A Phase I Study to Evaluate the Safety of Trigriluzole (FC-4157/BHV-4157) in Combination With PD-1 Blocking Antibodies
Phase: PHASE1
Conditions: Lymphoma, Metastatic Malignant Solid Neoplasm, Metastatic Melanoma, Metastatic Renal Cell Cancer, Recurrent Bladder Carcinoma, Recurrent Classical Hodgkin Lymphoma, Recurrent Head and Neck Squamous Cell Carcinoma, Recurrent Lymphoma, Recurrent Malignant Solid Neoplasm, Recurrent Renal Cell Carcinoma, Stage III Bladder Cancer, Stage III Lymphoma, Stage III Non-Small Cell Lung Cancer AJCC v7, Stage III Renal Cell Cancer, Stage III Skin Melanoma, Stage IIIA Non-Small Cell Lung Cancer AJCC v7, Stage IIIA Skin Melanoma, Stage IIIB Non-Small Cell Lung Cancer AJCC v7, Stage IIIB Skin Melanoma, Stage IIIC Skin Melanoma, Stage IV Bladder Cancer, Stage IV Lymphoma, Stage IV Non-Small Cell Lung Cancer AJCC v7, Stage IV Renal Cell Cancer, Stage IV Skin Melanoma, Stage IVA Bladder Cancer, Stage IVB Bladder Cancer, Unresectable Head and Neck Squamous Cell Carcinoma, Unresectable Solid Neoplasm
Sponsor: Rutgers, The State University of New Jersey

 
 
Official Title: 
A Phase I Study to Evaluate the Safety of Trigriluzole (FC-
4157/BHV-4157) in Combination with PD-1 Blocking 
Antibodies 
NCT number: 
NCT03229278 
Document Type:  
Protocol and Statistical Analysis Plan 
Date of the 
Document: 
10/04/2019 
 

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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STUDY INFORMATION
Title of Project: 
A Phase I Study to Evaluate the Safety of Trigriluzole (FC-4157/BHV-4157) in Combination with 
PD-1 Blocking Antibodies
Principal Investigator:
Name: Jyoti Malhotra, MD
Division & Department: Medical Oncology
Contact Information: Rutgers Cancer Institute of New Jersey
195 Little Albany Street
New Brunswick, NJ 08903
Telephone: (732) 235-7521   FAX: (732) 235-8808
Email: jyoti.malhotra@rutgers.edu
VERSION NUMBER: 
#8       Version Date:  12/4/18
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Table of Contents 
Skip To Section: Hold CTRL + Click (Below) To Follow Link in Blue
Research Introduction
4
Purpose/Specific Aims
4
Research Significance
5
Research Design and Methods
6
Preliminary Data
10
Sample Size Justification
21
Study Variables
21
Drugs/Devices/Biologics
21
Primary Specimen Collection
43
Interviews, Focus Groups, or Surveys
44
Timetable/Schedule of Events
46
Project Management
52
Research Staff and Qualifications
52
Resources Available
52
Research Sites
52
Multi-Site Research Communication & Coordination
52
Outside Research
52
Research Data Source/s
52
Primary Data – Subjects and Specimens
52
Subject Selection and Enrollment Considerations
52
Subject Randomization
55
Secondary Subjects
55
Number of Subjects
55
Consent Procedures
56
Special Consent Populations
57
Economic Burden and/or Compensation
58
Risks to Subjects
59
Secondary Data – Record/Chart Reviews, Databases, Tissue Banks, Etc.
65
Chart/Record Review Selection
65
Secondary Specimen Collection
65
Special Considerations
65
Health Insurance Portability and Accountability Act (HIPAA)
65
Family Educational Rights and Privacy Act (FERPA)
65
NJ Access to Medical Research Act
65
Code of Federal Regulations Title 45 Part 46 (Vulnerable Populations)
65
Research Data Protection and Reporting
65
Data Management and Confidentiality
72
Data Security
72
Data Safety And Monitoring
73
Reporting Results
75
Data and/or Specimen Banking
75
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Other Approvals/Authorizations
75
Bibliography
76
Appendix A
80
Appendix B
81
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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1.0 Research Introduction
1.1 Purpose/Specific Aims
1.1.1 Objectives: 
Primary Objectives

The primary objective of this study is to determine the safety of trigriluzole in 
combination with PD-1 inhibiting antibodies, and to define a maximum 
tolerated dose (MTD) of trigriluzole in combination therapy. 
Secondary Objectives

To characterize the efficacy of the combination therapy.

To identify markers of response to trigriluzole in the tumor microenvironment.
1.1.2 Hypotheses: 
Primary Hypotheses

Combination treatment with trigriluzole + PD-1 inhibitor will have a tolerable 
adverse event profile.
Secondary Hypothesis/Hypotheses

The combination therapy will induce tumor regression.

Features in the tumor microenvironment (TME) may predict response to 
therapy. 
1.1.3 Endpoints:
Primary Endpoint

The primary endpoint is the MTD/RP2D. Data on the adverse event type, 
severity and frequency will be recorded.
Secondary Endpoints

objective response rate (ORR)

adverse event type, severity and frequency 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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
survival time (OS), landmark survival rates at 1 and 2 years 

duration of response for responding patients

time to progressive disease (PFS)

time to treatment failure 

time to next therapy or death (TTNTD)

freedom from new metastases 
Correlative science endpoints: changes in the tumor microenvironment and 
peripheral blood in the following categories: 
o
TILs and PD-L1 expression
o
Immune cell phenotypes and gene expression
o
Angiogenesis markers
o
Metabolic effector molecules
o
Exosomal formation
1.2 Research Significance
GRM1 is a metabotropic glutamate receptor, which is expressed on 60-80% of melanomas and 
numerous other cancer types1,2.  GRM1 signal transduction results in a number of downstream 
effects mainly through activation of the MAPK and PI3k/AKT pathways1,2.  These effects include 
increased tumor growth, increased tumor angiogenesis, increase in tumor-derived exosome 
production, and decreased tumor apoptosis3-6. We have confirmed these findings using 
specimens from patients with advanced melanoma who participated on clinical trials using the 
GRM1-blocking agent riluzole7.  
Recently, we found that another effect of GRM1 signal transduction is suppression of tumor in 
the microenvironment. GRM1 signal transduction increases the expression of CCL4 and M-CSF 
in the tumor microenvironment in vivo, an effect that is likely mediated through tumor-derived 
exosome biogenesis and release6,8. Conversely, inhibiting GRM1 signal transduction results in a 
decrease in the numbers of M2-type (suppressive) tumor-associated macrophages (TAMs), 
myeloid-derived suppressor cells (MDSCs) and regulatory T cells (T regs), and an increase in the 
numbers of tumor-infiltrating lymphocytes (TILs). 
Response to immune checkpoint agents is more frequent in patients with tumors containing 
TILs and other markers of a so-called “hot” tumor. Agents such as riluzole or its pro-drug 
trigriluzole could therefore be used to convert a “cold” tumor into a “hot” tumor, priming the 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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tumor to respond to anti-PD-1 immune checkpoint antibodies. The primary objective of this 
study is therefore to determine the safety of trigriluzole in combination with PD-1 inhibiting 
antibodies, and to define a MTD of this agent in combination with PD-1 inhibiting antibodies for 
use in future combinatorial studies.
1.3 Research Design and Methods 
All visits are relative to the treatment start date, Day -14. If a treatment visit is delayed, 
the next visit will still occur on time relative to the initial start date (e.g. If Week 3 occurs 
7 days late, Week 5 will still occur at Week 5). 
1.3.1 Overview 
In the first portion of this study, cohorts of subjects will be treated with increasing doses 
of trigriluzole in combination with nivolumab. After the MTD of trigriluzole is identified, 
it will be tested in combination with pembrolizumab. The MTD of trigriluzole with 
nivolumab is likely to be safe and tolerable with pembrolizumab. The sequential design 
is justified because nivolumab and pembrolizumab are both PD-1-blocking antibodies 
and there are no discernible differences in the safety profiles. Thus, the data obtained 
from the pembrolizumab group are not independent of the data in the nivolumab 
treatment group. The sequential design limits the size and the cost of the trial. 
1.3.2 Duration of Study
Subjects will remain on the active treatment phase of the study until confirmed disease 
progression, unacceptable toxicity, or withdrawal of consent, up to a maximum 
treatment duration of 109 weeks. The entire study is expected to take 2 years to 
complete. Patients who have derived clinical benefit from study treatment may have 
access to trigriluzole through a separate continuation trial (rollover trial).
1.3.3 Screening period/Baseline
Screening evaluations must be performed no more than 28 days prior to registration. 
The subject must begin study treatment no more than 14 days after registration. 
Baseline research blood and tumor samples may be performed anytime prior to the 
start of therapy. Ideally, the research blood samples should be collected 3-14 days prior 
to the tumor biopsy, but it is also acceptable to collect them on the same day.
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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1.3.4 Active phase, lead-in period
During the 14-day lead-in period, subjects will take trigriluzole monotherapy. The 14-day 
period is: Week -2 and Week -1. 
1.3.5 Active phase, combination treatment 
After Week 2, regular study visits will occur in the outpatient clinic at an interval of 14 or 
21 days (depending on whether treatment includes nivolumab or pembrolizumab) as 
per the Study Calendar. 
Subjects will receive treatment up to 109 weeks.  Subjects may elect to discontinue 
therapy at any time for any reason. Subjects will remain on the active treatment phase 
of the study until confirmed disease progression, unacceptable toxicity, or withdrawal of 
consent, up to a maximum treatment duration of 109 weeks. Once the subject 
discontinues active treatment, the subject will enter the follow-up phase. 
1.3.6 Off treatment procedures (up to 1 year)
If a subject has discontinued active treatment due to reasons other than PD, the subject 
will continue to have toxicity assessments (H&P and bloodwork) and tumor assessments 
(CT scans, etc.) Q12 weeks (window can be widened to ± 28 days) for up to 1 year from 
the start of treatment.  
Subjects should be strongly encouraged to adhere to in-person toxicity assessments and 
tumor assessments per protocol for the 1-year active phase of the protocol. However, 
subjects who are unable or unwilling adhere to in-person assessments (but do not 
withdraw consent to be followed) should be contacted Q12 weeks to assess for adverse 
events. Safety labs and tumor assessments should be obtained at outside facilities if 
possible. This practice is allowable because it is preferable over removal of the patient 
from study entirely, and it will not be considered to be a protocol deviation. 
If cancer return/progression is observed within the 1-year treatment period (in the 
opinion of the treating investigator, no strict criteria) and the risk/benefit ratio of 
restarting study therapy (combination therapy or trigriluzole monotherapy) is 
acceptable to the treating investigator, the patient may be restarted on therapy with 
the approval of the PI for up to 12 additional months. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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1.3.7 Long term Follow-up phase
Subjects will remain in the follow-up phase of the trial for up to 3 years until start of 
another therapy, withdrawal of consent, or death. Subjects or their caretakers will be 
contacted by a member of the study team every 12 weeks (± 28 days) to collect post-
study survival status (alive or deceased) and receipt of subsequent anticancer therapy 
(yes or no). If available, start date and type of subsequent anticancer therapy should be 
documented in the medical record or research shadow chart.  Any method of data 
collection is acceptable for long-term follow-up (medical records, phone, electronic 
means, social security death index website, etc.) The source of the information should 
be noted in the medical record or research shadow chart. 
1.3.8 Study Population
Inclusion of Women and Minorities
Both men and women and members of all ethnic groups are eligible for this trial. No 
special recruitment will be performed based on gender or minority status.
Contraception for Men and Women of child-bearing potential (WOCBP)
Women of child-bearing potential (WOCBP) are defined as women who have the 
potential to become pregnant. Peri-menopausal women are considered WOCBP and 
must use effective contraception. Women who are menopausal (defined as no menses 
in >1 year) are excluded. WOCBP must have a negative serum pregnancy test prior to 
the first dose. During study treatment, pregnancy testing may be performed as 
indicated at the treating physician’s discretion.  WOCBP may opt out of pregnancy 
testing if they provide an acceptable reason with their treating provider (such as 100% 
abstinence from heterosexual intercourse).
WOCBP and men must agree to use effective contraception during the study 
participation, and for 5 months after the last dose of the drug.  Effective contraception 
options include: 100% abstinence from heterosexual intercourse, surgical (tubal 
sterilization or partner’s vasectomy), intrauterine device, and combination hormonal 
contraceptives including birth control pills, skin patches, shots, under-the-skin implants, 
or vaginal rings. Barrier methods of birth control such as condoms are not adequate as 
primary method of contraception, but may be used as a secondary method. 
Should a woman become pregnant or suspect she is pregnant while she or her partner is 
participating in this study, she should inform her treating physician immediately.
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Participation of Children
Children under the age of 18 will be excluded from this study. trigriluzole and 
pembrolizumab have not been adequately tested in children and the impact on fertility 
and learning disabilities are not known.  
Sources or Methods of Recruitment
Patients with advanced unresectable or metastatic cancer will be recruited from the 
surgical oncology and medical oncology clinics at the RCINJ or satellite site. The treating 
physician will determine if the patient is a potential candidate for the study and discuss 
the protocol with the patient. The patient will also meet with the research nurse 
clinician to review each page of the informed consent document. 
Investigators may contact referring doctors to tell them about the study by phone or 
email. Patients will not be recruited directly, as the information about the study will be 
shared with them through their treating physician. The study team will contact the 
patient only after the treating physician has determined that the patient is interested in 
learning more about the study.
Patients may also learn of the study through websites such as clinicaltrials.gov and 
cancer patient chatrooms and blogs. No patient recruiting materials will be posted by 
the study team members without IRB approval.
No payment will be offered to recruit subjects. Patients may be reimbursed if funds are 
available for expenses such as parking and hotel rooms. 
Study Enrollment Procedures 
A copy of the institution’s IRB-approved informed consent document and written 
justification for any changes made to the informed consent for this protocol must be on 
file at the Cancer Institute of New Jersey’s Office of Human Research Services (OHRS) 
before any participating institution may enter patients.  
To register eligible patients on this study, each site will contact the Cancer Institute of 
New Jersey’s OHRS Registration Desk (732) 235-8990 and fax (732) 235-9399 the signed 
and dated eligibility checklist, completed signature page of the consent form and 
additional source documents if requested by OHRS. Once the OHRS Registration Desk 
verifies eligibility, a unique patient study number will be issued.  The patient will not be 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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identified by name.  This is the point that the patient is considered on study.  Patients 
must not start protocol treatment prior to registration. 
1.4 Background and Preliminary Data
1.4.1 Glutamate Signaling in Cancer
The glutamatergic system plays a key role in tumor biology. The metabotropic glutamate 
receptors mediate angiogenesis and cell proliferation, thus promoting cancer progression. 
The growth inhibition of various human tumors including melanoma, colon 
adenocarcinomas, breast cancers, gliomas, and non-small cell lung cancers by specific 
antagonists to ionotropic glutamate receptors has been reported. 
Metabotropic glutamate receptors (GRM) are members of the seven-transmembrane 
domain G-protein-coupled receptor (GPCR) family.  GRMs bind glutamate as their natural 
ligand and are divided into three groups based on sequence homology, agonist selectivity, 
and effector coupling. Metabotropic glutamate receptor 1 (GRM1) and GRM5 comprise 
Group I and are mainly involved in excitatory responses induced by strong presynaptic 
stimulation. Group I GRMs are coupled to a Getabot protein and stimulate phospholipase C 
beta (PLCβ9-11.  Ectopic expression or constitutive activation of a variety of different GPCRs 
has been implicated in neoplastic transformation including the FSH receptor in ovarian 
cancer, CCK2 receptor in colorectal cancer 14, and the neuromedin B receptor in small-cell 
lung cancer12,13. GRM1 activation results in activation of PLCβ diacylglycerol (DAG). DAG 
activates protein kinase C (PKC) that in turn can activate the MAPK and PI3K/AKT 
pathways1,10. PKC plays a key role in a multitude of cellular processes including apoptosis, 
malignant transformation, and metastasis. Activation of the MAPK pathway also appears 
important for cell migration and cancer cell invasiveness and PI3K/AKT pathway activation 
appears important for tumor cell survival, epithelial-mesenchymal transition (EMT), and 
angiogenesis14.
The majority of human melanomas (>60%) express the GRM11,2. Western blot examination 
of over 175 different human melanoma samples representing all phases of progression 
demonstrated that 68% expressed GRM11-3.  A tissue microarray made up of melanoma 
samples from 100 individual patients with advanced disease was stained with anti-hGRM1 
antibodies and 80% were found to express GRM1.  Skin and melanocytes from these same 
patients fail to express this receptor.  Eighteen of 20 melanoma cell lines tested express 
GRM1 and stimulation of this receptor resulted in activation of the MAPK and PI3K/AKT 
pathways as evidenced by the upregulation of the activated forms of AKT and ERK.  GRM1 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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has been deemed both necessary and sufficient for melanocyte transformation9. 
Metabotropic glutamate receptor 1 (GRM1) has been implicated in melanomagenesis and 
has become a new promising target for melanoma therapy4,7,15.
In addition to cancer, glutamate abnormalities have been implicated in the pathophysiology 
of a number of disorders including Amyotropic Lateral Sclerosis (ALS), spinocerebellar ataxia 
(SCA), Alzheimer’s disease, Rett syndrome, dementia, tinnitus, anxiety, depression, and 
pain. Glutamate is the natural ligand for glutamate receptors, but a large number of 
agonists and antagonists of these receptors have been developed. Riluzole (RILUTEK) is an 
FDA-approved agent used to treat ALS, or Lou Gehrig's disease. Riluzole depletes glutamate 
by the inhibition of its release16. The exact mechanism of action of riluzole is not known, but 
it is a potent inhibitor of glutamate release from neurons, likely disrupting the autocrine loops 
responsible for the excitotoxicity thought to be the cause of ALS.
1.4.2 BHV-4157, a Pro-drug of Riluzole
Prodrug Development
Biohaven Pharmaceuticals Holding Company Limited [Biohaven] is developing a new 
glutamate modulating drug, trigriluzole (BHV-4157), as a potential therapy for the 
treatment of neurodegenerative, neuropsychiatric and other disorders associated with 
glutamate dysfunction. Trigriluzole is a novel tripeptide prodrug of the glutamate 
modulating agent riluzole. 
Trigriluzole was designed for improved bioavailability, optimized pharmacokinetics and 
broad dosing options. Riluzole tablets have 60% bioavailabilty, attributed to high first-
pass metabolism in the liver. This is thought to be related to metabolism by the 
heterogeneously expressed CYP1A2 enzyme, which is also attributable to the high PK 
variability associated with riluzole17-19. In addition, riluzole is associated with reduced 
exposure when taken with meals (i.e., a negative food effect), resulting in the guidance 
to take riluzole within a three hour fast (one hour before or two hours after a meal). 
Riluzole is also dosed twice a day, has dose-dependent effects on liver function tests and 
the drug substance itself has other intrinsic limitations including: very low solubility in 
water, poor oral palatability, pH dependent chemical stability and intense oral 
numbness if administered directly to the oral mucosa. 
In an effort to mitigate the aforementioned limitations of riluzole, several classes of 
prodrugs were designed, synthesized, and evaluated in multiple in vitro stability assays 
to predict in vivo drug levels20. Trigriluzole is a third generation of prodrug development 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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representing multiple years of chemistry effort with optimized in vivo and in vitro 
features based on stability while transiting the digestive system, enhanced 
gastrointestinal absorption, avoidance of first pass metabolism, favorable safety 
pharmacology, metabolic cleavage in the plasma, enhanced pharmacokinetic properties 
and good oral palatability. 
Trigriluzole offers an optimized pro-drug approach to exploit the active moiety, riluzole, 
with potentially better oral bioavailability, enhanced safety and tolerability profile, 
reduced PK variance, and once-daily administration without regards to meals. 
Clinical Safety Summary
Trigriluzole: Study BHV4157-101 is a phase 1 randomized, double-blind, placebo-
controlled study to evaluate the safety, tolerability and pharmacokinetics of single and 
multiple ascending doses of trigriluzole in normal healthy volunteers. In this study, the 
initial safety and tolerability of trigriluzole at single doses ranging from 9.5 mg to 200 mg 
and multiple doses ranging from 35 mg to 200 mg were assessed. Approximately 58 
healthy volunteers have been dosed with trigriluzole and 20 have been dosed with 
placebo. Dosing of all cohorts has completed.  Based on preliminary data, both single 
and multiple doses up to 200 mg have been well tolerated without evidence of novel, 
clinically significant safety signals or lab abnormalities. There is no apparent dose 
response regarding the frequency or severity of AEs.  In the blinded group, including 
subjects treated with both placebo and trigriluzole, the most common AEs were 
headache (five subjects, two with moderate severity and three with mild severity) and 
constipation (two subjects). No pattern of AEs or lab abnormalities has become 
apparent to provide specific cautions or to suggest cautions beyond what is appropriate 
for the active metabolite, riluzole. Based on this Phase 1 experience, the maker of 
trigriluzole, Biohaven, has advanced trigriluzole into an ongoing  Phase 2/3, double-blind 
placebo controlled trial of trigriluzole in 120 subjects with spinocerebellar ataxia, dosed 
with 140 trigriluzole mg daily.
Riluzole: The clinical experience of riluzole is relevant given the intention of dosing 
trigriluzole to yield riluzole exposures within the range already well described for 
riluzole. Riluzole is approved for treatment in ALS and US Prescribing Information 
reflects data from placebo-controlled trials and long-term follow-up. Riluzole doses of 
up to 200 mg per day were considered well-tolerated and studied in randomized 
controlled trials. Among all chronic randomized controlled trials the discontinuation rate 
due to AEs was approximately 14%. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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No AEs occurred greater than 5% in the riluzole group and twice that of placebo. The 
AEs occurring greater than 5% and at least 2% more than placebo included asthenia 
(18% vs. 12% placebo) and nausea (14% vs. 9%).
The most commonly observed AEs associated with the use of riluzole tablets more 
frequently than placebo treated patients were: asthenia nausea; dizziness; decreased 
lung function diarrhea; abdominal pain; pneumonia vomiting; vertigo; circumoral 
paresthesia; anorexia; and somnolence. 
Rare cases of neutropenia (3 out of 4000 subjects in USPI) and interstitial lung disease 
have been reported rarely. 
Phase 1 studies of riluzole safety explored much higher doses21. Twelve subjects each 
were administered single oral doses of 150mg, 200 mg, 250 mg and/or 300 mg. At doses 
of 250 mg and 300 mg, riluzole administration was associated with dose-dependent 
dizziness/vertigo and buccofacial or manual paresthesia. 
Lab abnormalities associated with riluzole consist of elevated transaminases that 
typically are below 5x upper limit of normal (ULN) and often resolve while on treatment. 
Experience with incidents of alanine aminotransferase (ALT) increasing >5xULN are 
limited, insofar as the USPI recommends immediate drug discontinuation. Effects on 
transaminases show a dose response22. Importantly, total daily doses of 50 mg were not 
associated with increased rates of marked ALT elevations (>5xULN) compared to 
placebo (1.3% vs. 2.1%, respectively) and such occurrences had a later onset than 
placebo (median 254 vs. 219 days). Total daily doses of 100 mg and 200 mg had greater 
rates of marked ALT elevations than placebo, and the median occurrence was within 60 
days. Trigriluzole is anticipated to have lesser effects on LFTs, as lower molar doses of 
trigriluzole will be expected to yield the riluzole exposures achieved with oral RILUTEK – 
by virtue of bypassing first-pass metabolism. In addition, peak liver concentrations are 
expected to be reduced via use of trigriluzole as compared to riluzole, which may reduce 
propensity for LFT changes. 
1.4.3 Trigriluzole Preliminary PK Data
Study BHV4157-101 is a phase 1 randomized, double-blind, placebo-controlled study to 
evaluate the safety, tolerability, and pharmacokinetics of single and multiple ascending 
doses of trigriluzole in normal healthy volunteers.  Based on this study, the Phase 2/3 dose 
of trigriluzole was determined to be 140 mg daily.  A Clinical Study Report (CSR) is not yet 
complete for this trial; PK from this study is presented below. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
14
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The study design consisted of the administration of single doses of trigriluzole (sequential 
cohorts with 17.5, 35, 70, 140 and 200 mg, with the last cohort undergoing repeat dosing 
under conditions of a high-fat meal) and 5 days of multiple dose (sequential cohorts 
administered doses of 17.5, 35, 70, and 100 mg BID followed by 200 mg qD).  To date of this 
writing, preliminary results are available (single doses up to 200 mg fasted and fed; multiple 
doses of 100 mg BID mg daily).  Overall, single doses up to 200 mg and multiple doses up to 
200 mg daily have been well tolerated without evidence of novel, clinically significant safety 
signals or lab abnormalities. In addition, PK suggests minimal accumulation with daily 
dosing. 
Under single dose fasting conditions, riluzole concentrations at 24 hours after dosing 
average under 5% of peak concentrations. PK appears linear.  No food effect was observed 
based on AUC; however, Cmax concentrations were reduced for both trigriluzole and 
riluzole.  A single dose of 140 mg trigriluzole yields exposures (e.g., AUCinf 1,014.7 ng*h/mL) 
that are expected to be similar to that achieved in clinical trials using riluzole tablets at 50 
mg BID (e.g., approximately 1254 ng*h/mL, based on Chandu et al 2010), a dose which was 
previously studied in ataxia (Romano et al 2015; Ristori et al 2010).  
Performance in healthy volunteers has been similar to what has been observed in preclinical 
species, insofar as the concentrations of trigriluzole have been negligible compared to 
active metabolite and time to peak concentration of the active metabolite have been 
delayed. That is, the AUC of the active metabolite riluzole is shown to be over 350-fold 
greater than trigriluzole 
Table 1).
In addition, the time to peak concentration of the active metabolite (Tmax) is delayed 
compared to trigriluzole and longer than seen with Rilutek tablets (Chandu 2010).  This PK 
pattern of delayed time to peak riluzole concentration is consistent with diminished first 
pass liver metabolism.   Inspection of multiple dose PK does not suggest substantial 
accumulation of trigriluzole or its metabolite (Table 2). 
Table 1. Preliminary PK results, Study BHV4157-101:  Single Dose Phase
Dose of BHV-4157
17.5 mg
35 mg
70 mg
140 mg
200 mg
200 mg 
FED State#
n
6
5
5
6
6
6
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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PK attributes of BHV-4157
Cmax (ng/mL) 
[CV%]*
…
0.360 
[29.1%]
1.81
[46.7%]
2.92
[42.9%]
3.78
[123.8%]
0.79
[65.8%]
Tmax (h) 
[range]
…
0.6 
[0.33-0.67]
0.38
[0.2 – 0.57]
0.67
[0.33-0.67]
0.44
[0.28-0.69]
1.58
[0.67-2.5]
AUCinf (ng*h/mL) 
[CV%]*
…
…
1.50
[132%]
2.61
[42.5%]
4.49
[114.3%]
3.19
[74.6%]
PK attributes of active metabolite (riluzole)
Cmax (ng/mL) 
[CV%]*
24.9 
[23.8%]
44.1
[26.3%]
107.7
[20%]
210.2
[37.0%]
307.3
[55.4%]
191.2
[50.0%]
Tmax (h) 
[range]
1.67 
[1.33 – 3.0]
2.03
[1.33-3.0]
2.07
[1.33 – 3.0]
1.53
[1.0-2.5]
2.64
[1.67-4.0]
2.83
[2.0-6.0]
AUCinf (ng*h/mL) 
[CV%]*
119.2
[37.6%]
294.5
[73%]
583.8
[30.3%]
1,014.7
[33.9%]
1,770
[47.0%]
1,595
[38.0%]
*, geometric mean
#, 200 mg dose administered in crossover manner to one cohort. Ratio of AUC(inf) for fed over fasted 
conditions was 90.1% for riluzole and 71% for BHV-4157. 
n/a, not available
(…) Due to small sample size or limited quantifiable values some parameters were not calculated
Pro20170000453
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           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Table 2. Preliminary PK results, Study BHV4157-101:  Multiple Dose Phase
Dose of BHV-4157
17.5 mg BID
35 mg 
BID
70 mg 
BID
100 mg 
BID
200 mg 
qD
n
6
6
6
6
6
BHV-4157, Day 1
Cmax (ng/mL) 
[CV%]*
…
…
0.95
[43.9%]
2.86
[31.6%]
n/a
Tmax (h) 
[range]
…
…
0.67
[0.33-1.33]
0.75
[0.67-1.0]
n/a
BHV-4157, Day 5
Cmax (ng/mL) 
[CV%]*
…
…
1.13
[56.8%]
2.73
[70.7%]
n/a
Tmax (h) 
[range]
…
…
0.89
[1.0 – 1.33]
0.72
[0.33-1.33]
n/a
AUC 0-24 (ng*h/mL) 
[CV%]*
…
…
0.90
[39.3%]
2.42
[138.2%]
n/a
Riluzole, Day 1
Cmax (ng/mL) 
[CV%]*
18.8
[38.9%]
44.5
[32.0%]
122.9
[48.2%]
138.1
[29.4%]
n/a
Tmax (h) 
[range]
1.45
[1.0-1.67]
1.44
[0.67-2.0]
1.33
[1.0-1.67]
1.72
[0.67-2.5]
n/a
Riluzole, Day 5
Cmax (ng/mL) 
[CV%]*
24.5
[39.2%]
55.6
[38.2%]
115.9
[37.7%]
153.4
[28.8%]
n/a
Tmax (h) 
[range]
1.67
[1.0 – 3.0]
1.31
[0.67-2.5]
1.58
[1.0-2.5]
1.67
[1.0-4.0]
n/a
AUC 0-24 (ng*h/mL) 
[CV%]*
129.2
[65.2%]
298.1
[32.6%]
717.9
[40.4%]
962.3
[20.5%]
n/a
*, geometric mean
#, 200 mg dose administered in crossover manner to one cohort. Ratio of AUC(inf) for fed over fasted 
conditions was 90.1% for riluzole and 71% for BHV-4157. 
n/a, not available
(…) Due to small sample size or limited quantifiable values some parameters were not calculated
1.4.4 Potential for Drug-Drug Interactions
Clinical drug interaction studies for trigriluzole have not been conducted yet. Trigriluzole, 
itself, is not expected to interfere with drug metabolism and its cleavage via plasma 
peptidases render it unlikely to be affected significantly by liver cytochrome P450 inhibitors. 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Trigriluzole is not an inhibitor of CYP3A4, CYP1A2, or CYP2D6. In CYP induction studies, the 
estimated EC50 and Emax for CYP1A2 mRNA was 1.44 μM and 3.47-fold induction, 
respectively. The estimated EC50 and Emax for CYP2B6 mRNA was 12.6 μM and 27.0-fold 
induction, respectively. Trigriluzole did not increase CYP3A4 mRNA at doses up to 30 μM.
The active metabolite, riluzole, is metabolized by CYP1A2. Subjects should be strongly 
discouraged from using potent CYP1A2 inhibitors and inducers that could affect the 
metabolism of trigriluzole. Further guidance is listed in the section “Concomitant 
Medications.”
1.4.5 Potential Risk to Fetal Development. 
Trigriluzole has not yet been assessed in fertility and fetal development studies. Riluzole has 
been assessed previously and has been characterized as a Category C drug. As described in 
the USPI, oral administration of riluzole to pregnant animals during the period of 
organogenesis caused embryotoxicity in rats and rabbits at doses of 27 mg/kg and 60 
mg/kg, respectively, or 2.6 and 11.5 times, respectively, the recommended maximum 
human daily dose on a mg/m2 basis. Evidence of maternal toxicity was also observed at 
these doses. When administered to rats prior to and during mating (males and females) and 
throughout gestation and lactation (females), riluzole produced adverse effects on 
pregnancy (decreased implantations, increased intrauterine death) and offspring viability 
and growth at an oral dose of 15 mg/kg or 1.5 times the maximum daily dose on a mg/m2 
basis. There are no adequate and well-controlled studies in pregnant women. Riluzole 
should be used during pregnancy only if the potential benefit justifies the potential risk to 
the fetus.
1.4.6 Pharmacokinetics and Dose Selection Rationale
Clinical pharmacokinetics is pending and will be available via an amendment to the IB. The 
starting dose of 140 mg of trigriluzole is the molar equivalent of 70 mg riluzole, which is 
below the well-tolerated riluzole dose of 100 mg per day that has been administered 
chronically to patients with ALS and SCA. This dose of trigriluzole is selected to provide 
riluzole exposure that is comparable to that achieved in the two positive randomized 
controlled trials of riluzole in SCA.
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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1.4.7 Immune Checkpoint Inhibitor Therapy 
Pembrolizumab and nivolumab are antibodies that target the immune checkpoint inhibitor 
programmed death-1 (PD-1). These agents have been used in the clinic since 2014. PD-1 and 
PD-L1 blocking antibodies have achieved regulatory approval in melanoma, renal cell 
carcinoma, non-small cell lung cancer, Hodgkin’s lymphoma, head and neck squamous cell 
carcinoma, and urothelial cancers. In addition, recent studies and reports demonstrate 
activity in Merkel cell carcinoma, as well as microsatellite-instable colorectal cancer, and 
other gastrointestinal and endometrial cancers associated with Lynch syndrome or 
Hereditary Non-polyposis Colorectal Cancer (HNPCC). Defects in DNA damage repair genes 
such as POLE23 and tumor mutation burden24,25 are emerging as predictive markers of 
response to checkpoint blockade. There are a great deal of trials currently investigating the 
use of checkpoint inhibiting antibodies in a variety of cancers, and the use of PD-1 inhibitors 
is rapidly expanding in clinical care. 
Nivolumab has demonstrated activity in multiple tumor types at a dose of 3mg/kg IV every 
two weeks or 240 mg flat dose IV every two weeks. Nivolumab treatment resulted in a 31% 
response rate and a 1 year survival rate of 62% in patients with previously treated 
metastatic melanoma26, and in the previously untreated population, the response rate was 
40% and the 1-year overall survival rate was 73%27. Nivolumab is also effective in renal cell 
carcinoma with a response rate of 20%28.  In a randomized study of nivolumab versus 
docetaxel in patients with previously-treated metastatic squamous cell carcinoma of the 
lung, patients receiving nivolumab had an improved overall survival29. 
Pembrolizumab has been studied at weight-based doses of 2 and 10 mg/kg every 2-3 weeks 
and a flat dose of 200 mg every 3 weeks. In melanoma patients previously treated with 
ipilimumab, the response rate was 29%. In the previously untreated population, the 
response rate was 45% and the 1-year overall survival rate was 73%30. In patients with non-
small cell lung cancer whose tumor cells have high PD-L1 expression (defined as 50% or 
more), pembrolizumab treatment was associated with median overall survival that was 7-9 
months longer than standard chemotherapy31. In October 2016, the FDA approval for 
pembrolizumab was extended to include first-line treatment of patients whose tumors have 
high PD-L1 expression32. 
Overall, across these cancers, the anti-PD-1 agents have response rates of 20-45% 33, 
meaning that the majority of cancer patients do not achieve an objective response to single-
agent treatment. Patients whose tumors lack immune cell infiltration more often fail to 
respond to anti-PD-1 and anti-CTLA-4 therapies, which highlights the importance of the 
Pro20170000453
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           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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tumor-immune system interaction in the tumor microenvironment as a target for 
therapeutic manipulation in combination strategies. 
1.4.8 Clinical Safety Summary 
Nivolumab and pembrolizumab have been administered to tens of thousands of patients, 
and are generally well-tolerated, but serious side effects related to auto-immunity can 
occur. The most common adverse reactions are fatigue, rash, musculoskeletal pain, 
pruritus, diarrhea, nausea, asthenia, cough, dyspnea, constipation, decreased appetite, back 
pain, arthralgia, upper respiratory tract infection, pyrexia, vitiligo, and headache. The most 
common laboratory abnormalities are hyponatremia and liver function test abnormalities. 
Refer to the United States Prescribing Information (USPI) for a full description of the clinical 
safety of each agent. 
1.4.9 Supporting Data for Combination Study
Riluzole for cancer therapy
Riluzole decreases migration, invasion and proliferation of melanoma cells in xenograft 
models6. Based on this finding, we evaluated riluzole, for potential anti-cancer activity in 
a preclinical setting and in a Phase 0 clinical trial for advanced stage melanoma7. We 
tested the efficacy of riluzole in melanoma patients with a poor prognosis and severely 
limited treatment options. Twelve subjects with Stage III/IV melanoma were treated 
with riluzole for two weeks7. Four subjects demonstrated reduction MAPK or PI3K/AKT 
signaling pathway and involution of tumors. Two other subjects demonstrated a clinical 
response as on radiologic examination. Objective response was observed in 34% in 
patients after only 14 days of treatment (riluzole 100 mg every 12 hours). 
GRM1 signal transduction up-regulates factors that suppress tumor immunity  
Further studies on the downstream effects of GRM1 signal transduction suggest that 
another effect of GRM1 signal transduction is suppression of tumor in the 
microenvironment. In order to study downstream signaling along the GRM1 pathway we 
designed a set of cell lines where the parental lines had low or absent GRM1 expression 
and the modified lines had enhanced expression of this cell surface receptor6.  We 
previously reported that enhanced GRM1 expression resulted in enhanced tumor 
angiogenesis and in vivo tumor growth4,6,7.  Using the same cell lines we have now 
demonstrated that xenografts produced from melanoma cell lines with enhanced GRM1 
expression have a more pro-tumor microenvironment as compared to xenografts 
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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produced from parental lines.  Enhanced GRM1 expression results in up-regulated 
expression of CCL2 and M-CSF in these melanoma lines.  Over-expression of M-CSF and 
its receptor, CSF-1R, in tumors has been associated with a poor prognosis and M-CSF 
and CCL4 have also been implicated in mobilization of tumor-associated macrophages 
into the tumor microenvironment8,34,35.  
Xenografts produced from melanoma cell lines with enhanced GRM1 expression have 
a more pro-tumor microenvironment as compared to xenografts produced from 
parental lines
To see if our in vitro findings of up-regulated expression of CCL2 and M-CSF with 
enhanced GRM1 expression would translate to a more tumor-permissive 
microenvironment in vivo, we produced xenografts with the parental and enhanced 
GRM1 expressing cell lines. We found an increased number of macrophages in the 
spleens and peripheral blood in the xenografts produced from the enhanced GRM1 
expressing cell lines as compared to the parental lines.  The GRM1 enhanced tumors 
also showed greater amounts of angiogenesis6 and an overall decrease in infiltrating 
lymphocytes as compared to the parental tumors. 
Eliminating macrophages inhibits tumor growth in a GRM1 driven transgenic mouse 
melanoma model
To further test our hypothesis that GRM1 signal transduction results in suppression of 
tumor immunity through an increase in M2 suppressive macrophages secondary to up-
regulation of M-CSF, we treated a small group of melanoma-prone transgenic mice1,2 
with liposome-encapsulated clodronate. The transgenic line ectopically expresses GRM1 
and this drives the development of melanocytic lesions, indistinguishable from 
melanoma, with a 100% penetrance.  Liposome-encapsulated clodronate is a 
macrophage “suicide” approach, which is used to deplete macrophages in vivo36. The 
liposome-encapsulated clondronate can be taken up by phagocytic cells but not 
excreted.  This results in the death of these cells. We treated a cohort of these animals 
with Liposome-encapsulated clodronate, and confirmed that we were suppressing 
macrophages in these animals.  An untreated cohort was used as controls. We found 
that both treated and untreated animals developed pigmented lesions early on, but in 
the treated group these lesions did not continue to grow and the animals remained 
healthy for up to 19 months.  The untreated controls had to be sacrificed at 3 months 
because of overgrowth of tumor (Figure 1).  
Pro20170000453
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           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Figure 1. Eliminating macrophages inhibits tumor growth in a GRM1 driven transgenic mouse 
melanoma model
A subset of the treated animals was taken off of liposome-encapsulated clodronate and 
within 2 weeks they once again began to show rapid tumor growth and had to be sacrificed 
one month later.  Necropsy demonstrated a resurgence of macrophages populations within 
this subset of animals.  This demonstrates that in a transgenic model of melanoma driven by 
GRM1 expression, depletion of macrophages will suppress tumor growth and reconstitution 
of macrophages results in a rapid return of tumor growth.
1.4.10 Summary of Supportive Data 
This body of work demonstrates that GRM1 signal transduction appears to suppress tumor 
immunity, likely through the up-regulation of tumor associated M2 macrophages.  Blocking 
the pathway with riluzole or trigriluzole could reduce or reverse this immunosuppressive 
tumor microenvironment in patients with cancer and increase TILs. It would therefore be 
logical to combine an agent such as trigriluzole, with an immune-based therapy such as an 
immune checkpoint inhibitor, in patients with advanced cancer.  This forms the rationale for 
the phase I trial that we propose in this application. 
While many combinations with a PD-1 blockade backbone are under investigation, there is 
the potential for toxicity with overlapping side effects. Dual checkpoint blockade with 
nivolumab in combination with ipilimumab, is effective in treating patients with metastatic 
melanoma37,38 and potentially other cancers28,39. Treatment results in a response rate of 
55%, but due to overlapping toxicity of these two, grade 3-4 immune-related adverse 
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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events occur in 55% of subjects37.  Because riluzole and trigriluzole have few adverse events 
and the toxicity does not overlap with the toxicity of the checkpoint inhibitors, we hope that 
the combination of PD-1 blockade and trigriluzole in this clinical study will be tolerable and 
effective. 
1.5 Sample Size Justification
Four dosing cohorts are planned in order to test a dose of trigriluzole up to 280 mg PO BID. We 
do not anticipate testing higher doses. With approximately 3 subjects per dosing cohort, the 
required sample size is 9 - 21 subjects for testing trigriluzole with nivolumab. The MTD will then 
be tested with pembrolizumab and an additional 3-6 subjects will be required. The total sample 
size will be 12 - 27 subjects (9 – 21 in the nivolumab group, plus 3 – 6 in the pembrolizumab 
group).
1.6 Study Variables

Independent Variables, Interventions, or Predictor Variables 

Treatment variable: Dose of trigriluzole

Treatment variable: pembrolizumab or nivolumab

Dependent Variables or Outcome Measures 

Adverse events

Tumor response

Survival time
1.7 Drugs/Devices/Biologics 
1.7.1 Drug/Device Accountability And Storage Location
Investigational drug will be stored in the RCINJ Research Pharmacy, a shared resourced. The 
investigational pharmacists will be responsible for preparation, dispensing, disposal, and 
drug accountability. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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1.7.2 Drug Accountability
The investigator is required to maintain adequate records of receipt, dispensing and final 
disposition of study drug.  This responsibility has been delegated to the pharmacy.  Include 
on receipt record (e.g. packing slip) from and to whom study drug was shipped, date, 
quantity, and batch or lot number.  On dispensing record, note quantities and dates study 
drug was dispensed to and returned by each subject.  It is permitted to dispense supply that 
will last until the next scheduled visit plus 1-3 days “emergency” supply to ensure patient 
has access to drug in the event that the visit is unexpectedly delayed.  
1.7.3 Drug Destruction/Disposal
Empty and partially empty containers of study drug will be disposed of in accordance with 
institutional policies and procedures.  Unused containers of study drug will be returned to 
the study sponsor following completion of the study.
1.7.4 Pharmaceutical Information
Investigational Agent: Trigriluzole (BHV-4157/FC-4157)
The investigational drug will be supplied by and Biohaven Pharmaceuticals. Refer to the 
Investigational Drug Brochure (IDB)

Product description: The dosage form for the intended clinical trials is Capsules for 
oral administration, consisting of a common blend formulation of the drug substance 
with standard excipients filled in size 1 hard gelatin capsule shells at a strength of 140 
mg. The manufacturing and packaging of BHV-4157 capsules in bottles (35-count, 75 
cc) is by QS Pharma, and the labeling of clinical supplies is by The Coghlan Group.  
•
Appearance: Size 1 White Opaque Capsules filled with white to off-white powder.
•
Storage and Handling: Controlled Room Temperature (68° - 77°F or 20° - 25°C).
•
Stability: The common blend capsules are expected to be stable for at least 1 year.  
Stability studies are ongoing and are expected to extended the retest period of 
clinical supplies.

Preparation (how the dose is to be prepared): n/a

Route of administration: oral

Drug Interactions: Clinical drug interaction studies for trigriluzole have not been 
conducted yet. Trigriluzole, itself, is not expected to interfere with drug 
metabolism and its cleavage via plasma peptides render it unlikely to be affected 
significantly by liver cytochrome P450 inhibitors.
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Commercial Agent: Pembrolizumab (KEYTRUDA)
Refer to the package insert for agent information. 
http://www.merck.com/product/usa/pi_circulars/k/keytruda/keytruda_pi.pdf 
Reconstitution of KEYTRUDA for Injection (Lyophilized Powder) 

Add 2.3 mL of Sterile Water for Injection, USP by injecting the water along the walls 
of the vial and not directly on the lyophilized powder (resulting concentration 25 
mg/mL). 

Slowly swirl the vial. Allow up to 5 minutes for the bubbles to clear. Do not shake the 
vial. 
Preparation for Intravenous Infusion 

Visually inspect the solution for particulate matter and discoloration prior to 
administration. The solution is clear to slightly opalescent, colorless to slightly 
yellow. Discard the vial if visible particles are observed. 

Dilute KEYTRUDA injection (solution) or reconstituted lyophilized powder prior to 
intravenous administration.

Withdraw the required volume from the vial(s) of KEYTRUDA and transfer into an 
intravenous (IV) bag containing 0.9% Sodium Chloride Injection, USP or 5% Dextrose 
Injection, USP. Mix diluted solution by gentle inversion. The final concentration of 
the diluted solution should be between 1 mg/mL to 10 mg/mL. 

Discard any unused portion left in the vial. 
Storage of Reconstituted and Diluted Solutions 
The product does not contain a preservative. Store the reconstituted and diluted solution 
from the KEYTRUDA 50 mg vial either: 

At room temperature for no more than 6 hours from the time of reconstitution. This 
includes room temperature storage of reconstituted vials, storage of the infusion 
solution in the IV bag, and the duration of infusion. 

Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the 
time of reconstitution. If refrigerated, allow the diluted solution to come to room 
temperature prior to administration. Store the diluted solution from the KEYTRUDA 
100 mg/4 mL vial either: 
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
25
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
At room temperature for no more than 6 hours from the time of dilution. This 
includes room temperature storage of the infusion solution in the IV bag, and the 
duration of infusion. 

Under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the 
time of dilution. If refrigerated, allow the diluted solution to come to room 
temperature prior to administration. Do not freeze. 
Administration 

Administer infusion solution intravenously over 30 minutes through an intravenous 
line containing a sterile, non-pyrogenic, low-protein binding 0.2 micron to 5 micron 
in-line or add-on filter. 

Do not co-administer other drugs through the same infusion line.
Commercial Agent: Nivolumab (OPDIVO)
Refer to the package insert for agent information. 
http://packageinserts.bms.com/pi/pi_opdivo.pdf
Preparation and Administration 
Visually inspect drug product solution for particulate matter and discoloration prior to 
administration. OPDIVO is a clear to opalescent, colorless to pale-yellow solution. Discard 
the vial if the solution is cloudy, discolored, or contains extraneous particulate matter other 
than a few translucent-to-white, proteinaceous particles. Do not shake the vial. 

Withdraw the required volume of OPDIVO and transfer into an intravenous 
container. 

Dilute OPDIVO with either 0.9% Sodium Chloride Injection, USP or 5% Dextrose 
Injection, USP to prepare an infusion with a final concentration ranging from 1 
mg/mL to 10 mg/mL.

Mix diluted solution by gentle inversion. Do not shake

Discard partially used vials or empty vials of OPDIVO. 
Storage of Infusion 
The product does not contain a preservative. After preparation, store the OPDIVO infusion 
either: 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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
at room temperature for no more than 4 hours from the time of preparation. This 
includes room temperature storage of the infusion in the IV container and time for 
administration of the infusion or 

under refrigeration at 2°C to 8°C (36°F to 46°F) for no more than 24 hours from the time of 
infusion preparation. Do not freeze. 
Administration 

Administer the infusion over 60 minutes through an intravenous line containing a sterile, 
non-pyrogenic, low protein binding in-line filter (pore size of 0.2 micrometer to 1.2 
micrometer). 

Do not co-administer other drugs through the same intravenous line. Flush the intravenous 
line at end of infusion.
1.7.5 TREATMENT PLAN
1.7.5.1 Study Agents
Trigriluzole 
All patients will receive trigriluzole, which will be self-administered as continuous oral daily 
to BID dosing, depending on the dosing cohort (see Table 3). Subjects will begin therapy 
with the prescribed dose of trigriluzole for a run-in period of 14 days. After the lead-in 
period, subjects will continue trigriluzole and begin therapy with pembrolizumab or 
nivolumab. The first dose of trigriluzole will be administered in the clinic. The patient will 
have PK and EKG done after the first dose.  
Anti-PD-1 antibody (pembrolizumab or nivolumab)
PD-1 inhibitor treatment will consist of either nivolumab or pembrolizumab. PD-1 inhibitor 
will begin at Week 1 (following 14 day lead-in with trigriluzole).  Subsequent PD-1 inhibitor 
treatments will occur at 2-3-week intervals, depending on the schedule of the PD-1 inhibitor 
as per the Study Calendar. 
Treatment Assignment
Dose escalation of trigriluzole with nivolumab will proceed up to a maximum of 280 mg PO 
BID to identify the MTD. Subjects will be enrolled on the trial starting with Cohort 1 (Table 
3) in a starting cohort size of 3 subjects.  Subjects will be followed for 4 weeks to observe for 
dose-limiting toxicity (DLT). The decision to escalate or deescalate to a new dosing cohort or 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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to expand a dosing cohort will be made using the procedure described in the statistical 
analysis section. 
Table 3. Dosing cohorts for Trigriluzole + Nivolumab
Escalation cohort
Nivolumab
Trigriluzole 
Cohort -1
240mg IV Q 2 weeks
140 mg PO every other day (QOD)
Cohort 1
240mg IV Q 2 weeks
140 mg PO daily
Cohort 2
240mg IV Q 2 weeks 
140 mg PO BID
Cohort 3
240mg IV Q 2 weeks 
140 mg PO QAM+
280 mg PO QHS
Cohort 4
240mg IV Q 2 weeks 
280 mg PO BID
After the MTD of trigriluzole with nivolumab is identified, the MTD of trigriluzole will be tested 
in combination with pembrolizumab in 3-6 patients in Cohort P1. If the MTD is not tolerable in 
Cohort P1, the dose will be decreased by 1 level. 
Table 4. Dosing cohort for Trigriluzole + Pembrolizumab
Escalation cohort
Pembrolizumab
Trigriluzole 
Cohort P -1
200 mg IV Q3 weeks
MTD -1 level
Cohort P1
200mg IV Q3 weeks
MTD
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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1.7.6 Treatment Administration
Trigriluzole Administration
Trigriluzole will be self-administered by the patient. Trigriluzole will be first administered in 
the clinic setting. Trigriluzole can be taken without regards to meals (on a full stomach or an 
empty stomach). Morning or evening administration is acceptable for once daily dosing. No 
weight-based dosing calculation is necessary as trigriluzole is administered using flat dosing.
Lead-in period. Subjects will begin therapy with continuous oral dosing of trigriluzole for a 
lead-in period of 14 days (Week -2, Day -14 to Week -1, Day -1). Day -1 is followed by Day 1 
(There is no Day 0 or Week 0). 
Combination treatment. At the start of Week 1, subjects will continue oral dosing of 
trigriluzole and begin therapy with PD-1 inhibitor. On the days of IV treatment visits, there is 
no window for administration of trigriluzole with respect to the PD-1 inhibitor. 
Compliance/adherence assessment. Subjects will be strongly encouraged to use the Pill 
Diaries that are provided by the study. If a patient reports compliance <80% of days, they 
should be re-educated by the research nurse and/or treating investigator on instructions for 
dosing trigriluzole at home. 
Nivolumab or Pembrolizumab Administration
Nivolumab or pembrolizumab will be administered in the outpatient setting.  
Nivolumab will be administered at the FDA-approved dose and schedule of 240 mg IV Q2 
weeks over 60 minutes. 
Pembrolizumab will be administered at the FDA-approved dose and schedule of 200 mg IV 
Q3 weeks over 30 minutes. 
1.7.7 Dose Modifications and Withholding
As toxicity of these agents is largely non-overlapping, management of toxicity is dependent 
on which agent is more likely to have resulted in the toxicity. Vertigo, somnolence, and 
circumoral paresthesia should be attributed to trigriluzole. Immune-related adverse events 
should be attributed to the anti- PD-1 antibody. Refer to agent-specific management 
instructions below for dose modifications and holdings. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Overlapping toxicities of trigriluzole and anti- PD-1 antibody include fatigue, asthenia, nausea, 
dizziness, diarrhea, anorexia and liver injury. When these toxicities occur, both drugs should be 
held until toxicity resolves to grade 0-1. 
Study therapy (both agents) may be held for up to 6 consecutive weeks. Subjects who are 
not able to resume at least 1 study drug within a period of 6 weeks should be removed from 
the active treatment phase of the study and begin follow-up procedures.
Dosing interruptions are permitted in the case of medical / surgical events or logistical 
reasons not related to study therapy (e.g., elective surgery, unrelated medical events, 
patient vacation, and/or holidays). Missed doses should be omitted, not delayed. Subjects 
should be placed back on study therapy within 3 weeks of the scheduled interruption, 
unless otherwise discussed with the study PI or co-PI. The reason for interruption should be 
documented in the patient's study record. Tumor assessments should continue per the 
study calendar even if study medication was missed.  
Delays due to holidays, weekends and bad weather will be permitted and will not be 
counted as a protocol violation, and efforts will be made to get the patient back on the 
original schedule so that assessments are uniform across subjects. If correlative samples are 
collected and the scheduled treatment that day is delayed/held for any reason, there is no 
need to re-collect correlative samples. 
Trigriluzole
Grade 3-4 Toxicity. Any Grade 3 or 4 adverse event thought to be related (possibly, 
probably, or definitely) to trigriluzole will require the dose to be held until the event 
recovers to Grade 1 or less. When therapy resumes, the dose must be reduced by one level. 
If the adverse event does not improve to Grade 0-1 within 4 weeks of holding trigriluzole, 
the patient will be removed from the study. 
Grade 1-2 Toxicity. Grade 1-2 adverse events do not require dose adjustment, except if the 
patient/physician considers them to be serious or intolerable—in this case, the dose may be 
reduced by one level as per the table below at the discretion of the treating investigator.  
An example is grade 1 dizziness that the patient finds intolerable. 
Table 5. Dose Modifications of Trigriluzole
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Escalation 
cohort
Trigriluzole dose
Dose Reduction #1
Dose Reduction 
#2
Dose Reduction 
#3
Cohort -1
140 mg PO every 
other day (QOD)
Discontinue        
Trigriluzole
Discontinue 
Trigriluzole
Discontinue 
Trigriluzole
Cohort 1
140 mg PO daily
140 mg PO every 
other day (QOD)
Discontinue 
Trigriluzole
Discontinue 
Trigriluzole
Cohort 2
140 mg PO BID
140 mg PO daily
140 mg PO every 
other day (QOD)
Discontinue 
Trigriluzole
Cohort 3
140 mg PO QAM + 
280 mg PO QHS 
140 mg PO BID 
140 mg PO daily 
Discontinue 
Trigriluzole
Cohort 4
280 mg PO BID
140 mg PO QAM + 
280 mg PO QHS
140 mg PO BID
Discontinue 
Trigriluzole
Pembrolizumab and Nivolumab Dose Modifications
No dose reductions of pembrolizumab or nivolumab are allowed. PD-1 inhibitor must be 
withheld (not delayed) for drug-related toxicities
Adverse events (both non-serious and serious) associated with PD-1 inhibitor exposure may 
represent an immunologic etiology.  These adverse events may occur shortly after the first 
dose or several months after the last dose of treatment. For suspected immune-mediated 
adverse reactions, ensure adequate evaluation to confirm etiology or exclude other causes. 
Grade 3-4 toxicity. For Grade 3-4 immune-related adverse event (irAE) related to PD-1 
inhibitor, withhold PD-1 inhibitor and if indicated, administer corticosteroids as per immune 
related adverse event guidelines. Upon improvement to Grade 1 or less, initiate 
corticosteroid taper and continue to taper over at least 4 weeks. Resume PD-1 inhibitor 
when the adverse reaction remains at Grade 1 or less following corticosteroid taper. 
Permanently discontinue PD-1 inhibitor for any Grade 3 immune-mediated adverse reaction 
that recurs and for any life-threatening immune-mediated adverse reaction. If steroids are 
indicated longer than 8 weeks, the subject must discontinue treatment with PD-1 inhibitor.  
Upon improvement to Grade 1 or less, the subject may resume treatment. The PD-1 
inhibitor dose should be skipped (not delayed) and treatment should resume at the next 
scheduled timepoint. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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If the toxicity is liver-related, trigriluzole must also be held (see above). Otherwise, PD-1 
inhibitor therapy may be continued at the discretion of the treating investigator. 
Grade 3-4 toxicity. For Grade 3-4 toxicity that is treatment-emergent and but not an irAE, 
(examples: fatigue, nausea), PD-1 inhibitor will be held until improvement of toxicity to a 
Grade 0-1. 
Grade 1-2 Toxicity. Grade 1-2 adverse events do not require dose adjustment, except if the 
patient/physician considers them to be serious or intolerable—in this case, the PD-1 
inhibitor may be held at the discretion of the treating investigator.  An example is grade 2 
fatigue. 
1.7.8 Concomitant Medications
No investigational or commercial agents or therapies other than those described below may 
be administered with the intent to treat the patient’s malignancy.  
Prohibited Medications. Systemic steroids (other than those used for replacement of 
adrenal insufficiency) or treatment of irAE are prohibited. If systemic steroids are indicated 
longer than 8 weeks, the subject must discontinue study treatment. Prophylactic use of 
Colony stimulating factors (CSFs) is not permitted. They may be used for supportive care 
and should be discontinued when the event resolves/improves. If needed longer than 4 
weeks, the subject must discontinue study treatment.
The following medicines are inhibitors of CYP1A2 and are prohibited (they may increase 
blood levels of the active form of the drug, riluzole): 

fluvoxamine

cimetidine

amiodarone

efavirenz

fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, gatifloxacin, ofloxacin or 
norfloxacin)

fluvoxamine

furafylline

interferon

methoxsalen

mibefradil

ticlopidine
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Subjects who are taking one of these medications at screening will be excluded if it cannot 
be discontinued. Subjects who are prescribed one of these medications (e.g. 
fluoroquinolone antibiotic for an infection) while on-study should be switched to another 
antibiotic as soon as the prescription is noted.
Strongly Discouraged Concomitant Foods and Medications. Subjects should be strongly 
discouraged from using potent CYP1A2 inhibitors and inducers that could affect the 
metabolism of trigriluzole. 
The following medicines are CYP1A2 inducers, which may increase the rate of elimination of 
the active metabolite riluzole, thus decreasing blood levels. The drugs should be 
discontinued if possible or another medicine may be substituted in its place:

Insulin

Omeprazole

Carbamazepine

Modafanil

Rifampin

Tobacco and nicotine products
Other common medications given for gastroesophageal reflux disease, such as antacids, 
esomeprazole, pantoprozole, lansoprazole, famotidine, ranitidine are acceptable to take 
while on study.
Of note, chronic use of nicotine has modest effects on riluzole exposure (i.e., approximately 
30 – 35% reduction in exposure).  This effect would not compromise subject safety (as it 
represents a decrease in exposure).  Subjects should be encouraged to consider smoking 
cessation or reduction, which is the standard of care.
Caffeine is an inhibitor of CYP1A2, however caffeine is considered a prototypical CYP1A2 
substrate itself.  There is theoretical potential for competitive inhibition; however, caffeine 
is not typically avoided with other drugs which are reliant on CYP1A2 metabolism.  
Therefore, subjects may use caffeine without any restriction due to drug interactions.  
Acceptable Concomitant Medications. All treatments that the investigator considers 
necessary for a subject’s welfare may be administered at the discretion of the investigator 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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in keeping with the community standards of medical care.  Inhaled, topical, and intra-
articular steroids are permitted. All concomitant medication will be recorded on the case 
report form (CRF) including all prescription, over-the-counter (OTC), herbal supplements, 
and IV medications and fluids.  Selected ones include:

IVIG

Erythropoietin

Hormone replacement therapy 
Vaccinations/Immunizations. Routine vaccinations are prohibited until Week 13, but there 
are no restrictions on vaccinations after Week 13. If the treating investigator feels that a 
vaccination is unsafe to delay, an exception may be granted by the PI. It is encouraged to 
administer the seasonal influenza vaccination (flu shot) prior to study entry. 
1.7.9 Supportive Care Guidelines
Patients are allowed to receive full supportive care therapies concomitantly during the 
study. Supportive medications may be used to treat fever, rash, diarrhea and other common 
adverse events. 
Management of infusion reactions should follow the site’s SOPs for infusion or 
hypersensitivity reactions. Premedications are not required but are allowed for patients 
with previous infusion reaction. 
Radiation therapy may be delivered to a non-target lesion and the patient may remain on-
study. For example, radiation therapy may be given to patients with isolated CNS 
progression. 
Surgery or radiation therapy may be performed to palliate a tumor if it is not a target lesion 
for tumor assessment. If a target lesion requires surgery, the patient should be removed 
from active treatment due to clinical progressive disease. 
1.7.10 Adherence/Compliance and Pill Diary
At each clinic visit each subject will be given a bottle containing capsules of study drug and 
instructed to return all unused capsules to the investigator.  Patients will be given a Pill 
Diary and instructed to record the number of capsules taken and the time taken. 
There are 3 different pill diaries for different portions of the protocol:
1. Trigriluzole Lead-in Period
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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2. Trigriluzole + Nivolumab
3. Trigriluzole + Pembrolizumab
Study staff should select the appropriate Pill Diary to give to the subject. Subjects will be 
strongly encouraged (but not required) to keep a pill diary to assess adherence as accurately 
as possible. 
At the end of each cycle of treatment, the actual amount of unused drug will be compared 
to the amount taken as recorded on the subject’s medication diary/verbal report. The 
desired level of compliance is  75%.  Patients who cannot maintain this level of compliance 
may be removed from the study. If a subject is not compliant, the treating investigator 
should reeducate the subject, assess barriers to compliance, and address correctable 
barriers. 
1.7.11 TOXICITY MONITORING AND ADVERSE EVENT REPORTING
All patients who receive one dose of protocol therapy will be evaluable for assessment of 
toxicity.  Prior to each cycle the treating physician will fully assess the patient’s condition with 
respect to possible treatment related toxicities.  All adverse events, whether observed by the 
physician or reported by the patient, occurring during the active portion of therapy, or up to 30 
days after the last dose of treatment will be graded by a numerical score according to the NCI’s 
Common Terminology Criteria for Adverse Events (CTCAE), Version 4.0 
(http://ctep.cancer.gov/reporting/ctc.html) and recorded in the patient’s medical record. For 
the purposes of reporting laboratory abnormalities, only Grade 3-4 adverse events will be 
recorded on the adverse event CRF pages.  Grade 1-2 laboratory abnormalities will not be 
recorded on the adverse event CRF pages, unless the investigator judges it to be clinically 
significant and wishes to report it.  Information entered on the adverse event CRF pages will 
include: 

Specific type and duration of reaction (i.e., start and stop dates, resolution).

Severity/grade. 

Relationship to study drug (causality, attribution).

Management of the event, if treated with medication and other actions taken to alleviate 
the clinical event.

Whether or not it was considered a SAE. 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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A preexisting condition is one that is present at the start of the study.  A preexisting condition 
will be recorded as an adverse event if the frequency, intensity, or the character of the 
condition worsens during the study period.
Adverse Event Reporting Requirements 
An adverse experience is defined as any unintended or abnormal clinical observation that is 
not of benefit to the patient.  Either the condition was not present prior to exposure to the 
study therapy, or it has worsened in intensity or frequency following exposure to the study 
therapy.  
SAE Reporting Period 
The SAE reporting period starts at start of treatment and lasts through 30 days after the 
patient’s last dose or start of subsequent therapy, whichever comes sooner.  SAE’s that 
during screening period prior to the start of therapy are presumed to be unrelated to the 
study and need not be reported as SAEs.
SAE Reporting Timeline 
All “unexpected” (defined below) and/or “serious” (defined below) adverse events related 
to pembrolizumab/nivolumab or the combination of pembrolizumab/nivolumab + 
trigriluzole and occurring during the active portion of therapy, or up to 30 days after the last 
dose of treatment, will be reported to the Office of Human Research Services at (732) 235-
7577 or (732) 235-8675. Events will be promptly reported, in writing, to the local IRB in 
accordance with IRB policy.  If a death occurs the IRB will be notified within 24-hours of 
initial receipt of information.  All other SAEs must be reported to the IRB within 3 to 10 days 
of initial receipt of information. Written follow-up reports are required when additional 
information is needed to fully characterize the event. Copies of each report sent to the IRB 
will be kept in the study regulatory file.
Collaborating institutions will report all SAEs to RCINJ Office of Human Research Services 
(OHRS) and RCINJ OHRS will be responsible for forwarding SAE reports to the IRB, FDA, Fox 
Chase Chemical Diversity Center, Inc. and Biohaven Pharmaceuticals.
In addition to reporting to the local IRB, reporting to external bodies such as industry and/or 
the FDA may be necessary.
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Reporting SAEs using commercially available drugs
In addition, any unexpected (not listed in the package insert) and serious adverse events 
that are related (definitely, probably or possibly related) with the use of 
pembrolizumab/nivolumab, it must be reported to the FDA within 10 business days using a 
FDA Form MedWatch 3500 form http://www.fda.gov/medwatch/safety/3500.pdf (fax # 1-
800-FDA-0178).
Reporting SAEs for Investigational Agent Trigriluzole
The PI shall notify the FDA of any adverse experience related to the use of trigriluzole or the 
combination of pembrolizumab/nivolumab + trigriluzole that is both serious and 
unexpected, as soon as possible and in no event later than 15 calendar days after the PI’s 
discovery of the event. Each written notification may be submitted on FDA Form MedWatch 
3500A http://www.fda.gov/medwatch/safety/3500a.pdf (fax # 1-800-FDA-0178).
The PI shall also notify the FDA by telephone or by facsimile transmission of any unexpected 
fatal or life-threatening experiences associated with the use of trigriluzole or the or the 
combination of pembrolizumab/nivolumab + trigriluzole, as soon as possible but no later 
than 7 calendar days from the PI’s discovery of the event information.
Definitions
Definition of SAE
A serious adverse event (SAE) is one occurring at any dose level that results in any of the 
following outcomes:  

Death

Life-threatening- immediate risk of death from the reaction.

Requires inpatient hospitalization or prolongation of existing hospitalization.

Results in persistent or significant disability/incapacity.

Results in a congenital anomaly/birth defect.

Requires intervention to prevent one of the outcomes listed in this definition.
The definition of serious adverse event (experience) also includes important medical events.  
Medical and scientific judgment will be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the 
patient or may require intervention to prevent one of the other outcomes listed in the 
definition above.  These events will usually be considered serious.  Examples of such events 
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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are intensive treatment in an emergency room or at home for allergic bronchospasm; blood 
dyscrasias or convulsions that do not result in hospitalization.
Definition of Related
There is a reasonable possibility that the drug caused the adverse experience.  That is, the 
event is judged by the investigator to be possibly, probably or definitely related to the 
treatment.  
Definition of Unexpected
Any adverse drug experience and/or specificity, that is not included in the current 
investigator’s brochure and/or package insert. 
1.7.12 TREATMENT EVALUATION/CRITERIA FOR RESPONSE
RECIST and Modified RECIST Definition
RECIST
Response and progression will be evaluated in this study using the revised international 
criteria called RECISTv1.1 proposed by the Response Evaluation Criteria in Solid Tumors 
(RECIST) Committee40.  RECIST v1.1 criteria will be modified for this protocol to include a 
stipulation that PD must be confirmed to account for pseudoprogression (tumor flare 
phenomenon). The first instance of PD must be confirmed by either: 
1) confirmation of disease progression by repeat assessment 4-12 weeks later OR 
2) association with clinical deterioration (such as a significant decline in performance 
status).
Changes in only the largest diameter (unidimensional measurement) of the tumor lesions 
are used in the RECIST criteria. Note:  Lesions are either measurable or non-measurable 
using the criteria provided below. The term “evaluable” in reference to measurability will 
not be used because it does not provide additional meaning or accuracy.
Timing of Assessments
For the purposes of this study, patients should be evaluated at baseline and then 
reevaluated for response at Week 7, Week 13, and then every 12 weeks thereafter per the 
Study Calendar. Confirmatory scans should be obtained not less than 4 weeks following 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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initial documentation of objective response or progressive disease (PD). If a subject has 
discontinued active treatment due to reasons other than PD, the subject will continue to 
have CT scans Q12 weeks until Week 49 (window can be widened to ±28 days).
Measurable Disease 
Measurable lesions are defined as those that can be accurately measured in at least one 
dimension (longest diameter to be recorded) as >20 mm with conventional techniques (CT, 
MRI, x-ray) or as >10 mm with spiral CT scan.  All tumor measurements must be recorded in 
millimeters (or decimal fractions of centimeters).
Non-Measurable Disease
All other lesions (or sites of disease), including small lesions (longest diameter <20 mm with 
conventional techniques or <10 mm using spiral CT scan), are considered non-measurable 
disease.  Bone lesions, leptomeningeal disease, ascites, pleural/pericardial effusions, 
lymphangitis cutis/pulmonis, inflammatory breast disease, abdominal masses (not followed 
by CT or MRI), and cystic lesions are all non-measurable.
Target Lesions
All measurable lesions up to a maximum of 2 lesions per organ and 5 lesions in total, 
representative of all involved organs, will be identified as target lesions and recorded and 
measured at baseline.  Target lesions will be selected on the basis of their size (lesions with 
the longest diameter) and their suitability for accurate repeated measurements (either by 
imaging techniques or clinically).  A sum of the longest diameter (LD) for all target lesions 
will be calculated and reported as the baseline sum LD.  The baseline sum LD will be used as 
reference by which to characterize the objective tumor response.  There may be occasions 
when progressive disease is suspected but cannot be fully characterized. In these cases the 
treating physician may decide to continue treatment for one or two cycles before 
reassessment, if he/she feels it is in the patients’ best interest and the patient agrees to 
continue treatment.
Non-Target Lesions
All other lesions (or sites of disease) will be identified as non-target lesions and will be 
recorded at baseline.  Non-target lesions include measurable lesions that exceed the 
maximum numbers per organ or total of all involved organs as well as non-measurable 
lesions.  Measurements of these lesions are not required, but the presence or absence of 
each will be noted throughout follow-up. 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Guidelines for Evaluation of Measurable Disease
All measurements will be taken and recorded in metric notation using a ruler or calipers.  All 
baseline evaluations will be performed as closely as possible to the beginning of treatment 
and never more than 4 weeks before the beginning of the treatment.
The same method of assessment and the same technique will be used whenever possible to 
characterize each identified and reported lesion at baseline and during follow-up. Imaging-
based evaluation is preferred to evaluation by clinical examination when both methods 
have been used to assess the antitumor effect of a treatment. When necessary, the tumor 
assessment method may be a combination two methods (clinical lesion measurement for a 
dermal metastasis + CT scan for a liver metastasis), if the investigator feels this is the most 
accurate way to assess the tumors.
CT scans with contrast are preferred over PET/CT scans, but PET/CT scans are acceptable in patients 
who have relative contraindications to IV contrast, at the discretion of the treating investigator. 
Conventional CT and MRI- These techniques will be performed with cuts of 10 mm or less 
in slice thickness contiguously.  Spiral CT will be performed using a 5 mm contiguous 
reconstruction algorithm.  This applies to tumors of the chest, abdomen, and pelvis.  
Clinical lesions- Clinical lesions will only be considered measurable when they are 
superficial (e.g., skin nodules and palpable lymph nodes).  In the case of skin lesions, 
documentation by color photography, including a ruler to estimate the size of the lesion. 
Chest x-ray- Lesions on chest x-ray are acceptable as measurable lesions when they are 
clearly defined and surrounded by aerated lung.  However, CT is preferable. 
Ultrasound (US)- US will not be used to measure tumor lesions.  US might be used, at 
the discretion of the investigator, to confirm the complete disappearance of superficial 
lesions assessed by clinical examination.
Tumor markers- Tumor markers (e.g. LDH) alone will not be used to assess response.  If 
markers are initially above the upper normal limit, they must normalize for a patient to 
be considered in complete clinical response.  
Cytology, histology- These techniques may be used to differentiate between partial 
responses (PR) and complete responses (CR) if necessary and determined by the 
investigator. Cytological confirmation of the neoplastic origin of any effusion that 
appears or worsens during treatment when the measurable tumor has met criteria for 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
40
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response or stable disease is mandatory to differentiate between response or stable 
disease (an effusion may be a side effect of the treatment) and progressive disease.
RECIST Response Categories
Evaluation of Target Lesions
Complete Response (CR):
Disappearance of all target lesions
Partial Response (PR):
At least a 30% decrease in the sum of the longest diameter 
(LD) of target lesions, taking as reference the baseline sum 
LD.
Progressive Disease (PD):
At least a 20% increase in the sum of the LD of target lesions, 
taking as reference the smallest sum LD 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. (Note: the appearance of one or more new lesions is 
also considered progression).
Stable Disease (SD):
Neither sufficient shrinkage to qualify for PR nor sufficient 
increase to qualify for PD, taking as reference the smallest 
sum LD since the treatment started.
Evaluation of Non-Target Lesions
Complete Response (CR):
Disappearance of all non-target lesions and normalization 
of tumor marker level. All
lymph nodes must be non-pathological in size
(<10mm short axis).
Non-CR/Non-PD
Persistence of one or more non-target lesion(s) and/or 
maintenance of tumor marker level above the normal 
limits.
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
41
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Progressive Disease (PD):
Unequivocal progression of existing non-target lesions. 
(Note: the appearance of one or more new lesions is also 
considered progression).
Although a clear progression of “non-target” lesions only is exceptional, in such 
circumstances the opinion of the investigator will prevail.
*Note:  If tumor markers are initially above the upper normal limit, they must normalize for 
a patient to be considered in complete clinical response.
Evaluation of Best Overall Response
The best overall response is the best response recorded from the start of the treatment 
until disease progression/recurrence (taking as reference for progressive disease the 
smallest measurements recorded since the treatment started).  The patient's best response 
assignment will depend on the achievement of both measurement and confirmation 
criteria.
Target Lesions
Non-Target Lesions
New Lesions
Overall Response
CR
CR
No
CR
CR
Incomplete 
response/SD
No
PR
PR
Non-PD
No
PR
SD
Non-PD
No
SD
PD
Any
Yes or No
PD
Any
PD
Yes or No
PD
Any
Any
Yes
PD
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
42
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Notes:
Patients with a global deterioration of health status requiring discontinuation of treatment 
without objective evidence of disease progression at that time should be classified as having 
“symptomatic deterioration.”  Every effort will be made to document the objective 
progression.
In some circumstances, it may be difficult to distinguish residual disease from normal tissue.  
When the evaluation of complete response depends on this determination, the residual 
lesion will be investigated (fine needle aspirate/biopsy if possible) before confirming the 
complete response status. 
Modified RECIST
Note on modified RECIST: In this particular study, RECIST criteria are modified with a 
stipulation that PD must be confirmed to account for pseudoprogression (tumor flare 
phenomenon). The first instance of PD must be confirmed by either: 
1) confirmation of disease progression by repeat assessment 4-12 weeks later, 
and/or 
2) association with clinical deterioration (such as a significant decline in performance 
status).
Confirmatory Measurement/Duration of Response
Confirmation
To be assigned a status of PR or CR, changes in tumor measurements must be confirmed by 
repeat assessments that will be performed no less than 4 weeks after the criteria for 
response are first met.  In the case of SD, follow-up measurements must have met the SD 
criteria at least once after study entry at a minimum interval of not less than 6 weeks.
Duration of Overall Response
The duration of overall response is measured from the time measurement criteria are met 
for CR or PR (whichever is first recorded) until the first date that recurrent or progressive 
disease is objectively documented (taking as reference for progressive disease the smallest 
measurements recorded since the treatment started).
The duration of overall CR is measured from the time measurement criteria are first met for 
CR until the first date that recurrent disease is objectively documented.
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Duration of Stable Disease
Stable disease is measured from the start of the treatment until the criteria for progression 
are met, taking as reference the smallest measurements recorded since the treatment 
started. 
1.7.13 REMOVAL OF PATIENTS FROM STUDY/OFF STUDY CRITERIA
In the absence of treatment delays due to adverse events, treatment may continue up to 
109 weeks until one or more of the following criteria applies:
a. Disease progression/relapse during active treatment, defined per modified RECIST 
v1.1 criteria
b. Intercurrent illness that prevents further administration of treatment
c.
Unacceptable adverse event(s)
d. In the event of any drug-related life-threatening toxicity or laboratory abnormality 
the patient will be withdrawn from further treatment
e. Patient decides to withdraw from the study
f.
Non-compliance with treatment plan as per investigator discretion 
g. General or specific changes in the patient's condition render the patient 
unacceptable for further treatment in the judgment of the investigator
h.
Protocol violation - any patient found to have entered this study in violation of the 
protocol might be discontinued from the study at the discretion of the Principal 
Investigator.
1.8 Primary Specimen Collection
Collection of Blood and Tumor Tissue for Laboratory Correlative Studies
Tumor biopsies and blood samples will be performed for correlative analyses to measure 
changes in the tumor microenvironment and peripheral blood including, but not limited to, 
the following categories: 

Immune cell phenotypes and gene expression

Angiogenesis markers

Metabolic effector molecules

Exosome biogenesis 

Pharmacokinetic (PK)
Please refer to Lab Manual for analysis plan for laboratory correlative assays.
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
44
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If correlative samples are collected and the scheduled treatment that day is delayed/held for 
any reason, there is no need to re-collect correlative samples. 
Tumor Sampling

Archival tissue (a block or 6-10 unstained slides) will be obtained for all subjects, when 
available.

Tumor biopsies for research purposes are optional, but strongly encouraged, at 
Baseline/Week -2 (anytime  pre-treatment, untimed sample), Week 1 (pre-infusion, 
untimed sample) and Week 7 (pre-infusion, untimed sample). 

Regarding the method of biopsy, excisional biopsy or punch biopsy is preferred over 
core needle biopsy for purposes of tissue sampling for correlative studies. An optimal 
size is 15 x 15 mm, but 5 mm x 5 mm is also useful, and there is no minimum size that is 
required. If a core needle biopsy is performed, 1-3 cm of core is required. If the lesion is 
< 2 cm in longest diameter and it is a RECIST target lesion, care should be taken to 
ensure that the overall size of the target lesion is not affected by the tissue sampling. In 
this case, a small excisional biopsy or core biopsy should be performed. 

Refer to the Lab Manual for more details on collection, processing and storage. 
Blood sampling for correlative studies

Research blood collection for correlative studies is to be performed at Baseline/Week -2 
(anytime pre-treatment), Week 1 (pre-infusion, untimed sample), Week 7 (pre-infusion, 
untimed sample), and Week 13 (pre-infusion, untimed sample). 

At Baseline, 1 green top tube and 1 red top tube will be collected. 

At Week 1, 1 green top tube and 1 red top tube will be collected. 

At Week 7, 1 green top tube and 1 red top tube will be collected. 

At Week 13, 1 green top tube and 1 red top tube will be collected. 

Refer to the Lab Manual for details on collection, processing and storage. 
Blood sampling for PK analysis

Research blood collection for PK analysis is to be performed at the following treatment 
visits: a) Week -2 at pre-treatment, and at 2 hours and 4 hours post trigriluzole (window 
± 30 minutes), b) Week 1 (untimed sample pre-infusion), and c) Week 7 (untimed 
sample pre-infusion). 

Approximately 2 mL of blood will be collected in a lavender top EDTA tube, which should 
be immediately placed on ice.
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
45
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
Refer to the Lab Appendix for details on collection, processing and shipping. 
1.9 Interviews, Focus Groups, or Surveys 
N/A

Study Design Flow Chart
Trigriluzole Dose Escala on
with nivolumab
Trigriluzole Cohort 1
Trigriluzole Cohort 2
Trigriluzole Cohort 3
Test MTD of trigriluzole
with pembrolizumab
Iden fy MTD of trigriluzole
Trigriluzole Cohort 4
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
46
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1.10 Timetable/Schedule of Events
Schema
Week
-2
-1
1
2
3
4
5
6
7
8
9
10
11
12
Nivo
CT Scan
Con nuous oral Trigriluzole dosing………………………………………………………
Nivo
Nivo
Nivo
Nivo
Nivo
Trigriluzole + Nivolumab
Pembro
Pembro
Pembro
Pembro
CT Scan
Trigriluzole + Pembrolizumab
Week
-2
-1
1
2
3
4
5
6
7
8
9
10
11
12
Con nuous oral Trigriluzole dosing………………………………………………………
biopsy
biopsy
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
47
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Trigriluzole + Nivolumab Study Calendar
Treatment Week
Screening/
Baseline1 
Week
-2
Week 
-1
Week 
1
Week 
3
Week 
5
Week 
7 
Week 
9
Q2 
weeks 
(Weeks 
11 – 
109)
Q4 
weeks8
(Weeks 
13 – 
109) 
Weeks 
13, 25, 
37, 49
Scheduling Window 
(Days):
Within 
14 d
±3
±1
±7
±7
±7
±7
±7
±7
±7
Informed Consent
X
Inclusion/Exclusion 
Criteria
X
Demographics and 
Medical History, 
including BRAF status
X
Prior and Concomitant 
Medication Review
X
X
X
X
X
X
X
X
X
X
X
Assess Baseline 
Symptoms/Adverse 
Events and 
Compliance
X
X
X
X
X
X
X
X
X
X
X
Vital Signs and Weight X
X
X
X
X
X
X
X
X
X
X
ECOG Performance 
Status, Physical 
Examination
X
X
X
X
X
X
X
X
X
Routine Safety 
Laboratory Studies2
X
X2
X
X
X
X
X
X
X
Serum GGT 
X
X
X
X
ECG3
X
X
X
X
X3
Trigriluzole 
Administration (PO 
continuous dosing)
X
X
X
X
X
X
X
X
X
X
Nivolumab 
Administration
X
X
X
X
X
X
X
X
Research Blood 
Collection for PK4
X
X
X
Research Blood 
Collection for 
correlative science5
X
X
X
X5
Tumor Tissue 
Collection6
X
X
X
Tumor Assessment7
X
X
X
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
48
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Footnotes
1. Screening evaluations must be performed no more than 28 days prior to registration. The subject must 
begin study treatment no more than 14 days after registration. 
2. Routine safety labs: CBC with Differential, Comprehensive Metabolic Panel, Amylase, Lipase, TSH, Free 
T4, LDH.  Routine safety labs do not need to be repeated on Week -2 if performed in the past 14 days. 
More frequent labs may be performed as clinically necessary, as determined by treating investigator. 
WOCBP must have a negative serum beta-HCG pregnancy test prior to the first dose. During study 
treatment, pregnancy testing may be performed as indicated at the treating physician’s discretion.  
3. ECG monitoring is to be performed at the following treatment visits: a) at baseline (prior to dose on start 
date Week -2), and at expected Cmax 4 hours post trigriluzole (window ± 30 minutes), b) at steady state 
on Week -1 and c) at steady state at Week 1 (untimed), d) at steady state at weeks 7, 13, 25, 37, and 49. 
If trigriluzole has been discontinued, EKG monitoring may be discontinued.
4. Research blood collection for PK analysis is to be performed at the following treatment visits: a) start date 
(Week -2) at pre-treatment, and at 2 hours and 4 hours post trigriluzole (window ± 30 minutes), b) Week 
1 (untimed sample, pre-infusion), and c) Week 7 (untimed sample, pre-infusion). No PK collections after 
Week 7. 
5. Research blood collection for correlative studies is to be performed at Screening/Week -2 (pre-treatment, 
untimed), Week 1 (pre-infusion, untimed), Week 7 (pre-infusion, untimed), and Week 13 (pre-infusion, 
untimed). Baseline research blood and tumor samples may be performed anytime prior to the start of 
therapy. Ideally, the research blood samples should be collected 3-14 days prior to the fresh tumor 
biopsy, but it is also acceptable to collect them on the same day. No research bloods after Week 13.
6. Tumor Tissue Collection. Archival tissue (a block or 6-10 unstained slides) will be obtained for all subjects, 
when available. Research biopsies are optional but strongly encouraged at Baseline/Week -2, and Week 
1, and Week 7.  No biopsies after Week 7.
7. Tumor Assessment must be performed at Screening, Weeks 7, 13, 25, 37, 49, 61, 73, 85, 97, and 109. 
8. Q4 weeks starting from Week 13:  Weeks 13, 17, 21, 25, 29, 33, 37, 41, 45, 49, etc. 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
49
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Form Version v120116
Trigriluzole + Pembrolizumab Study Calendar
Treatment Week
Screening/
Baseline1 
Week
-2
Week 
-1
Week 
1
Week 
4
Week 
7 
Q3 weeks 
(Weeks 
10 – 109)
Q6 weeks8
(Weeks 
13 – 109) 
Weeks 13, 
25, 37, 49
Scheduling 
Window (Days):
Within 
14 d
±3
±1
±7
±7
±7
±7
±7
Informed Consent
X
Inclusion/Exclusion 
Criteria
X
Demographics and 
Medical History, 
including BRAF 
status
X
Prior and 
Concomitant 
Medication Review
X
X
X
X
X
X
X
X
X
Assess Baseline 
Symptoms/Adverse 
Events and 
Compliance
X
X
X
X
X
X
X
X
X
Vital Signs and 
Weight 
X
X
X
X
X
X
X
X
X
ECOG Performance 
Status, Physical 
Examination
X
X
X
X
X
X
X
Routine Safety 
Laboratory 
Studies2
X
X2
X
X
X
X
X
Serum GGT 
X
X
X
X
ECG3
X
X
X
X
X3
Trigriluzole 
Administration (PO 
continuous dosing)
X
X
X
X
X
X
X
X
Pembrolizumab 
Administration
X
X
X
X
X
X
Research Blood 
Collection for PK4
X
X
X
Research Blood 
Collection for 
correlative science5
X
X
X
X5
Tumor Tissue 
Collection6
X
X
X
Tumor 
Assessment7
X
X
X
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
50
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Footnotes
1. Screening evaluations must be performed no more than 28 days prior to registration. The subject must 
begin study treatment no more than 14 days after registration. 
2. Routine safety labs: CBC with Differential, Comprehensive Metabolic Panel, Amylase, Lipase, TSH, Free 
T4, LDH. Routine safety labs do not need to be repeated on Week -2 if performed in the past 14 days. 
More frequent labs may be performed as clinically necessary, as determined by treating investigator. 
WOCBP must have a negative serum beta-HCG pregnancy test prior to the first dose. During study 
treatment, pregnancy testing may be performed as indicated at the treating physician’s discretion.  
3. ECG monitoring is to be performed at the following treatment visits: a) at baseline (prior to dose on 
start date Week -2), and at expected Cmax 4 hours post trigriluzole (window ± 30 minutes), b) at steady 
state on Week -1 and c) at steady state at Week 1 (untimed), and d) at steady state at weeks 7, 13, 25, 37, 
and 49. If trigriluzole has been discontinued, EKG monitoring may be discontinued.
4. Research blood collection for PK analysis is to be performed at the following treatment visits: a) start 
date (Week -2) at pre-treatment, and at 2 hours and 4 hours post trigriluzole (window ± 30 minutes), b) 
Week 1 (untimed sample, pre-infusion), and c) Week 7 (untimed sample, pre-infusion). No PK collections 
after Week 7. 
5. Research blood collection for correlative studies is to be performed at Screening/Week -2 (pre-
treatment, untimed), Week 1 (pre-infusion, untimed), Week 7 (pre-infusion, untimed), and Week 13 (pre-
infusion, untimed). Baseline research blood and tumor samples may be performed anytime prior to the 
start of therapy. Ideally, the research blood samples should be collected 3-14 days prior to the fresh 
tumor biopsy, but it is also acceptable to collect them on the same day. No research bloods after Week 
13.
6. Tumor Tissue Collection. Archival tissue (a block or 6-10 unstained slides) will be obtained for all 
subjects, when available. Research biopsies are optional but strongly encouraged at Baseline/Week-2, 
Week 1, and Week 7. No biopsies after Week 7.
7. Tumor Assessment must be performed at Screening, Weeks 7, 13, 25, 37, 49, 61, 73, 85, 97, and 109. 
8. Q6 weeks:  Weeks 13, 19, 25, 31, 37, 43, and 49, etc. 
Study Calendar:  Follow-Up (Nivolumab and Pembrolizumab cohorts)
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Off 
treatment 
but on study 
Q6 weeks1
Off 
treatment 
but on study 
Q12 weeks1
Safety 
Follow-up
(12 weeks after 
last dose of rx)3
Long-Term 
Follow-up4
Q12 weeks
Scheduling Window (Days):
±14
±14
 ±28
± 28
Prior and Concomitant 
Medication Review
X
X
X
Assess Baseline 
Symptoms/Adverse Events 
and Compliance
X
X
X
Vital Signs and Weight, ECOG 
Performance Status, Physical 
Examination
X
X
X
Routine Safety Laboratory 
Studies
X
X
X
Tumor Assessment2
X
X
Post-study survival status, and 
receipt of subsequent 
anticancer therapy
X
Footnotes
1. If a subject has discontinued active treatment due to reasons other than PD (such as toxicity or patient 
preference), the subject will continue to have CT scans and follow-up visits  to monitor them until Week 49. 
2. Tumor Assessment must be performed at the same Weeks as subjects who remain on active treatment 
(Week 7, Week 13, and then Q12 weeks up until Week 49). 
3. Safety follow-up visit will occur at Week 61 for subjects who complete all treatment (Week 49), but it will 
occur prior to Week 61 if active treatment is discontinued early for PD or other reasons. 
4. Long-term Follow-up. Subjects will remain in the follow up phase of the trial for up to 3 years until the 
start of another therapy, withdrawal of consent or death.
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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2.0 Project Management
2.1 Research Staff and Qualifications
The Phase I/Developmental research team (Investigators, nurses, data coordinators, 
regulatory specialists, etc) is part of the RCINJ Office for Human Research Subjects and 
Rutgers University. Annual compliance and human subjects training is required. 
2.2 Resources Available
N/A
2.3 Research Sites
Rutgers Cancer Institute of New Jersey (RCINJ)
3.0 Multi-Site Research Communication & Coordination 
N/A
4.0 Research Data Source/s
4.1 Primary Data-Subjects and Specimens
4.1.1 Subject Selection and Enrollment Considerations 
Recruitment Details
The subjects will be adults age 18 years and older who have a diagnosis of advanced 
cancer for whom medical therapy is indicated. Advanced cancer patients will be 
recruited specifically for this prospective study evaluating the safety of combining 
trigriluzole with PD-1 blocking antibody. After written informed consent is obtained, 
each subject will undergo screening for inclusion and exclusion criteria. These 
criteria, assessed by experienced clinical investigators who are familiar with 
expected toxicities of the drugs, help ensure the selection of the subjects who stand 
to benefit the most and the exclusion of medically inappropriate subjects. 
Source of Subjects 
Subjects will be identified from the medical oncology and surgical oncology clinics at 
RCINJ and by referring providers. 
Method to Identify Potential Subjects
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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Patients with advanced unresectable or metastatic cancer will be recruited from the 
surgical oncology and medical oncology clinics at RCINJ. The treating physician will 
determine if the patient is a potential candidate for the study and discuss the 
protocol with the patient. 
Subject Screening
The treating physician and study nurse will interview the patient and review the 
chart to determine if the patient is a potential candidate for the study. Patients who 
have cancer that is curable by surgery are not eligible to participate, as surgery 
would be a better choice. Patients whom are considered too frail to participate will 
not meet eligibility criteria for performance status and organ function and will not 
be eligible to participate.  Subjects who do not meet all inclusion criteria are thought 
to be unable to tolerate study treatment safety and their enrollment will be 
recorded as screening failures.
Inclusion Criteria
A patient/subject is eligible for enrollment if all of the following inclusion criteria are 
met.
1) Patients must have histologically confirmed solid malignancy or lymphoma that is 
metastatic or unresectable 
2) There is reasonable expectation of response to pembrolizumab or nivolumab, and 
one of the drugs is available from the commercial supply. This includes (but is not 
limited to) the following tumor types: melanoma, non-small cell lung cancer, renal 
cell carcinoma, squamous cell carcinoma of the head and neck, bladder cancer, 
and classic Hodgkin lymphoma. 
3) The patient must have failed at least one line of standard treatment, with the 
following exceptions in which a PD-1 antibody is FDA approved in the first-line 
setting: 
a. melanoma patients
b. non-small cell lung cancer patients without EGFR or ALK genomic tumor 
aberrations whose tumors have high PD-L1 expression [(Tumor Proportion 
Score (TPS) ≥50%)] as determined by an FDA-approved test.
4) Age ≥ 18 years old
5) Patients must give informed consent.
6) Prior chemotherapy, immunotherapy, radiotherapy or major surgery (including 
radiation therapy or surgery for treatment of brain metastases) must be 
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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completed at least 3 weeks before study entry.  Prior PD-1 or PD-L1 therapy is 
acceptable. 
7) Patients must have an ECOG performance status ≤2 (Appendix A).
8) Patients must have normal organ and marrow function as defined below:
a. Hemoglobin >8.0 mg/dL (without transfusion in the preceding 7 days)
b. Platelets ≥70,000 /µL 
c.
Total bilirubin within normal institutional limits (patients with Gilbert's 
Syndrome must have a total bilirubin < 3.0 mg/dL).
d. AST(SGOT) <2X institutional ULN
e. ALT(SGPT) <2X institutional ULN
9) Patients must have measurable disease, defined as at least one lesion that can be 
accurately measured in at least one dimension (longest diameter to be recorded) 
as ≥10 mm by CT scan, PET/CT scan, MRI or caliper/ruler measurement by clinical 
exam. Lymph nodes: to be considered pathologically enlarged and measurable, a 
lymph node must be ≥15mm in short axis when assessed by CT scan. Lesions that 
have been radiated in the advanced setting cannot be included as sites of 
measurable disease unless clear tumor progression has been documented in these 
lesions since the end of radiation therapy.
10) Ability to swallow pills
Exclusion Criteria
A patient /subject will not be eligible for this study if any of the following exclusion 
criteria are met.
1) Systemic immunosuppressive medications such as steroids. The following steroid 
formulations are permitted: intranasal, intra-articular, and inhaled steroids. 
2) History of immune-related adverse event from prior immunotherapy treatment 
that has not improved to grade 0-1. Subjects with grade 2 hypothyroidism and 
grade 2 adrenal insufficiency requiring continued medical treatment may enroll 
provided that they are asymptomatic and stable on their dose of hormone 
replacement. 
3) Serious concomitant systemic disorders (including active infections) that would 
compromise the safety of the patient or compromise the patient’s ability to 
complete the study, at the discretion of the investigator, including active 
autoimmune disease requiring treatment within the past 30 days.
4) Any condition requiring systemic treatment with either corticosteroids (>10 mg 
daily prednisone equivalents) or other systemic immunosuppressive medications 
within 14 days of study drug administration. Inhaled or topical steroids and 
adrenal replacement doses <10 mg daily prednisone equivalents are permitted in 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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the absence of active autoimmune disease. Patients are permitted to use topical, 
ocular, intra-articular, intranasal, and inhalational corticosteroids (with minimal 
systemic absorption). Physiologic replacement doses of systemic corticosteroids 
are permitted, even if <10 mg/day prednisone equivalents. A brief course of 
corticosteroids for prophylaxis (e.g., contrast dye allergy) or for treatment of non-
autoimmune conditions (e.g., delayed-type hypersensitivity reaction caused by contact 
allergen) is permitted.
5)
Second primary malignancy, except those second primary malignancies that are not 
considered to be competing causes of death in the opinion of the treating investigator. 
Examples include:  in situ carcinoma of the cervix, adequately treated non-melanoma 
carcinoma of the skin, or other malignancy treated at least 5 years previously with no 
evidence of recurrence.
6)
Patients with active, untreated central nervous system (CNS) metastases will be excluded 
from this clinical trial because of their poor prognosis and because they often develop 
progressive neurologic dysfunction that would confound the evaluation of neurologic and 
other adverse events. Patients who have brain metastases that been treated with 
radiation therapy or surgery will be required to have a washout period of at least 3 weeks 
prior to study entry, must be neurologically asymptomatic, and must not require systemic 
steroids.
7)
Women of child-bearing potential and men must agree to use adequate contraception 
prior to the start of treatment, for the duration of treatment, and for 5 months after last 
dose of study treatment.  
8)
Patients with immune deficiency have impaired immune responses, therefore, known 
HIV-positive patients are excluded from the study because of interference with the 
correlative goals of the study.  
9)
Patients who require one or more of the following prohibited medications:  fluvoxamine, 
cimetidine, amiodarone, efavirenz, fluoroquinolones, fluvoxamine, furafylline, interferon, 
methoxsalen, mibefradil, or ticlopidine.
Recruitment Materials 
N/A
Lead Site Recruitment Methods
N/A  
4.1.2 Subject Randomization
N/A
4.1.3 Secondary Subjects
N/A 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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4.1.4 Number of Subjects
Total Number of Subjects
A total of 12-27 advanced cancer patients will be recruited specifically for this 
prospective study.
Total Number of Subjects If Multicenter Study
N/A
Require Number of Subjects to Complete Research
12 - 27 subjects.
Feasibility of Recruiting
Investigators may contact referring doctors to tell them about the study by phone or 
email. Patients will not be recruited directly, as the information about the study will 
be shared with them through their treating physician. The study team will contact 
the patient only after the treating physician has determined that the patient is 
interested in learning more about the study.
Patients may also learn of the study through websites such as clinicaltrials.gov and 
cancer patient chatrooms and blogs. No patient recruiting materials will be posted 
by the study team members without IRB approval.
4.1.5 Consent Procedures
Consent
Documenting Consent
Written informed consent is required. Informed consent must be obtained prior 
to commencing any research procedures. The informed consent document may 
not include any exculpatory language through which the subject or 
representative is made to waive any of the subject’s legal rights or releases, or 
appears to release the investigator, the sponsor or the institution from liability 
for negligence.
Waiver of Documentation of Consent
N/A
Waiver or Alteration of Consent Process 
N/A
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Consent Process
Location of Consent Process
The informed consent discussion will take place in the Cancer Institute. Subjects 
must sign consent in person at the Cancer Institute. If the patient wishes to 
enroll on the study, he or she will sign the informed consent in the presence of a 
physician or nurse on the study team.  
Ongoing Consent
Subjects will be re-consented if there is new information or protocol 
amendments and the IRB has required that subjects be verbally informed or 
reconsent in writing. 
Individual Roles for Researchers Involved in Consent
The treating physician will determine if the patient is a potential candidate for 
the study and discuss the protocol with the patient. The patient will also meet 
with the research nurse clinician to review the informed consent document.
Consent Discussion Duration
The length of time varies, typically from 30-60 minutes per visit. The patient 
will be encouraged to take the informed consent document home to read it 
over in full and if desired, discuss the protocol with their primary care 
physician or another third party. The process often lasts more than one visit.
Coercion or Undue Influence
The study staff shall seek such consent only under such circumstances that 
provide the prospective patient the opportunity to consider whether or not 
to participate, and that minimize the possibility of coercion or undue 
influence.
Subject Understanding
The patient and his or her family will be given the opportunity to ask 
questions. The discussion with the patient, or the representative, shall be in a 
language understandable to the subject or representative. 
4.1.6 Special Consent/Populations
Minors-Subjects Who Are Not Yet Adults - N/A
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Children under the age of 18 will be excluded from this study. Riluzole and PD-1 
inhibition have not been adequately tested in children and so should be studied 
separately.  Because solid tumor cancer is primarily a disease of adults it is 
anticipated that the exclusion of children will not adversely impact accrual to the 
trial.
Gender and Minorities
Both men and women and members of all ethnic groups are eligible for this trial. No 
special recruitment will be performed based on gender or minority status. Based on 
data examining the ethnic and racial mix of patients presenting with cancer at our 
institution over the past 10 years, we expect the majority of the population to be 
white, non-Hispanic subjects, but appropriate patients of all race and ethnic groups 
will be offered participation.  
Non-English Speaking Subjects
Process for Non-English Speaking Subjects
A professional medical translation telephone service called Auracom will be used 
to facilitate the consent discussion. 
Short Form Consent for Non-English Speakers
Yes, a short form will be provided. 
Adults Unable to Consent / Cognitively Impaired Adults 
N/A
4.1.7 Economic Burden and/or Compensation for Subjects
Expenses 
The costs of participating on the trial will be addressed during the informed consent 
process. General questions will be answered to the best of the study team’s ability, 
but patients will be encouraged to call their insurance company for more specific 
information. Patients or their insurance companies will be billed for all standard-of-
care assessments, as defined on the billing grid.  Institutional financial SOPs (e.g. 
pre-authorizations for medications and scans) will be followed to minimize excess 
financial impact on the subject. Patients will be educated that additional medical 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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interventions may be needed in the event of adverse events, which may result in 
more healthcare-related costs to them.   
Compensation/Incentives
No payment will be offered to recruit subjects. Patients may be reimbursed if funds 
are available for expenses such as parking and hotel rooms.  
Economic/Financial Considerations
This is an investigator-initiated trial that is sponsored by Fox Chase Chemical 
Diversity Center, Inc. and Biohaven Pharmaceuticals. Additional funding is being 
sought from governmental and foundations to support the correlative science aims. 
4.1.8 Risks to Subjects
Physical Risk of Study Treatments
Adverse events are expected to occur on this study. Please see section on expected 
toxicities. These risks are acceptable because pembrolizumab and nivolumab are both FDA-
approved drugs for this indication so the risks are within what is acceptable for standard of 
care. Trigriluzole is an investigational drug, but the related drug riluzole is also FDA-
approved and toxicities are expected to be mild. The risks of the combined study treatment 
are minimized by careful assessments by trained study staff, as well as frequent laboratory 
monitoring for safety. Once treatment arm assignment takes place, subjects will be treated 
and monitored according to the study calendar. Treatment is dosed IV once every 2-3 weeks 
only after clinician and laboratory assessment. Trigriluzole is self-administered by subjects at 
home as oral daily to twice daily dosing—subjects will be given clinic phone numbers and 
after-hours contact information and be instructed to call for guidance if they develop any 
side effects in between the in-person assessments. Pembrolizumab or nivolumab treatment 
is dosed IV once every 2-3 weeks only after clinician and laboratory assessment. Trigriluzole 
is self-administered by subjects at home as oral dosing. To minimize risk, subjects will be 
given clinic phone numbers and after-hours contact information and be instructed to call for 
guidance if they develop any side effects in between the in-person assessments.
Potential for Drug-Drug Interactions
Clinical drug interaction studies for Trigriluzole have not been conducted yet. 
Trigriluzole, itself, is not expected to interfere with drug metabolism and its cleavage 
via plasma peptidases render it unlikely to be affected significantly by liver 
cytochrome P450 inhibitors. Trigriluzole is not an inhibitor of CYP3A4, CYP1A2, or 
CYP2D6. In CYP induction studies, the estimated EC50 and Emax for CYP1A2 mRNA 
was 1.44 μM and 3.47-fold induction, respectively. The estimated EC50 and Emax for 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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CYP2B6 mRNA was 12.6 μM and 27.0-fold induction, respectively. Trigriluzole did 
not increase CYP3A4 mRNA at doses up to 30 μM.
Tumor Biopsy and Venipuncture Risks
There is a small risk of bleeding, pain, or infection with tumor biopsies. These risks 
will be minimized by use of adequate hemostasis, local anesthetic and aseptic 
technique. This level of risk is considered to be acceptable as patients routinely have 
similar biopsies performed when pathologic evaluation is necessary to confirm 
diagnosis or a site of tumor progression. Tumor biopsies are mandatory, however, 
may be omitted without deviation due to unacceptable risk (warfarin therapy, tumor near 
location with high risk for bleeding or other complication, etc.) with prior authorization from 
the PI (see PI contact information on cover page of protocol). There is a very small risk of 
bleeding, pain, or infection with venipuncture; however this is minimized as the correlative 
blood samples are being taken at the same time as the standard of care laboratory bloods.
Procedures for Risks to Embryo, Fetus, and/or Pregnant Subjects
Trigriluzole has not yet been assessed in fertility and fetal development studies. 
Riluzole has been assessed previously and has been characterized as a Category C 
drug. As described in the USPI, oral administration of riluzole to pregnant animals 
during the period of organogenesis caused embryotoxicity in rats and rabbits at 
doses of 27 mg/kg and 60 mg/kg, respectively, or 2.6 and 11.5 times, respectively, 
the recommended maximum human daily dose on a mg/m2 basis. Evidence of 
maternal toxicity was also observed at these doses. When administered to rats prior 
to and during mating (males and females) and throughout gestation and lactation 
(females), riluzole produced adverse effects on pregnancy (decreased implantations, 
increased intrauterine death) and offspring viability and growth at an oral dose of 15 
mg/kg or 1.5 times the maximum daily dose on a mg/m2 basis. There are no 
adequate and well-controlled studies in pregnant women. Riluzole should be used 
during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Women of child-bearing potential (WOCBP) are defined as women who have the 
potential to become pregnant. Peri-menopausal women are considered WOCBP and 
must use effective contraception. Women who are menopausal (defined as no 
menses in >1 year) are excluded. WOCBP must have a negative serum pregnancy 
test prior to the first dose. During study treatment, pregnancy testing may be 
performed as indicated at the treating physician’s discretion.  WOCBP may opt out 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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of pregnancy testing if they provide an acceptable reason with their treating 
provider (such as 100% abstinence from heterosexual intercourse).
WOCBP and men must agree to use effective contraception during the study 
participation, and for 5 months after the last dose of the drug.  Effective 
contraception options include: 100% abstinence from heterosexual intercourse, 
surgical (tubal sterilization or partner’s vasectomy), intrauterine device, and 
combination hormonal contraceptives including birth control pills, skin patches, 
shots, under-the-skin implants, or vaginal rings. Barrier methods of birth control 
such as condoms are not adequate as primary method of contraception, but may be 
used as a secondary method. 
Should a woman become pregnant or suspect she is pregnant while she or her 
partner is participating in this study, she should inform her treating physician 
immediately.
Risk-Benefit Ratio
The hypothesis to be addressed in the proposed study is potential therapeutic, 
diagnostic, and/or prognostic importance for patients with advanced malignancy. 
GRM1 blockade with riluzole is generally safe and well tolerated and operates by a 
different mechanism from the anti-PD1 antibodies so the toxicity profiles are non-
overlapping. Therefore, we do not anticipate any untoward safety findings with 
trigriluzole. Nonetheless, this protocol includes measures to increase safety such as 
DLT observation period and AE reporting procedures. Patients may alternative 
treatment options including chemotherapy or other therapy. The results of this 
study may assist in the development of new biomarkers to improve 
diagnosis/prognosis in this population and could lead to new therapeutic targets for 
patients with advanced cancer. Therefore, the potential benefits of the proposed 
study outweigh potential risks.
Potential Benefits
There may be direct benefit to the subject for participation in this proposed study 
because the subject will receive pembrolizumab or nivolumab, which are FDA-
approved and have been shown to prolong survival in patients with various 
advanced malignancies, although this does not guarantee that each individual 
patient will benefit. This study may demonstrate enhanced efficacy for 
pembrolizumab/nivolumab when combined with trigriluzole in this patient 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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population, so patients may benefit from trigriluzole as well. Subjects may 
experience prolonged survival or decrease in cancer symptoms. Data gathered from 
the proposed study may allow us to identify molecules have the potential to be used 
as predictive biomarkers or therapeutic targets that could result benefit to the 
patient or society as a whole in the future.
Risks to Non-Subjects
N/A
Assessment of Social Behavior Considerations
N/A
Reasonably Foreseeable Risks
N/A
Risk Of Imposing An Intervention On Subject With Existing Condition
N/A
Other Foreseeable Risks
N/A
Observation And Sensitive Information
N/A
Minimizing Risks
To minimize risk, subjects will be evaluated frequently and given clinic phone 
numbers and after-hours contact information and be instructed to call for 
guidance if they develop any side effects in between the in-person assessments. 
Institutional financial SOPs (e.g. pre-authorizations for medications and scans) 
will be followed to minimize excess financial impact on the subject.
Other foreseeable risks may include risks associated with a possible loss of 
confidentiality. Patient confidentiality will be strictly maintained according to 
NIH guidelines. Computerized clinical data are protected by a series of 
passwords. Detailed clinical information will be kept in a research patient chart, 
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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which will be kept in a separate private and locked location. All of the data that is 
to be delivered to the non-clinical researchers is non-PHI, and anonymous. The 
biospecimens will be processed, analyzed and presented by the issued patient 
number. The patient will not be identified by name and no PHI will be directly 
attached to the specimens.
Certificate of Confidentiality
N/A
Potential Benefits to Subjects
There may be direct benefit to the subject for participation in this proposed 
study because the subject will receive pembrolizumab or nivolumab, which are 
FDA-approved and have been shown to prolong survival in patients with various 
advanced malignancies, although this does not guarantee that each individual 
patient will benefit. 
This study may demonstrate enhanced efficacy for pembrolizumab/nivolumab 
when combined with trigriluzole in this patient population, so patients may 
benefit from trigriluzole as well. Subjects may experience prolonged survival or 
decrease in cancer symptoms. Data gathered from the proposed study may 
allow us to identify molecules have the potential to be used as predictive 
biomarkers or therapeutic targets that could result benefit to the patient or 
society as a whole in the future. 
Provisions to Protect the Privacy Interests of Subjects
Patient confidentiality will be strictly maintained according to NIH guidelines. 
Computerized clinical data are protected by a series of passwords. Detailed 
clinical information will be kept in a research patient chart, which will be kept in 
a separate private and locked location. All of the data that is to be delivered to 
the non-clinical researchers is non-PHI, and anonymous. The biospecimens will 
be processed, analyzed and presented by the issued patient number. The patient 
will not be identified by name and no PHI will be directly attached to the 
specimens.
Research Team Access To Subject Data
The research team is permitted to access the medical record and research chart. 
Annual training on privacy is required. 
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Protocol Title: A Phase I Study to Evaluate 
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Antibodies
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4.2 Secondary Data – Records/Chart Reviews/Databases/Tissue Banks/etc.
N/A
5.0 Special Considerations
5.1 Health Insurance Portability and Accountability Act (HIPAA)
It is necessary that PHI be accessed to achieve the goals of this study.  All study staff are 
trained in HIPAA and routine protections of PHI will apply. 
5.2 Family Educational Rights and Privacy Act (FERPA)
N/A
5.3 NJ Access to Medical Research Act
N/A
5.4 Code of Federal Regulations Title 45 Part 46 (Vulnerable Populations)
N/A
6.0 Research Data Protection and Reporting
6.1 Data Management /Statistical Considerations
Primary Hypothesis and Endpoint
We hypothesize that combination therapy will be safe in patients with metastatic 
cancer. Data on the adverse event type, severity and frequency will be recorded.
The primary endpoint will be the MTD/RP2D. The MTD/RP2D of trigriluzole in 
combination with nivolumab is expected to also be the tolerable in combination with 
pembrolizumab. 
Secondary Hypotheses and Endpoints
We hypothesize that combination therapy will lead to regression of tumors. Therefore, 
the following secondary endpoints will be recorded: 

objective response rate (ORR) according to modified RECIST v.1.1.

survival time (OS) 

landmark survival rates at 1 and 2 years 

duration of response for responding patients

time to progressive disease (PFS)
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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
time to treatment failure 

time to next therapy or death (TTNTD)

freedom from new metastases 
We hypothesize that features in the tumor microenvironment (TME) and/or tumor 
genome may be associated with response to therapy. Therefore, we will quantify 
changes in immune cell phenotypes and gene expression, markers of angiogenesis, 
metabolic effector molecules, and exosomal formation and contents.
Study Design /Analysis Plan for Primary Endpoint
Overview of sequential testing with nivolumab then pembrolizumab
In the first portion of this study, cohorts of subjects will be treated with increasing 
doses of trigriluzole in combination with nivolumab. After the MTD of trigriluzole is 
identified, it will be tested in combination with pembrolizumab (Cohort P1). The 
MTD of trigriluzole with nivolumab is likely to be safe and tolerable in combination 
with pembrolizumab. 
Escalation Procedure
There 4 dosing cohorts of trigriluzole (Cohorts -1, 1, 2, 3, and 4). Please refer to 
dosing cohort tables. 
Starting with Cohort 1, dose escalation of trigriluzole with nivolumab will proceed up 
to a maximum of 280 mg PO BID (Cohort 4) to identify the MTD. Subjects will be 
enrolled on the trial in a starting cohort size of 3 subjects. 
After the MTD of trigriluzole with nivolumab is identified, the MTD of trigriluzole will 
be tested in combination with pembrolizumab in 3-6 patients in Cohort P1. If the 
MTD is not tolerable in Cohort P1, the dose will be decreased by 1 level. 
Escalation Rules
The decision to escalate or deescalate to a new dosing cohort or to expand a dosing 
cohort will be made using the procedure described in the table below. The dose 
escalation procedure is a Semi-Bayesian modified toxicity probability interval (mTPI) 
method.41 Each cohort size will be 3 patients (i.e., same as 3+3 design), but the 
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
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method can handle varying cohort size when real data have different cohort sizes.  
There will be no within-patient dose escalation. 
The following table displays the escalation/de-escalation/stay/ decisions using the 
set-up: maximum number of patients at a given dose =18, true probability of toxicity 
pT=0.3, and the higher and lower ends of the equivalence interval =0.05.  
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
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Table 6. Number of patients treated at current dose:
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
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In this procedure, patients are entered at an initial dose (Cohort 1, trigriluzole 140 mg PO daily) in 
groups of three, and depending on the outcome, the dose is either escalated, de-escalated, or it remains 
the same. The procedure continues until all dose levels have been exhausted, or until six patients have 
been entered at a particular dose. The final dose will be the maximum tolerated dose, or MTD.
The table below summarizes the probabilities of observing the numbers of subjects under different 
assumptions of true DLT rate θ0, which can be interpreted as the one-sided p-values for testing the null 
hypothesis that the true DLT rate is less than θ0.  However, these p-values are considered non-binding 
guidelines; recommendations would not be based solely on statistical grounds, as many other factors 
(ie, all aspects of the data from the trial) may be part of the decision process. 
Table 7. Probability of observing the number (%) of subjects with DLT out of a cohort of 6 subjects
Probability (p-value) under different assumptions
Observed 
number (%) of 
subjects with 
DLT
θ0 = 0.20
θ0 = 0.25
θ0 = 0.30
θ0 = 0.35
θ0 = 0.40
0 (0%)
0.74
0.82
0.88
0.92
0.95
1 (17%)
0.34
0.47
0.58
0.68
0.77
2 (34%)
0.099
0.17
0.26
0.35
0.46
3 (50%)
0.017
0.038
0.07
0.12
0.18
Through this procedure, the MTD of trigriluzole in combination with nivolumab will be identified. The 
MTD will then be tested in combination with pembrolizumab using the same escalate/de-escalate/stay 
rules. 
Dose Limiting Toxicity
Definition of DLT
The occurrence of any Grade 3 or higher toxicity during the DLT evaluation period (i.e., 
occurred during the first 4 weeks of therapy) will be considered a DLT, if judged by the 
treating investigator to be related to the administration of either study drug or the 
combination of study drugs. 
EXCEPTION: Grade 3 amylase or lipase elevation without clinical symptomatology of 
pancreatitis (i.e. no epigastric pain and vomiting) will not be considered a DLT and does 
not require SAE reporting.
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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DLT observation period
There will be a 5-week evaluation period for observation of DLT during which time new 
subjects may be accrued within the same dose cohort, but dose escalation or de-
escalation beyond the current dose cohort shall not be allowed. The date of reference 
for the 5 weeks is the first day of treatment including the lead-in period (Day -14); 
therefore the end of the DLT observation period occurs at Week 3. The end of the DLT 
observation period will not coincide with an office visit in the pembrolizumab cohorts; if no DLT 
has been reported by that time, the evaluation period will be considered to be passed.  
Sample Size Justification 
Four dosing cohorts are planned in order to test a dose of trigriluzole up to 280 mg PO 
BID. We do not anticipate testing higher doses. With approximately 3 subjects per 
dosing cohort, the required sample size is 9 - 21 subjects for testing trigriluzole with 
nivolumab. The MTD will then be tested with pembrolizumab and an additional 3-6 
subjects will be required. The total sample size will be 12 - 27 subjects (9 – 21 in the 
nivolumab group, plus 3 – 6 in the pembrolizumab group). 
Analysis Plan for Secondary Endpoints
Clinical Secondary Endpoints. The frequency of AEs and SAEs will be recorded. Clinical 
measures of efficacy will be described, including overall survival, progression-free 
survival, etc. (see Secondary Endpoints above). Descriptive statistical will be used, 
except where otherwise specified. Continuous variables will be presented by summary 
statistics (such as mean, median, standard error and 90% CI) and the categorical 
variables by frequency distributions (i.e., frequency counts, percentages and 90% CI).
Correlatives. We will collect pre- and post-treatment tumor samples from responders 
and non-responders to test for differences in signal transduction in key pathways 
(MAPK, Pi3K/AKT), presence of TILs and other immune effector cells, PD-L1 expression, 
the expression of VEGF, IL-8, CD34, CCL2, M-CSF, and immune-related gene expression 
profile. We will determine if the presence of GRM1 expression, activating mutations in 
B-RAF or N-RAS, or PTEN inactivation (or activating B-RAF mutations and PTEN 
inactivation together) in the pre-treatment tumor samples correlates with response to 
therapy.  We will examine the change in key pathways before and after the trigriluzole 
monotherapy lead-in period (Baseline vs. Week 1) and compare to the samples taken 
after exposure to combination therapy (Week 7).
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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We will also collect pre- and post-treatment peripheral blood samples from responders 
and non-responders and determine the expression of VEGF, IL-8, CD34, CCL2, and M-
CSF, and changes in the quantity and contents of tumor-derived exosomes. We will 
determine if the expression of these markers in pre-treatment peripheral blood samples 
correlates with response to therapy. Next, we will compare the pre-treatment and post-
treatment blood and tumor samples to see if response to treatment correlates with 
activation or suppression of signal transduction through the MAPK and Pi3K/AKT 
pathways, changes in immune effector cells in the tumors and peripheral blood, or 
changes in the quantity or contents of peripheral blood exosomes. 
Treatment effect for each patient will be measured as paired differences between pre- 
and post- measurements of these parameters at various times. Transformation of the 
data will be performed if appropriate, e.g. log transformation, and hence treatment 
effect will be expressed on a log scale. 
This analysis of the data obtained in these correlative studies will be descriptive in 
nature.  Sample size may not be adequate to test the correlations; these studies will be 
used to demonstrate the feasibility of including these studies in larger future trials.
Definitions of Evaluable for Toxicity and Response
Evaluable for toxicity.  All subjects who received at least one dose of each study drug 
will be considered evaluable for toxicity.
Evaluable for objective response.  All subjects who undergo at least one on-study tumor 
assessment will be considered evaluable for response.  
Compliance and Missing Data
Compliance/Adherence
Compliance with study procedures is defined as the patient making a good faith effort 
to complete all protocol-related assessments. If a subject is not compliant, the treating 
investigator should assess barriers to compliance. Patients whose actions cause 2 or 
more deviations despite efforts to improve non-compliance may be removed from the 
study. 
Compliance with oral medication is defined as the patient taking ≥75% of the prescribed 
doses/days within a treatment cycle.  The desired level of compliance is > 75%.  Patients 
who cannot maintain this level of compliance may be removed from the study. Patients 
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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who consistently cause deviations despite efforts to improve non-compliance may be 
removed from the study. See monitoring compliance with oral medication. 
Subjects who leave the study for non-compliance will not be followed-up. 
Missing data
Subjects who do not start study treatment or are not evaluable for toxicity for the entire 
DLT observation period will be replaced (up to 5 replacements).
Interim Analysis
An interim analysis of safety data in the first 9 - 12 subjects may be reported at 
academic conference(s). 
6.2 Data Collections and Records to be Kept
Case Report Forms
Completion of the electronic CRFs (eCRFs) will be done in accordance with the 
instructions in a study specific data capture plan.  The electronic CRF stored in Oncore® 
will be the primary data collection document for the study. All eCRFs will be completed 
by clinical research coordinators of the   Office of Human Research Services (OHRS) at 
the Cancer Institute of New Jersey. The eCRFs will be maintained in a confidential 
format in a secure database. The CRFs will be updated in a timely manner following 
acquisition of new source data. Only the key personnel delegated on the delegation of 
authority log are permitted to make entries, changes, or corrections in the CRF. All users 
of this system will complete user training, as required or appropriate per regulations. An 
audit trail will be maintained automatically by the electronic CRF management system. 
Data Submission Timeline and Forms
Completion of eCRFs will occur in accordance with NCI guidelines.  Baseline (pre-study) 
eCRFs (e.g., enrollment, medical history, concomitant medications, disease assessment, 
etc.) will be completed no later than 14 days after the start of treatment.   Treatment 
eCRFs (e.g., drug administration, adverse events, chemistries, etc.) will be completed no 
later than 14 days following each cycle of treatment.  Off-treatment information (e.g., 
follow-up, best response, etc.) will be completed no later than 14 days after the end of 
protocol treatment.
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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Research Charts
A research chart (i.e., shadow chart) is maintained at OHRS for each patient enrolled.  
Copies of significant study source documents will be maintained in the research chart.  
Examples of source document copies that will be maintained in the research chart 
include: signed informed consent form, documents that verify eligibility and treatment 
and documents that verify Grade 3-4 adverse events and response. This information will 
be updated on a prospective basis and will be confidentially maintained at the Cancer 
Institute of New Jersey, OHRS.
Reports
The RCINJ PI is the sponsor-investigator of the IND (IND#133666) and RCINJ will be 
responsible for episodic and annual reporting to the FDA. Publications for submission 
and annual reports for the IRB will be written by the RCINJ PI and OHRS using the data 
captured on the e-CRFs.
6.3 Data and Safety Monitoring Plan
Monitoring of this study will occur in accordance with the NCI approved Data and Safety 
Monitoring Plan (DSMP) of RCINJ.  The study team reviews all toxicity during the dose-
escalation phase of studies and presents this data to the weekly Phase I meetings. The 
RCINJ Human Research Oversight Committee (HROC) is responsible for annual data and 
safety monitoring of phase I and phase II, therapeutic interventional studies that do not 
have an independent Data Safety Monitoring Board (DSMB). The primary focus of the HROC 
is review of safety data, toxicities and new information that may affect subject safety or 
efficacy. Annual safety reviews includes but may not be limited to review of safety data, 
enrollment status, stopping rules if applicable, accrual, toxicities, reference literature, and 
interim analyses as provided by the sponsor-investigator. The HROC in concert with the 
Quality Assurance Monitoring Team oversees the conduct of RCINJ cancer-related, sponsor-
investigator therapeutic intervention and prevention intervention studies that do not have 
an external monitoring plan, ensuring subject safety and that the protocol is conducted, 
recorded and reported in accordance with the protocol, standing operating procedures 
(SOPs), Good Clinical Practice (GCP), and applicable regulatory requirements. All study staff 
must complete training and maintaining active certification in the use of human subjects in 
research. 
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Periodic Data Evaluation
HROC meets approximately twice a month and each disease group is reviewed at least 
every 3 months. HROC will review all Dose Administration Memos (DAM) and dose-
limiting toxicities (DLTs) for Phase I dose-escalation trials.   Protocol suspensions and re-
opening of accrual to the next cohort based on DLT evaluation, fall under the purview of 
the HROC.
An “initiation audit” will be conducted at the RCINJ in accordance with the DSMP 
following enrollment of the first two (2) or three (3) patients.  Subsequent audits will 
occur on an annual basis prior to annual IRB continuing review, if the findings from the 
initiation audit were satisfactory.  More frequent audits of patient data and study 
conduct will occur if necessary.  Prior audit findings and/or situations that may arise 
during the course of the study will determine the need for more frequent auditing.  All 
audit findings will be discussed with the principal investigator and reported to the RCINJ 
HROC and the Rutgers University IRB.
Type of Data Evaluated
HROC monitors accrual, deviations, and SAEs. 
Collection of Safety Information
Safety information is collected and tallied in reports using OnCore. 
Frequency Of Data Collection
Data is collected at each study visit and follow-up contact. Safety data collection 
(including SAEs) starts after the first study treatment.  
Reviewer of Data
The members of OHRS management staff review the data for completeness. HROC 
monitors accrual, deviations, and SAEs. The PI will review data as needed for accuracy 
and consistency. 
Schedule Of Review Of Cumulative Data
There will be one planned interim analysis after 9-12 subjects are enrolled. 
Tests for Safety Data
N/A
Suspension of Research
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Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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If the combination is found to not be tolerable (MTD reached at lowest dosing cohort), 
accrual will halt until further review/amendment. 
6.4 Reporting Results
Sharing of Results with Subjects 
Individual subject results of routine diagnostic clinical tests and incidental findings will 
be shared with subjects at their office visits or by telephone by appropriate study staff 
(clinicians). 
Individual Results 
Individual subject results of routine diagnostic clinical tests and incidental findings will 
be shared with subjects at their office visits or by telephone by appropriate study staff 
(clinicians). 
Aggregate Results 
N/A 
Professional Reporting
The policies and procedures of Rutgers University’s legal department (see: Investigator’s 
Brochure) will govern publication of the trial.  It is expected that the results of this trial 
will be submitted for publication in a timely manner following the conclusion.  The RCINJ 
PI, and all co-authors prior to submission or use, must review any abstract or 
manuscript. 
ClinicalTrials.Gov Registration And Data Reporting
This study is registered at clinicaltrials.gov. 
7.0 Data and/or Specimen Banking
N/A
8.0 Other Approvals/Authorizations
N/A
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Protocol Number: RCINJ# 051707
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Protocol Title: A Phase I Study to Evaluate 
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4157) in Combination with PD-1 Blocking 
Antibodies
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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32) Reck M, Rodríguez-Abreu D, Robinson AG, et al. Pembrolizumab versus Chemotherapy 
for PD-L1–Positive Non–Small-Cell Lung Cancer. New England Journal of Medicine. 
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in untreated melanoma. N Engl J Med. 2015;372(21):2006-2017.
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ipilimumab in recurrent small-cell lung cancer (CheckMate 032): a multicentre, open-
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finding trials. Clin Trials. 2010;7(6):653-663.
 
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Appendix A:  Performance Status Criteria
ECOG Performance Status Scale
Karnofsky Performance Scale
Grade
Descriptions
Percent
Description
0
Normal activity.  Fully active, able to 
carry on all pre-disease performance 
without restriction.
100
Normal, no complaints, no evidence of 
disease.
90
Able to carry on normal activity; minor 
signs or symptoms of disease.
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).
80
Normal activity with effort; some signs or 
symptoms of disease.
70
Cares for self, unable to carry on normal 
activity or to do active 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.
60
Requires occasional assistance, but is 
able to care for most of his/her needs.
50
Requires considerable assistance and 
frequent medical care.
3
In bed >50% of the time.  Capable of 
only limited self-care, confined to bed 
or chair more than 50% of waking 
hours.
40
Disabled, requires special care and 
assistance.
30
Severely disabled, hospitalization 
indicated.  Death not imminent.
4
100% bedridden.  Completely 
disabled.  Cannot carry on any self-
care.  Totally confined to bed or chair.
20
Very sick, hospitalization indicated. 
Death not imminent.
10
Moribund, fatal processes progressing 
rapidly.
5
Dead.
0
Dead.
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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 Appendix B:  Trigriluzole (BHV-4157) + Anti-PD-1 Lab Appendix
I.
Overview of samples to be collected
Tumor biopsies with be performed and blood samples will be collected for correlative analyses.  We 
will measure changes in the tumor microenvironment and peripheral blood in pre- and post-
treatment samples in the following categories: 

Immune cell phenotypes and gene expression

Angiogenesis markers

Metabolic effector molecules

Exosome biogenesis 

Pharmacokinetic (PK)
The expected sample size is 12 to 27 subjects. Detailed Study Calendars are located in the Protocol. 
The following table lists the samples that are expected to be collected from each subject.
Time
Samples needed
Screening or 
Baseline

Archival tissue (block or 6-10 unstained slides) when 
available

Tumor biopsy (optional but strongly encouraged)

Peripheral blood collection for biologic correlative studies 
(1 green top tube and 1 red top tube)
Week -2 

PK samples x 3 (lavender top tubes)
1. Pre-treatment 
2. 2 hours post-trigriluzole (window +/- 30 minutes)
3. 4 hours post trigriluzole (window +/- 30 minutes)
Week 1

Tumor biopsy (optional but strongly encouraged)

Peripheral blood collection for biologic correlative studies 
(1 green top and 1 red top tube)

PK sample (lavender top)
Week 7

Tumor biopsy (optional but strongly encouraged)

Peripheral blood collection for biologic correlative studies 

PK sample  (lavender top)
Week 13

Peripheral blood collection for biologic correlative studies 
(1 green top and 1 red top tube)
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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II. Handling of archival tumor tissue 
Archival tumor tissue (for example, in paraffin blocks or pathology slides) should be logged and 
labeled in BRS and then delivered to the laboratory and kept at room temperature until analysis.
III. Collection of fresh tumor tissue 
a.
Method of biopsy:  Excisional biopsy or punch biopsy is preferred over core needle 
biopsy for purposes of tissue sampling for correlative studies. An optimal size is 15 x 
15 mm, but 5 mm x 5 mm is also acceptable.  There is no minimum size that is 
required.  If a core needle biopsy is performed, 1-3 cm of core is recommended.  If 
the lesion is < 2 cm in longest diameter and it is a RECIST target lesion, care should 
be taken to ensure that the overall size of the target lesion is not affected by the 
tissue sampling. In this case, a small excisional biopsy or core biopsy should be 
performed. 
b. The RCINJ Biospecimen Repository Service (BRS) will process, label and store the 
tissues samples. 
c.
Fresh tumor tissue for Western blotting will be collected by biopsy and immersed 
(completely) in sterile cold (2-7oC) RPMI in a sterile specimen cup (for example, VWR 
catalog# 15704-088) on ice.
d.  Fresh tumor tissue for murine experiments will be collected in sterile cold (2-7oC) 
RPMI in a sterile 50 ml centrifuge tube.
e.
The specimen cup or centrifuge tube will be labeled with the patient ID, date, and 
time of tumor tissue collection.
f.
The sample will be immediately transported on ice from the collection site to the 
BRS laboratory. 
g. Tissue processing should be performed as soon as possible after tissue 
collection/receipt (maximum time from tissue acquisition and processing should be 
no more than 3 hours).
IV. Processing of tumor tissue
The RCINJ Biospecimen Repository Service (BRS) will process, label and store the tissues 
samples until delivery to the analysis lab.
As clinical samples are often small, the allocation of small tumor samples for different 
correlative studies will be determined per the following table:
 
Prioritization Table for Fresh Tumor Biopsies 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Priority 
Level
Type of Preserved 
Tissue
Biomarker Analysis Method
1st
Flash frozen in 
liquid nitrogen
-
Western blotting
o
Expression of MAPK and 
PI3K/AKT signaling pathway 
components
o
M-CSF and CCL2 expression
o
HIF-1a, IL-8, and VEGF 
expression
Gene expression profiling
2nd
Formalin fixed 
paraffin embedded 
(FFPE) 
-
IHC
o GRM1 expression
o pERK and pAKT 
-
H&E
-
Lymphocytic Infiltration
o
Fat will be trimmed from the tumor. Tumor tissue specimens will be measured in the 2 
longest dimensions.  Tumor tissue will be sectioned into specimens by the following 
prioritization rules:
Prioritization Rules for Allocation of Tumor Tissue at Baseline
Tumor Size in 2 
dimensions 
Allocation of Tissue
<5 x <5 mm
 Cut into 2 equal sections. 
2. Allocate one of the sections to liquid nitrogen
3. Allocate one of the sections to formalin
≥5 x ≥5 mm
 Split tumor into 3 equal sections:
1. Allocate one third to RPMI 
2. Allocate one third to liquid nitrogen
3. Allocate one third to formalin 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Prioritization Rules for Allocation of Tumor Tissue at Weeks 1 and 6
Tumor Size in 2 
dimensions 
Allocation of Tissue
<5 x <5 mm
1.  Allocate entire specimen to liquid nitrogen 
≥5 x ≥5 mm
Split tumor into 2 equal sections. 
1. Allocate one of the sections to liquid nitrogen
2. Allocate one of the sections to formalin 
1) RPMI preservation
A
Sterile forceps will be used to gently place the specimen in a sterile labeled cryovial or 
specimen container (whichever is large enough to hold the tissue full submerged and 
surround by cold [2-8oC] RPMI. Additional RPMI will be added (under sterile conditions) 
with the volume required to fully submerge the tissue in the solution and fill the 
vial/container completely without air pockets.
B
Care should be taken to avoid crushing artifacts and a separate forceps must be used for 
each specimen to avoid cross contamination.
C
The cryovial/specimen container lid will be secured. 
D
The cryovial/specimen container must be kept at 2-8oC and transported immediately to 
the Immune Monitoring Core laboratory for processing.
2) Liquid nitrogen storage
A
The sample will be placed in a 30 ml cryovial and immediately placed in liquid nitrogen.  
B
The Dewar will be transported within 60 minutes to the cryo-storage facility
C
The cryovial will be transferred to a liquid nitrogen freezer or a mechanical -80oC freezer 
for long-term storage until processed for Western Blotting.
3) Formalin fixation
A
Specimens intended for formalin fixation should be processed after the completion of 
other fresh tissue procedures, such as flash freezing and submersion in RNA stabilizing 
reagent.
B
The tissue sample should be trimmed such that it is maximally 0.5 cm in thickness. 
Specimens that exceed this dimension may not allow for adequate perfusion of the 
formalin.
C
After trimming, the specimen will be transferred to a container with formalin using a 
forceps. To avoid cross-contamination, a separate forceps should be used for each tissue 
sample. The volume of formalin should be a minimum of 15-20 times the volume of the 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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tissue sample - e.g., 20 ml of formalin per 1 cm3 of tissue. A 15 ml sterile centrifuge or 
conical tube or alternatively, a specimen cup can be used.
D
The specimen must be completely submerged in the formalin fixative and the container 
lid securely tightened to avoid any spillage.
E
The tissue will be fixed at room temperature for a minimum of 24 hours and maximum of 
48 hours.
F
Formalin should not be discarded down the drain. The chemical disposal plan at the 
institution will be followed for an appropriate method of disposal.
V. Blood sampling for biologic correlative studies
1) Collection of peripheral blood
A
Research blood collection for correlative studies is to be performed at Baseline/Week -
2, Week 1, Week 7, and Week 13. 
a)
Baseline/Week 2: Approximately 20 mL of blood will be collected in 1 green top tubes 
and 1 red top tube. 
b)
Week 1: Approximately 20 mL of blood will be collected in 1 green top tube and 1 red 
top tube. 
c)
Week 7: Approximately 20 mL of blood will be collected in 1 green top tube and 1 red 
top tube. 
d)
Week 13: Approximately 20 mL of blood will be collected in 1 green top tube and 1 red 
top tube. 
B
The RCINJ Biospecimen Repository Service (BRS) will process, label and store the blood 
samples. 
C
Peripheral blood will be collected by venipuncture into venous blood collection tubes (Red 
Top tubes with no additive; for example, BD vacutainers catalog# 366430 and Green Top 
tubes with sodium heparin; for example BD vacutainers catalog# 366480). 
D
The samples will be transported at room temperature (18°C to 25°C) in a double container 
from the collection site to the sample processing laboratory.
E
Red Top tubes for serum processing should be kept sitting upright at room temperature for 
at least 30 minutes and at most 60 minutes prior to processing to allow clotting. If the blood 
is not immediately processed after the clotting period, then tubes should be stored (after the 
30-60 minutes of clotting time) at 4oC for no longer than 4 h.
F
Green Top tubes for peripheral blood mononuclear cell (PBMC) processing should be kept on 
a rocker at room temperature until processed (to avoid clotting) and processed as soon as 
possible (within 4 h maximum) after blood collection. 
G
The collection tubes will be labeled with the patient ID, date, and time of venous blood draw.
2) Processing of peripheral blood
A
The RCINJ Biospecimen Repository Service (BRS) will process, label and store the 
blood samples until delivery to the analysis lab. 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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B
Peripheral blood from Red Top tubes will be used for serum acquisition and peripheral 
blood from green top tubes will be used for PBMC acquisition..
C
Red Top tubes will be processed as follows:
a) Red Top tubes will be centrifuged for 20 minutes at 1400 rpm at room 
temperature. 
b) Using a pipette, serum from both Red Top tubes will be transferred into a 50 ml 
conical tube and mixed. 
c) The serum will then be pipetted into the labeled cryovials at an aliquot volume of 
250-500 μl per tube. The caps on the vials will be closed tightly.
d) This process should be completed within 1 hour of centrifugation.
e) Care must be taken to not pick up red blood cells when aliquoting. This can be 
done by keeping the pipet above the red blood cell layer and leaving a small 
amount of serum in the tube.
f)
All aliquots will be stored upright at -80ºC or colder freezer in a specimen box. 
D
Green Top tubes will be processed as follows:
a) Green Top tubes will be mixed by inverting the tube gently 6 to 8 times. 
b) Up to 10 ml of peripheral blood will be added to 10 ml of PBS in a 50 ml Falcon 
tube and mixed by inverting the tube gently 6 to 8 times. 
c) The 20 ml peripheral blood/PBS mixture will be overlayed by slow careful pipetting 
onto a 20 ml layer of Ficoll in a 50 ml tube. 
d) The peripheral blood/PBS/Ficoll tube will be centrifugated for 20 min at 1750 rpm 
at room temperature without the break. 
e) Using a transfer pipette the clear top plasma layer will be removed and discarded 
as biological waste.
f)
Using a new transfer pipette, the cloudy PBMC layer will be transferred to a 50 ml 
conical tube. 
g) Care must be taken not to disrupt the erythrocyte layer during the transfer by 
using gentle pipetting above the Ficoll layer and keeping the tube stationary.
h) The cells will be counted (using a standard hemocytometer) and the total cell 
count recorded.
i)
PBS will be added to the PBMC tube up to the 50 ml mark and the tube will be 
centrifugated for 5 min at 1750 rpm at room temperature with the break.
j)
The supernatant will be discarded and the pellet dissolved in Cryopreserve 
solution (1 ml Cryopreserve solution per 1 ml of blood) and transferred to cryovials 
(1 ml per cryovial). The cell concentration and solution volume will be recorded.
k) All aliquots will be stored upright at -80ºC or colder freezer in a specimen box. 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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VI. Delivery to Analysis Laboratory and Storage
1) Upon receipt of the samples an entry will be made and sample number issued for the 
expected sample in the Biospecimen Repository Database.
2) Samples stored in liquid nitrogen and formalin will be delivered to the laboratory as 
needed for batch processing.  BRS will deliver samples to:
Daniel J. Medina, PhD
Immune Monitoring Core
195 Little Albany Street, Room 4531
New Brunswick, NJ 08901
Phone: (732) 235-5641
Once specimens arrive at analysis lab, they will be immediately placed at 4oC (for formalin-
fixed tumor tissue) or -80ºC (or lower for all other tissues and PBMCs) for pending correlative 
science work or for storage.
VII. Correlative Analyses 
A. Immunophenotyping
a) Immune cells in the blood and the tumor will be profiled using cells obtained from 
RPMI-preserved tumor tissue samples and PBMCs (controls) obtained from 
peripheral blood using flow cytometry to look for TILs, Tregs, MDSC, TAM and other 
immune cells. 
b) Tumor biopsy tissue will be preserved in RPMI solution and PBMCs frozen at -80oC or 
colder and delivered to the Rutgers CINJ Immune Monitoring Core. 
c) Tumor samples will be dissociated into a single-cell suspension by the Rutgers CINJ 
Immune Monitoring Core, as described below.
d) Cell in single suspension of tumor or PBMCs (controls) will be analyzed by the Rutgers 
CINJ Immune Monitoring Core utilizing 14-parameter flow cytometry with an LSR-II 
flow cytometer, whereby cells will be stained with fluorescent antibodies to the 
validated cell markers (purchased primarily from eBioscience, Biolegend, and BD 
Biosciences). 
e) Cell population ratios will include identifying cells as cytotoxic CD8+ T cells (Tcs), CD4+ 
helper T cells (Ths) regulatory CD4+ T cells (Tregs), MDSCs, B cells, NK cells, and DCs. 
f)
Markers evaluated will include CD3, CD4, CD8, CD11b, CD11c, CD14, CD16, CD19, 
CD25, CD33, CD45RA, CD56, CD80, CD86, CCR7, FoxP3, Granzyme B, HLA-DR, NKp46, 
PD-1, and PD-L1. 
g) Specifically:
(i) The tumor tissue will be mechanically dissociated upon receipt using a 
GentleMACs OctoDissociator (Miltenyi) using the B_01 program. 
Pro20170000453
           10/4/2019
           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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(ii) The resulting tumor-derived cells will be passed through a 70 µm screen (BD 
Biosciences) to ensure a single cell suspension, and washed in PBS, and frozen 
down, as described previously at 2x106 in cryopreservation solution at -80oC 
or colder.
h) Frozen cells from tumor tissue will be thawed quickly by immersion of the bottom 
90% of the cryovial in a 37oC water bath and washed once in PBS (with centrifugation 
and reconstitution of the cell pellet in 50 µl PBS per sample in a 96 well plate) prior to 
flow cytometric antibody staining.
i)
For extracellular markers:
j)
Plates with cells to be stained will be centrifuged at standard conditions (4°C, 1500 
rpm, 5 min) and decanted by inversion.
k) Extracellular marker antibodies will be added at titrated concentrations (for example, 
0.5 µl antibody in 50 µl of PBS for antibodies used at 1:100).
l)
The plate will be incubated in the dark for 30 minutes at room temperature and then 
centrifuged at standard conditions and washed once with PBS.
m) Cells not requiring intracellular staining (ICS) will be analyzed immediately by flow 
cytometry or fixed in 50/50 v/v 10% formalin in PBS, kept in the dark at 4oC, and 
analyzed within 24 hours. Prior to analysis, 5 µl of Countbright beads will be added to 
each well (and the bead concentration recorded from the Countbright bottle).  
n) For intracellular markers:
o) Cells requiring ICS, will be centrifugated at standard conditions and reconstituted with 
100 µl of BD Perm/Fix per well, incubated at 4oC for 15 min, receive 100 µl of 10% 
PermWash to each well, and centrifuged immediately at standard conditions. 
p) The plate will be then decanted and a 100 µl ICS stain mixture (with antibodies) added 
to each well in a 10% PermWash mixture.
q) The plate will be incubated at 4oC for 30 minutes, centrifuged at standard conditions, 
decanted, washed 2x with 200 µl of 10%  PermWash per well,  centrifuged at standard 
conditions, decanted, and analyzed by flow cytometry or fixed in 10% formalin for up 
to 24 hours.
r)
Prior to analysis, 5 µl of Countbright beads will be added to each well (and the bead 
concentration recorded from the Countbright bottle).  
s)
Flow cytometry panels will be based on Optimized Multicolor Immunofluorescence 
Panel (OMIPs) published in the journal Cytometry Part A. 
http://qap2.onlinelibrary.wiley.com/journal/10.1002/(ISSN)1552-
4930/homepage/information_on_omips.htm
1) PD-L1 Expression
a) Determination of PD-L1 expression in the tumor will be conducted using tumor 
Pro20170000453
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           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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tissue samples obtained from biopsy and formalin fixed/paraffin embedded.
b) Tumor biopsy tissue will be formalin fixed at each site. 
c) Formalin-fixed tumor tissue samples will be paraffin embedded by the Immune 
Monitoring Core at Rutgers CINJ. 
d) The samples will be batched by the Immune Monitoring Core at Rutgers CINJ.
e) PD-L1 will be determined by immunohistochemistry staining. 
f)
This assay will be performed by QualTek Molecular Laboratories biomarker and 
tissue-based assay services using the BMS DAKO antibody (Dako, Carpinteria, CA). 
g) Details regarding accuracy, precision, controls, reference standards, etc. of this 
assay can be obtained from the conducting laboratory.
2) Cytokine levels  
a) Analysis of cytokines within the tumor microenvironment will be performed 
using tumor tissue obtained from RPMI-preserved samples and frozen serum 
samples.
b) Tumor biopsy tissue will be preserved in RPMI solution at each site and serum 
frozen obtained from peripheral blood and delivered to the Rutgers CINJ Immune 
Monitoring Core. 
c) Tumor tissue samples will be mechanically homogenized upon receipt using the 
GentleMACs OctoDissociator (Miltenyi), as per the manufacturer instructions.
d) Samples will be frozen at -80oC or colder until analysis of cytokines.
e) Cytokine standards will be prepared as per manufacturer instructions from the 
manufacturer’s master standard stock, for the cytokines of interest. 
f)
Biolegend 
flow 
cytometry-based 
LEGENDplex 
technology 
for 
cytokine 
multiplexing will be utilized. The LEGENDplex Human Anti-Virus Response Panel 
(Cat. No. 740390) is a bead-based multiplex assay, utilizing fluorescence-encoded 
beads suitable for use on flow cytometers. This panel allows simultaneous 
quantification of 13 human proteins, including interferons (α, β, γ, and λ), 
interleukins (1, 6, 8, 10, 12), TNF-α, IP-10 and GM-CSF. 
g) The panel has been validated by the manufacturer and is a standard assay of the 
Immune Monitory Core at Rutgers CINJ for determination of cytokine levels using 
flow cytometry (LSR2; BD). 
h) Details regarding accuracy, precision, and published references for this system are 
available from the manufacturer. 
i)
The plate will be analyzed on an LSR-II Flow Cytometer, as per the manufacturer 
instructions within 1 hour of last incubation.
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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B. Immune gene and protein expression profiling
a) Immune gene and protein expression profiling will be conducted from RNA derived 
from RNA preservation media and protein extracted from cell obtained from RPMI-
preserved tumor tissue samples. 
b) Tumor biopsy tissue will be delivered to the Rutgers CINJ Immune Monitoring Core. 
c) RNA will be extracted from frozen tissue upon receipt using RNeasy mini spin columns 
(Qiagen) according to the manufacturer’s protocol, and protein will be extracted from 
RPMI-preserved tissue cells (derived as previously described). 
d) The concentration and quality of the total RNA preparation will be determined by 
measuring absorbance at 260 and 280 nm using the Nanodrop system (Thermo 
Scientific). 
e) Each hybridization reaction will require 100-150 ng of total RNA. The integrity of the 
total RNA preparation will be verified on a Bioanalyzer (model 2100, Agilent 
Technologies) before proceeding with the hybridization reaction. RNA should be 
aliquoted (to avoid freeze/thaw cycles) and stored for up to several years at −80◦C.
f)
Hybridization of the target mRNA to the gene-specific probe pairs will be carried out 
in triplicate with each sample containing 5 μl RNA (150 ng), 10 μl reporter probe (final 
40 pM), 5 μl capture probe (final 200 pM), and 10 μl hybridization buffer (5× SPPE, pH 
7.5, with 0.1% Tween-20).
g) Using a thermocycler, the hybridization reaction will be conducted will be at 65oC for 
optimally 16 h (at least 12 h but not more than 30 h).
h) After the hybridization reactions are completed, post-hybridization processing will 
immediately continue using the nCounter Prep Station, as per the manufacturer 
instructions on using the instrument.
i)
After post-hybridization processing, the nCounter Digital Analyzer will be used to 
acquire images of the immobilized fluorescently labeled target mRNA and protein 
molecules in the sample cartridge using a CCD camera and a microscope objective lens 
and the expression level of a gene will be measured and tabulated in a CSV format by 
the system. 
j)
Using Excel, the individual data files will be imported into a collector file template 
provided by the analyzer manufacturer. The abundance of target mRNA and protein 
will be compared across multiple different samples and thus normalized for all target 
genes in all samples based on the positive spike-in controls to account for differences 
in hybridization efficiency and post-hybridization processing, including purification 
and immobilization of complexes. 
k) To determine if the normalized, background-subtracted counts are statistically above 
background, a Student’s t test will be performed against eight human negative 
controls. A gene will be considered to be above background if the average count for 
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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the target gene is greater than the average counts for the eight negative control genes 
and if the P value of the t test is less than 0.05.
l)
The relative changes in the abundance of target mRNA molecules and protein will be 
calculated using the normalized, background-subtracted counts for one or more 
reference genes/proteins included in the manufacturer set.
C. Angiogenesis Metabolic Pathway Analysis
a) Markers of angiogenesis will be analyzed, including IL-8 and VEGF using Western 
blotting.
b) Signal transduction in key metabolic pathways will be analyzed using Western 
blotting and will include total and pERK, total and pAKT, WNT pathway components, 
beta-catenin, M-CSF, and CCL4. 
D. Exosome Analysis
a) Exosomes will be isolated from peripheral blood using a standard isolation kit.
b) Pre- and post-treatment peripheral blood exosomes will be analyzed for exosome 
quantity (using the NanoSight instrument) and contents (using Mass Spectrometry 
and microRNA array analysis).  
VIII. Blood Samples for Pharmacokinetic (PK) Analysis  
Blood samples for PK analysis will be processed, stored, and shipped as per the graphic 
below. 
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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Labeled samples will be shipped on dry ice to inVentiv with the completed request form. 
Samples may be  stored at < -20 degrees C for up to 30 days prior to shipping and shipped in 
batches. Samples will be analyzed at inVentiv. 
inVentiv Health
2500 rue Einstein
Québec, QC, G1P 0A2
Canada
IX. Other Analyses
If samples are available, some or all of the following analyses may also be performed, 
including but not limited to: additional gene expression analysis, additional flow cytometry, 
additional IHC, proteomic analysis, TCR repertoire analysis, and tumor mutational load. No 
germline genetic sequencing will be performed. The experimental protocol will follow 
laboratory SOPs and published procedures.
Pro20170000453
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Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
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X. Safety Precautions
Universal precautions (i.e., a method of infection control in which all human blood and body 
fluids are treated as if they are infectious for Hepatitis Viruses, Human Immunodeficiency 
virus, and other known and unknown infectious agents) will be utilized when handling all 
unfixed cells and tissues.
1) Hepatitis B and Hepatitis C viruses may be transmitted through blood and other body 
fluids, and are associated with acute hepatitis, chronic liver disease, and hepatocellular 
carcinoma in humans. The probability of seroconversion after needlestick exposure is 
estimated at 7%. Untreated virus can persist for up to one week at room temperature. All 
staff who work with human tissue must provide evidence of Hepatitis B vaccination.
2) Human 
Immunodeficiency 
virus 
(HIV) 
is 
a 
retrovirus 
that 
causes 
severe 
immunodeficiency. Infection increases the risk of developing malignancies, infection by 
opportunistic organisms, and death. The probability of seroconversion after needlestick 
exposure is estimated at 0.5%. Infectivity of untreated virus persists for up to one week 
at room temperature.
3) Other potentially infectious agents, both known and unknown, pose hazards to those 
working with human tissue. Included are tuberculosis, HTLV1, Coccidiomycosis, 
Creutzfeldt-Jacob disease, amongst others.
4) Individual institutional and OSHA guidelines must be followed when handling human cells 
and tissues, and referred to for additional information on bloodborne pathogens, 
laboratory safety, chemical safety, and biohazardous waste disposal. Briefly:
5) Personal protective equipment (PPE) must be used at all times while working with human 
tissue. These include disposable latex or nitrile gloves, face shield, protective splash-
resistant laboratory coat (disposable preferred), and covered protective shoes.
6) Gloves should be immediately removed and replaced in the event that they become torn 
or perforated. Gloves must be removed prior to leaving the work area, and disposed of in 
an appropriate waste disposal container. Hands must be washed in a "clean" sink after 
removal of gloves.
7) Face shields, goggles and masks should be worn whenever a potential for exposure to 
splashes, spray, splatter, droplets, aerosols of blood or tissue fluid, or other potentially 
infectious materials may be generated, and if there is a potential for eye, nose or mouth 
contamination. They should be worn at all times while handling tissue for processing.
8) Protective lab coats, preferably disposable types, must be donned while working with 
tissue. Contaminated clothing must be removed prior to leaving the work area, and 
appropriately laundered or discarded, as per individual institutional guidelines.
Pro20170000453
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           4/3/2020

Protocol Number: RCINJ# 051707
PI Name: Jyoti Malhotra, MD
Protocol Title: A Phase I Study to Evaluate 
the Safety of Trigriluzole (FC-4157/BHV-
4157) in Combination with PD-1 Blocking 
Antibodies
93
RESERVED FOR IRB STAMP
DO NOT MODIFY THIS SPACE
Form Version v120116
9) All waste must be disposed of prior to leaving the work area. Biohazardous sharps must 
be properly disposed of in an approved "sharps" container. All other non-sharp waste 
must be disposed of in an approved orange or red biohazardous waste disposal bag.
10) After completion of work with human tissue, all work surfaces must be disinfected with a 
product that has been demonstrated to be effective against bacteria, viruses, 
pseudomonas, tuberculosis and fungi. Product literature should be referred to for 
appropriate use.
11) Any injuries or exposure to human tissue or potentially infectious biologic agents must be 
reported promptly as specified in individual institutional safety guidelines.
Pro20170000453
           10/4/2019
           4/3/2020