Clinical trial NCT02730195
Conditions: Chronic Myelogenous Leukemia, BCR-ABL1 Positive Recurrent Chronic Myelogenous Leukemia, BCR-ABL1 Positive
Sponsor: Emory University
Start date: 2016-05-01; Completion date: 2018-07-01
Enrollment: 9 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This phase II trial studies how well pioglitazone hydrochloride and tyrosine kinase inhibitor (TKI) therapy works in treating patients with chronic myeloid leukemia (CML) that has come back after a period of improvement (relapsed) after a first TKI discontinuation. TKI may stop the growth of cancer cells by blocking certain enzymes need for cell growth. Although TKI therapies are effective against CML, there are residual cancer cells called leukemia stem cells that are able to hide from TKIs. Pioglitazone is a drug approved by the Food and Drug Administration to treat diabetes and has been shown in laboratory studies to increase CML stem cell death when given together with TKI therapy. Giving pioglitazone with TKI therapy may be effective in treating patients with CML.

Detailed description:
PRIMARY OBJECTIVES:

I. To assess safety of the combination of pioglitazone (PIO) and TKI in CML subjects who experience a loss of major molecular response (MMR) following a first TKI discontinuation.

II. To assess survival without loss of MMR following a second TKI discontinuation in subjects who achieve or maintain \< molecular response (MR)\^4.5 with the combination PIO and TKI administered for at least 6 months.

OUTLINE:

Patients receive pioglitazone orally (PO) once daily (QD) on days 1-28. Patients also start or continue the same TKI therapy at the pre-discontinuation doses. Courses repeat every 28 days for 6 months in the absence of disease progression or unacceptable toxicity.

After completion of study treatment, patients are followed up every month for 3 months, every 3 months for 1 year, and then every 6 months for 4 years.

Arms: arm 1: Patients receive pioglitazone PO QD on days 1-28. Patients also start or continue the same tyrosine kinase inhibitor (TKI) therapy at the pre-discontinuation doses. Courses repeat every 28 days for 6 months in the absence of disease progression or unacceptable toxicity.
Interventions: intervention 1: Pioglitazone intervention 2: Tyrosine Kinase Inhibitor (TKI)
Intervention descriptions: intervention 1: Given PO intervention 2: Given TKI therapy

Protocol documents:
Prot_SAP_000.pdf: 
Study Title:  
Combination of Pioglitazone and Tyrosine Kinase Inhibitor (TKI) in 
Relapsed Chronic Myeloid Leukemia Following a First TKI Discontinuation  
 
Study Phase:  
Phase 2                        
 
Product Name:  
Pioglitazone 
 
IND 
Reference Number:  
129280 
 
Sponsor:  
 
Vamsi Kota, MD 
 
Protocol Issue Date: 
04/05/2017 
 
Version Number:  
Version 5.0 
 
 
 
 
 
 
 
PROTOCOL REVISION HISTORY: 
Amendment Number 
Protocol Version Number 
Date 
IRB Initial approval 
1.0 
12/18/2015 
 
2.0 
02/03/2016 
 
3.0 
9/23/2016 
 
4.0 
03/15/2017 
 
5.0 
04/05/2017 
 
 
 
 
 
1 
 


TABLE OF CONTENTS 
 
1. Background 
1.1 Chronic Myeloid Leukemia 
1.2 Definition of Response in CML  
1.3 Tyrosine Kinase Inhibitor Discontinuation Trials 
1.4 CML stem cell and Peroxisome Proliferator-Activated Receptors γ  
1.4.1 
The role of leukemia stem cell in CML 
1.4.2 
The role of STAT5 in CML  
1.4.3 
Peroxisome Proliferator-Activated Receptors  
1.4.4 
Interactions between PPARγ and STAT5 in CML 
1.4.5 
Clinical activity of a combination of PPARγ ligands and TKI in CML 
1.5 Pioglitazone  
1.5.1 
Pharmacokinetics and Pharmacodynamics 
1.5.2 
Side effects associated with the use of PIO 
1.5.3 
Warnings and Precautions associated with the use of PIO 
1.5.4 
Contraindications for the use of PIO 
1.6 Rationale for the Study 
 
2. Study Objectives and Hypothesis  
2.1 Objectives 
2.2 Hypothesis 
 
3. Investigational Plan 
3.1 Overall Study Design and Plan 
3.2 Endpoints 
3.3 Description of Treatment 
 
4. Selection of Study Population 
4.1 Inclusion Criteria 
4.2 Exclusion Criteria 
 
5. Study Procedures 
5.1 Schedule of Events 
5.2 Description of Study Visits 
5.2.1 
Visit 1 (Day -14 to -1): Screening 
5.2.2 
Visit 2 (Day 1): Baseline/Drug Dispensing/Initiation of Treatment 
5.2.3 
Visits 3 (Days 15 ± 2): Early Follow-up 
5.2.4 
Visits 4+ (Day 30 ±2, then monthly during combination of PIO and TKI) 
5.2.5 
Post-discontinuation of PIO and TKI Visits 
5.2.6 
Unscheduled Visits 
5.2.7 
End of Treatment Visit (±14 days) 
5.3 Subject Registration and Identification 
5.3.1 
Screen Failure 
5.3.2 
Early Discontinuation 
5.4 Study Duration 
5.5 Withdrawal Criteria 
5.6 Study Termination 
 
6. Safety Assessments  
 
2 
 


7. Study Treatments 
7.1 Dose Selection, Treatment Administration, Compliance and Dose Modifications 
7.2 Allocation of Treatment 
7.3 Concomitant Medications 
7.4 Treatment Supply 
7.4.1 
Formulation, Packaging and Labeling 
7.4.2 
Treatment Storage, Dispensing, and Accountability 
7.4.3 
Disposition of used and unused supplies 
 
8. Adverse Events Reporting 
8.1 Adverse Events 
8.1.1 
Adverse Event Definition 
8.1.2 
Abnormal Laboratory Tests 
8.1.3 
Performing Adverse Event Assessment 
8.1.4 
Reporting Period 
8.1.5 
Adverse Event Severity  
8.1.6 
Causality 
8.1.7 
Expectedness 
8.2 Serious Adverse Events 
8.2.1 
Serious Adverse Event Definition 
8.2.2 
Reporting Serious Adverse Events 
8.2.3 
Follow-up Information of Serious Adverse Events 
8.3 Other Safety Issues 
8.3.1 
Pregnancy 
8.3.2 
Overdose  
 
9. Statistical Considerations 
9.1 General Considerations 
9.2 Analysis Population 
9.3 Study Endpoints 
9.4 Determination of Sample Size  
9.5 Safety and Efficacy Analysis  
9.6 Interim Analysis 
9.7 Protocol Deviations and Violations 
 
10. Quality Control and Quality Assurance and Study Monitoring  
 
11. Ethical Conduct of the Study 
11.1 
Institutional Review Boards Approval 
11.2 
Subject Information and Consent 
11.3 
Subject Confidentiality 
11.4 
Data Safety Monitoring Committee 
 
12. Data Handling and Record Keeping 
12.1 
Case Report Forms and Study Records 
12.2 
Source Documents 
12.3 
Retention of Data  
12.4 
Study Termination 
 
13. References  
14. Appendix 1 and 2 
 
3 
 


PROTOCOL SYNOPSIS 
Study Treatments 
Pioglitazone  
Study Title 
Combination of Pioglitazone and Tyrosine Kinase Inhibitor (TKI) in Relapsed 
Chronic Myeloid Leukemia Following a TKI Discontinuation  
Phase 
II 
Summary and  
Study Rationale 
Approximately 40-60% of patients with chronic myeloid leukemia (CML) 
who discontinue imatinib (IM) or second-generation TKI after sustained deep 
molecular remission will experience molecular relapse, but regain molecular 
response after restarting TKI. The success rate of a second TKI discontinuation 
trial is low (25%), and continuous TKI is recommended for these patients. 
Pioglitazone (PIO) is a well-tolerated orally bioavailable Peroxisome 
Proliferator-Activated Receptorsᵧ (PPARᵧ) agonist with in vitro BCR-ABL1 
tyrosine kinase inhibition activity that is synergistic with TKI. In this study, we 
will assess safety and efficacy of PIO combined with TKI in CML patients 
with molecular relapse following a first TKI discontinuation trial. Success of a 
second TKI discontinuation trial, following 6 months of sustained deep 
molecular response while on PIO and TKI combination will be assessed. 
Study Design 
This is a single-center, prospective, phase II trial. For the purposes of this 
protocol and all analyses, a cycle of treatment is defined as 28 days. Eligible 
subjects will start PIO in addition to TKI, at 30mg/d for 2 cycles (56 days) and, 
in the absence of grade 2 or higher toxicities, increase to 45mg/d. Subjects will 
receive PIO in addition to TKI for 6 months from the first documented < 
molecular response (MR)4.5 and if subjects maintain < MR4.5 for 6 months with 
less or equal than 2 BCR/ABL1 transcript fluctuation <major molecular 
response (MMR) will be eligible for a second TKI discontinuation. Subjects 
who fail to achieve MMR after 4 months, or <MR4.5 after 6 months of the 
combination treatment of PIO and TKI will be taken off treatment. Subjects 
who lose MMR while on the combination will be taken off study and managed 
at the discretion of the treating physician. 
While the combination of PIO and TKI, blood quantitative real time 
Polymerase Chain Reaction (qRT-PCR) for BCR-ABL1 will be collected on a 
monthly basis, and after discontinuation of PIO and TKI, disease be monitored 
by blood qRT-PCR for BCR-ABL1 obtained monthly for the first 3 months, 
quarterly for 1 year, and then bi-annually for 1 year. 
Study Objectives 
• 
To assess safety of the combination of PIO and TKI in CML subjects who 
experience a loss of MMR following a first TKI discontinuation  
• 
To assess survival without loss of MMR following a second TKI 
discontinuation trial in subjects who achieve or maintain <MR4.5 for at 
least 6 months with the combination PIO and TKI  
Study Endpoints 
• 
Safety: To describe adverse events (AE) in subjects receiving the 
combination of PIO and TKI. AEs will be graded according to the 
Common Terminology Criteria for Adverse Events (CTCAE) v.4.03 
assessed through scheduled assessment and subject reported diary 
• 
To determine the proportion of subjects who maintain MMR following 
discontinuation of PIO and TKI using blood qRT-PCR for BCR-ABL1 
obtained monthly for the first 3 months, quarterly following 1 year and bi-
annually thereafter. 
Diagnosis and  
Main Inclusion Criteria 
Age > 16 diagnosed with CML in any phase 
Molecular relapse (loss of MMR) post-first TKI discontinuation trial  
Complete cytogenetic and complete hematologic response  
4 
 


Number of Subjects 
26 subjects 
Duration of  
Subject Participation 
2 years 
Approximate  
Duration of Study 
5years 
Dosage and 
Administration 
PIO 30mg/d, 45mg/d, oral tablets 
Concomitant 
Medications/treatment 
TKI 
Safety Evaluations 
Monthly assessments as needed with CTCAE v. 4.0 
Statistical Analysis 
Under Simon’s optimal two stage design with a 5% significance level, 80% 
power, and 8% drop out rate assuming a lower boundary of interest in the 
response rate of 20% and an upper boundary of interest in the response rate of 
50%, a total of 26 evaluable subjects are required for the evaluation of the 
primary endpoint; 9 in Stage 1, additional 15 in Stage 2 and 2 for drop out. 
 If less than 2 of 9 evaluable subjects in Stage 1 maintain MMR after second-
TKI discontinuation or > 2 subject develop > grade 3 cardiac toxicity then the 
study will terminate, otherwise the study shall continue as planned and 
enrollment of an additional 15 subjects shall continue into Stage 2. If, at the 
final analysis, less than 9 of 24 evaluable subjects in both Stage 1 and 2 
maintain MMR then it will be concluded that PIO and TKI does not deserve 
further investigation.   
Fisher exact test and the χ2 test were used to compare categorical variables, 
and the Mann-Whitney U test was used for continuous variables. The 
probability of molecular relapse free survival will be estimated using the 
Kaplan-Meier method, and be calculated as the time from the first day of TKIs 
discontinuation to the date of the first documentation of molecular relapse or 
the last follow up day for patients who did not relapse. P <0.05 will be 
considered statistically significant. 
5 
 


ABBREVIATIONs 
 
2G 
 
Second-Generation  
AE 
 
Adverse Event  
AP 
 
Accelerated Phase 
AUC 
 
area under the curve 
BC 
 
Blast crisis 
BM 
 
Bone Marrow 
BOS 
 
Bosutinib 
BP 
 
Blood Pressure 
CBC 
 
Complete Blood Count 
CCyR 
 
Complete Cytogenetic Response 
CHR 
 
Complete Hematologic Response 
CLcr 
 
Creatinine Clearance 
Cmax 
 
Peak Serum Concentration 
Cmin 
 
Trough Serum Concentrations 
CML  
 
Chronic Myeloid Leukemia 
CMR 
 
Complete molecular remission 
CP 
 
Chronic Phase 
CRF 
 
Case Report Form 
CTCAE  
Common Terminology Criteria for Adverse Events 
DAS 
 
Dasatinib 
DSMC  
the Data and Safety Monitoring Committee 
ELN 
 
European Leukemia Net 
FDA 
 
Food and Drug Administration 
GCP 
 
Good Clinical Practice 
HCG 
 
Human Chorionic Gonadotropin 
ICH 
 
International Conference on Harmonization 
IRB 
 
Institutional Review Board  
IS 
 
International Scale 
IM  
 
Imatinib Mesylate 
IND 
 
Investigational New Drug 
LSC 
 
Leukemia Stem Cell 
mCyR  
minor Cytogenetic Response 
minCyR  
minimal Cytogenetic Response 
MMAS  
Morisky Medication Adherence Scales 
MMR 
 
Major Molecular Response 
MR 
 
Molecular Response 
NCCN  
National Comprehensive Cancer Network 
NCI 
 
The National Cancer Institute 
NIL 
 
Nilotinib 
noCyR  
no Cytogenetic response 
NYHA  
New York Heart Association  
PCyR 
 
Partial Cytogenetic Response 
Ph + 
 
Philadelphia chromosome 
PI 
 
Principal Investigator 
PIO  
 
Pioglitazone 
PON 
 
Ponatinib 
PPAR   
Peroxisome Proliferator-Activated Receptors 
PPRE                   Peroxisome Proliferator Response Elements  
qRT-PCR 
quantitative Real-Time Polymerase Chain Reaction  
RFS 
 
Relapse-Free Survival  
RXR 
 
Retinoid X Receptor 
SAE 
 
Serious Adverse Events  
TKI  
 
Tyrosine Kinase Inhibitor 
6 
 


TZD 
 
Thiazolidinedione 
UA 
 
Urine Analysis 
UP 
 
Unanticipated Problem posing risks to subjects or others 
USD 
 
United States dollar 
 
 
7 
 


1. Background 
1.1 
Chronic Myeloid Leukemia  
Chronic myeloid leukemia (CML) is a clonal myeloproliferative stem cell disorder characterized by the 
presence of a signature hybrid oncogene, the BCR-ABL1 [1], and a unique triphasic clinical course. The 
majority of patients (~80%) are diagnosed during the early phase, or chronic phase (CP), however, 
without effective treatment, CML invariably progresses to the advanced phases of the disease: accelerated 
phase (AP) or blast crisis (BC). The Philadelphia chromosome (Ph+), the driving leukemogenic 
mechanism in CML, is a reciprocal translocation between chromosome 9 and 22 that juxtaposes two 
genes involved in cell signaling, signal transduction, and cell proliferation: BCR and ABL1. The ABL1 
gene encodes non-receptor tyrosine kinases that become deregulated and constitutively active by the 
juxtaposition of BCR. BCR-ABL is central in controlling downstream pathways involved in cell 
proliferation, regulation of cellular adhesion and apoptosis [1]. The understandings of the 
pathophysiology of CML led to development of drugs that specifically target the tyrosine kinase activity 
in BCR-ABL. These tyrosine kinase inhibitors (TKI) became the mainstay of modern therapy in CML 
and have revolutionized patients’ outcomes. Currently, there are 5 TKIs approved for the treatment CML: 
Imatinib (IM), nilotinib (NIL), and dasatinib (DAS) for both first- and second-line therapy, bosutinib 
(BOS) for second- or third-line therapy and ponatinib (PON) for patients with the T315I mutation or for 
whom no other TKI is indicated. Indeed, treatment of patients with CML with TKIs is ranked as one of 
the great medical success stories of the past 30 years, which translates into life spans indistinguishable 
from those of similar persons without leukemia [2].  
1.2 
Definitions of Response in CML  
Several organizations, such as the European 
Leukemia 
Net 
(ELN) 
and 
the 
National 
Comprehensive Cancer Network (NCCN), provide 
extensive evidence based recommendations that 
define response and provide milestones or 
algorithms 
to 
monitor 
response 
on 
TKIs 
(http://www.nccn.org/clinical.asp) [3]. Response 
criteria for hematologic, cytogenetic (based on 
metaphase 
cytogenetic 
preparations), 
and 
molecular responses (MR) are shown in Table 1. 
In the absence of universal standards or reagents, 
the International Scale (IS) was developed to 
harmonize MRs across laboratories by applying a 
laboratory specific conversion factor [4]. All 
molecular response criteria and recommendations 
for intervention in the NCCN or ELN guidelines 
are based on IS molecular responses. Major 
molecular response (MMR) is defined by a level 
of BCR-ABL1 transcript by quantitative Real-Time 
Polymerase Chain Reaction (qRT-PCR) of 
Table 1. Definitions of Response in CML 
Response 
Definition 
Hematologic 
 
 Complete (CHR) 
WBC < 10 × 109/L  
 
Basophils < 5% 
 
No myelocytes, promyelocytes, 
myeloblasts in the differential 
 
Platelet count < 450 × 109/L  
 
Spleen nonpalpable 
Cytogenetic* 
 
 Complete (CCyR) 
No Ph+ metaphases 
 
 Partial (PCyR) 
1% to 35% Ph+ metaphases 
 
 Minor (mCyR) 
36% to 65% Ph+ metaphases 
 
 Minima (minCyR) 
66% to 95% Ph+ metaphases 
 
 None (noCyR) 
> 95% Ph+ metaphases 
Molecular† 
 
    Major (MMR) 
Ratio of BCR-ABL1 to ABL (or other 
housekeeping genes) ≤ 0.1% on the 
IS 
 
    MR 4.0 
Ratio of BCR-ABL1 to ABL <0.01% 
    MR 4.5 
Ratio of BCR-ABL1 to ABL <0.032% 
    MR 5.0 
Ratio of BCR-ABL1 to ABL <0.001% 
8 
 


<0.1%, MR4 by a BCR-ABL1< 0.01%, MR4 by a BCR-ABL1< 0.0032%, and MR5.0 by a BCR-ABL1< 
0.001%. Complete molecular remission (CMR) is defined by a BCR-ABL1 level < MR4.5.   
1.3 
Tyrosine Kinase Inhibitor Discontinuation Trials  
Although TKIs dramatically improved CML patient outcomes and improved quality of life compared to 
previous treatments, therapy with a TKI is currently life-long therapy, requiring patients to take 
medication daily and to make frequent visits for monitoring. Patients often exposed to chronic, frequently 
low grade adverse events (AE), and negative emotional consequences can manifest even in the absence of 
overt disease symptoms [5]. Thus, daily adherence to TKI therapy might be challenging for a significant 
proportion of patients. However, TKI may not appear to be needed as a lifelong therapy. Recent data 
suggests that in patients in CP and AP treated with IM for >3 years and who have maintained CMR for at 
least 2 years, IM can be safely discontinued without reappearance of the BCR-ABL1 in approximately 
40~60% of patients, and these remissions are durable. (Figure 1. A~D) [6-9]. Although BCR-ABL1 
becomes detectable in the other 40~60% within a year from IM discontinuation, reinstitution of IM is 
associated with a second molecular remission in all cases. No patients transformed to BC on any of these 
discontinuation trials.  Similar to IM, discontinuation of the second-generation (2G) DAS or NIL used in 
front-line or for IM intolerance or resistance is associated with a 60% treatment-free survival without loss 
of MMR [10].  
However, for CP-CML patients who lose MMR after first IM discontiuation and regain CMR following a 
restart of IM, the current recommendations are to keep these patients on IM lifelong given the low success 
rates (25%) of a second TKI discontinuation trial [11]. 
 
  
 
 
 
 
Figure 1. Molecular relapse free survival following imatinib discontinuation: A. data on 100 patients; B. data on 40 
patients, C. data on 43 patients; D. data on 48 patients 
A 
B 
C 
D 
9 
 


Institutional Experience with TKIs discontinuation. From Jan 2010 and Jul 2015, 24 subjects with CML 
in CP ( n=21), AP ( n=2) and lymphoid BC (n=1) discontinued IM (n=17), DAS (n=4), or BOS (n=3), 
(the case of CML BC was previously published [12].). Subjects were treated with TKI for a median of 
78.1(38.4-168.1) months, and had sustained CMR for median 54.2 (10.4-156.5) months. Subjects were 
monitored by qRT-PCR for BCR-ABL1 monthly 
for the first 3 months, quarterly for the following 
2 years and then bi-annually. Reason for TKI 
discontinuation was predominantly driven by 
patients’ request and TKI intolerance. Seven 
subjects discontinued 2G TKIs for resistance 
(n=3) or intolerance (n=4) to previous TKIs. 
With a median follow-up of 38.3 months (range, 
2.3-69.7), probability of survival without loss of 
MMR (molecular relapse free survival) at 1 year 
was 68%, as depicted in Figure 2. Eight (33 %) 
subjects lost MMR a median of 4 months (range, 
1-14) after IM was stopped. Among seven 
evaluable subjects, 5 regained MMR, of which 4 
<MR4.5 following restart of IM. Median time to 
regain MMR after restart of IM was 2.2 (1.5-
28) months, and <MR4.5 was 2.2 (1.5-2.9) 
months. 
1.4 
CML stem cell and Peroxisome Proliferator-Activated Receptors γ  
1.4.1 The role of leukemia stem cell in CML 
Targeting the leukemic stem cell (LSC) is currently one of the major therapeutic focuses in leukemia 
research. The definition of a stem cell is functional rather than morphological, and these cells are 
characterized by three distinct properties: self-renewal, differentiation, and proliferative capacity [13]. 
The LSC is responsible for disease initiation, drug resistance and relapse [14, 15]. The precise molecular 
mechanism of LCS mediated resistance to current therapies has not been fully elucidated, but one critical 
factor might be the quiescence of these cells that allows this population to evade therapies that target 
rapidly dividing cells. These LSC are thought to be the reservoir for disease progression [16-22]. Given 
that CML is a stem cell disease, and given the known resistance of CML LSC to TKI [22], novel 
approaches targeting the CML LSC are needed.  
1.4.2 The role of STAT5 in CML  
 BCR-ABL activates many signaling pathways in leukemic cells, such as STAT5, RAS, PI-3K and NF-
κB [23]. STAT5 was one of the first pathways to be described as being constitutively activated by BCR-
ABL [24-26]. BCR/ABL activates STAT5 not only directly [27], but also indirectly via phosphorylation 
of JAK2 (Figure 3) [28, 29]. Phosphorylated STAT5 forms STAT5 dimers that translocate to nucleus, 
bind to DNA binding domains, and promote activation of downstream target genes. These target genes 
include  the anti-apoptosis Bcl-XL6 [30],  the drug resistance phenotype Rad51 [31] and the Peroxisome 
Proliferator-Activated Receptor γ (PPARγ).  
Figure 2. Kaplan-Meier curve of probability of molecular 
Relapse Free Survival (RFS); TKI, Tyrosine Kinase 
Inhibitor 
10 
 


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11 
 


PPARγ is an important regulator of STAT 5 activity. Indeed in 
hematopoietic stem cells, a bidirectional crosstalk between 
STAT5 and PPARγ signaling occurs. Phosphorylated STAT5 
dimers bind in the nucleus to promotor of PPARγ to initiate 
transcription. Increased PPARγ, in return, downregulates 
STAT5 and decreases cell proliferation (Figure 5) [39, 40]. 
Synthetic ligands of PPARγ such as the commercially available 
TZD, pioglitazone (PIO) was shown to decrease expression of 
STAT5 as well as proliferation of CD34+ cells collected from 
CML-CP patients as evidenced by a decrease the number of 
colony forming cells in vitro. In addition, PIO appeared to  
induce non dividing cells into cycling by decreasing key 
guardians of the quiescence and stemness of CML LSCs 
(HIF2a and CITED2) [41].  
 
1.4.5 Clinical activity of a combination of PPARγ ligands and TKI in CML 
The combination of PIO and IM was 
administered to 3 (2 diabetics and 1 non-
diabetic) CML patients who never achieved 
CMR while on IM (Figure. 6). Patient 1 
received 2 courses of PIO: one for 10 months 
and the second for 8 months, after a 28 months 
gap. Patient attained CMR 10 months after the 
first exposure to the combination of PIO and 
IM, and maintained CMR despite transient 
discontinuation of PIO. This patient remains in 
CMR on continuous IM 56 months after the 
initiation of PIO. Patient 2 achieved CMR 
within 1 year of initiating PIO, and maintained 
CMR after sequential discontinuation of PIO 
and IM. Patient 3 achieved CMR 6 months 
after starting PIO and also maintained CMR 
for 38 months after sequential discontinuation 
of PIO and IM. Of note all 3 patients had a 
single fluctuation in the PCR below the MMR level after initial achievement of CMR. Of interest, the 
level of STAT5 mRNA in the BM CD34+ cells collected from patient 3 decreased by 11.9 fold from 
baseline following initiation of PIO [41]. These observations suggest that the combination of PIO and 
TKI can lead to BCR-ABL1 eradication in patients unable to achieve CMR with TKI alone, and served 
as basis for an ongoing multi-center phase 2 clinical trial assessing the incidence of CMR conversion 
following the addition of PIO to IM in patients who never reached CMR with IM alone 
(https://www.clinicaltrialsregister.eu/ctr-search/trial/2009-011675-79/FR#E).  
Figure 
5. 
The 
phosphorylated 
STAT5s 
translocate to the nucleus where they bind to 
specific DNA binding sites on PPARγ promoter 
and initiate transcription.  
Figure 6. Pioglitazone induces complete and sustained 
molecular response (CMR) in CML patients. 
12 
 


1.5 
Pioglitazone  
PIO and Rosiglitazone belong to the TZD class of synthetic PPARγ ligands, and are approved as anti-
diabetic medication by the Food and Drug Administration (FDA) in the US. PIO is approved for 
noninsulin dependent type 2 diabetes mellitus as monotherapy or combination therapy in adjunct to diet 
and exercise, to improve glycemic control. PIO controls blood glucose by increasing insulin sensitivity 
[42]. Via activation of the PPARγ nuclear receptor, PIO modulates gene expression, trigger adipocyte 
differentiation, and induce remodeling of adipose tissue, which is associated with changes in adipocyte 
signal output. Those signals include free fatty acids and peptide hormones (adiponectin, resistin, leptin, 
and tumor necrosis factor-α), and mediate the PIO-induced improvement of skeletal muscle glucose 
disposal [43-45].  
1.5.1 Pharmacokinetics and Pharmacodynamics 
Following once-daily administration of PIO, steady-state serum concentrations of both PIO and its major 
active metabolites, M-III (keto derivative of PIO) and M-IV (hydroxyl derivative of PIO), are achieved 
within seven days. At steady-state, M-III and M-IV reach serum concentrations equal to or greater than 
that of PIO. At steady-state, in both healthy volunteers and patients with type 2 diabetes, PIO comprises 
approximately 30% to 50% of the peak total PIO serum concentrations (PIO plus active metabolites) and 
20% to 25% of the total area under the curve (AUC). Peak serum concentration (Cmax), AUC, and 
trough serum concentrations (Cmin) for PIO and M-III and M-IV, increased proportionally with doses of 
15 mg and 30 mg per day. The mean serum half-life (t1/2) of PIO and its metabolites (M-III and M-IV) 
range from three to seven hours and 16 to 24 hours, respectively. PIO has an apparent clearance, CL/F, 
calculated to be five to seven L/hr.  
 
Bioavailability and Food Effects. Following oral administration of PIO, Tmax of PIO was reached within 
two hours. Food delays the Tmax to three to four hours but does not alter the extent of absorption (AUC). 
 
Distribution; The mean apparent volume of distribution (Vd/F) of PIO following single-dose 
administration is 0.63 ± 0.41 (mean ± SD) L/kg of body weight. PIO is extensively protein bound (>99%) 
in human serum, principally to serum albumin. PIO also binds to other serum proteins, but with lower 
affinity. M-III and M-IV are also extensively bound (>98%) to serum albumin. 
 
Metabolism; PIO is extensively metabolized in the liver by hydroxylation and oxidation; the metabolites 
also partly convert to glucuronide or sulfate conjugates. In vitro data demonstrate that multiple CYP 
isoforms are involved in the metabolism of PIO, which include CYP2C8 and, to a lesser degree, CYP3A4 
with additional contributions from a variety of other isoforms including the mainly extrahepatic CYP1A1. 
In vivo study of PIO in combination with gemfibrozil, a strong CYP2C8 inhibitor, showed that PIO is a 
CYP2C8 substrate. Urinary 6ß-hydroxycortisol/cortisol ratios measured in patients treated with PIO 
showed that PIO is not a strong CYP3A4 enzyme inducer. 
 
Excretion and Elimination; Following oral administration, approximately 15% to 30% of the PIO dose is 
recovered in the urine. Renal elimination of PIO is negligible, and the drug is excreted primarily as 
metabolites and their conjugates in the feces.  
 
13 
 


Special population:  
Renal Impairment; The serum elimination half-life of PIO, M-III, and M-IV remains unchanged in 
patients with moderate (creatinine clearance [CLcr] 30 to 50 mL/min) and severe (CLcr <30 mL/min) 
renal impairment when compared to subjects with normal renal function. Therefore, no dose adjustment 
in patients with renal impairment is required.  
Hepatic Impairment; Compared with healthy controls, subjects with impaired hepatic function (Child-
Turcotte-Pugh Grade B/C) have an approximate 45% reduction in PIO and total PIO (PIO, M-III, and M-
IV) mean Cmax but no change in the mean AUC values. Therefore, no dose adjustment in patients with 
hepatic impairment is required.  
Geriatric Patients; in healthy elderly subjects, Cmax of PIO was not significantly different, but AUC 
values were approximately 21% higher than those achieved in younger subjects. The mean t1/2 of PIO 
was also prolonged in elderly subjects (about ten hours) as compared to younger subjects (about seven 
hours). These changes were not of a magnitude that would be considered clinically relevant.  
Ethnicity; Pharmacokinetic data among various ethnic groups are not available. 
1.5.2 Side effects associated with the use of PIO  
A summary of the overall incidence and types of common AEs reported in the PROactive trial (the 
Prospective Pioglitazone Clinical Trial in Macrovascular Events) is provided in Table 2. PROactive is an 
randomized, double-blind outcome study in 5238 patients with type 2 diabetes managed with diet and/or 
oral blood glucose-lowering drugs + insulin [46]. Patients were randomized to PIO (forced titration from 
15 to 30 to 45 mg, depending on tolerability) or placebo in addition to existing therapy. Table 2 
summarizes AEs that occurred in >5% of subjects. 
 
Table 2. PROactive Trial: Incidence and Types of Adverse Events Reported in >5% of Patients Treated with 
PIO  and More Commonly than Placebo 
 
% of Patients 
 
Placebo N=2633 
PIO  N=2605  
Hypoglycemia  
18.8  
27.3  
Edema  
15.3  
26.7  
Cardiac Failure  
6.1  
8.1  
Pain in Extremity  
5.7  
6.4  
Back Pain  
5.1  
5.5  
Chest Pain  
5.0  
5.1  
 
 
1.5.3 Warnings and Precautions associated with the use of PIO (Package insert) 
Congestive Heart Failure; PIO, like other TZD, can cause dose-related fluid retention when used alone 
or in combination with other antidiabetic medications and is most common when PIO is used in 
combination with insulin. Fluid retention may lead to or exacerbate congestive heart failure. Patients 
should be observed for signs and symptoms of congestive heart failure.  
 
14 
 


Hypoglycemia; Patients receiving PIO in combination with insulin or other antidiabetic medications 
(particularly insulin secretagogues such as sulfonylureas) may be at risk for hypoglycemia. A reduction in 
the dose of the concomitant antidiabetic medication may be necessary to reduce the risk of hypoglycemia.  
 
Hepatic Effects; There have been post-marketing reports of fatal and non-fatal hepatic failure in patients 
taking PIO, although the reports contain insufficient information necessary to establish the probable 
cause. There has been no evidence of drug-induced hepatotoxicity in the PIO controlled clinical trial 
database to date. Patients with type 2 diabetes may have fatty liver disease or cardiac disease with 
episodic congestive heart failure, both of which may cause liver test abnormalities, and they may also 
have other forms of liver disease, many of which can be treated or managed. Patient who develop 
abnormal liver tests (ALT greater than 3 times the upper limit of the reference range); PIO treatment 
should be interrupted.  
 
Urinary Bladder Tumors; Tumors were observed in the urinary bladder of male rats in the two-year 
carcinogenicity study. In two 3-year trials in which PIO was compared to placebo or glyburide, there were 
16/3656 (0.44%) reports of bladder cancer in patients taking PIO compared to 5/3679 (0.14%) in patients 
not taking PIO. After excluding patients in whom exposure to study drug was less than one year at the 
time of diagnosis of bladder cancer, there were six (0.16%) cases on PIO and two (0.05%) cases on 
placebo. A five-year interim report of an ongoing 10-year observational cohort study found a no 
significant increase in the risk for bladder cancer in subjects ever exposed to PIO, compared to subjects 
never exposed to PIO (HR 1.2 [95% CI 0.9 −1.5]). Compared to never exposure, a duration of PIO 
therapy longer than 12 months was associated with an increase in risk (HR 1.4 [95% CI 0.9 −2.1]), which 
reached statistical significance after more than 24 months of PIO use (HR 1.4 [95% CI 1.03 −2.0]). 
Interim results from this study suggested that taking PIO longer than 12 months increased the relative risk 
of developing bladder cancer in any given year by 40% which equates to an absolute increase of three 
cases in 10,000 (from approximately seven in 10,000 [without PIO] to approximately 10 in 10,000 [with 
PIO]). There are insufficient data to determine whether PIO is a tumor promoter for urinary bladder 
tumors. Consequently, PIO should not be used in patients with active bladder cancer and the benefits of 
glycemic control versus unknown risks for cancer recurrence with PIO should be considered in patients 
with a prior history of bladder cancer.  
 
Edema; In controlled clinical trials, edema was reported more frequently in patients treated with PIO than 
in placebo-treated patients and is dose-related. In post marketing experience, reports of new onset or 
worsening edema have been received. PIO should be used with caution in patients with edema. Because 
TZD, including PIO, can cause fluid retention, which can exacerbate or lead to congestive heart failure, 
PIO should be used with caution in patients at risk for congestive heart failure. Patients treated with PIO 
should be monitored for signs and symptoms of congestive heart failure. 
 
Fractures; In PROactive (the Prospective Pioglitazone Clinical Trial in Macrovascular Events), 5238 
patients with type 2 diabetes and a history of macrovascular disease were randomized to PIO (N=2605), 
and were force-titrated up to 45 mg daily or placebo (N=2633) in addition to standard of care. During a 
mean follow-up of 34.5 months, the incidence of bone fracture in females was 5.1% (44/870) for PIO 
versus 2.5% (23/905) for placebo. This difference was noted after the first year of treatment and persisted 
during the course of the study. The majority of fractures observed in female patients were non-vertebral 
15 
 


fractures including lower limb and distal upper limb fractures. No increase in the incidence of fracture 
was observed in men treated with PIO (1.7%) versus placebo (2.1%).  
 
Macular Edema; Macular edema has been reported in post marketing experience in diabetic patients 
who were taking PIO or another TZD. Some patients presented with blurred vision or decreased visual 
acuity, but others were diagnosed on routine ophthalmologic examination. Most patients had peripheral 
edema at the time macular edema was diagnosed. Some patients had improvement in their macular edema 
after discontinuation of the TZD.  
 
Ovulation; Therapy with PIO, like other TZD, may result in ovulation in some premenopausal 
anovulatory women. As a result, these patients may be at an increased risk for pregnancy while taking 
PIO. This effect has not been investigated in clinical trials, so the frequency of this occurrence is not 
known. Adequate contraception in all premenopausal women treated with PIO is recommended.  
 
Macrovascular Outcomes; There have been no clinical studies establishing conclusive evidence of 
macrovascular risk reduction with PIO or any other antidiabetic drug. 
1.5.4 Contraindications for the use of PIO (Package insert):  
PIO is contraindicated in the following settings: 
- 
Hypersensitivity to PIO or any component of the formulation;  
- 
New York Heart Association (NYHA) Class III/IV heart failure  
- 
pregnancy 
- 
serious hepatic impairment (Canadian labeling) 
- 
Active bladder cancer; history of bladder cancer; uninvestigated macroscopic hematuria (Canadian 
labeling)  
1.6 
Rationale for the Study 
New approaches are needed for the management of the 50% of CML patients who experience a molecular 
relapse following a first trial of TKI discontinuation. Given the potential risks of long-term TKI exposure, 
the contra-indication for pregnancies/child conception while on TKI, and the expenses associated with the 
use of these agents (92,000 USD/year for IM, > 120,000 USD/year for DAS or NIL), many patients 
express interests in TKI discontinuation trials. However, with the low success rate of a second 
discontinuation trial (20%), patients who fail their first TKI discontinuation have currently no other 
option but to continue TKI therapy.  
Given the interactions between PPARγ and STAT5 in CML LSCs, the synergy between PIO and IM [41], 
and the safety profile of PIO, a trial testing the combination of PIO and TKIs is a reasonable novel 
approach to eradicate minimal residual disease in CML .  
 
 
16 
 


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17 
 


Subjects may enter the study before or after restarting the TKI that was previously discontinued. Disease 
status can therefore be > MMR but still in CCyR and CHR or ≤ MMR. Subject will start PIO in addition 
to TKI, at 30mg/d for 2 cycles (56 days) and, in the absence of grade 2 or higher toxicities, PIO doses will 
be increased to 45mg/d. If grade 2 or higher toxicities occur on PIO 45 mg/d, PIO dose will be held until 
toxicities are < grade 1, and PIO doses will be decreased to 30 mg/d (Dose modification was described 
section 7.1). Subjects will receive PIO in addition to TKI for 6 months from the first documented < 
MR4.5. During the combination of PIO and TKI, subjects will be monitored by blood qRT-PCR for BCR-
ABL1 obtained monthly. 
Subjects entering the study in > MMR but still in CCyR and CHR who do not achieve MMR within 4 
months of the combination of PIO and TKI will be taken off study. Subjects entering the study in ≤ MMR 
or who achieve MMR within 4 months of combination of PIO and TKI, will receive PIO for 6 months 
from the first documented <MR4.5. Subjects who lose MMR at any time on the combination of PIO and 
TKI will be taken off treatment. Subjects who fail to achieve < MR4.5 after 6 months of the combination 
will also be taken off treatment. Fluctuations of PCR from MR4.5 at < MMR levels are expected and are 
acceptable during the combination of PIO and TKI.  
Subjects who maintain < MR4.5 for 6 months with less or equal than 2 BCR/ABL1 transcript fluctuation 
<MMR will be eligible for a second TKI discontinuation trial. Subjects who discontinue TKI will be 
monitored by blood qRT-PCR for BCR-ABL1 obtained monthly for the first 3 months, quarterly for 1 
year, and then bi-annually for 1 year. After 2 years of follow-up off TKI, or if MMR is lost off TKI, 
subjects will have completed their participation on the trial and will enter the Long-Term Follow-up 
which includes once a year update on disease status (qRT-PCRs) for 5 years. 
3.2        Endpoints  
• 
Safety: To describe AEs in subjects receiving the combination of PIO and TKI. AEs will be 
graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v.4.03 
assessed through scheduled assessment and subject reported diary 
• 
Efficacy: To determine the proportion of subjects who maintain MMR following a second 
discontinuation of TKI. 
3.3 
Description of Treatment 
Trial will be discussed with subjects in the out-patient clinic. Interested subjects will be offered to 
participate in the study. The primary physician (co-investigator) will discuss the study and counsel both 
subject and family. The objectives of the study, procedures, alternative therapies and potential risks and 
benefits of participation will be explained. Subject will be given the time to read the consent and the 
opportunity to ask questions before signing the consent form approved by Institutional Review Board 
(IRB). Protocol registration procedures will be completed within 48 hours of enrollment. Eligibility 
checklist form will be completed prior to enrollment.  
Eligible subjects will start PIO 30 mg/d orally for 2 cycles (56 days) and then increase to 45 mg/d.  
Subjects will either start or continue the same TKI at the pre-discontinuation doses. After initiation of 
PIO, blood qRT-PCR for BCR-ABL1 will be collected on a monthly basis. Disease status will be 
monitored by blood qRT-PCR for BCR-ABL1 at study specific time points (Figure 7). 
18 
 


 
4. Selection of Study Population  
4.1 
Inclusion Criteria 
1. 
CML in any phase 
2. 
Philadelphia chromosome positive acute lymphoblastic leukemia  
3. 
Loss of MMR following a first TKI discontinuation trial  
4. 
Age >16 years  
5. 
Serum bilirubin <1.5 x upper limit of normal values 
6. 
AST (SGOT)/ALT (SGPT) <2.5x upper limit of normal values 
7. 
Females of child bearing potential must agree to abstain from sexual activity or to use a 
medically approved contraceptive measure/regimen during and for 3 months after the 
treatment period. Women of child bearing potential must have a negative urine pregnancy 
test at the time of enrollment. Acceptable methods of birth control include oral 
contraceptive, intrauterine device, transdermal/implanted or injected contraceptives and 
abstinence.  
8. 
Patient requiring anti-diabetic medications to manage hyperglycemia are eligible.  
Adjustments of other anti-diabetic agents will be made with close monitoring of blood 
glucose  
9. 
Males must agree to abstain from sexual activity or agree to utilize a medically-approved 
contraception method during and for 3 months after the treatment period. 
10. 
Informed consent 
11. 
Be able and willing to comply with study visits and procedures 
4.2 
Exclusion Criteria 
1. 
Known loss of CCyR by marrow cytogenetic or blood FISH for BCR-ABL1 
2. 
Loss of CHR  
3. 
Participation in another clinical trial with any investigative drug within 30 days prior to 
study enrolment 
4. 
Chronic graft-versus-host disease requiring systemic immunosuppression post-allogeneic 
hematopoietic stem cell transplantation  
5. 
Cardiovascular disease: history of congestive heart failure, myocardial infarction within 
the 6 months of study entry, symptomatic cardiac arrhythmia requiring treatment 
6. 
History of bladder cancer  
7. 
Gross (visible) hematuria  
8. 
Known history of osteoporosis  
9. 
Known history of macular edema 
10. 
Known history of ABL1-domain mutation that predicts resistance to the discontinued TKI   
11. 
Significant medical or psychiatric disorder that would interfere with consent, study 
participation, or follow-up 
12. 
Known allergy to PIO 
13. 
Pregnant or breastfeeding 
14. 
Use of TZD within 28 days prior to enrollment 
19 
 


15. 
Significant gastrointestinal condition that could potentially impair the absorption or 
disposition of the drug 
16. 
Uncontrolled peripheral edema (2+ or more) of any etiology. 
17. 
Active cancer that requires therapy in the form of chemotherapy or radiation 
5. Study Procedures  
5.1 
Schedule of Events 
The following describes the procedures/tests required for this study: 
Screening, on study, and end of study procedures are shown in Table 3. Screening tests and procedures to 
establish eligibility of the subject for the trial will be done within 14 days prior to initiation of study drug. 
Evaluation, visit samples or activities should occur within range defined below.  
Table 3. Schedule of Events 
 
Screening 
± 14days 
Day1 
On PIO and TKI 
Off PIO and TKI 
End of 
Treatment  
12Long-
Term 
Follow 
up 
Evaluations 
on day 14 ± 
2days 
Evaluations 
on days 28 ± 
2days then 
monthly ± 
2days 
Monthly 
Evaluations 
± 2days for 
first 3 
months 
Quarterly 
Evaluations 
± 7days 
for one 
year 
1Informed Consent 
and Registration 
X 
 
 
 
 
 
 
 
2History and 
Demographics 
X 
 
 
 
 
 
 
 
3CML history, 
prior therapy, and 
response  
X 
 
 
 
 
 
 
 
4Vital Signs, 
Physical 
Examination 
X 
 
X 
X 
 
 
X 
 
5Concomitant 
medications 
X 
 
X 
X 
 
 
X 
 
6CBC and 
differential, and 
Serum Chemistries 
X 
 
X 
X 
 
 
X 
 
7Urine HCG 
X 
 
 
 
 
 
 
 
8Blood qRT-PCR 
for BCR-ABL1 
X 
 
 
X 
X 
X 
X 
X 
9Diary card 
 
 
X 
X 
 
 
 
 
10MMAS-8 
 
 
X 
X 
 
 
 
 
11Adverse Events 
Assessments 
 
    X 
PIO 
administration 
 
X 
 
X 
 
 
 
 
 
1Informed Consent: All subjects must take part in the informed consent process prior to any study related 
activity. During the consent process, the person obtaining consent must inform the subject of all elements 
of informed consent. Adequate time must be allowed for questions and for the subject to make a voluntary 
decision. No protocol-specific procedures are to be performed until the subject has signed and dated the 
20 
 


IRB approved informed consent form. Each subject's participation in the trial begins with the signing and 
dating of the informed consent form. 
2Medical/Surgical History and Demographics: Medical/surgical history that includes diagnoses and 
therapies as well as demographic information that consists of the subject’s age, gender, race, and ethnicity 
will be recorded. 
3CML History, Prior Therapy, and Response: The initial presentation history and pathology including the 
date of onset of CML must be recorded. TKI therapy including date of initiation and stop, doses, dose 
reductions or interruptions will be recorded. Sequential monitoring response to therapy and date of first 
TKI discontinuation, as well as post-discontinuation monitoring data will be collected. If TKI was 
restarted prior to enrollment on study, date of re-initiation, and dosing information, as well as response 
monitoring data will be collected. 
4Vital signs and Physical Examination: Vital signs including temperature, pulse, and blood pressure, and 
complete physical examination, including weight, must be performed at screening, day 14 and 28 as part 
of study. After that, this will be done every two to three months as part of standard of care unless new 
symptoms occur. 
 5Concomitant medications: All prescribed, over the counter, and supplemental/herbal medications, 
including route of administration (oral, topical, intravenous, rectal, subcutaneous, etc.), frequency, and 
duration will be recorded.  
6Complete Blood Count (CBC), differential and Serum Chemistries: CBC with automated differential and 
serum chemistries will be obtained at screening as part of standard of care, and day 14 and 28 as part of 
study. After that, this will be done every two to three months as part of standard of care unless new 
symptoms occur.  
7Urine human chorionic gonadotropin (HCG): HCG will only be performed in pre-menopausal women 
of childbearing age with no history of hysterectomy or bilateral tubal ligation. 
8Blood qRT-PCR for BCR-ABL1: Blood qRT-PCR for BCR-ABL1 will be obtained monthly while on PIO 
and TKI. Following discontinuation of TKI, monthly blood qRT-PCR for BCR-ABL1 for the first 3 
months, quarterly for a year and bi-annually thereafter will be done as part of standard of care. 
9Diary card: A diary card will be completed daily to indicate the date and approximate time of 
administration of each dose of PIO and TKI, including any deviations from schedule such as missed or 
repeated doses. (Appendix 1) 
10 Morisky Medication Adherence Scales – 8 (MMAS-8): A MMAS-8 will be completed at each clinic 
visits while on PIO and TKI. (Appendix 2) 
11 Adverse event assessments: All AEs will be assessed at each clinic visit as part of standard of care 
regardless the event is considered related to the treatment or not. 
End of Treatment or Early Termination Procedures: The End-of-Treatment (or early termination) Visit 
should be performed within 2 weeks (14 days) of the subject’s last dose of study drug or the 
subject/investigator decision to end treatment, whichever is later. Subjects will also return to the clinic or 
21 
 


will be contacted for a safety follow-up assessment 30 days ± 3 days after the last dose of study drug was 
taken. 
12Long Term Follow-up:  
- 
Safety: All AEs ongoing or starting within 30 days after the End-of-Treatment must be recorded on 
the case report form (CRF). After this time, ongoing AEs thought to be at least possibly study-drug 
related and all ongoing serious adverse events (SAE) should be followed at least every 4 weeks until 
they resolve to baseline (or CTCAE grade ≤1), stabilize, or are considered to be chronic or 
irreversible. 
-Relapse-free Survival: After 2 years of follow-up off TKI, if MMR is lost at any time, or if subjects 
withdraw from study for toxicity or any reasons, information on disease status (qRT-PCRs) will be 
collected once a year for 5 years as part of the Long-Term Follow-up. This information does not need 
to be obtained during a visit; review of local hematologist’s records is acceptable. 
5.2  
Description of Study Visits 
5.2.1 Visit 1 (Day -14 to -1): Screening 
- 
Obtain written informed consent 
- 
Record demographic data including age, gender, and race 
- 
Review medical, surgical, and CML history described above. 
- 
Record prior and concomitant medications including start/stop dates, indication, dose and 
frequency taken within 30 days of Day 1. 
- 
Collect blood samples for CBC with differential count and serum chemistries. 
- 
 
- 
Collect urine for pregnancy test for female subjects who are not postmenopausal or surgically 
sterile. If positive, repeat and confirm results within a week and prior to start of study drug. A 
second positive test will result in exclusion of the subject from the study. 
- 
Unless done within 72 hours, measure and record height in cm and weight in kg, record vital 
signs. Measure body temperature, systolic / diastolic blood pressure (BP) and pulse rate. Perform 
and record physical examination. 
- 
Collect blood samples for qRT-PCR of BCR/ABL1 unless done it within 30 days 
 5.2.2 Visit 2 (Day 1): Baseline/Drug Dispensing/Initiation of Treatment 
- 
Review and document all inclusion and exclusion criteria to ensure that subjects meet all 
inclusion criteria and none of the exclusion criteria. 
- 
Record AEs as part of standard of care.   
- 
Dispense PIO at 30 mg/d and instruct subjects how to take study drug, daily every 24 hours and 
how to fill the diary card. 
 5.2.3 Visits 3 (Days 14 ± 2): Early Follow-up 
- 
Measure and record height in cm and weight in kg. Record vital signs. Measure body 
temperature, systolic/diastolic BP and pulse rate. Perform and record physical examination.  
22 
 


- 
Record medications including start/stop dates, indication, dose and frequency for any changes 
since previous visit. 
- 
Collect blood samples for CBC with differential count and serum chemistries.  
- 
Assess study drug compliance by pill count, review of the diary card and MMAS-8. 
- 
Assess and record AEs and SAEs 
5.2.4 Visits 4+ (Day 28 ±2, then q28+/-2 days during combination of PIO and TKI) 
- 
On day 28, measure and record height in cm and weight in kg. Record vital signs. Measure body 
temperature, systolic / diastolic BP and pulse rate. Perform and record physical examination. 
Unless new symptoms occur, these will be performed every other month as part of standard of 
care. 
- 
On day 28, record medications including start/stop dates, indication, dose and frequency for any 
changes since previous visit. Unless new symptoms occur, these will be performed every other 
month as part of standard of care. 
- 
On day 28, collect blood samples for CBC with differential count and serum chemistries. Unless 
new symptoms occur, these will be performed every other month as part of standard of care. 
- 
On day 56, in the absence of grade 2 or higher toxicities, PIO doses will be increased to 45 mg/d 
- 
Dispense drug supply for self-dosing, remind subjects of dosing instructions, and obtain all 
unused study drug  
- 
Assess study drug compliance by pill count, review of the diary card and MMAS-8. 
- 
Collect blood samples for qRT-PCR of BCR/ABL1 every month. 
- 
Assess and record AEs and SAEs continuously 
5.2.5 Post-discontinuation of PIO and TKI Visits (Monthly for 3 months ± 2 days and quarterly ±7 
days for 1 year and biannually thereafter) 
- 
Collect blood samples for qRT-PCR of BCR/ABL1 as part of standard of care 
- 
Assess and record AEs and SAEs continuously 
5.2.6 Unscheduled Visits 
Unscheduled visits may occur at any time at the investigator's discretion, and appropriate clinical 
and laboratory measurements performed based on AEs or other findings. 
       5.2.7 End of Treatment Visit (±14 days) 
At the time of last study monitoring, loss of MMR, failure to achieve <MMR after 4 months or < 
MR4.5 after 6 months of combination treatment of PIO and TKI, the End of Treatment Visit 
should be completed for all subjects as soon as possible, and every effort should be made to 
perform the procedures required. Subjects will also return to the clinic or will be contacted for a 
safety follow-up assessment 30 days ± 3 days after the last dose of study drug was taken. Only 
information about AEs and SAEs will be collected at this visit. 
The following procedures will be performed at End of Treatment Visit: 
23 
 


- 
Measure and record height in cm and weight in kg. Record vital signs. Measure body 
temperature, systolic / diastolic BP and pulse rate. Perform and record physical examination 
which is part of standard of care 
- 
Record medications including start/stop dates, indication, dose and frequency for any changes 
since previous visit. 
- 
Collect blood samples for CBC with differential count, blood chemistries, and qRT-PCR of 
BCR/ABL1 as part of standard of care 
- 
Collect blood samples for ABL1 domain mutation analysis as part of standard of care in case of 
loss of MMR 
- 
Obtain all unused study drug if subjects drop out before discontinuation of PIO and TKI. 
- 
Assess study drug compliance by pill count and review of the diary card 
- 
Assess and record AEs and SAEs 
5.3 
 Subject Registration and Identification 
Demographic information on all subjects who sign the Informed Consent Form will be recorded on the 
master subject log. Those subjects who complete screening procedures and meet all eligibility criteria 
may be enrolled. At the time of registration, the subject will be assigned a unique identification code 
(number), consisting of a study site number and a unique consecutive number. 
5.3.1 Screen Failure 
Subjects who have signed informed consent and subsequently fail to meet the inclusion and/or exclusion 
criteria are defined as screen failures. For all screen failures, the Investigator is to maintain a screening 
log that documents the subject initials and reason(s) for screen failure. A copy of the log will be retained 
in the Investigator’s study files. Any subject who is rescreened after screen failure must, in addition to the 
failed procedure, repeat only those screening procedures outlined in the Schedule of Events that have 
fallen outside the specified screening period. 
5.3.2 Early Discontinuation 
In the event that a subject is withdrawn from the study, every effort will be made by the Investigator to 
document and report the reasons for withdrawal as thoroughly as possible. The reason(s) for termination 
must be clearly reported in the subject’s CRF. An End-of-Treatment reason for discontinuation must be 
recorded for any subject who is registered. If a subject is discontinued from the trial for any reason, every 
effort must be made to perform all clinical and laboratory procedures as scheduled for the End-of-
Treatment Visit. In the event that the subject fails to return for the necessary visit(s), an effort must be 
made to contact the subject to determine the reason, and this information should be recorded in the 
appropriate source record and the end-of-treatment CRF. 
5.4 
Study Duration 
The total estimated duration of the study is 5 years, including 2 years to accrue subjects, and 3 years of 
follow up for the last subject enrolled. Subjects will be supplied the study drug PIO until they discontinue 
treatment. 
5.5 
Withdrawal Criteria 
24 
 


Subjects will be discontinued from further study drug administration if any of the following occur:  
• 
Loss of MMR at any time  
• 
Subjects entering the study in > MMR but still in CCyR and CHR who do not achieve MMR 
within 4 months of the combination of PIO and TKI  
• 
Subjects who fail to achieve < MR4.5 after 6 months of the combination of PIO and TKI 
• 
Intolerable toxicity as determined by the Investigator or the subject 
• 
Any grade 3 or higher cardiac toxicity 
• 
Any grade 4 toxicity possibly associated with PIO 
• 
A treatment interruption for study-drug related non-hematologic toxicities lasting > 28 days 
• 
Intolerance to PIO  
• 
Significant deviation from the protocol or eligibility criteria 
• 
Noncompliance with study or follow-up procedures 
• 
Pregnancy 
• 
Subject withdrawal of consent and decision to discontinue participation 
• 
Termination of the trial  
• 
Any other reason that, in the opinion of the Investigator, would justify removal of the subject 
from the study 
5.6 
Study Termination 
If the sponsor-investigator, Data Monitoring Committee, or regulatory agencies discover conditions 
during the study that indicate that the study should be terminated, this action may be taken after 
appropriate consultation between the sponsor-investigator, and Data Monitoring Committee. Conditions 
that may warrant termination of the study include, but are not limited to: 
• 
The discovery of a serious, unexpected, or unacceptable risk to subjects enrolled in the study 
• 
Submission of knowingly false information from the research facility to the regulatory authorities 
• 
Insufficient adherence to protocol requirements 
Study termination and follow-up will be performed in compliance with the conditions set forth in the 
guidelines for Good Clinical Practice (GCP), International Conference on Harmonization (ICH) of 
Technical Requirements for Registration of Pharmaceuticals for Human Use. 
 
6. Safety Assessments  
Safety Assessments: Safety will be assessed by routine physical and laboratory evaluations according to 
the schedule (Table 3) and as medically indicated. AEs will be recorded and the severity will be graded 
according to the CTCAE v.4.03.  
Adverse Events: Type, incidence, severity (graded in accordance with the CTCAE v.4.03), timing, 
seriousness and relatedness, outcome, action taken with study drug, and treatment will be assessed and 
documented by the investigator continuously throughout the study. Baseline malignancy-related signs and 
25 
 


symptoms will be recorded as AEs during the study if they worsen in severity or increase in frequency. 
Procedures for following AEs at the end of treatment and beyond are outlined in Section 5.1. 
7. Study Treatment 
Subjects will be provided with the study drug PIO to take in addition to TKI. The TKI that was previously 
discontinued will be restarted at doses administered prior to the first discontinuation. PIO will be self-
administered on a once daily schedule. 
7.1 
Dose Selection, Treatment Administration, Compliance, and Dose Modifications 
The starting dose of PIO will be 30 mg and will be taken orally once daily. After 56 days of PIO 30 mg/d, 
the dose will be increased to 45 mg/d in the absence of grade >1 related AE. The dose of PIO was 
selected based on previously published pilot report [47]. 
Subjects will take the prescribed tablets at approximately the same time each day, regardless of meals. 
Subjects will be provided a diary card where the date and time of administration will be recorded 
(Appendix 1).  Subjects who forget to take their dose can make up the missed dose as long as this is done 
within the 12 hours of the due time. Any missing dose should be recorded. Drug compliance will be 
measured using the Morisky Medication Adherence Scales-8 (MMAS8) at every visit while on PIO and 
TKI (Appendix 2). Dose modification will be done as follows: 
Table 4. Dose Modification 
Toxicity 
Immediate action 
Later action 
Hematologic 
toxicity 
> Grade  3 
Neutropenia 
or 
Thrombocytopenia 
1. Hold PIO and TKI 
until < Grade 1  
 
1. First episode: resume TKI and PIO without dose 
modifications  
2. Second episode: resume at 1 lower dose level 
(previous dose -15 mg) 
3. Third episode: permanent discontinuation of PIO, 
resume TKI alone 
< Grade 3 anemia 
1. Continue PIO 
2. RBC transfusion if 
indicated 
 
1. First episode: resume TKI and PIO without dose 
modifications  
2. Second episode: resume PIO at 1 lower dose level 
(previous dose -15 mg) 
3. Third episode: permanent discontinuation of PIO, 
resume TKI alone 
Grade 4 anemia 
1. Hold PIO and TKI 
2. RBC transfusion if 
indicated 
1. First episode: resume PIO at 1 lower dose level 
(previous dose -15 mg) 
2. Second episode: permanent discontinuation of 
PIO, resume TKI alone 
Non-
hematologic 
toxicity 
Grade 2 
1. Hold PIO until < 
Grade 1  
1. First episode: resume TKI and PIO without dose 
modifications  
2. Second episode: resume at 1 lower dose level 
(previous dose -15 mg) 
> Grade 3* 
1. Hold PIO and TKI 
until < Grade 1 
 
1. First episode: resume PIO at 1 lower dose level 
(previous dose -15 mg) 
2. Second episode: permanent discontinuation of 
PIO, resume TKI alone 
*In case of cardiac toxicity, subject will be taken off the study 
26 
 


 
7.2 
Allocation of Treatment   
The results of screening assessments for each subject will be reviewed by the study principal investigator 
(PI), who will approve each subject. Upon this approval, subjects will receive a 28 days (1 cycle) + 2days 
supply of 30 tablets of PIO.  
7.3 
Concomitant Medications 
All concomitant medications administered from the time of informed consent signature through 30 days 
after the end of treatment (last dose or investigator/subject decision to discontinue, whichever is later) are 
to be reported on the CRF for each subject. No medications will be prohibited, but caution will be used 
for medications that interact with PIO according to the package insert.  
7.4 
Treatment Supply:  
7.4.1 Formulation, Packaging and Labeling:  
PIO will be purchased by the Investigational Pharmacy at Emory for use in this trial. PIO is available as a 
tablets for oral administration containing 15, 30, and 45 mg of PIO (as the base) formulated with the 
following excipients: lactose monohydrate NF, hydroxypropylcellulose. Tablet will be supplied as 
follows: 30 counts in Rexam’s 1-ClicR vials (Rexam PLC, London, UK) that comes with induction-
sealed child resistant caps. Bottle labels will bear the appropriate label text as required by governing 
regulatory agencies, to include product name, product strength, number of capsules, and lot number. 
 
7.4.2 Treatment Storage, Dispensing, and Accountability 
The recommended storage condition for PIO is room temperature (15-30°C), and should be kept in the 
original container to protect from light and from humidity. The study pharmacist or designee at the site 
will be responsible for handling, dispensing study drug, completing associated documentary paperwork, 
handling dispensing log/accountability form. Each time study medication is dispensed for a subject, the 
following information will be recorded: the subject’s initials, the subject’s study number, tablet strength, 
the number of tablets dispensed with the corresponding lot number, and the initials of the person 
dispensing the drug. These logs are to be maintained by the study pharmacist in the pharmacy throughout 
the duration of the study. The Investigator is responsible for ensuring that the subject diary card(s) and 
study drug provided to the subject and returned from the subject are accounted for and noted in source 
documentation. 
7.4.3 Disposition of used and unused supplies 
All used bottles or packs of study drug must be destroyed according to the standard practice. Destruction 
of such supplies will be documented. During the trial and at termination, subjects must return all unused 
study drug supplies and the return of these unused study drug supplies must be recorded. Returned 
supplies must not be re-dispensed. No other utilization of PIO intended for use in this study will be 
authorized. The investigator or his/her designee will be responsible for the appropriate handling and 
disposition of residual study drug.  
27 
 


 
8. Adverse Event Reporting  
8.1 
Adverse Events 
8.1.1 
Adverse Event Definition 
An AE is any untoward medical occurrence in a subject or clinical investigation subject administered a 
pharmaceutical product which does not necessarily have to have a causal relationship with this treatment. 
An AE can be any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, 
or disease temporally associated with the use of a medicinal product whether or not considered related to 
the medicinal product. Any worsening of a preexisting condition, which is temporally associated with the 
use of the study drug (i.e., occurs after the first dose of study drug), is also an AE. AEs include:  
• 
Abnormal test findings  
• 
Changes in physical exam findings 
• 
Other untoward medical events, regardless of their relationship to the study drug, such as injury, 
events that require surgery, accidents, or apparently unrelated illnesses, and hypersensitivity 
• 
AEs may include signs or symptoms resulting from: drug overdose, drug withdrawal, drug abuse, 
drug misuse, drug interactions, drug dependency, and, in utero drug exposure  
8.1.2 
Abnormal Laboratory Tests 
The criteria for determining whether an abnormal objective test finding should be reported as an AE are 
as follows: 
• 
Test result is associated with accompanying symptoms that are considered clinically significant in 
the opinion of the investigator 
• 
Test result requires additional diagnostic testing (other than merely repeating an abnormal test) or 
medical/surgical intervention 
• 
Test result leads to a change in study drug dosing or discontinuation from the study, significant 
additional concomitant drug treatment, or other therapy 
• 
Test result is considered to be an AE by the investigator  
8.1.3 
Performing Adverse Event Assessment 
All observed or volunteered AEs, regardless of suspected causal relationship to the investigational 
product, will be reported as described in the following sections. For all AEs, the investigator must pursue 
and obtain information adequate to determine the outcome of the AE and to assess whether it meets the 
criteria for classification as a serious AE requiring immediate notification to the appropriate regulatory 
agencies. 
8.1.4 
Reporting Period 
Serious AEs require notification of the appropriate regulatory agencies beginning from the time the 
subject starts receiving the investigational product, through and including 30 days after the last 
28 
 


administration of the assigned study treatment or the investigator/subject decision to discontinue 
treatment, whichever occurs later. Any SAE occurring any time after the reporting period must be 
promptly reported if a causal relationship to the investigational product is suspected. Any SAE ongoing at 
the end of the reporting period should be followed as described below. For all enrolled subjects, AEs 
(serious and non-serious) should be recorded on the CRF beginning with the signing of the informed 
consent form and concluding 30 days following the last dose of the assigned study treatment or the 
investigator/subject decision to discontinue treatment, whichever occurs later. AEs ongoing after the 
reporting period: Any ongoing AEs thought to be at least possibly study-drug related and all ongoing 
SAEs after this time should be followed at least every 4 weeks until they resolve to baseline (or CTCAE 
grade ≤ 1), stabilize, or are considered to be chronic/irreversible. 
8.1.5 
Adverse Event Severity 
The severity of AEs will be assessed according to the CTCAE, v.4.03 If the AE is not defined in the 
CTCAE, the investigator will determine the severity of the AE based on the following definitions: 
• 
Mild (grade 1): The AE is noticeable to the subject but does not interfere with routine activity. 
The AE does not require discontinuing administration or reducing the dose of the study drug 
• 
Moderate (grade 2): The AE interferes with routine activity but responds to symptomatic therapy 
or rest. The AE may require reducing the dose, but not discontinuing administration of the study 
drug 
• 
Severe (grade 3): The AE significantly limits the subject’s ability to perform routine activities 
despite symptomatic therapy. In addition, the AE leads to discontinuing administration or 
reducing the dose of the study drug 
• 
Life-Threatening (grade 4): The AE requires discontinuing administration of the study drug. The 
subject is at immediate risk of death 
• 
Death (grade 5): The subject dies as a direct result of the complication or condition induced by 
administration of the study drug 
8.1.6 
Causality 
The investigator’s assessment of causality must be provided for all AEs (serious and non-serious). An 
investigator’s causality assessment is the determination of whether there exists a reasonable possibility 
that the investigational product caused or contributed to the AE. In addition, if the investigator determines 
a SAE is associated with study procedures, the investigator must record this causal relationship in the 
source documents and on the SAE form and report such an assessment in accordance with the SAE 
reporting requirements. The investigator will use medical consideration and use the following categories 
of causality to determine the relatedness of an AE with the study drug based on the following definitions. 
Not all criteria in each category of relatedness must be present. 
• 
Definitely Not Related (not drug related):  The subject did not receive study drug, OR the 
temporal sequence of the AE onset relative to the administration of the study drug is not 
reasonable, OR there is another obvious cause of the AE 
• 
Probably Not Related (not drug related): there is evidence of exposure to study drug, there is 
another more likely cause of the AE, dechallenge (if performed) is negative or ambiguous, 
rechallenge (if performed) is negative or ambiguous 
29 
 


• 
Possibly Related (drug related): there is evidence of exposure to study drug, the temporal 
sequence of the AE onset relative to administration of the study drug is reasonable, the AE could 
have been due to another equally likely cause, dechallenge (if performed) is positive 
• 
Probably Related (drug related): there is evidence of exposure to study drug, the temporal 
sequence of the AE onset relative to administration of the study drug is reasonable, the AE is 
more likely explained by the study drug than by another cause 
• 
Definitely Related (drug related): there is evidence of exposure to study drug, the temporal 
sequence of the AE onset relative to administration of the study drug is reasonable, dechallenge is 
positive, rechallenge (if feasible) is positive, the AE shows a pattern consistent with previous 
knowledge of the test drug or a test drug class 
8.1.7 
Expectedness 
The expectedness of an AE is assessed by the Investigator in the overall classification of AEs and SAEs 
for regulatory reportability.  
8.2 
Serious Adverse Events 
The definitions and reporting requirements of FDA and ICH Guidelines for Clinical Safety Data 
Management, Definitions and Standards for Expedited Reporting, Topic E2A, will be adhered to. 
8.2.1 
Serious Adverse Event Definition 
An AE is considered an SAE if at least one of the following conditions applies: 
• 
Death: An AE that results in death is any subject death within 30 days of the last dose of study 
drug administration. The cause of death or AE that resulted in a fatal outcome is the SAE 
• 
Life-threatening AE: An AE that places the subject, in the view of the investigator or the sponsor, 
at immediate risk of death from the event as it occurred (i.e., this does not include an event that 
had it occurred in a more severe form might have caused death) 
• 
Results in a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions: Any substantial disruption of a person’s ability to conduct normal life 
functions 
• 
Inpatient hospitalization or prolongation of existing hospitalization: Hospitalization refers to 
admission of a subject into a hospital for any length of time 
• 
A congenital anomaly/birth defect: A fixed, permanent impairment established at or before birth 
• 
Cancer: Occurrence or diagnosis of a new cancer during the study is considered an SAE. A new 
cancer is a cancer that is histopathologically different than the cancer under study in the trial (i.e., 
does not include metastatic or progressive disease) 
• 
Overdose: Occurrences of overdose must be reported as an SAE 
• 
Important medical event: Medical and scientific judgment should be exercised in determining 
whether an event is an important medical event. An important medical event may not result in 
death, be life-threatening, or require hospitalization. However, if it is determined that the event 
may jeopardize the subject and/or may require intervention to prevent one of the other outcomes 
listed in the definition above, the important medical events should be reported as serious. 
Examples of such events are intensive treatment in an emergency room or at home for allergic 
30 
 


bronchospasm, blood dyscrasias, or convulsions that do not result in hospitalization; or the 
development of drug dependency or drug abuse. 
AEs (reported from clinical studies) that require hospitalization or prolongation of hospitalization are 
considered serious. Any initial admission (even if less than 24 hours) to a health care facility meets these 
criteria. AEs that require emergency room care that do not result in hospital admission are not SAEs 
unless assessed by the investigator to be an important medical event. Hospitalization does not include the 
following: Hospice facilities, Respite care, skilled nursing facilities, Nursing home, Routine emergency 
room admissions, and same day surgeries (as outpatient/same day/ambulatory procedure) 
Hospitalization or prolongation of hospitalization in the absence of a precipitating AE is not in itself an 
SAE. Examples include: social admission (e.g., subject has no place to sleep), optional admission not 
associated with a precipitating AE (e.g., for elective cosmetic surgery that was planned prior to study 
enrollment [appropriate documentation is required for these cases]), hospitalization or prolongation of 
hospitalization for scheduled therapy of the target malignancy of the study is not considered an SAE 
8.2.2 
Reporting Adverse Events 
Written Investigational New Drug (IND) safety reports will be submitted to the FDA by the IND sponsor, 
for serious, unexpected suspected adverse reactions within 15 calendar days of the sponsor determining 
that the information requires reporting. If the event is fatal or is deemed to be life threatening, the report 
will be made within 7 calendar days.  The IND sponsor will also make an assessment of whether the event 
constitutes an unanticipated problem posing risks to subjects or others (UP). This assessment will be 
provided to the Emory University IRB, which, in turn will make a final determination.  If the Emory IRB 
determines an event is a UP it will notify the appropriate regulatory agencies and institutional officials. 
The Sponsor- Investigator is responsible for reviewing all IND Action Letters, Safety Reports and any 
other safety related Investigator Notification and determining the action to be taken (i.e. prompt reporting 
to the IRB, consent change/modification, routine reporting, etc). 
The following information about the subject and the event will need to be collected and available: 
• 
Investigator identification 
• 
Subject identification code (e.g., sex, age, or date of birth) 
• 
Information on study drug (e.g., start/stop date, dose and frequency of study drug administered) 
• 
Description of event 
In addition to the above information, the sponsor will require the investigator’s assessment of the 
following: 
• 
Severity of the SAE 
• 
Relationship of the SAE to the study drug 
• 
Outcome of the SAE 
8.2.3 
Follow-up Information of Serious Adverse Events 
Appropriate diagnostic tests should be performed and therapeutic measures, as medically indicated, 
should be instituted. Appropriate consultation and follow-up evaluations should be carried out until the 
31 
 


event has resolved or is otherwise explained by the investigator. For all SAEs, the investigator is 
obligated to pursue and provide information to the appropriate regulatory agencies. There should be 
routine follow-up through and including 30 days after the last administration of assigned study treatment 
or the investigator/ subject decision to discontinue treatment, whichever occurs later, in all subjects in 
order to monitor for the occurrence of SAEs. If an SAE continues after the 30-day evaluation period, then 
the subject must be followed until the event resolves or returns to baseline. The medical monitor may 
specify a longer period of time if required to assure the safety of the subject. 
8.3 
Other Safety Issues 
8.3.1 
Pregnancy 
Females of childbearing potential and fertile males will be informed as to the potential risk of conception 
while participating in this study and will be advised that they must use effective contraception from 
beginning study drug through at least 30 days after the end of treatment. A pregnancy test will be 
performed on each pre-menopausal female of childbearing potential immediately prior to beginning study 
drug. A negative pregnancy test must be documented prior to administration of study drug. If a subject is 
confirmed pregnant during the trial, study drug administration must be discontinued immediately. The 
investigator must immediately notify the appropriate regulatory agencies of this event and record the 
pregnancy on a Pregnancy Form. The investigator must also report follow-up information to the 
appropriate regulatory agencies regarding the course of the pregnancy, including perinatal and neonatal 
outcome, regardless of whether the subject has discontinued participation in the study. If the pregnancy 
results in the birth of a child, additional follow-up information may be requested. If the pregnancy results 
in spontaneous abortion or stillbirth, the event should be reported as an SAE. Pregnancy outcomes must 
be collected for the female partners of any males who took study drug in this study. Consent to report 
information regarding these pregnancy outcomes should be obtained from the female partner. 
8.3.2 
Overdose  
An overdose is defined as the accidental or intentional ingestion or infusing of any dose of a product that 
is considered BOTH excessive AND medically important. All occurrences of overdose must be reported 
as an SAE. These AEs will be monitored as instructed in the schedule of events and as clinically 
indicated. 
 
9. Statistical Considerations 
9.1 
General Considerations 
For the purposes of this protocol and all analyses, a cycle of treatment is defined as 28 days.  
9.2 
Analysis Population 
Intention to treat (ITT) population: The ITT population includes all subjects who are enrolled in the study.  
Safety Population: The safety population includes all subjects who have received at least 1 dose of PIO.  
32 
 


Per-protocol Population: The per-protocol population includes all subjects who are enrolled, receive at 
least one dose of study drug, and have no major protocol violations that could be expected to impact 
response data, such as: failure to satisfy one or more eligibility criteria, administration of other anti-cancer 
therapy concurrent with study drug, and administration of incorrect study drug dose. Major protocol 
violations will be finalized and documented prior to final data analysis. 
9.3 
Study Endpoints 
The primary endpoint of this study is to determine safety and efficacy of PIO administered in combination 
with TKI. Therefore, description of AEs in subjects receiving the combination of PIO and TKI will be 
collected. AEs will be graded according to the CTCAE v.4.03 assessed through scheduled assessment and 
subject reported diary. Efficacy is determined by the proportion of subjects who achieve and maintain < 
MR4.5 using blood qRT-PCR for BCR-ABL1 obtained monthly while on PIO and TKI. 
Secondary endpoint of the study is to determine the proportion of subjects who lose MMR following 
discontinuation of PIO and TKI using blood qRT-PCR for BCR-ABL1 obtained monthly for the first 3 
months then quarterly.  
9.4 
Determination of Sample Size  
Previous reports suggest that PIO is well tolerated at the doses of 30 and 45 mg [47]. Under Simon’s 
optimal two stage design with a 5% significance level and 80% power, assuming a lower boundary of 
interest in the response rate of 20% and an upper boundary of interest in the response rate of 50%, a total 
of 24 evaluable subjects are required for the evaluation of the primary endpoint; 9 in Stage 1 and an 
additional 15 in Stage 2. If < 2/9 evaluable subjects in Stage 1 maintain MMR after second-TKI 
discontinuation or > 2 subject develop > grade 3 cardiac toxicity then the study will terminate, otherwise 
the study shall continue as planned and enrollment of an additional 15 subjects shall continue into Stage 
2. If, at the final analysis, less than 9 of 24 evaluable subjects in both Stage 1 and 2 maintain MMR then it 
will be concluded that the combination of PIO and TKI does not deserve further investigation. After 
adjusting for 8% drop out rate, the actual required sample size will be 26 subjects. Therefore, the total 
sample size of the study will be 26 subjects.  
9.5 
Safety and Efficacy Analysis 
All subjects receiving at least 1 dose of study drug will be considered evaluable for safety. Listings of 
laboratory test results will also be generated, and descriptive statistics summarizing the changes in 
laboratory tests over time will be presented. Exposure to study drug over time will also be summarized. 
The AE incidence rates, as well as the frequency of occurrence of overall toxicity, categorized by toxicity 
grades (severity) will be described. The number of subjects that has reappearance of BCR-ABL1 will be 
described. Descriptive statistics that will summarize the changes in BCR-ABL1 testing over time will be 
presented. Loss of MMR is defined as a BCR-ABL1 >0.1% by qRT-PCR confirmed within a week and 
associated with a rise in the titer on a confirmatory test obtained 4 weeks later (ELN definition). For the 
primary and secondary efficacy endpoints, subgroup analyses will be performed by baseline potential 
prognostic factors. Subgroups will include: age, gender, race, underlying diagnosis, and other disease-
related prognostic factors (disease status). 
33 
 


9.6  
Interim Analysis 
An interim analysis is planned after 9 subjects have been enrolled and their results have been obtained. 
This interim analysis will focus on efficacy as discussed in section 9.4 and safety. If grade 3-4 toxicity is 
observed at any moment in 2 subjects, the trial will be put on hold and no further subjects will be enrolled 
until analyses of these cases is complete and reviewed by the data safety monitoring board (DSMB). 
9.7 
Protocol Deviations and Violations 
To be protocol-compliant, a subject must not have any major protocol deviations during the study period. 
Protocol deviations will be identified prior to final analysis and will be listed by treatment group in the 
clinical study report. 
 
10.  Quality Control and Quality Assurance and Study Monitoring 
The investigator is responsible for performing quality control and assurance checks. Before enrolling any 
subjects into this study, the investigator will review the protocol, the CRFs and instructions for their 
completion, the procedure for obtaining informed consent, and the procedure for reporting AEs with all 
personnel listed on the delegation of authority and FDA1572. The investigator will evaluate the conduct 
of the trial at least once monthly and perform the following: 
• 
Review information recorded in the CRFs and verify against source documents 
• 
Review data for safety information and to identify missing data   
• 
Review protocol violations, out-of-range data, and other data inconsistencies 
This study will be monitored by the DSMB Winship Committee. 
 
11. Ethical Conduct of the Study 
This study will be conducted in accordance with the ethical standards that have their origin in the 
Declaration of Helsinki and that are consistent with GCP guidelines and the applicable regulatory 
requirements. 
11.1 
Institutional Review Boards Approval 
The protocol and the informed consent document must have the initial and at continuing approvals of the 
IRB. The signed IRB approval letter must identify the documents approved (i.e., list the investigator’s 
name, the protocol number and title, the date of the protocol and informed consent document, and the date 
of approval of the protocol and the informed consent document). Any advertisements used to recruit 
subjects should also be reviewed by the IRB.  
11.2 
Subject Information and Consent 
The study informed consent form will follow regulations that provide protection for human subjects in 
clinical investigations and describe the general requirements for informed consent. The informed consent 
34 
 


document will contain all of the elements of the informed consent specified in the regulations. Nothing in 
this protocol or the regulations is intended to limit the authority of a physician to provide emergency 
medical care under applicable regulations. In addition, regulatory agencies will be granted permission to 
conduct inspections and review records pertaining to this clinical investigation. 
11.3 
Subject Confidentiality 
Throughout the course of the study, all private information will be kept securely using password protected 
computer terminals. Access to the data will be on a need to know basis, therefore, only those investigators 
listed in the protocol will have access to the data. A high premium will be placed on ensuring that 
identifying information is not made available to staff engaged in routine care of the subject unless 
necessary for the safe performance of their duties. For this reason, all research-related samples and 
clinical data will be de-identified using assigned study-specific registration numbers for such non-
standard of care procedures as much as possible. 
The investigator agrees to keep all information in strict confidence and to request similar confidentiality 
from his/her staff and the IRB. Study documents will be stored appropriately to ensure their 
confidentiality. The information provided to the investigator may not be disclosed to others without direct 
written authorization, except to the extent necessary to obtain informed consent from subjects who wish 
to participate in the trial.  
11.4 
Data Safety Monitoring Committee 
Subject safety, study efficacy and compliance will be reviewed at the weekly Hematology working group 
meetings. The Data and Safety Monitoring Committee (DSMC) of the Winship Cancer Institute will also 
oversee the conduct of this study. This committee will review pertinent aspects of study conduct including 
subject safety, compliance with protocol, data collection and efficacy. The committee will review the 
charts of 10% of subjects enrolled to the study and two of the first 5 subjects entered to the study. The 
Committee reserves the right to conduct additional audits if necessary. The PI or designee is responsible 
for notifying the DSMC about the accrual of subjects when the first 5 have been entered to the study. The 
PI or designee will also notify the DSMC of study status within 2 months before the next scheduled 
review is due. 
 
12. Data Handling and Record Keeping 
12.1 
Case Report Forms and Study Records 
Study-specific CRFs will be made available for the conduct of this study. Study data, contained in source 
documentation, will be entered into the CRFs for all subjects enrolled in the study. All pertinent data 
records will be maintained as required after completion or termination of the study. 
12.2 
Source Documents 
The investigator agrees that qualified representatives of the sponsor and regulatory agencies will have the 
right, both during and after this study, to conduct inspections and to audit and review medical records 
pertinent to the clinical study as permitted by the regulations. Subjects will not be identified by name in 
35 
 


any reports stemming from the study, and confidentiality of information in medical records will be 
preserved. The confidentiality of the subject will be maintained unless disclosure is required by 
regulations.  
12.3 
Retention of Data 
Trial documents (including correspondence related to this clinical study, subject records, source 
documents, CRFs, study drug inventory records and IRB and sponsor correspondence pertaining to the 
study, original subject, laboratory, and study drug inventory records relating to the study) will be retained 
as specified in FDA regulations and institutional policy. 
12.4 
Study Termination 
The study will be terminated at any time for any of the following reasons: 
• 
Less than 2 of 9 evaluable subjects maintain MMR after second-TKI discontinuation   
• 
More than 2 subjects develop > grade 3 cardiac toxicities 
• 
More than 2 subjects develop grade 4 toxicity possibly associated with PIO 
• 
Failure to enroll subjects 
• 
Protocol violations 
• 
Inaccurate or incomplete data 
• 
Unsafe or unethical practices 
• 
Questionable safety of the study drug 
• 
Administrative decision 
In the event of the termination of the Study, a written statement describing why the study was terminated 
prematurely will be made available by the investigator. 
 
36 
 


 
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39 
 


Appendix 1:  Diary Card 
Medication Diary 
Today’s date ___________________________  
 
 
 
 
Page 1 
Subject’s Initials_________________________ Subject Study ID________________________ 
 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form for each cycle. 
2. 
You will take your dose PIO each day at approximately the same time.  PIO tablets should be swallowed 
whole, and should not be broken, chewed or opened.  You will take ____mg tablets each day. 
3. 
Record the date, the number of PIO tablets of each size you took, and when you took them.   
4.    Record the number of TKI tablets of each size you took. 
4. 
If you have any comments or notice any side effects, please record them in the Comments column. 
5. 
Please bring your pill bottle and this form to your physician when you go for your next 
appointment. 
 
Date 
 
Day 
Time of 
daily dose 
PIO 
TKI__________ 
Comments 
15 mg 
30 mg 
45 mg 
__________mg 
 
 
1 
 
 
 
 
 
 
 
2 
 
 
 
 
 
 
 
3 
 
 
 
 
 
 
 
4 
 
 
 
 
 
 
 
5 
 
 
 
 
 
 
 
6 
 
 
 
 
 
 
 
7 
 
 
 
 
 
 
 
8 
 
 
 
 
 
 
 
9 
 
 
 
 
 
 
 
10 
 
 
 
 
 
 
 
11 
 
 
 
 
 
 
 
12 
 
 
 
 
 
 
 
13 
 
 
 
 
 
 
 
14 
 
 
 
 
 
 
 
PLEASE BRING EMPTY BOTTLE AND 
REMAINING PILLS AT EACH CLINIC 
VISIT 
40 
 


Subject’s Initials _________________________ Subject Study ID________________________ 
 
INSTRUCTIONS TO THE PATIENT: 
1. 
Complete one form for each cycle. 
2. 
You will take your dose PIO each day at approximately the same time.  PIO tablets should be sw
whole, and should not be broken, chewed or opened.  You will take ____mg tablets each day. 
3. 
Record the date, the number of PIO tablets of each size you took, and when you took them.   
4.    Record the number of TKI tablets of each size you took. 
4. 
If you have any comments or notice any side effects, please record them in the Comments column. 
5. 
Please bring your pill bottle and this form to your physician when you go for your next appoi
 
Date 
 
Day 
Time of 
daily dose 
PIO 
TKI__________ 
Comments 
15 mg 
30 mg 
45 mg 
__________mg 
 
 
15 
 
 
 
 
 
 
 
16 
 
 
 
 
 
 
 
17 
 
 
 
 
 
 
 
18 
 
 
 
 
 
 
 
19 
 
 
 
 
 
 
 
20 
 
 
 
 
 
 
 
21 
 
 
 
 
 
 
 
22 
 
 
 
 
 
 
 
23 
 
 
 
 
 
 
 
24 
 
 
 
 
 
 
 
25 
 
 
 
 
 
 
 
26 
 
 
 
 
 
 
 
27 
 
 
 
 
 
 
 
28 
 
 
 
 
 
 
 
Patient’s Signature: __________________________________________ Date: _________________________ 
 
Physician’s Office will complete this section: 
1. Patient’s planned daily dose______________   Total number of pills taken this month _________________ 
Physician/Nurse/Data Manager’s Signature ___________________________Date : ___________________ 
41 
 


Appendix 2:  Morisky Medication Adherence Scales – 8 (MMAS-8) 
1) Do you sometimes forget to take your pills? 
YES=0  □     NO=1 □  
2) People sometimes miss taking their medications for reasons other than 
forgetting. Thinking over the past two weeks, were there any days when 
you did not take your medicine? 
YES=0  □     NO=1 □ 
3) Have you ever cut back or stopped taking your medicine without telling 
your doctor because you felt worse when you took it? 
YES=0 □     NO=1 □ 
4) When you travel or leave home, do you sometimes forget to bring along 
your medicine? 
YES=0 □     NO=1 □ 
5) Did you take all your medicine yesterday? 
YES=1 □     NO=0 □ 
6) When you feel like your symptoms are under control, do you sometimes 
stop taking your medicine? 
YES=0 □     NO=1 □ 
7) Taking medicine every day is a real inconvenience for some people. Do 
you ever feel hassled about sticking to your treatment plan?  
YES=0 □     NO=1 □ 
8) How often do you have difficulty remembering to take all your 
medicine? 
   ___A. Never/rarely 
   ___B. Once in a while 
   ___C. Sometimes 
   ___D. Usually 
   ___E. All the time 
          A=4  □ 
          B=3  □   
          C=2  □   
          D=1  □   
          E=0  □   
 
Divide score by 4 
 
Adherence 
MMAS‐8 Score 
High Adherence 
8 
Medium Adherence 
6-<8 
Low Adherence 
<6 
 
Adherence MMAS‐4 Score MMAS‐8 Score 
42