Phase 2 Pilot Study to Evaluate Efficacy and Safety of Anakinra to Prevent CD19-Targeted CAR-T Cell-Related Cytokine Release Syndrome (CRS) and Neurotoxicity in Patients With B Cell Lymphoma
Phase: PHASE2
Conditions: B-Cell Non-Hodgkin Lymphoma
Sponsor: Fred Hutchinson Cancer Center

 
 
Official Title 
Phase 2 pilot study to evaluate efficacy and safety of 
anakinra to prevent CD19-targeted CAR-T 
cell-related cytokine release syndrome (CRS) and 
neurotoxicity in patients with B cell lymphoma 
NCT Number 
NCT04359784 
Document Type 
Protocol and Statistical Analysis Plan 
Document Date 
6/5/2024 
 
 

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FRED HUTCHINSON CANCER CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 
 
Phase 2 pilot study to evaluate efficacy and safety of anakinra to prevent CD19-targeted CAR-T 
cell-related cytokine release syndrome (CRS) and neurotoxicity in patients with B cell lymphoma  
 
 
Current date: 05/23/2024   
Previous date: 06/23/2023   
 
 
 
Principal Investigator 
 
Professional Title 
 
Phone Number 
Jordan Gauthier, MD, MSc 
Associate Professor, FHCC 
Associate Professor, UW  
(206) 667-2713 
Investigators 
 
 
David Maloney, MD, PhD 
Professor, FHCC 
Professor, UW 
 
(206) 667-5616 
Alexandre V. Hirayama, MD 
Research Associate, FHCC 
Acting Instructor, UW 
 
(206) 667-6909 
 
Emily Liang, MD 
Hematology Oncology Fellow, 
UW/FHCC 
(206) 667-5710 
Biostatistician 
 
 
Qian (Vicky) Wu, PhD 
Assistant Professor, FHCC 
 
(206) 667-3358 
Research Staff 
 
 
Nikki Pin, RN 
Research Nurse 
(206) 667-2340 
Joseph De Los Reyes 
Clinical Research Coordinator 
(206) 667-2098 
 
 
 
EMERGENCY (24-HOUR) PHONE:  206-598-8902 
 
 

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Protocol Synopsis 
Protocol Number:  10373 (RG1006866) 
Title of Study: Phase 2 pilot study to evaluate efficacy and safety of anakinra to prevent CD19-targeted CAR-T cell-related 
cytokine release syndrome (CRS) and neurotoxicity in patients with B-cell lymphoma (B-NHL) 
Financial Support: Sobi 
Phase of Development: 2 
IND Number: 147757 
 
Study Objectives: 
Primary: 
Decrease the incidence of CRS after treatment with lisocabtagene ciloleucel (liso-cel; Breyanzi®) 
 
Secondary: 
1. Decrease the severity of CRS. 
2. Decrease the incidence and severity of neurotoxicity. 
3. Decrease the rate and duration of hospitalization. 
4. Decrease corticosteroid usage. 
5. Evaluate the safety of anakinra after liso-cel infusion.  
6. Evaluate the effect of anakinra on liso-cel efficacy for treatment of B-NHL  
 
Exploratory: 
1. To assess the pharmacokinetics of anakinra in B-NHL patients undergoing CAR T-cell therapy 
2. To evaluate the effects of anakinra on the immune system (e.g, CAR T cells, other immune cells, serum cytokine 
concentrations) 
 
Study Purpose and Rationale:   
T cells engineered with CD19-targeted chimeric antigen receptors (CD19 CAR T cells) have shown promising efficacy in 
patients with relapsed or refractory B cell malignancies, including B cell non-Hodgkin lymphomas (B-NHL), but this 
approach is limited by significant toxicities: cytokine release syndrome (CRS) and immune effector cell-associated 
neurotoxicity syndrome (ICANS). Severe toxicities have been reported across all FDA-approved CD19 CAR T cell 
products for B-NHL1-7 (grade ≥3 CRS, 2-22%; grade ≥3 ICANS, 8-37%). Murine models have shown monocyte-derived 
IL-1 and IL-6 are required for the development of CRS and ICANS after CD19 CAR T-cell therapy, and that these toxicities 
could be mitigated using anakinra (Kineret®), a recombinant, nonglycosylated form of the human interleukin-1 receptor 
antagonist. Anakinra is FDA-approved for the treatment of rheumatoid arthritis and neonatal-onset multisystem 
inflammatory disease. Early clinical data suggest anakinra might be efficacious in humans to treat severe CRS and ICANS 
after CAR T cell therapy, but there are no data to date regarding its use in the prophylactic setting. This pilot study aims at 
evaluating the feasibility and efficacy of the administration of anakinra to prevent CRS and ICANS in LBCL patients 
treated with the FDA-approved CD19 CAR T-cell product liso-cel. 

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Study Population:   
Inclusion Criteria: 
1) Subjects must be 18 years of age or older. 
2) Karnofsky performance status of ≥ 60%. 
3) Patients with B-NHL eligible for treatment with liso-cel. Patients treated with non-conforming (out-of-
specification) liso-cel may remain on study. 
4) Negative serum pregnancy test within 2 weeks of enrollment for women of childbearing potential, defined as those 
who have not been surgically sterilized or who have not been free of menses for at least 1 year. 
5) Fertile male and female subjects must be willing to use an effective contraceptive method before, during, and for at 
least 4 months after the last dose of anakinra.  
6) Ability to understand and provide informed consent.  
 
Exclusion Criteria: 
1) Subjects requiring ongoing daily corticosteroid therapy at a dose of >15 mg of prednisone 
     per day (or equivalent). Pulsed corticosteroid use for disease control is acceptable.  
2) Active autoimmune disease requiring immunosuppressive therapy is excluded unless 
    discussed with the PI.  
3) Known hypersensitivity to E coli-derived proteins, anakinra, or to any component of the 
     product. 
4) Major organ dysfunction defined as:  
a. Serum creatinine > 2.5 mg/dL  
b. Significant hepatic dysfunction (Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) > 5x 
upper limit of normal; bilirubin > 3.0 mg/dL) unless due to malignancy or Gilbert’s syndrome in the opinion of 
the PI or designee. 
c. Subjects with clinically significant pulmonary dysfunction, as determined by medical history and physical exam 
should undergo pulmonary function testing. Those with an FEV1 of < 50 % of predicted or DLCO (corrected) < 
40% will be excluded.  
d. Significant cardiovascular abnormalities as defined by any one of the following:  
    NYHA class III or IV congestive heart failure, clinically significant hypotension, 
    uncontrolled symptomatic coronary artery disease, or a documented ejection fraction of <35%. 
5)  Uncontrolled serious and active infection. 
 

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Test Product, Dose, and Mode of Administration:   
In the first 15 treated patients, anakinra 200 mg/day was administered as two simultaneous 100 mg subcutaneous injections 
daily (approximately every 24 hours) for 14 days, with the first administration approximately 2-4 hours prior to liso-cel 
infusion (day 0 through day 13). 
Prophylactic dosing: 
In the expansion cohort (n=10), anakinra will be administered first at the prophylactic dosing of 200 mg once daily 
intravenously (approximately every 24 hours) for 14 days, with the first administration approximately 2-4 hours prior to 
liso-cel infusion (day 0 through day 13). 
 
Anakinra up-titration: 
Step 1 (8 mg/kg/day): In patients who develop CRS or ICANS during anakinra prophylaxis at 200 mg/day, anakinra will be 
increased to 8 mg/kg/day. The step 1 anakinra dose will be calculated using the participant’s actual or ideal body weight as 
per PI discretion. The total daily dose will be divided over three doses in 24 hours, each dose will be rounded to the nearest 
100 mg, diluted in NaCl 0.9%, and given IV over approximately 10-30 minutes. Once CRS and ICANS symptoms are 
improved or resolved, as evaluated by the PI or designee, anakinra will be decreased to the prophylactic dosing (200 
mg/day). 
 
Step 2 (1 mg/kg/h): In the absence of improvement or worsening of CRS or ICANS symptoms despite anakinra treatment at 
8 mg/kg/day, as evaluated by the PI or designee, anakinra will be increased once to 1 mg/kg/h administered as a continuous 
IV infusion for 72 hours. The step 2 anakinra dose will be calculated using the participant’s actual or ideal body weight as 
per PI discretion, rounded to the nearest 100 mg, and diluted in NaCl 0.9%. After 72 hours of anakinra at 1 mg/kg/h, 
anakinra will be decreased to 8 mg/kg/day. Once CRS and ICANS symptoms are improved or resolved on anakinra at 8 
mg/kg/day, as evaluated by the PI or designee, anakinra will be further decreased to the prophylactic dosing. 
 
Anakinra up-titration algorithm: 
 
 
Study schema: 
 
Safety Assessments:  
Adverse events will be monitored and recorded throughout the investigative phases of the study: from the first dose of 
anakinra through day 28 after liso-cel infusion. Related AEs will be monitored until stabilization or resolution. 

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Efficacy Assessments:   
CRS and ICANS will be monitored and recorded throughout the investigative phases of the study: from the first dose of 
anakinra through day 28 after liso-cel infusion. 
Statistical Methods: 
The efficacy of anakinra in preventing the occurrence of any grade CRS will be assessed using the Bayesian optimal phase 
2 (BOP2) design with a planned interim analysis after 15 patients are treated. We will conclude that the primary endpoint is 
not met if < 9 patients without CRS are observed in the first 15 patients treated with anakinra, or if ≤18 patients without 
CRS are observed in 25 patients treated with anakinra.  
Since this is a pilot study, the decision to include the additional 10 patients might be considered based on both the primary 
and secondary endpoints. 
February 2023 update: although our interim analysis did not meet the primary endpoint, anakinra prophylaxis was 
feasible, safe, and associated with low rates of mild CRS (8/15; 53%) and ICANS (3/15; 20%). Longitudinal analyses of the 
participants’ temperature and CRP data suggested faster resolution of systemic inflammation compared to patients receiving 
liso-cel alone. Therefore, we will plan to treat 10 additional patients with the following protocol modification: change from 
SC to IV administration route, up-titration of the anakinra dose in case of breakthrough CRS or ICANS. 
Sample size:   
Up to 25 patients 
 
 
 

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TABLE OF CONTENTS 
 
Protocol Synopsis ....................................................................................................................................................... 2 
1.0 
BACKGROUND ........................................................................................................................... 8 
1.1 
CD19-targeted CAR T-cell therapy for relapsed or refractory B-cell NHL ................................................. 8 
1.2 
Significant toxicities after CD19 CAR T-cell therapy in patients with R/R B-cell NHL ............................. 8 
1.3 
Current management of CRS and ICANS in patients undergoing CD19 CAR T-cell therapy .................... 9 
2.0 
STUDY PURPOSE AND RATIONALE .................................................................................... 9 
2.1 
Description of the investigational drug product anakinra ............................................................................. 9 
2.2 
Summary of the biological effects of anakinra ............................................................................................. 9 
2.3 
Rationale for the use of anakinra to prevent CRS And ICANS after CD19 CAR T-cell therapy ................ 9 
2.3.1 
Preclinical data ....................................................................................................................................... 10 
2.3.2 
Clinical data ........................................................................................................................................... 10 
2.4 
Rationale for anakinra dosing, administration route, treatment duration, up-titration ................................ 12 
2.5 
Rationale for the use of a single CD19 CAR T-cell product ...................................................................... 13 
3.0 
STUDY OBJECTIVES AND ENDPOINTS ............................................................................. 13 
3.1 
Primary Objective ....................................................................................................................................... 13 
3.2 
Secondary Objectives .................................................................................................................................. 13 
3.3 
Exploratory Objectives ................................................................................................................................ 13 
3.4 
Primary Endpoint ........................................................................................................................................ 13 
3.5 
Secondary Endpoints ................................................................................................................................... 14 
3.6 
Projected Target Accrual ............................................................................................................................. 14 
4.0 
STUDY DESIGN AND INVESTIGATIONAL PLAN ............................................................ 14 
4.1 
Overall Study Design .................................................................................................................................. 14 
4.2 
Protocol Enrollment .................................................................................................................................... 15 
5.0 
STUDY POPULATION ............................................................................................................. 15 
5.1 
Inclusion Criteria ......................................................................................................................................... 15 
 ............................................................................................................................................ Exclusion criteria
 .................................................................................................................................................................................. 15 
5.2 ............................................................................................................................................................................. 15 
5.3 
Reproductive Potential and Contraception Requirements .......................................................................... 16 
6.0 
TREATMENT PLAN ................................................................................................................. 16 
6.1 
Anakinra Treatment .................................................................................................................................... 16 
6.2 
Anakinra Drug Product ............................................................................................................................... 18 
6.3 
Liso-cel treatment ........................................................................................................................................ 18 
7.0 
POTENTIAL RISKS OF ANAKINRA TREATMENT .......................................................... 18 
7.1 
Management of Other Toxicities ................................................................................................................ 19 
8.0 
INFORMED CONSENT OF SUBJECT AND DONOR ......................................................... 20 
9.0 
SUBJECT REGISTRATION .................................................................................................... 20 
10.0 
CLINICAL AND LABORATORY EVALUATIONS ............................................................. 20 
10.1 
Screening & prelymphodepletion evaluations ............................................................................................ 20 
10.2 
Evaluations on the day of liso-cel infusion (day 0) ..................................................................................... 21 
10.3 
Evaluations following liso-cel infusion ...................................................................................................... 21 
10.4 
Evaluations before and after each anakinra administration ........................................................................ 22 

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10.5 
Research Blood samples ............................................................................................................................. 22 
Pharmacokinetic samples ......................................................................................................................................... 22 
10.6 
Assessment of Disease Response to CAR-T Cell Therapy ......................................................................... 22 
10.7 
Long-Term Follow-up ................................................................................................................................. 22 
11.0 
ADVERSE EVENT REPORTING ........................................................................................... 23 
11.1 
Adverse Event Definitions .......................................................................................................................... 23 
11.2 
Monitoring and Recording Adverse Events ................................................................................................ 23 
11.3 
Grading of the Severity of an Adverse Event ............................................................................................. 24 
11.4 
Attribution of Adverse Event ...................................................................................................................... 24 
11.5 
Adverse Event Reporting Period ................................................................................................................. 25 
11.6 
Adverse Event Reporting Requirements ..................................................................................................... 25 
12.0 
STATISTICAL CONSIDERATIONS ...................................................................................... 25 
12.1 
Primary endpoint: ........................................................................................................................................ 25 
12.2 
Secondary Endpoints ................................................................................................................................... 26 
12.3 
Data Analysis .............................................................................................................................................. 26 
12.4 
Stopping Rules ............................................................................................................................................ 27 
13.0 
DATA AND SAFETY MONITORING PLAN ........................................................................ 27 
13.1 
Overall Scope of Monitoring Activities ...................................................................................................... 27 
13.2 
Monitoring the Progress of Trial and Safety of Participants ....................................................................... 28 
14.0 
DATA MANAGEMENT/CONFIDENTIALITY ..................................................................... 28 
15.0 
TERMINATION OF STUDY .................................................................................................... 28 
16.0 
REFERENCES ............................................................................................................................ 30 
APPENDIX A:  ASTCT Cytokine Release Syndrome (CRS) Consensus Grading45 .............................................. 33 
APPENDIX B. 2014 NIH CRS Grading (“Lee criteria”) ........................................................................................ 34 
APPENDIX C: ASTCT ICANS* Consensus Grading45 .......................................................................................... 35 
 
 
 
 

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1.0 BACKGROUND 
 
This is a phase 2 pilot study to evaluate the efficacy and safety of anakinra to prevent CD19-targeted 
CAR-T cell-related cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity 
syndrome ICANS in patients with B-cell non-Hodgkin lymphoma (B-NHL). The study will be 
conducted in compliance with the Institutional Review Board (IRB) approved protocol, associated 
Federal regulations and all applicable IRB requirements. 
 
1.1 
CD19-targeted CAR T-cell therapy for relapsed or refractory B-cell NHL 
Immunotherapy with T cells engineered to express a CD19-targeted chimeric antigen receptor (CD19 
CAR T-cell therapy) has shown promising efficacy in patients with relapsed or refractory B cell 
malignancies. To date, three CD19-targeted CAR-T cell products have already been approved by the FDA 
for patients with R/R B-NHL: axicabtagene ciloleucel (axi-cel; Yescarta®) and tisagenlecleucel (tisa-cel, 
Kymriah®) for R/R large B cell lymphoma (LBCL), and brexucabtagene autoleucel (brexu-cel; 
Tecartus®) for R/R mantle cell lymphoma based on the pivotal clinical trials ZUMA-11, JULIET3, and 
ZUMA-26, respectively. Another CD19 CAR T-cell product, lisocabtagene ciloleucel (liso-cel; 
Breyanzi®), was recently approved by the FDA for R/R B-NHL based on the results of the TRANSCEND 
NHL 001 clinical trial7. In this high-risk population, overall and complete responses were achieved in 52-
93% and 40-67% of patients, respectively. 
 
1.2 
Significant toxicities after CD19 CAR T-cell therapy in patients with R/R B-cell NHL 
The promising results of CD19 CAR-T cell therapy in R/R B-cell NHL are tempered by two potentially 
life-threatening toxicities: CRS and ICANS. The incidence, severity, and timing of CRS and ICANS 
across pivotal trials and non-trial settings are detailed in Table 1. Higher incidence of severe CRS and 
ICANS have been reported after axi-cel and brexu-cel treatment compared to tisa-cel and liso-cel. While 
the most favorable toxicity profile has been observed after liso-cel, 42% and 30% of patients treated on 
the TRANSCEND clinical trial still experienced any grade CRS and ICANS, respectively. 
 
Table 1. CRS and ICANS after CD19 CAR T-cell therapy for R/R LBCL 
 
Axi-cel 
Brexu-cel 
Tisa-cel 
Liso-cel 
 
ZUMA-11 
Nastoupil et al 8 
Jacobson et al 9 
ZUMA-26 
JULIET3 
TRANSCEND7 
No. of patients treated 
101 
275 
122 
60 
93 
269 
CRS (graded according to the 2014 Lee criteria for all studies except JULIET*) 
Any grade  / ≥ grade 3 
93 % / 11% 
91% / 7% 
93% / 16% 
91%/15% 
58%/22% 
42%/2% 
Median time to onset, 
range 
2 days (1-12) 
NR 
3 days (0-20) 
3 days (1-13) 
3 days (3-9) 
5 days (1-14) 
Median duration, range 
8 days (NR) 
NR 
6 days (1-27) 
10 days (1-50) 
7 days (2-30) 
NR 
ICANS (graded according to the CTCAE 4.03) 
 
 
 
Any grades / ≥ grade 3 
64 % / 28% 
69% / 31% 
70% / 35% 
63%/31% 
21%/12% 
30%/10% 
Median time to onset, 
range 
5 days (1-17) 
NR 
5 days (0-34) 
6 days (1-32) 
6 days (1-17) 
9 days (1-66) 
Median duration, range 
17 days (NR) 
NR 
7 days (1-52) 
21 days (2-454) 
14 (NR) 
NR 
Abbreviations: Axi-cel, axicabtagene ciloleucel; brexu-cel, brexucabtagene autoleucel; tisa-cel, tisagenlecleucel; liso-cel, lisocabtagene 
maraleucel; CRS, cytokine release syndrome; ICANS, immune effector cell-associated neurotoxicity syndrome; NR, not reported. *CRS 
graded using the PENN scale. 
 
 

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1.3 
Current management of CRS and ICANS in patients undergoing CD19 CAR T-cell therapy 
 
The current management of CRS and ICANS recommended in the product-specific Risk Evaluation and 
Mitigation Strategies10,11 are based on the use of tocilizumab (IL-6 receptor[IL-6R]-directed monoclonal 
antibody) and corticosteroids, which showed efficacy in early phase I/II clinical trials of CD19 CAR T-
cell therapy12-15. While tocilizumab can efficiently treat CRS in most patients, it may not be as effective 
in preventing or treating ICANS.16 This might be due to: (i) the poor CNS penetration of tocilizumab when 
administered intravenously17; (ii) the increase in the serum concentrations of IL-6 following tocilizumab 
administration, possibly due to impaired IL-6R-mediated clearance of IL-618, and receptor-mediated 
endocytosis of the IL-6R upon binding to tocilizumab.19  
Overall, the efficacy of tocilizumab and corticosteroids remain suboptimal, particularly to prevent or treat 
ICANS; this represents a critically unmet need to improve the toxicity profile of CD19 CAR T-cell 
therapies. 
2.0 STUDY PURPOSE AND RATIONALE 
 
2.1 
Description of the investigational drug product anakinra 
 
Anakinra (Kineret®) is a recombinant, nonglycosylated form of the IL-1R antagonist (IL-1Ra), which is 
FDA-approved for the treatment of rheumatoid arthritis and Neonatal-Onset Multisystem Inflammatory 
Disease (NOMID). Anakinra differs from native human IL-1Ra in that it has the addition of a single 
methionine residue at its amino terminus. Anakinra consists of 153 amino acids and is a large molecule 
with a molecular weight of 17.3 kilodaltons. Anakinra is produced by recombinant DNA technology using 
an Escherichia coli bacterial expression system.  
 
2.2 
Summary of the biological effects of anakinra 
 
IL-1 is a pleiotropic cytokine produced primarily by monocytes and macrophages in response to 
inflammatory stimuli, which mediates various inflammatory and immunological responses20. The 
biological effects of IL-1 are in part regulated by IL1-Ra. The natural IL-1Ra is produced primarily by 
monocytes and macrophages in response to a wide range of stimuli (e.g., lipopolysaccharide21, bacterial 
endotoxin22, IL-1 alpha, IL-3, IL-4 and GM-CSF23). IL-1Ra competitively binds to both type I and type 
II IL-1 receptors, at least partially blocking cellular responses mediated by IL-1-alpha and IL-1-beta. 
Compared to natural IL-1Ra, anakinra retains a comparable ability to inhibit IL-1 binding in vitro.24,25 In 
vitro studies showed that a 50% inhibition of IL-1-induced biological responses required amounts of 
anakinra up to 100-fold in excess of the amounts of IL-l alpha or IL-1 beta present26. In a primate model, 
a 1,000 fold molar excess of anakinra could successfully inhibit the hemodynamic effects of IL-1-alpha 
administration27. 
 
2.3 
Rationale for the use of anakinra to prevent CRS And ICANS after CD19 CAR T-cell therapy 
 

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2.3.1 
Preclinical data 
Using immunodeficient beige mice receiving intraperitoneal injection of Raji cells followed by human 
CD19 CAR T cells, Giavridis et al28 induced CRS, but only in mice who developed high tumor burden. 
Importantly, the authors failed to induce CRS under the same conditions using NSG mice, which are 
known to harbor development and maturation defects of monocytes and macrophages. In the beige mice, 
human CD19 CAR T cells activated peritoneal macrophages, which were the main source of IL-6. 
Treatment with a blocking antibody against the murine IL-6R in this model prevented CRS-related 
mortality. Furthermore, peritoneal macrophages produced high levels of inducible nitric oxide synthase 
(iNOS), and CRS severity could be diminished using iNOS inhibitors. Since iNOS production was both 
IL-6 and IL-1-dependent, the authors administered anakinra intraperitoneally to antagonize the IL-1R, 
which successfully prevented CRS while preserving anti-tumor efficacy. Despite the limitations of a non-
humanized mouse model (e.g., peritoneal disease, murine myeloid lineage, anakinra administered 
intraperitoneally instead of subcutaneously in humans), this data suggest anakinra may be efficacious at 
preventing or treating CRS. 
 
Norelli et al29 described a humanized mouse model more closely reflecting human biology, by providing 
bystander human hematopoiesis and generating xenotolerant CAR T cells. To achieve this, the authors 
transplanted human cord blood hematopoietic stem and progenitor cells into sublethally irradiated triple 
transgenic NSG (SGM3) mice expressing human stem cell factor, granulocyte-macrophage colony-
stimulating factor (GM-CSF), and IL-3. CAR T cells were then engineered from human T cells that 
matured in the newborn humanized SGM3 mice (nHuSGM3). Intravenous infusion of CD19 or CD44v6-
targeted nHuSGM3 CAR T cells did not cause CRS in non-humanized SGM3 mice. In contrast, when 
infused into humanized mice CAR T cells caused a significant systemic inflammatory syndrome 
resembling CRS, characterized by severe weight loss, increased systemic human IL-6, TNF-a, IL-10 
levels and high fever. In this model, CRS occurred in the absence of tumor, due to the presence of normal 
human CD19+ B cells and CD44v6+ myeloid cells, but was worsened in the presence of tumor. Single 
cell RNA sequencing revealed that human monocytes were the predominant source of IL-1 and IL-6 
during CRS. They observed distinct cytokine kinetics, IL-1 production preceding IL-6 production by 
approximately 24 hours. Although both IL-1R and IL-6R blockage prevented CRS without impacting 
CAR T-cell expansion or antitumor effects, only anakinra prevented the development of fatal ICANS. 28,29. 
These findings strongly suggest the early administration of anakinra could abrogate CRS and ICANS after 
CD19 CAR T-cell therapy. 
2.3.2 
Clinical data 
Anakinra treatment was shown to be effective in treating CRS associated with hemophagocytic 
lymphohistiocytosis (HLH) features in children and young adults with B-ALL receiving CD22-targeted 
CAR T cells30. After incorporation of CD8+ and CD4+ T cell selection (TCS) in the starting leukapheresis 
material at the second dose level (DL2), more participants developed HLH-like manifestations (DL2, 3 of 
18; DL2-TCS, 5 of 7; P = .017), despite a similar incidence and grade of CRS, with a higher frequency of 
participants at DL2-TCS developing coagulopathy. HLH-like toxicities occurred only in participants who 
experienced CRS; 19 (38%) of 50 participants with CRS developed HLH-like manifestations. The average 
time to onset of HLH-like features was 14 days (range, 7-26 days) post-CAR, and CRS was generally 
resolved or resolving before the onset of HLH-like manifestations. The incidence of HLH-like toxicities 
was higher in those who underwent TCS (16 [55.2%] of 29 versus 3 [14.3%] of 21; P = .0039). Peak 
ferritin was substantially higher in those at DL2 versus DL2-TCS and among all who received a product 
with TCS, with a median ferritin of 163,200 mg/L (range, 5,769-565,510 mg/L) versus 14,349 mg/L 
(range, 106-590,100 mg/L; P = .0007). Peak IL-1β serum concentrations were significantly higher in 

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patients who received CAR T cell products with TCS compared to patients who received a bulk product 
(median, 1.1pg/mL versus 0.7 pg/mL; IQR, 0.8-7 pg/mL versus 0.5-1.1 pg/mL, respectively; p=0.030). 
HLH-directed treatment was initiated in 14 of 58 participants (24%) because of worsening laboratory 
parameters or clinical symptoms (e.g., pulmonary edema; renal dysfunction; worsening coagulopathy; 
steadily increasing inﬂammatory markers concerning for a worsening trajectory or symptomatic global 
inﬂammation, such as noninfectious cholecystitis). Systematic use of anakinra at starting doses of 5-8 
mg/kg/day subcutaneously was incorporated to treat or prevent worsening of HLH-like manifestations in 
participants with clinically relevant ﬁndings on the basis of data in treatment of secondary HLH. Treatment 
was initiated with anakinra alone (n = 3), corticosteroids plus anakinra (n = 5), or corticosteroids alone (n 
= 6). All treated participants had resolution of HLH-like toxicities without any apparent negative impact 
on response or CAR T-cell expansion. In one participant, HLH-like manifestations developed at day 28 
after bone marrow restaging revealed a minimal residual disease–positive CR. Within 1 month of anakinra 
monotherapy, all laboratory abnormalities normalized, and subsequent restaging demonstrated ongoing 
CAR activity with eradication of MRD. The efficacy of anakinra on ICANS symptoms was not 
specifically reported. 
A retrospective case series (n=8) by Strati et al suggested anakinra may be efficacious in treating severe 
or refractory CRS and ICANS in LBCL patients receiving axi-cel31. The indication for the use of anakinra 
was high-grade ICANS in 6 patients and HLH in 2 patients. At the time of initiation of anakinra, the 
median cumulative dexamethasone equivalent dose was 273 mg (range, 0-1344), and the median 
cumulative tocilizumab dose was 1080 mg (range, 0-1480; with a median of 2 doses of 8 mg/kg each). 
Anakinra was started at a median of 12 days (range, 6-41) after axi-cel infusion, with a median daily dose 
of 100 mg (range, 50200 mg) subcutaneously, for a median of 7 days (range, 1-7) and a median cumulative 
dose of 700 mg (range, 200-700 mg). Although none of the patients continued to receive tocilizumab after 
initiation of anakinra, all continued to receive corticosteroids, for a cumulative dexamethasone equivalent 
dose of 722 mg (range, 10-1545 mg). Overall, 4 patients (50%) had a clinical response after initiation of 
anakinra, and 4 (50%) were refractory. In all 4 responders, the indication for use of anakinra was high-
grade ICANS, and all received 100 mg SC daily for 7 days. Patient 1 started anakinra on day 6 for grade 
4 ICANS (after a cumulative dexamethasone dose of 336 mg and a cumulative tocilizumab dose of 1480 
mg), with durable conversion to low-grade ICANS on day 10 and a decrease to grade 0 on day 22 (a 
cumulative dexamethasone dose of 1081 mg was provided during treatment with anakinra). The patient 
achieved complete response (CR) on day 30 and was in remission 9 months after axi-cel infusion. Patient 
2 started anakinra on day 41 for grade 3 ICANS (after a cumulative dexamethasone dose of 1344 mg and 
a cumulative tocilizumab dose of 1180 mg), with durable conversion to low-grade ICANS on day 46 (a 
cumulative dexamethasone dose of 333 mg was provided during treatment with anakinra). The patient 
died of severe pneumonia on day 80, while in CR and with persistent grade 1 ICANS (mild cognitive 
impairment). Patient 3 started anakinra on day 31 for grade 3 ICANS (with no previous exposure to 
corticosteroids and/or tocilizumab), with a decrease to grade 0 on day 35 (a single dose of dexamethasone 
10 mg was provided during treatment with anakinra), but died of HLH on day 71, while in CR. Patient 4 
started anakinra on day 7 for grade 4 ICANS (after a cumulative dexamethasone dose of 140 mg and a 
cumulative tocilizumab dose of 1400 mg), with temporary conversion to lowgrade ICANS on day 13 (a 
cumulative dexamethasone dose of 1336 mg was provided during treatment with anakinra). After the 
patient completed 7 days of anakinra, high-grade (grade ≥3) ICANS recurred on day 16, and he died of 
progressive LBCL on day 18. 
 

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In the pivotal clinical trial ZUMA-1, investigating the use of axi-cel in patients with relapsed or refractory 
LBCL, higher IL-1R antagonist peak serum concentrations were associated with CRS and ICANS 
severity32. 
 
An interim analysis of the first 15 patients treated on this protocol with subcutaneous (SC) anakinra, all 
patients received all doses of anakinra as planned, without dose adjustments or interruptions, and there 
were no adverse events (AEs) attributed to anakinra. The rates of any grade CRS and ICANS were 53% 
(≥ grade 3: n = 1) and 20% (all ≥ grade 3), respectively, which are lower than those in patients treated at 
our institution who received liso-cel without prophylactic anakinra (CRS: 68%; ICANS: 27%). We also 
observed faster resolution of inflammatory biomarkers, such as temperature, CRP, and IL-6. Day+28 
complete and overall response rates were comparable in the two cohorts (complete response rate: 33% in 
anakinra cohort vs. 45% in no-anakinra cohort; overall response rate: 75% in anakinra cohort vs. 85% in 
no-anakinra cohort). 
 
2.4 
Rationale for anakinra dosing, administration route, treatment duration, up-titration 
Dosing 
We hypothesize the low RA flat dose of 100 mg/day may not be sufficient to mitigate ICANS after CD19 
CAR T-cell therapy. Anakinra is a large 17kD-molecule with low permeation into the CSF; high doses of 
anakinra are needed to achieve neuroprotective concentrations in rhesus monkey models of NOMID33, 
and in humans developing subarachnoid hemorrhage34. NOMID, which is characterized by chronic aseptic 
meningitis, typically respond to higher doses of anakinra (1-8 mg/kg/day). As described above, higher 
anakinra doses (5-8 mg/kg/day) have been used safely and successfully to treat CAR T-cell related CRS 
with HLH features30. Very high doses of anakinra were also shown to be safe in patients with sepsis35 (1-
2 mg/kg/h intravenously (IV), acute GVHD36-38 (up to 3200 mg/day IV), stroke39 (2 mg/kg/h IV), and 
subarachnoid hemorrhage34,40 (100-500 mg bolus, then 2-10 mg/kg/h IV). In healthy human subjects 
anakinra doses up to 10 mg/kg IV are not associated with clinical symptoms, and the authors did not report 
impairment of in vitro T cell proliferation41. 
 
Pharmacokinetic studies in healthy adults across a spectrum of body weights have demonstrated that the 
maximum plasma concentration of anakinra (Cmax) is up to 30-fold higher with IV administration 
compared to SC administration (~20,000-30,000 ng/mL vs. ~600-1,000 ng/mL). In addition, the area 
under the concentration-time curve (AUC) was also higher in patients receiving IV anakinra (~10,000-
15,000 ng-hour/mL vs. ~8,000-13,000 ng-hour/mL). No new safety concerns were observed42.  
Therefore, we hypothesize that the IV route will improve the efficacy of anakinra to prevent CRS and 
ICANS. Anakinra 200 mg will be diluted in 200 mL of sodium chloride 0.9% and administered over 
approximately 10-30 minutes once daily (prophylactic dose), which can be practically administered in the 
outpatient setting. Given the encouraging safety data and response rates in patients who received SC 
anakinra, we do not anticipate significant AEs or impact on CAR T-cell efficacy associated with IV 
administration. 
 
Administration schedule 
To assess our primary objective – to decrease the incidence of CRS of any grade after treatment with liso-
cel – anakinra will be administered IV, first at the prophylactic dose of 200 mg/day for 14 days (through 
day +13 after liso-cel infusion). The first dose of anakinra will be administered approximately 2-4 hours 
prior to CAR T-cell infusion. 
 

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Treatment duration 
Since ICANS after CD19 CAR T-cell therapy is in most cases delayed (median time to onset, 5-9 days) 
and prolonged (median duration, 7-14 days), anakinra will be administered for 14 days after liso-cel 
infusion. 
 
Up-titration of anakinra during CRS and ICANS 
 
Given the high variance in the degree of systemic inflammation observed across patients during CRS and 
ICANS, we hypothesize a two-step, clinically driven, up-titration of the anakinra dose will decrease 
CRS/ICANS severity and accelerate symptom resolution. Up-titration of anakinra has been previously 
reported to treat CRS or ICANS43, and secondary HLH44. Details regarding up-titration of the anakinra 
dose are provided in Section 6.1. 
 
2.5 
Rationale for the use of a single CD19 CAR T-cell product 
Pivotal clinical trial data suggest significant differences in the incidence and severity of CRS and 
ICANS across FDA-approved CAR T-cell products. Since this is a pilot study with limited sample 
size, we will restrict the inclusion criteria to patients treated with liso-cel to analyze a population with 
a more homogeneous risk of CRS/ICANS. 
3.0 STUDY OBJECTIVES AND ENDPOINTS  
 
3.1 
Primary Objective 
 
Decrease the incidence of CRS by day 28 after liso-cel treatment for B-NHL. 
 
3.2 
Secondary Objectives 
 
1. Decrease the severity of CRS by day 28 after liso-cel treatment . 
2. Decrease the incidence and severity of neurotoxicity by day 28 after liso-cel treatment. 
3. Decrease the rate and duration of hospitalization 
4. Decrease corticosteroid usage after liso-cel treatment 
5. Evaluate safety of anakinra use after CAR-T cell infusion. 
6. Evaluate the effect of anakinra on liso-cel efficacy for treatment of B-NHL, as evaluated at 
approximately day 28 and day 90 after treatment.  
 
3.3 
Exploratory Objectives 
 
1. To assess the pharmacokinetics of anakinra in B-NHL patients undergoing treatment with liso-cel 
2. To evaluate the effects of anakinra on the immune system (e.g., CAR T cells in vivo kinetics, other 
immune cells, serum cytokine concentrations) 
 
3.4 
Primary Endpoint 
 

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Absence of any grade CRS 
3.5 
Secondary Endpoints 
 
• Peak CRS grade according to the 2019 American Society for Transplantation and Cellular Therapy 
(ASTCT) consensus criteria45 within 28 days after liso-cel infusion. CRS will also be graded 
according to the 2014 NIH criteria46 to allow comparisons to historical controls. 
• Peak ICANS grade according to the 2019 ASTCT consensus criteria45 within 28 days after liso-cel 
infusion. ICANS will also be graded according to the NCI CTCAE Version 5.0 to allow 
comparisons to historical controls. 
• Rate and duration of hospitalization after liso-cel treatment. 
• Cumulative corticosteroids dose within 28 days after liso-cel infusion. 
• Adverse events (AEs) according to the NCI CTCAE Version 5.0 within the first 28 days after liso-
cel administration. 
• Disease response to CAR T-cell therapy approximately 28 days and 90 days after CAR T-cell 
infusion according to the Lugano criteria47. 
3.6 
Projected Target Accrual 
 
Table 1: Targeted / Planned Enrollment 
Ethnic Category 
            Patient Numbers                  
Females     Males 
Total 
Hispanic or Latino 
0 
0 
0 
Not Hispanic or Latino 
10 
15 
25 
Ethnic Category Total of All Subjects 
10 
15 
25 
Racial Category 
 
 
 
American Indian / Alaska Native 
0 
0 
0 
Asian 
0 
0 
0 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
0 
0 
0 
White 
10 
15 
25 
More than One Race 
0 
0 
0 
Racial Categories:  Total of All Subjects 
10 
15 
25 
4.0 STUDY DESIGN AND INVESTIGATIONAL PLAN 
 
4.1 
Overall Study Design 
 
Phase 2 single-center pilot study to evaluate the efficacy and safety of anakinra to prevent liso-cel-
related CRS and neurotoxicity 
 
 

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Figure 1. Study Schema 
 
4.2 
Protocol Enrollment 
 
Enrollment is expected to take approximately 2 years.  Disease restaging should be performed per 
standard of care approximately 28 and 90 days after liso-cel infusion. The study team may contact the 
local oncologist office by a letter/phone call to request the results of the day 90 restaging. 
5.0 STUDY POPULATION 
 
The target study population consists of adult patients with B-NHL receiving treatment with liso-cel. 
Patients must meet all of the inclusion criteria and have none of the exclusion criteria to be enrolled in 
this study.  
 
5.1 
Inclusion Criteria 
 
Results of tests and/or procedures conducted as per standard of care purposes may be used for research 
purposes if conducted within the protocol-defined window prior to screening/leukapheresis and/or T-
Cell Therapy.  
1) Subjects must be 18 years of age or older. 
2) Karnofsky performance status of ≥ 60%. 
3) Patients with B-NHL and eligible for treatment with liso-cel. Patients treated with non-
conforming (out-of-specification) liso-cel may remain on study. 
4) Negative serum pregnancy test within 2 weeks of enrollment for women of childbearing 
potential, defined as those who have not been surgically sterilized or who have not been free of 
menses for at least 1 year. 
5) Fertile male and female subjects must be willing to use an effective contraceptive method before, 
during, and for at least 4 months after the last dose of anakinra.  
6) Ability to understand and provide informed consent.  
5.2 
Exclusion criteria 
1) Subjects requiring ongoing daily corticosteroid therapy at a dose of >15 mg of prednisone per day 
(or equivalent). Pulsed corticosteroid use for disease control is acceptable.  
2) Active autoimmune disease requiring immunosuppressive therapy is excluded unless discussed 
with the PI.  
3) Known hypersensitivity to E coli-derived proteins, anakinra, or to any component of the product. 
4) Major organ dysfunction defined as:  

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a. Serum creatinine > 2.5 mg/dL  
b. Significant hepatic dysfunction (Alanine aminotransferase (ALT) and aspartate  
aminotransferase (AST) > 5x upper limit of normal; bilirubin > 3.0 mg/dL) unless due to 
malignancy or Gilbert’s syndrome in the opinion of the PI or designee. 
c. Subjects with clinically significant pulmonary dysfunction, as determined by medical history 
and physical exam should undergo pulmonary function testing. Those with an FEV1 of < 50 % 
of predicted or DLCO (corrected) < 40% will be excluded.  
d. Significant cardiovascular abnormalities as defined by any one of the following:  
    NYHA class III or IV congestive heart failure, clinically significant hypotension, 
    uncontrolled symptomatic coronary artery disease, or a documented ejection fraction of <35%. 
5)  Uncontrolled serious and active infection.  
 
5.3 
Reproductive Potential and Contraception Requirements 
Pregnancy test for females of reproductive potential must be negative within 2 weeks before enrollment. 
Any female patient who does not meet at least one of the following criteria will be considered to have 
reproductive potential: 
• Post-menopausal for at least 12 consecutive months (i.e., no menses), or 
• Undergone a sterilization procedure (hysterectomy, salpingectomy, or bilateral     
   oophorectomy; tubal ligation is not considered a sterilization procedure) 
Female subjects with reproductive potential who are not sexually abstinent and male subjects who are 
sexually active with females of reproductive potential must agree to use a suitable method of 
contraception for the duration of the study and for at least 4 months after the last dose of anakinra, for 
example: 
• Condom with spermicidal agent 
• Diaphragm or cervical cap with spermicidal agent 
• Intrauterine device 
• Hormonal contraceptives in combination with either a condom, diaphragm, or cervical     
   Cap 
6.0 TREATMENT PLAN 
 
6.1 
Anakinra Treatment 
 
Prophylactic dose: 
Anakinra 200 mg will be diluted in 200 mL of sodium chloride 0.9% and administered IV over 
approximately 10-30 minutes once daily (approximately every 24 hours,) for 14 days, with the first dose 
administered 2-4 hours before liso-cel infusion (day 0 through day 13). Scheduling variations in the timing 
of anakinra administration are acceptable, e.g., in case of clinical events (e.g., unplanned hospitalization) 
or if changes to the patient’s schedule occur. The anakinra dose may be modified or held at the discretion 
of the PI or designee (e.g., in case of severe and/or uncontrolled infection). Should patients receive the 
first dose of anakinra but do not receive liso-cel for any reason, they may be re-treated with anakinra if 
liso-cel is given at a later point.  

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Anakinra dose modification: in patients with severe renal insufficiency or end-stage renal disease, 
defined as CrCl less than 30 mL/min, anakinra will be administered every other day instead of every 
day. Local injection-site reactions should be managed per institutional standards. 
Up-titration in case of CRS or ICANS: 
Step 1 (8 mg/kg/day): In patients who develop CRS or ICANS during anakinra prophylaxis at 200 mg/day, 
anakinra will be increased to 8 mg/kg/day. The step 1 anakinra dose will be calculated using the 
participant’s actual or ideal body weight as per PI discretion. The total daily dose will be divided over 
three doses in 24 hours, each dose will be rounded to the nearest 100 mg, and diluted in NaCl 0.9% at a 
volume sufficient to achieve a goal concentration of 1 mg/ml, and given IV over approximately 10-30 
minutes. Once CRS and ICANS symptoms are improved or resolved, as evaluated by the PI or designee, 
anakinra will be decreased to the prophylactic dosing (200 mg/day). 
Anakinra dose modification: in patients with severe renal insufficiency or end-stage renal disease, defined 
as CrCl less than 30 mL/min, the anakinra dose will be reduced to 50% of the target dose (4 mg/kg/day). 
 
Step 2 (1 mg/kg/h): In the absence of improvement or worsening of CRS or ICANS symptoms despite 
anakinra treatment at 8 mg/kg/day, as evaluated by the PI or designee, anakinra will be increased once to 
1 mg/kg/h administered as a continuous IV infusion for 72 hours. The step 2 anakinra dose will be 
calculated using the participant’s actual or ideal body weight as per PI discretion, rounded to the neared 
100 mg, and diluted in NaCl 0.9% at a volume sufficient to achieve a goal concentration of 1 mg/ml. After 
72 hours of anakinra at 1 mg/kg/h, anakinra will be decreased to 8 mg/kg/day. Once CRS and ICANS 
symptoms are improved or resolved on anakinra at 8 mg/kg/day, as evaluated by the PI or designee, 
anakinra will be further decreased to the prophylactic dosing. 
Anakinra dose modification: in patients with severe renal insufficiency or end-stage renal disease, defined 
as CrCl less than 30 mL/min, the anakinra dose will be reduced to 50% of the target dose (0.5 mg/kg/h). 
 
Anakinra up-titration algorithm: 
 
 
 

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6.2 
Anakinra Drug Product 
 
Anakinra is supplied in single use 1 mL prefilled glass syringes with 27 gauge needles as a sterile, clear, 
colorless-to-white, preservative- free solution for daily subcutaneous (SC) administration. Each 1 mL 
prefilled glass syringe contains: 0.67 mL (100 mg) of anakinra in a solution (pH 6.5) containing sodium 
citrate (1.29 mg), sodium chloride (5.48 mg), disodium EDTA (0.12 mg), and polysorbate 80 (0.70 mg) 
in Water for Injection, USP. Anakinra will be supplied by Sobi and dispensed through Investigational 
Drug Services.  
 
6.3 
Liso-cel treatment 
 
Liso-cel will be infused per institutional practice and according to the Breyanzi Risk Evaluation and 
Mitigation Strategies (REMS)48. 
7.0 POTENTIAL RISKS OF ANAKINRA TREATMENT  
 
Injection-site Reactions  
The most common and consistently reported treatment-related adverse event associated with anakinra is 
injection-site reaction (ISR). In clinical trials using anakinra for treatment of Rheumatoid Arthritis 71% 
of patients developed an ISR, which was typically reported within the first 4 weeks of therapy. The 
majority of ISRs were reported as mild (72.6% mild, 24.1% moderate and 3.2% severe). The ISRs 
typically lasted for 14 to 28 days and were characterized by 1 or more of the following: erythema, 
ecchymosis, inflammation, and pain.  
 
Hypersensitivity Reactions  
Hypersensitivity reactions including anaphylactic reactions, angioedema, urticaria, rash, and pruritus have 
been reported with anakinra.  
 
If a severe hypersensitivity reaction occurs, administration of anakinra should be discontinued and 
appropriate therapy initiated according to institutional or clinical standard. 
 
Infections  
In clinical trials using anakinra for treatment of Rheumatoid Arthritis, the incidence of infection was 39% 
in the anakinra-treated patients and 37% in placebo-treated patients during the first 6 months of blinded 
treatment. The incidence of serious infections was 2% in anakinra-treated patients and 1% in patients 
receiving placebo over 6 months. The incidence of serious infection over 1 year was 3% in anakinra-
treated patients and 2% in patients receiving placebo. These infections consisted primarily of bacterial 
events such as cellulitis, pneumonia, and bone and joint infections. Majority of patients (73%) continued 
on study drug after the infection resolved. No serious opportunistic infections were reported. Patients with 
asthma appeared to be at higher risk of developing serious infections when treated with anakinra (8 of 177 
patients, 4.5%) compared to placebo (0 of 50 patients, 0%). In open-label extension studies, the overall 
rate of serious infections was stable over time and comparable to that observed in controlled trials. In 
clinical studies and post marketing experience, cases of opportunistic infections have been observed and 
included fungal, mycobacterial and bacterial pathogens. Infections have been noted in all organ systems 

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and have been reported in patients receiving anakinra alone or in combination with immunosuppressive 
agents.  
 
Antimicrobial prophylaxis and infection surveillance and treatment will be according to institutional 
standard for patient receiving CD19-targeted CAR-T cell therapy  
 
Malignancies  
Among 5300 Rheumatoid Arthritis patients treated with anakinra in clinical trials for a mean of 15 months 
(approximately 6400 patient years of treatment), 8 lymphomas were observed for a rate of 0.12 cases/100 
patient years. This is 3.6 fold higher than the rate of lymphomas expected in the general population, based 
on the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database (SEER 
Incidence Crude Rates, 11 Registries, 1992-1999) An increased rate of lymphoma, up to several fold, has 
been reported in the Rheumatoid Arthritis population, and may be further increased in patients with more 
severe disease activity. Thirty-seven malignancies other than lymphoma were observed. Of these, the most 
common were breast, respiratory system, and digestive system. There were 3 melanomas observed in one 
Rheumatoid Arthritis study and its long-term open-label extension, greater than the 1 expected case. The 
significance of this finding is not known. While patients with Rheumatoid Arthritis, particularly those 
with highly active disease, may be at a higher risk (up to several fold) for the development of lymphoma, 
the role of IL-1 blockers in the development of malignancy is not known.  
 
Hematologic Events  
In placebo-controlled studies with anakinra, 8% of patients receiving anakinra had decreases in total white 
blood counts of at least one WHO toxicity grade, compared with 2% of placebo patients. Nine anakinra-
treated patients (0.4%) developed neutropenia (ANC < 1 x 109 /L). 9% of patients receiving anakinra had 
increases in eosinophil differential percentage of at least one WHO toxicity grade, compared with 3 % of 
placebo patients. 2% of patients receiving anakinra had decreases in platelet count, all WHO toxicity grade 
one, compared to 0% of placebo patients.  
 
Immunogenicity  
As with all therapeutic proteins, there is potential for immunogenicity. In Studies using anakinra for 
treatment of Rheumatoid Arthritis, from which data is available for up to 36 months, 49% of patients 
tested positive for anti-anakinra binding antibodies at one or more time points using a biosensor assay. Of 
the 1615 patients with available data at Week 12 or later, 30 (2%) tested positive for neutralizing 
antibodies in a cell-based bioassay. Of the 13 patients with available follow-up data, 5 patients remained 
positive for neutralizing antibodies at the end of the studies. No correlation between antibody development 
and adverse events was observed. The detection of antibody formation is highly dependent on the 
sensitivity and specificity of the assays.  
 
Hyperlipidemia 
Cholesterol elevations were observed in some patients treated with anakinra. 
 
7.1 
 Management of Other Toxicities 
CRS: Patients who develop CRS will be treated according to institutional standard practice.. 
 
ICANS: Patients who develop ICANS will be treated according to institutional standard practice. 
 

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If a new onset CTCAE v.5 Grade ≥ 3 toxicity is observed, the patient will receive investigation and 
medical treatment appropriate for the physiological abnormalities.   
8.0 INFORMED CONSENT OF SUBJECT AND DONOR 
Subjects will be seen at the FHCC/UWMC for consideration of treatment options for their disease.  The 
protocol will be discussed thoroughly with the patient and other family members if appropriate, and all 
known and potential risks to the patient will be described.  The procedure and alternative forms of therapy 
will be presented as objectively as possible, and the risks and hazards of the procedure explained to the 
patient.  Consent from the patient will be obtained using forms approved by the Cancer Consortium IRB.  
A summary of the clinic visit detailing what was covered will be dictated for the medical record. 
9.0 SUBJECT REGISTRATION 
Eligible subjects will be identified and registered into the system by the Clinical Coordinator’s Office 
(CCO; Intake Office) and assigned a Unique Patient Number (UPN).  The CCO will register the patient 
for the protocol through the Data Management Office. 
 
Enrollment to the study will occur after data are reviewed for all inclusion and exclusion criteria by the 
Immunotherapy attending physician and the patient signs the study consent. 
 
A study number will be allocated to each patient and a log of enrolled subjects will be maintained.   
10.0 CLINICAL AND LABORATORY EVALUATIONS 
 
10.1 
Screening & prelymphodepletion evaluations 
The following evaluations should be conducted within 6 weeks prior to lymphodepletion: 
1) Medical history and physical examination including height and weight 
2) Karnofsky performance status 
3) Laboratory tests, including: 
a. CBC, differential, platelet count 
b. Renal/Hepatic Function Panel 
c. Serum ferritin 
d. Serum CRP 
e. Uric acid 
f. Quantitative serum IgG level  
g. Prothrombin time (PT), partial thromboplastin time (PTT) 
h. Triglycerides (non-fasting levels are acceptable) 
i. Serum pregnancy test for females of childbearing potential within 2 weeks of planned 
enrollment 
4) Baseline pulse oximetry and documentation of O2 saturation on room air 
 
The following evaluations should be conducted within 3 months prior to lymphodepletion: 
5) Baseline chest x-ray 
6) Baseline 12-lead EKG 

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7) Echocardiogram or MUGA scan 
8) Pulmonary function testing, if clinically indicated 
9) CT/PET or CT 
10) Bone marrow aspirate and biopsy, if clinically indicated 
11) Lumbar puncture for CSF analysis, if clinically indicated 
 
10.2 
Evaluations on the day of liso-cel infusion (day 0) 
The below tests will be done as part of the clinical evaluation prior to liso-cel infusion:: 
1. Interval history and physical examination 
2. ICE score 
3. Recording of CRS and ICANS-related interventions 
4. Recording of AEs 
5. Blood draw for laboratory studies: 
a. CBC, differential, and platelets 
b. Renal/Hepatic Function Panel 
c. Uric acid 
d. Serum ferritin 
e. Serum CRP 
f. Serum IL-6 level 
g. DIC panel without platelets (PT, PTT, fibrinogen, D-dimer) 
h. Triglycerides (non-fasting levels are acceptable) 
 
10.3 
Evaluations following liso-cel infusion 
The proposed days of all assessments and laboratory evaluations are approximate and may vary due to 
scheduling, clinical factors, research priorities or other considerations. All timepoints may not be 
collected. Laboratory research evaluations may vary according to clinical and research priorities. 
The following evaluations will be performed as part of the clinical evaluation after  liso-cel infusion:  
1) Interval history and physical examination approximately on day +1, +3, +7, +10, +14, +21, +28 
2) ICE score approximately on day +1, +3, +7, +10, +14, +21, +28 
3) Continuous recording of CRS and ICANS-related interventions through day +28 
4) Continuous recording of AEs through day +28 as described in section XX 
5) The following laboratory studies approximately on day +1, +3, +7, +10, +14, +21, +28: 
a. CBC, differential, and platelet count 
b. Renal/Hepatic Function Panel 
c. C-reactive protein (CRP) 
d. Serum ferritin 
e. Serum IL-6 level 
f. DIC panel without platelets (PT, PTT, fibrinogen, D-dimer) 
g. Triglycerides (non-fasting levels are acceptable) 
6) If subjects become febrile or develop symptoms of cytokine release or tumor lysis between the 
indicated time points, serum ferritin, CRP, DIC panel, and tumor lysis markers at additional 
times, may be measured as clinically indicated. 

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10.4 
Evaluations before and after each anakinra administration 
Vital signs including pulse oximetry before and 30 minutes after each anakinra administration on days 0 
through day +13. For patients receiving step-up dosing, vital signs will be obtained every 4 hours per 
standard-of-care. 
 
10.5 
Research Blood samples 
 
Pharmacokinetic samples 
• Approximately 4 hours after the end of the first anakinra administration, up to 10mL of blood may 
be obtained 
• Approximately 24 hours (+/- 1 hour) after the end of the first anakinra administration and 
immediately prior to the second anakinra administration, up to 10mL of blood may be obtained 
Details regarding the tube type, handling, receiving laboratory, are detailed in a separate Research 
Sample Manual. 
Because the clinical treatment and follow-up schedule may differ between patients, variation in 
the proposed blood sampling schedule is acceptable. It is also acceptable to collect fewer samples and/or 
less than the maximum sample number or volume depending on clinical, logistical and/or research 
priorities. If the patient’s schedule is modified, samples may be recollected. 
 
Tissue/fluid samples 
 
If sampling of tissues or fluids (e.g., cerebrospinal fluid, pleural fluid, ascites, skin) is performed for 
clinical indications (e.g., in the context of CRS or ICANS), an additional sample may be obtained during 
the same procedure and sent to the FHCC for research studies. The planned procedure should be 
discussed with the PI. 
 
Additional research samples 
 
In consenting patients, other research samples may be obtained using the sample acquisition partner 
protocol FHCC 8682 “Collection of Samples and Data from Patients Undergoing Treatment with 
Commercial Chimeric Antigen Receptor Engineered T Cells”. 
 
10.6 
 Assessment of Disease Response to CAR-T Cell Therapy  
Objective responses to the therapeutic regimen will be assessed approximately 28 days and 90 days after 
liso-cel infusion  using physical examination, imaging studies, and if necessary, bone marrow biopsies, 
as clinically indicated. If CT or PET/CT data are available, response will be defined per the Lugano 
criteria47. The study team may contact the local oncologist office by a letter/phone call to request the 
results of the day 90 restaging. 
 
10.7 
Long-Term Follow-up 
 
Subjects will be followed per institutional standard of care. 

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11.0 ADVERSE EVENT REPORTING 
 
11.1 
 Adverse Event Definitions 
 
• Adverse Event 
An Adverse Event (AE) is any untoward medical occurrence in a clinical investigation subject 
administered a medicinal product; the event does not necessarily have a causal relationship with study 
drug administration or usage. An adverse event can therefore be any unfavorable and unintended sign 
(including an abnormal laboratory finding), symptom, or disease temporally associated with the use 
of a medicinal product, whether or not considered related to the medicinal product. 
 
• Serious Adverse Event  
A serious adverse event (SAE) is defined as an untoward medical occurrence that results in any of 
the following outcomes: 
1. Death. 
2. Life-threatening situation (i.e., with an immediate risk of death from the event as it occurred 
but not including an event that, had it occurred in a more serious form, might have caused 
death). 
3. In-patient hospitalization or prolongation of existing hospitalization. Inpatient hospitalization 
comprises formal admission to a hospital for medical reasons, for any length of time, whether 
or not hospitalization extends overnight. However, hospital admissions for administration of 
the study drug, procedures required by the study protocol, or tumor-related diagnostic 
procedures are not considered serious. 
4. Persistent or significant disability/incapacity or substantial disruption of the ability to 
conduct normal life functions. 
5. Congenital anomaly/birth defect. 
6. An important medical event that requires intervention to prevent one of the above outcomes. 
 
• Unexpected Adverse Event 
An unexpected adverse event is defined as an event that has a nature or severity, or frequency that axis 
not consistent with the investigator brochure, protocol, or consent form.  
 
11.2 
 Monitoring and Recording Adverse Events 
Grade >3 AEs will be assessed by the investigator or qualified designee and recorded in the CRFs. In 
addition, grade 1-2 AEs contributing to the diagnosis and grading of CRS (including for example, fever, 
hypotension, hypoxia) and/or neurologic symptoms contributing to the diagnosis and grading of ICANS 
(including for example, delirium, seizure, encephalopathy) will be collected. The investigator should 
attempt to establish a diagnosis of the event on the basis of signs, symptoms and/or other clinical 
information. In such cases, the diagnosis should be documented as the adverse event and/or serious 
adverse event and not described as the individual signs or symptoms. The following information should 
be recorded: 
• Description of the adverse event using concise medical terminology 
• Description as to whether or not the adverse event is serious  
• The start date (date of adverse event onset) 
• The stop date (date of adverse event resolution or return to baseline) 

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• The severity (grade) of the adverse event  
• A description of the potential relatedness of the adverse event to study drug or a study procedure  
• Expectedness of the adverse event based on prior observed and documented adverse events 
• The outcome of the adverse event 
 
11.3 
 Grading of the Severity of an Adverse Event 
AEs will be graded in severity according to the NCI Common Terminology Criteria for Adverse Events 
(CTCAE) Version 5.0. If a CTCAE criterion does not exist, the investigator should use the grade or 
adjectives: Grade 1 (mild), Grade 2 (moderate), Grade 3 (severe), Grade 4 (life-threatening), or Grade 5 
(fatal) to describe the maximum intensity of the adverse event.  CRS will be graded according to the 2019 
ASTCT consensus criteria45 (Appendix A) and the 2014 NIH Lee criteria46 (Appendix B), the latter to 
allow for comparisons with historical controls. ICANS will be graded according to the 2019 ASTCT 
criteria (Appendix C) and the CTCAE 5.0, the latter to allow for comparisons with historical controls. In 
addition, therapeutic interventions related to CRS and ICANS management will be recorded. 
 
11.4 
 Attribution of Adverse Event 
Association or relatedness to the study agent will be assessed by the investigator as follows: 
 
Definite 
(must have all 4) 
• 
Has a reasonable temporal relationship to the intervention 
• 
Could not have readily been produced by the subject's clinical 
state or have been due to environmental or other interventions 
• 
Follows a known pattern of response to intervention 
• 
Disappears or decreases with reduction in dose or cessation of 
intervention and recurs with re-exposure 
Probable 
(must have 3) 
• 
Has a reasonable temporal relationship to the intervention 
• 
Could not have readily been produced by the subject's clinical 
state or have been due to environmental or other interventions 
• 
Follows a known pattern of response to intervention 
• 
Disappears or decreases with reduction in dose or cessation of 
intervention 
Possible 
(must have 2) 
• 
Has a reasonable temporal relationship to the intervention 
• 
Could not have readily been produced by the subject's clinical 
state 
• 
Could not readily have been due to environmental or other 
interventions 
• 
Follows a known pattern of response to intervention 
Unlikely 
(must have 2) 
1. Does not have a temporal relationship to the intervention 
2. Could readily have been produced by the subject's clinical state 
3. Could have been due to environmental or other interventions 
4. Does not follow a known pattern of response to intervention 
5. Does not reappear or worsen with reintroduction of intervention 

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Unrelated 
• 
The AE is clearly NOT related to the intervention 
 
For AE assessment, an AE is considered related if it is assessed as definitely, probably, or possibly 
related; unrelated if it is assessed as unlikely related or unrelated.  
 
11.5 
Adverse Event Reporting Period  
Adverse events will be monitored and recorded in study-specific case report forms (CRFs) throughout 
the investigative phases of the study: from the first dose of Anakinra through day 28 after the liso-cel 
infusion.  Related AEs will be monitored until stabilization or resolution.  
 
A subject withdrawn from the study because of an adverse event must be followed until the clinical 
outcome from the adverse event is determined.  
 
The following events are not identified as AEs in this study:  
 
• Disease progression or relapse.   
• Medical or surgical procedures in and of themselves, including those that require hospitalization 
(e.g., surgery, endoscopy, biopsy procedures) are not considered AEs.  However, an event or 
condition requiring such procedures may be an AE. 
 
11.6 
Adverse Event Reporting Requirements 
The investigator or designee will report events to the Fred Hutch IRB in accordance with the policies of 
the IRB. 
12.0 STATISTICAL CONSIDERATIONS 
 
This is a pilot study to assess the efficacy of anakinra to prevent any grade CRS (primary endpoint) after 
liso-cel treatment in patients with B-NHL. 
 
12.1 
 Primary endpoint: 
We will assess the efficacy of anakinra in preventing the occurrence of any grade CRS using the Bayesian 
optimal phase 2 (BOP2) design 49 with a planned interim analysis after 15 patients are treated (!, interim 
sample size). Unlike other existing Bayesian designs, the BOP2 design explicitly controls the type I error 
rate, thereby bridging the gap between Bayesian designs and frequentist designs. " denote the maximum 
sample size.  
Based on the TRANSCEND clinical trial data in LBCL patients, the incidence of any grade CRS liso-cel 
therapy is estimated to be approximately 40%.7 Let #!"" denote the proportion of patients without any grade 
CRS (efficacy) and define the null hypothesis $#: #!"" ≤0.6 , representing that the treatment is 
inefficacious. We assume a vague Beta(0.6,0.4) prior distribution for #!"". Let y be defined as the absence 
of any grade CRS and the posterior probability will be computed as follows using 100,000 simulations: 
*+!"" = *+(#!""|/, !) = 2345(#!""|/ + 0.6, ! −/ + 0.4) 
This primary endpoint will not be met if 

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*+(#!"" > 0.6|:545) < <(!
")$, 
where <=0.9 and ==0.51 are design parameters optimized to minimize the chance of incorrectly claiming 
that an efficacious treatment is not promising (i.e., type II error) under the alternative hypothesis 
$%: #!"" = 0.85, while controlling the type I error rate (i.e., the probability of incorrectly claiming that the 
treatment is acceptable under $#) at 0.1. This design yields a statistical power of 0.928 under $%. 
 
12.2 
 Secondary Endpoints 
• Peak CRS grade within 28 days after liso-cel infusion 
• Peak ICANS grade within 28 days after liso-cel infusion 
• Rate and duration of hospitalization after liso-cel treatment 
• Cumulative corticosteroids dose within 28 days after liso-cel infusion  
• Grade ≥3 AEs according to the NCI CTCAE Version 5.0 within the first 28 days after liso-cel 
administration. 
• Disease response to CAR T-cell therapy approximately 28 days and 90 days after CAR T-cell 
infusion according to the Lugano 2014 criteria47 
 
12.3 
Data Analysis  
 
We will perform a first analysis when the number of enrolled patients reaches 15. The posterior 
probabilities of the absence of any grade CRS will be computed as described above. In our case, we will 
conclude that the primary endpoint is not reached if no CRS is observed in ≤ 9 patients in the first 15 
patients treated. Since this is a pilot study, the decision to include the additional 10 patients might be 
considered based on both the primary and secondary endpoints. 
 
If the total number of patients reaches the maximum sample size of 25, we will reject the null hypothesis 
and conclude that the primary endpoint is met if the number of patients without CRS is greater than 18 (19 
or more patients with no evidence of any grade CRS); otherwise we conclude that the primary endpoint is 
not met. 
 
February 2023 update: although our interim analysis did not meet the primary endpoint, anakinra 
prophylaxis was feasible, safe, and associated with low rates of mild CRS (8/15; 53%) and ICANS (3/15; 
20%). Longitudinal analyses of the participants’ temperature and CRP data suggested faster resolution of 
systemic inflammation compared to patient receiving liso-cel alone. Therefore, we will plan to treat 10 
additional patients with the following protocol modification: change from SC to IV administration route, 
up-titration of the anakinra dose in case of breakthrough CRS or ICANS. 
 
Statistical analysis will include descriptive statistics for which categorical variables will be summarized 
by number and percentage, and continuous variables will be summarized by median, standard deviation, 
and range. For binary endpoints, such as the proportion of patient without any grade CRS and the overall 
response rate (ORR), an exact 95% confidence interval using a binomial distribution will be provided. 
Time-to-event data will be analyzed using Kaplan-Meier method and the results will be summarized by 
the median with a 95% CI if appropriate. 

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12.4 
Stopping Rules 
 
To protect the safety of patients, the study incorporates the following stopping rules: 
 
1. If the lower bound of a 1-sided 80% exact binomial confidence interval of death that are probably 
or definitely attributable to anakinra treatment is > 3%. Operationally, any of the following would 
trigger such a rule: 1 death out of the first £ 7 patients or 2 death out of the first £ 15 patients that 
are probably or definitely attributable to anakinra treatment. If the true probability of death is 1%, 
the probability of study suspension under the above rule is approximately 0.08; if the true 
probability is 15%, the probability of suspension is approximately 0.93 (probabilities estimated 
from 5,000 simulations).  
 
2. If the upper bound of a 2-sided 95% exact binomial confidence interval of responses (ORR) is < 
75% with 15 subjects at the interim analysis. Operationally, if there are 7 or fewer responses 
(ORR) among the first 15 subjects, the study will be stopped. Otherwise, the study will continue 
until 25 subjects are enrolled. If the true probability of ORR is 40%, the probability of stopping 
under the above rule is approximately 80%; if the true probability of ORR is 80%, the probability 
of stopping is approximately 0.5% (probabilities estimated from 5,000 simulations). 
 
When a stopping rule is triggered, further enrollment will be suspended pending review by the study 
Steering Committee (as discussed in section 13.1). 
13.0 DATA AND SAFETY MONITORING PLAN 
 
13.1 
 Overall Scope of Monitoring Activities 
Institutional support of trial monitoring will be in accordance with the FRED HUTCH/University of 
Washington Cancer Consortium Institutional Data and Safety Monitoring Plan (DSMP).  Under the 
provisions of this plan, FRED HUTCH Clinical Research Support coordinates data and compliance 
monitoring conducted by consultants, contract research organizations, or FRED HUTCH employees 
unaffiliated with the conduct of the study.  Independent monitoring visits occur at specified intervals 
determined by the assessed risk level of the study and the findings of previous visits per the institutional 
DSMP.  
 
A Steering Committee, comprising the PI and/or designee, the IMTX medical director and study 
biostatistician, will act in an advisory capacity to the PI throughout the trial, as needed. If a stopping rule 
is triggered, further enrollment will be suspended pending review by the Steering Committee. 
 
In addition, protocols are reviewed at least annually and as needed by the Consortium Data and Safety 
Monitoring Committee (DSMC), FRED HUTCH Scientific Review Committee (SRC) and the FRED 
HUTCH/University of Washington Cancer Consortium Institutional Review Board (IRB).  The review 
committees evaluate accrual, adverse events, stopping rules, and adherence to the applicable data and 
safety monitoring plan for studies actively enrolling or treating subjects.  The IRB reviews the study 
progress and safety information to assess continued acceptability of the risk-benefit ratio for human 
subjects.  Approval of committees as applicable is necessary to continue the study. 

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The trial will comply with the standard guidelines set forth by these regulatory committees and other 
institutional, state and federal guidelines. The conduct of this trial will be further monitored by the IIRC 
Data and Safety Monitoring Board (DSMB) in accordance with an approved DSMB Charter. 
 
13.2 
Monitoring the Progress of Trial and Safety of Participants 
The first level of trial oversight for this protocol will be provided by the Principal Investigator, the 
Research Nurse, and Research Coordinator(s), who will provide continuous oversight of the trial.  These 
individuals will meet at least monthly to review recently acquired data, stopping rules, and adverse events. 
Serious adverse events will be reviewed upon occurrence to ensure prompt and accurate reporting to the 
Institutional Review Board (IRB).  The data recorded in the research charts and protocol database will be 
compared with the actual data available from the medical record and/or clinical histories.  Data detailed 
in the research case report forms (CRFs) will include the nature and severity of all toxicities.  The Principal 
Investigator and all other investigators on the protocol have received formal training in the ethical conduct 
of human research. 
 
 
14.0 DATA MANAGEMENT/CONFIDENTIALITY 
The medical record containing information regarding treatment of the patient will be maintained as a 
confidential document, within the guidelines of the Fred Hutchinson Cancer Center and the University of 
Washington Medical Center.  
 
The investigator will ensure that data collected conform to all established guidelines for coding collection, 
key entry and verification. Each subject is assigned a unique subject number to assure subject 
confidentiality. Information forwarded to the FDA, NIH, NCI or other agencies about subjects on this 
protocol refers to subjects by a coded identifier and not by name.  Subjects will not be referred to by this 
number, by name, or by any other individual identifier in any publication or external presentation. The 
licensed medical records department, affiliated with the institution where the subject receives medical 
care, maintains all original inpatient and outpatient chart documents.  
 
The research team will maintain Case Report Forms (CRFs) and associated research documentation for 
each patient treated under the protocol.  This documentation includes both clinical data and study-specific 
documents for each patient.  The Principal Investigator or a designee will verify completed CRFs against 
source documentation on an ongoing basis as they are completed for individual subjects. Data required 
for analysis of subjects treated on this protocol will be maintained in a password-protected study-specific 
database. Data from the CRFs are keyed directly into the database by authorized research staff and verified 
on an ongoing basis.  
15.0 TERMINATION OF STUDY 
The study will terminate after the last treated patient has completed 90 days of follow-up following liso-
cel infusion.  CRS and ICANS will be evaluated until day 28 post liso-cel treatment. Disease restaging 
should be performed approximately on day 28 and day 90. Day-90 disease restaging may be performed 

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by the patient’s local oncologist The study team will contact the local oncologist office by a letter/phone 
call to request the results of the day-90 restaging, if completed as per standard-of-care. 
 
The PI may terminate the study at any time. The IRB and FDA also have the authority to terminate the 
study should it be deemed necessary. 
 
 
 

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Gust J, Hay KA, Hanafi LA, et al. Endothelial Activation and Blood-Brain Barrier Disruption in 
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induced by IL-1 alpha, IL-3, IL-4 and GM-CSF. Cytokine. 1993;5(5):407-415. 
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Carter DB, Deibel MR, Jr., Dunn CJ, et al. Purification, cloning, expression and biological 
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Eisenberg SP, Evans RJ, Arend WP, et al. Primary structure and functional expression from 
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Arend WP, Welgus HG, Thompson RC, Eisenberg SP. Biological properties of recombinant 
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Norelli M, Camisa B, Barbiera G, et al. Monocyte-derived IL-1 and IL-6 are differentially 
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Shah NN, Highfill SL, Shalabi H, et al. CD4/CD8 T-Cell Selection Affects Chimeric Antigen 
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Trial. J Clin Oncol. 2020;38(17):1938-1950. 
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Strati P, Ahmed S, Kebriaei P, et al. Clinical efficacy of anakinra to mitigate CAR T-cell 
therapy-associated toxicity in large B-cell lymphoma. Blood Adv. 2020;4(13):3123-3127. 
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Locke FL, Rossi J, Xue X, et al. Abstract CT020: Immune signatures of cytokine release 
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Fox E, Jayaprakash N, Pham TH, et al. The serum and cerebrospinal fluid pharmacokinetics of 
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Gueorguieva I, Clark SR, McMahon CJ, et al. Pharmacokinetic modelling of interleukin-1 
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Fisher CJ, Jr., Dhainaut JF, Opal SM, et al. Recombinant human interleukin 1 receptor antagonist 
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Antin JH, Weinstein HJ, Guinan EC, et al. Recombinant human interleukin-1 receptor antagonist 
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37. 
Antin JH, Weisdorf D, Neuberg D, et al. Interleukin-1 blockade does not prevent acute graft-
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McCarthy PL, Jr., Williams L, Harris-Bacile M, et al. A clinical phase I/II study of recombinant 
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Emsley HC, Smith CJ, Georgiou RF, et al. A randomised phase II study of interleukin-1 receptor 
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Singh N, Hopkins SJ, Hulme S, et al. The effect of intravenous interleukin-1 receptor antagonist 
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randomised controlled trial. J Neuroinflammation. 2014;11:1. 
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Granowitz EV, Porat R, Mier JW, et al. Pharmacokinetics, safety and immunomodulatory effects 
of human recombinant interleukin-1 receptor antagonist in healthy humans. Cytokine. 1992;4(5):353-
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Yang BB, Gozzi P, Sullivan JT. Pharmacokinetics of Anakinra in Subjects of Heavier vs. Lighter 
Body Weights. Clin Transl Sci. 2019;12(4):371-378. 
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Park JH, Sauter CS, Palomba ML, et al. A Phase II Study of Prophylactic Anakinra to Prevent 
CRS and Neurotoxicity in Patients Receiving CD19 CAR T Cell Therapy for Relapsed or Refractory 
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Monteagudo LA, Boothby A, Gertner E. Continuous Intravenous Anakinra Infusion to Calm the 
Cytokine Storm in Macrophage Activation Syndrome. ACR Open Rheumatol. 2020;2(5):276-282. 
45. 
Lee DW, Santomasso BD, Locke FL, et al. ASTCT Consensus Grading for Cytokine Release 
Syndrome and Neurologic Toxicity Associated with Immune Effector Cells. Biol Blood Marrow 
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46. 
Lee DW, Gardner R, Porter DL, et al. Current concepts in the diagnosis and management of 
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47. 
Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and 
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Association FaD. Approved Risk Evaluation and Mitigation Strategies (REMS) Breyanzi 
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Zhou H, Lee JJ, Yuan Y. BOP2: Bayesian optimal design for phase II clinical trials with simple 
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APPENDIX A:  ASTCT Cytokine Release Syndrome (CRS) Consensus Grading45 
Organ toxicities associated with CRS may be graded according to CTCAE v5.0 but  
they do not influence CRS grading. 
 
1    Fever is defined as temperature ≥38°C not attributable to any other cause. In patients who have CRS 
then receive antipyretic or anticytokine therapy such as tocilizumab or steroids, fever is no longer 
required to grade subsequent CRS severity. In this case, CRS grading is driven by hypotension and/or 
hypoxia. 
2    CRS grade is determined by the more severe event: hypotension or hypoxia not attributable to any 
other cause. For example, a patient with temperature of 39.5°C, hypotension requiring 1 vasopressor, and 
hypoxia requiring low-flow nasal cannula is classified as grade 3 CRS. 
3    Low-flow nasal cannula is defined as oxygen delivered at ≤6L/minute. Low flow also includes blow-
by oxygen delivery, sometimes used in pediatrics. High-flow nasal cannula is defined as oxygen delivered 
at >6L/minute. 
 
 
CRS 
Parameter 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Fever1 
Temperature 
≥38°C 
Temperature ≥38°C Temperature ≥38°C 
Temperature ≥38°C 
With 
Hypotension None 
Not requiring 
vasopressors 
Requiring a vasopressor with 
or without vasopressin 
Requiring multiple 
vasopressors (excluding 
vasopressin) 
And/or2 
Hypoxia 
None 
Requiring low-flow 
nasal cannula3 or 
blow-by 
Requiring high-flow nasal 
cannula3, facemask, 
nonrebreather mask, or 
Venturi mask 
Requiring positive pressure 
(e.g.,, CPAP, BiPAP, 
intubation and mechanical 
ventilation) 

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APPENDIX B. 2014 NIH CRS Grading (“Lee criteria”) 
 
Criteria defining high-dose vasopressor use 
Vasopressor 
Dose 
Norepinephrine monotherapy 
≥ 20 µg/min 
Dopamine monotherapy 
≥ 10 µg/min 
Phenylephrine monotherapy 
≥ 200 µg/min 
Epinephrine monotherapy 
≥ 10 µg/min 
If on vasopressin 
Vasopressin + norepinephrine equivalent of ≥ 
10µg/min* 
If on combination vasopressors (not 
vasopressin) 
Norepinephrine equivalent of ≥20µg/min 
*VASST Trial vasopressor equivalent equation: norepinephrine equivalent dose = 
[norepinephrine (µg/min)] + [dopamine (µg/kg/min) 2] + [epinephrine (µg/min)] + 
[phenylephrine (µg/min)  10]. 
 
 
Grade 
Toxicity 
Grade 1 
Symptoms are not life threatening and require symptomatic treatment only, e.g., fever, nausea, 
fatigue, headache, myalgias, malaise 
Grade 2 
Symptoms require and respond to moderate intervention 
Oxygen requirement <40% or  
Hypotension responsive to fluids or low dose of one vasopressor or Grade 2 organ toxicity per 
CTCAE 4.0 
Grade 3 
Symptoms require and respond to aggressive intervention 
Oxygen requirement ≥40% or  
Hypotension requiring high dose or multiple vasopressors or  
Grade 3 organ toxicity or grade 4 transaminitis 
Grade 4 
Life-threatening symptoms 
Requirement for ventilator support or  
Grade 4 organ toxicity (excluding transaminitis) 
Grade 5 
Death 

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APPENDIX C: ASTCT ICANS* Consensus Grading45 
 
* Immune Effector Cells (IEC)-associated neurotoxicity syndrome (ICANS) 
 
Neurotoxicity 
Domain 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
ICE score1, 2 
7-9 
3-6 
0-2 
0 (patient is unarousable and 
unable to perform ICE) 
Depressed level 
of consciousness3 
Awakens 
spontaneously 
Awakens 
to voice 
Awakens only to tactile 
stimulus 
Patient is unarousable or requires 
vigorous or repetitive tactile 
stimuli to arouse. Stupor or coma 
Seizure 
N/A 
N/A 
Any clinical seizure focal or 
generalized that resolves rapidly 
or nonconvulsive seizures on 
EEG that resolve with 
intervention 
Life-threatening prolonged 
seizure (>5 min); or Repetitive 
clinical or electrical seizures 
without return to baseline in 
between 
Motor findings4 
N/A 
N/A 
N/A 
Deep focal motor weakness such 
as hemiparesis or paraparesis 
Elevated 
ICP/cerebral 
edema 
N/A 
N/A 
Focal/local edema on 
neuroimaging5 
Diffuse cerebral edema on 
neuroimaging; decerebrate or 
decorticate posturing; or cranial 
nerve VI palsy; or papilledema; or 
Cushing's triad 
ICANS grade is determined by the most severe event (ICE score, level of consciousness, seizure, motor 
findings, raised ICP/cerebral edema) not attributable to any other cause; for example, a patient with an 
ICE score of 3 who has a generalized seizure is classified as grade 3 ICANS. 
N/A indicates not applicable. 
 
1    ICE Score: 
• 
Orientation: orientation to year, month, city, hospital; 4 points 
• 
Naming: ability to name 3 objects (e.g. point to clock, pen, button): 3 points 
• 
Following commands: ability to follow simple commands (e.g., “show me 2 fingers” 
or “close your eyes and stick out your tongue”): 1 point 
• 
Writing: ability to write a standard sentence (e.g. “Our national bird is the bald 
eagle”): 1 point 
• 
Attention: ability to count backwards from 100 by 10: 1 point 
2    A patient with an ICE score of 0 may be classified as grade 3 ICANS if awake with global aphasia, but 
a patient with an ICE score of 0 may be classified as grade 4 ICANS if unarousable. 
3    Depressed level of consciousness should be attributable to no other cause (e.g., no sedating 
medication). 
4    Tremors and myoclonus associated with immune effector cell therapies may be graded according to 
CTCAE v5.0, but they do not influence ICANS grading. 
5    Intracranial hemorrhage with or without associated edema is not considered a neurotoxicity feature and 
is excluded from ICANS grading. It may be graded according to CTCAE v5.0.

Protocol 10373 
RG1006866 
 
 
 
                Page 36 of 37  
 
APPENDIX D:  Schedule of Assessments 
Assessment 
Pre-Lymphodepletion 
Evaluations 
Day of liso-cel 
Infusion (Day 0) 
Follow-up Evaluations 
1 
3 
7 
10 
13 
14 
21 
28 
90 
Comments 
I/E criteria 
X 
  
  
  
  
  
  
  
  
  
  
  
Medical history 
X 
X 
X 
  
X 
  
  
X 
X 
X 
  
  
Physical exam 
X 
X 
X 
  
X 
  
  
X 
X 
X 
  
  
ICE score 
  
X 
X 
X X 
X 
  
X 
X 
X 
  
  
Height/weight 
 X 
  
  
  
  
  
  
  
  
  
  
  
Karnofsky performance status 
X 
  
  
  
  
  
  
  
  
  
  
  
CRS/ICANS-related interventions 
  
Continuous recording from day 0-28 
  
  
AEs 
  
Continuous recording from day 0-28 
  
  
Vitals including pulse oximetry 
X 
Prior to and 30 minutes after anakinra 
administration on days 0 through 13 
  
  
  
  
For patients 
receiving step-
up dosing, vital 
signs will be 
obtained every 4 
hours per 
standard-of-
care. 
Chest x-ray 
X 
  
  
  
  
  
  
  
  
  
  
  
12-lead ECG 
X 
  
  
  
  
  
  
  
  
  
  
  
MUGA/ECHO 
X 
  
  
  
  
  
  
  
  
  
  
  
CT/PET or CT 
X 
  
  
  
  
  
  
  
  
X 
X 
As clinically 
indicated 
BMA and biopsy 
X 
  
  
  
  
  
  
  
  
X 
X 
As clinically 
indicated 
Lumbar puncture 
X 
  
  
  
  
  
  
  
  
X 
X 
As clinically 
indicated 
Lymphodepleting chemotherapy 
 
  
  
  
  
  
  
  
  
  
  
Lymphodepleting 
chemotherapy per 

Protocol 10373 
RG1006866 
 
 
 
                Page 37 of 37  
 
Assessment 
Pre-Lymphodepletion 
Evaluations 
Day of liso-cel 
Infusion (Day 0) 
Follow-up Evaluations 
1 
3 
7 
10 
13 
14 
21 
28 
90 
Comments 
institutional 
practice 
Liso-cel administration 
 
X 
  
  
  
  
  
  
  
  
  
liso-cel infusion 
per institutional 
practice 
Anakinra administration 
 
day 0-13 
  
  
  
  
 
Laboratory evaluations 
  
  
  
  
  
  
  
  
  
  
  
  
Pregnancy test 
X  
  
  
  
  
  
  
  
  
  
  
  
CBC, differential 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
Renal/Hepatic Function Panel 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
Uric acid 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
Serum ferritin 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
CRP 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
IL-6 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
PT, PTT, fibrinogen, thrombin time 
and D-dimer 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
Quantitative serum IgG level 
X 
  
  
  
  
  
  
  
  
  
  
  
Triglycerides 
X 
X 
X 
X X 
X 
  
X 
X 
X 
  
  
PK samples 
 
X1 
X2 
  
  
  
  
  
  
  
  
  
1Approximately 4 hours after the end of the first anakinra administration 
2Approximately 24 hours (+/- 1 hour) after the end of the first anakinra administration and prior to the second anakinra administration 
The proposed days of all assessments and laboratory evaluations are approximate and may vary due to scheduling, clinical factors, research priorities or other 
considerations. All timepoints may not be collected. Laboratory research evaluations may vary according to clinical and research priorities.