Clinical trial NCT03433781
Conditions: Myelodysplastic Syndromes
Keywords: ASCORBIC ACID
Sponsor: NYU Langone Health
Start date: 2018-05-01; Completion date: 2023-05-16
Enrollment: 4 participants; Allocation: NON_RANDOMIZED; Intervention model: SINGLE_GROUP

Brief summary:
This is an open label, Phase Ib study designed to evaluate the safety, toxicity and biological activity of high dose Vitamin C in bone marrow and peripheral blood when administered as therapy to patients with intermediate or high risk myelodysplastic syndrome according to the revised IPSS (international prognostic scoring system) criteria whose disease has a Ten-eleven translocation-2, (TET2) mutation. The primary objectives phase 1 study is to establish safety and confirm a steady level of Vitamin C on ≥1 mM in \> 75% of the patients is achieved. All patients will receive at least 1 cycle of treatment (4 weeks). Patients with clinical benefit (CR,PR, or SD) then will undergo a second 4-week cycle of treatment.

Detailed description:

Arms: arm 1: Patients will receive Vitamin C as a continuous intravenous infusion (CIVI) of 50 grams (g) daily over 24 hours for 5 days for total of 250 grams over 5 days up. arm 2: Patients will receive Vitamin C as a continuous intravenous infusion (CIVI) of 75 grams (g) daily over 24 hours for 5 days for total of 375 grams over 5 days. arm 3: Patients will receive Vitamin C as a continuous intravenous infusion (CIVI) of 100 grams (g) daily over 24 hours for 5 days for total of 500 grams over 5 days.
Interventions: intervention 1: Vitamin C
Intervention descriptions: intervention 1: All patients will receive at least 1 cycle of treatment (4 weeks) of Vitamin C as a continuous intravenous infusion (CIVI). Patients with clinical benefit (CR, PR, or SD) then will undergo a second 4-week cycle of treatment. Patients to receive a maximum of 16 weeks of treatment (4 cycles). If a patient progress after receiving a cycle of treatment then the patient will be withdrawn from the study. Patients will be maintained on 1 gram oral Vitamin C daily from the end of the CIVI until the beginning of the next cycle (from day 6 till 28).

Protocol documents:
Prot_SAP_000.pdf: 
 
 
Study number: S17-00978 
 
Clinical Research Protocol 
  
 
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A Phase Ib Study Evaluating the Safety and Tolerability of 
Vitamin C in Patients with Intermediate or high 
Risk 
Myelodysplastic Syndrome with TET2 Mutations 
 
Protocol No.: 
S17-00978 
Test Product: 
Vitamin C 
Indication: 
Intermediate or high Risk myelodysplastic syndrome 
patients with TET2 Mutations 
Sponsor: 
New York University Langone Medical Center Perlmutter 
Cancer Center 
 
Development Phase: 
Ib 
Sites: 
NYU Langone’s Ambulatory Care Center 
University of Miami Health System 
 
 
Principal Investigator: 
Mohammad Maher Abdul Hay 
Assistant Professor of Medicine 
New York University School of Medicine 
240 East 38th Street, 19th Floor 
New York, NY 10016 
Email: Maher.Abdulhay@nyulangone.org 
Phone: 646-501-4818 
 
Co-Investigators: 
Michael Grossbard, MD 
Kenneth Hymes, MD 
Bruce Raphael, MD 
Tibor Moskovits, MD 
David Kaminetzky, MD 
Matija Snuderl, MD 
Luisa Cimmino, PhD  
 
Judith Goldberg, PhD 
 
Tsivia Hochman, MS  
 
Justin Watts, MD 
 
Drew Jones, Ph.D 
 
Judith D. Goldberg,  
ScD 
 
 
Medical Monitor:  
 
David Araten, MD 
 
Date of the Protocol: 
March 08, 2022  
Version of the Protocol:                        3.0  
Clinical Research Protocol 


 
 
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A Phase Ib Study Evaluating the Safety and Tolerability of 
Vitamin C in Patients with Intermediate or high 
Risk 
Myelodysplastic Syndrome with TET2 Mutations 
 
Methodology: 
This is an open label, Phase Ib study designed to evaluate the safety, toxicity and biological 
activity of high dose Vitamin C in bone marrow and peripheral blood when administered as 
therapy to patients with intermediate or high risk myelodysplastic syndrome according to the 
revised IPSS (international prognostic scoring system) criteria whose disease has a TET2 
mutation. 
 
Number of Patients: 
We propose to treat up to 12 patients in Phase 1b and defer 34 patients in Phase IIa for a later 
clinical trial with intermediate or high risk MDS with a TET2 mutation who have failed 
hypomethylating agent therapy. We will evaluate the safety and toxicity of continuous infusion high 
dose Vitamin C in MDS patients, confirm that we can achieve Vitamin C plasma concentrations 
needed to target TET2 mutations, and monitor response and pharmacodynamics markers. 
 
Diagnosis and Main Eligibility Criteria: 
This study will enroll patients with intermediate or high risk myelodysplastic syndrome 
 
Sponsor: 
NYU Perlmutter Cancer Center 
550 First Avenue, New York, NY 10016 
 
Planned Study Period: 
Q1 2018 to Q42022 (first patient first visit to last patient last visit) 
 
Objectives: 
Primary objectives are: 
1. Evaluate the safety and toxicity of high dose Vitamin C 
2. Estimate the proportion of MDS patients with TET2 mutations who exhibit a biological response 
defined as maintaining a vitamin C serum concentration of ≥1 mM over the treatment cycle. 
 
Secondary objectives are: 
1. Estimate the clinical efficacy, namely objective response rate (ORR), [including complete 
response (CR) and partial response (PR)], duration of response (DOR) and progression-free 
survival (PFS) as defined in the IWG (International Working Group) response criteria in 
myelodysplasia 
2. Estimate the Maximum measure Vitamin C plasma concentration (Cmax) 
3. Evaluate the pharmacokinetic profile (PK) of Vitamin C as hypomethylating or demethylating 
agent 
 
Inclusion criteria: 
1. Age ≥18 years 
2. Histologically confirmed Myelodysplastic Syndrome with positive TET2 mutations (We will test 
all MDS patients for TET2 mutations using next generation sequencing and only patients 
with TET2 mutations will be included in our study) 
3. Myeloblasts account for less than 20% of leukocytes on peripheral blood and bone marrow 
aspirate 


 
 
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4. Eastern Cooperative Oncology Group (ECOG) performance status ≤2 (Appendix 1) 
5. Adequate organ function 
a) Platelets ≥20,000/μL 
b) Absolute neutrophil count ≥ 500/μL 
c) Bilirubin < 1.5 x institutional upper limit of normal (ULN) or < 3 x ULN in patients with 
Gilbert's disease or liver involvement 
d) Serum albumin ≥ 2.0 g/dL 
e) Aspartate aminotransferase (AST)/Alanine aminotransferase (ALT) ≤2.5 institutional 
ULN or, in the case of liver involvement by the primary disease AST/ALT ≤ 5 x ULN 
f) Creatinine≤1.5 x institutional ULN or estimated creatinine clearance of ≥45 mL/min by 
the Cockcroft-Gault equation or measured creatinine clearance >45 mL/min 
6. Females of child bearing potential must have a negative serum pregnancy test with 7  days 
prior to first dose of treatment and use 2 methods of contraceptives while on treatment 
7. Ability to understand and the willingness to sign a written informed consent document 
8. Patients currently receiving or who previously received Hydroxyurea, Erythrocyte stimulating 
agents (ESA), or granulocyte colony stimulating factors (G-CSF) are allowed to participate in the 
study.  
 
Exclusion criteria: 
1. Concurrent hypomethylation agent usage; the last dose of treatment must be ≥4 weeks before the 
start of the Vitamin C infusion 
2. Myeloblast count ≥20% in peripheral blood or bone marrow aspirate 
3. Major surgery within 2 weeks prior to first dose of study drug 
4. Allogeneic stem cell transplant 
5. Any previous chemotherapy agent other than hypomethylating agents (e.g., Venetoclax) 
6. Uncontrolled concurrent serious illness 
7. Concurrent malignancy or history of a previous malignancy within 1 year prior to first dose of 
the current study, unless curatively resected basal, squamous cell carcinoma of the skin, breast 
ductal/lobular carcinoma in situ or cervical carcinoma in situ. 
8. Active infections including hepatitis B carrier status, hepatitis C virus (HCV) infection (patients 
must have a negative Hep B and Hep C viral load at screening) 
9. Known HIV-positive status 
10. 
Any significant medical conditions, laboratory abnormality, or psychiatric illness that would 
exclude the subject from participation or interfere with study treatment, monitoring and 
compliance such as: 
a) Unstable angina pectoris, symptomatic congestive heart failure (NYHA III or IV), 
myocardial infarction ≤ 6 months prior to first study drug, clinically significant and 
uncontrolled cardiac arrhythmia (e.g. atrial fibrillation/flutter ventricular cardiovascular 
physiology is allowed), cerebrovascular accidents ≤ 6 months before study drug start 
b) Severely impaired lung function 
11. Serious, systemic infection requiring treatment ≤7 days before the first dose of study drug 
12. Any severe, uncontrolled disease or condition which in the investigator's opinion, may put the 
subject at significant risk, may confound the study results, or impact the subject's participation in 
the study 
13. History of any renal calculi or hyperoxaluria or any other preexisting renal disorder 
14. History of G6PD deficiency, hereditary spherocytosis or hemochromatosis 
15. Patients on therapeutic or prophylactic anticoagulation will be excluded from enrollment on the 
protocol. However, patients can remain on the study if they develop a  thrombosis that requires 
therapeutic anticoagulation during the course of protocol therapy 
16. Uncontrolled hyponatremia, SIADH, hypokalemia, hyerpkalemia, hypomagnesemia or 
hypermagnesemia


 
 
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Study Design, Product, Dose modification, Mode of Administration and Sample 
Storage 
Study Design, Test Product and Dose: 
The gene that encodes L-gulonolactone oxidase (GULO), a key enzyme in Vitamin C 
biosynthesis, is dysfunctional in humans [2]. Consequently, we depend on constant dietary 
Vitamin C intake and digestive uptake, which occurs via two sodium-dependent Vitamin C 
Transporters (SVCTs). SVCT activity is homeostatically down-regulated in enterocytes, 
limiting the blood levels that can be achieved following oral administration of Vitamin C to a 
plasma concentration of approximately 70-80 µM [3]. This limitation can be circumvented by 
parenteral (intravenous, IV) injection. Notably, the early studies of Cameron and Pauling 
suggested anti-neoplastic effects of parenteral Vitamin C on various solid tumors [4], but 
these results were not reproduced in subsequent trials, including those by NIH investigators 
[5, 6]. However, the latter investigators only tested oral Vitamin C at up to 10 grams/d, 
and might not have achieved levels high enough for efficacy. Specifically, peak 
ascorbate levels were ~ 220-250 µM and declined rapidly after 30 minutes due to renal 
excretion. In addition, those studies, unlike the ones proposed here, were not 
biomarker-informed or –directed. There have been limited studies of the effects of Vitamin 
C in AML/MDS patients. In one trial, Vitamin C at 1 gram/day was given IV in combination 
with arsenic trioxide to AML patients, and showed no additive efficacy [7]. Another study 
combined a very low dose of parenteral Vitamin C with decitabine in MDS and AML patients, 
with limited clinical evidence of efficacy [8]. In that study, the standard decitabine dose for 
MDS (20 mg/m2/day intravenously for 5 days) was safely added to Vitamin C 1 g IV for 5 
days in combination with arsenic trioxide. Vitamin C was also continued orally weekly 
between the cycles of decitabine and was well tolerated. Vitamin C did not add any benefit, 
but it was given at a low dose (1 gram), for a short period of time (less than 2 hours infusion), 
and to unselected MDS patients. There has been no clinical study using high-dose Vitamin 
C (50 grams or more daily) as a hypomethylating agent to regulate levels of 5mC and 5hmC. 
Moreover, TET2 mutations have not been previously used as a potential biomarker for 
choosing Vitamin C therapy, as suggested by the extensive pre-clinical data described 
above. We hypothesize that high doses of Vitamin C are necessary to achieve therapeutic 
levels and efficacy in MDS patients, and that response will be restricted to, or at least 
maximized in, patients with TET2 mutations. Based on previous pharmacokinetic analyses, 
IV administration can produce blood levels at least 25 times those achieved by maximal oral 
dosing. Furthermore, such doses can be administered safely [9]. For example, high-dose 
intravenous Vitamin C was combined with gemcitabine and Erlotinib in a phase 1 study of 
pancreatic cancer without any major side effects [10]. Patients in that trial received different 
Vitamin C doses, with one group receiving up to 100 g intravenously 3 times/week per cycle 
without major adverse events. 
 
We propose a Phase 1 component with 3 dose-escalation cohorts in a 3+3 design to 
determine the maximum tolerated dose (MTD) of Vitamin C. Vitamin C will be provided from 
McGuff based on a confidential agreement with them and McGuff provides the only FDA-
approved injectable preparation of Vitamin C in the USA. For the dose- escalation cohorts, 
we suggest a starting Vitamin C dose for MDS patients of 50 grams, continuous 
intravenous infusion (CIVI) over 24 hours, given daily for 5 days for a total of 250 grams, 
followed by a 50% increase in dose for the next cohort to 75 grams/ day Vitamin C CIVI for 
5 days for total of 375 grams for 5 days. The third cohort will have a 100% increase in the 
original dose with an additional 3 patients treated with a dose of 100 grams/ day CIVI for 5 
days for total of 500 grams for 5 days (see below for schematic diagram). Patients will be 
maintained on 1 gram oral Vitamin C from the end of the CIVI until the beginning of the next 
cycle. One subject at a time will be enrolled into the first cohort until the first dose level cohort 
is completed and all patients treated successfully for one cycle. Two additional cohorts will 


 
 
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be treated similarly. If, as expected no patient experiences dose-limiting toxicity (DLT), then 
the last dose level cohort will be expanded to 6 subjects to confirm safety. After determining 
the recommended Phase 2 dose (RP2D) from the dose-escalation cohorts, we will proceed 
to a Phase 2 two-stage clinical trial at this dose however the phase 2 portion of our clinical 
trial have been deferred to a new clinical trial to conduct in the future and not as a part of 
this trial. The Vitamin C dose will not be increased above 100 grams/ day, even if, as 
expected, no DLTs are encountered, because higher dosages require larger volumes than 
the CADD pump can accommodate and potentially have more toxicity with limited to no 
additional benefit on Vitamin C pharmacokinetics and pharmacodynamics. Three patients in 
the first cohort (Vitamin C 50 grams CIVI) have been enrolled before the study redesign and 
tolerated treatment well without any side effects and should account for the completion of 
the first cohort.  
 
 
 
 
We have incorporated plans to evaluate pharmacokinetics (PK) to identify the doses required 
to achieve our targeted dose. We performed extensive tests to confirm the safety and 
stability of diluting Vitamin C in normal saline, and its use in 24 hour infusions via CADD 
pumps. The rationale for starting the first cohort at a dose of 50 grams of Vitamin C is that 
when this dose is given in humans as an IV bolus, a peak concentration in plasma of at least 
15-20 mM is achieved with a half-life around 30-45 minutes [11]. Accordingly, giving 50 
grams daily Vitamin C as a continuous intravenous infusion (CIVI) should achieve a 
concentration of at least 1 mM continuously in the plasma of patients, and this is the 
expected concentration (based on our pre-clinical studies) required for demethylation. For 
further cohorts we expect to achieve at least a plasma concentration of 2 mM and 3 mM 
respectively for the 75 grams and the 100 grams Vitamin C doses cohorts and accordingly 
with higher Vitamin C plasma concentrations in TET2 mutated MDS patients we expect to 
achieve higher demethylation effects and a better clinical response. Moreover, a very recent 
publication in BMC in May 2019 supported our PK assessments, and showed that the peak 
(Cmax) and the area under the curve (AUC) Vitamin C plasma concentrations increased 
Phase 1 Study Design  
A 3+ 3 design will be used for the Phase 1 Dose Escalation Cohorts; 3 patients will receive Vitamin C as a continuous 
intravenous infusion (CIVI) of 50 grams (g) daily over 24 hours for 5 days for total of 250 grams over 5 days, then 
another 3 patients will receive 75 grams for total of 375 grams over 5 days, followed by a final cohort of 3 patients at 
100 grams for total of 500 grams over 5 days. Each cycle will be 28-days, and patients can receive up to 4 cycles. 
Patients will be continued between each cycle on oral Vitamin C as 1 grams daily (from day 6 till 28). 


 
 
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with higher doses. In that trial they used doses up to 1.5g/kg/ day Vitamin C as no MTD was 
seen, and they were able to achieve Vitamin C plasma concentrations up to 10-20 mM for 4 
hours at 1.5g/kg dose with Cmax and AUC appearing to reach maximum values at this dose 
[12]. Also, Levine et al. showed earlier that patients receiving high doses of IV Vitamin C 
achieved plasma concentrations up to 14 mM, compared with a maximum plasma 
concentration of only 220 µM following high doses of oral Vitamin C [13]. Accordingly, given 
the above data we planned our study with 3 dosage escalations cohorts with Vitamin C 100 
grams being the maximum planned dose. To measure plasma Vitamin C levels, we will use 
liquid chromatography, coupled with triple quadrupole mass spectrometry (LC-MS) on 
samples obtained from the peripheral blood of MDS patients [14]. The LC column is a 
Millipore TM ZIC-pHILIC (2.1 x150 mm, 5 μm), coupled to Dionex Ultimate 3000 TM system, 
and the column oven temperature will be set to 25o C for the gradient elution. MS analyses 
will be carried out by coupling the LC system to a Thermo Q Exactive HF TM mass 
spectrometer, operating in heated electrospray ionization mode (HESI). The method 
duration will be 30 minutes with a polarity switching data-dependent top 5 methods for both 
positive and negative modes. Vitamin C measurements from both PCC and from the 
University of Miami site will be performed by Dr. Drew Jones, the director of the PCC 
Metabolomics Developing Shared Resource. 
 
 
Dose modifications, Mode of Administration and Sample Storage:  
 
For patients who present with a low absolute neutrophil count, no dose modifications will be 
required for cycle 2 and subsequent cycles. Vitamin C dosage for subsequent treatment will 
be at the discretion of the Principal Investigator. 
 
Patients will require central access prior to starting the continuous infusion of vitamin C. 
Patients will require either an implantable device (e.g. Port-a-Cath) or a PICC line 
(peripherally inserted central catheter). Both procedures represent safe and effective 
methods of obtaining central access. The patient will sign a separate consent discussing 
the risks and benefits of catheter placement prior to the procedure. Peripheral inserted 
central catheter (PICC) placement has a minimal risk of thrombus formation and bleeding 
while Port-a-Cath placement has a minimal risk of thrombus formation and infection. 
 
Bone marrow aspirates and peripheral blood samples will be stored in Dr. Neel’s and Dr. 
Aifantis’ Laboratory and measuring Vitamin C will be conducted at Dr. Drew Jones 
laboratory at NYU core facility and samples will be shipped directly for his facility. Samples 
collected at University of Miami will be kept and processed in the lab of Luisa Cimmino, PhD 
until all time points have been collected. University of Miami will send replicate samples to 
NYU. We plan for store the samples until all the studies required for this clinical trial are 
completed. The linking key between the samples and patient will only be kept with the PI of 
the study; any patient can ask to withdraw his/her sample from the study in writing to the PI.   
  
Intended Duration of Treatment: 
All patients will receive at least 1 cycle of treatment (4 weeks). Patients with clinical benefit 
(CR, PR, or SD) then will undergo a second 4-week cycle of treatment. Complete 
response (CR) is defined as myeloblasts <5% in bone marrow and peripheral blood 
showing neutrophils count >1000/μL, hemoglobin >11g/dL and platelets count>100,000/μL. 
Partial response (PR) is defined as any decrease in myeloblasts in the bone marrow or 
peripheral blood or improvement in peripheral blood count but not meeting CR criteria 
while stable disease (SD) shows no evidence of progression. Patients to receive a 
maximum of 16 weeks of treatment (4 cycles). If a patient progress after receiving a cycle 
of treatment then the patient will be withdrawn from the study. 


 
 
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We plan to follow up the patients that complete treatment for 6 months after finishing 
the last dose of treatment to continue to assess their response. After the end of treatment, 
each subject will be followed for 30 days for adverse event monitoring.  
 
Assessments may continue for ongoing reportable adverse events. A visit is to be 
performed at 30 days after the last study drug is given plus/ minus 3 days.  
 
After finishing last does of treatment, each subject will be followed for 6 months to continue 
to assess his or her response. Subjects to be contacted once a month by telephone to 
assess survival status and CBC records if available reviewed every 6 months after 
completing the study until they meet criteria for removal of study below. 
 
• 
Withdrawal of permission to record at least survival data 
• 
Lost to follow-up 
• 
Death 
 
If a subject withdraws permission to record at least survival data after coming off treatment, 
this must be documented along with the date the subject withdraws permission. Subjects will 
be considered lost to follow up if no medical records are available to be reviewed and two 
phone calls each to the subject and then the subject's next-of-kin (if the subject does not 
respond) are not returned over two consecutive 3 month periods.  
 
Assessments: 
Safety Assessments (primary endpoint) 
(We will establish safety in all  patients within and across dose levels and study phases) 
 
Determine the safety profile for each dose in Phase I  
 
Biological effects (primary endpoint) within and across dose levels and study phases 
 
Estimate the serum bioavailability of Vitamin C in MDS patients with TET2 
mutations 
 
Estimate the bioavailability of Vitamin C in isolated cell extracts from MDS 
patients to ensure it is increasing the intracellular concentrations as well 
 
Activity Assessments (secondary endpoint) within and across dose levels and study Phases 
 
ORR (CR, PR) 
 
DOR 
 
PFS 
 
Pharmacokinetic Assessments (secondary endpoint)  
 
Maximum measured Vitamin C plasma concentration (Cmax) 
 
Evaluate the pharmacokinetic profile (PK) of Vitamin C as hypomethylating 
or demethylating agent 
 
Immunological Effects 
 
Phenotypic characterization of myeloblasts in bone marrow and peripheral blood 
 
Correlative studies: 
 
To evaluate our therapeutic hypothesis, it is essential to study the effect of 
high dose Vitamin C on myeloblasts from MDS patients. In addition, a recent 
study of wild type and gulonolactone (L-) oxidase (Gulo) knockout mice 


 
 
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reported that parenteral Vitamin C increased Tregs in a sepsis model [15]. 
Vitamin C also plays an essential role in macrophage activation [16]. It is 
important to study the potential effects of high dose Vitamin C on these 
aspects of the MDS microenvironment, as they could modulate or enhance 
the cell-autonomous effects of Vitamin C on MDS blasts and might suggest 
future combination therapies. According we will evaluate the association of 
methylation, gene expression with response  in Phase II.  
 
Statistical Methods: 
Statistical considerations: 
Phase 1: At each dose level, safety data will be summarized by grade for each adverse 
experience by cycle and for each patient by worst grade recorded. The proportion of patients 
with each adverse experience will be reported, along with the proportion of patients who 
achieve a response. Responses will be defined as in the IWG (International Working Group) 
response criteria in myelodysplasia as: complete remission (CR), partial remission (PR), or 
hematologic improvement (HI) after completion of cycle 4 [17]. Overall response rate (PR+ 
CR+ HI) will be provided for each dose level and across dose levels for the Phase 1 portion 
of the trial (with exact 95% confidence intervals). The operating characteristics and the 
estimated probabilities of dose escalation are provided in Table 1. Table 1 lists the probability 
of escalating to the next dose, based on the true, but unknown DLT rate as the true DLT rate 
increases. 
 
Table 1: Probability of Dose Escalation in Phase 1 
 
 
 
 
 
 
 
 
Initial Safety Evaluation 
Adverse Events: In the phase I study, 3 patients per cohort will be treated unless a subject 
experiences a DLT, probably, possibly, or definitely related to treatment. DLT is defined as 
grade 3 or higher of any duration or as a Grade ≥2 adverse event (AE) that persists for ≥96 
hours with the exception of Grade ≥ 2 AEs clearly related to the underlying MDS. Based on 
prior experience with Vitamin C, however, we do not anticipate any DLTs. In the unlikely 
event that ≥ 1 patients develop grade 2 or more toxicity the cohort will be expanded to enroll 
a total of 6 subjects at its current dose escalation cohort. If ≥ 2 patients experience DLT at 
that expanded cohort then MTD would be achieved. Upon completion of the dose-escalation 
phase, if no DLT is identified as expected, then the RP2D will be set at Vitamin C 100 grams 
CIVI over 5 days every 28 days, and that dose will be used for the Phase 2 trial. Given the 
established safety record of high-dose Vitamin C, it is unlikely that we will observe Grade 3 
or greater toxicity. If, however, such an event where to occur, enrollment will be halted, and 
the study team will review all available safety data to determine if further accrual into that 
cohort is acceptable. After 3 patients in a cohort have been treated for at least 1 cycle of 28 
days (the DLT period), we will perform a safety evaluation of continuous infusion high-dose 
Vitamin C. If two (2) or more grade II or greater toxicities (probably, possibly, or definitely 
related to treatment) that persist are observed, the dose will be considered too toxic, and we 
will select the preceding dose for the phase 2 trial. If only 3 patients were treated at the lower 
dose, we would expand to 6 patients at that dose. After 3 patients have completed at least 
one cycle at the lowest dose safely and without any toxicity, we will proceed with the dose-
expansion cohort. Vitamin C at concentrations of up to 100 grams, delivered by IV infusion, 
True Toxicity 
DLT Rate 
Probability of 
escalating to next 
0.1 
0.91 
0.2 
0.71 
0.3 
0.49 
0.4 
0.31 


 
 
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has been used in cancer patients, and either no or rare, very mild toxicities been reported. 
Reported toxicities were mainly central nervous system (CNS)-related, and consisted only 
of dizziness or headaches. Other non-CNS toxicities were mild (grades 1-2), and include 
thirst, nausea, vomiting, and mildly increased urinary frequency. There have been case 
reports of patients developing renal calculi due to high Vitamin C infusion, but most of these 
individuals had other risk factors for this disorder. Accordingly, any patient with history of any 
renal calculi or hyperoxaluria or any other preexisting renal disorder will be excluded from 
enrollment. 
 
 


 
 
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A Phase Ib Study Evaluating the Safety and Tolerability of 
Vitamin 
C 
in 
Patients with 
Intermediate 
or 
High 
Risk 
Myelodysplastic Syndrome with TET2 Mutations 
 
I. Background: 
 
A. Significance: Myelodysplastic syndromes (MDS) comprise a heterogeneous group of 
clonal stem cell disorders with an intrinsic tendency for transformation into acute myeloid 
leukemia (AML). The 2008 World Health Organization (WHO) classification system for 
hematologic neoplasms defines MDS as one of five major categories of malignant myeloid 
hematopoietic disorders [18], and includes refractory cytopenias with unilineage or multi-
lineage dysplasia and refractory anemia with ring sideroblasts or excess blasts. 
Consequently, MDS is diagnosed based on peripheral blood cytopenia, peripheral blood and 
bone marrow (BM) dysplasia/blasts, and clonal cytogenetic abnormalities. With an incidence 
of 5 cases/ 100,000 individuals in the United States, there are ~13,000 new cases of MDS 
per year [19]. The incidence of MDS increases significantly in individuals above age 60, 
with 30-50 cases/100,000 per year in this population. In addition to age, risk factors include 
a history of exposure to chemotherapy or radiation and, to a lesser extent, tobacco use or 
occupational exposure to solvents or agricultural chemicals [20]. Up to 30% of high-risk MDS 
transforms into AML. Cytogenetic abnormalities are found at diagnosis in 20-70% of MDS 
patients, with the highest frequency occurring in patients with the refractory anemia with 
excessive blasts (RAEB) variant [21]. Survival of MDS patients depends on their R-IPSS 
(revised international prognostic scoring system) risk group classification. Low-risk patients 
have a median survival of 5.7 years, while those with intermediate risk have a median 
survival ranging from 1.2-3.5 years for high intermediate or low intermediate risk, 
respectively [22]. For patients in the high-risk group, median survival is only 5 months. 
Clearly, new treatments are needed to improve survival for MDS patients, especially those 
at intermediate and high risk. This need is made even more urgent by the strong association 
of MDS with age, as disease burden will likely increase substantially in the next few decades 
owing to our aging population.  
 
MDS is part of the large spectrum of myeloid malignancies, which include AML and 
myeloproliferative neoplasms (MPNs) [23]. In the past, it was felt that these diseases were 
distinct biological entities, but we now know that they share significant genetic overlap. Over 
50 recurrently mutated genes are involved in MDS pathogenesis, including those that 
encode proteins involved in pre-mRNA splicing, epigenetic regulation, and transcription. 
More recently, exome sequencing of peripheral blood samples from over 30,000 patients 
without known hematologic malignancies demonstrated recurrent somatic myeloid 
malignancy-associated mutations in up to 10% of patients over the age of 65 and in more 
than 20% of patients over the age of 90 [24, 25]. This phenomenon is now termed clonal 
hematopoiesis of indeterminate potential (CHIP) [26]. The most common recurrently mutated 
genes in MDS patients are DNA methyltransferase 3A (DNMT3A), TET2, additional sex 
combs-like 1 (ASXL1), TP53 (which encodes p53), Janus kinase 2 (JAK2) and SF3B1 [27]. 
Most of the initial mutations in MDS lead to increased HSC self-renewal, clonal expansion, 
and development of CHIP. As the mutant clone expands, it develops additional genetic or 
epigenetic defects that promote progression to frank hematological malignancy. These 
secondary, sub-clonal events tend to cause dysplasia, leading to MDS and eventually, 
secondary AML. Therefore, there are considerable similarities between MDS and AML.  
 
B.TET2 and MDS: Ten-eleven translocation-2 (TET2) belongs to a small sub-family 
(comprising TET1-3) of α-ketoglutarate- and Fe2+-dependent dioxygenases (αKGDDs). The 


 
 
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60-80 αKGDDs (many only inferred by sequence similarity) in mammals catalyze a wide 
variety of hydroxylation and oxidative demethylation reactions by using αKG and O2 as 
substrates and Fe+2/Fe+3/Fe+4 shuttling for catalysis. TET proteins catalyze the sequential 
oxidation of 5-methyl cytosines (5mC) in DNA [28, 29] to 5-hydroxymethyl cytosine (5hmC), 
5-formylcytosine (5-fC) and 5-carboxylcytosine (5caC), respectively. These modified 
nucleotides are key intermediates in DNA demethylation, which can occur actively, via base-
excision repair (BER), or passively, following replication [30]. Either way, TET deficiency 
results in impaired 5mC oxidation and DNA hypermethylation [31]. Alterations in multiple 
genes that share the property of regulating DNA methylation [32] are causally associated 
with MDS pathogenesis. Accordingly, hematopoietic cells from MDS patients have globally 
altered methylation profiles [33], and DNA demethylating agents (azacitidine and decitabine) 
are the current mainstay of MDS therapy. Loss-of-function mutations in TET2 are among the 
most frequent, occurring in ~ 30% of MDS patients [34]. Similar TET2 mutations are found 
in other myeloid neoplasms, including ~50% of chronic myelomonocytic leukemia (CMML) 
and ~10% of sporadic acute myeloid leukemia (AML). TET2 mutations are also seen at a 
high allele frequency in CD34-positive hematopoietic stem cells of patients with other 
myeloid malignancies [31, 35], as well as other hematopoietic neoplasms [33], suggesting 
that such mutations are early drivers of transformation in cells with multi-lineage potential. 
Frameshift, nonsense, or missense alternations in TET2 are reported in MDS patients [31] 
and have the same effect on methylation [36]. As noted above, TET2 mutations are also 
seen in the white blood cells (WBCs) of otherwise healthy adults with CHIP [37]. Hence, 
TET2 mutations are associated with pre-leukemic lesions that can enable disease 
progression by altering the epigenetic landscape and/or by promotion of the acquisition of 
additional oncogenic lesions in aberrantly self-renewing stem cells. Therefore, restoring 
TET2 function could provide therapeutic benefit to patients with CHIP or MDS.  
 
C.Vitamin C and TETs: Vitamin C (ascorbic acid/ascorbate) is an essential co-factor for 
TET family demethylases, as well as for most αKGDDs [38]. It interacts directly with the C-
terminal catalytic domain (CD domain) of TET proteins [39], acting to reduce Fe+4 generated 
during the reaction cycle back to Fe+2. Intriguingly, previous studies suggested that high-
dose Vitamin C, acting via TET family members and possibly Jumonji-type histone 
demethylases, could dramatically enhance the function of embryonic stem cells (ESC) [40] 
and the generation of induced pluripotent cells (iPSCs). The use of Vitamin C in cancer has 
a sullied history, dating to claims by Cameron and Pauling, based largely on single arm 
studies or post-hoc analyses, that high dose Vitamin C has global anti-neoplastic and 
immune-stimulatory effects [41, 42]. Subsequently, controlled clinical trials of high dose oral 
Vitamin C showed no anti-cancer efficacy [5, 6]. However, oral administration of Vitamin C 
at up to 10 grams/day does not produce the millimolar blood levels seen after parenteral 
administration, and recently, there has been renewed attention to the possible anti-
neoplastic effects of high dose, intravenous (IV) Vitamin C [9, 43]. 
 
D. Summary and Potential Impact: Finding a treatment with high efficacy and a lower 
toxicity profile than hypomethylating agents is essential for improving the treatment of MDS 
patients. Recently, our group found that genetic restoration of Tet2 is sufficient to block 
aberrant self-renewal of pre-leukemic stem/progenitor cells and reverse Tet2-deficient 
disease in mouse models. We also found that, by enhancing the activity of residual TET2 
and TET3, high dose Vitamin C can act as a “pharmacologic mimic” of Tet2 restoration, 
reversing the cellular and molecular features of TET2 deficiency in mouse and human 
models [1]. Our proposed clinical trial of continuous infusion Vitamin C could lead to a new 
therapeutic strategy for MDS patients with TET2 mutations, who represent ~30% of MDS 
patients overall. Our pre-clinical data also suggest salutary effects of Vitamin C on CMML 
and AML, and potential synergy with PARP inhibitors. Hence, our approach could have even 
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II. Vitamin C and its Utility as a Hypomethylating Agent: 
 
Vitamin C (Ascorbic Acid/Ascorbate) first was used in the treatment of scurvy. Most animals 
have an ability to synthesize ascorbic acid (AA); however, humans depend upon dietary 
AA intake due to an inherited mutation in the gene that encodes L-gulonolactone oxidase 
(GULO), a key enzyme in AA biosynthesis [8]. DNA demethylation can be initiated by the 
oxidation of 5- methylcytosine (5mC) and the formation of 5-hydroxymethylcytosine 
(5hmC), which are catalyzed by the enzymatic activity of the TET1-3 family of 
dioxygenases. 5hmC is oxidized by TET proteins to form 5-formylcytosine (5fC) and 5-
carboxylcytosine (5caC) [9]. AA is a cofactor of TET mediated oxidation of 5mC and 
accordingly has the capacity to regulate DNA methylation processes at the cellular level. 
 
Studies demonstrate that AA directly interacts with the C-terminal catalytic domain (CD 
domain) of TET proteins [9]. AA significantly increases the level of all 5mC oxidation 
products (5fC and 5caC) leading to global loss of 5mC. The catalytic activity of TET 
dioxygenases for 5mC oxidation requires 2  cofactors:  Iron  (Fe2+)  and  2-oxoglutarate.  
AA enhances hydroxylase activity by reducing the inactive Iron (Fe3+) to Fe2+ required for 
the activity for dioxygenases including prolyl- 4-hydroxylase. This strongly supports that 
Fe2+ and 2-oxoglutarate acts as a co-factor and co- substrate respectively to initiate the 
conversion of 5mC to 5hmC [10]. The epigenetic marker 5mC is largely erased by inhibiting 
or eliminating the activity of DNA methylation [11], a critical step for multiple biological 
processes like animal cloning, nuclear re-programing, development and highly locus-
specific regulation of gene activities. AA also has been identified as the KSR component 
responsible for Dazl induction that occurs with the DNA methyltransferase (Dnmt) inhibitor  
5-Azacytidine,  suggesting  that  AA   promotes DNA demethylation [12]. Finally, TET1 CD 
domain significantly represses the expression of Cdh1 and Epcam only in the presence of 
AA suggesting that MET (mesenchymal-to-epithelial) might be a crucial step in controlling 
TET activity in the presence of AA [13]. Also as part of our preclinical laboratory work it 
was already shown in 2 different TET2 knock in mutated mice with myeloid diseases 
that were created to be more sensitive to vitamin C treatment than the wild type (WT) 
mice. Accordingly AA can be utilized as a possible treatment for MDS patients with TET2 
mutations instead of the current available hypomethylating agents and the biggest 
advantage of AA would be a much better toxicity profile. 
 
Most MDS patients will have been treated with hypomethylating agents (HMAs), the current 
standard of care, prior to trial entry. We will enroll patients on our trial if they have previously 
received HMAs, as long as the last dose was given at least 4 weeks before enrollment. No 
patient will be allowed to receive HMAs while on this study. In the open-label Phase 2 portion 
of the trial, two co-primary endpoints will be evaluated: the pharmacodynamic endpoint of 
demethylation and overall response rate. HMAs inhibit DNMTs to promote passive DNA 
demethylation and should not affect demethylation promoted by Vitamin C through its active 
conversion of 5-methylcytosine (5mC) to 5-hydroxymethylcytosine (5hmC) by TET enzymes. 
Furthermore, earlier studies have shown that patients who fail one hypomethylating agent 
can still respond to other hypomethylating agents as second line therapy. For example, in 
one study patients who failed or had loss of response to azacitidine had a 28% overall 
response rate to decitabine in the second line, and each HMA had different effects on global 
methylation [44]. Accordingly, we expect to achieve similar or even greater response 
frequencies in our MDS patient population, given the difference in expected demethylation 
mechanism between HMAs and Vitamin C. The design of our study to give Vitamin C for 5 
consecutive days every 28-days is similar to how HMAs are given (decitabine is used for 5 


 
 
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consecutive days and azacitidine for 7 consecutive days in every 28-day cycle). As effects 
on DNA methylation, and presumably, their biological consequences, can last for weeks, we 
will start with Vitamin C CIVI for 5 days to achieve the highest demethylation effect and then 
maintain patients on Vitamin C as 1 gram daily afterwards to prolong the demethylation effect 
between cycles. Oral Vitamin C (1 gram daily) will start after the completion of Vitamin C 5 
days CIVI and continue until the beginning of the next cycle (from day 6 until day 28 of the 
28-day cycle). 
 
III. Preclinical Data: 
 
Hematopoietic stem/progenitors from mice with TET2 deficiency exhibit increased self-
renewal capacity, as manifested by enhanced serial re-plating (in vitro) and a substantial 
advantage and myeloid bias in competitive bone marrow 
transplantation (BMT) assays (Figure 1) [1].  
 
 
 
Several groups have developed mouse models of TET2 deficiency, either by generating 
Tet2 knockout mice [45] or by inducibly expressing Tet2 shRNA [46]. Tet2 reversible 
knockdown mice were generated by our group; these mice express a doxycycline (Dox)-
regulated, Tet2-specific miR30-based shRNA (shTet2) with linked green fluorescence 
protein (GFP) from the Col1a1 locus (Figure 2) [1].  
 
Tet2-knockdown mice manifest progressive defects in hematopoiesis, characterized by 
myeloid lineage expansion, and a substantial fraction develop CMML-like disease, 
characterized by increased circulating WBCs, mainly monocytes and splenomegaly (Figure 
3) [1]. 
Figure 1: Tet2 Restoration Blocks Aberrant 
Hematopoietic Stem Cell Self-Renewal in 
Vitro and In Vivo 
(A) Schematic of colony-forming assays 
performed with Tet2 knockdown cells. 
(B) Total number of colony-forming units (CFU) 
generated by VTA shRen control or VTA shTet2 
knockdown cells. 
(C) Representative appearance of colonies 
generated after 4 passages (P4) with Tet2 
knockdown re-plated ± Dox from P4–P5. 
(D) Number of CFUs from passage 5 (P5) Tet2 
knockdown (KD) and Tet2-restored (RS) cells. 
(E) Tet2 mRNA levels normalized to Hprt in RS 
cells relative to KD from (D).  Adapted from 
Cimmino et al. [1] 
Figure 2: Generation of Inducible and Reversible Tet2 
Knockdown Mice 
(A) Schematic representation of Vav-tTA-driven (VTA) 
reversible Tet2 knockdown mice. 
(B) Schematic representation of Rosa-rtTA-driven (RTA) 
inducible Tet2 knockdown mice. 
(C) Tet2 mRNA levels (normalized to Hprt) in bone 
marrow, thymus, and spleen cells from VTA shTet2mice, 
compared with cognate cells from VTA shRen control mice. 
(D) Schematic representation of Tet2 restoration (RS) 
versus knockdown (KD) in mice treated 
with doxycycline (Dox) food for 28 days (D0–D28). 
Adapted from Cimmino et al. [1] 


 
 
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Remarkably, by toggling Tet2 expression on and off using our reversible shRNA system, we 
found that Tet2-deficient phenotypes (including CMML-like disease and even Tet2-mutant 
AML) and its biochemical effects (altered methylation) could be reversed by restoring Tet2 
expression (Figure 4) [1]. For example, as shown in Figures 4A-G, TET2 restoration 
promotes DNA demethylation, differentiation and the death of cKit+ cells, respectively [1].  
 
 
 
These studies confirm the causal role of TET2 mutations in myeloid neoplasia and, more 
importantly, show that the epigenetic changes evoked by, and pathogenic consequences of, 
decreased TET2 levels are potentially reversible. Consistent with this notion, although only 
a minority of MDS patients respond to hypomethylating agents (azacitidine and decitabine), 
TET2-mutant patients (especially those lacking additional ASXL1 mutations) respond better 
to hypomethylating agents [47]. Unfortunately, even in this sub-group, the effects are not 
durable, and ultimately, disease progression ensues. Nearly all TET2 mutations in patients 
with MDS or other hematologic neoplasms are heterozygous, leaving one normal copy of 
TET2, as well as a full complement of the other TET2 family members, TET1 and TET3. The 
pathogenic impact of TET2 haploinsufficiency indicates that even small decreases in TET2 
activity cause disease; conversely, the reversibility of myeloid neoplasia in Tet2-knockdown 
(Tet2-KD) mice argues that small increases in activity might be therapeutic. Capitalizing on 
the biochemical function and properties of TET2, our group found that high-dose Vitamin C 
could activate the remaining TET2 protein, as well as TET3 (Figure 5A-5D), block aberrant 
Figure 3: Tet2-Knockdown Mice Show Aberrant Stem 
Cell Phenotypes and Develop Myelo-erythroid Neoplasms 
(A) Cohorts of Vav-tTA (VTA) shRen (n = 16) and VTA shTet2 mice (n = 
21) were aged for 2 years in the absence of Dox treatment.  Peripheral 
blood cell (PBC) lineages were monitored by flow cytometry at 6 months 
and 20 months. Cells were stained for B220 (B cells), CD3 (T cells) 
CD11b and Gr1 (Myeloid cells) and CD71 and Ter119 (erythroid cells). 
B, T, M, and E cell frequencies, respectively, were measured in GFP+ 
(shRNA)-expressing cells (70%–90% of PBCs). (B) Kaplan-Meier curve 
of untreated VTA shRen and VTA shTet2 mice. 
Figure 4:  Tet2 Restoration Promotes DNA 
Demethylation, Differentiation, and Cell 
Death. 
(A)Tet2 mRNA levels (normalized to Hprt). 
(B) Proliferation.  
(C) Apoptosis as assessed by Annexin V 
staining of Tet2 RS versus sustained Tet2 KD 
cells.  
(D) Representative flow cytometry histograms 
of stem and progenitor (cKit and CD34) or 
differentiation (CD11b) marker expression 
upon Tet2 KD or Tet2 RS after 21 days in 
culture. 
(E) Quantification of GFP by relative 
mean fluorescence intensity (MFI)  
(F and G) Global changes in methylation were 
measured in genomic DNA isolated from 
cKit+ cells during inducible Tet2 RS, and 
compared to cells with sustained Tet2 KD. 
Quantification was performed using ELISAs for 
5mC (F) and 5hmC (G).  
Adapted from Cimmino et al.[1] 
 
(C and D) Spleen weights (C) and shape (D) of sick VTA 
shTet2 mice compared with age-matched control VTA 
shRen mice. (E and F) Histological analysis showing 
GFP/hematoxylin staining (upper panels) and H&E staining 
(lower panels) of spleen (E) and liver (F) sections from age-
matched control VTA shRen and sick VTA shTet2 mice. 
Adapted from Cimmino et al.[1] 


 
 
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hematopoietic self-renewal, and reverse the consequences of TET2 deficiency in mice 
(Figure 5E- 5G) [1].  
 
  
 
 
Furthermore, although MDS patient-derived xenografts (PDXs) were not available, similar 
effects of high-dose Vitamin C were seen in human AML cultures (data not shown, but see 
Ref. [1]) and PDXs (Figure 6).  
 
 
 
 
 
 
The ability of Vitamin C to block self-renewal and myeloid disease progression in mice 
motivated us to explore its effects on TET function and 5hmC generation in the HL60 and 
MOLM13 cell lines, representative of acute myeloblastic and acute monocytic leukemia, 
respectively. Consistent with our observations using mouse hematopoietic stem and 
progenitor cells (HSPCs), Vitamin C treatment for 72 hours (hr) caused increased 5hmC 
formation in both lines (Figure 7A) without altering TET1-3 expression (Figure 7B). We 
performed 5hmC DNA immunoprecipitation (5hmeDIP) with genomic DNA from untreated 
HL60 cells (0 hr) and cells treated for 72 hr with Vitamin C. Nearly all differentially 
B 
C 
D 
 
Figure 5:  Vitamin C Treatment Mimics Tet2 Restoration in HSCs and Blocks Myeloid Disease Progression. 
(A) Colony-formation assays with Tet2+/+, Tet2+/_, and Tet2_/_ bone marrow cells treated with L-AA. Cells were re-plated for four passages (P1-P4). 
(B) Tet2_/_ CFUs re-plated from passage 4 to 5 (P4–P5) and Tet2+/_, Tet2_/_, and Tet2/3 double-deficient colonies re-plated from P4 to P5. 
(C) Relative Tet1, Tet2, and Tet3 mRNA levels in cKit+ cells, quantified by RT-PCR and normalized to Hprt 
(D) DNA dot-blot for 5hmC in primary mouse cKit+ cells cultured for 6 days ± L-ascorbic acid (L-AA). 
(E-G) Vitamin C treatment of mice reconstituted with Tet2+/+ and Tet2−/− bone marrow. Mice were injected i.p. with PBS (control) or ascorbate (ASC, 4 
g/kg), and WBC counts were monitored for 24 weeks post-transplant (PT) (E). Frequency (F) and number (G) of donor B and T lymphocytes and 
myeloid cells (M) in peripheral blood of recipients at 24 weeks PT treated with ASC or control (PBS). Adapted from Cimmino et al.[1] 
E
A 
F 
G 
A 
Figure 6: Vitamin C treatment of PDXs impairs human leukemia progression 
(A) Schematic representation of primary human AML PDX generation and Vitamin C treatment.  
(B) Disease progression in AML PDXs treated with Vitamin C (ASC) or vehicle (PBS) was monitored by flow 
cytometric analysis of hCD45+ cells in peripheral blood.  Adapted from Cimmino et al.[1] 
B 


 
 
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hydroxymethylated peaks (29,492; 97%) exhibited gain of 5hmC upon Vitamin C treatment 
(Figure 7C). Increased 5hmC was enriched within gene bodies, compared with transcription 
start sites (TSS) or transcription end sites (TES) (Figure 7D) [1]. 
 
 
 
 
 
 
Our results comport with other published work. In a study published virtually simultaneously 
with ours, Vitamin C deficiency was found to phenocopy the effects of Tet2 deficiency in 
promoting increased self-renewal and myeloid bias of HSPCs, as well as to cooperate with 
leukemogenic fusion proteins to generate AML in mice [48]. These data support the 
hypothesis that high-dose Vitamin C might have therapeutic efficacy in TET2-mutant human 
MDS. Our exciting pre-clinical data provide the foundation for the clinical trial and correlative 
studies proposed herein. Restoring normal TET function in TET2-mutant MDS patients might 
be more specific than using global hypomethylating agents, and thereby have greater 
efficacy with less toxicity. 
 
IV. Objectives of the Study: 
 
This is a phase Ib study to help us test the utility of Vitamin C as a treatment for patients 
with MDS. Many genes involved in pathways like Ras signaling, the p53 network and 
apoptosis are transcriptionally inactivated by the hypermethylation of specific CpG islands 
in cancer cells, making DNA methylation an effective therapy to target in MDS patients 
[14]. Multiple molecular subtypes of myeloid disease have been found to exhibit highly 
distinct DNA methylation profiles [15] and hypomethylating agents like decitabine and 5-
Azacytidine have been used in the treatment of MDS patients, especially in elderly 
patients who are unable to tolerate intensive chemotherapy induction [16]. 
 
MDS patients with TET2 mutations will be enrolled in this study with the following objectives: 
 
A. Primary objectives: 
 
A 
C 
Figure 7: Vitamin C Treatment Increases TET Activity in 
Human AML and Drives DNA Hypomethylation. 
(A) DNA dot blots for 5hmC in MOLM13 (acute monocytic 
leukemia cell line) and HL60 cells (acute myeloblastic 
leukemia cell line) treated for 72 hr with 250 mM L-ascorbic 
acid (L-AA). 
(B) TET mRNA levels (assessed by qRT-PCR) in the human 
leukemia cell lines HL60 and MOLM13 treated for 3 days with 
L-AA (250 μM, 72 hr) or left untreated. 
(C and D) Differentially hydroxymethylated peaks (Diff Peaks) 
with gain or loss of 5hmC (Diff Peaks, q < 0.05), assayed by 
5hmeDIP-seq, in HL60 cells treated with 250 mM L-AA for 72 
hr. Frequency and total number of significant Diff Peaks (C) 
and gene body distribution of the top 10,000 significant peaks 
following L-AA treatment (D), displayed as peak density ± 3 
kb from the transcription start site (TSS) to the transcription 
B 
D 


 
 
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1. Evaluate the safety and toxicity of high dose Vitamin C 
2. Estimate the proportion of MDS patients with TET2 mutations who exhibit a biological 
response defined as maintaining a vitamin C serum concentration of ≥1 mM over the 
treatment cycle within and across dose levels and study phases 
 
B. Secondary objectives: 
1. Estimate the clinical efficacy, namely objective response rate (ORR), [including 
complete response (CR) and partial response (PR)], duration of response (DOR) and 
progression-free survival (PFS) as defined in the IWG (International Working Group) 
response criteria in myelodysplasia within and across dose levels and study phases.  
2. Estimate the Maximum measure Vitamin C plasma concentration (Cmax) 
3. Evaluate the pharmacokinetic profile (PK) of Vitamin C as hypomethylating or 
demethylating agent 
 
 
V: Dosing and Patient Selection: 
Patients will receive up to 4 cycles of treatment, and responders will be allowed to continue 
treatment beyond the 4 cycles. MDS patients will be enrolled in the study if they have any 
of the following revised international prognostic scoring system (R-IPSS) risk scores: 
intermediate score (>3 and ≤ 4.5), high score (>4.5 and ≤6) or very high score (>6). MDS 
patients with very low score ≤1.5 or low score (>1.5 and ≤ 3) will be excluded, as they do 
not require treatment and have a better prognosis than patients with higher R-IPSS score. 
R-IPSS score will be calculated based on Table 2 specifics.  
 
We propose a Phase 1 component with 3 dose-escalation cohorts in a 3+3 design to 
determine the maximum tolerated dose (MTD) of Vitamin C, followed by a Phase 2 dose-
expansion cohort. Vitamin C will be provided from McGuff based on a confidential 
agreement with them and McGuff provides the only FDA-approved injectable preparation 
of Vitamin C in the USA. Such a trial using Vitamin C in MDS patients could lay the 
foundation for utilizing ascorbic acid as an anticancer agent and improve outcomes in this 
challenging group of patients. 
 
Table 2: Revised International Prognostic Scoring System: 
IPSS-R prognostic score values 
 
Prognostic variable 
0 
0.5 
1 
1.5 
2 
3 
4 
Cytogenetics 
Very good 
— 
Good 
— 
Intermediate 
Poor 
Very 
poor 
BM blast, % 
≤ 2 
— 
> 2%- < 5% 
— 
5%-10% 
> 10% — 
Hemoglobin 
≥ 10 
— 
8- < 10 
< 8 
— 
— 
— 
Platelets 
≥ 100 
50-< 100 
< 50 
— 
— 
— 
— 
ANC 
≥ 0.8 
< 0.8 
— 
— 
— 
— 
— 
 
BM= bone marrow, ANC=absolute neutrophils count 
 


 
 
 
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VI. Safety Objectives: 
Research Risks and Benefits 
Risks associated to study participation include breach of confidentiality and risks associated 
with blood draw. Privacy procedures in place and good clinical practice guidelines are 
followed in the study to minimize risks associated with research procedures and 
participation. The risks associated with blood draw include weaknesses, redness, pain, 
bruising, bleeding or infection at the needle site. There may be no direct potential benefits 
to subjects participating in the sturdy, but the information obtained from this research may 
help others with this disease in the future. Intravenous vitamin C in high doses has been 
studied earlier with no major adverse events reported. However regardless we will be 
monitoring for any adverse event as follows.  
1. Adverse Events 
All adverse events (AEs) recorded during the study will be coded by MedDRA (Medical 
Dictionary for Regulatory Activities). AEs will be summarized by cohort, overall, primary 
system organ class, preferred terms and severity based on CTCAE version 5.0. 
Relationship to Vitamin C, AEs leading to discontinuation of study drug and SAEs will 
be summarized. No infusion-related AEs are expected; however if any do occur then 
they will be summarized by preferred term and severity. A list of AEs related to skin 
toxicity using pre-defined MedDRA preferred terms will be used to identify any AEs of 
special interest. All AEs will be listed. 
 
2. Laboratory Abnormalities 
Laboratory values will be converted into international system of units (SI) units, severity 
grades will be calculated using CTCAE version 4.0. For those parameters where there is 
no CTCAE grading then a defined classification into lower limit, normal and higher limit 
will be used. Shift tables for change from baseline will be presented as well as descriptive 
statistics mean, standard deviation, median, and range for absolute values by visit 
and change from baseline will be summarized. All lab values, abnormalities will be listed. 
The safety set will be used. 
 
3. Vital Signs and Physical examination 
Vital signs will be summarized by mean, standard deviation, median and range for 
absolute values by visit and change from baseline. The number of abnormal vital signs 
will be summarized by visit. All values will be listed. The safety set will be used. 
 
Physical examination should include assessments of the following body parts/systems: 
heart, lungs, abdomen, extremities and a neurological exam. 
 
4. Other Safety Parameters 
All other safety parameters such as ECG will be listed for the safety set. Twelve-
lead ECG measurements will be conducted in triplicate at protocol specified time point 
(see Table 3) keeping the leads in place and patient supine during recordings. Additional 
ECG measurements should be performed as clinically indicated. Electronic copies of the 
tracings will be submitted to the sponsor’s designee for central assessment. 
 
5. Interim Analysis 
The NYUCI Data Safety Monitoring Committee (DSMC) will review the safety data 


 
 
 
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after 6 patients are enrolled and evaluated to assure the safety of the participating 
patients based on the rules described in Section VII. 
A formal interim analysis is planned at the completion of the first stage of the Simon 
2-stage design (see Statistical Considerations).  
 
6. Clinical Laboratory Tests 
The following laboratory assessments will be performed by local laboratories at 
the scheduled time points (See Table 3) during the course of the study: 
 
• 
Weekly CBC with differential count to include the following tests: white blood cell 
count with 
five 
part 
differential 
(neutrophils, 
lymphocytes, 
monocytes, 
eosinophils, and basophils), platelet count, hemoglobin and hematocrit. Also, 
CBC to include peripheral myeloblast count (if present). 
• 
Weekly chemistry panel to include the following tests: sodium, potassium, 
bicarbonate, chloride, glucose, magnesium, calcium, phosphorus, albumin, 
alkaline  phosphatase, ALT, AST, blood urea, nitrogen, calcium creatinine, LDH, 
phosphorus, total bilirubin, and uric acid 
• 
Weekly urinalysis with microscopy to assess for hematuria since vitamin C may 
cause oxalate nephropathy. 
• 
Weekly serum anion gap as vitamin C can be associated with elevated anion gap 
acidosis. If anion gap is elevated (>11mEq/L) then we will hold the study drug 
for one week and recheck anion gap. If still elevated (>11mEq/L), we will 
withdraw the patient from the study, If not elevated (≤11mEq/L) we will resume 
vitamin C treatment. 
• 
A serum or urine β-HCG pregnancy test for females of childbearing potential to 
be done within one week of starting the trial and before starting a new cycle. 
• 
Creatinine clearance-the same method of assessment should be used at each 
time point. 
• 
PT/PTT/INR 
 
7. ECOG Performance Status 
ECOG performance status will be evaluated at protocol specific time points (See 
Table 3) 
 
 
VII. Subject Identification, Recruitment and Consent 
A. Method of Subject Identification and Recruitment 
Patients will be recruited from physicians at the NYU Langone’s Ambulatory Care Center 
(ACC) in New York, USA, and at University of Miami, Health System. Consenting, 
screening, and treatment will take place at the NYU ACC or at University of Miami, 
Health System under the supervision of the PI or Co-Investigators. Prospective subjects 
will receive detailed information about this study: its investigational nature, required study 
procedures, alternative treatments, risks and potential benefits of the study. They will 
also receive the informed consent document to read. All questions are answered by the 
PI, Co investigators and qualified research personnel. 
The patients who are eligible for this research study will come directly from the study 
investigators’ clinical patient population. Thus, the investigators are very familiar with their 
patients’ disease status and potential eligibility given the protocol’s inclusion and exclusion 


 
 
 
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criteria. All efforts will be made to actively recruit and retain women and members of 
minority groups in this study. The inclusion and exclusion criteria in this study should not 
have a negative effect on the enrollment of these populations. Target enrollment for 
this study is up to 12 patients.  The target accrual goal is 6 patients per year.  Patients 
will be recruited from the outpatient clinics in the NYU ambulatory cancer center as well 
as University of Miami Cancer Center for any patients undergoing workup or treatment for 
Myelodysplastic Syndrome (MDS). 
The investigator will approach eligible potential subjects and explain the study in a private 
room, including the reasons why subjects will be eligible, risks, benefits, and the regimes 
to be evaluated. It is NYULMC policy that Nurses and Fellows cannot obtain consent 
to greater than minimal risk trials, unless Fellows are listed as co-investigators. Consent 
will be obtained in a private room by the PI or a Co-investigator at the time of the 
subject’s visit prior to any study assessments/procedures. 
 
The subjects will be given a chance to ask questions to the person consenting him/her 
and will be able to take the consent home to discuss it with family/friends prior to 
signing. If the subject agrees s/he will sign the consent form either at the first contact 
(if the investigator/delegate is convinced that the subject understands) or at the time of 
a return visit after having had time to study the consent in more depth. Study procedures 
will not begin until after the consent form has been properly obtained. The subject is 
entitled to decide not to participate in the trial, without affecting their right to other 
medical care, and may discontinue participation in the trial at any time without penalty or 
loss of benefits to which they are entitled. 
 
For non-English speaking patients, institutional translation services will be utilized.  All 
procedures for consenting non-English speaking patients will be in accordance with 
NYULMC PCC CTO guidelines and policy.   
 
For patients who cannot read a witness, not related to the research study will be 
present. The consent will be read to the patient. The patient will also be allowed to ask 
any questions s/he may have. The investigator will ask the patient questions to ensure 
s/he understands the study. If the investigator determines the subject understands the 
study, the patient will mark an X where his/her name would go and the witness will sign 
the consent form. 
  
 
B. Documentation of Consent 
The Principal Investigator or IRB approved Co-investigator will be responsible for 
documentation in the medical record that consent has been obtained from all participants. 
A signed copy of the consent form will be given to each participant. Original consent 
forms will be stored in the subject’s medical chart. 


 
 
 
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C. Multi-Site Surveillance 
 
As the lead investigator in a multi-site trial, the Overall Principal Investigator is 
responsible for organizing and conducting monthly teleconferences with all participating 
sites. The PI will also be responsible for including data from all of the participating sites 
within the overall trial’s yearly Data and Safety Monitoring report to the DSMC to include 
minutes from monthly PI teleconferences. Each participating site will be responsible for 
submitting the results and recommendations from the DSMC’s yearly review to their IRB 
of record at the time of continuing review. 
 
 
D. Patient Informed Consent at Additional Sites 
 
The Principal Investigator (PI) at each participating site will identify the physician members 
of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. 
 
The Investigator must ensure that each participant, or his/her legally acceptable 
representative, is fully informed about the nature and objectives of the study and 
possible risks associated with participation. All participants must be provided a consent 
form describing this study and providing sufficient information for participants to make an 
informed decision about their participation in this study. The formal consent of a 
participant, using the IRB approved consent form, must be obtained before the participant 
is involved in any study-related procedure. The consent form must be signed and dated 
by the participant or the participant’s legally authorized representative (if applicable), 
and by the person obtaining the consent. The participant must be given a copy of the 
signed and dated consent document. The original signed copy of the consent document 
must be retained in the medical record or research file. 
 
All parties will ensure protection of participant personal data and will not include 
participant names on any sponsor forms, reports, publications, or in any other 
disclosures, except where required by laws. In case of data transfer, NYULMC Perlmutter 
Cancer Center (PCC) will maintain high standards of confidentiality and protection of 
participant personal data. 
 
The informed consent form must be in compliance with ICH/GCP, local regulatory 
requirements, and legal requirements. The informed consent form used in this study, 
and any changes made during the course of the study, must be prospectively approved 
by both the IRB and NYULMC before use. 


 
 
 
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E. Method of Assigning Subject Identification 
 
All potential study patients will be screened and eligibility will be determined prior to 
enrollment. Each patient must sign and date an informed consent form before undergoing 
any study specific procedure unless a procedure is being performed as part of the patient’s 
standard of care.  Once a patient has signed consent, the PI, Co-investigator will: 
 
1. Obtain written informed consent and privacy authorization prior to initiating any 
protocol- required procedure that is not considered standard of care 
2. Review eligibility criteria 
3. Review medical chart for past medical/surgical history 
4. Record medications and prior treatment regiments 
6. Documentation of MDS 
7. Assess and record ECOG Performance Status (Appendix 1) 
8. Submit registration to NYULMC Perlmutter Cancer Center (PCC) Clinical Trials Office 
(CTO) 
9. Receive registration confirmation from the Research Coordinator at NYULMC PCC CTO 
 
F. Registration 
 
Each patient must sign and date an informed consent form before undergoing any study 
specific procedure unless a procedure is being performed as part of the patient’s 
standard of care. Enrollment in the study requires that all inclusion and exclusion criteria 
have been met. Enrolment occurs upon confirmation of registration from the NYULMC 
PCC Clinical Trials Office. The following materials must be submitted to the Research 
Coordinator for registration: 
 
1. 
Complete signed and dated informed consent form 
2. Complete signed and dated eligibility checklist 
3. All supporting documentation verifying each criterion has been met 
4. Planned date of bone marrow aspirate and biopsy if applicable 
 
Registration will occur within 48 hours of research coordinator receipt of all of the above 
documents. A written confirmation of enrollment including a unique study identification 
number assigned by the research coordinator will be distinguished to the study team 
upon registration. Pretreatment evaluation will therefore be as directed by standard clinical 
practice.  Eligible subjects will be entered on study by the study coordinator. 
 
Once eligibility is verified, a unique patient study number will be issued within 24 hours 
of receiving all required registration material. The patient will not be identified by name. 
This is the point, at which, the patient is considered accrued on study.  
 
Patient Registration at Other Participating Institutions 
The Principal Investigator (PI) at each participating site will identify the physician members 
of the study team who will be obtaining consent and signing the consent form for 
therapeutic protocols. It is NYULMC policy that Nurses and Fellows cannot obtain consent 
to greater than minimal risk trials, unless Fellows are listed as co-investigators. 
 
Enrollment at additional sites can occur once each site’s IRB has approved this protocol, a 
copy of each site’s IRB approval, Citi training certificates, Medical Licenses and signed CVs 


 
 
 
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are provided to NYULMC Perlmutter Cancer Center (PCC) Clinical Trials Office. Once, all 
required documents are provided to NYULMC PCC Clinical Trials Office an activation 
notification will be sent to the PI and research coordinator at that site. 
 
Central registration for this study will take place at NYULMC PCC CTO. 
 
Each patient must sign and date an informed consent form before undergoing any study 
procedures unless a procedure is being performed as part of the patient’s standard of 
care. Once a patient has signed consent, each site must notify the NYULMC PCC Clinical 
Trial Office within 24 hours. 
 
Enrollment in the study requires that all inclusion and exclusion criteria have been met. 
Enrollment occurs upon confirmation of registration from the NYULMC PCC Clinical 
Trials Office and forward a copy of the signed consent to NYULMC PCC Clinical Trials 
Office within 24 hours. 
 
The following materials must be submitted to the Research Coordinator at NYULMC via 
email for registration: 
 
1. Complete signed and dated informed consent form 
2. Complete signed and dated informed consent checklist 
3. Complete signed and dated eligibility checklist 
4. All supporting documentation verifying each criterion has been met 
5. Planned date of bone marrow aspirate and biopsy if applicable 
 
Registration will occur within 48 hours of research coordinators receipt of all of the above 
documents. Once eligibility is verified, a unique subject study number will be issued 
within 24 hours of receiving all required registration material. This number is unique to the 
participant and must be written on all data and correspondence for the participant. The 
NYULMC PCC Clinical Trials Office will return a signed eligibility confirmation worksheet 
with the subject’s unique study number. The subject will not be identified by name; this 
is the point, at which, the patient is considered on the study. 
 
Except in very unusual circumstances, each participating institution will order the study 
agent directly from the supplier. Each site is responsible for reporting all unexpected 
problems involving risks to participants or others to NYULMC PCC Clinical Trials Office 
and to their IRB as per site institutional policy. 
 
 
 
-Costs to the Subject. 
No additional cost beyond the required standard of care procedures will be incurred. 
 
-Payment for Participation 
Neither reimbursements nor payments will be given for the participants in this study 
 


 
 
 
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VIII. Data Analysis and Safety Monitoring 
At the NYU PCC, all investigator-initiated protocols are subject to a standardized data and 
safety monitoring plan, which includes scientific peer review and IRB review for 
therapeutic protocols. This investigator-initiated study will be monitored by the Data and 
Safety Monitoring Committee (DSMC) of the New York University (NYU) Perlmutter 
Cancer Center (PCC). The DSMC operates based on the National Cancer Institute 
approved Charter. It is an existing and multidisciplinary committee (consisting of clinical 
investigators/oncologists, biostatisticians, nurses, and research administration staff 
knowledgeable of research methodology and design and in proper conduct of clinical 
trials) that is responsible for monitoring safety, conduct and compliance in accordance 
with protocol data monitoring plans for clinical trials conducted in the NYULMC 
Perlmutter Cancer Center that are not monitored by another institution or agency. The 
DSMC reports to the Director of the NYULMC PCC. 
 
Per the NYU PCC Institutional Data Safety and Monitoring Plan, this phase Ib trial will be 
monitored by DSMC quarterly (from the date the first patient is enrolled), after the first 6 
patients are enrolled and evaluated for safety, at times of pre-specified response 
assessment, and at the completion of the study prior to study closure. This review 
includes accrual data, subject demographics and adverse events. Accrual to the next dose 
within a cohort will be held until real-time review of the toxicity from the prior cohort has 
occurred to assure no defined DLTs have occurred prior to proceeding to the next level 
or expanding the current cohort. Principal Investigators are required to attend the review 
of their studies. Additional reviews can be scheduled based on SAE reports, investigator 
identified issues, external information, etc.  
 
This study will be monitored according to the monitoring plan detailed 
below. The review of AEs and trial conduct for this trial occurs at several 
levels: 
(1) Principal Investigator: Adverse events are evaluated monthly by the principal 
investigator in conjunction with the research nurses, data manager and research 
team. 
 
(2) DSMC, quarterly 
 
(3) Institutional Review Board (IRB): An annual report to the IRB is submitted by 
the trial PI for continuation of the protocol. It includes a summary of all AEs, total 
enrollment with 
demographics, protocol violations, and current status of subjects as well as 
available research data. 
 
(4) In addition, the quality assurance unit will monitor this trial extensively, 
including real-time review of all eCRFs to ensure completeness and compliance 
with the protocol, accuracy and consistency of the data; and adherence to ICH 
Good Clinical Practice guidelines.  Also, a first subject audit will be conducted 
within four weeks of enrollment. 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable Institution compliance and quality 
assurance offices. The investigator will contact the PCC CTO immediately if contacted by 
a regulatory agency about an inspection at the center. 


 
 
 
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A. Safety monitoring and reporting 
 
- 
Adverse Events 
All adverse events (AEs) per the description below will be captured in the Adverse Event 
Form. 
 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria: 
• Unexpected in nature, severity, or frequency (i.e. not described in study-related 
documents such as the IRB-approved protocol or consent form, the investigators 
brochure, etc.) 
• Related or possibly related to participation in the research (i.e. possibly related 
means there is a reasonable possibility that the incident experience, or outcome 
may have been caused by the procedures involved in the research) 
• Suggests that the research places subjects or others at greater risk of harm 
(including physical, psychological, economic, or social harm). 
 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or 
worsens in severity during the course of the study. Intercurrent illnesses or injuries 
should be regarded as adverse events. Abnormal results of diagnostic procedures are 
considered to be adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
Serious Adverse Event 
Adverse events are classified as serious or non-serious. A serious adverse event is 
any AE that is: 
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are 
clearly of major clinical significance. They may jeopardize the subject, and may require 
intervention to prevent one of the other serious outcomes noted above. For example, drug 
overdose or abuse, a seizure that did not result in in-patient hospitalization or intensive 
treatment of bronchospasm in an emergency department would typically be considered 
serious. 
 
All adverse events that do not meet any of the criteria for serious should be regarded 
as non- serious adverse events. 
 
Adverse Event Reporting Period 
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period from the initiation of any study procedures to the end of the study treatment 
follow-up. For this study, the study treatment follow-up is defined as 30 days following the 
last administration of study treatment. 
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study. A preexisting 
condition should be recorded as an adverse event if the frequency, intensity, or the 
character of the condition worsens during the study period. 
 
General Physical Examination Findings 
At screening, any clinically significant abnormality should be recorded as a preexisting 
condition. At the end of the study, any new clinically significant findings/abnormalities that 
meet the definition of an adverse event must also be recorded and documented as an 
adverse event. 
 
Post-study Adverse Event 
All unresolved adverse events should be followed by the investigator until the events are 
resolved, the subject is lost to follow-up, or the adverse event is otherwise explained. At 
the last scheduled visit, the investigator should instruct each subject to report any 
subsequent event(s) that the subject, or the subject’s personal physician, believes 
might reasonably be related to participation in this study. The investigator should notify 
the study sponsor of any death or adverse event occurring at any time after a subject 
has discontinued or terminated study participation that may reasonably be related to this 
study. The sponsor should also be notified if the investigator should become aware of the 
development of cancer or of a congenital anomaly in a subsequently conceived offspring 
of a subject that has participated in this study. 
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one 
of the following conditions is met: 
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the 
abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change 
of dose, discontinuation of the drug, more frequent follow-up assessments, further 
diagnostic investigation, etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization should be 
documented and reported as a serious adverse event unless specifically instructed 
otherwise in this protocol. Any condition responsible for surgery should be documented 
as an adverse event if the condition meets the criteria for and adverse event. 
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported 
as an adverse event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical 
procedures for a preexisting condition. Surgery should not be reported as an 
outcome of an adverse event if the purpose of the surgery was elective or 
diagnostic and the outcome was uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy measurement 
for the study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the 


 
 
 
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study, unless it is a worsening or increase in frequency of hospital admissions as 
judged by the clinical investigator.  
 
1. Recording of Adverse Events 
At each contact with the subject, the investigator must seek information on adverse 
events by specific questioning and, as appropriate, by examination. Information on all 
adverse events should be recorded immediately in the source document, and also in 
the appropriate adverse event module of the case report form (CRF). All clearly related 
signs, symptoms, and abnormal diagnostic procedures results should recorded in the 
source document, though should be grouped under one diagnosis. 
 
All adverse events occurring during the study period must be recorded. The clinical 
course of each event should be followed until resolution, stabilization, or until it has been 
determined that the study treatment or participation is not the cause. Serious adverse 
events that are still ongoing at the end of the study period must be followed up to 
determine the final outcome. Any serious adverse event that occurs after the study period 
and is considered to be possibly related to the study treatment or study participation 
should be recorded and reported immediately. 
 
 
2. Reporting of Serious Adverse Events and Unanticipated Problems 
 
Investigators and the protocol sponsor must conform to the adverse event reporting 
timelines, formats and requirements of the various entities to which they are responsible, 
but at a minimum those events that must be reported are those that are: 
 
• related to study participation, 
• unexpected, and 
• serious or involve risks to subjects or 
others (see definitions, Section 8.1). 
 
Serious adverse event reporting will begin in conjunction with the date of informed 
consent. Any SAEs occurring prior to study drug administration that the investigator 
believes may have been caused by a protocol procedure must be reported immediately 
to the Sponsor or its designee and recorded on the case report form. 
 
All fatal or life-threatening adverse events must be immediately reported to the Sponsor 
by telephone or e-mail. Within 24 hours of the event, the Serious Adverse Event (SAE) 
Form supplied by NYULMC must be faxed to the Sponsor, who must then inform the 
NYULMC IRB, PCC CTO, and DSMC within 24 hours of the event whether full information 
regarding the event is known or not. Additional follow-up by the investigator will be 
required if complete information is not known. De-identified source documentation of all 
examinations, diagnostic procedures, etc. which were completed with respect to the 
event should be included with the SAE form. Care should be taken to ensure that the 
patient’s identity is protected and the patient’s identifiers (as assigned at the time of study 
enrollment) are properly mentioned on any copy of source document provided to the 
Sponsor. For laboratory results, include the laboratory normal ranges. 
 


 
 
 
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Other Reportable events: 
 
• 
Deviations from the study protocol 
Deviations from the protocol must receive both Sponsor and the investigator’s IRB 
approval before they are initiated. Any protocol deviations initiated without Sponsor and 
the investigator’s IRB approval that may affect the scientific soundness of the study, or 
In case of accidental or intentional overdose of study drug, even if asymptomatic or not 
fulfilling a seriousness criterion, the overdose is to be reported to the Sponsor immediately 
(within 1 working day) using the AE and SAE forms supplied by NYULMC. Overdose of 
study drug will be defined as at least 2 times the intended dose of study drug within the 
intended therapeutic window. 
 
All serious adverse events (SAEs) will be evaluated by the DSMC If meeting the requirements for 
expedited reporting, the Sponsor will report the adverse event to all regulatory authorities with 
jurisdiction over ongoing trials with the study drug and to all other investigators involved in clinical 
trials with the study drug. The investigator is responsible for reporting all SAEs to the appropriate 
IRB, DSMC, and FDA. For Narrative Reports of Safety Events 
 
If the report is supplied as a narrative, the minimum necessary information to be provided at the 
time of the initial report includes: 
 
• 
Study identifier 
• 
Study Center 
• 
Subject number 
• 
A description of the event 
• 
Date of onset 
• 
Current status 
• 
Whether study treatment was discontinued 
• 
The reason why the event is classified as 
serious 
• 
Investigator assessment of the association 
between the event and study treatment 
 
 
In the event the investigator is informed of an SAE that occurs after 30 days after the last dose of 
study treatment, only those SAEs or other AEs of concern deemed by the investigator to be 
related to study treatment will be reported to the sponsor. The investigator should make every 
effort to obtain follow-up information on the outcome of a treatment-related SAE until the event is 
considered chronic and/or stable. 
 
Additionally, an FDA Form 3500A (MEDWATCH Form) must be completed by the investigator and 
faxed to the study sponsor within 24 hours. The investigator shall maintain a copy of the 
MEDWATCH Form on file at the study site or can be obtained from the FDA website: 
http://www.fda.gov/safety/medwatch/howtoreport/downloadforms/default.htm 
 
Contacts: 
 
NYUPCCsafetyreports@nyulangone.org 
AND 
Mohammad Maher Abdul Hay, MD 
New York University School of Medicine 240 
East 38th Street, 19th Floor 
New York, NY 10016 
Email: 
Maher.Abdulhay@nyulangone.org 
Phone: 646-501-4818 
 


 
 
 
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• 
Anything that affect the rights, safety, or welfare of study subjects, must be reported to the 
Sponsor and to the investigator’s IRB as soon as a possible, but no later than 5 working 
days of the protocol deviation. 
• 
Withdrawal of IRB approval 
An investigator shall report to the sponsor a withdrawal of approval by the investigator’s 
reviewing IRB as soon as a possible, but no later than 5 working days of the IRB 
notification of withdrawal of approval. 
 
 
 
3. Investigator reporting: notifying the IRB 
 
Federal regulations require timely reporting by investigators to their local IRB of unanticipated 
problems posing risks to subjects or others. The IRB requirements reflect the current guidance 
documents released by the Office of Human Research Protection (OHRP), and the Food and 
Drug Administration (FDA) and are respectively entitled “Guidance on Reviewing and Reporting 
Unanticipated Problems Involving Risks to Subjects or Others and Adverse Events” and “Guidance 
for Clinical Investigators, Sponsors, and IRBs: Adverse Event Reporting-Improving Human 
Subject Protection.” The following describes the NYULH IRB reporting requirements, though 
Investigators at participating sites are responsible for meeting the specific requirements of their IRB 
of record. 
The NYU IRB address is: 
 
NYULH IRB 
1 Park Avenue, 6th Floor 
New York, NY 10016 
 
Report promptly, but no later than 5 working days: 
Researchers are required to submit reports of the following problems promptly but no later than 5 
working days from the time the investigator becomes aware of the event: 
• 
Unanticipated problems including adverse events that are unexpected and related 
– Unexpected: An event is “unexpected” when its specificity and severity are not 
accurately reflected in the protocol-related documents, such as the IRB-approved 
research protocol, any applicable investigator brochure, and the current IRB-approved 
informed consent document and other relevant sources of information, such as product 
labeling and package inserts. 
– Related to the research procedures: An event is related to the research procedures if 
in the opinion of the principal investigator or sponsor, the event was more likely than 
not to be caused by the research procedures. 
– Harmful: either caused harm to subjects or others, or placed them at increased risk 
 
Other Reportable events: 
The following events also require prompt reporting to the IRB, though no later than 5 working 
days: 
• Complaint of a research subject when the complaint indicates unexpected risks or the 
complaint cannot be resolved by the research team. 
• Protocol deviations or violations (includes intentional and accidental/unintentional 
deviations from the IRB approved protocol) for any of the following situations: 
– one or more participants were placed at increased risk of harm 
– the event has the potential to occur again 
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• Breach of confidentiality 
• Incarceration of a participant when the research was not previously approved under 
Subpart C and the investigator believes it is in the best interest of the subject to remain on 
the study. 
• New Information indicating a change to the risks or potential benefits of the research, 
in terms of severity or frequency. (e.g. analysis indicates lower-than-expected response 
rate or a more severe or frequent side effect; Other research finds arm of study has no 
therapeutic value; FDA labeling change or withdrawal from market) 
 
Reporting Process 
The reportable events noted above will be reported to the IRB using the form: “Reportable Event 
Form” or as a written report of the event (including a description of the event with information 
regarding its fulfillment of the above criteria, follow-up/resolution and need for revision to consent 
form and/or other study documentation). 
Copies of each report and documentation of IRB notification and receipt will be kept in the Clinical 
Investigator’s study file. 
 
 
4. 
Sponsor reporting: Notifying the FDA 
 
The study sponsor is required to report certain study events in an expedited fashion to the FDA. 
These written notifications of adverse events are referred to as IND safety reports. The following 
describes the safety reporting requirements by timeline for reporting and associated type of event: 
 
• Within 7 calendar days (via telephone or facsimile report) 
Any study event that is: 
– associated with the use of the study drug 
– unexpected, 
– fatal or life-threatening 
 
• Within 15 calendar days (via written report) 
Any study event that is: 
– associated with the use of the study drug, 
– unexpected, and 
– serious, but not fatal or life-threatening 
-or- 
– a previous adverse event that was not initially deemed reportable but is later found to 
fit the criteria for reporting (reporting within 15 calendar days from when event was 
deemed reportable). 
Any finding from tests in laboratory animals that: 
– suggest a significant risk for human subjects including reports of mutagenicity, 
teratogenicity, or carcinogenicity. 
 
Additional reporting requirements 
Sponsors are also required to identify in IND safety reports all previous reports concerning similar 
adverse events and to analyze the significance of the current event in light of the previous 
reports. 
 
Reporting Process 
Adverse events may be submitted on FDA Form 3500A (MEDWATCH Form, obtained from the 
FDA website: http://www.fda.gov/safety/medwatch/howtoreport/downloadforms/default.htm), or in 
a narrative format. If supplied as in a narrative format, the minimum information to be supplied   is 


 
 
 
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noted above at the beginning of section 8.3. The contact information for submitting IND safety 
reports is noted below: 
 
Email: 
NYUPCCsafetyreports@nyulangone.org  
Tel: 212-263-4427 
 
 
5. Sponsor reporting: Notifying participating investigators 
 
It is the responsibility of the study sponsor to notify all participating investigators of any adverse 
event that meets the FDA 15-day reporting requirement criteria as note above. The same materials 
and timeline used to report to the FDA are used for notifying participating investigators. 
 
 
B. Medical Monitoring 
It is the responsibility of the Overall Principal Investigator to oversee the safety of the study at all 
participating sites.  This safety monitoring will include careful assessment and appropriate 
reporting of adverse events as noted above, as well as the construction and implementation of a 
site data and safety-monitoring plan.  The Data Safety and Monitoring Committee (DSMC) will 
review the study at least annually.  Medical monitoring will include a regular assessment of the 
number and type of serious adverse events. 
 
When necessary (due to logistical constraints), Sub-sites will be monitored remotely by a 
designated Quality Assurance Specialist.  Sites will be informed of this remote monitoring 
process on a site by site basis.  Sub-sites will be monitored by the Quality Assurance Specialist 
on both a regulatory level, as well as a clinical data/source documentation review level. 
 
C. Data Collection and Storage. 
 
- Data Labeling. 
 
Once a subject is enrolled on this trial s/he will be assigned a unique study ID number. 
We will code the data collected from the patients with this unique study ID.  Samples will 
be labeled with a unique ID number and disease type. The link between the patients and 
the numbers will only be kept with Dr. Abdul Hay, the Principal Investigator. The reason 
for such a link is to identify specific data and samples to discard if a patient decided to 
withdraw from the study. Numbers will be assigned randomly to maintain confidentiality. 
 
- Data Storage and Access 
 
This study will store data in an electronic database capture system that will be created to 
record the data for this trial Research coordinators will input clinical trial data into the 
database. This database is password protected and only the PI, assigned research 
coordinator, and CTO quality assurance specialists will have access to the database. 
The electronic database capture system is the primary data collection instrument for the 
study. All data required for this study must be inputted into the system. All missing data 
must be explained. The quality assurance specialists will monitor this trial every 4-6 weeks 
for data entry accuracy. 
 
Information collected in the database includes patients’ information, which will constitute 
a medical records number, date of birth, gender, ethnicity, complete blood count and 
percentage of blast. 


 
 
 
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The study team will maintain clinical and laboratory data in a designed manner to ensure 
subject confidentiality. All study personnel have passed human subject protection courses. 
If applicable, blood and tissue samples sent to collaborators outside of NYU will only be 
labeled with an identification number; no patient identifiers will be used. Systems used for 
electronic data capture are compliant with FDA regulations in 21 CFR Part 11 and 
applicable local regulatory agency guidelines. All documents are kept in strictly 
confidential password protected files and are only made accessible for review of 
sponsors, monitors and authorized representatives of regulatory agencies as described 
in the informed consent document. 
 
Samples will be labeled with a unique subject ID. The PI and Co-Investigators are the only 
ones to have access to the samples and data. Only the PI will have the linking keys. It is 
the investigator’s responsibility to retain study essential documents for at least 3 years 
after formal closure of the study. Also Tsivia Hochman from the statistics department will 
have access to the data collected to help with the analysis of the study and the outcome. 
 
- Case Report Forms 
All the data requested in the CRF must be recorded.  All missing data must be explained.  If 
a space on the CRF is left blank because the procedure was not done or the question was 
not asked, write alit Assurance Specialist”.  All entries should be printed legibly in black ink.  
If any entry error has been made, to correct such an error, draw a single straight line through 
the incorrect entry and enter the correct data above it.  All such changes must be initialed 
and dated.  DO NOT ERASE OR WHITE OUT ERRORS.  For clarification of illegible or 
uncertain entries, print the clarification above the item, then initial and date it. 
 
-Records Retention 
The CTOs Retention for records retention will be followed.  It is the investigator was not 
asked, write alit Assurance Specialist”.   
 
-Subject Data Withdrawal Subjects can withdraw from the study at any time. Request for 
withdrawal should be in writing to the PI, Dr. Abdul Hay. Once a request is received, then 
the data collected from the subject will be completely discarded. Any unused specimens 
will be destroyed as well. 
 
 
Auditing and Inspecting 
 
The investigator will permit study-related monitoring, audits, and inspections by the 
IRB, the sponsor, government regulatory bodies, and Institution compliance and quality 
assurance groups of all study related documents (e.g. source documents, regulatory 
documents, data collection instruments, study data etc.). The investigator will ensure the 
capability for inspections of applicable study-related facilities (e.g. pharmacy, diagnostic 
laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by 
government regulatory authorities and applicable Institution compliance and quality 
assurance offices. The investigator will contact the PCC CTO immediately if contacted by 
a regulatory agency about an inspection at the center. 
 
Statistical Evaluation: 


 
 
 
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1. Statistical Methods 
This is a 2 center study with a Phase ib component. This study will enroll up to 12 
patients in Phase 1b and 34 patients in Phase IIa has been deferred for a later study. The 
patients enrolled in Phase Ib will be evaluated for safety. The proportion of patients with 
biological responses will be based on the data collected from the phase 1b. There will 
be demographic and baseline characteristics documented, 
biological activity 
measurements, safety observations, efficacy observations, PK and potential biomarker 
observations. The clinical database lock will occur after all the data are reconciled (I.E. 
“cleaned”) for all patients. A single clinical study report will be generated for this 
study. The Statistical Analysis Plan (SAP) will be finalized and signed before the database 
lock. 
 
 
2. Sample Size and Power 
 
Phase 1: At each dose level, safety data will be summarized by grade for each adverse 
experience by cycle and for each patient by worst grade recorded. The proportion of 
patients with each adverse experience will be reported, along with the proportion of patients 
who achieve a response. Responses will be defined as in the IWG (International Working 
Group) response criteria in myelodysplasia as: complete remission (CR), partial remission 
(PR), or hematologic improvement (HI) after completion of cycle 4 [17]. Overall response 
rate (PR+ CR+ HI) will be provided for each dose level and across dose levels for the Phase 
1 portion of the trial (with exact 95% confidence intervals).  
 
Once our phase 1 study is completed to establish safety and confirm we are achieving 
steady level of Vitamin C on ≥1 mM in > 75% of our patients we will aim to proceed with a 
Phase 2 study. The phase 2 study will be a separate clinical trial. The co-primary endpoints 
of the Phase 2 study will be the pharmacokinetics endpoint, achievement of a steady level 
of Vitamin C of ≥1 mM in 75% of patients expected to be associated with demethylation, 
and the overall response (PR, CR or HI) by the completion of 4 cycles of treatment. With 
18 patients planned in the first stage of the 2-stage Phase 2 portion of the study (12 from 
our phase 1 study), we can estimate this feasibility rate with an exact 95% Clopper Pearson 
confidence interval of 49.4% to 92.0% if the observed rate is 75%. With the combined 24 
patients (6 from RP2D in Phase 1 and 18 from Phase 2), we can detect a difference from 
the null hypothesis of +/-25% in the percentage of patients achieving Vitamin C levels of ≥1 
mM with alpha of 0.047 and power of greater than 80.4%. We expect to achieve higher 
pharmacodynamic effects on demethylation with higher Vitamin C doses. At the same time, 
the co-primary endpoint of response (CR+PR+HI) by 4 months will be evaluated in the 
Phase 2 Simon 2-stage optimal design to test the null hypothesis that the rate is ≤10%, 
versus the alternative that the rate is ≥30%, with alpha of 0.031 and power of 81.3%. The 
first stage will include the 18 patients enrolled into the Phase 2 cohort and evaluated for 
Vitamin C levels at the same 4-cycle time point. If the Vitamin C levels are adequate based 
on the assessment in these patients, and there are 4 or more responses in these first 18 
patients combined from phase 1 and 2 study, the trial would proceed to the full accrual of 
34 patients in the combined stages of the Simon design, and the Vitamin C regimen would 
be considered for further study if a total of 7 or more responses are observed in the total 
cohort. There will be no statistical adjustment for the simultaneous testing of the two co-
primary endpoints. Because the expected response rate in this population is unknown, we 
define a response rate (CR + PR + HI) ≤10% as futile and ≥30% promising. Overall 
response rates (CR+PR+HI) will be summarized by dose cohort in the Phase 1 and Phase 
2 portions of the study using exact 95% confidence intervals.  


 
 
 
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Patient and disease characteristics will be summarized descriptively for each dose cohort 
of the trial by using summary statistics and graphical displays for continuous variables and 
frequency distributions and contingency tables for qualitative variables. Times to best 
response will be measured from start of treatment. Duration of responses will be measured 
from initial response to relapse. 
 
 
3. Study Population 
The safety set consists of all patients that have received at least one dose of Vitamin C. If 
a patient drops out before completing at least one cycle of treatment that patient will be 
replaced with another patient to complete at least one cycle. Data from all patients 
entered will be included in the estimate of biological activity. Patients who are not 
evaluable are considered non responders in the primary analysis. 
 
 
4. Demographics, Baseline Characteristics and Medical History 
Demographics, baseline characteristics and medical history will be summarized for the 
first 6 safety patients and for the entire cohort. Similarly, summaries will be provided 
by completion status. For continuous variables, descriptive statistics will be presented 
including: mean, standard deviation, median and range. For categorical variables 
frequency distributions with percentages will be presented. All patients will have baseline 
measurements and at the end of the study we will compare patients that completed the 
study versus those that only got partial treatment and didn’t complete the study. 
 
 
5. Treatment, Compliance, Disposition and Protocol Deviations 
As part of compliance we will summarize the actual number of weeks of vitamin C 
received per patient. The reason for discontinuation of a study treatment including study 
completion as per protocol will be presented. Patients with major protocol deviations as 
defined by the study team prior to database lock will be summarized. The safety set will 
be used. All data will be listed. 
 
 
6. Ethical Considerations: 
 
This study is to be conducted in accordance with applicable US government 
regulations and international standards of Good Clinical Practice, and applicable 
institutional research policies and procedures. This protocol and any amendments will 
be submitted to the NYU Institutional Review Board (IRB) in agreement with local legal 
prescriptions, for formal approval of the study conduct. The decision of the IRB 
concerning the conduct of the study will be made in writing to the investigator and a copy 
of this decision will be provided to the sponsor before commencement of this study. 
 
All subjects for this study will be provided a consent form describing this study and 
providing sufficient information for subjects to make an informed decision about their 
participation in this study. This consent form will be submitted with the protocol for review 
and approval by the IRB for the study. The formal consent of a subject, using the IRB-
approved consent form, must be obtained before that subject undergoes any study 
procedure. The consent form must be signed by the subject or legally acceptable 


 
 
 
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surrogate, and the investigator-designated research professional obtaining the consent. 
 
The consenting process and documentation will follow Standard Operating Procedures 
(Obtaining Informed Consent for Clinical Trials) of the NYULMC PCC CTO and 
University of Miami Cancer Center. 
 
 
7. Publication Plan 
 
The study PI holds the primary responsibility for publication of the results of the study.


 
 
 
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8. Schedule of Assessments: (Table 3) 
Table 3:  Schedule of Assessments 
Week 
Screening 
1 
1 
1 
1 
1 
2 
3 
4* 
EoS/PD 
FU 
Day 
-28 to 0 
1 
2 
3 
4 
5 
8 
15 
22 
Last dose 
+1w 
Last Dose 
+30 days 
Vitamin C pump 
Administration a 
x 
x 
x 
x 
x 
Informed consent 
x 
Eligibility 
x 
Demographics 
x 
Medical/surgical history 
x 
ECOG performance status 
x 
x 
x 
x 
x 
Pregnancy test 
x 
x 
Bone marrow aspirate and 
biopsy§  
x 
  
See Below 
x 
Physical examination c 
x 
x 
x 
x 
x 
ECG (rest 12-lead) d 
x 
Vital signs e 
x 
x 
x 
x 
x 
Clinical chemistry 
x 
x 
x 
x 
x 
Hematology 
x 
x 
x 
x 
x 
G6PD levels f 
x 
Hepatitis Profile 
x 
Coagulation 
x 
Urinalysis 
x 
x 
x 
x 
x 
Vitamin C Serum levels g,h 
x 
x 
x 
x 
x 
Correlative Studiesi 
x 
 
 
 
x 
x 
x 
x 
Circulating Myeloblasts 
x 
x 
x 
x 
x 
Concomitant medication 
x 
x 
x 
x 
x 
Adverse event 
x 
x 
x 
x 
 
x 


 
 
 
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ECOG=Eastern Cooperative Oncology Group; ECG=electrocardiogram; EoS=end of study; PD= progression of 
disease. PK=pharmacokinetics; SD=stable disease; PR=partial response; CR=complete response 
Additional assessments may be conducted as clinically indicated 
Assessments made on drug administration days are to be conducted prior to the start of study medication infusion, 
unless specified otherwise 
*Subjects with clinical benefit (SD, PR, CR) will receive a second cycle starting at week 5 (Maximum treatment: 4 
cycles). 
 
§ 
Restaging to be done after cycle 2 and cycle 4  or end of study  
a. 
Vitamin C to be administered by a pump as CIVI/ 24 hours with the cassette for the CADD pump replaced every 
24 hours. 
b. 
A histological confirmation of MDS must be established before enrolling patients for treatment. However, if a 
previous bone marrow biopsy is available that was performed within 4 weeks before screening without any 
worsening in peripheral blood counts a repeat bone marrow aspirate and biopsy can be deferred before enrolling 
the patient in the study. 
c. 
Physical examination will include recording the patient's weight and height at screening and weight at the end of 
study visit. Symptom-directed physical examinations at other time points are to be done as needed. 
d. 
Further ECGs will be conducted as needed. 
e. 
Vital signs collected will include temperature, systolic blood pressure, diastolic blood pressure, heart rate and 
respiratory rate. 
f. 
If G6PD deficiency is detected the patient will be excluded from the trial. 
g. 
Blood samples for full PK to be taken prior to pump exchange on weekly bases with the exception of week one of 
cycle 1. 
h. 
Blood needs to be centrifuged and serum to be frozen. 
i. 
Day 5 PBMC collected at NYULH site ONLY 
 


 
 
 
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Appendices 
 
Appendix 1:  ECOG Performance Status Scale 
ECOG PERFORMANCE STATUS 
Grade 
ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction. 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out 
work of a light or sedentary nature, eg, light house work, office work. 
2 
Ambulatory and capable of all self-care but unable to carry out any work 
activities. Up and about more than 50% of waking hours. 
3 
Capable of only limited self-care, confined to bed or chair more than 50% of 
waking hours. 
4 
Completely disabled. Cannot carry on any self-care. Totally confined to bed or 
chair. 
5 
Dead 
 
 
Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, and Carbone PP. Toxicity 
and Response Criteria of the Eastern Cooperative Oncology 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
 
 
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Appendix 2. Summary of Revisions  
 
Changes made from protocol version 1.1 (Dated March 28, 2018) to version 1.2 
(Dated July 09th, 2018) 
 
Section 
Changes 
Inclusion criteria 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Test Product, Dose, and Mode of 
Administration 
 
 
 
 
IX. Statistical evaluation 
1. Statistical Methods 
 
 
 
 
 General 
- Revised the structure of inclusion 
criterion #8 to clarify that inclusion 
criteria #9,10,11 are all subsets of 
inclusion criterion #8. The 
protocol should read as below: 
 
#8Patients are currently receiving 
or have previously received one 
of the following therapies: 
a. Hypomethylating agent, OR 
b. Hydroxyurea, OR 
c. Erythrocyte stimulating agents 
(ESA) OR granulocyte colony 
stimulating factors (G-CSF), OR 
d. Allogenic stem cell transplant 
 
Added language specifying that a 
low ANC will not require a dose 
modification for cycle 2 and onward, 
and that subsequent treatment 
dosage will be at the discretion of 
the PI.  
- Revised the first sentence of this 
section to clarify that the trial 
includes 2 participating sites in 
addition to NYU the coordinating 
center. 
 
- Administrative changes were 
made throughout the protocol 
 
 
Changes made from protocol version 1.2 (Dated July 09th, 2018) to version 1.3 
(Dated August 28, 2018) 
  
Section 
Changes 
V. Schedule of Assessments: 
(Table 3) 
i. Correlative Studies: Day 5 
PBMC collected at NYULH 
site ONLY 
 


 
 
 
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Changes made from protocol version 1.3 (Dated August 28, 2018) to version 
1.4 (Dated March 1, 2019) 
  
Section 
Changes 
Title Page 
 
 
 
 
 
 
 
 
 
 
Test Product, Dose and Mode of 
Administration 
 
 
 
 
 
Intended Duration of Treatment: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sites 
• Removal of Princess 
Margaret Cancer Center, 
University Health Network 
 
Co-Investigators 
• Removal of Mark Minden, 
MD 
• Removal of Simon 
Kavanagh, MD 
 
Addition of: Samples collected 
at University of Miami kept and 
processed at Luisa Cimmino, 
PhD lab at University of Miami 
 
 
 
Clarification of Follow Up 
Schedule. 
• Subject followed for 30 
days for adverse event 
monitoring.  
• A visit is to be performed 
at 30 days after the last 
study drug is given plus/ 
minus 3 days.  
 
• After finishing last does 
of treatment, each subject 
will be followed for 6 
months to continue to 
assess their response.  
 
• Subjects to be contacted 
once a month by 
telephone to assess 
survival status  
 
• CBC records if available 
reviewed every 6 months 
after completing the study  
 


 
 
 
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Schedule of Assessments 
• Criteria for removal of 
study added 
 
Addition of Follow Up (Last Dose 
+30days) 
 
Changes made from protocol version 1.4 (Dated March 1, 2019) to version 2.0 
dtd 2020 Oct 01 
 
Protocol Summary/ Synopsis 
 
• Increasing target accrual from 18 
to 30 patients. 
• Extending planned study period 
from Q3 2019 to Q4 2022. 
• Updated inclusion and exclusion 
criteria  
Study Design, Product, Dose 
modification, Mode of Administration 
and Sample Storage 
• Scientific 
rational 
added 
to 
support the study’s hypothesis 
• Changing the study from 1 cohort 
to a 3 cohort dose-escalation 
study to determine the maximum 
tolerated dose of Vitamin C 
Assessments 
• Updated safety assessments to 
include 30 subjects 
• Updating 
correlative 
studies 
based 
on 
recent 
research 
findings 
Statistical Methods  
Initial Safety Evaluation 
• Sections updated to reflect the 
new dose-escalation cohorts  
I. Background 
• Updating language regarding the 
scientific rational for the study 
II. Vitamin C and its Utility as a 
Hypomethylating Agent 
• Information 
added 
regarding 
prior HMA therapy and trial 
eligibility 
III. Preclinical Data 
• Section 
added 
to 
support 
scientific rationale for the study 
V. Dosing and Patient Selection 
• Section 
updated 
to 
include 
language regarding the new 
dose-escalation cohorts 
Safety Monitoring and Reporting 
• Language was rearranged in this 
section for clarity. 
VIII. Statistical Evaluation 
• Updated to include the new 
target accrual of 30 subjects 
along 
with 
the 
new 
dose-
escalation cohorts 
References 
• Updated 
to 
reflect 
correct 
references within the protocol  
 


 
 
 
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Changes made from protocol version 2.0 (Dated October 1, 2020) to version 
2.1 (dated March 17, 2021) 
 
Protocol Summary/ Synopsis 
 
• Clarification 
added 
regarding 
number of proposed patients to 
enroll  
Study Design, Product, Dose 
modification, Mode of Administration 
and Sample Storage 
• Clarification added regarding PK 
evaluation 
• Sentence added to state that the first 
3 patients enrolled in the study prior 
to its redesign tolerated treatment 
well and shall count as the first 
cohort.  
Assessments 
• Clarification added to include all 
dose levels and all study phases 
Statistical Methods  
Initial Safety Evaluation 
• Removal of “The Simon stage 2 
patients would be enrolled with 
separate funding from the PCC.” 
• Updated definition of DLT to include 
any event grade 3 or higher  
IV. Objectives of the study 
• Clarification added to include all 
dose levels and all study phases 
VI. Safety Objectives  
• Added “A formal interim analysis is 
planned at the completion of the first 
stage of the Simon 2-stage design” 
VII. Subject Identification, Recruitment 
and Consent 
• Clarified 
target 
enrollment 
and 
accrual numbers. 
VIII. Data Analysis and Safety 
Monitoring 
• Clarification added to state that this 
is a 2 center with phase Ib and 
Phase II components.  
 
 
 
 
 
 
 
 
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