitinib 
15 mg/day 
iv 
days -7 to -2 from +5 p/o in 
three doses 
× 
× 
× 
× 
× 
× 
 
 
1 
Busulfan 10 mg/kg: 1 mg/kg per os 4 times a day, days -5, -4 and -3 before transplantation. In D-5, the patient performs only 2 evening medications 
Table 5-3: Busulfan 12 mg/kg conditioning regime 
Drug 
Dose 
Route of administration 
Days 
D -7 D -6 D -5 
D -4 
D -3 
D -2 D -1 
SCT 
Fludarabine 
30 mg/m2/day 
iv 
days -7 to -2, 1-hour infusion 
× 
× 
× 
× 
× 
× 
 
 
Busulfan1 
4 mg/kg/day 
p/o 
days -5 to -3 p/o at 0600, 1200, 
1800 and 2400 
 
 
×××× ×××× ×××× 
 
 
 
Ruxolitinib 
15 mg/day 
iv 
days -7 to -2 from +5 p/o in 
three doses 
× 
× 
× 
× 
× 
× 
 
 
1 
Busulfan 12 mg / kg: 1 mg / kg per os 4 times a day at Day -5, Day -4 and Day -3 

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Table 5-4: Busulfan 14 mg/kg conditioning regime 
Drug 
Dose 
Route of administration 
Days 
D -7 D -6 D -5 
D -4 
D -3 
D -2 D -1 
SCT 
Fludarabine 
30 mg/m2/day 
iv 
days -7 to -2, 1-hour infusion 
× 
× 
× 
× 
× 
× 
 
 
Busulfan1 
4 mg/kg/day 
p/o 
day -6 at 1800 and 2400; 
days -5 to -3 p/o at 0600, 1200, 
1800 and 2400 
 
×× 
×××× ×××× ×××× 
 
 
 
Ruxolitinib 
15 mg/day 
iv 
days -7 to -2 from +5 p/o in 
three doses 
× 
× 
× 
× 
× 
× 
 
 
1 
Busulfan 14 mg / kg: 1 mg / kg per os 4 times a day, D-6, -5, -4, -3. In D-6, the patient performs only 2 evening medications 
Table 5-5: Busulfan 16 mg/kg conditioning regime 
Drug 
Dose 
Route of administration 
Days 
D -7 D -6 
D -5 
D -4 
D -3 
D -2 D -1 SCT 
Fludarabine 
30 mg/m2/day 
iv 
days -7 to -2, 1-hour infusion 
× 
× 
× 
× 
× 
× 
 
 
Busulfan1 
4 mg/kg/day 
p/o 
days -6 to -3 p/o at 0600, 1200, 
1800 and 2400 
 
×××× ×××× ×××× ×××× 
 
 
 
Ruxolitinib 
15 mg/day 
iv 
days -7 to -2 from +5 p/o in 
three doses 
× 
× 
× 
× 
× 
× 
 
 
1 
Busulfan 16 mg / kg: 1 mg / kg per os 4 times a day, D-6, -5, -4, -3 
Calculation of doses of busulfan is carried out on the adjusted weight with a difference between real and ideal weight of more than 20%. The formula of ideal 
weight for men is 50 + 0.91 * (“height” -152), for women 45 + 0.91 * (“height” -152). The formula for the adjusted weight for men is “ideal weight” +0.25 * 
(“real weight” - “ideal weight”), for women “ideal weight” +0.25 * (“real weight” - “ideal weight”). Investigational sites will be provided with a spreadsheet for 
automatic calculation of doses of medications for conditioning regimen and GVHD prophylaxis. 
If there is a concomitant pathology that does not allow for conditioning using busulfan, it is possible to use alternative regimens with prior agreement with the 
principal investigator. 
Oral busulfan can be replaced with an intravenous form (currently not registered in the Russian Federation). The dose conversion factor for intravenous form is 
0.8. Thus, the total intravenous dose for the recommended regimen with reduced toxicity is 6.4 mg / kg, and for the myeloablative one it is 11.2-12.8 mg / kg. 
The frequency of administration for this protocol is 4 times a day. 

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5.3 Prophylaxis of graft-versus-host disease 
5.3.1 PTCy + CNI + MMF 
There are two possible treatment regimen for prophylaxis of GVHD in PTCy + CNI + MMF 
arm. 
First one: 
 Cyclophosphamide 50 mg kg at D+3, D+4 and 500 ml 0.9% NaCl intravenous. in 2 
hours. Calculation of doses of cyclophosphamide is carried out on the adjusted weight 
with a difference between real and ideal weight of more than 20%. 
 Uromitexan 100% of the dose of cyclophosphamide, 24-hour infusion, starting 3 hours 
before the administration of cyclophosphamide, ending 24 hours after the end of the 
administration. It is acceptable to increase the dose of uromitexan up to 200% of the dose 
of cyclophosphamide with the development of abdominal pain syndrome or cystalgia 
during the administration. Calculation of doses of uromitexan is always carried out on 
real weight. 
 Tacrolimus 0.03 mg/kg intravenous 24-hour infusion from D+5. In the presence of 
antifungal prophylaxis with fluconazole, the dose is reduced by 25%, with the use of 
voriconazole by 50%. Transfer to the oral form is carried out after the transplant 
engraftment. Tacrolimus concentration target values are 3-15 ng/ml. 
Second one: 
 Cyclosoprin A 1.5 mg/kg and 100-250 ml 0.9% NaCl intravenous in 2 hours 2 times a 
day from D +5. Transfer to the oral form is carried out after the transplant engraftment. 
Cyclosoprin A concentration target values of 150-350 ng/ml. 
 Mycophenolate mofetil 30 mg/ kg/day per os with 10/10 HLA compatible donor and 45 
mg/kg/day per os with <10/10 HLA compatible donor from D+5 to D+35. With the 
development of mucositis, dispersion of tablets or the use of an intravenous form in a 1: 1 
ratio is permissible. 
Calcineurin inhibitors are continued until D+100, when the dose is gradually tappered in 
accordance with the standard medical practice of the participating center. In the absence of 
GVHD D+150, calcineurin inhibitors should be discontinued. Recommendations for dose 
adjustment of calcineurin inhibitors and transition from intravenous to oral form are presented in 
Appendix 1. 
Introduction of glucocorticosteroids: in the absence of life-threatening conditions, it is highly 
desirable to avoid the introduction or administration of glucocorticosteroids from D-5 to D+5. 
The administration of glucocorticosteroids outside this time interval is not limited. After a 
transfusion of the graft, the patient may develop cytokine release syndrome (CRS). Most often, 

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the CRS is resolved on D+3 after the introduction of cyclophosphamide without specific therapy. 
Staging of the CRS and procedure are presented in Appendix 2. Transfusion of the graft is 
performed WITHOUT premedication with glucorticosteroids, and with premedication with 
dimedrol and metamizole, or without premedication. Management of mild transfusion 
complications and mild episodes of hemolysis is also performed without glucorticosteroids. 
5.3.2 RTCy + ruxolitinib 
 Cyclophosphamide 50 mg / kg D+3, D+4 + 500 ml 0.9% NaCl intravenous in 2 hours. 
Calculation of doses of cyclophosphamide is carried out on the adjusted weight with a 
difference between real and ideal weight of more than 20%. 
 Uromitexan 100% of the dose of cyclophosphamide, 24-hour infusion, starting 3 hours 
before the administration of cyclophosphamide, ending 24 hours after the end of the 
administration. It is acceptable to increase the dose of uromitexan up to 200% of the dose 
of cyclophosphamide with the development of abdominal pain syndrome or cystalgia 
during the administration. Calculation of doses of uromitexan is always carried out on 
real weight. 
 Ruxolitinib 5 mg 3 times a day from D-7 to D-2. 
 Ruxolitinib 5 mg 3 times a day from D+5 to D+21. 
 Ruxolitinib 5 mg 2 times a day from D+22 to D+150. 
Introduction of glucocorticosteroids: in the absence of life-threatening conditions, it is highly 
desirable to avoid the introduction or administration of glucocorticosteroids from D-5 to D+5. 
The administration of glucocorticosteroids outside this time interval is not limited. After a 
transfusion of the graft, the patient may develop cytokine release syndrome (CRS). Most often, 
the CRS is resolved on D+3 after the introduction of cyclophosphamide without specific therapy. 
Staging of the CRS and procedure are presented in Appendix 2. Transfusion of the graft is 
performed WITHOUT premedication with glucorticosteroids, and with premedication with 
dimedrol and metamizole, or without premedication. Management of mild transfusion 
complications and mild episodes of hemolysis is also performed without glucorticosteroids. 
5.4 Acute graft-versus-host disease treatment 
The morphological verification is not required prior to skin and liver acute GVHD therapy 
initiation. However, it is necessary before gut GVHD treatment starts if there are no other 
clinical signs. If the patient has both skin and/or liver involvement signs requiring systemic 
therapy and gut involvement the latter may be verified morphologically at the moment of 
treatment initiation or later during its course. 
Grade II-IV acute GVHD treatment in control group (PTCy+CNI+MMF) is preformed according 
to local guidelines and standards of investigational sites. 

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For grade II-IV acute GVHD treatment in PTCy+ruxolitinib group there is a good chance of 
obtaining complete response without administration of systemic steroids: 
 For grade III acute skin GVHD without accompanying grade 3-4 cytopenia the daily 
ruxolitinib dose is increased to 20 mg; 
 If the patient has grade III acute skin GVHD and accompanying grade -4 cytopenia 
he/she should be given cyclosporine-A 3 mg/kg or tacrolimus 0.03 mg/kg intravenous or 
per os; 
 Patients with grade III acute skin GVHD without response to increased ruxolitinib dose 
are given cyclosporine-A 3 mg/kg or tacrolimus 0.03 mg/kg intravenous or per os; 
 Patients with grade III acute skin GVHD without response to increased ruxolitinib dose 
and CNIs are treated according to investigational sites’ guidelines; 
 Grade I acute gut or hepatic GVHD without any accompanying grade 3-4 cytopenia 
requires an increase of daily ruxolitinib dose to 20 mg; 
 If the patient has grade I acute gut or hepatic GVHD with any accompanying grade 3-4 
cytopenia he/she should be given cyclosporine-A 3 mg/kg or tacrolimus 0.03 mg/kg 
intravenous or per os; 
 Patients with grade I acute gut or hepatic GVHD without response to increased 
ruxolitinib dose are given cyclosporine-A 3 mg/kg or tacrolimus 0.03 mg/kg intravenous 
or per os; 
 Patients with grade I acute gut or hepatic GVHD without response to increased 
ruxolitinib dose and CNIs are treated according to investigational sites’ guidelines; 
 Grade IV acute skin GVHD and/or grade ≥ II gut GVHD and/or grade ≥ II hepatic 
GVHD is an indication for oral or iv cyclosporine-A 3 mg/kg or tacrolimus 0.03 mg/kg + 
systemic steroids in accordance to investigational sites’ guidelines; 
Ruxolitinib is given up to D+150 after complete GVHD response registration and until all other 
immunosuppressive medication are withdrawn. 
5.5 Dose regimen and modification 
Rationale for dose adjustment of ruxolitinib: 
1. The presence of thrombocytopenia, leukopenia or neutropenia of 4 grade after the 50th 
day from transplantation, with no other identified causes, except for toxicity: reduction to 
2.5 mg BID. 
2. Life-threatening viral infection in the presence of GVHD manifestations: reduction to 2.5 
mg BID to D + 60 or cancellation after D + 60. 

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3. Detectable minimal residual disease: reduction to 2.5 mg BID to D + 60 or cancellation 
after D + 60. 
4. Acute kidney injury after conditioning or graft transfusion or treatment with reduced 
GFR less than 30 ml/m2/min: 5 mg 2 BID, further correction for hematological toxicity 
after engraftment. In the case of a decrease in GFR of less than 15 ml/m2/min, it is 
recommended to conduct dialysis on D +5, taking into account the likelihood of 
occurrence of complications not only due to ruxolitinib, but also due to PTCy. 
Figure 5-1 summarizes the possible dose modifications. 
Figure 5-1: Dose regimen and modifications 
 
Postponement of the onset of prophylaxis with ruxolitinib is not allowed with the development of 
any complications of therapy. 
5.6 Drug supplies 
The investigational medical product (IMP) ruxolitinib will be labeled and provided by Novartis 
Company. 
IMP’s label will contain all necessary legal information such as drug name, batch/series number, 
expiration date, qualitative/quantitative composition, administration guidelines, storage 
conditions and patient identification code, which one must be fulfilled by site responsible person. 
5.7 Other study treatments 
All other study treatments defined in Sections 6.1, 6.2, 6.3, 6.4 and 6.5 will be provided to 
patients as a part of standard medical care. For these treatments only dose regimen information 
must be recorded into e-CRF and source documentation. 
5.8 Concomitant medications 
5.8.1 Permitted medications 
Permitted medications and anti-infective prophylaxis can be carried out in accordance with the 
local standards of the participating centers. In the absence of local standards, it is possible to use 
the following scheme: 
 Infusion therapy in a volume of 3 l/m2 from D-7 to D+5, then 30 ml/kg/day before 
engraftment and transfer to oral hydration. 

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 Oral hydration of at least 30 ml/kg/day after stopping infusion therapy and until 
immunosuppressive therapy is discontinued. 
 Ondansetron 8 mg TID i.v. on days of taking busulfan and cyclophosphamide and for at 
least 1 day after. With insufficient effect or history of severe nausea after chemotherapy - 
aprepitant 125-80-80 mg. 
 Levetiracetam 1000 mg 2 times a day per os, starting 24 hours before the first dose of 
busulfan, 24 hours after the last dose of busulfan. Relanium jet or microjet with the 
development of neurotoxicity. 
 Allopurinol 300 mg 1 time per day from D-7 to D + 5 
 Omeprazole 20-40 mg 2 times a day from D-7 to D + 180 
 Sulfamethoxazole / trimethoprim 960 mg 1 time per day from D-7 to D + 180 
 Acyclovir 200 mg 3 times a day from D-7 to D + 180 
 Fluconazole 400 mg 1 time per day from D0 until engraftment. In the presence of 
probable or proven invasive aspergillosis, voriconazole 200 mg BID from D0. It is 
advisable to avoid the use of voriconazole during conditioning. If active treatment of 
invasive aspergillosis is necessary, it is recommended one day   before the first 
administration of busulfan to transfer the patient to echinocandin and resume therapy 
with voriconazole 24 after the last administration of busulfan. Alternatively, 
posaconazole 200 mg TID or 400 mg BID can be used. 
 Ciprofloxacin 200 mg BID i.v. from D0 until engraftment, then 500 mg BID per os to D 
+ 60. Further, amoxicillin 500 mg TID from D + 61 to D + 180. 
 For women, 0.03 mg Ethinylestradiol 0.150 mg Levonorgestrel 1 tablet 1 time per day 
from D-7 to platelet levels above 50 thousand per μl after engraftment OR buserelin nasal 
0.15 mg TID from D-7 to a platelet level of more than 50 thousand per μl after 
engraftment OR buserelin depot 3.75 mg every 4 weeks subcutaneously OR goserelin 
10.8 mg once before transplantation. 
5.8.2 Prohibited medications 
During the study period the patient should not receive any kinase inhibitors but ruxolitinib. The 
only exception is post-transplant relapse prophylaxis in Ph-positive ALL patients if that is a part 
of local center’s standard practice. 
The following registered drugs affecting the immune system should also be avoided: anti-human 
T-lymphocyte immunoglobulin, tumor necrosis factor antagonists, antagonists of interleukin-6 or 
its receptor, anti-CD19, CD25, or CD56 antibodies. 

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The patient should not receive immune checkpoints inhibitors, e.g. nivolumab, pembrolizumab, 
avelumab etc. 
6 EFFICACY AND SAFETY ASSESMENTS 

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6.1 Efficacy assesments 
The presence of acute GVHD is confirmed either by morphology or based on complex 
evaluation performed by a head of appropriate study center clinical unit. The morphological 
confirmation of acute gut GVHD involving intestine or gaster is mandatory. In patients with skin 
or hepatic acute GVHD the clinical diagnosis is also appropriate.  
The types of acute GVHD and stage of GVHD and response to steroids are determined by 
treating physician according to international classification (MAGIC criteria, Harris et al., 2016) 
and presented in Table 6-1. Since acute and chronic GVHD is one of the endpoints, the 
physicians will follow the discrimination between these two forms based on MAGIC definition 
also presented in Table 6-1. 
Table 6-1: Acute GVHD types and staging 
 
Acute GvHD onset 
Classic  
First episode of aGvHD*  
≤Day 100  
Late  
First episode of aGvHD*  
>Day 100  
Recurrent  Recurrence of aGvHD*, after a period of aGvHD control, inactivity 
or resolution  
>Day 100  
Persistent  aGvHD* signs persist beyond day 100 from a prior active classic 
aGvHD  
>Day 100  
 
*Presenting acute features only: maculopapular erythematous skin rash; and/or 
hyperbilirubinemia; and/or anorexia with weight loss, nausea, vomiting, diarrhea, severe 
abdominal pain, GI bleeding and/or ileus 
 
Stage 
Skin 
Liver (bilirubin) 
Stomach 
Intestine (stool 
volume) 
0 
No 
active 
(erythematous) 
GVHD rash 
<35 mkmol/l 
No or intermittent 
nausea, vomiting, 
or anorexia 
<500 ml/day 
1 
Maculopapular 
rash 
<25% of body surface  
35-50 mkmol/l 
Persistent 
nausea, 
vomiting 
or 
anorexia 
500-1000 
ml/day 
2 
Maculopapular 
rash 
25-50% 
of 
body 
surface  
51-100 mkmol/l 
 
1000-1500 
ml/day 
3 
Maculopapular 
rash 
>50% of body surface 
101-260 mkmol/l 
 
>1500 ml/day 
4 
Generalized 
erythroderma (>50% 
>260 mkmol/l 
 
Intensive 
abdominal pain 

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of body surface) plus 
bullous formation and 
desquamation >5% of 
body surface  
or 
ileus, 
intestinal 
bleeding 
Overall 
stage 
 
 
 
 
I  
Stages 1-2 
No 
No 
No 
II  
Stage 3 or 
Stage 1 or 
Stage 1 or 
Stage 1 
III  
- 
Stage 2-3 or 
Stage 0-1 
Stage 2-3 
IV  
Stage 4 or 
Stage 4 
Stage 0-1 
Stage 4 
 
Presence of chronic GVHD is evaluated based on clinical signs or morphological picture. 
However, histological confirmation is not required for chronic GVHD diagnosis. The final 
diagnosis may be based on evaluation of clinical signs by the head of a transplant unit in one of 
sites.  
The chronic GVHD severity is assessed according to NIH 2015 consensus (Jagasia et al., 2015) 
with separate overall grade and organ involvement grade evaluation (Jagasia et al., 2015) 
presented in Table 6-2. 
Table 6-2: Overall grade and organ involvement grade evaluation 
Grade 
0 
1 
2 
3 
General functions 
No symptoms 
Some symptoms 
present, 
outpatient 
treatment, some 
functional 
limitations 
to 
physical activity 
(ECOG 
1, 
Karnofsky 
80-
90%) 
Some symptoms 
present, 
outpatient 
treatment, 
the 
patient 
is 
capable of self-
service, 
>50% 
time 
spent 
actively (ECOG 
2, 
Karnofsky 
60-70%)  
Some symptoms 
present, 
outpatient 
treatment, 
limited 
capability 
for 
self-service, 
>50% of time 
spent 
in 
bed 
(ECOG 
3-5, 
Karnofsky 
<60%) 
Skin 
No symptoms 
<18% of body 
surface 
involved,  no 
sclerotic 
changes 
19-50% of body 
surface involved 
or 
superficial 
sclerotic 
changes 
(the 
>50% of body 
surface involved 
or deep sclerotic 
changes (no skin 
fold 
can 
be 

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Grade 
0 
1 
2 
3 
skin fold can be 
formed) 
formed) 
or 
limited mobility, 
ulceration 
or 
intensive itching 
Oropharynx 
mucosa 
No symptoms 
Mild symptoms, 
normal 
food 
intake 
Moderate 
symptoms 
severity 
with 
partial limitation 
of food intake 
Severe 
symptoms with 
significant oral 
food 
intake 
limitation 
Eyes 
No symptoms 
Mild 
sicca 
syndrome 
symptoms, 
normal everyday 
activity 
(requires 
moisturizing  ≤3 
times\day) 
or 
asymptomic 
stream 
keratoconjunctiv
itis  
sicca 
Moderate sicca 
syndrome 
symptoms, 
partial everyday 
activity 
limitation 
(requires 
moisturizing ≥3 
times\day) 
without eyesight 
impairment  
Severe 
sicca 
syndrome 
symptoms, 
significant 
everyday 
activity 
limitation 
(requires 
analgesia) 
or 
inability to work 
due 
to 
ophthalmologica
l symptoms or 
loss of vision 
due 
to 
keratoconjunctiv
itis Sicca 
Gastrointestinal 
tract 
No symptoms 
Dysphagy, 
anorexy, nausea, 
vomiting, 
gastric pain or 
diarrhea without 
significant 
weight 
loss 
(<5%). 
Symptomatic 
with 
moderate 
weight loss (5-
15%) 
Symptomatic 
with significant 
weight 
loss 
(>15%) 
requiring 
nutritional 
support 
or 
esophageal 
surgery 
Liver 
Normal 
biochemistry 
values with PA, 
ALAT or ASAT 
Normal 
bilirubin, ALAT 
or 
ASAT 
≥3 
norms and <5 
Raised 
total 
bilirubin, 
but 
less 
than 
50 
mkmol/l 
or 
Bilirubin 
>50 
mkmol/l 

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Grade 
0 
1 
2 
3 
< 3 norms 
norms or AP ≥3 
norms 
ALAT ≥5 norms 
Lungs 
No symptoms 
FEV1>80% 
or 
LFS 
(Lung 
function 
score)=2 
Mild symptoms 
(dyspnea 
after 
climbing 1 floor 
of stairs) 
FEV1 
60-79% 
or LFS 3-5 
Moderate 
symptoms 
(dyspnea 
after 
walking 
on 
square surface) 
FEV1 
40-59% 
or LFS 6-9 
Severe 
symptoms 
(dyspnea in rest, 
O2 dependence) 
FEV1<59% 
or LFS 10-12 
LFS is calculated as a sum of score points for FEV1 and diffusion capacity: >80%= 1; 70-
79%= 2; 60-69%=3; 50-59% = 4; 40-49% = 5; <40% = 6. Diffusion capacity is evaluated 
based on hematocrit = diffusion capacity measurement + (hematocrit -44)* 1.35%. 
Joints and fasciae 
No symptoms 
Mild discomfort 
while 
moving 
arms and legs, 
normal 
or 
slightly 
decreased 
movement 
range, 
no 
impairment  to 
everyday 
activity 
Discomfort 
while 
moving 
arms and legs or 
joint 
contractures, 
erythema due to 
fasciitis, 
moderate 
movement range 
decrease 
and 
mild 
to 
moderate 
impairment  to 
everyday 
activity 
Contractures 
with 
severe 
decrease 
of 
movement range 
and 
severe 
impairment 
to 
everyday 
activity 
(inability to tie 
shoelaces, 
button up a coat, 
undress without 
help etc.)  
Genitalia 
No symptoms 
 
Some symptoms 
with mild visual 
changes with no 
discomfort 
during coitus or 
gynecological 
examination 
Some symptoms  
accompanied by 
moderate visual 
changes with no 
tenderness 
during coitus or 
gynecological 
examination 
Some symptoms  
accompanied by 
evident 
visual 
changes 
(strictures, 
pudendal 
lips 
agglutination or 
severe 
ulceration) 
accompanied by 
pronounced 
tenderness 

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Grade 
0 
1 
2 
3 
during coitus or 
gynecological 
examination 
Other 
signs 
of 
GVHD:  
Ascitis 
Polyserositis 
Hydropericardium 
nephrotic 
syndrome 
Perypheral 
neuropathy 
Polymyositis 
Eosinophilia more 
than 500 per µl. 
No symptoms 
 
Mild symptoms 
Moderate 
symptoms 
Severe form 
Overall chronic GVHD grade (if applicable) 
Grade 0: no GVHD symptoms 
I (mild):  1-2 organs involvement with 
maximal grade 1 (besides lungs). 
II (moderate severity): at least 1 organ with 
changes grade ≥2 or ≥3 organs with maximal 
grade 1 or lungs with grade ≥1 
III (severe):  at least 1 organ with grade ≥3 or 
lungs with grade ≥2 
Overall survival (OS), acute GVHD, chronic GVHD, time to relapse, transplant-related mortality 
were evaluated as time from transplant to event.  
Relapse is diagnosed in patients with more than 5% of clonal blast cells at the time of HSCT or 
less than 5% blast cells with pre-transplant phenotype after any specific antitumor therapy was 
administered (donor lymphocyte infusion, chemotherapy, targeted therapy). During event-free 
survival (EFS) evaluations events re death, relapse or primary non-engraftment. For relapse-free 
survival (RFS) or GVHD-free survival evaluation events were death due to any reason, relapse, 
Gr III-IV acute GVHD, moderate or severe chroniv GVHD (Hotlan et al., 2015).  
The primary non-engraftment is defined as lack of donor chimerism in bone marrow aspirate at 
Д+40. Donor chimerism determination after HSCT requires recipient and donor genetic profile 
determination prior to HSCT with subsequent evaluation of ratio of donor-derived and recipient-
derived cells in recipient’s peripheral blood and bone marrow. The method of chimerism 
determination is not limited by current protocol. The study center may use any effective method, 
which corresponds to its standard operation procedures. Time to engraftment is evaluated as time 

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from transplant to the moment of reaching peripheral neutrophil count of more than 500 cells per 
µl without G-CSF stimulation. 
6.2 Safety assessments 
The frequency and selection of instrumental studies and laboratory tests used to evaluate the 
safety in this study is determined by standard operational procedures of participating centers. 
However in all patients chimerism should be evaluated at least once, at D+100 after HSCT.  
The clinical complications of hemopoietic stem cell transplant procedure are evaluated according 
to the following criteria: 
 Sepsis is diagnosed based on Sepsis-3 (Singer et al., 2016) criteria OR presence of 
positive blood culture obtained during episode of fever; 
 Severe sepsis is diagnosed in a patient fulfilling sepsis criteria and with signs of organ 
failure; 
 Invasive mycosis is diagnosed based on invasive mycoses diagnostics and treatment 
criteria ECIL-4 (Groll  et al., 2014); 
 Hepatic veno-occlusive disease is diagnosed and staged according to revised EBMT-2016 
criteria (Mohty et al., 2016); 
 Thrombotic microangiopathy is diagnosed based on “General TMA” criteria (Cho et al., 
2010); 
 CMV reactivation is determined based on quantative real-time PCR data and NGS 
results. The lower copy number threshold for CMV reactivation is 500 copies per ml. 
Any infection (with lungs, GIT or bone marrow involvement) is treated as reactivation 
even if there are no positive blood tests; 
 All other complication during safety evaluation are determined and staged according to 
NCI CTCAE 5.0. 
6.3 Adverse events 
6.3.1 Definitions 
An adverse event is defined as the appearance of (or worsening of any pre-existing) undesirable 
sign(s), symptom(s), or medical condition(s) that occur after patient’s signed informed consent 
has been obtained. 
Abnormal laboratory values or test results occurring after informed consent constitute adverse 
events only if they induce clinical signs or symptoms, are considered clinically significant, 
require therapy (e.g., hematologic abnormality that requires transfusion or hematological stem 
cell support), or require changes in study medication(s). 

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Adverse events considered related by the investigator to the investigational treatment that begin 
or worsen after informed consent should be recorded in the Adverse Events CRF. Conditions that 
were already present at the time of informed consent should be recorded in the Medical History 
page of the patient’s CRF. Adverse event monitoring should be continued for at least 30 days 
following the last dose of study treatment. Adverse events (including lab abnormalities that 
constitute AEs) should be described using a diagnosis whenever possible, rather than individual 
underlying signs and symptoms. When a clear diagnosis cannot be identified, each sign or 
symptom should be reported as a separate Adverse Event. 
Adverse events will be assessed and graded according to the Common Terminology Criteria for 
Adverse Events (CTCAE) version 5.0. 
If CTCAE grading does not exist for an adverse event, the severity of mild, moderate, severe, 
and life-threatening, death related to the AE corresponding respectively to Grades 1 - 5, will be 
used. 
The occurrence of adverse events should be sought by non-directive questioning of the patient 
(subject) during the screening process after signing informed consent and at each visit during the 
study. Adverse events also may be detected when they are volunteered by the patient (subject) 
during the screening process or between visits, or through physical examination, laboratory test, 
or other assessments. As far as possible, each adverse event should be evaluated to determine: 
 The severity grade (CTCAE Grade 1-5); 
 Its duration (Start and end dates); 
 Its relationship to the study treatment; 
 Action taken with respect to study treatment; 
 Whether medication or therapy was given (no concomitant medication/non-drug therapy, 
concomitant medication/non-drug therapy); 
 Whether it is serious, where a serious adverse event (SAE) and which seriousness criteria 
have been met. 
6.3.2 Seriousness criteria 
Serious adverse event (SAE) is defined as one of the following: 
 Is fatal or life-threatening; 
 Results in persistent or significant disability/incapacity; 
 Constitutes a congenital anomaly/birth defect; 
 Is medically significant, i.e., defined as an event that jeopardizes the patient or may 
require medical or surgical intervention to prevent one of the outcomes listed above; 

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 Requires inpatient hospitalization or prolongation of existing hospitalization; 
 Note that hospitalizations for the following reasons should not be reported as serious 
adverse events: 
 Routine treatment or monitoring of the studied indication, not associated with any 
deterioration in condition 
 Elective or pre-planned treatment for a pre-existing condition that is unrelated to the 
indication under study and has not worsened since signing the informed consent 
 Social reasons and respite care in the absence of any deterioration in the patient’s general 
condition 
 Note that treatment on an emergency outpatient basis that does not result in hospital 
admission and involves an event not fulfilling any of the definitions of a SAE given 
above is not a serious adverse event 
 Note that progression of malignancy (including fatal outcomes), if documented by use of 
appropriate method (as per 2014 NIH response criteria, Lee 2015), should not be reported 
as a serious adverse event. 
6.3.3 Reporting 
To ensure patient safety, every SAE considered related to investigational treatment by the 
investigator occurring after the patient has provided main informed consent and until at least 30 
days after the patient has stopped study treatment must be reported to the study sponsor within 
24 hours of learning of its occurrence. 
Any additional information for the SAE including complications, progression of the initial SAE, 
and recurrent episodes must be reported as follow-up to the original episode within 24 hours of 
the investigator receiving the follow-up information. An SAE occurring at a different time 
interval or otherwise considered completely unrelated to a previously reported one should be 
reported separately as a new event. 
Any SAEs experienced after the 30 day safety evaluation follow-up period should only be 
reported to the study sponsor if the investigator suspects a causal relationship to the study 
treatment. 
Information about all SAEs is collected and recorded on the Serious Adverse Event Report 
Form; all applicable sections of the form must be completed in order to provide a clinically 
thorough report. The investigator must assess and record the relationship of each SAE to each 
specific study treatment (if there is more than one study treatment), complete the SAE Report 
Form in English, and submit the completed form within 24 hours to the study sponsor. Detailed 
instructions regarding the SAE submission process and requirements for signatures are to be 
found in the investigator folder provided to each site. 

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Follow-up information is submitted in the same way as the original SAE Report. Each 
reoccurrence, complication, or progression of the original event should be reported as a follow-
up to that event regardless of when it occurs. The follow-up information should describe whether 
the event has resolved or continues, if and how it was treated, whether the blind was broken or 
not, and whether the patient continued or withdrew from study participation. If the SAE is not 
previously documented in the Investigator’s Brochure or Package Insert (new occurrence) and is 
thought to be related to the study treatment, the study sponsor may urgently require further 
information from the investigator for Health Authority reporting. 
The sponsor may need to issue an Investigator Notification (IN), to inform all investigators 
involved in any study with the same drug that this SAE has been reported. 
The study sponsor will collect the following safety information: 
 All SAEs; 
 All records of drug exposure during pregnancy; 
 All non-serious AEs; 
 All reports of misuse and abuse of an IMP, other medication errors and uses outside of 
what is foreseen in the protocol (irrespective if a clinical event has occurred). 
As soon as Novartis is a marketing authorization holder of IMP, the following safety information 
must be transferred to Novartis safety department by study sponsor within 15 days of awareness: 
 All collected SAEs in subjects exposed to the Novartis IMP; 
 All collected pregnancy reports in subjects exposed to the Novartis IMP; 
 All collected reports of abuse and misuse of the Novartis IMP. 
6.3.4 Pregnancy 
To ensure patient safety, each pregnancy occurring while the patient is on study treatment must 
be reported to the study sponsor within 24 hours of learning of its occurrence. The pregnancy 
should be followed up to determine outcome, including spontaneous or voluntary termination, 
details of the birth, and the presence or absence of any birth defects, congenital abnormalities, or 
maternal and/or newborn complications. 
Pregnancy should be recorded on a Clinical Trial Pregnancy Form and reported by the 
investigator to the study sponsor. Pregnancy follow-up should be recorded on the same form and 
should include an assessment of the possible relationship to the study treatment any pregnancy 
outcome. Any SAE experienced during pregnancy must be reported on the SAE Report Form. 

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Pregnancy outcomes must be collected for the female partners of any males randomized to BAT 
who took study treatment in this study (if required per label or as per local regulation). Consent 
to report information regarding these pregnancy outcomes should be obtained from the mother. 
7 DATA ANALYSIS AND STATISTICAL METHODS 
The size of the patient group is calculated based on the primary objective of the study. In the 
pilot study in patients with myelofibrosis, the incidence of acute GVHD II-IV with the use of 
PTCy-ruxolitinib prophylaxis was 25%. According to the literature, the incidence of acute 
GVHD with the use of the PTCy-CNI-MMF combination is 15–20% (Luznik L, 2008, and 
others). For analysis, a value of 20% was taken. The Table 7-1 below shows the size of the 
sample, options for the boundaries of non-inferiority, significance and power of the study. 
Table 7-1: Sample size 
Sample size  
N in each 
group 
GVHD rate 
in control 
group 
Study power 
p-value 
Non-
inferiority 
border 
504 
252 
20% 
80% 
0.025 
10% 
224 
112 
20% 
80% 
0.025 
15% 
128 
64 
20% 
80% 
0.025 
20% 
396 
198 
20% 
80% 
0.05 
10% 
176 
88 
20% 
80% 
0.05 
15% 
98 
49 
20% 
80% 
0.05 
20% 
2188 
1094 
20% 
80% 
0.025 
10% 
548 
274 
20% 
80% 
0.025 
15% 
244 
122 
20% 
80% 
0.025 
20% 
1724 
862 
20% 
80% 
0.05 
10% 
432 
216 
20% 
80% 
0.05 
15% 
192 
96 
20% 
80% 
0.05 
20% 
With a double margin of significance, the margin of difference is 20% and the power of the study 
is 80%, the size of the group was 64 people in each group. 
Stratification during randomization will include 2 parameters that most significantly affect the 
results of HSCT with PTCy: the disease risk index (DRI, Armand P, 2014) and the type of the 
donor (unrelated or haploidentical). Given that one of the secondary points of the study is the 
frequency of relapses, using the risk index of the disease will allow the group to balance this risk 
and reliably evaluate the effect of the prophylaxis regimen on this parameter. The use of 
stratification by type of the donor is  based on the registry studies that demonstrated that despite 
comparable efficacy of haploidentical transplantation with MRD and MUD after conventional 
GVHD prophylaxis, when compared to PTCy-based MUD, haploidetical demonstrate worse 
outcome primary due to graft failure and higher incidence of GVHD (Ruggeri A et al., 2018, 

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Brissot E et al. Haematologica. 2015). Given that the primary objective of the study is to 
compare the frequency of acute GVHD, a correction is necessary for this factor. 
The distribution among the test arms will be based on the chi-square test. The goal in the 
distribution will be to achieve the maximum sum of alpha values for DRI and type of donor. 
Comparison of cumulative frequencies in the study groups is planned using the Gray test. 
Comparison of survival rates is planned using the Kaplan-Meier method and log-rank test. 
Comparison of complication rates is planned using the Fisher and chi-square tests. To assess the 
non-inferiority it is planned to use the Faring Manning test. Equivalence will be ascertained by 
insignificant results of both non-inferioty and superiority tests. The significance level for all tests 
is set at 0.05. 
Intermediate analyzes of the study will be conducted annually after the inclusion into the study 
of 40 and 80 patients. The interim analysis will assess the following parameters: overall survival, 
event-free survival (event: relapse, death and primary graft failure), cumulative relapse rate, non-
relapse mortality, acute GVHD II-IV degree, moderate and severe chronic GVHD (according to 
the NIH 2018 criteria), the incidence of severe poor graft function (leukopenia, neutropenia or 
thrombocytopenia, grade 4). 
8 DIRECT ACCESS TO SOURCE DATA 
The investigator agrees to keep the following study-related records during 15 years after the end 
of the study: 
 Site specific Investigator's trial master file; 
 All original signed informed consent forms and information sheets; 
 All filled case report forms; 
 All SAE reports; 
 Relevant correspondence; 
 Source documents 
The investigators agrees to provide all mentioned above documentation available for regulatory 
authorities or sponsor’s audits. If the investigators becomes unable to continue to retain study-
related records, he must to notify the sponsor. 
9 AUDITS AND INSPECTIONS / QUALITY CONTROL 
Authorized representatives of sponsor or a regulatory authority may perform audits or 
inspections at the investigational sites, including source data verification. The purpose of an 
audit or inspection is to systematically and independently examine all study-related activities and 
documents, to determine whether these activities were conducted, and data were recorded, 

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analyzed, and accurately reported according to the protocol, GCP and any applicable regulatory 
requirements. The investigator will contact sponsor immediately if contacted by a regulatory 
agency about an inspection at the site. 
10 ETHICAL CONSIDERATIONS 
10.1 Institutional review board / Independent ethics committee 
The study protocol, protocol amendments, patient information sheet and informed consent form, 
case report form and other relevant documents will approved in Central Ethics Committee (CEC) 
of Russian MoH and local Ethics Committees (LEC) in each investigational site. Submission the 
mentioned above documentation to the CEC is under the sponsor’s responsibility, submission the 
documents to LEC is under the investigator’s responsibility. All correspondence with CEC/LEC 
(e.g. notification letters, submission letters, approval letters, CEC/LEC SOPs, etc.) will be 
retained in the appropriate section of the General trial master file. 
10.2 Patient information and informed consent 
The investigator, or a person designated by the investigator, will obtain written informed consent 
from each patient before the start of any study-related procedures. The investigator must ensure 
that each patient is fully informed about the objectives of the study and possible risks/benefits 
associated with participation. 
10.3 Confidentiality 
All parties will ensure protection of subject personal data and will not include subject names on 
any sponsor forms, reports, publications, or in any other disclosures, except where required by 
laws. 
Patient personal data will be replaced by a numerical code consisting order to de-identify the trial 
subject. 
10.4 Study discontinuation 
Each investigational site will be closed during the site closure-visit after the LPLV. 
The end of the clinical part of the study is defined as the time at which it is deemed that 
sufficient subjects have been recruited and completed the study as stated in the protocol. 
The end of the whole study is defined as the moment, when the CSR is finalized. 
An investigator in any centre has the right for its own publication and presentation of study 
results at conferences (congresses, symposia, etc.) providing that a written agreement regarding 
the fact, place and content of the publication from the sponsor’s representative and providing that 
all data for publication have been obtained in its center.  
Writing of research works that are based on the results of the study is allowed as long as there is 
preliminary written agreement with the sponsor. 

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10.5 Confidentiality 
All parties will ensure protection of subject personal data and will not include subject names on 
any sponsor forms, reports, publications, or in any other disclosures, except where required by 
laws. 
Patient personal data will be replaced by a numerical code consisting order to de-identify the trial 
subject. 
11 DATA MANAGEMENT 
In this study will be used an electronic case report form (e-CRF) 
e-CRF does not contain fields for data recorded directly and considered as primary data (without 
prior written or electronic recording); All data entered in the e-CRF must be indicated in the 
sourse documentation. 
The investigator is fully responsible for the collection and provision of all clinical and laboratory 
data, as well as safety data that are entered into the e-CRF, and must guarantee their authenticity 
and compliance with the primary documentation. 
If necessary, after the completion of the clinical part of the study, the sponsor may request the 
investigator to provide an explanation for any entry in the e-cRF by sending a special data data 
resolution form. 
12 AUDITS AND INSPECTIONS / QUALITY CONTROL 
Authorized representatives of sponsor or a regulatory authority may perform audits or 
inspections at the investigational sites, including source data verification. The purpose of an 
audit or inspection is to systematically and independently examine all study-related activities and 
documents, to determine whether these activities were conducted, and data were recorded, 
analyzed, and accurately reported according to the protocol, GCP and any applicable regulatory 
requirements. The investigator will contact sponsor immediately if contacted by a regulatory 
agency about an inspection at the site. 
13 FINANCIAL ASPECTS AND INSURANСE 
The life and health of all patients who signed the ICF form and successfully completed all 
screening procedures will be insured in accordance with the RF PP No. 714 “On the approval of 
standard rules for compulsory life and health insurance of a patient participating in clinical trials 
of a medicinal product”. The sponsor is responsible for the insurance of study subjects. 
The financial aspects of the study will be described in separate agreements. 
14 STUDY RESULTS AND PUBLICATIONS 
Results of this study can be published or made public in any other manner by an investigator 
only way by a written assent given by an authorized sponsor’s representative. Among authors of 

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a centralized publication should be listed principal investigators from all centres. It is possible to 
include as co-authors co-investigators, representatives of the sponsor company or the 
organization that is responsible for conducting this study.  
 
 

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27. Slade M, DiPersio JF, Westervelt P, Vij R, Schroeder MA, Romee R.  Haploidentical 
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Biol Blood Marrow Transplant. 2017 Oct;23(10):1736-1743. 
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16 APPENDICES 
16.1 Appendix 1: Dose adjustment of calcineurin inhibitors 
The chart for Cyclosporine А dose correction depending on its concentration: 
 100-150 ng/ml: the dose is increased by 25% 
 50-100 ng/ml: the dose is increased by 50-75% 
 350-500 ng/ml: the dose is increased by 25-50% 
 500-1000 ng/ml: pause in infusion or oral intake for 24 hours, dose reduction by 50% 
 >1000 ng/ml: pause in infusion or oral intake for 48 hours, dose reduction by 50%, before 
the drug is reinitiated a new concentration test is highly advisable 
The shift to oral cyclosporine A is performed after engraftment if the patient has no severe 
mucositis impairing oral intake of the drug. The recommended coefficient followed when 
shifting from iv to oral cyclosporine A forms based on its blood concentration:  
 300-350 ng/ml: 1:1 
 200-300 ng/ml: 1:1.3 
 150-200 ng/ml: 1:1.5 
 <150 ng/ml: 1:1.8 
During the shift it is important to provide adequate hydration (oral or intravenous). 
The drug is taken up to the D+100, then tapered by 25% of initial dose once per week 
(withdrawed in 8 weeks). 
The chart for tacrolimus dose correction depending on its concentration: 
 2-3 ng/ml: the dose is increased by 25% 
 <2 ng/ml: the dose is increased by 50-75% 
 12-18 ng/ml: the dose is increased by 25-50%  
 18-30 ng/ml: pause in infusion or oral intake for 24 hours, dose reduction by 50% 
 >30 ng/ml: pause in infusion or oral intake for 48 hours, dose reduction by 50%, before 
the drug is reinitiated a new concentration test is highly advisable. 
The shift to oral tacrolimus is performed after engraftment if the patient has no severe mucositis 
impairing oral intake of the drug. The recommended coefficient followed when shifting from iv 
to oral tacrolimus forms based on its blood concentration: 

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 10-15 ng/ml: 1:1 
 7-10 ng/ml: 1:1.3  
 5-7 ng/ml: 1:1.5 
 <5 ng/ml: 1:1.8 
During the shift it is important to provide adequate hydration (oral or intravenous). 
The drug is taken up to the D+100, then tapered by 25% of initial dose once per week 
(withdrawed in 8 weeks). 
If acute renal damage develops the preemptive CNIs dose reduction by 25-50% is recommended 
as in patients with inadequate renal function the drug is rapidly accumulated, which may lead to 
further renal damage. 
 
 

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16.2 Appendix 2: Clinical manifestations of the cytokine release syndrome and clinical 
intervention 
Clinical signs 
Grade 1  
Grade 2  
Grade 3  
Grade 4  
Fever 
Yes 
Yes 
Yes 
Yes 
Hypotension 
No 
Response 
to 
cristalloids 
and 
low vasopressor 
doses 
High vasopressor 
doses 
Poor response to 
vasopressors, 
life-threatening 
Respiratory 
failure 
No 
ALV 
not 
required, oxygen 
inhalation 
Fast-flow 
noninvasive 
ventilation 
or 
significant 
oxygen 
concentrations 
required 
ALV required 
Sinus 
tachycardia 
Asymptomatic 
Symptomatic, no 
correction 
required 
Symptomatic, 
urgent correction 
required 
_ 
Arrhythmia 
Asymptomatic 
Symptomatic, no 
correction 
required 
Symptomatic, 
urgent correction 
required 
Life-threatening 
Low ejection 
fraction 
No 
EF 40-50% or 
10-19% decrease 
compared 
to 
baseline  
EF 20-39% or 
>20% 
decrease 
compared 
to 
baseline 
EF<20% 
Pleural 
effusion 
Asymptomatic 
Symptomatic, 
requires diuretics 
or 
thoracocentesis 
Symptomatic, 
with respiratory 
failure 
- 
Pulmonary 
edema 
Minimal dyspnea Moderate 
dyspnea, 
decrease 
in 
everyday activity 
Dyspnea at rest, 
oxygenation 
required 
ALV required 
Vomiting 
1-2 episodes 
3-5 episodes 
More 
than 
6 
episodes 
Life-threatening 
Diarrhea 
1-3 times daily 
4-6 times daily 
>6 times daily 
Life-threatening 
Raised 
ALAT/ASAT 
1-3 norms 
3-5 norms 
5-20 norms 
>20 norms 
Raised 
bilirubin 
1-1.5 norms 
1.5-3 norms 
3-10 norms 
>10 norms 

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Clinical signs 
Grade 1  
Grade 2  
Grade 3  
Grade 4  
Diuresis 
- 
- 
oliguria 
anuria 
ARF, creatinin 1.5-2 norms 
2-3 norms 
>3 norms 
Dialysis required 
DIC 
- 
Only laboratory 
changes 
Laboratory 
changes 
and 
hemorrhagic 
syndrome 
Life-threatening 
Rash 
<10% of body 
surface area 
10-30% of body 
surface area 
>30% of body 
surface area 
Life-threatening 
Medical 
tactics 
Symptomatic 
therapy 
until 
PTCy 
Symptomatic 
therapy 
until 
PTCy 
Adequate 
supportive 
therapy 
depending 
on 
clinical 
signs, 
transfer to ICU 
recommended, 
specific therapy 
Transfer to ICU 
required, specific 
therapy 
should 
be given in first 
24 hours 
Tocilizumab 8 
mg/kg 
- 
- 
+ 
+ 
Steroids 
1-2 
mg/kg 
- 
- 
+ 
+ 
Ruxolitinib15-
20 mg/day 
- 
- 
- 
+ 
The CRS most often develops in first hours after transplant infusion. Several SRC symptoms are 
usually present, severe forms may be presented by multiorgan failure. The most difficult 
differentional diagnosis is with hepatic veno-occlusive disease and severe sepsis.  As this 
protocol is aimed at recruitment of patients in remission, they are not likely to have 
agranulocytosis at D0. Also, veno-occlusive disease more often develops at egraftment, early 
cases are seen in about 10% of all cases. Therefore for this protocol all cases of multiorgan 
failure at D0-D+1 should be viewed as CRS.