Phase Ib Trial of L-NMMA in Combination With Pembrolizumab in Patients With Melanoma, Non-Small Cell Lung Cancer, Head and Neck Squamous Cell Carcinoma, Classical Hodgkin Lymphoma, Urothelial Carcinoma, Cervical Cancer, Esophageal Cancer, Gastric Cancer, Hepatocellular Carcinoma, Merkel Cell Carcinoma, Primary Mediastinal Large B-cell Lymphoma, Renal Cell Carcinoma, Small Cell Lung Cancer, Microsatellite Instability-High/Mismatch Repair Deficient Cancer, or for the Treatment of Adult Patients With Unresectable or Metastatic Tumor Mutational Burden-High Solid Tumors
Phase: PHASE1
Conditions: Non-Small Cell Lung Cancer, Malignant Melanoma, Head and Neck Squamous Cell Carcinoma, Classical Hodgkin Lymphoma, Urothelial Carcinoma Bladder, DNA Repair-Deficiency Disorders
Sponsor: The Methodist Hospital Research Institute

 
 
1/v7.0 (10Aug20) 
 
 
 
 
SPONSOR: Houston Methodist Cancer Center & Houston Methodist Research Institute 
 
TITLE: Phase Ib Trial of L-NMMA in Combination with Pembrolizumab in Patients with 
Melanoma, Non-Small Cell Lung Cancer, Head and Neck Squamous Cell Carcinoma, 
Classical Hodgkin Lymphoma, Urothelial Carcinoma, Cervical Cancer, Esophageal Cancer, 
Gastric Cancer, Hepatocellular Carcinoma, Merkel Cell Carcinoma, Primary Mediastinal 
Large B-cell Lymphoma, Renal Cell Carcinoma, Small Cell Lung Cancer, Microsatellite 
Instability-High/Mismatch Repair Deficient Cancer, or for the Treatment of Adult Patients 
with Unresectable or Metastatic Tumor Mutational Burden-High Solid Tumors 
 
 
 
 
 
SPONSOR-INVESTIGATOR/ 
PRINCIPAL INVESTIGATOR:  Eric Bernicker, M.D. 
 
 
 
 
 
Houston Methodist Cancer Center 
 
 
 
 
 
Houston Methodist Hospital System 
 
 
 
 
 
6565 Fannin Street 
 
 
 
 
 
Houston, TX 77030 
 
 
 
 
 
 
 
MEDICAL MONITOR: 
 
Eric Bernicker,, M.D. 
 
 
 
 
 
Office: 713-441-9823 
 
 
 
 
 
Email: bernicker@houstonmethodist.org  
 
IND NUMBER:  
 
 
135888 
 
 
IRB NUMBER:  
 
 
Pro00017492 
 
 
VERSION:   
 
 
9.0 
 
 
DATE:  
 
 
 
February 26, 2021 
 
 

 
 
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TABLE OF CONTENTS 
 
Table of Contents ........................................................................................................ 2 
List of Abbreviations .................................................................................................. 6 
1.0 Background & Rationale ............................................................................................ 8 
1.1 Background ........................................................................................................... 8 
1.1.1 Programmed Death-1 Targeting for Cancer Immunotherapy ....................... 8 
1.1.2 Pembrolizumab ............................................................................................. 8 
1.1.2.1 Pembrolizumab and Melanoma ............................................................ 9 
1.1.2.2 Pembrolizumab and NSCLC ............................................................... 10 
1.1.2.3 Pembrolizumab and HNSCC .............................................................. 12 
1.1.2.4 Pembrolizumab and cHL .................................................................... 13 
1.1.2.5 Pembrolizumab and Urothelial Carcinoma ......................................... 14 
1.1.2.6 Pembrolizumab and MSI-H/dMMR Cancer ....................................... 15 
1.1.2.7 Pembrolizumab and Cervical Cancer .................................................. 16 
1.1.2.8 Pembrolizumab and Esophageal Cancer ............................................. 16 
1.1.2.9 Pembrolizumab and Gastric Cancer .................................................... 17 
1.1.2.9.1 Pembrolizumab and Hepatocellular Carcinoma............................... 18 
1.1.2.9.2 Pembrolizumab and Merkel Cell Carcinoma ................................... 18 
1.1.2.9.3 Pembrolizumab and Renal Cell Carcinoma ..................................... 18 
1.1.2.9.4 Pembrolizumab and Small Cell Lung Cancer .................................. 19 
1.1.2.9.5 Pembrolizumab and Primary Mediastinal Large B-cell Lymphoma19 
1.1.3 Tumor Immune Microenvironment and Immune Checkpoint Inhibitor 
Response .................................................................................................. 20 
1.1.4 Nitric Oxide Synthase and the TIME.......................................................... 21 
1.1.5 NG-Monomethyl-L-Arginine Preclinical and Clinical Data ...................... 23 
1.2 Rationale ............................................................................................................. 24 
1.2.1 Rationale for the Trial and Selected Subject Population ............................ 19 
1.2.2 Rationale for Dose Selection ...................................................................... 20 
2.0 Objectives ................................................................................................................. 25 
2.1 Primary Objective ............................................................................................... 25 
2.2 Secondary Objectives ......................................................................................... 25 
3.0 Endpoints .................................................................................................................. 25 
3.1 Primary Endpoint ............................................................................................... 25 
3.2 Secondary Endpoints .......................................................................................... 25 

 
 
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4.0 Trial Design ............................................................................................................... 26 
4.1 Description of Study Design ............................................................................... 26 
5.0 Methodology  ............................................................................................................ 27 
5.1 Entry Criteria ...................................................................................................... 27 
5.1.1 Diagnosis/Condition for Entry into the Trial .............................................. 27 
5.1.2 Subject Inclusion Criteria ........................................................................... 27 
5.1.3 Subject Exclusion Criteria .......................................................................... 30 
5.2 Trial Treatment ................................................................................................... 32 
5.2.1 Dose Selection/Modification ...................................................................... 32 
5.2.1.1 Dose Selection ..................................................................................... 32 
5.2.1.2 Dose Modification ............................................................................... 32 
5.2.2 Timing of Dose Administration .................................................................. 34 
5.2.3 Trial Blinding/Masking ............................................................................... 34 
5.3 Concomitant Medications/Vaccinations (allowed & prohibited) ....................... 34 
5.3.1 Acceptable Concomitant Medications ........................................................ 35 
5.3.2 Prohibited Concomitant Medications/Therapies......................................... 35 
5.4 Rescue Medications & Supportive Care ............................................................. 36 
5.4.1 Supportive Care Guidelines ........................................................................ 36 
5.5 Diet/Activity/Other Considerations .................................................................... 37 
5.5.1 Diet .............................................................................................................. 37 
5.5.2 Contraception .............................................................................................. 37 
5.5.3 Use in Pregnancy ........................................................................................ 37 
5.5.4 Use in Nursing Women ............................................................................... 37 
5.6 Subject Withdrawal/Discontinuation Criteria ..................................................... 37 
6.0 Trial Flow Chart ........................................................................................................ 41 
7.0 Trial Procedures ........................................................................................................ 44 
7.1 Trial Procedures .................................................................................................. 44 
7.1.1 Administrative Procedures .......................................................................... 44 
7.1.1.1 Informed Consent..................................................................................... 44 
7.1.1.2 Inclusion/Exclusion Criteria................................................................ 44 
7.1.1.3 Medical History ................................................................................... 45 
7.1.1.4 Prior and Concomitant Medications Review ...................................... 45 
7.1.1.4.1 Prior Medications ........................................................................ 45 
7.1.1.4.2 Concomitant Medications ........................................................... 45 
7.1.1.5 Disease Details and Treatments .......................................................... 45 
7.1.1.5.1 Disease Details ............................................................................ 45 

 
 
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7.1.1.5.2 Prior Treatment Details ............................................................... 45 
7.1.1.5.3 Subsequent Anticancer Therapy Status ....................................... 45 
7.1.2 Clinical Procedures/Assessments................................................................ 46 
7.1.2.1 AE Monitoring .................................................................................... 46 
7.1.2.2 Physical Exam ..................................................................................... 46 
7.1.2.3 Vital Signs ........................................................................................... 46 
7.1.2.4 ECOG Performance Status .................................................................. 46 
7.1.2.5 Electrocardiogram/Multigated Acquisition Scan/Echocardiogram .... 46 
7.1.2.6 Tumor Imaging and Disease Assessment ........................................... 47 
7.1.2.6.1 RECIST 1.1 ................................................................................. 47 
7.1.2.7 PK Assessment .................................................................................... 45 
7.1.2.8 Blood Sample Collection, Storage, and Use for Future Research ...... 47 
7.1.3 Laboratory Procedures/Assessments .......................................................... 47 
7.1.3.1 Laboratory Tests.................................................................................. 47 
7.1.4 Continuation of Pembrolizumab Treatment................................................ 48 
7.1.5 Other Procedures ......................................................................................... 48 
7.1.5.1 Withdrawal/Discontinuation ............................................................... 49 
7.1.5.2 Visit Requirements .............................................................................. 49 
7.1.5.2.1 Post-Treatment Visits .................................................................. 49 
7.1.5.2.1.1 Safety Follow-Up Visit ............................................................ 49 
7.1.5.2.1.1 Survival Follow-Up .................................................................. 50 
7.2  Assessing and Recording AEs ........................................................................... 50 
7.2.2 Reporting of Pregnancy and Lactation  ...................................................... 49 
7.2.3 Immediate Reporting of AEs ...................................................................... 49 
7.2.3.1 SAEs .................................................................................................... 49 
8.0 Statistical Considerations .......................................................................................... 50 
9.0 Ethical Considerations .............................................................................................. 55 
10.0 References ................................................................................................................ 56 
11.0 Appendices ............................................................................................................... 61 
 
List of Figures 
Figure 1: Study Diagram .................................................................................................. 26 
 
List of Tables 
Table 1: MSI-H/dMMR Trials ......................................................................................... 20 
Table 2: Hemodynamic Outcomes................................................................................... 23 

 
 
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Table 3: Serious Adverse Events ..................................................................................... 23 
Table 4: Adequate Organ Function Laboratory Values ................................................... 27 
Table 5: Trial Treatment .................................................................................................. 30 
Table 6: Trial Flow Chart ................................................................................................ 39 
Table 7: Laboratory Tests ................................................................................................ 47 
Table 8: L-NMMA Dose Escalation ................................................................................ 51 
Table 9: Phase I Design Operating Characteristics .......................................................... 52 
 

 
 
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List of Abbreviations 
Abbreviation 
Definition 
ALK 
Anaplastic lymphoma kinase 
ALT 
Alanine transaminase 
ANC 
Absolute neutrophil count 
aPTT 
Activated partial thromboplastin time 
AST 
Aspartate transaminase 
AE 
Adverse event 
-HCG 
Beta-human chorionic gonadotropin 
cHL 
Classical Hodgkin lymphoma 
CI 
Confidence interval 
CR 
Complete response 
CRC 
Colorectal cancer 
CrCl 
Creatinine clearance 
CRF 
Case report form 
CRM 
Continual Reassessment Method 
CTCAE 
Common Terminology Criteria for Adverse Events 
CT 
Computed tomography 
CTLA-4 
Cytotoxic T-lymphocyte-associated antigen-4 
dMMR 
DLT 
Mismatch repair deficient 
Dose-limiting toxicity 
DoR 
Duration of Response 
ECHO 
Echocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
EGFR 
Epidermal growth factor receptor 
EOT 
End of treatment 
FDA 
Food and Drug Administration 
FSH 
Follicle-stimulating hormone 
HIV 
Human immunodeficiency virus 
HNSCC 
Head and neck squamous cell carcinoma 
HR 
Hazard ratio 
HSCT 
Hematopoietic stem cell transplantation 
Ig 
Immunoglobulin 
IL-2 
Interleukin-2 
iNOS 
Inducible nitric oxide synthase 
INR 
International normalized ratio 
IRB 
Institutional review board 
IV 
Intravenous 
KN 
L-NMMA 
KEYNOTE 
NG-monomethyl-L-arginine 
MDSC 
Myeloid-derived suppressor cell 
MSI-H 
Microsatellite instability-high 
MTD 
Maximum tolerated dose 

 
 
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Abbreviation 
Definition 
MUGA 
Multigated acquisition  
NCI 
National Cancer Institute 
NO 
Nitric oxide 
NOS 
Nitric oxide synthase 
NSCLC 
Non-small cell lung cancer 
ORR 
Objective response rate 
OS 
Overall survival 
PD 
Progressive disease 
PD-1 
Programmed death-1 
PD-L1 
Programmed death-ligand 1 
PD-L2 
Programmed death-ligand 2 
PDX 
Patient-derived xenograft 
PFS 
Progression-free survival 
PK 
Pharmacokinetics 
PR 
Partial response 
PT 
Prothrombin time 
Q2W 
Every 2 weeks 
Q3W 
Every 3 weeks 
RECIST 
Response Evaluation Criteria in Solid Tumors 
RP2D 
Recommended Phase II dose 
SAE 
Serious adverse event 
SD 
Stable disease 
TIL 
Tumor-infiltrating lymphocyte 
TIME 
Tumor immune microenvironment 
TNBC 
Triple negative breast cancer 
TPS 
Tumor proportion score 
Tregs 
Regulatory T-cells 
ULN 
Upper limit of normal 
 
 
 
 
 

 
 
8/v7.0 (10Aug20) 
 
1.0 BACKGROUND & RATIONALE 
1.1 Background 
1.1.1 Programmed Death-1 Targeting for Cancer Immunotherapy 
Immune checkpoints are negative regulators of the immune system that are crucial for 
maintaining self-tolerance, preventing autoimmunity, and protecting tissues from immune 
collateral damage. Tumors are able to hijack immune checkpoint pathways, thus restraining 
the ability of the immune system to mount an effective antitumor response. Blockade of 
immune checkpoints such as cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) and 
programmed death-1 (PD-1) has proved to be a promising approach for inducing antitumor 
immunity. 
Upregulation of programmed death-ligand 1 (PD-L1) and its ligation to PD-1 on antigen-
specific CD8+ T-cells (termed adaptive immune resistance) represents a major mechanism by 
which cancer tissues limit the host immune response.1,2 Under healthy conditions, PD-1, 
expressed on the cell surface of activated T-cells, functions to downmodulate unwanted or 
excessive immune responses, including autoimmune reactions. PD-1 (encoded by the gene 
Pdcd1) is an immunoglobulin (Ig) superfamily member related to CD28 and CTLA-4 that has 
been shown to negatively regulate antigen receptor signaling upon engagement of its ligands 
(PD-L1 and/or PD-L2).  
The mechanism by which PD-1 downmodulates T-cell responses is similar to but distinct from 
that of CTLA-4, as both molecules regulate an overlapping set of signaling proteins.3 PD-1 
was shown to be expressed on activated lymphocytes including peripheral CD4+ and CD8+ T-
cells, B-cells, regulatory T-cells (Tregs), and natural killer cells.4 PD-1 expression has also 
been shown during thymic development on CD4-CD8- (double negative) T-cells as well as 
subsets of macrophages and dendritic cells.5 The ligands for PD-1 (PD-L1 and PD-L2) are 
constitutively expressed or can be induced in a variety of cell types, including non-
hematopoietic tissues and various tumors. Binding of either PD-1 ligand to PD-1 inhibits T-
cell activation triggered through the T-cell receptor. PD-L1 is expressed at low levels on 
various non-hematopoietic tissues, most notably on vascular endothelium, whereas PD-L2 
protein is only detectably expressed on antigen-presenting cells found in lymphoid tissue and 
chronic inflammatory environments.6 PD-L2 is thought to control immune T-cell activation in 
lymphoid organs, whereas PD-L1 serves to dampen unwarranted T-cell function in peripheral 
tissues. Although healthy organs express little (if any) PD-L1, a variety of cancers have been 
demonstrated to express abundant levels of this T-cell inhibitor. PD-1 has been suggested to 
regulate tumor-specific T-cell expansion in subjects with melanoma.7 This suggests that the 
PD-1/PD-L1 pathway plays a critical role in tumor immune evasion and should be considered 
an attractive target for therapeutic intervention. 
1.1.2 Pembrolizumab  
Pembrolizumab (MK-3475; trade name Keytruda) is a potent and highly selective humanized 
monoclonal antibody of the IgG4/kappa isotype designed to directly block the interaction 

 
 
9/v7.0 (10Aug20) 
 
between PD-1 and its ligands, PD-L1 and PD-L2. Antibody-mediated PD-1 blockade with 
pembrolizumab and other similar agents reinvigorates the immune system, allowing for cancer 
cell targeting and destruction. Pembrolizumab is one of a number of closely related therapies 
dubbed immune checkpoint blockade and is approved for the treatment of melanoma, non-
small cell lung cancer (NSCLC), head and neck squamous cell carcinoma (HNSCC), classical 
Hodgkin lymphoma (cHL), urothelial carcinoma, cervical cancer, esophageal cancer, gastric 
cancer, hepatocellular carcinoma, merkel cell carcinoma, primary mediastinal large B-cell 
lymphoma, renal cell carcinoma, small cell lung cancer, microsatellite instability-high (MSI-
H)/mismatch repair deficient (dMMR) cancer and  for the treatment of adult patients with 
unresectable or metastatic tumor mutational burden-high (TMB-H) [≥10 mutations/megabase 
(mut/Mb)] solid tumors.  
 
1.1.2.1 Pembrolizumab and Melanoma  
Melanoma is the deadliest form of skin cancer. Although it comprises less than 5% of skin 
cancer cases, melanoma accounts for the great majority of skin cancer-related deaths. The 
CTLA-4 antibody ipilimumab is standard of care for patients with advanced melanoma. 
Patients with melanoma that progresses on or after ipilimumab and BRAF or mitogen-activated 
protein kinase kinase inhibitor-based therapy if disease is BRAFV600 mutated have few 
therapeutic options. 
 
Pembrolizumab has been  approved by the United States Food and Drug Administration (FDA) 
for the treatment of patients with unresectable or metastatic melanoma and disease progression 
following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor. FDA approval 
was based on the results of KEYNOTE (KN)001 (NCT01295827) and KN002 
(NCT01704287). KN001 was an open-label, first-in-human Phase Ib trial of pembrolizumab 
in subjects with progressive locally advanced or metastatic carcinomas. The melanoma cohort 
included subjects with advanced disease previously treated with ipilimumab or ipilimumab in 
combination with a BRAF inhibitor (for BRAF mutation carriers).7 After mandatory biopsy, 
subjects were treated with one of three doses of pembrolizumab for 12 weeks; responders 
continued on treatment until disease progression. Among 173 subjects treated with the 
recommended 2-mg/kg pembrolizumab dose, the overall response rate was 24%, with a 
duration of response (DoR) of 1.4 to 8.5 months.  
 
KN002 was a partially blinded, randomized Phase II trial designed to evaluate 2 doses of 
pembrolizumab versus a chemotherapy control arm in subjects with ipilimumab-refractory 
metastatic melanoma.8 Subjects (n = 540) were randomized to receive pembrolizumab 2 mg/kg 
every 3 weeks (Q3W; n = 180), pembrolizumab 10 mg/kg Q3W (n = 181), or chemotherapy 
(according to current clinical practice; n = 179). Subjects assigned to the control chemotherapy 
arm could cross over to the experimental pembrolizumab arm once progression was confirmed 
(approximately ≥ Week 12). Based on 410 progression-free survival (PFS) events, PFS was 
improved in the pembrolizumab 2 mg/kg (hazard ratio [HR]: 0.57; 95% confidence interval 
[CI]: 0.45–0.73; P < 0.0001) and pembrolizumab 10 mg/kg groups (HR: 0.50; 95% CI: 0.39–
0.64; P < 0.0001) compared with the chemotherapy group. The 6-month PFS rate was 34% 

 
 
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(95% CI: 27–41) in the pembrolizumab 2 mg/kg group, 38% (95% CI: 31–45) in the 
pembrolizumab 10 mg/kg group, and 16% (95% CI: 10–22) in the chemotherapy group. Grade 
3–4 treatment-related adverse events (AEs) occurred in 20 (11%) subjects in the 
pembrolizumab 2 mg/kg group, 25 (14%) subjects in the pembrolizumab 10 mg/kg group, and 
45 (26%) subjects in the chemotherapy group. The most common Grade 3–4 treatment-related 
AE in the pembrolizumab groups was fatigue (2 [1%] of 178 subjects in the 2 mg/kg group 
and 1 [<1%] of 179 subjects in the 10 mg/kg group compared with 8 [5%] of 171 subjects in 
the chemotherapy group). Other Grade 3–4 treatment-related AEs included generalized edema 
and myalgia (each in 2 [1%] subjects) in the pembrolizumab 2 mg/kg group; hypopituitarism, 
colitis, diarrhea, decreased appetite, hyponatremia, and pneumonitis (each in 2 [1%] subjects) 
in the pembrolizumab 10 mg/kg group; and anemia (9 [5%] subjects), fatigue (8 [5%] subjects), 
neutropenia (6 [4%] subjects), and leucopenia (6 [4%] subjects) in the chemotherapy group. 
 
Results of the KN006 trial (NCT01866319) led to the expanded indication of pembrolizumab 
for the frontline treatment of patients with unresectable or metastatic melanoma. KN006 was 
a randomized, controlled Phase III trial of pembrolizumab versus ipilimumab in subjects with 
unresectable stage III or IV advanced melanoma who had received no more than one prior 
systemic therapy.9 Subjects (n = 834) were randomized to receive pembrolizumab 10 mg/kg 
Q3W, pembrolizumab 10 mg/kg every 2 weeks (Q2W), or four cycles of ipilimumab 3 mg/kg 
Q3W. The estimated 6-month PFS rates were 47.3% and 46.4% for pembrolizumab Q2W and 
Q3W, respectively, compared with 26.5% for ipilimumab (HR: 0.58; 95% CI: 0.46–0.72 and 
0.47–0.72, respectively; P < 0.001 for both pembrolizumab regimens vs. ipilimumab). 
Estimated 12-month survival rates were 74.1% for pembrolizumab Q2W, 68.4% for 
pembrolizumab Q3W, and 58.2% for ipilimumab (HR for pembrolizumab Q2W: 0.63; 95% 
CI: 0.47–0.83; P = 0.0005; HR for pembrolizumab Q3W: 0.69; 95% CI: 0.52–0.90; P = 
0.0036). Response rates were higher for pembrolizumab Q2W and Q3W compared with 
ipilimumab (33.7% and 32.9% vs. 11.9%; both P < 0.001). Response rate was similar between 
the two pembrolizumab regimens. Rates of Grade 3–5 treatment-related AEs were lower in the 
pembrolizumab Q2W and Q3W groups than in the ipilimumab group (13.3% and 10.1% vs. 
19.9%). 
 
1.1.2.2 Pembrolizumab and NSCLC 
Lung cancer is the leading cause of cancer death in the United States. Lung cancer is expected 
to account for an estimated 222,500 new cases (116,990 in men and 105,510 in women) and 
155,870 deaths (84,590 in men and 71,280 in women) in 2017. NSCLC accounts for over 85% 
of all lung cancer cases. Most patients with NSCLC are diagnosed at an advanced stage and 
have a poor prognosis, with a 5-year survival rate of <5%. Despite the development of new 
chemotherapeutic and molecularly targeted agents, outcomes remain poor. Platinum-based 
chemotherapy is the standard of care for the initial management of advanced and metastatic 
NSCLC. Fifteen to 30% of NSCLC patients have chemorefractory disease.10 Furthermore, 
patients who respond well initially to chemotherapy will ultimately develop resistance.11 
Treatment options for patients with refractory/relapsed NSCLC are limited. 
 

 
 
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Pembrolizumab has been approved for the treatment of patients with metastatic PD-L1-positive 
(tumor proportion score [TPS] ≥1%) NSCLC whose disease has progressed on or after 
platinum-containing chemotherapy or targeted therapy against anaplastic lymphoma kinase 
(ALK) or epidermal growth factor receptor (EGFR), if appropriate. FDA approval was based 
on the results from KN001 and KN010 (NCT01905657). In KN001, subjects with metastatic 
NSCLC (n = 550) were treated with various pembrolizumab regimens (2 mg/kg Q2W, 10 
mg/kg Q2W or Q3W).12 The objective response rate (ORR) in the efficacy population, which 
comprised 61 subjects with PD-L1 strongly positive tumors, was 41% (95% CI: 28.6–54.3); 
all were partial responses (PRs). At the time of the analysis, responses were ongoing in 21 of 
25 (85%) subjects, with 11 (44%) subjects having a DoR of ≥ 6 months. KN010 was a 
randomized, adaptively designed Phase II/III trial of pembrolizumab at 2 dose levels versus 
docetaxel in subjects with NSCLC with PD-L1 positive tumors who experienced disease 
progression after platinum-containing systemic therapy.13 Subjects were randomized 
according to their TPS: TPS ≥ 50%, strongly positive and TPS = 1% to 49%, weakly positive. 
In the total population, median overall survival (OS) was significantly longer for the 
pembrolizumab 2 mg/kg and 10 mg/kg groups compared with the docetaxel group (10.4 and 
12.7 months vs. 8.5 months, respectively; P = 0.0008 and P < 0.0001, respectively). Median 
PFS was not significantly different between the pembrolizumab 2 mg/kg and 10 mg/kg groups 
and the docetaxel group (3.9 and 4.0 months vs. 4.0 months, respectively; P = 0.07 and P = 
0.004, respectively). Among subjects with strongly PD-L1 positive NSCLC, median OS was 
significantly longer with pembrolizumab 2 mg/kg and pembrolizumab 10 mg/kg than with 
docetaxel (14.9 and 17.3 months vs. 8.2 months, respectively; P = 0.0002 and P < 0.0001, 
respectively). For this population, median PFS was also significantly longer in the 
pembrolizumab 2 mg/kg and 10 mg/kg groups compared with the docetaxel group (5.0 and 5.2 
months vs. 4.1 months, respectively; P = 0.0001 and P < 0.0001, respectively). 
 
Pembrolizumab has also been approved for the frontline treatment of patients with metastatic 
NSCLC whose tumors have high PD-L1 expression (TPS ≥ 50% as determined by an FDA-
approved test) and no ALK or EGFR genomic tumor aberrations. Approval was based on the 
results from the open-label, Phase III KN024 trial (NCT02142738). Subjects (n = 305) were 
randomly assigned to receive either pembrolizumab (200 mg Q3W) or investigator's choice of 
platinum-based chemotherapy.14 Crossover from the chemotherapy group to the 
pembrolizumab group was permitted in the event of disease progression. Median PFS was 
significantly longer in the pembrolizumab group than in the chemotherapy group (10.3 months 
[95% CI: 6.7 to not reached] vs. 6.0 months [95% CI: 4.2−6.2]; P < 0.001). The estimated 6-
month OS rate was 80.2% in the pembrolizumab group versus 72.4% in the chemotherapy 
group (HR for death: 0.60; 95% CI: 0.41−0.89; P = 0.005). ORR was higher (44.8% vs. 27.8%) 
and median DoR was longer (not reached [range: 1.9+ to 14.5+ months] vs. 6.3 months [range: 
2.1+ to 12.6+]) in the pembrolizumab group than in the chemotherapy group. Frequency of 
treatment-related AEs was lower in the pembrolizumab group than in the chemotherapy group 
(73.4% vs. 90.0%). The most common treatment-related AEs were diarrhea (in 14.3% of 
subjects), fatigue (10.4%), and pyrexia (10.4%) in the pembrolizumab group and anemia 
(44.0%), nausea (43.3%), and fatigue (28.7%) in the chemotherapy group. Grade 3−5 
treatment-related AEs occurred in twice as many subjects in the chemotherapy group as in the 
pembrolizumab group (53.3% vs. 26.6%). Grade 3−5 treatment-related AEs that occurred in 

 
 
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four or more subjects were diarrhea (in 3.9% of subjects) and pneumonitis (2.6%) in the 
pembrolizumab group and anemia (19.3%), neutropenia (13.3%), decreased platelet count 
(6.0%), thrombocytopenia (5.3%), decreased neutrophil count (4.0%), fatigue (3.3%), and 
decreased appetite (2.7%) in the chemotherapy group. Treatment-related serious adverse 
events (SAEs) occurred in a similar percentage of subjects in the pembrolizumab and 
chemotherapy groups (21.4% and 20.7%, respectively). Discontinuation of treatment because 
of treatment-related AEs occurred in 7.1% of subjects in the pembrolizumab group and 10.7% 
of subjects in the chemotherapy group. Treatment-related AEs that led to death occurred in one 
subject in the pembrolizumab group (sudden death of unknown cause) and three subjects in 
the chemotherapy group (one death each due to pulmonary sepsis, pulmonary alveolar 
hemorrhage, and unknown cause). 
 
1.1.2.3 Pembrolizumab and HNSCC 
 
Head and neck cancer is expected to account for an estimated 59,340 new cancer cases and 
13,000 deaths in the United States in 2017. Approximately 90% of head and neck cancers are 
squamous cell carcinomas. Most patients with HNSCC present with locoregionally advanced 
disease, and more than 50% have recurrence within 3 years.15-17 Platinum-based chemotherapy 
is generally used for the treatment of advanced-stage HNSCC; however, treatment efficacy is 
limited by intrinsic and acquired resistance.18,19 An estimated 10–30% of newly diagnosed 
patients and more than 70% of relapsed patients are resistant to platinum-based 
chemotherapy.19,20 Patients with HNSCC who have cancer progression within 6 months after 
platinum-based chemotherapy for primary or recurrent disease have a median survival of 6 
months or less.21 
 
Pembrolizumab has shown great promise in the treatment of HNSCC and has been approved 
for the treatment of patients with recurrent or metastatic HNSCC with disease progression on 
or after platinum-containing chemotherapy. FDA approval was based on results from the 
multicenter, open-label, nonrandomized Phase Ib KN012 trial (NCT01848834).22 KN012 
evaluated the safety of pembrolizumab in subjects with recurrent or metastatic HNSCC (n = 
192). Efficacy was evaluated in 174 of these subjects who had disease progression on or after 
platinum-containing chemotherapy administered for recurrent or metastatic HNSCC or 
following platinum-containing chemotherapy administered as part of induction, concurrent, or 
adjuvant therapy. The median number of prior lines of therapy administered for the treatment 
of HNSCC was two. Subjects received pembrolizumab at a dose of 10 mg/kg Q2W (n = 53) 
or a 200-mg fixed dose Q3W (n = 121) until unacceptable toxicity or disease progression. 
Subjects without disease progression were treated for up to 24 months. The ORR was 16% 
(95% CI: 11−22). The median DoR had not been reached at the time of analysis. The range for 
DoR was 2.4 months to 27.7 months (response ongoing). Among the 28 responding subjects, 
23 (82%) had responses of 6 months or longer. The ORR and DoR were similar irrespective 
of dosage regimen. SAEs occurred in 45% of subjects. The most frequent SAEs (reported in 
at least 2% of subjects) were pneumonia, dyspnea, confusional state, vomiting, pleural 
effusion, and respiratory failure. The incidence of AEs, including SAEs, was similar between 
dosage regimens (10 mg/kg Q2W or 200 mg Q3W). The most common AEs (reported in at 
least 20% of patients) were fatigue (46%), decreased appetite (22%), and dyspnea (20%).  

 
 
13/v7.0 (10Aug20) 
 
 
Preliminary results from KN055 have also demonstrated the significant clinical activity of 
pembrolizumab in subjects with heavily pretreated recurrent/metastatic HNSCC. KN055 
(NCT02255097) is an ongoing Phase II trial of single-agent pembrolizumab in subjects (n = 
171) with recurrent or metastatic HNSCC who have failed platinum and cetuximab (EGFR 
inhibitor).23 Subjects with recurrent or metastatic HNSCC received pembrolizumab at 200 mg 
Q3W. The median number of prior therapies was 2, and nearly half of subjects (42%) had 
received ≥ 3 prior systemic therapies. After a median follow-up of 7 months, 54% of subjects 
experienced a decrease in target lesion size. Median time to response was 2 months, and 75% 
of responses continued at the time of analysis. Median PFS was 2.1 months and the 6-month 
PFS rate was 24%. Median OS was 8 months (95% CI: 8−11), with a 6-month OS rate of 65%. 
The ORR was 17% (95% CI: 9–28) in subjects with PD-L1-positive tumors (n = 76; expression 
in stroma or ≥ 1% of tumor cells by immunohistochemistry). In the PD-L1-negative group (n 
= 13), the ORR was 8% (95% CI: 0.2–36). Sixty percent of subjects experienced a treatment-
related AE of any grade, which included fatigue (15%), hypothyroidism (8%), diarrhea (6%), 
decreased appetite (5%), nausea (5%), alanine transaminase (ALT) increase (5%), and rash 
(5%). Grade 3–5 AEs occurred in 12% of subjects and included anemia, ALT increase, alkaline 
phosphatase increase, and hepatitis (in 1% of subjects each). There was 1 treatment-related 
death from pneumonitis and 3 subjects discontinued treatment due to AEs. 
 
Pembrolizumab is currently being evaluated in two Phase III studies for the treatment of head 
and neck cancer: KN040 (NCT02252042; A Phase III Randomized Trial of MK-3475 
[Pembrolizumab] Versus Standard Treatment in Subjects With Recurrent or Metastatic Head 
and Neck Cancer) and KN048 (NCT02358031; A Phase III Clinical Trial of Pembrolizumab 
[MK-3475] in First Line Treatment of Recurrent/Metastatic Head and Neck Squamous Cell 
Carcinoma). 
1.1.2.4 Pembrolizumab and cHL 
cHL accounts for 94% of all Hodgkin lymphoma cases. Frontline therapy is curative in a high 
percentage of patients. However, treatment failure occurs in approximately 10% of patients 
with limited-stage disease.24 In advanced-stage disease, up to 10% of patients will not achieve 
complete remission and 20–30% of responders eventually relapse after treatment.25 Second-
line chemotherapy followed by high-dose therapy (HDT) and hematopoietic stem cell 
transplantation (HSCT) is the standard treatment for patients with refractory/relapsed cHL. 
Unfortunately, approximately 50% of patients experience relapse or disease progression after 
HSCT.26 Patients who relapse after HSCT or who are not eligible for HDT are usually treated 
with targeted agents including the CD30-directed antibody-drug conjugate brentuximab 
vedotin. cHL that is refractory to or relapses after HSCT or brentuximab vedotin represents a 
significant unmet medical need with very limited treatment options. 
 
Pembrolizumab has been approved for the treatment of patients with cHL who are refractory 
to treatment or who have relapsed after three or more lines of therapy. Pembrolizumab is the 
only anti-PD-1 therapy approved for the treatment of cHL regardless of prior HSCT or 
brentuximab vedotin therapy. FDA approval was based on data from the multicohort, open-

 
 
14/v7.0 (10Aug20) 
 
label, Phase Ib KN013 trial (NCT01953692) and the multicenter, nonrandomized, open-label, 
Phase II KN087 trial (NCT02453594).27-29 In the KN013 trial, subjects with relapsed or 
refractory cHL (n =31) received pembrolizumab 10 mg/kg Q2W until disease progression. 
Fifty percent of subjects had more than 4 lines of prior therapy, and 71% of subjects had 
relapsed after HSCT. The overall response rate was 65% (90% CI: 48–79), with complete 
response (CR) and PR rates of 16% and 48%, respectively. Most responses (70%) lasted longer 
than 24 weeks (range: 0.14+ to 74+ weeks), with a median follow-up of 17 months. The PFS 
rate was 69% at 24 weeks and 46% at 52 weeks. Overall, 68% of subjects experienced one or 
more AEs that were deemed related to the study treatment. The most common treatment-
related AEs were hypothyroidism (16%), diarrhea (16%), nausea (13%), and pneumonitis 
(10%). Five subjects (16%) experienced Grade 3 treatment-related AEs, which included colitis, 
increased ALT and aspartate transaminase (AST) levels, nephrotic syndrome, joint swelling, 
back pain, and axillary pain. There were no treatment-related Grade 4 AEs or deaths. 
 
In the KN087 trial, subjects with relapsed or refractory cHL (n = 210) received pembrolizumab 
200 mg Q3W until unacceptable toxicity or documented disease progression, or for up to 24 
months in subjects who did not progress. The median number of prior lines of therapy 
administered for the treatment of cHL was 4 (range: 1 to 12). Fifty-eight percent of subjects 
were refractory to the last prior therapy, including 35% with primary refractory disease and 
14% whose disease was chemorefractory to all prior regimens. Additionally, 61% of subjects 
had undergone prior HSCT, 83% had received prior brentuximab, and 36% had prior radiation 
therapy. The ORR was 69% (95% CI: 62–75), with CR and PR rates of 22% and 47%, 
respectively. The median follow-up time was 9.4 months. Among the 145 responding subjects, 
the median DoR was 11.1 months (range: 0.0+ to 11.1 months). Five percent of subjects 
discontinued treatment due to AEs, and 26% of subjects experienced treatment interruption 
due to AEs. The most common AEs included fatigue (26%), pyrexia (24%), cough (24%), 
musculoskeletal pain (21%), diarrhea (20%), and rash (20%). SAEs occurred in 16% of 
subjects. The most frequent SAEs (≥ 1%) included pneumonia, pneumonitis, pyrexia, dyspnea, 
graft-versus-host disease (GVHD), and herpes zoster. Two subjects died from causes other 
than disease progression; one from GVHD after subsequent allogeneic HSCT and one from 
septic shock.  
 
Pembrolizumab is currently being evaluated in a Phase III study for the treatment of 
relapsed/refractory cHL: KN204 (NCT02684292; Phase III, Randomized, Open-label, Clinical 
Trial to Compare Pembrolizumab With Brentuximab Vedotin in Subjects With Relapsed or 
Refractory cHL).  
1.1.2.5 Pembrolizumab and Urothelial Carcinoma 
Urothelial carcinomas, malignant tumors arising from the urothelial epithelium, can involve 
the lower (bladder and urethra) or upper (renal pelvis and ureter) urinary tract. Bladder tumors 
account for 90–95% of urothelial carcinomas, whereas upper urinary tract urothelial 
carcinomas are relatively rare, accounting for 5% of urothelial carcinomas.30,31 Most urothelial 
carcinomas are localized to the urinary tract, but 25% present with or develop locally advanced 
or 
metastatic 
disease.32 Cisplatin-based 
chemotherapy 
is 
the 
cornerstone 
of 

 
 
15/v7.0 (10Aug20) 
 
advanced/metastatic urothelial carcinoma treatment. Although urothelial carcinoma is 
chemosensitive, responses are short-lived and most patients relapse within a median of 12 
months. Patients with advanced/metastatic urothelial carcinoma that progresses after platinum-
based chemotherapy have a poor prognosis and limited treatment options. 
Pembrolizumab was granted FDA accelerated approval for the treatment of patients with 
locally advanced or metastatic urothelial carcinoma who are not eligible for cisplatin-
containing chemotherapy. The FDA granted regular approval to pembrolizumab for patients 
with locally advanced or metastatic urothelial carcinoma who have disease progression during 
or following platinum-containing chemotherapy or within 12 months of neoadjuvant or 
adjuvant treatment with platinum-containing chemotherapy. 
The accelerated approval for the first-line indication was based on data from the single-arm, 
open-label, Phase II KN052 trial (NCT02335424).28 Subjects (n = 370) with locally advanced 
or metastatic urothelial carcinoma who were not eligible for cisplatin-containing chemotherapy 
received pembrolizumab 200 mg Q3W. With a median follow-up time of 7.8 months, the ORR 
was 28.6% (95% CI: 24–34), with CR and PR rates of 7% and 22%, respectively. The median 
DoR was not reached (range: 1.4+ to 17.8+ months). 
The regular approval for the second-line indication was based on data from KN045 
(NCT02256436). KN045 was an open-label, multicenter, randomized, active-controlled Phase 
III trial of pembrolizumab versus paclitaxel, docetaxel, or vinflunine in subjects (n = 542) with 
advanced urothelial cancer that recurred or progressed after platinum-based chemotherapy.33 
Subjects were randomized to receive pembrolizumab 200 mg Q3W (n = 272) or investigator’s 
choice of chemotherapy with paclitaxel 175 mg/m2 (n = 84), docetaxel 75 mg/m2 (n =84), or 
vinflunine 320 mg/m2 (n = 87) Q3W. Treatment continued until unacceptable toxicity or 
disease progression. Significant improvements in OS and ORR were demonstrated for the 
pembrolizumab arm compared with the chemotherapy arm. Median OS was 10.3 months (95% 
CI: 8.0–11.8) in the pembrolizumab group compared with 7.4 months (95% CI: 6.1–8.3) in the 
chemotherapy group (HR for death: 0.73; 95% CI: 0.59–0.91; P = 0.002). ORR was 21.1% 
(95% CI: 16.4–26.5) in the pembrolizumab group and 11.4% (95% CI: 7.9–15.8) in the 
chemotherapy group (P = 0.001). Median time to response was 2.1 months in both groups. 
Median DoR was not reached in the pembrolizumab group (range: 1.6+ to 15.6+ months) and 
was 4.3 months (range: 1.4+ to 15.4+) in the chemotherapy group. PFS was not significantly 
different between the pembrolizumab and chemotherapy groups (HR for death or disease 
progression: 0.98; 95% CI: 0.81–1.19; P = 0.42). Fewer treatment-related AEs of any grade 
were reported in the pembrolizumab group than in the chemotherapy group (60.9% vs. 90.2%); 
fewer Grade 3–5 AEs were also observed in the pembrolizumab group than in the 
chemotherapy group (15.0% vs. 49.4%). 
1.1.2.6 Pembrolizumab and MSI-H/dMMR Cancer 
MSI-H is a tumor phenotype associated with somatic or germline inactivating alterations in 
DNA mismatch repair genes. dMMR leads to an accumulation of genetic mutations, especially 
in repetitive coding or non-coding DNA sequences (microsatellites), that contributes to 

 
 
16/v7.0 (10Aug20) 
 
carcinogenesis.34 Mutation rates in tumor cells with dMMR are 100–1000-fold as compared 
with normal cells.35,36 The MSI-H phenotype is mainly found in colorectal cancer (CRC), 
endometrial cancer, and gastric cancer. Less commonly, the phenotype can also occur in breast, 
prostate, bladder, and thyroid cancers. Given the high mutation load and increased potential 
neoantigen expression of MSI-H tumors, immune checkpoint immunotherapies are being 
actively investigated as a treatment strategy. In a Phase II trial (NCT01876511), 
pembrolizumab demonstrated promising efficacy in the treatment of MSI-H/dMMR tumors. 
Subjects with dMMR CRC, MMR proficient CRC, and dMMR non-CRC received 
pembrolizumab 10 mg/kg Q2W.37 The ORR and disease control rate was 0% (0/25) and 16% 
in the MMR proficient CRC cohort, 62% (8/13) and 92% in the dMMR CRC cohort, and 60% 
(6/10) and 70% in the non-CRC cohort, respectively. Mutation associated-neoantigens and 
mutational load correlated with improved PFS. 
On May 23, 2017, the FDA granted accelerated approval to pembrolizumab for the treatment 
of adult and pediatric patients with unresectable or metastatic, MSI-H/dMMR solid tumors that 
have progressed after prior treatment and who have no satisfactory alternative treatment 
options, as well as for patients with MSI-H/dMMR CRC following progression on a 
fluoropyrimidine, oxaliplatin, and irinotecan. The approval was based on data from 149 
subjects with MSI-H/dMMR cancers enrolled across 5 single-arm clinical trials (KN016 [n = 
58], KN164 [n = 61], KN012 [n = 6], KN028 [n = 5], and KN158 [n = 19]; see Table 1).28 
Ninety subjects had CRC and the remaining 59 subjects had 1 of 14 other tumor types. 
Pembrolizumab was administered at 200 mg Q3W or 10 mg/kg Q2W until disease progression, 
unacceptable toxicity, or a maximum of 24 months. The ORR was 39.6% (95% CI: 31.7–47.9), 
with CR and PR rates of 7.4% and 32.2%, respectively. The ORR was 36% in subjects with 
CRC and 46% in subjects with other tumor types. The median DoR was not yet reached (range: 
1.6+ months to 22.7+ months). Among subjects who responded to pembrolizumab, 78% had 
responses that lasted for at least 6 months.  
1.1.2.7 Pembrolizumab and Cervical Cancer 
The Food and Drug Administration (FDA) granted accelerated approval to Keytruda 
(pembrolizumab) for the treatment of patients with advanced, PD-L1–positive cervical cancer 
with disease progression on or after chemotherapy. The agency based its decision on data from 
the global, open-label, nonrandomized, multicohort, multicenter phase 2 KEYNOTE-158 trial 
– an ongoing study designed to evaluate the efficacy of Keytruda in more than 1,300 adults 
who have advanced solid tumors that progressed on chemotherapy. Data for the approval 
included 98 patients with recurrent or metastatic cervical cancer enrolled in a single cohort of 
the study. Patients in the study intravenously received Keytruda at a dose of 200 mg every 
three weeks until unacceptable toxicity or documented disease progression.  
At a median follow-up of 11.7 months, the overall response rate (ORR) was 14.3 percent in 77 
patients, which included a complete response rate of 2.6 percent and a partial response rate of 
11.7 percent among the cervical cancer cohort. In total, 10 patients (12 percent) experienced 
grade 3/4 treatment-related side effects. The recommended pembrolizumab dose for treatment 
of cervical cancer is 200 mg every 3 weeks. 

 
 
17/v7.0 (10Aug20) 
 
1.1.2.8 Pembrolizumab and Esophageal Cancer 
The Food and Drug Administration approved pembrolizumab for patients with recurrent, 
locally advanced or metastatic, squamous cell carcinoma of the esophagus (ESCC) whose 
tumors express PD-L1 (Combined Positive Score [CPS] ≥10), as determined by an FDA-
approved test, with disease progression after one or more prior lines of systemic therapy. FDA 
also approved a new use for the PD-L1 IHC 22C3 pharmDx kit as a companion diagnostic 
device for selecting patients for the above indication. Efficacy was investigated in two clinical 
trials, KEYNOTE‑181 (NCT02564263) and KEYNOTE‑180 (NCT02559687). KEYNOTE-
181 was a randomized, open-label, active-controlled trial that enrolled 628 patients with 
recurrent locally advanced or metastatic esophageal cancer who progressed on or after one 
prior line of systemic treatment for advanced or metastatic disease. Patients were randomized 
(1:1) to receive either KEYTRUDA 200 mg intravenously (IV) every 3 weeks or the 
investigator’s choice of the following regimens: paclitaxel 80-100 mg/m2 IV on days 1, 8, and 
15 of every 4‑week cycle; docetaxel 75 mg/m2 IV every 3 weeks; or irinotecan 180 mg/m2 IV 
every 2 weeks (control arm). Randomization was stratified by geographic region and histologic 
subtype (squamous versus adenocarcinoma). PD-L1 status was determined using the PD-L1 
IHC 22C3 pharmDx kit. The primary efficacy outcome measure of KEYNOTE-181 was 
overall survival (OS) in patients with ESCC, patients with tumors expressing PD-L1 CPS ≥10, 
and all randomized patients. Additional efficacy outcome measures were progression-free 
survival (PFS), overall response rate (ORR), and response duration.  The hazard ratio for OS 
in patients with ESCC whose tumors expressed PD-L1 CPS ≥10 was 0.64 (95% CI: 0.46, 0.90). 
Median OS was 10.3 months (95% CI: 7.0, 13.5) and 6.7 months (95% CI: 4.8, 8.6) in the 
pembrolizumab and control arms, respectively. 
 
KEYNOTE‑180 was a single arm, open-label trial that enrolled 121 patients with locally 
advanced or metastatic esophageal cancer who progressed on or after at least 2 prior systemic 
treatments for advanced disease. With the exception of the number of prior lines of treatment, 
the eligibility criteria were similar to and the dosage regimen identical to KEYNOTE-181. 
 
The major efficacy outcome measures of KEYNOTE-180 were ORR and response duration. 
In the 35 patients with ESCC expressing PD-L1 CPS ≥10, ORR was 20% (95% CI: 8, 37) and 
response durations ranged from 4.2 to 25.1+ months, with 71% (5 patients) having responses 
of 6 months or longer and 57% (3 patients) having responses of 12 months or longer. 
 
The recommended pembrolizumab dose for esophageal cancer is 200 mg every 3 weeks.  
 
1.1.2.9 Pembrolizumab and Gastric Cancer 
The U.S. Food and Drug Administration (FDA) has granted approval for pembrolizumab for 
the treatment of patients with recurrent, locally advanced or metastatic, with disease 
progression on or after two or more systemic therapies, including fluoropyrimidine‐ and 
platinum‐containing chemotherapy and, if appropriate, HER2/neu‐targeted therapy, and whose 
tumors express programmed death‐ligand 1 (PD‐L1), as determined by an FDA‐approved test. 
Approval was based on demonstration of durable overall response rate (ORR) in a multicenter, 

 
 
18/v7.0 (10Aug20) 
 
open‐label, multicohort trial (KEYNOTE‐059/Cohort 1) that enrolled 259 patients with locally 
advanced or metastatic gastric or GEJ adenocarcinoma. Among the 55% (n = 143) of patients 
whose tumors expressed PD‐L1 based on a combined positive score ≥1 and either were 
microsatellite stable or had undetermined microsatellite instability or mismatch repair status, 
the confirmed ORR as determined by blinded independent central review was 13.3% (95% CI, 
8.2–20.0); 1.4% had complete responses. Response durations ranged from 2.8+ to 19.4+ 
months; 11 patients (58%) had response durations of 6 months or longer, and 5 patients (26%) 
had response durations of 12 months or longer. The recommended pembrolizumab dose for 
gastric cancer is 200 mg administered as an intravenous infusion over 30 minutes every 3 
weeks until disease progression, unacceptable toxicity, or up to 24 months in patients without 
disease progression. 
1.1.2.9.1 Pembrolizumab and Hepatocellular Carcinoma  
The Food and Drug Administration has granted approval to pembrolizumab for patients with 
hepatocellular carcinoma (HCC) who have been previously treated with sorafenib. Approval 
was based on KEYNOTE 224 (NCT02702414), a single-arm, multicenter trial enrolling 104 
patients with hepatocellular carcinoma. Patients were required to have disease progression on 
or after sorafenib or were intolerant to sorafenib, have measurable disease, and Child-Pugh 
Class A liver impairment. Twenty-one percent of the patients enrolled were HBV 
seropositive, 25% were HCV seropositive, and 9 patients (9%) were seropositive for both 
HBV and HCV. Patients with active autoimmune disease, more than one etiology of 
hepatitis, medical conditions requiring immunosuppression, or clinical evidence of ascites by 
physical exam were ineligible. Patients received pembrolizumab 200 mg as an intravenous 
infusion every three week until disease progression, unacceptable toxicity, or up to 24 
months in patients without disease progression. The major efficacy outcome measure was 
confirmed overall response rate, as assessed by independent central review (ICR) according 
to RECIST 1.1 (modified to follow a maximum of 10 target lesions and a maximum of 5 
target lesions per organ). The confirmed ICR-assessed overall response rate was 17% (95% 
CI: 11, 26), with one complete response and 17 partial responses. Response durations ranged 
from 3.1 to 16.7 months; 89% of responders had response durations of 6 months or longer 
and 56% had response durations of 12 months or longer. The recommended pembrolizumab 
dose for hepatocellular carcinoma is 200 mg administered as an intravenous infusion over 30 
minutes every 3 weeks. 
1.1.2.9.2 Pembrolizumab and Merkel Cell Carcinoma  
The Food and Drug Administration has granted approval to pembrolizumab for adult and 
pediatric patients with recurrent locally advanced or metastatic Merkel cell carcinoma (MCC). 
Approval was based on Cancer Immunotherapy Trials Network protocol 9 (CITN-09), also 
known as KEYNOTE-017 (NCT02267603), a multicenter, non-randomized, open-label trial 
that enrolled 50 patients with recurrent locally advanced or metastatic MCC who had not 
received prior systemic therapy for their advanced disease. Patients received pembrolizumab 
2 mg/kg every 3 weeks. The major efficacy outcome measures were overall response rate 
(ORR) and response duration assessed by blinded independent central review per RECIST 1.1. 

 
 
19/v7.0 (10Aug20) 
 
The ORR was 56% (95% CI: 41, 70) with a complete response rate of 24%. The median 
response duration was not reached. Among the 28 patients with responses, 96% had response 
durations of greater than 6 months and 54% had response durations of greater than 12 months. 
The recommended pembrolizumab dose for MCC is 200 mg administered as a 30-minute 
intravenous infusion every 3 weeks for adults; 2 mg/kg (to a maximum of 200 mg) 
administered as a 30-minute intravenous infusion every 3 weeks for patients less than 18 years 
of age (pediatric patients). 
1.1.2.9.3 Pembrolizumab and Renal Cell Carcinoma  
The Food and Drug Administration approved pembrolizumab plus axitinib for the first-line 
treatment of patients with advanced renal cell carcinoma (RCC). Approval was based on 
KEYNOTE‑426 (NCT02853331), a randomized, multicenter, open-label trial conducted in 
861 patients who had not received systemic therapy for advanced RCC. Patients were 
enrolled regardless of PD-L1 tumor expression status and were randomly allocated to receive 
either pembrolizumab 200 mg intravenously every 3 weeks in combination with axitinib 5 
mg orally twice daily, or sunitinib 50 mg orally once daily for 4 weeks and then off treatment 
for 2 weeks. Treatment continued until confirmed disease progression or unacceptable 
toxicity. Pembrolizumab was received for maximum of 24 months. The main efficacy 
measures were overall survival (OS) and progression-free survival (PFS), assessed by 
blinded independent central review (RECIST 1.1.) The trial demonstrated a statistically 
significant improvement in OS in a pre-specified interim analysis for patients on the 
pembrolizumab plus axitinib arm (HR 0.53; 95% CI: 0.38, 0.74; p<0.0001). With deaths 
reported in 18% of patients, the median OS was not reached in either arm. The 12-month OS 
rate was 90% in the pembrolizumab plus axitinib arm and 78% for those treated with 
sunitinib. The trial also demonstrated a PFS improvement for patients receiving 
pembrolizumab plus axitinib (HR 0.69; 95% CI: 0.57, 0.84; p=0.0001). Median PFS was 
15.1 and 11.1 months for those receiving pembrolizumab plus axitinib vs. sunitinib, 
respectively. The recommended pembrolizumab dose for this indication is 200 mg every 3 
weeks with axitinib 5 mg orally twice daily. 
 
1.1.2.9.4 Pembrolizumab and Small Cell Lung Cancer 
 
The Food and Drug Administration has granted approval to pembrolizumab for patients with 
metastatic small cell lung cancer (SCLC) with disease progression on or after platinum-based 
chemotherapy and at least one other prior line of therapy. 
 
Efficacy was investigated in 83 patients with SCLC who had disease progression on or after 
two or more prior lines of therapy enrolled in one of two multicenter, multi-cohort, non-
randomized, open label trials: KEYNOTE-158 (NCT02628067) Cohort G or KEYNOTE-028 
(NCT02054806) Cohort C1. Patients received either pembrolizumab 200 mg intravenously 
every 3 weeks (n=64) or 10 mg/kg intravenously every 2 weeks (n=19). Treatment continued 
until documented disease progression, unacceptable toxicity, or a maximum of 24 months. 
 

 
 
20/v7.0 (10Aug20) 
 
The main efficacy outcome measures were overall response rate (ORR) and duration of 
response (modified RECIST v1.1) assessed by blinded independent central review. The ORR 
was 19% (95% CI: 11, 29); the complete response rate was 2%. Responses were durable for 
6 months or longer in 94%, 12 months or longer in 63%, and 18 months or longer in 56% of 
the 16 responding patients. 
 
The recommended pembrolizumab dose for SCLC is 200 mg administered as an intravenous 
infusion over 30 minutes every 3 weeks until disease progression, unacceptable toxicity, or 
up to 24 months in patients without disease progression. 
 
1.1.2.9.5 Pembrolizumab and Primary Mediastinal Large B-cell Lymphoma 
 
The Food and Drug Administration has granted approval to pembrolizumab for the treatment 
of adult and pediatric patients with refractory primary mediastinal large B-cell lymphoma 
(PMBCL), or who have relapsed after two or more prior lines of therapy. Approval was 
based on data from 53 patients with relapsed or refractory PMBCL enrolled in a multicenter, 
open-label, single-arm trial, KEYNOTE‑170 (NCT02576990). Patients were treated with 
pembrolizumab 200 mg intravenously every 3 weeks until unacceptable toxicity or 
documented disease progression, or for up to 24 months for patients who did not progress. 
The overall response rate was 45% (95% CI: 32, 60), including 11% complete responses and 
34% partial responses. The median duration of response was not reached within the follow-
up period (median 9.7 months).  The median time to first objective response was 2.8 months; 
pembrolizumab is not recommended for treatment of patients with PMBCL who require 
urgent cytoreductive therapy. 
The recommended pembrolizumab dose for treatment of adults with PMBCL is 200 mg 
every 3 weeks.  The recommended dose in pediatric patients is 2 mg/kg (up to a maximum of 
200 mg) every three weeks. 
1.1.2.10 Pembrolizumab and TMB-H solid tumors 
Efficacy of  pembrolizumab was investigated in a prospectively-planned retrospective 
analysis of 10 cohorts of patients with various previously treated unresectable or metastatic 
TMB-H solid tumors enrolled in a multicenter, non-randomized, open-label trial, 
KEYNOTE-158 (NCT02628067). Patients received pembrolizumab 200 mg intravenously 
every 3 weeks until unacceptable toxicity or documented disease progression. The main 
efficacy outcome measures were overall response rate (ORR) and duration of response (DoR) 
in patients who have received at least one dose of pembrolizumab as assessed by blinded 
independent central review according to RECIST v1.1, modified to follow a maximum of 
10 target lesions and a maximum of 5 target lesions per organ. A total of 102 patients (13%) 
had tumors identified as TMB-H, defined as TMB ≥10 mut/Mb. The ORR for these patients 
was 29% (95% CI: 21,39), with a 4% complete response rate and 25% partial response rate. 
The median DoR was not reached, with 57% of patients having response durations 
≥12 months and 50% of patients having response durations ≥24 months. Adverse reactions 
occurring in patients with TMB-H cancer enrolled in KEYNOTE-158 were similar to those 
occurring in patients with other solid tumors who received pembrolizumab as a single agent. 

 
 
21/v7.0 (10Aug20) 
 
The most common adverse reactions to pembrolizumab are fatigue, musculoskeletal pain, 
decreased appetite, pruritus, diarrhea, nausea, rash, pyrexia, cough, dyspnea, constipation, 
pain, and abdominal pain. Pembrolizumab is associated with immune-mediated side effects, 
including pneumonitis, colitis, hepatitis, endocrinopathies, nephritis, and skin adverse 
reactions. 
The recommended pembrolizumab dosage regimen for TMB-H solid tumors is 200 mg every 
3 weeks or 400 mg every 6 weeks for adults. The FDA also approved the 
FoundationOneCDx assay (Foundation Medicine, Inc.) as a companion diagnostic for 
pembrolizumab. 
 
Table 1. MSI-H/dMMR Trials28 
1.1.3 Tumor Immune Microenvironment and Immune Checkpoint Inhibitor Response 
 
Immune checkpoint inhibitors such as the anti-PD-1 antibody pembrolizumab have shown 
great promise for cancer treatment. However, a majority of patients do not respond to this type 
of treatment. The tumor immune microenvironment (TIME) has emerged as a critical 
determinant of immune checkpoint inhibitor response, with responses correlated with an 
immunologically 
active 
T-cell-inflamed 
microenvironment.38 
Accumulation 
of 
immunosuppressive cells such as myeloid-derived suppressor cells (MDSCs) and Tregs and 
insufficient accumulation of effector T-cells and other tumor-infiltrating lymphocytes (TILs) 
in the TIME have been implicated in the resistance to immune checkpoint therapy. Under 
healthy conditions, MDSCs and Tregs play critical roles in immune homeostasis. However, 

 
 
22/v7.0 (10Aug20) 
 
tumor-induced recruitment and activation of Tregs and MDSCs is an important mechanism of 
tumor-mediated immunosuppression, leading to impaired efficacy of cancer immunotherapy. 
In vivo studies have shown that elevated MDSCs cause resistance to anti-PD-1 immune 
checkpoint therapy, whereas MDSC suppression eradicates metastatic mouse cancers resistant 
to anti-PD-1 immune checkpoint therapy.39 Comparison of in vivo anti-PD-1-sensitive and 
anti-PD-1-resistant tumors has suggested that intratumoral Tregs might be responsible for 
limiting anti-PD-1 therapeutic efficacy.40 Tregs and MDSCs in the TIME represent a 
significant obstacle to immune checkpoint blockade therapies via suppression of immune 
checkpoint blockade-mediated antitumor T-cell responses. Immune checkpoint blockade has 
been shown to be most effective in so-called “inflamed” tumors populated with tumor-specific 
CD8+ TILs.41 Agents capable of increasing the number and activity of T-cells or TILs in the 
tumor microenvironment may enhance the response to anti-PD-1 therapy. 
 
1.1.4 Nitric Oxide Synthase and the TIME 
We and others have shown that nitric oxide synthase (NOS) expression in the TIME is a 
powerful driver of tumor-mediated immunosuppression.42-44 Therefore, TIME-targeting with 
NOS inhibitors may offer a novel combinatorial approach to enhance anti-PD-1 therapeutic 
efficacy. Nitric oxide (NO) is a bioactive molecule that exhibits pleotropic effects within 
cancer cells and tumors, with concentration-dependent protumor and antitumor effects. NO is 
produced by three different NOS isoforms: neuronal NOS, inducible NOS (iNOS), and 
endothelial NOS. The role of iNOS in carcinogenesis, tumor progression, tumor survival, and 
tumor aggressiveness is well recognized. Increased iNOS expression has been found in various 
cancers including melanoma, NSCLC, HNSCC, and lymphoma and is associated with poor 
survival.45-53 iNOS inhibition has been shown to inhibit melanoma growth in vivo and to extend 
the survival of tumor-bearing mice.54 Furthermore, iNOS inhibition enhanced cisplatin-
mediated growth inhibition in cisplatin-sensitive and cisplatin-resistant melanoma cell lines in 
vitro and a mouse xenograft model in vivo.54 NOS inhibition with the pan-NOS inhibitor L-
NAME (NG-nitro-L-arginine methyl ester) resulted in a 23% increase in median OS, 33% 
reduction in tumor volume doubling rate, and 29% reduction in total lung tumor burden in a 
mouse model of Kras mutation-positive NSCLC.55 iNOS inhibition has been shown to 
decrease invasion and enhance the antitumor effect of cisplatin in vitro in HNSCC cells.56,57  
Intratumoral NO and NO-derived molecules induce T-cell dysfunction by negatively 
impacting T-cell signaling, activation, and migration58 and prevent intratumoral infiltration of 
tumor-specific T-cells.59 iNOS is a known effector of MDSC-mediated immune suppression.60 
In syngeneic mouse melanoma models, iNOS inhibition blocked the intratumoral 
accumulation of MDSCs, leading to increased recruitment of tumor-infiltrating CD8+ T-
cells.61,62 Furthermore, iNOS inhibition was found to drive macrophages from the 
immunosuppressive M2 phenotype towards the antitumor M1 phenotype.63 Taken together, 
these data provide solid evidence of the potential of NOS inhibition to dramatically reshape 
the TIME to improve the efficacy of anti-PD-1 therapy.  
 
1.1.5 NG-Monomethyl-L-Arginine Preclinical and Clinical Trial Data 
 

 
 
23/v7.0 (10Aug20) 
 
We have demonstrated the potent antitumor activity of the pan-NOS inhibitor NG-
monomethyl-L-arginine (L-NMMA) against triple negative breast cancer (TNBC) in vitro and 
in vivo.42 L-NMMA was found to decrease cell proliferation, migration, and mammosphere 
formation in TNBC cell lines and significantly reduce tumor growth, lung metastases, tumor 
initiation, and self-renewal in TNBC patient-derived xenografts (PDXs).42 Furthermore, L-
NMMA in combination with docetaxel significantly inhibited in vivo tumor growth compared 
with docetaxel alone in TNBC xenograft models.42 Based on these findings, we have an 
ongoing Phase Ib clinical trial with proprietary L-NMMA and docetaxel in subjects with 
relapsed/refractory TNBC (NCT02834403). 
 
The safety of L-NMMA has been well established, and the anticipated SAEs are few, known, 
and documented.64 TRIUMPH was a randomized, controlled Phase III trial of L-NMMA in 
subjects with acute myocardial infarction and cardiogenic shock. The study was conducted at 
130 centers in 8 countries in North America and Europe. Inclusion required all of the following: 
(1) myocardial infarction, confirmed by ischemic symptoms for at least 30 minutes with 
elevated cardiac markers and/or ST-segment elevation or left bundle-branch block; (2) patency 
(<70% stenosis) of the infarct artery, either occurring spontaneously and confirmed at 
angiography or after percutaneous revascularization; (3) refractory cardiogenic shock of less 
than 24 hours’ duration, confirmed by peripheral signs of tissue hypoperfusion and systolic 
blood pressure less than 100 mmHg despite vasopressor therapy (dopamine ≥ 7 μg/kg per 
minute or norepinephrine or epinephrine ≥ 0.15 μg/kg per minute) continuing longer than 1 
hour after infarct artery patency; (4) clinical or hemodynamic evidence of elevated left 
ventricular filling pressures; and (5) left ventricular ejection fraction of less than 40%. 
Hemodynamics and requirement for vasopressor treatment were reconfirmed after 
randomization just prior to study drug administration; subjects with resolving shock were 
excluded. Between January 2005 and August 2006, 398 subjects met the study inclusion 
criteria and were enrolled. All baseline characteristics were well balanced between the 
treatment groups. More than one quarter of the population was older than 75 years; the majority 
were male and of white race. More than half of the subjects had hypertension and one third 
had diabetes; 84 (21%) had a history of heart failure and almost a third of those had advanced 
heart failure symptoms in the 6 weeks prior to enrollment. A quarter of the subjects had 
baseline creatinine levels of 1.7 mg/dL (150 mol/L) or higher. The median supported blood 
pressure just prior to study drug administration was 88/52 mmHg. Most subjects were 
supported with a single vasopressor at the time of study drug administration. The majority of 
subjects presented with anterior, ST-segment elevation myocardial infarction with left anterior 
descending infarct artery location. Percutaneous coronary intervention was performed in nearly 
all subjects to achieve the requirement for less than 70% infarct artery stenosis before study 
entry. L-NMMA had no effect on mortality in subjects with myocardial infarction complicated 
by refractory cardiogenic shock. Importantly, L-NMMA was well tolerated with few AEs other 
than transient (minutes) reversible hypertension. Hemodynamic outcomes and SAEs are 
shown in Tables 2 and 3, respectively. Subjects who received L-NMMA had a greater increase 
in systolic blood pressure at 2 hours compared with subjects who received placebo (12.0 
mmHg vs. 7.0 mmHg; P < 0.001). There were a total of 274 SAEs reported (130 in the placebo 
group and 144 in the L-NMMA group). No significant differences in safety were noted. 
 

 
 
24/v7.0 (10Aug20) 
 
Table 2. Hemodynamic Outcomes 
Hemodynamic 
Outcomes 
L-NMMA 
Placebo 
P Value 
2-hour change in systolic 
blood pressure, median, 
mmHg 
12.0 (2.5 to 23.0) 
7.0 (-2.0 to 17.0) 
0.001 
2-hour 
change 
in 
diastolic blood pressure, 
median, mmHg 
5.0 (-4.0 to 11.0) 
1.0 (-5.0 to 8.0) 
0.16 
7-day 
change 
in 
creatinine, mg/dL 
0.01 (-0.20 to 0.19) 
-0.15 (-0.32 to 0.16) 
0.16 
 
Table 3. Serious Adverse Events 
 
L-NMMA 
(n = 206) 
Placebo 
(n = 190) 
Cardiovascular, n (%) 
 
 
       Worsening heart failure 
56 (27.2) 
46 (24.3) 
       Arrhythmias 
10 (4.9) 
6 (3.2) 
       Myocardial infarction 
7 (3.4) 
6 (3.2) 
       Thromboembolism 
1 (0.5) 
2 (1.1) 
       Worsening shock 
1 (0.5) 
2 (1.1) 
       Valve disorders 
0 
1 (0.5) 
       Other cardiovascular 
2 (1.0) 
5 (2.6) 
Infectious, n (%) 
18 (8.7) 
15 (7.9) 
Respiratory, n (%) 
7 (3.4) 
10 (5.3) 
Neurological, n (%) 
7 (3.4) 
9 (4.7) 

 
 
25/v7.0 (10Aug20) 
 
Renal, n (%) 
7 (3.4) 
4 (2.1) 
Coagulopathy, n (%) 
8 (3.9) 
2 (1.1) 
Gastrointestinal, n (%) 
5 (2.4) 
4 (2.1) 
Other events, n (%) 
16 (7.8) 
7 (3.7) 
 
The ability of L-NMMA to overcome the hypotensive effects of interleukin-2 (IL-2) was 
evaluated in subjects with metastatic renal cell carcinoma. Bolus injections of L-NMMA at 3, 
6, and 12 mg/kg were shown to be safe when administered to subjects with metastatic renal 
cell carcinoma prior to infusion of IL-2 (n = 3 per cohort).65 L-NMMA was not associated with 
any hematologic, liver, or renal abnormalities. Doses of 3 and 6 mg/kg did not induce clinically 
apparent side effects and blood pressure remained unchanged. A transient increase in systolic 
blood pressure up to 25 mmHg in the absence of any other clinical symptoms was observed 
with the 12 mg/kg dose; however, this increase in blood pressure normalized rapidly (less than 
5 min) on stopping infusion.  
 
1.2 Rationale 
1.2.1 Rationale for the Trial and Selected Subject Population 
Pembrolizumab has demonstrated significant clinical activity in patients with melanoma, 
NSCLC, HNSCC, cHL, urothelial carcinoma,cervical cancer, esophageal cancer, gastric 
cancer, hepatocellular carcinoma, merkel cell carcinoma, primary mediastinal large B-cell 
lymphoma, renal cell carcinoma, small cell lung cancer, MSI-H/dMMR cancer, and for the 
treatment of adult and pediatric patients with unresectable or metastatic tumor mutational 
burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid tumors, as determined by an 
FDA-approved test, that have progressed following prior treatment and who have no 
satisfactory alternative treatment options.. However, a significant proportion of these patients 
do not respond to or progress after anti-PD-1 therapy, highlighting the need for novel strategies 
to optimize the efficacy of this therapy. The TIME has emerged as a critical determinant of 
immune checkpoint inhibitor response, with responses correlated with an immunologically 
active T-cell-inflamed microenvironment.38 We and others have shown that NOS induces 
immune dysfunction in the tumor microenvironment.42-44 Therefore, we hypothesize that NOS 
inhibition, by targeting the immunosuppressive tumor microenvironment, will reverse 
resistance to PD-1 blockade and enhance response rates to pembrolizumab in patients with 
melanoma, NSCLC, HNSCC, cHL, urothelial carcinoma, cervical cancer, esophageal cancer, 
gastric cancer, hepatocellular carcinoma, merkel cell carcinoma, primary mediastinal large B-
cell lymphoma, renal cell carcinoma, small cell lung cancer, MSI-H/dMMR cancer or patients 
with 
unresectable 
or 
metastatic 
tumor 
mutational 
burden-high 
(TMB-H) 
[≥10 mutations/megabase (mut/Mb)] solid tumors. We will increase the number of subjects 
enrolled to 20 subjects to allow for Screen-Fails/withdrawals/deaths. The protocol study 
population will remain at 12 evaluable subjects. 

 
 
26/v7.0 (10Aug20) 
 
 
1.2.2 Rationale for Dose Selection  
All subjects will be treated with the recommended dose of pembrolizumab.  
L-NMMA will be initially administered at a dose of 15.0 mg/kg. L-NMMA dose will de-
escalate (12.5 mg/kg) or escalate (20.0 mg/kg) based on the occurrence of dose-limiting 
toxicities (DLTs). We previously demonstrated that L-NMMA at a dose of 200 mg/kg was 
effective in reducing tumor volume in TNBC PDX mouse models.42 The 200 mg/kg dose of 
L-NMMA translates into a 10−15 mg/kg human equivalent dose.66 We are currently 
conducting a Phase Ib/II trial evaluating the safety and efficacy of proprietary L-NMMA at 
doses ranging from 7.5−20.0 mg/kg in combination with docetaxel in subjects with 
relapsed/refractory TNBC (NCT02834403). 
2.0 OBJECTIVES  
2.1 Primary Objective  
• To assess the maximum tolerated dose (MTD) of the L-NMMA and pembrolizumab 
combination in subjects with melanoma, NSCLC, HNSCC, cHL, urothelial carcinoma, 
cervical cancer, esophageal cancer, gastric cancer, hepatocellular carcinoma, merkel 
cell carcinoma, primary mediastinal large B-cell lymphoma, renal cell carcinoma, small 
cell lung cancer, MSI-H/dMMR cancer or for the treatment of adult patients with 
unresectable 
or 
metastatic 
tumor 
mutational 
burden-high 
(TMB-H) 
[≥10 mutations/megabase (mut/Mb)] solid tumors. 
 
2.2 Secondary Objectives    
• To describe the DLTs and other toxicities associated with the L-NMMA and 
pembrolizumab combination in subjects with melanoma, NSCLC, HNSCC, cHL, 
urothelial carcinoma, cervical cancer, esophageal cancer, gastric cancer, hepatocellular 
carcinoma, merkel cell carcinoma, primary mediastinal large B-cell lymphoma, renal 
cell carcinoma, small cell lung cancer, MSI-H/dMMR cancer, or metastatic tumor 
mutational burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid tumors, 
as assessed by the National Cancer Institute Common Terminology Criteria for 
Adverse Events (NCI CTCAE) v4.03 (see Section 11.1).  
• To determine the recommended Phase II dose (RP2D) of the L-NMMA and 
pembrolizumab combination.  
• To evaluate the antitumor activity of the L-NMMA and pembrolizumab combination, 
as assessed by the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 (see 
Sections 7.1.2.6.1 and 11.2). 
• To study the plasma pharmacokinetics (PK) and pharmacodynamics of the L-NMMA 
and pembrolizumab combination. 
   

 
 
27/v7.0 (10Aug20) 
 
3.0 ENDPOINTS 
3.1 Primary Endpoint 
• The primary endpoint will be the identification of the MTD of the L-NMMA and 
pembrolizumab combination. DLT will be defined as any treatment-related death or any ≥ 
Grade 3 AE (NCI CTCAE v4.03) unless there is clear alternative evidence that the AE was 
not caused by the trial treatment (see Section 8.0 ― Statistical Considerations for a detailed 
list of DLTs). The DLT assessment window will be defined as the duration required to 
complete one full cycle of treatment with the L-NMMA and pembrolizumab combination. 
If treatment is delayed, the timelines for dose escalation and MTD determinations will be 
adjusted to allow for the completion of the DLT assessment window. Subjects will be 
considered evaluable for the purpose of establishing dose escalation decisions and the 
MTD if they satisfy one of the following criteria: receive at least one complete cycle of the 
L-NMMA and pembrolizumab combination and complete trial assessments without a DLT 
within the DLT assessment window or experience a DLT within the DLT assessment 
window and are withdrawn from the trial. 
3.2 Secondary Endpoints 
• Secondary endpoints will include evaluation of the A) DLTs and other toxicities (as 
assessed by the NCI CTCAE v4.03), B) RP2D, C) antitumor activity (as assessed by the 
RECIST 1.1), and D) plasma PK and pharmacodynamics of the L-NMMA and 
pembrolizumab combination. 
 
4.0 TRIAL DESIGN 
4.1 Description of Trial Design 
This is a Phase Ib trial assessing the safety of the pan-NOS inhibitor L-NMMA in combination 
with pembrolizumab in subjects with melanoma, NSCLC, HNSCC, cHL, urothelial carcinoma, 
cervical cancer, esophageal cancer, gastric cancer, hepatocellular carcinoma, merkel cell 
carcinoma, primary mediastinal large B-cell lymphoma, renal cell carcinoma, small cell lung 
cancer, MSI-H/dMMR cancer, or for the treatment of adult patients with unresectable or 
metastatic tumor mutational burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid 
tumors. This trial will determine the MTD, DLTs and other toxicities, and RP2D of the L-
NMMA and pembrolizumab combination and will utilize a standard Bayesian model averaging 
continual reassessment method (CRM) approach to determine the appropriate dose of L-
NMMA (see Section 8.0 ― Statistical Considerations). A cohort size of 2 will be used. 
 
 
 

 
 
28/v7.0 (10Aug20) 
 
Figure 1. Study Diagram 
 
 
 
5.0 METHODOLOGY 
5.1 Entry Criteria 
5.1.1 Diagnosis/Condition for Entry into the Trial 
Female or male subjects ≥ 18 years of age with melanoma, NSCLC, HNSCC, cHL, urothelial 
carcinoma, cervical cancer, esophageal cancer, gastric cancer, hepatocellular carcinoma, 
merkel cell carcinoma, primary mediastinal large B-cell lymphoma, renal cell carcinoma, small 
cell lung cancer, MSI-H/dMMR cancer or unresectable or metastatic tumor mutational burden-
high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid tumors will be eligible for the trial.  
5.1.2 Subject Inclusion Criteria 

 
 
29/v7.0 (10Aug20) 
 
Subjects must meet all the following inclusion criteria in order to be eligible for participation 
in this trial: 
• Female or male aged ≥ 18 years on the day of informed consent signing; 
• Has histologically confirmed metastatic melanoma that is treatment naïve or has 
relapsed after or is refractory to ipilimumab or BRAF inhibitor (if BRAF mutation 
positive),  
OR 
histologically confirmed metastatic NSCLC that has high PD-L1 expression (TPS ≥ 
50%) with no EGFR or ALK genomic tumor aberrations or histologically confirmed 
metastatic NSCLC that is PD-L1 positive (TPS ≥ 1%) and has progressed on or after 
platinum containing therapy (subjects with NSCLC harboring EGFR/ALK genomic 
aberrations must have received an FDA-approved targeted therapy for these 
aberrations) 
OR  
histologically confirmed HNSCC that has relapsed after or is refractory to platinum-
containing chemotherapy,  
OR 
histologically confirmed cHL that has relapsed after three or more lines of therapy or 
is refractory to treatment 
OR 
histologically confirmed locally advanced or metastatic urothelial carcinoma that is not 
eligible for platinum-containing chemotherapy or that has relapsed after or is refractory 
to platinum-containing chemotherapy 
OR 
histologically confirmed advanced, PD-L1–positive cervical cancer with disease 
progression on or after chemotherapy that is not eligible for platinum-containing 
chemotherapy or that has relapsed after or is refractory to platinum-containing 
chemotherapy 
OR 
histologically confirmed recurrent, locally advanced or metastatic, squamous cell 
carcinoma of the esophagus (ESCC) whose tumors express PD-L1 (Combined Positive 
Score [CPS] ≥10), as determined by an FDA-approved test, with disease progression 
after one or more prior lines of systemic therapy. 
OR 
histologically confirmed recurrent, locally advanced or metastatic Gastric Cancer , with 
disease progression on or after two or more systemic therapies, including 
fluoropyrimidine‐ and platinum‐containing chemotherapy and, if appropriate, 
HER2/neu‐targeted therapy, and whose tumors express programmed death‐ligand 1 
(PD‐L1), as determined by an FDA‐approved test.  
 
OR 
histologically confirmed hepatocellular carcinoma (HCC) who have been previously 
treated with sorafenib. recurrent locally advanced or metastatic MCC who had not 
received prior systemic therapy for their advanced disease.OR 

 
 
30/v7.0 (10Aug20) 
 
histologically confirmed recurrent, locally advanced or metastatic Merkel Cell 
Carcinoma (MCC) who had not received prior systemic therapy for their advanced 
disease. 
OR 
histologically confirmed advanced renal cell carcinoma (RCC) first-line treatment. 
OR 
histologically confirmed metastatic small cell lung cancer (SCLC) with disease 
progression on or after platinum-based chemotherapy and at least one other prior line 
of therapy. 
OR 
histologically confirmed refractory primary mediastinal large B-cell lymphoma 
(PMBCL), who have relapsed after two or more prior lines of therapy. 
OR 
MSI-H or dMMR unresectable or metastatic cancer that has relapsed after prior 
treatment and has no satisfactory alternative treatment options;  
 OR 
adult patients with unresectable or metastatic tumor mutational burden-high (TMB-H) 
[≥10 mutations/megabase (mut/Mb)] solid tumors; 
• Measurable disease based on RECIST 1.1;   
• Eastern Cooperative Oncology Group (ECOG) performance status of 0−2 (see Section 
11.3); 
• Life expectancy ≥ 6 months; 
• Adequate organ function as defined in Table 4. All screening labs should be performed 
within 28 days of treatment initiation.  
 
Table 4  
System 
Laboratory Value 
Hematological 
 
Absolute neutrophil count (ANC) 
≥1,500/mm3 
Platelets 
≥100,000/mm3 
Hemoglobin 
≥9 g/dL (transfusion permitted) 
Renal 
 
Serum creatinine OR 
Measured or calculateda creatinine 
clearance (CrCl) 
(glomerular filtration rate can be used in 
place of creatinine or CrCl) 
≤1.5 X upper limit of normal (ULN) OR 
 
≥60 mL/min for subject with creatinine levels > 1.5 X 
institutional ULN 
Hepatic 
 
Serum total bilirubin 
≤1.5 X ULN OR 
 
Direct bilirubin ≤ ULN for subjects with total bilirubin levels > 
1.5 ULN 
ALT and AST 
≤2.5 X ULN  OR 
≤5 X ULN for subjects with liver metastases 
Albumin 
>2.5 mg/dL 
Coagulation 
International normalized ratio (INR) or 
prothrombin time (PT) 
 
Activated partial thromboplastin time 
(aPTT) 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 
≤1.5 X ULN unless subject is receiving anticoagulant therapy 
as long as PT or PTT is within therapeutic range of intended use 
of anticoagulants 

 
 
31/v7.0 (10Aug20) 
 
aCrCl should be calculated per institutional standard. 
• Cardiac ejection fraction of ≥ 45%;  
• Female subjects of childbearing potential should have a negative serum pregnancy (-
human chorionic gonadotropin [-HCG]) within 7 days prior to receiving the first dose 
of trial treatment and should not be lactating;   
• Female subjects of childbearing potential must be willing to use an adequate method 
of contraception as outlined in Section 5.5.2 ― Contraception for the course of the trial 
through 120 days after the last dose of trial treatment; 
• Male subjects of childbearing potential must be willing to use an adequate method of 
contraception as outlined in Section 5.5.2 ― Contraception for the course of the trial 
through 120 days after the last dose of trial treatment; 
• Willing and able to provide written informed consent/assent for the trial. 
 
5.1.3 Subject Exclusion Criteria 
Subjects meeting any of the following exclusion criteria must be excluded from participating 
in the trial: 
• History of poorly controlled hypertension (defined as systolic blood pressure > 150 
mmHg). Subjects with medication-controlled hypertension are allowed provided they 
have been on their current medication for at least 4 weeks prior to Cycle 1, Day 1; 
• History of New York Heart Association class III or greater cardiac disease (see Section 
11.4); 
• History of myocardial infarction, stroke, ventricular arrhythmia, or symptomatic 
conduction abnormality within the past 12 months; 
• History of congenital QT prolongation; 
• Absolute corrected QT interval of > 480 msec in the presence of potassium >4.0 mEq/L 
and magnesium > 1.8 mg/dL; 
• Currently participating and receiving study therapy or has participated in a study of an 
investigational agent and received study therapy or used an investigational device 
within 4 weeks of the first dose of the trial treatment; 
• Concurrent use of medications that interact with nitrate/nitrites (see Section 11.5); 
• Concurrent use of any complementary or alternative medicines;   
• Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any 
other form of immunosuppressive therapy within 7 days prior to the first dose of trial 
treatment; 
 
• Known history of active tuberculosis (Bacillus Tuberculosis); 
• Hypersensitivity to L-NMMA, pembrolizumab, or any of their excipients; 
• Has had a prior anticancer monoclonal antibody within 4 weeks prior to study Day 1 
or who has not recovered (i.e., ≤ Grade 1 or at baseline) from AEs due to agents 
administered more than 4 weeks earlier; 
• Has had prior chemotherapy, targeted small molecule therapy, or radiation therapy 
within 4 weeks prior to study Day 1 or who has not recovered (i.e., ≤ Grade 1 or at 
baseline) from AEs due to a previously administered agent. 

 
 
32/v7.0 (10Aug20) 
 
- 
Note:  Subjects with ≤ Grade 2 neuropathy are an exception to this criterion and 
may qualify for the trial. 
- 
Note:  If subject received major surgery, they must have recovered adequately 
from the toxicity and/or complications from the intervention prior to starting 
the trial treatment.   
• Has a known additional malignancy that is progressing or requires active treatment.  
Exceptions include basal cell carcinoma of the skin or squamous cell carcinoma of the 
skin that has undergone potentially curative therapy or in situ cervical cancer. 
• Has known active central nervous system metastases and/or carcinomatous meningitis. 
Subjects with previously treated brain metastases may participate provided they are 
stable (without evidence of progression by imaging for at least 4 weeks prior to the first 
dose of trial treatment and any neurologic symptoms have returned to baseline), have 
no evidence of new or enlarging brain metastases, and are not using steroids for at least 
7 days prior to trial treatment. This exception does not include carcinomatous 
meningitis which is excluded regardless of clinical stability;   
• Has active autoimmune disease that has required systemic treatment in the past 2 years 
(i.e., with use of disease-modifying agents, corticosteroids or immunosuppressive 
drugs). Replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid 
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a form 
of systemic treatment;  
• History of non-infectious pneumonitis that required steroids or current pneumonitis; 
• Has an active infection requiring systemic therapy; 
• History or current evidence of any condition, therapy, or laboratory abnormality that 
might confound the results of the trial, interfere with the subject’s participation for the 
full duration of the trial, or is not in the best interest of the subject to participate, in the 
opinion of the treating investigator;   
• Known psychiatric or substance abuse disorders that would interfere with cooperation 
with the requirements of the trial; 
• Is pregnant or breastfeeding, or expecting to conceive a child within the projected 
duration of the trial, starting with the prescreening or screening visit through 120 days 
after the last dose of trial treatment; 
• Received prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent; 
• Known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies); 
• Has known active hepatitis B (e.g., HBsAg reactive) or hepatitis C (e.g., HCV RNA 
[qualitative] is detected); 
• Received a live vaccine within 30 days of planned start of the trial treatment. 
Note:  Seasonal influenza vaccines for injection are generally inactivated flu vaccines 
and are allowed; however, intranasal influenza vaccines (e.g., Flu-Mist®) are live 
attenuated vaccines and are not allowed; 
• Unwilling or unable to comply with the trial protocol. 

 
 
33/v7.0 (10Aug20) 
 
 
5.2 Trial Treatment 
The treatment to be used in this trial is outlined below in Table 5.  
Table 5. Trial Treatment 
Drug 
Dose/Potency 
Dose 
Frequency 
Route of 
Administration 
Regimen/Treatment Period 
 
L-NMMA 
15.0 
mg/kg 
(starting dose) 
Q3W 
IV infusion 
Days 1−5 of each 3-week cycle 
Pembrolizumab 
200 mg 
Q3W 
IV infusion 
Day 5 of each 3-week cycle 
Q3W = every 3 weeks; IV = intravenous 
 
L-NMMA and pembrolizumab will be administered for 6 cycles. Cycle length will be 21 days. 
L-NMMA will be administered as a 2-hour intravenous (IV) infusion on Days 1−5 at each 
cycle. The dose levels of L-NMMA are as follows: Dose Level -1, 12.5 mg/kg; Dose Level 0 
(starting dose), 15.0 mg/kg; and Dose Level 1, 20.0 mg/kg. L-NMMA dose will escalate/de-
escalate based on the occurrence of DLTs (see Section 8.0 ― Statistical Considerations). 
Pembrolizumab at a fixed dose of 200 mg will be IV infused over 30 minutes on Day 5 at each 
cycle. Pembrolizumab will be administered 1 hour (± 10 minutes) after L-NMMA infusion on 
Day 5 at each cycle.  Subjects will receive the trial treatment past 3 weeks only if they have 
tolerated the trial treatment without a DLT and their disease has not progressed. Subjects 
without disease progression after 6 cycles of L-NMMA and pembrolizumab will continue 
pembrolizumab until disease progression or unacceptable AEs. Subjects will be followed for a 
maximum of 3 months after the final treatment dose. 
5.2.1 Dose Selection/Modification 
5.2.1.1 Dose Selection 
The rationale for the selection of doses to be used in this trial is provided in Section 1.2.2 ― 
Rationale for Dose Selection.   
5.2.1.2 Dose Modification 
Pembrolizumab: 
AEs (both non-serious and serious) associated with pembrolizumab exposure may represent 
an immunologic etiology. These AEs may occur shortly after the first dose or several months 
after the last treatment dose.  
Withhold pembrolizumab for any of the following: 
• Grade 2 pneumonitis  

 
 
34/v7.0 (10Aug20) 
 
• Grade 2 or 3 colitis  
• Grade 3 or 4 endocrinopathies  
• Grade 4 hematological toxicity in subjects with cHL  
• Grade 2 nephritis  
• AST or ALT > 3 and up to 5 X ULN or total bilirubin > 1.5 and up to 3 X 
ULN 
• Any other severe or Grade 3 treatment-related AE  
 
Resume pembrolizumab in subjects whose AEs recover to Grade 0–1.  
 
Permanently discontinue pembrolizumab for any of the following: 
• Any life-threatening AE (excluding endocrinopathies controlled with hormone 
replacement therapy or hematological toxicity in subjects with cHL) 
• Grade 3 or 4 pneumonitis or recurrent pneumonitis of Grade 2 severity  
• Grade 3 or 4 nephritis  
• AST or ALT > 5 X ULN or total bilirubin > 3 X ULN 
o For subjects with liver metastasis who begin treatment with Grade 2 
ALT or AST, if ALT or AST increases by ≥ 50% relative to baseline 
and lasts for at least 1 week 
• Grade 3 or 4 infusion-related reactions  
• Inability to reduce corticosteroid dose to 10 mg or less of prednisone or equivalent 
per day within 12 weeks 
• Persistent Grade 2 or 3 AEs (excluding endocrinopathies controlled with hormone 
replacement therapy) that do not recover to Grade 0–1 within 12 weeks after the last 
dose of pembrolizumab 
• Any severe or Grade 3 treatment-related AE that recurs  
 
L-NMMA: 
Blood pressure will be monitored during L-NMMA infusions. At each L-NMMA infusion, 
blood pressure will be measured before infusion, 1 hour (± 15 minutes) after infusion start, and 
at infusion completion. Automatic blood pressure readings will be performed unless manual 
reading is needed. If systolic blood pressure is >180 mmHg at the 1-hour (± 15 minutes) check, 
stop the infusion and recheck blood pressure after 15−30 minutes. If blood pressure is not <160 
mmHg, recheck blood pressure after another 15−30 minutes. If blood pressure is still not <160 
mmHg, the subject is to be discontinued from the trial. The infusion can be resumed in subjects 
whose blood pressure lowers to <160 mmHg at the first or second recheck. If systolic blood 
pressure again increases beyond 180 mmHg, the infusion should be stopped and the subject is 
to be discontinued from the trial. If systolic blood pressure is >180 mmHg at infusion 
completion, recheck blood pressure after 15−30 minutes. If blood pressure is not <160 mmHg, 
recheck blood pressure after another 15−30 minutes. If blood pressure is still not <160 mmHg, 
the subject is to be discontinued from the trial. 

 
 
35/v7.0 (10Aug20) 
 
Subjects whose treatment is interrupted or permanently discontinued due to an AE including 
abnormal laboratory value must be followed at least once a week for 4 weeks and subsequently 
at 4-week intervals until resolution of the event to Grade 1 or better. Dose interruptions should 
be reported on the appropriate Dosage Administration case report form (CRF). Any AE during 
Cycle 1 that delays administration of Cycle 2 by more than 7 days will be considered a DLT 
(see Section 8.0 ― Statistical Considerations).The maximum time allowed for toxicity-related 
treatment interruption for all subsequent cycles is 3 weeks from the intended dosing day. If 
interruption is > 3 weeks, the subject must be discontinued from the trial treatment. However, 
the subject will continue to be followed for toxicity. 
5.2.2 Timing of Dose Administration 
Trial treatment will be administered on an outpatient basis. 
L-NMMA will be administered as a 2-hour IV infusion on Days 1−5 at each cycle. 
Pembrolizumab will be administered 1 hour (± 10 minutes) after L-NMMA infusion on Day 5 
at each cycle. Pembrolizumab 200 mg will be administered as a 30-minute IV infusion.   
5.2.3 Trial Blinding/Masking 
This is an open-label trial; therefore, the Sponsor, investigator, and subject will know the 
treatment administered. 
5.3 Concomitant Medications/Vaccinations (allowed & prohibited) 
Medications or vaccinations specifically prohibited in the exclusion criteria are not allowed 
during the ongoing trial. If there is a clinical indication for one of these or other medications 
or vaccinations specifically prohibited during the trial, discontinuation from trial therapy or 
vaccination may be required.  
5.3.1 Acceptable Concomitant Medications 
All treatments that the investigator considers necessary for a subject’s welfare may be 
administered at the discretion of the investigator in keeping with the community standards of 
medical care. All concomitant medication will be recorded on the CRF including all 
prescription, over-the-counter, and IV medications and fluids. If changes occur during the trial 
period, documentation of drug dosage, frequency, route, and date may also be included on the 
CRF. 
Subjects with medication-controlled hypertension will continue to take their current blood 
pressure medication. 
All concomitant medications received within 28 days before the first dose of trial treatment 
and 30 days after the last dose of trial treatment should be recorded. Concomitant medications 
administered after 30 days after the last dose of trial treatment should be recorded for SAEs.  

 
 
36/v7.0 (10Aug20) 
 
5.3.2 Prohibited Concomitant Medications/Therapies 
Subjects are prohibited from receiving the following during the length of the trial: 
• Antineoplastic systemic chemotherapy, hormone therapy, or targeted/biological 
therapy;  
• Immunotherapy not specified in this protocol; 
• Investigational treatment other than the combination of L-NMMA and 
pembrolizumab (i.e., marketed and approved but investigational in combination 
with L-NMMA);  
• Live vaccines within 30 days prior to the first dose of trial treatment and while 
participating in the trial.  Examples of live vaccines include, but are not limited to, 
the following: measles, mumps, rubella, varicella/zoster, yellow fever, rabies, 
bacillus Calmette-Guérin, and typhoid vaccine;  
• Systemic glucocorticoids for any purpose other than to modulate symptoms from 
an AE of suspected immunologic etiology; 
• Concurrent use of medications that interact with nitrate/nitrites (see Section 10.5); 
• Concurrent use of any complementary or alternative medicines.   
 
Subjects who, in the assessment by the investigator, require the use of any of the 
aforementioned treatments for clinical management should be removed from the trial.   
Subjects may receive other medications that the investigator deems to be medically necessary. 
There are no prohibited therapies during the post-treatment follow-up phase. 
 
5.4 Rescue Medications & Supportive Care 
5.4.1 Supportive Care Guidelines 
Subjects should receive appropriate supportive care measures as deemed necessary by the 
treating investigator.  
L-NMMA: 
Subjects with medication-controlled hypertension will continue to take their current blood 
pressure medication. Subjects not currently taking blood pressure medication will be 
premedicated with the calcium channel blocker amlodipine to control any L-NMMA-mediated 
transient increase in blood pressure. Amlodipine will be administered as 10 mg orally once 
daily for 6 days at each cycle. Amlodipine administration will start the day before the first dose 
of L-NMMA. Amlodipine dose may be adjusted by the treating physician if needed. 
Amlodipine dose will be held if systolic blood pressure remains below 100 mmHg. 
 
Pembrolizumab: 
Suggested supportive care measures for the management of AEs with potential immunologic 
etiology are outlined below. For each disorder, attempts should be made to rule out other causes 

 
 
37/v7.0 (10Aug20) 
 
such as metastatic disease or bacterial or viral infection, which might require additional 
supportive care. The treatment guidelines are intended to be applied when the investigator 
determines the events to be related to pembrolizumab.  
 
Immune-Mediated Pneumonitis 
Pembrolizumab can cause immune-mediated pneumonitis, including fatal cases. Monitor 
subjects for signs and symptoms of pneumonitis.  
≥ Grade 2 pneumonitis: Administer corticosteroids at an initial dose of 1 to 2 mg/kg/day 
prednisone or equivalent followed by a taper. 
 
Immune-Mediated Colitis 
Pembrolizumab can cause immune-mediated colitis. Monitor subjects for signs and symptoms 
of colitis.  
≥ Grade 2 colitis: Administer corticosteroids at an initial dose of 1 to 2 mg/kg/day prednisone 
or equivalent followed by a taper. 
 
Immune-Mediated Hepatitis 
Pembrolizumab can cause immune-mediated hepatitis. Monitor subjects for changes in liver 
function.  
Grade 2 hepatitis: Administer corticosteroids at an initial dose of 0.5 to 1 mg/kg/day 
prednisone or equivalent followed by a taper.  
≥ Grade 3 hepatitis: Administer corticosteroids at an initial dose of 1 to 2 mg/kg/day 
prednisone or equivalent followed by a taper. 
 
Immune-Mediated Endocrinopathies  
 
Hypophysitis 
Pembrolizumab can cause hypophysitis. Monitor for signs and symptoms of hypophysitis 
(including hypopituitarism and adrenal insufficiency). Administer corticosteroids and 
hormone replacement as clinically indicated.  
 
Thyroid Disorders 
Pembrolizumab can cause thyroid disorders, including hyperthyroidism, hypothyroidism and 
thyroiditis. Monitor subjects for changes in thyroid function and for clinical signs and 
symptoms of thyroid disorders. Administer replacement hormones for hypothyroidism and 
manage hyperthyroidism with thionamides and beta-blockers as appropriate.  
 
Type 1 Diabetes Mellitus 
Pembrolizumab can cause type 1 diabetes mellitus, including diabetic ketoacidosis. Monitor 
patients for hyperglycemia or other signs and symptoms of diabetes. Administer insulin for 
type 1 diabetes.  
 
Immune-Mediated Nephritis and Renal Dysfunction 
Pembrolizumab can cause immune-mediated nephritis. Monitor patients for changes in renal 
function. 

 
 
38/v7.0 (10Aug20) 
 
≥ Grade 2: Administer corticosteroids at an initial dose of 1 to 2 mg/kg/day prednisone or 
equivalent followed by a taper. 
 
Other Immune-Mediated Adverse Reactions 
Pembrolizumab can cause other clinically important immune-mediated adverse reactions. For 
suspected immune-mediated adverse reactions, ensure adequate evaluation to confirm etiology 
or exclude other causes. Based on the severity of the adverse reaction, withhold 
pembrolizumab and administer corticosteroids. Upon improvement to Grade 1 or less, initiate 
corticosteroid taper and continue to taper over at least 1 month. Based on limited data from 
clinical studies in subjects whose immune-related adverse reactions could not be controlled 
with corticosteroid use, administration of other systemic immunosuppressants can be 
considered. 
 
5.5 Diet/Activity/Other Considerations 
 
5.5.1 Diet 
 
Subjects should be on a low nitrite/nitrate diet, including avoidance of processed meats such 
as hot dogs, ham, bacon, and sausage, 1 week before study treatment start and for the duration 
of the trial. Subjects should also keep a food diary the week before and the week of the L-
NMMA infusion during Cycles 1 and 2. 
 
5.5.2 Contraception 
Pembrolizumab may have adverse effects on a fetus in utero.  It is not known if pembrolizumab 
has transient adverse effects on the composition of sperm. It is not known whether L-NMMA 
can cause fetal harm when administered to a pregnant woman.  
For this trial, male subjects will be considered to be of nonreproductive potential if they have 
azoospermia (whether due to having had a vasectomy or due to an underlying medical 
condition).   
Female subjects will be considered of nonreproductive potential if they are either:  
(1) postmenopausal (defined as at least 12 months with no menses without an alternative 
medical cause; in women < 45 years of age, a high follicle-stimulating hormone [FSH] 
level in the postmenopausal range may be used to confirm a postmenopausal state in 
women not using hormonal contraception or hormonal replacement therapy. In the absence 
of 12 months of amenorrhea, a single FSH measurement is insufficient.);  
OR  
(2) have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy, or 
bilateral tubal ligation/occlusion at least 6 weeks prior to screening;  
OR  

 
 
39/v7.0 (10Aug20) 
 
(3) have a congenital or acquired condition that prevents childbearing. 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or 
impregnating a partner, respectively, while receiving trial treatment and for 120 days after the 
last dose of trial treatment by complying with one of the following:  
  
(1) practice abstinence† from heterosexual activity;  
 
OR  
 
(2) use (or have their partner use) acceptable contraception during heterosexual activity.   
 
Acceptable methods of contraception are‡: 
 Single method (one of the following is acceptable): 
• intrauterine device 
• vasectomy of a female subject’s male partner  
• contraceptive rod implanted into the skin 
Combination method (requires use of two of the following): 
• diaphragm with spermicide (cannot be used in conjunction with cervical 
cap/spermicide) 
• cervical cap with spermicide (nulliparous women only)   
• contraceptive sponge (nulliparous women only)  
• male condom or female condom (cannot be used together) 
• hormonal contraceptive: contraceptive skin patch, vaginal contraceptive ring, or 
subcutaneous contraceptive injection 
 
 †Abstinence (relative to heterosexual activity) can be used as the sole method of contraception 
if it is consistently employed as the subject’s preferred and usual lifestyle.  Periodic abstinence 
(e.g., calendar, ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are 
not acceptable methods of contraception.  
Subjects should be informed that the trial treatment may involve unknown risks to the fetus 
(unborn baby) if pregnancy were to occur during the trial. In order to participate in the trial, 
subjects of childbearing potential must adhere to the contraception requirement (described 
above) from the day of trial treatment initiation throughout the trial period up to 120 days after 
the last dose of trial treatment. If there is any question that a subject of childbearing potential 
will not reliably comply with the requirements for contraception, that subject should not be 
entered into the trial. 
5.5.3 Use in Pregnancy 
If a subject inadvertently becomes pregnant while on the trial treatment, the subject will 
immediately be removed from the trial. The site will contact the subject at least monthly and 
document the subject’s status until the pregnancy has been completed or terminated. The 
outcome of the pregnancy will be reported to the Sponsor without delay and within 24 hours 

 
 
40/v7.0 (10Aug20) 
 
to the Sponsor if the outcome is a serious adverse experience (e.g., death, abortion, congenital 
anomaly, or other disabling or life-threatening complication to the mother or newborn).   
The study investigator will make every effort to obtain permission to follow the outcome of 
the pregnancy and report the condition of the fetus or newborn to the Sponsor. If a male subject 
impregnates his female partner, the study personnel at the site must be informed immediately 
and the pregnancy reported to the Sponsor and followed as described above and in Section 
7.2.2. 
5.5.4 Use in Nursing Women 
It is unknown whether pembrolizumab and L-NMMA are excreted in human milk. Since many 
drugs are excreted in human milk and because of the potential for serious adverse reactions in 
the nursing infant, subjects who are breastfeeding are not eligible for enrollment. 
5.6 Subject Withdrawal/Discontinuation Criteria 
Subjects may withdraw consent at any time for any reason or be dropped from the trial at the 
discretion of the investigator should any untoward effect occur. In addition, a subject may be 
withdrawn by the investigator or Sponsor if enrollment into the trial is inappropriate, the trial 
plan is violated, or for administrative and/or other safety reasons. Specific details regarding 
discontinuation or withdrawal are provided in Section 7.1.4 ― Other Procedures. 
A subject must be discontinued from the trial for any of the following reasons: 
• The subject or legal representative (such as a parent or legal guardian) withdraws 
consent 
• Confirmed radiographic disease progression 
• Any AE during Cycle 1 that delays administration of Cycle 2 by more than 7 days or 
dose interruption that exceeds 21 days in subsequent cycles  
• Unacceptable adverse experiences  
• Any ≥ Grade 4 AE 
• Severe (Grade 3) or life-threatening (Grade 4) immune-mediated complication 
• Intercurrent illness that prevents further treatment administration 
• Investigator’s decision to withdraw the subject 
• The subject has a confirmed positive serum pregnancy test 
• Noncompliance with trial treatment or procedure requirements 
• The subject is lost to follow-up 
• Death 
• Administrative reasons 
• Subjects whose blood pressure is >180 during or after L-NMMA infusion and does not 
return to <160 mmHg after 2 rechecks spaced 15−30 minutes apart  
 
The end of treatment (EOT) and follow-up visit procedures are listed in Section 6.0 (Trial Flow 
Chart) and 7.1.4.2 (Visit Requirements). At EOT, each subject will be followed for 30 days for 
AE monitoring (SAEs will be collected for 90 days after EOT as described in Section 7.2.3.1). 

 
 
41/v7.0 (10Aug20) 
 
Subjects who discontinue for reasons other than progressive disease (PD) will have post-
treatment follow-up for disease status until disease progression, initiating a non-study cancer 
treatment, withdrawing consent, or becoming lost to follow-up. 

 
42 
 
 
 
 
 
 
 
6.0 TRIAL FLOW CHART 
 
  
Table 6. Trial Flow Chart 
Trial Period: 
 
Treatment Cycles: L-NMMA + 
Pembrolizumab 
EOT 
Continued 
Pembrolizumabu 
                        Treatment Cycle: 
Screeninga 
Baselineb 
1 
2  
3 
4 
5 
6 
 
 
Scheduling Window (Days): 
-28 to -7 
-7 to -1 
± 5 
± 5 
± 5 
± 5 
 
± 5 
 
± 5 
 
 
± 5 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
 
 
 
 
 
 
Demographics  
X 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
Physical Examc 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
ECOG Performance Status 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
12-Lead ECGd 
X 
 
X 
X 
X 
X 
X 
X 
X 
 
MUGA Scan or ECHOe 
X 
 
 
 
 
 
 
 
 
 
Serum Pregnancy Test (β-HCG)f 
X 
 
 
 
 
 
 
 
 
 
PT/INR and aPTTg 
X 
 
 
 
 
 
 
 
 
 
Hematologyh 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Clinical Chemistryi  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Sedimentation Ratej 
 
X 
 
X 
 
X 
 
X 
 
X 
T3, FT4, and TSHk 
 
X 
 
 
 
 
 
 
 
 
Viral Testingl 
X 
 
 
 
 
 
 
 
 
 
Urinalysism 
 
X 
 
 
 
 
 
 
 
 
CT Scann 
X 
 
 
X 
 
X 
 
X 
X 
X 
Brain CT or MRIo 
 
X 
 
 
X 
 
 
X 
 
X 

 
43 
 
 
 
 
 
 
 
Trial Period: 
 
Treatment Cycles: L-NMMA + 
Pembrolizumab 
EOT 
Continued 
Pembrolizumabu 
                        Treatment Cycle: 
Screeninga 
Baselineb 
1 
2  
3 
4 
5 
6 
 
 
Scheduling Window (Days): 
-28 to -7 
-7 to -1 
± 5 
± 5 
± 5 
± 5 
 
± 5 
 
± 5 
 
 
± 5 
L-NMMA Administrationp 
 
 
X 
X 
X 
X 
X 
X 
 
 
Pembrolizumab Administrationp 
 
 
X 
X 
X 
X 
X 
X 
 
X 
PK/Pharmacodynamics Blood Collectionq 
 
 
X 
X 
 
 
 
 
 
 
Blood Collection for Future Researchr 
 
X 
 
X 
 
 
 
 
X 
 
Tissue Collections 
 
X 
 
 
 
 
 
 
 
 
AEs and SAEst 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
AE = adverse event; ALT = alanine transaminase; aPTT = activated partial thromboplastin time; AST = aspartate transaminase; β-hCG = beta-human chorionic gonadotropin; BUN 
= blood urea nitrogen; CBC = complete blood count; CT = computed tomography; CyTOF= mass cytometry;  DLT = dose-limiting toxicity; ECG = electrocardiogram; ECHO = 
echocardiogram; ECOG = Eastern Cooperative Oncology Group; EOT = end of treatment; FT4 = free thyroxine; HIV = human immunodeficiency virus; INR = international 
normalized ratio; IV = intravenous; LDH = lactate dehydrogenase; MRI = magnetic resonance imaging; MUGA = multigated acquisition; PK = pharmacokinetics; PT = prothrombin 
time; RP2D = recommended Phase II dose; SAE = serious adverse event; T3 = triiodothyronine; TSH = thyroid-stimulating hormone; WBC = white blood cell. 
 
A window of ± 5 days is allowed for trial visits and assessments/procedures (except as otherwise specified). 
EOT is defined as 30 ± 5 days after the last dose of trial treatment. 
a. Within 28 days prior to Cycle 1, Day 1. 
b. Within 7 days prior to Cycle 1, Day 1. 
c. Physical exam will be performed at screening/baseline, before every cycle of L-NMMA and pembrolizumab, and at EOT. The baseline symptom-directed medical history and 
physical examination are not required if the screening medical history and physical examination were conducted within 7 days prior to Cycle 1, Day 1. Physical exam will include 
vital sign (blood pressure, oral temperature, pulse, and respiratory rate) measurements. Weight will also be measured at each physical exam. Height will be measured at screening 
only. 
d. A 12-lead ECG will be performed at screening, before every cycle of L-NMMA and pembrolizumab, at EOT, and when clinically indicated.  
e. MUGA scan or ECHO will be performed at screening and when clinically indicated. The same method (MUGA scan or ECHO) must be used throughout the duration of the trial. 

 
44 
 
 
 
 
 
 
 
f. For women of childbearing potential, the results of a serum β-hCG pregnancy test must be negative within 7 days prior to the administration of the first dose of trial treatment. If 
the screening serum β-hCG pregnancy test is performed more than 7 days before dosing, it must be repeated at baseline, with results known to be negative prior to the administration 
of the first dose of trial treatment. Serum β-hCG pregnancy testing is to be performed as clinically indicated. 
g. Coagulation parameters (INR/PT/aPTT) will be tested at screening. 
h. A blood sample for CBC with platelet count and differential WBC count will be obtained at screening/baseline, before every cycle of L-NMMA and pembrolizumab, at EOT, and 
when clinically indicated. 
i. A blood sample for clinical chemistry panel (glucose, albumin, sodium, potassium, carbon dioxide, calcium, chloride, BUN, creatinine, total protein, total bilirubin, alkaline 
phosphatase, ALT, and AST) and evaluation of magnesium, uric acid, and LDH will be obtained at screening/baseline, before every cycle of L-NMMA and pembrolizumab, at EOT, 
and when clinically indicated. An extra tube of blood will be collected for CyTOF analysis at baseline, after Cycle 2 and at EOT. 
j. For subjects with classical Hodgkin lymphoma, sedimentation rate testing will be performed at baseline and Cycles 2, 4, and 6 of L-NMMA and pembrolizumab. 
k. TSH, FT4, and total T3 testing will be performed at baseline and when clinically indicated. 
l. Hepatitis panel and HIV testing will be performed at screening. 
m. Urinalysis (blood, glucose, protein, specific gravity) will be performed at baseline and when clinically indicated. 
n. CT scans of the chest, abdomen, and pelvis and/or other sites as appropriate (e.g., head and neck, upper extremities, lower extremities) will be performed at screening, after every 
2 cycles of L-NMMA and pembrolizumab and/or at the discretion of the treating physician, and 3 months after the last dose of trial treatment. 
o. For subjects with previously treated stable brain metastases, brain CT or MRI will be performed at baseline and every 2 months (± 7 days) as per standard of care. 
p. L-NMMA and pembrolizumab will be administered for six 21-day cycles. The dose levels of L-NMMA are as follows: Dose Level -1, 12.5 mg/kg; Dose Level 0 (starting dose), 
15.0 mg/kg; and Dose Level 1, 20.0 mg/kg. L-NMMA dose will escalate/de-escalate based on the occurrence of DLTs (see Section 8.0 ― Statistical Considerations). L-NMMA will 
be administered as a 2-hour IV infusion on Days 1−5 at each cycle. Pembrolizumab will be administered at a fixed dose of 200 mg. Pembrolizumab will be IV infused over 30 
minutes on Day 5 (1 hour ± 10 minutes after L-NMMA infusion) at each cycle. Blood pressure will be monitored during L-NMMA infusions. At each L-NMMA infusion, blood 
pressure will be measured before infusion, 1 hour (± 15 minutes) after infusion start, and at infusion completion. Automatic blood pressure readings will be performed unless manual 
reading is needed. If systolic blood pressure is >180 mmHg at the 1-hour (± 15 minutes) check, stop the infusion and recheck blood pressure after 15−30 minutes. If blood pressure 
is not <160 mmHg, recheck blood pressure after another 15−30 minutes. If blood pressure is still not <160 mmHg, the subject is to be discontinued from the trial. The infusion can 
be resumed in subjects whose blood pressure lowers to <160 mmHg at the first or second recheck. If systolic blood pressure again increases beyond 180 mmHg, the infusion should 
be stopped and the subject is to be discontinued from the trial. If systolic blood pressure is >180 mmHg at infusion completion, recheck blood pressure after 15−30 minutes. If blood 
pressure is not <160 mmHg, recheck blood pressure after another 15−30 minutes. If blood pressure is still not <160 mmHg, the subject is to be discontinued from the trial (see 
Section 5.2.1.2). 
q. Blood samples for assessment of plasma PK and pharmacodynamics will be collected predose (10-30 minutes before L-NMMA infusion) on Days 1, 2, and 5 of Cycles 1 and 2. 
One 5-mL sample will be collected for PK assessment and one 5-mL sample will be collected for pharmacodynamics assessment. NOTE: For PK/pharmacodynamics assessment, 
subjects should be fasted (nothing to eat or drink except water) for 12 hours prior to each collection time point. Subjects should also keep a food diary the week before and the week 
of the L-NMMA infusion during Cycles 1 and 2. 
r. Blood samples will be collected for future research at baseline, after Cycle 2, and 3 months after the last dose of trial treatment. Blood (20−30 cc) will be collected into standard 
vacutainer tubes and processed for plasma and viable cryopreserved peripheral blood mononuclear cells for future analyses.  
s. Tissue collection at baseline for archival use. 
t. AEs and SAEs will be captured from the time of informed consent signing up to and including 30 days after the last treatment dose. Trial treatment-related SAEs occurring beyond 
90 days after the last dose of trial treatment and any subject death should also be reported. 
u. Patients without disease progression after 6 cycles of L-NMMA and pembrolizumab will continue pembrolizumab until disease progression or unacceptable AEs. CT scans of the 
chest, abdomen, and pelvis and/or other sites as appropriate (e.g., head and neck, upper extremities, lower extremities) will be performed every 3 cycles of pembrolizumab and/or at 
the discretion of the treating physician. For subjects with previously treated stable brain metastases, brain CT or MRI will be performed every 2 months (± 7 days) as per standard of 
care. Blood samples for CBC with platelet count and differential WBC count, clinical chemistry panel (glucose, albumin, sodium, potassium, carbon dioxide, calcium, chloride, 
BUN, creatinine, total protein, total bilirubin, alkaline phosphatase, ALT, and AST), and evaluation of magnesium, uric acid, and LDH will be obtained at every cycle of 
pembrolizumab. For subjects with classical Hodgkin lymphoma, sedimentation rate testing will be performed at every other cycle.  
 

 
45 
 
 
 
 
 
 
 
 

46 
 
  
 
 
 
7.0 TRIAL PROCEDURES 
7.1 Trial Procedures 
The Trial Flow Chart ― Section 6.0 summarizes the trial procedures to be performed at each 
visit. Individual trial procedures are described in detail below. It may be necessary to perform 
these procedures at unscheduled time points if deemed clinically necessary by the investigator. 
Furthermore, additional evaluations/testing may be deemed necessary by the investigator for 
reasons related to subject safety. In some cases, such evaluation/testing may be potentially 
sensitive in nature (e.g., HIV, hepatitis C, etc.) and thus, local regulations may require that 
additional informed consent be obtained from the subject. In these cases, such 
evaluations/testing will be performed in accordance with those regulations. 
7.1.1 Administrative Procedures 
7.1.1.1 Informed Consent 
The investigator or qualified designee must obtain documented consent from each potential 
subject prior to participating in a clinical trial. 
Consent must be documented by the subject’s dated signature or by the subject’s legally 
acceptable representative’s dated signature on a consent form along with the dated signature 
of the person conducting the consent discussion.  
A copy of the signed and dated consent form should be given to the subject before participation 
in the trial. 
The initial informed consent form, any subsequent revised written informed consent form, and 
any written information provided to the subject must receive the institutional review board 
(IRB) approval in advance of use. The subject or his/her legally acceptable representative 
should be informed in a timely manner if new information becomes available that may be 
relevant to the subject’s willingness to continue participation in the trial. The communication 
of this information will be provided and documented via a revised consent form or addendum 
to the original consent form that captures the subject’s dated signature or by the subject’s 
legally acceptable representative’s dated signature. 
The informed consent will adhere to IRB requirements, applicable laws and regulations, and 
Sponsor requirements. 
7.1.1.2 Inclusion/Exclusion Criteria 
All inclusion and exclusion criteria will be reviewed by the investigator or qualified designee 
to ensure that the subject qualifies for the trial. Written informed consent is required before 
performing any trial-specific tests or procedures. Signing of the informed consent form can 
occur outside the 28-day screening period. All screening evaluations must be completed and 
reviewed to confirm that subjects meet all eligibility criteria before trial entry. Results of 
standard-of-care tests or examinations performed prior to obtaining informed consent and 

47 
 
  
 
 
 
within 28 days prior to trial entry (except where otherwise specified) may be used for screening 
assessments rather than repeating such tests. The investigator will maintain a screening log to 
record details of all subjects screened and to confirm eligibility or record reasons for screening 
failure, as applicable. 
7.1.1.3 Medical History 
A medical history will be obtained by the investigator or qualified designee. Medical history 
will include all active conditions and any condition diagnosed within the prior 10 years that 
are considered to be clinically significant by the investigator. Details regarding the disease for 
which the subject has enrolled in this trial will be recorded separately and not listed as medical 
history.   
7.1.1.4 Prior and Concomitant Medications Review 
7.1.1.4.1 Prior Medications 
The investigator or qualified designee will review prior medication use, including any 
protocol-specified washout requirement, and record prior medication taken by the subject 
within 28 days before starting the trial. Treatment for the disease for which the subject has 
enrolled in this trial will be recorded separately and not listed as a prior medication.  
7.1.1.4.2 Concomitant Medications 
The investigator or qualified designee will record medication, if any, taken by the subject 
during the trial. All medications related to reportable SAEs should be recorded as defined in 
Section 7.2.  
 
7.1.1.5 Disease Details and Treatments 
7.1.1.5.1 Disease Details 
The investigator or qualified designee will obtain prior and current details regarding disease 
status.  
7.1.1.5.2 Prior Treatment Details 
The investigator or qualified designee will review all prior cancer treatments including 
systemic treatments, radiation, and surgeries. 
7.1.1.5.3 Subsequent Anticancer Therapy Status 
The investigator or qualified designee will review all new antineoplastic therapy initiated after 
the last dose of trial treatment. If a subject initiates a new anticancer therapy within 30 days 
after the last dose of trial treatment, the 30 day safety follow-up visit must occur before the 
first dose of the new therapy.  

48 
 
  
 
 
 
7.1.2 Clinical Procedures/Assessments 
7.1.2.1 AE Monitoring 
The investigator or qualified designee will assess each subject to evaluate for potential new or 
worsening AEs as specified in the Trial Flow Chart and more frequently if clinically indicated.  
AEs will be graded and recorded throughout the trial and during the follow-up period according 
to the NCI CTCAE v4.03 (see Section 11.1). Toxicities will be characterized in terms of 
seriousness, causality, toxicity grading, and action taken with regard to the trial treatment.  
Please refer to section 7.2 for detailed information regarding the assessment and recording of 
AEs.   
7.1.2.2 Physical Exam 
The investigator or qualified designee will perform a complete physical exam at 
screening/baseline, before every cycle of L-NMMA and pembrolizumab, and at EOT.  
7.1.2.3 Vital Signs 
The investigator or qualified designee will take vital signs at each physical exam.  Vital signs 
should include temperature, pulse, respiratory rate, and blood pressure. Blood pressure will 
also be monitored during L-NMMA infusions as described in Section 5.2.1.2 − Dose 
Modification. Weight will also be measured at each physical exam.  Height will be measured 
at screening only.  
 
7.1.2.4 ECOG Performance Status 
 
ECOG performance status will be assessed at screening/baseline, before every cycle of L-
NMMA and pembrolizumab, and at EOT.  
 
7.1.2.5 Electrocardiogram/Multigated Acquisition Scan/Echocardiogram 
A 12-lead electrocardiogram will be performed at screening, before every cycle of L-NMMA 
and pembrolizumab, at EOT, and when clinically indicated. Multigated acquisition (MUGA) 
scan or echocardiogram (ECHO) will be performed at screening and when clinically indicated. 
The same method (MUGA scan or ECHO) must be used throughout the duration of the trial. 
7.1.2.6 Tumor Imaging and Disease Assessment  
Computed tomography (CT) scans of the chest, abdomen, and pelvis and/or other sites as 
appropriate (e.g., head and neck, upper extremities, lower extremities) will be performed at 
screening, after every 2 cycles of L-NMMA and pembrolizumab and/or at the discretion of the 
treating physician and 3 months after the last dose of trial treatment. Disease status will be 
assessed using the RECIST 1.1.  
 

49 
 
  
 
 
 
For subjects with previously treated stable brain metastases, brain CT or magnetic resonance 
imaging (MRI) will be performed at baseline and every 2 months (± 7 days) as per standard of 
care. 
 
7.1.2.6.1 RECIST 1.1 
 
The RECIST 1.1 will be used to assess treatment response. Only subjects with measurable 
disease will be entered into the study. Measurable disease is defined as tumor lesions that can 
be accurately measured in at least one dimension (longest diameter to be recorded) as  10 mm 
on CT, bone metastases with soft tissue masses measuring ≥ 10 mm on CT (CT scan slice 
thickness no greater than 5 mm), palpable masses measured as ≥ 10 mm with calipers, and 
clearly delineated lung lesions surrounded by lung parenchyma measured as ≥ 20 mm on chest 
radiographs. Non-measurable lesions include leptomeningeal disease, ascites, pleural or 
pericardial effusion, inflammatory breast disease, lymphangitic involvement of the skin or 
lung, and abdominal masses/abdominal organomegaly identified by physical exam that are not 
measurable by reproducible imaging techniques. All measurable lesions (up to 5 measurable 
lesions [2/organ]) representative of all involved organs should be identified as target lesions 
and recorded and measured at baseline. A sum of the longest diameter for all target lesions will 
be calculated and reported as the baseline sum longest diameter.  
• CR 
Disappearance of all target lesions.  
• PR 
At least a 30% decrease in the sum of the longest diameter of target lesions, using the baseline 
sum longest diameter as a reference. 
• Stable disease (SD)  
Neither sufficient shrinkage to qualify for PR nor sufficient increase to qualify for progressive 
disease (PD), using the smallest sum longest diameter since treatment start as a reference. 
• PD 
At least a ≥ 20% increase in the sum of the longest dimensions of the target lesions taking as a 
reference the smallest sum of the longest dimensions recorded since the treatment started, or 
the appearance of one or more new lesions. In addition to the relative increase of 20%, the sum 
must also demonstrate an absolute increase of at least 5 mm. 
• Clinical PD 
Subjects who in the opinion of the treating principal investigator have clinical evidence of PD 
may be classified as having PD. 
 
7.1.2.7 PK/Pharmacodynamics Assessment 
 
Blood samples for plasma PK and pharmacodynamics assessment will be collected predose 
(10-30 minutes before L-NMMA infusion) on Days 1, 2, and 5 of Cycles 1 and 2. One 5-mL 

50 
 
  
 
 
 
sample will be collected for PK assessment and one 5-mL sample will be collected for 
pharmacodynamics assessment. NOTE: For PK/pharmacodynamics assessment, subjects 
should be fasted (nothing to eat or drink except water) for 12 hours prior to each collection 
time point. Subjects should also keep a food diary the week before and the week of the L-
NMMA infusion during Cycles 1 and 2.  
 
7.1.2.8 Blood Sample Collection, Storage, and Use for Future Research 
 
Blood samples will be collected for future research at baseline, after Cycle 2 of L-NMMA and 
pembrolizumab, and 3 months after the last dose of trial treatment. Blood (20−30 cc) will be 
collected into standard vacutainer tubes and processed for plasma and viable cryopreserved 
peripheral blood mononuclear cells for future analyses. The samples will be stored at the 
Houston Methodist Research Institute Biorepository Core. 
 
7.1.3 Laboratory Procedures/Assessments 
 
7.1.3.1 Laboratory Tests 
 
Details regarding specific laboratory procedures/assessments to be performed in this trial are 
provided below. 
 
Laboratory Safety Evaluations (Hematology, Chemistry, and Urinalysis):  
Coagulation parameters (INR/PT/aPTT) will be tested at screening. Hepatitis panel and HIV 
testing will be performed at screening. Thyroid-stimulating hormone, free thyroxine, and total 
triiodothyronine testing and urinalysis (blood, glucose, protein, specific gravity) will be 
performed at baseline and when clinically indicated. A blood sample for complete blood count 
with platelet count and differential white blood cell count will be obtained at 
screening/baseline, before every cycle of L-NMMA and pembrolizumab, at EOT, and when 
clinically indicated. A blood sample for clinical chemistry panel (glucose, albumin, sodium, 
potassium, carbon dioxide, calcium, chloride, blood urea nitrogen, creatinine, total protein, 
total bilirubin, alkaline phosphatase, ALT, and AST) and evaluation of magnesium, uric acid, 
and lactate dehydrogenase will be obtained at screening/baseline, before every cycle of L-
NMMA and pembrolizumab, at EOT, and when clinically indicated. For subjects with cHL, 
sedimentation rate testing will be performed at baseline and Cycles 2, 4, and 6 of L-NMMA 
and pembrolizumab. For women of childbearing potential, the results of a serum -hCG 
pregnancy test must be negative at screening. If the screening serum -hCG pregnancy test is 
performed more than 7 days before the first dose of trial treatment, it must be repeated at 
baseline, with results known to be negative prior to the administration of the first treatment 
dose. -hCG pregnancy testing is to be repeated when clinically indicated. Laboratory tests 
may be done more frequently if medically indicated.  
 
Laboratory tests for hematology, chemistry, urinalysis, and others are specified in Table 7.   
 

51 
 
  
 
 
 
Table 7. Laboratory Tests 
Hematology 
Chemistry 
Urinalysis 
Other 
Hemoglobin 
Platelet count 
White blood cell 
count (total and 
differential) 
ANC 
Sedimentation rate* 
 
Albumin 
Alkaline phosphatase 
ALT 
AST 
Lactate dehydrogenase 
Carbon dioxide  
Creatinine 
Uric acid 
Calcium 
Chloride 
Glucose 
Potassium 
Sodium   
Magnesium 
Total bilirubin 
Total protein 
Blood urea nitrogen 
Blood 
Glucose 
Protein 
Specific gravity  
Microscopic exam (If 
abnormal results are 
noted) 
Serum β- hCG† 
PT  (INR) 
aPTT 
Total triiodothyronine  
Free thyroxine  
Thyroid-stimulating hormone  
Hepatitis panel 
HIV test 
  
  
  
  
  
  
†Perform on women of childbearing potential only.  
*Perform on subjects with classical Hodgkin lymphoma only. 
 
7.1.4 Continuation of Pembrolizumab Treatment 
Subjects without disease progression after 6 cycles of L-NMMA and pembrolizumab will 
continue pembrolizumab until disease progression or unacceptable AEs. CT scans of the chest, 
abdomen, and pelvis and/or other sites as appropriate (e.g., head and neck, upper extremities, 
lower extremities) will be performed every 3 cycles of pembrolizumab and/or at the discretion 
of the treating physician. For subjects with previously treated stable brain metastases, brain CT 
or MRI will be performed every 2 months (± 7 days) as per standard of care. Blood samples 
for CBC with platelet count and differential WBC count, clinical chemistry panel (glucose, 
albumin, sodium, potassium, carbon dioxide, calcium, chloride, BUN, creatinine, total protein, 
total bilirubin, alkaline phosphatase, ALT, and AST), and evaluation of magnesium, uric acid, 
and LDH will be obtained at every cycle of pembrolizumab. For subjects with cHL, 
sedimentation rate testing will be performed at every other cycle.  
7.1.5 Other Procedures 
7.1.5.1 Withdrawal/Discontinuation 
When a subject discontinues/withdraws prior to trial completion, all applicable activities 
scheduled for the final trial visit should be performed at the time of discontinuation. Any AEs 
which are present at the time of discontinuation/withdrawal should be followed in accordance 
with the safety requirements outlined in Section 7.2 ― Assessing and Recording Adverse 
Events.   

52 
 
  
 
 
 
7.1.5.2 Visit Requirements 
Visit requirements are outlined in Section 6.0 ― Trial Flow Chart. Specific procedure-related 
details are provided above in Section 7.0 ― Trial Procedures. 
7.1.5.2.1 Post-Treatment Visits 
7.1.5.2.1.1 Safety Follow-Up Visit 
The mandatory safety follow-up visit should be conducted approximately 30 days after the last 
dose of trial treatment or before the initiation of a new anticancer treatment, whichever comes 
first. All AEs that occur prior to the safety follow-up visit should be recorded.  Subjects with 
an AE of > Grade 1 will be followed until the resolution of the AE to Grade 0–1 or the 
beginning of a new antineoplastic therapy, whichever occurs first. SAEs that occur within 90 
days of EOT or before initiation of a new anticancer treatment should also be followed and 
recorded.   
 
7.1.5.2.1.2 Survival Follow-Up 
Patients who continue to receive pembrolizumab will be followed up for survival status 30 
days after the last dose of pembrolizumab. 
7.2 Assessing and Recording AEs 
An AE is defined as any untoward medical occurrence in a patient or clinical investigation 
subject administered a pharmaceutical product and which does not necessarily have to have a 
causal relationship with this treatment. An AE can, therefore, be any unfavorable and 
unintended sign (e.g., abnormal laboratory finding), symptom, or disease temporally 
associated with the use of a medicinal product or protocol-specified procedure, whether or not 
considered related to the medicinal product or protocol-specified procedure. Any worsening 
(i.e., any clinically significant adverse change in frequency and/or intensity) of a preexisting 
condition that is temporally associated with the trial treatment is also an AE. Progression of 
the cancer under study is not considered an AE.  
From the time of informed consent signing through 30 days following cessation of treatment, 
all AEs must be reported by the investigator. AE reporting will be performed according to 21 
CFR 312.32. AEs will be recorded at each examination on the Adverse Event CRFs. AEs 
(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 AE. 
Conditions that were already present at the time of informed consent should be recorded in the 
Medical History page of the subject’s CRF. The reporting timeframe for AEs meeting any 
serious criteria is described in section 7.2.3.1. The investigator will make every attempt to 
follow all subjects with non-SAEs for outcome. 
AEs will not be collected for subjects during the prescreening period as long as that subject 
has not undergone any protocol-specified procedure or intervention. If the subject requires a 

53 
 
  
 
 
 
blood draw, fresh tumor biopsy etc., the subject is first required to provide consent to the main 
study and AEs will be captured according to guidelines for standard AE reporting.  
The occurrence of AEs should be sought by non-directive questioning of the subject at each 
study visit. AEs may also be detected when they are volunteered by the subject during or 
between visits or through physical examination, laboratory test, or other assessments. As far 
as possible, each AE should be evaluated to determine: 
 
1. Severity grade (CTCAE Grade 1–4) 
2. Duration (start and end dates or if continuing at the safety follow-up visit) 
3. Relationship to the study treatment (reasonable possibility that AE is related: no, yes)  
4. Action taken with respect to trial treatment (none, dose adjusted, temporarily interrupted, 
permanently discontinued, hospitalized, unknown, not applicable) 
5. Whether medication or therapy was given (no concomitant medication/non-drug therapy, 
concomitant medication/non-drug therapy) 
6. Outcome (not recovered/not resolved, recovered/resolved, recovering/resolving, 
recovered/resolved with sequelae, fatal, unknown) 
7. Whether it is serious, where a SAE is defined as in Section 7.2.3.1. 
 
All AEs should be treated appropriately. Such treatment may include changes in trial treatment 
including possible interruption or discontinuation, starting or stopping concomitant treatments, 
changes in the frequency or nature of assessments, hospitalization, or any other medically 
required intervention. Once an AE is detected, it should be followed until its resolution, and 
assessment should be made at each visit (or more frequently, if necessary) of any changes in 
severity, the suspected relationship to the trial treatment, the interventions required to treat it, 
and the outcome.  
 
7.2.2 Reporting of Pregnancy and Lactation  
Although pregnancy and lactation are not considered AEs, it is the responsibility of 
investigators or their designees to report any pregnancy or lactation in a subject (spontaneously 
reported to them) that occurs during the trial. 
Pregnancies and lactations that occur from the time of informed consent signing through 120 
days following cessation of treatment or 30 days following cessation of treatment if the subject 
initiates new anticancer therapy, whichever is earlier, must be reported by the investigator. All 
reported pregnancies must be followed to the completion/termination of the pregnancy. 
Pregnancy outcomes of spontaneous abortion, missed abortion, benign hydatidiform mole, 
blighted ovum, fetal death, intrauterine death, miscarriage, and stillbirth must be reported as 
serious events (Important Medical Events). If the pregnancy continues to term, the outcome 
(health of infant) must also be reported. Such events must be reported within 24 hours to the 
Sponsor (hmccsaereports@houstonmethodist.org; FAX 713-790-5106). 
 

54 
 
  
 
 
 
7.2.3 Immediate Reporting of AEs  
7.2.3.1 SAEs 
A SAE is any untoward medical occurrence that at any dose: 
• Results in death; 
• Is life threatening; 
• Results in persistent or significant disability/incapacity; 
• Results in or prolongs an existing inpatient hospitalization, unless hospitalization is for: 
o routine treatment or monitoring of the studied indication and not associated 
with any deterioration in condition 
o elective or preplanned treatment for a preexisting condition that is unrelated to 
the indication under study and has not worsened since the start of trial treatment 
o treatment on an emergency outpatient basis for an event not fulfilling any of 
the definitions of a SAE given above and not resulting in hospital admission 
o social reasons and respite care in the absence of any deterioration in the 
subject’s general condition; 
• Is a congenital anomaly/birth defect; 
• Is another important medical event. This refers to an AE that may not result in death, 
be immediately life threatening, or require hospitalization, but may be considered 
serious when, based on appropriate medical judgment, may jeopardize the subject, 
require medical or surgical intervention to prevent one of the outcomes listed above, or 
involves suspected transmission via a medicinal product of an infectious agent.  
From the time of informed consent form signing through 90 days following cessation of 
treatment or 30 days following cessation of treatment if the subject initiates new anticancer 
therapy, whichever is earlier, any SAE or follow up to a SAE, including death due to any cause 
other than progression of the cancer under study, whether or not related to the trial treatment, 
must be reported within 24 hours to the Sponsor (hmccsaereports@houstonmethodist.org; 
FAX 713-790-5106). 
Additionally, any SAE considered by an investigator who is a qualified physician to be related 
to the trial treatment that is brought to the attention of the investigator at any time following 
consent through the end of the specified safety follow-up period specified in the paragraph 
above or at any time outside of the time period specified in the previous paragraph also must 
be reported immediately to the Sponsor. 
All subjects with SAEs must be followed up for outcome. 
8.0 STATISTICAL CONSIDERATIONS 
This is a Phase Ib trial investigating the use of L-NMMA in combination with pembrolizumab 
in subjects with melanoma, NSCLC, HNSCC, cHL, urothelial carcinoma, cervical cancer, 
esophageal cancer, gastric cancer, hepatocellular carcinoma, merkel cell carcinoma, primary 
mediastinal large B-cell lymphoma, renal cell carcinoma, small cell lung cancer, MSI-
H/dMMR cancer or  for the treatment of adult patients with unresectable or metastatic tumor 

55 
 
  
 
 
 
mutational burden-high (TMB-H) [≥10 mutations/megabase (mut/Mb)] solid tumors. The 
study is designed to determine the DLTs and MTD of the L-NMMA plus pembrolizumab 
combination.  DLT will be defined as any treatment-related death or any ≥ Grade 3 AE (NCI 
CTCAE v4.03) unless there is clear alternative evidence that the AE was not caused by the 
trial treatment. DLT will also include any AE during Cycle 1 that delays administration of 
Cycle 2 by more than 7 days: 
• Grade 4 neutropenia (ANC < 500/mm3) lasting ≥ 7 days 
• Grade 3 febrile neutropenia lasting > 24 hours (single temperature of > 38.3ºC or a 
sustained temperature of  > 38ºC for > 1 hour (non-axillary) with ANC < 1000/mm3) 
• Grade 4 febrile neutropenia of any duration 
• Grade 4 thrombocytopenia (platelets < 25,000/mm3) or Grade 3 thrombocytopenia with 
significant bleeding 
• Hematological toxicities can be managed for a period that will not exceed more than 7 
days. In the event that the hematological toxicity persists for more than the allowed 
time, it will be considered a DLT 
• Grade 3−4 elevation in ALT or AST associated with a Grade 2 elevation in bilirubin 
that is at least possibly related to study drug (Hy’s Law) 
• Any ≥ Grade 3 electrolyte abnormality considered clinically significant or which lasts 
≥ 72 hours 
• Grade 3 infusion-related reactions that recur despite appropriate medical management  
• Any other treatment-related ≥ Grade 3 non-hematological AE except hyperlipidemia 
in subjects not receiving maximum medical management or electrolyte abnormalities 
that may be managed with supplements 
 
The study will utilize the sequential CRM for two-dimensional dose finding method of Yuan 
and Yin,67 a method based entirely on a Bayesian decision framework. The trial is designed to 
investigate the combination at one dose level of pembrolizumab (200 mg IV Q3W) and 3 dose 
levels of L-NMMA (12.5, 15.0, and 20.0 mg/kg).  The starting dose will be pembrolizumab at 
200 mg IV Q3W and L-NMMA at 15.0 mg/kg.  The trial will be comprised of 12 subjects and 
will utilize a standard Bayesian model averaging CRM approach to determine the appropriate 
dose of L-NMMA. A cohort size of 2 will be used. 
The study was designed and will be conducted using Bayesian model averaging CRM software 
developed by the Biostatistics Department of the University of Texas M. D. Anderson Cancer 
Center (https://biostatistics.mdanderson.org/SoftwareDownload/).68,69 The software assumes 
the probability of toxicity at dose i (πi) is modeled as πi = pi×exp(α) where pi is a constant and 
α is distributed a priori as a normal random variable with mean 0 and variance 2. The software 
requires the investigator to specify the prior median probability of toxicity at each of the 3 
doses of L-NMMA under consideration (si, i = 1, 2, 3).  The CRM model assumes that toxicity 
is a monotonic increasing function with dose and thus, the si values may not decrease as i 
increases. The values pi in the probability model are selected so that E[pi×exp(α)] = si. After 
the first cohort, each successive cohort is given the dose whose posterior probability of toxicity 
given the data collected thus far is closest to the target toxicity (the software does not allow an 
untried dose to be skipped). Thus as information accumulates, the model is continually updated 
posteriorly and decisions are made on the posterior distribution. As a result, no data is lost and 

56 
 
  
 
 
 
there is the assurance that the decision to increase or decrease the dose level is consistently 
reassessed as more information becomes available. For a dose level to be chosen as the MTD, 
at least 6 subjects must have received said dose. 
Table 8. L-NMMA Dose Escalation  
Dose Level 
L-NMMA (mg/kg) 
-1 
12.5 
0 
15.0 
1 
20.0 
 
The target toxicity probability will be 0.25 to 0.30 and a maximum of 12 subjects will be 
treated. The first cohort of subjects will be treated at dose level 0. As an extra measure of 
safety, the trial will be stopped early if the lowest dose level is unacceptably toxic, formally if  


80
.0
|
25
.0
1



−
data
e
p
Pr

. 
The Bayesian model averaging CRM will be implemented using the following three toxicity 
probability sets: 1) (p-1, p0, p1) = (0.05, 0.10, 0.15); 2) (p-1, p0, p1) = (0.15, 0.275, 0.40); and 3) 
(p-1, p0, p1) = (0.40, 0.50, 0.60).  Operating characteristics of the design under five dose-toxicity 
scenarios are tabulated below.  
 
Table 9. Phase Ib Design Operating Characteristics (optimal decisions are given in 
boldface type) 
Scenario 
Study 
Parameter 
Dose Level 
None 
-1 
0 
1 
1 
Prob[toxicity] 
0.05 
0.10 
0.15 
0.03 
% Selected 
0.03 
0.18 
0.77 
# treated 
1.0 
3.3 
7.5 
2 
Prob[toxicity] 
0.10 
0.175 
0.25 
0.10 
% Selected 
0.13 
0.32 
0.46 
# treated 
2.1 
3.9 
5.2 

57 
 
  
 
 
 
3 
Prob[toxicity] 
0.15 
0.25 
0.35 
0.20 
% Selected 
0.24 
0.34 
0.22 
# treated 
2.9 
4.0 
3.5 
4 
Prob[toxicity] 
0.20 
0.30 
0.40 
0.29 
% Selected 
0.30 
0.27 
0.13 
# treated 
3.2 
3.8 
2.7 
5 
Prob[toxicity] 
0.40 
0.50 
0.60 
0.75 
% Selected 
0.17 
0.05 
0.01 
# treated 
2.8 
2.6 
0.8 
 
Under Scenario 5 in which all dose levels are too toxic, the estimated probability of finding no 
acceptable dose is 0.75 with the trial design choosing a dose with 40% toxicity 17% of the 
time.  Scenario 1 represents a setting in which none of the doses is too toxic. For this scenario, 
the design would chose the highest dose as the MTD 77% of the time. 
Data management. CRFs will be designed and utilized to capture all patient data. An 
electronic database will be designed to store patient CRFs. Data quality control will be 
performed regularly by the research coordinator to ensure timely, accurate, and complete 
patient data collection as well as protocol compliance. Queries will be generated and resolved 
prior to the generation of interim and final summary reports.    
9.0 ETHICAL CONSIDERATIONS 
Compliance with laws and regulations. This study will be conducted in full conformance 
with the International Conference on Harmonisation E6 guideline for Good Clinical Practice 
and the principles of the Declaration of Helsinki, or the laws and regulations of the country in 
which the research is conducted, whichever affords the greater protection to the individual. 
The study will comply with U.S. FDA regulations and applicable local, state, and federal laws. 
IRB. The protocol and informed consent form will be submitted to the IRB for review and 
approval. Approval of both the protocol and the consent form must be obtained before any 
participant is enrolled. Any amendment to the protocol will require review and approval by 
the IRB before the changes are implemented to the study. All changes to the consent form will 
be IRB approved; a determination will be made regarding whether previously consented 
participants need to be re-consented. 

58 
 
  
 
 
 
Informed Consent. The consent form will be IRB-approved and the participant will be asked 
to read and review the document. The investigator will explain the research study to the 
participant and answer any questions that may arise. All participants will receive a verbal 
explanation in terms suited to their comprehension of the purposes, procedures, and potential 
risks of the study and of their rights as research participants. Participants will have the 
opportunity to carefully review the written consent form and ask questions prior to signing. 
The participants should have the opportunity to discuss the study with their surrogates or think 
about it prior to agreeing to participate. The participant will sign the informed consent 
document prior to any procedures being done specifically for the study. The participants may 
withdraw consent at any time throughout the course of the trial. A copy of the informed 
consent document will be given to the participants for their records. The rights and welfare of 
the participants will be protected by emphasizing to them that the quality of their medical care 
will not be adversely affected if they decline to participate in this study. 
Confidentiality. The Sponsor maintains confidentiality standards by coding each patient 
enrolled in the study through assignment of a unique patient identification number. Patient 
medical information obtained by this study is confidential and may be disclosed to third parties 
only as permitted by the informed consent form signed by the patient, unless permitted or 
required by law. Data generated by this study must be available for inspection upon request by 
representatives of the U.S. FDA and other national and local health authorities, and the IRB. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

59 
 
  
 
 
 
 
 
 
 
 
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11.0 APPENDICES 
11.1 Common Terminology Criteria for Adverse Events v4.03 
The descriptions and grading scales found in the revised NCI CTCAE v4.03 will be utilized 
for AE reporting. (http://evs.nci.nih.gov/ftp1/CTCAE/About.html) 
11.2 RECIST 1.1  
RECIST version 1.1 will be used in this study for assessment of tumor response. While either 
CT or magnetic resonance imaging may be utilized, as per RECIST 1.1, CT is the preferred 
imaging technique in this trial. 
Eisenhauer, EA, et al. New response evaluation criteria in solid tumors: Revised RECIST 
guideline (version 1.1). Eur J Cancer 2009;45:228-47. 
11.3 ECOG Performance Status Scale 
Grade 
Description 
0 
Normal activity. Fully active, able to carry on all pre-disease 
performance without restriction. 
1 
Symptoms, but ambulatory. Restricted in physically strenuous 
activity, but ambulatory and able to carry out work of a light or 
sedentary nature (e.g., light housework, office work). 
2 
In bed <50% of the time. Ambulatory and capable of all self-care, but 
unable to carry out any work activities. Up and about more than 50% 
of waking hours. 
3 
In bed >50% of the time. Capable of only limited self-care, confined 
to bed or chair more than 50% of waking hours. 
4 
100% bedridden. Completely disabled. Cannot carry on any self-care. 
Totally confined to bed or chair. 
5 
Dead. 
Oken MM, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin 
Oncol 1982;5:649-55.  
 

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11.4 New York Heart Association Functional Classifications  
Class 
Description 
I 
Patients with cardiac disease but without resulting limitations of 
physical activity. Ordinary physical activity does not cause undue 
fatigue, palpitation, dyspnea, or anginal pain. 
II 
Patients with cardiac disease resulting in slight limitation of physical 
activity. They are comfortable at rest. Ordinary physical activity results 
in fatigue, palpitation, dyspnea, or anginal pain. 
III 
Patients with cardiac disease resulting in marked limitation of physical 
activity. They are comfortable at rest. Less than ordinary physical 
activity causes fatigue, palpitation, dyspnea, or anginal pain. 
IV 
Patients with cardiac disease resulting in inability to carry on physical 
activity without discomfort. Symptoms of cardiac insufficiency or of 
angina syndrome may be present at rest. If any physical activity is 
undertaken, discomfort is increased. 
 
11.5 Nitrate/Nitrite Drug Interactions 
Drug Class 
Medications 
Phosphodiesterase inhibitors 
sildenafil, tadalafil, vardenafil, avanafil 
Nitrates 
isosorbide dinitrate, isosorbide mononitrate, 
nitroglycerin,  
Nitrites 
amyl nitrite, sodium nitrite 
General anesthetics 
Nitrous oxide