Clinical trial NCT03298984
Conditions: Acute Myeloid Leukemia
Sponsor: Sumitomo Pharma America, Inc.
Start date: 2017-09-25; Completion date: 2020-03-20
Enrollment: 32 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
The purpose of this Phase I study is to determine the safety and tolerability including the maximum dose (MTD) and dose-limiting toxicities (DLTs) of alvocidib when administered over a range of doses on Days 1-3 followed by cytarabine/daunorubicin (7+3) on Days 5-11 in adults with newly diagnosed and previously untreated AML

Detailed description:
Primary Objective:

• To determine the safety and tolerability including the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of alvocidib when administered over a range of doses on Days 1-3 followed by cytarabine/daunorubicin (7+3) on Days 5-11 in adults with newly diagnosed and previously untreated AML

Secondary Objectives:

* To observe patients for any evidence of antileukemic activity of alvocidib plus 7+3 using the 2017 ELN response criteria
* To establish the Recommended Phase 2 Dose (RP2D) for future studies with alvocidib in combination with 7+3

Exploratory Objective:

• To assess levels of minimal residual disease (MRD) using standardized techniques (ie, multiparametric flow cytometry \[MPFC\] and next generation sequencing \[NGS\] and evaluate other potential biomarkers including, but not limited to, MCL-1 dependency.

Arms: arm 1: The starting dose of alvocidib will be 20 mg/m2 as a 30-minute intravenous (IV) bolus followed by 30 mg/m2 over 4 hours as an IV infusion administered daily on Days 1-3 of Induction. Patients will have a one day drug holiday (Day 4) before initiation of the 7+3 regimen. Beginning on Day 5, cytarabine will be administered as a 100 mg/m2/day continuous IV infusion for seven consecutive days (Days 5-11) plus daunorubicin administered at a dosage of 60 mg/m2 IV on Days 5-7.
Interventions: intervention 1: Alvocidib intervention 2: Cytarabine intervention 3: Daunorubicin
Intervention descriptions: intervention 1: IV bolus followed by IV infusion intervention 2: continuous infusion intervention 3: IV bolus

Protocol documents:
Prot_000.pdf: 


Protocol No. TPI-ALV-101 Amendment 8 
 
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PROTOCOL SIGNATURE PAGE 
 
SPONSOR SIGNATURE 
I have carefully read the protocol, TPI-ALV-101 Amendment 8, titled “A Phase 1, Open-
label, Dose-escalation, Safety and Biomarker Prediction Study of Alvocidib and 
Cytarabine/Daunorubicin (7+3) in Patients with Newly Diagnosed Acute Myeloid 
Leukemia (AML)” and confirm this is the approved current version.  
 
Sponsor’s Signature 
 
Date (DD/MMM/YYYY) 
 
Printed Name 
 
 
INVESTIGATOR’S SIGNATURE 
I have carefully read this protocol, TPI-ALV-101 Amendment 8, and commit to conduct 
the study as outlined herein, in accordance with the International Council on 
Harmonisation (ICH), Good Clinical Practices (GCPs) and the Declaration of Helsinki, 
and comply with the obligations and requirements of the Clinical Investigator and other 
requirements as listed in Title 21 of the United States Code of Federal Regulations 
(CFR) and other applicable regulations. 
 
Investigator’s Signature 
 
Date (DD/MMM/YYYY) 
 
Printed Name 
 
Name of Institution/Research Facility 
 
 
 


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TABLE OF CONTENTS 
 
PROTOCOL SIGNATURE PAGE ............................................................................. 2 
TABLE OF CONTENTS ............................................................................................ 3 
LIST OF TABLES ...................................................................................................... 7 
ABBREVIATIONS ..................................................................................................... 8 
STUDY SUMMARY ................................................................................................. 10 
1. INTRODUCTION ............................................................................................... 18 
1.1 Acute Myeloid Leukemia (AML) ...................................................................... 18 
1.1.1 
Role of MCL-1 in AML ........................................................................................18 
1.1.2 
Newly Diagnosed and Previously Untreated AML ..............................................19 
1.2 Rationale ........................................................................................................ 19 
2. DRUG INFORMATION – ALVOCIDIB .............................................................. 21 
2.1 Background..................................................................................................... 21 
2.2 Chemistry........................................................................................................ 21 
2.3 Drug Description ............................................................................................. 21 
2.4 Mechanism of Action ...................................................................................... 22 
2.5 Preclinical Studies .......................................................................................... 22 
2.5.1 
In Vitro/In Vivo Studies .......................................................................................22 
2.5.2 
Safety Pharmacology .........................................................................................24 
2.5.3 
Nonclinical Absorption, Distribution, Metabolism and Excretion .........................24 
2.5.4 
Animal Toxicology ..............................................................................................24 
2.5.5 
Genotoxicity .......................................................................................................25 
2.5.6 
Reproductive and Developmental Toxicity .........................................................25 
2.5.7 
Other Toxicity Studies ........................................................................................25 
2.6 Clinical Studies ............................................................................................... 26 
2.6.1 
Phase 1 and 2 Clinical Studies of Bolus and Hybrid FLAM Regimens in 
Patients with AML ..............................................................................................26 
2.6.2 
Phase 2 Studies in Patients with Newly Diagnosed and Previously 
Untreated AML ...................................................................................................29 
2.6.2.1 Summary of Safety in NCI-7845 (J-0669) FLAM in Newly-diagnosed 
Poor-risk AML ..............................................................................................30 
2.6.2.2 Summary of Safety in NCI-8237 (J-0856) FLAM in Newly-diagnosed 
Poor-risk AML ..............................................................................................30 
2.6.2.3 Summary of Safety in NCI-8972 (J-1101) FLAM in Newly-diagnosed 
Poor-risk AML ..............................................................................................30 
2.7 Justification for Study Treatment Plan ............................................................ 30 
2.8 Summary of Risk and Benefits ........................................................................ 31 
3. STUDY OBJECTIVES ....................................................................................... 32 
4. INVESTIGATIONAL PLAN ............................................................................... 33 
4.1 Overall Study Design ...................................................................................... 33 
4.2 Patient Population ........................................................................................... 35 


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4.2.1 
Number of Patients ............................................................................................35 
4.2.2 
Inclusion Criteria ................................................................................................35 
4.2.3 
Exclusion Criteria ...............................................................................................36 
4.3 Study Treatments ........................................................................................... 37 
4.3.1 
Calculation of Dose ............................................................................................37 
4.3.2 
Study Drug Administration ..................................................................................37 
4.3.3 
Dose Escalation of Alvocidib ..............................................................................38 
4.3.3.1 Dose Escalation of Alvocidib – Step 1 ..........................................................39 
4.3.3.2 Identifying and Confirming the MTD – Step 2 ...............................................39 
4.4 Management of Toxicities and Dosage Modifications ..................................... 39 
4.4.1 
Management of Nonhematologic Toxicities ........................................................39 
4.4.1.1 Hyperkalemia and Tumor Lysis Syndrome ...................................................40 
4.4.1.2 Diarrhea .......................................................................................................42 
4.4.1.3 Nausea/Vomiting ..........................................................................................42 
4.4.1.4 Infection Prevention ......................................................................................43 
4.4.2 
Management of Hematologic Toxicities ..............................................................43 
4.4.3 
Dose-limiting Toxicities ......................................................................................43 
4.4.4 
Dose Modifications .............................................................................................44 
4.5 Concomitant Medications and Therapies ........................................................ 44 
4.5.1 
Previous Therapies ............................................................................................44 
4.5.2 
Concomitant Therapies ......................................................................................45 
4.5.2.1 Mandated / Permitted Therapies ..................................................................45 
4.5.2.2 Prohibited Therapies ....................................................................................46 
4.5.3 
Birth Control Requirements for Fertile Patients ..................................................46 
4.6 Protocol Deviations ......................................................................................... 46 
4.7 Other Precautions ........................................................................................... 46 
5. ON-STUDY CLINICAL AND LABORATORY EVALUATIONS......................... 47 
5.1 Screening (Within 2 Weeks Prior to First Dose of Alvocidib) .......................... 47 
5.1.1 
Within 2 Weeks Prior to First Dose .....................................................................47 
5.1.2 
Within 72 Hours Prior to First Dose of Alvocidib .................................................47 
5.2 Induction – Alvocidib and 7+3 ......................................................................... 48 
5.2.1 
Assessments Required Prior to First Dose .........................................................48 
5.2.1.1 Induction – At Least 10 Hours Prior to First Dose .........................................48 
5.2.1.2 Induction, Day 1 – Just Prior to First Dose....................................................49 
5.2.2 
Induction, Day 1 – Dosing ..................................................................................49 
5.2.3 
Induction – Daily during Hospitalization for Chemotherapy.................................50 
5.2.4 
Induction – Weekly after Completion of Chemotherapy Regimen .......................50 
5.2.5 
Induction, Day 14 (±3 Days) ...............................................................................51 
5.2.6 
Induction – At Hematologic Recovery or Day 50 (±3 days), Whichever 
Occurs First........................................................................................................51 
5.3 Reinduction (if Day 14 [±3 Days] Positive Marrow) ......................................... 52 
5.3.1 
Reinduction – At Hematologic Recovery or Day 60 (±3 days), Whichever 
Occurs First........................................................................................................52 
5.4 Consolidation – HiDAC ................................................................................... 52 
5.4.1 
Consolidation, Day 1 – Just Prior to First Dose ..................................................52 
5.4.2 
Consolidation, Day 1 – Dosing ...........................................................................53 
5.4.3 
Consolidation – Daily during Hospitalization for HiDAC ......................................53 


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5.4.4 
Consolidation – Weekly after Completion of HiDAC ...........................................54 
5.4.5 
Consolidation – Response Assessment .............................................................54 
5.4.6 
Consolidation – Cycles 2 through 4 ....................................................................54 
5.5 End of Study Assessments ............................................................................. 55 
5.6 Follow-up Assessments .................................................................................. 55 
5.6.1 
Safety Follow-up (30 Days Post Last Dose) .......................................................55 
5.6.2 
Long-term Follow-up (Starting 30 Days Post End of Study out to 2 Years) .........56 
6. OFF-STUDY CRITERIA .................................................................................... 57 
6.1 Withdrawal of Patients .................................................................................... 57 
6.2 Reasons for Withdrawal .................................................................................. 57 
6.3 Follow-up for Patients Withdrawn from Study ................................................. 58 
7. CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS ..................... 59 
7.1 Safety Endpoints ............................................................................................. 59 
7.2 Efficacy Endpoints .......................................................................................... 59 
8. ADVERSE EVENTS .......................................................................................... 60 
8.1 Definitions ....................................................................................................... 60 
8.2 Causality ......................................................................................................... 61 
8.3 Serious Adverse Events ................................................................................. 61 
8.4 Eliciting and Reporting Adverse Events .......................................................... 62 
8.5 Serious Adverse Events and/or Adverse Events Requiring Discontinuation 
of Study Drug .................................................................................................. 62 
8.6 Follow-up of Adverse Events .......................................................................... 63 
8.7 Patient Deaths ................................................................................................ 64 
8.8 Reporting Adverse Events to the Regulatory Authorities ................................ 64 
9. STUDY DRUG MANAGEMENT ........................................................................ 65 
9.1 Study Drug ...................................................................................................... 65 
9.2 Study Drug Dispensing and Accountability ..................................................... 65 
9.3 Preparation and Administration ....................................................................... 66 
9.4 Storage at Study Center ................................................................................. 66 
9.5 Compliance ..................................................................................................... 66 
10. RECORD MANAGEMENT ................................................................................ 67 
10.1 Data Collection ............................................................................................. 67 
10.2 Source Document Maintenance ................................................................... 67 
10.3 Record Maintenance .................................................................................... 69 
10.4 Study Center File Management .................................................................... 69 
11. STATISTICAL ANALYSIS ................................................................................ 71 
11.1 Statistical Methods ....................................................................................... 71 
11.2 Sample Size ................................................................................................. 71 
11.3 Data Analyses .............................................................................................. 71 
11.3.1 Demographics and Baseline Characteristics ......................................................72 


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11.3.2 Efficacy Analyses ...............................................................................................72 
11.3.3 Biomarker Prediction Endpoint Analyses ............................................................73 
11.3.4 Safety Analyses .................................................................................................73 
12. PROTOCOL AMENDMENTS ............................................................................ 75 
13. MONITORING ................................................................................................... 76 
14. AUDITING ......................................................................................................... 77 
15. ETHICS AND RESPONSIBILITY ...................................................................... 78 
15.1 Principal Investigator’s Responsibilities ........................................................ 78 
15.2 Informed Consent ......................................................................................... 78 
15.3 Institutional Review Board/Independent Ethics Committee .......................... 79 
16. CONFIDENTIALITY .......................................................................................... 80 
17. NONPROTOCOL RELATED RESEARCH ....................................................... 81 
18. PUBLICATIONS ................................................................................................ 82 
19. REFERENCES .................................................................................................. 83 
APPENDIX A – SCHEDULE OF ACTIVITIES ......................................................... 87 
APPENDIX B – ECOG PERFORMANCE STATUS SCALE ................................... 93 
APPENDIX C – NCI COMMON TERMINOLOGY CRITERIA FOR ADVERSE 
EVENTS ......................................................................................... 94 
APPENDIX D – LABORATORY TESTS ................................................................. 95 
APPENDIX E – RESPONSE CRITERIA (2017 EUROPEAN LEUKEMIANET 
RECOMMENDATIONS) ................................................................. 96 
APPENDIX F – MULTIVARIATE ANALYSIS AND RISK SCORE PREDICTION 
MODEL FOR DEVELOPMENT OF TUMOR LYSIS SYNDROME 
IN AML ........................................................................................... 99 
APPENDIX G – ASSESSMENT OF PRIOR AND CUMULATIVE 
ANTHRACYCLINE/ANTHRACENEDIONE EXPOSURE* ........... 100 
 
 
 


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LIST OF TABLES 
Table 1: 
Overview of Alvocidib Phase 1 & 2 Clinical Studies in AML  (In 
Chronologic Order) ............................................................................. 27 
Table 2: 
Alvocidib/FLAM in Newly Diagnosed Poor-risk AML .......................... 29 
Table 3: 
Dose Escalation of Alvocidib .............................................................. 38 
 


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ABBREVIATIONS 
5+2 
Refers to the regimen of Ara-c: Days 5-9 and  
Daunorubicin: Days 5 and 6 
7+3 
Refers to the regimen of Ara-c: Days 5-11 and  
Daunorubicin: Days 5, 6, 7 
ACD 
Alvocidib/Ara-c/daunorubicin (alvocidib plus 7+3) 
ACM 
Alvocidib/Ara-c/mitoxantrone (historically known as “FLAM”) 
AE 
Adverse event 
AGC 
Absolute granulocyte count 
ALP 
Alkaline phosphatase 
ALT 
Alanine aminotransferase 
AML 
Acute myeloid leukemia 
ANC 
Absolute neutrophil count 
AP 
Accelerated phase 
APL 
Acute promyelocytic leukemia 
Ara-c 
Cytarabine 
AST 
Aspartate aminotransferase 
AUC 
Area under the curve 
BID 
Every 12 hours 
BM 
Bone marrow 
BUN 
Blood urea nitrogen 
CBC 
Complete blood count 
CHR 
Complete hematologic remission 
Cl 
Clearance 
CLL 
Chronic lymphocytic leukemia 
CNS 
Central nervous system 
COV 
Close out visit 
CR 
Complete remission/response 
CRA 
Clinical research associate 
CRi 
All CR criteria except for residual neutropenia (<1000/μL) or 
thrombocytopenia (<100,000/μL) 
CRF 
Case report form 
CRMRD– 
CR without MRD 
CTCAE 
Common Terminology Criteria for Adverse Events 
DCF 
Data clarification form 
DLT 
Dose-limiting toxicity 
DNA 
Deoxyribonucleic acid 
DSMB 
Data Safety Monitoring Board 
ECHO 
Echocardiogram 
ECOG 
Eastern Cooperative Oncology Group 
EFS 
Event-free survival 
EMD 
Extramedullary disease 
FDA 
Food and Drug Administration 
FLAM 
Alvocidib (Flavopiridol)/Ara-c/Mitoxantrone (termed “ACM” in this study) 
GCP 
Good Clinical Practice 
GCSF 
Granulocyte colony stimulating factor 
GM-CSR 
Granulocyte-macrophage colony stimulating factor 
HCG 
Human chorionic gonadotropin 
HCT 
Hematocrit 
Hgb 
Hemoglobin 


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HI 
Hematologic improvement 
HiDAC 
High-dose Ara-c 
IC50 
Inhibitory concentration in 50% of animals 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug Application 
IP 
Intraperitoneal 
IRB 
Institutional Review Board 
ITT 
Intent to treat (population) 
LD50 
Lethal dose in 50% of animals 
LDH 
Lactate dehydrogenase 
LVEF 
Left ventricular ejection fraction 
MedDRA 
Medical Dictionary for Regulatory Activities 
MDS 
Myelodysplastic syndrome 
MPFC 
Multiparametric flow cytometry 
MLFS 
Morphologic leukemia-free state 
MRD 
Minimal residual disease 
MTD 
Maximum tolerated dose 
MUGA 
Multigated acquisition (scan) 
NCCN 
National Comprehensive Cancer Network 
NCI 
National Cancer Institute 
NDNFR 
Newly diagnosed Nonfavorable Risk (AML) 
NGS 
Next generation sequencing 
OS 
Overall survival 
PR 
Partial remission/response 
PS 
Performance status 
RBC 
Red blood cell 
RFS 
Relapse-free survival 
RNA 
Ribonucleic acid 
RT-PCR 
Reverse transcription-polymerase chain reaction 
SAE 
Serious adverse event 
SAS 
Statistical Analysis System (software) 
SGOT (AST) 
Serum glutamic-oxaloacetic transaminase 
SGPT (ALT) 
Serum glutamic-pyruvic transaminase 
SIV 
Study initiation visit 
SOP 
Standard operating procedure(s) 
T1/2 
Half-life 
Tmax 
Time to maximum concentration 
TRM 
Treatment-related mortality 
TST 
Timed sequential therapy 
ULN 
Upper limit of normal 
Vd 
Volume of distribution 
Vss 
Volume at steady state 
WBC 
White blood cell 
WHO 
World Health Organization 
 


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STUDY SUMMARY 
Title of Study: A Phase 1, Open-label, Dose-escalation, Safety and Biomarker 
Prediction Study of Alvocidib and Cytarabine/Daunorubicin (7+3) in 
Patients with Newly Diagnosed Acute Myeloid Leukemia (AML) 
Study 
Indication: 
Adults with newly diagnosed AML 
Clinical 
Phase: 
1 
Objectives: 
Primary Objective: 
x 
To determine the safety and tolerability including the maximum 
tolerated dose (MTD) and dose-limiting toxicities (DLTs) of 
alvocidib when administered over a range of doses on Days 1-3 
followed by cytarabine/daunorubicin (7+3) on Days 5-11 in adults 
with newly diagnosed and previously untreated AML. 
Secondary Objectives: 
x 
To observe patients for any evidence of antileukemic activity of 
alvocidib plus 7+3 using the 2017 ELN response criteria  
x 
To establish the Recommended Phase 2 Dose (RP2D) for future 
studies with alvocidib in combination with 7+3 
Exploratory Objectives: 
x 
To assess levels of minimal residual disease (MRD) using 
standardized techniques (ie, multiparametric flow cytometry 
[MPFC] and next generation sequencing [NGS]) and evaluate 
other potential biomarkers including, but not limited to, MCL-1 
dependency 
Study Design: This is an open-label, multicenter, dose-escalation, safety and biomarker 
prediction study of alvocidib followed by 7+3 therapy in adults with newly 
diagnosed and previously untreated AML.  
Induction 
The starting dose of alvocidib will be 20 mg/m2 as a 30-minute 
intravenous (IV) bolus followed by 30 mg/m2 over 4 hours as an IV 
infusion administered daily on Days 1-3 of Induction. Patients will have a 
one day drug holiday (Day 4) before initiation of the 7+3 regimen. 
Beginning on Day 5, cytarabine will be administered as a 100 mg/m2/day 
continuous IV infusion for seven consecutive days (Days 5-11) plus 
daunorubicin administered at a dosage of 60 mg/m2 IV on Days 5-7.  
Escalation of the alvocidib dose will follow a 3+3 design with sequential 
cohorts of 3 patients treated with incrementally higher doses of alvocidib 
until a DLT is observed and the MTD is established. Three patients within 
a dose cohort may be enrolled without a waiting period between patients. 
Escalation to the next higher dose level will not occur until all patients 
within the current dose cohort have undergone full safety assessments 
(including count recovery or disease assessment).  
Dose-limiting toxicities (DLTs) for alvocidib and 7+3 will be determined 
during Induction and Reinduction therapy, determined to be at least 


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possibly related to study drug and defined as follows based on the NCI 
CTCAE version 4.03:  
x 
Any Grade 4 nonhematologic toxicity considered at least possibly 
drug related 
x 
Any Grade 3 nonhematologic toxicity considered at least possibly 
drug related and that does not resolve to Grade 2 within 
48 hours, with the following exceptions: 
o Grade 3 diarrhea, mucositis, nausea or vomiting will be 
considered dose-limiting only if resolution to Grade 2 
(including use of supportive care) requires more than 
7 days 
x 
*UDGHF\WRSHQLDVODVWLQJ50 days from the start of the cycle in 
the absence of residual leukemia if subject received one cycle of 
induction 
x 
*UDGHF\WRSHQLDVODVWLQJGD\VLQthe absence of residual 
leukemia if subject received 2 cycles of induction 
x 
Grade 3 or 4 tumor lysis syndrome or related electrolyte 
disturbances 
(eg, 
hyperkalemia, 
hypophosphatemia, 
K\SHUXULFHPLDWKDWGRQRWUHVROYHWR*UDGHZLWhin 14 days 
x 
*UDGHHOHYDWLRQVLQFUHDWLQLQHWKDWGRQRWUHVROYHWR*UDGH
within 7 days 
x 
$Q\ $67 DQG $/7 HOHYDWLRQ5 ×ULN accompanied by serum 
bilirubin levels >2 ×ULN, regardless of duration 
x 
Any Grade 5 toxicity that is not clearly and incontrovertibly related 
to the underlying disease or extraneous causes 
x 
Anorexia, alopecia, fever, neutropenic fever, and infections of any 
grade should not be designated as DLTs since they are known 
and expected toxicities associated with the study drugs. 
If 1 of 3 patients in a cohort experiences a DLT, up to 3 additional patients 
will be treated at that dose level. If all patients in the expanded cohort 
have undergone full safety assessments (including count recovery or 
disease assessment) with no additional DLTs observed, the alvocidib 
dose will be escalated in a new cohort of 3 patients. If 2 or more of 3-6 
patients at a given dose level experience a DLT during the first cycle, 
then the MTD will have been exceeded and up to a total of 6 patients will 
be treated at the previous lower dose level. If 0 or 1 of 6 patients 
experiences a DLT at this previous lower dose level, this dose will be 
declared the MTD. 
7KH07'LVGHILQHGDVWKHGRVHDWZKLFKRISDWLHQWVH[SHULHQFHD
DLT during Cycle 1 with the next higher dose having at least 2 of 
3 to 6 patients experiencing a DLT during Cycle 1. 
Any AEs that occur during Reinduction and meet DLT criteria will be 
taken into consideration when determining whether to escalate the dose 
of alvocidib and when defining the MTD.  
Once the MTD has been established, up to 20 additional patients will be 
enrolled at the MTD level for confirmation of safety as well as additional 


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safety analysis and feasibility for determining MRD by dual methods (ie, 
MPFC and NGS) at a central laboratory. 
Disease Assessment 
On Day 14 (±3 days), unless medically contraindicated, peripheral blood 
and bone marrow samples will be collected for disease assessment 
including MRD. 
Patients with no HYLGHQFHRIUHVLGXDOOHXNHPLDERQHPDUURZEODVWV
SOXV  FHOOXODULW\ ZLOO EH PRQLWRUHG ZHHNO\ DQG ZLOO XQGHUJR
response assessment at the time of hematologic recovery (ie, absolute 
neutrophil count [ANC] >1000/μL and platelet count >100,000/μL) or 
Day 50 (±3 days), counted from Day 1 of Induction therapy, whichever 
occurs first. At this time, the patient may continue to Consolidation 
therapy with HiDAC. 
Reinduction – Alvocidib and 5+2 
Patients with evidence of residual leukemia (>5% bone marrow blasts 
plus >10% cellularity) may be eligible for a second induction cycle (or 
‘Reinduction’) with alvocidib and 5+2 at the discretion of the Investigator. 
The dose of alvocidib will remain the same, but the 7+3 regimen will be 
changed to 5+2: cytarabine, 100 mg/m2/day, as a continuous IV infusion 
on Days 5-9 plus daunorubicin administered at a dosage of 45 mg/m2 IV 
on Days 5 and 6.  
Should a patient undergo Reinduction therapy, they will be monitored 
weekly and will undergo response assessment at the time of hematologic 
recovery (ie, ANC >1000/μL and platelet count >100,000/μL) or Day 60 
(±3 days), counted from Day 1 of Induction therapy, whichever occurs 
first. Upon documented hematologic recovery, the patient may continue 
to Consolidation therapy with HiDAC.  
Additional bone marrow assessments may be obtained per investigator 
discretion. Investigators are permitted to administer intrathecal (IT) 
chemotherapy per institutional protocols after Induction (preferably 
during marrow aplasia), but before starting Consolidation therapy. 
Additional doses of IT chemotherapy may be administered after 
discussion with the Medical Monitor. 
During both Induction and Reinduction, if necessary, care must be taken 
to ensure the patient’s lifetime daunorubicin equivalent does not exceed 
460 mg/m2 (see Appendix G for conversion table) or that their left 
ventricular ejection fraction (LVEF) does not drop below 45%. 
No intra-patient escalation of the alvocidib dose is permitted. 
 
Consolidation - HiDAC 
Consolidation therapy will consist of high-dose cytarabine (HiDAC) which 
may be initiated at the time of hematologic recovery or within 90 days of 
recovery. Consolidation therapy may start before complete hematologic 
recovery after discussion with the Medical Monitor. It is not anticipated 
that all patients will undergo Consolidation therapy. 
The HiDAC regimen will consist of 3 gm/m2 IV every 12 hours on Days 1, 
3, and 5 (a reduced dosage of 1.5 gm/m2 is permitted for patients aged 
60 to 65 years) (ie, a total of 6 doses over the 3-day regimen). The 


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starting dose of HiDAC may be decreased pending discussion between 
the investigator and Medical Monitor.  
Patients who plan to receive chemotherapy-based consolidation should 
get a minimum of two cycles of Consolidation up to a maximum of 
four cycles. Patients proceeding to stem cell transplant for Consolidation 
should get one cycle of Consolidation, if possible, to ensure disease 
stability while transplant plans are being made.  
Patient 
Population: 
Patients enrolled in this study will be newly diagnosed with previously 
untreated AML excluding those patients with acute promyelocytic 
leukemia (APL-M3) or core-binding factor AML (CBF-AML) who meet all 
of the inclusion criteria and none of the exclusion criteria. 
Inclusion 
Criteria: 
To be eligible for participation in the study, patients must meet all of the 
following inclusion criteria: 
1. %HEHWZHHQWKHDJHVRIDQG\HDUV  
2. Have an established, pathologically confirmed diagnoses of AML by 
World Health Organization (WHO) criteria with 20% bone marrow 
blasts based on histology or flow cytometry  
3. Be newly diagnosed and previously untreated 
4. Have an Eastern Cooperative Oncology Group (ECOG) performance 
status (PS)  
5. Have a serum creatinine level 1.8 mg/dL 
6. Have 
an 
alanine 
aminotransferase 
(ALT) 
and 
aspartate 
aminotransferase (AST) level 5 times upper limit of normal (ULN) 
7. Have a total bilirubin level PJG/XQOHVVVHFRQGDU\WRGilbert 
syndrome, hemolysis, or leukemia) 
8. Have a left ventricular ejection fraction (LVEF) >45% by 
echocardiogram (ECHO) or multigated acquisition (MUGA) scan 
9. Be nonfertile or agree to use an adequate method of contraception. 
Sexually active patients and their partners must use an effective 
method of contraception associated with a low failure rate prior to 
study entry, for the duration of study participation, and for at least 
6 months after the last dose of study drug (see Section 4.5.3).  
10. Be able to comply with the requirements of the entire study. 
11. Provide written informed consent prior to any study related 
procedure. (In the event that the patient is re-screened for study 
participation or a protocol amendment alters the care of an ongoing 
patient, a new informed consent form must be signed.) 
Exclusion 
Criteria: 
Patients meeting any one of these exclusion criteria will be prohibited 
from participating in this study. 
1. Received any previous treatment for AML  
2. Diagnosed with APL-M3 or CBF-AML 
3. Require 
concomitant 
chemotherapy, 
radiation 
therapy, 
or 
immunotherapy. Hydroxyurea is allowed up to the evening before 
starting (but not within 12 hours) of starting Induction therapy. 
4. Received >200 mg/m2 equivalents of daunorubicin (see Appendix G 
for conversion table) 


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5. Have a peripheral blast count of >30,000/μL (may use hydroxyurea 
as in #3 above) 
6. Have active central nervous system (CNS) leukemia 
7. Have 
evidence 
of 
uncontrolled 
disseminated 
intravascular 
coagulation 
8. Have an active, uncontrolled infection 
9. Have other life-threatening illness 
10. Have other active malignancies or diagnosed with other 
malignancies within the last 6 months, except nonmelanoma skin 
cancer or cervical intraepithelial neoplasia 
11. Have mental deficits and/or psychiatric history that may compromise 
the ability to give written informed consent or to comply with the study 
protocol. 
12. Are pregnant and/or nursing 
Study 
Treatment: 
Study Drug Administration 
Induction – Alvocidib and 7+3 
x 
Days 1, 2, 3:  Alvocidib at a starting dose of 20 mg/m2 as a 
30-minute (±10 minutes) IV bolus followed by 30 mg/m2 
administered as a 4-hour (±15 minutes) IV infusion (this is the 
starting dose for Cohort 1; see table in this section for assigned 
alvocidib doses per treatment cohort) 
x 
Day 4:  Drug-free day 
x 
Days 5, 6, 7: (7+3) Daunorubicin 60 mg/m2 via IV bolus of up to 
15 minutes’ (±5 minutes) duration each day followed immediately 
by;   
x 
Days 5, 6, 7, 8, 9, 10, 11: Cytarabine 100 mg/m2/day via 
continuous 24-hour IV infusion (±2 hours for infusion duration 
each day) 
Reinduction – Alvocidib and 5+2 
Patients with evidence of residual leukemia defined as >5% bone 
marrow blasts plus >10% cellularity, based on the Day 14 (±3 days) bone 
marrow may be eligible to start a second induction therapy with alvocidib 
plus 5+2 (Reinduction) at the discretion of the Investigator. 
x 
Days 1, 2, 3:  Alvocidib at same dosage during Induction 
x 
Day 4:  Drug-free day 
x 
Days 5, 6:  (5+2) Daunorubicin 45 mg/m2/day via IV bolus of up 
to 15 minutes’ (±5 minutes) duration each day followed 
immediately by: 
x 
Days 5, 6, 7, 8, 9: Cytarabine 100 mg/m2/day via continuous IV 
infusion (±2 hours for infusion duration each day) 
Consolidation –HiDAC  
Consolidation therapy will consist of high-dose cytarabine (HiDAC) which 
may be initiated at the time of hematologic recovery or within 90 days of 
recovery. Consolidation therapy may start before complete hematologic 


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recovery after discussion with the Medical Monitor. It is not anticipated 
that all patients will undergo Consolidation therapy. 
x 
Days 1, 3, 5:  HiDAC 3 gm/m2 IV every 12 hours (1.5 gm/m2 in 
patients aged 60 to 65 years) (ie, a total of 6 doses over the 3-day 
regimen); a lower starting dose may be permitted at discretion of 
Investigator and after discussion with the Medical Monitor. 
Patients who plan to receive chemotherapy-based consolidation should 
get a minimum of two cycles of Consolidation up to a maximum of four 
cycles. Patients proceeding to stem cell transplant for Consolidation 
should get one cycle of Consolidation, if possible, to ensure disease 
stability while transplant plans are being made. 
Dose Escalation of Alvocidib 
Dose Levelsa 
Alvocidib Dosing 
Number of  
Patients 
IV Bolus 
Continuous IV × 4 hrs 
Cohort –1b 
10 mg/m2 
15 mg/m2 
3-6 
Cohort 1c 
20 mg/m2 
30 mg/m2 
3-6 
Cohort 2 
30 mg/m2 
40 mg/m2 
3-6 
Cohort 3 
30 mg/m2 
50 mg/m2 
3-6 
Cohort 4 
30 mg/m2 
60 mg/m2 
3-6 
a It is possible for additional and/or intermediate dose levels to be added during the 
cycle of the study. 
b Dose level -1 represents treatment doses for patients requiring a dose reduction from 
the starting dose level. It will also serve as a lower dose level if SDWLHQWVDWthe 
Starting Dose level experience a DLT. 
c 
Starting Dose Level for first cohort of patients. 
 
Once the MTD has been established, up to 20 additional patients will be 
enrolled at the MTD level for confirmation of safety as well as additional 
safety analysis and feasibility for determining MRD by dual methods (ie, 
MPFC and NGS) at a central laboratory. 
Supportive Care 
x 
Tumor Lysis Prevention and Treatment 
o Mandatory IV hydration with 0.45% NaCl (or similar 
hydration fluid per institutional standard) sterile solution at 
100 cc/hour for at least 10 hours prior to initiation of first 
dose of chemotherapy during Induction (optional for 
subsequent cycles). If, by Day 4, there is no evidence of 
tumor lysis syndrome, the hydration rate can be reduced 
to a maintenance level. 
x 
Diligent monitoring of urine output frequently to ensure that it 
equals fluid input. If input is greater than output by 10%, 
administration of diuretics is encouraged. Replacement of 
excessive fluid losses, including from diarrhea, should be done 
unless otherwise clinically indicated. 
x 
Mandatory allopurinol orally each day of dosing during Induction 
(optional in subsequent cycles) to be started at same time as 
initiation of IV hydration. 
x 
Mandatory oral phosphate binder to be started at the same time 
as initiation of IV hydration during Induction (optional in 
subsequent cycles) unless contraindicated. 


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x 
Evaluation of laboratory indicators of tumor lysis syndrome (TLS) 
during Induction: 
o Tumor lysis laboratory evaluations (tumor lysis labs) 
include electrolytes (sodium, potassium, chloride, and 
carbon dioxide) as well as creatinine, calcium, lactate 
dehydrogenase (LDH), uric acid, and phosphorus levels  
o Monitor tumor lysis labs at the start of treatment and 
throughout the treatment cycle according to the schedule 
outlined in Section 4.4.1.1. [Note: there are different blood 
collection schedules for monitoring of TLS labs for 
patients at high risk of TLS and for those NOT at high risk 
for TLS.]  
o Monitor fibrinogen levels at baseline and then as clinically 
indicated 
o Patients who are determined to be at intermediate- or 
high-risk for TLS should be considered for rasburicase 
prophylaxis according to institutional standards 
x 
Infection Prevention 
O Prophylactic 
antibiotics 
including 
levofloxacin 
(or 
equivalent) 500 mg orally once daily and valacyclovir (or 
equivalent) 500 mg orally BID each day should be 
administered to patients at the start of chemotherapy. 
Alternative prophylactic antibiotic and antiviral therapy is 
left to the discretion of the treating physician and 
institutional standards. 
O Antifungal prophylaxis to be administered according to 
each institution’s standard of care  
O 5RXWLQH JURZWK IDFWRU VXSSRUW LV QRW DOORZHG 'D\ 
unless otherwise discussed with the Medical Monitor. 
Growth factor support can be given at the discretion of the 
Investigator >Day 35 of Induction/Reinduction therapy in 
the presence of life threatening infection with ongoing 
neutropenia. Growth factor support during Consolidation 
therapy may be administered according to each 
institution’s standard of care.  
Suggested doses of these supportive care therapies are provided in the 
protocol; however, adjustment of the dosages based on the patient’s 
clinical condition or each institution’s standard of care is permitted. 
Safety 
Evaluations: 
Through escalation of the dosage of alvocidib, the MTD and any DLTs 
will be defined. Safety and tolerability will also be assessed by analyzing 
the incidence rates of treatment-emergent adverse events summarized 
within treatment groups at the MedDRA preferred term and primary 
system organ class levels. Similar summaries will be made for subsets 
of AEs such as (1) those judged by the Investigator to be related to study 
treatment, and (2) serious adverse events (SAEs).  
The multivariate analysis and risk score prediction model by Montesinos 
and colleagues [38] will be used to assess the potential for development 
of TLS (Appendix F). 


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Other routine safety assessments (eg, clinical laboratory parameters and 
vital signs) will be summarized by shift tables and treatment group using 
mean, standard deviation, median, minimum and maximum observed 
values and changes from baseline values. 
Efficacy 
Evaluations: 
Objective response to treatment will be determined using the remission 
definitions 
detailed 
in 
the 
2017 
European 
LeukemiaNet 
Recommendations in AML (see Appendix E) at hematologic recovery (ie, 
ANC >1000/μL and platelet count >100,000/μL) or Day 50 (±3 days), 
counted from Day 1 of Induction therapy, whichever occurs first. If a 
patient receives a second induction cycle (or ‘Reinduction’) of alvocidib 
and 5+2, then the patient will undergo response assessment at the time 
of hematologic recovery (ie, ANC >1000/μL and platelet count 
>100,000/μL) or Day 60 (±3 days), counted from Day 1 of Induction 
therapy, whichever occurs first.  
x 
CRMRD- = CR without MRD 
x 
CR = Complete Remission (including patients with morphologic 
CR who are MRD+ and cytogenetic and/or molecular marker 
positive) 
x 
CRi = CR with incomplete hematologic recovery 
x 
MLFS = Morphologic leukemia-free state 
x 
PR = Partial Remission 
x 
SD = Stable Disease 
x 
PD = Progressive Disease  
x 
Overall Complete Remission Rate (patients with a best objective 
response of CRMRD, CR, CRi or MLFS) 
x 
Overall Remission Rate (patients with a best objective response 
of CRMRD, CR, CRi, MLFS or PR) 
x 
Overall Survival  
x 
Relapse-free Survival  
x 
Duration of Remission 
Additional bone marrow assessments may be obtained per Investigator 
discretion.  
Pharmaco-
dynamic 
Evaluations: 
Any evidence of MRD will be determined using standardized techniques 
(ie, MPFC and NGS) and potential biomarkers including, but not limited 
to, MCL-1 dependency will also be assessed using bone marrow 
aspirates and peripheral blood samples. 
Study 
Duration: 
The study is expected to take 12-18 months to enroll up to 40 patients. 


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1. INTRODUCTION 
1.1 Acute Myeloid Leukemia (AML) 
The clinical objective of induction chemotherapy is to obtain ‘first CR’ (complete 
remission with recovery of blood counts) in as many newly diagnosed AML 
patients as possible. Attaining initial CR enables application of further therapies 
of curative intent (consolidation and transplant). Once CR is obtained, survival 
also varies as a function of age, cytogenetic risk status, and possibly, by minimal 
residual disease (MRD). In patients with unfavorable-risk AML, <60% achieve 
CR, many patients relapse quickly, and survival among responders is woefully 
low with 5% to 10% experiencing chemotherapy-related deaths due to severe 
toxicity. These data amplify the decades’ long tragedy and debilitating nature of 
available treatments for newly diagnosed AML patients, particularly for older 
patients >60 years, those with adverse and complex cytogenetics, and patients 
with secondary AML. 
1.1.1 
Role of MCL-1 in AML 
The ability to resist cell death is an important hallmark of all cancer cells, 
allowing them to divide uncontrollably [1, 2]. The BCL-2 family of polypeptides 
has been widely studied as regulators of cell death [3]. Because members of 
this protein family can exhibit pro- or anti-apoptotic functions, they are highly 
involved in the development of cancer and in mechanisms of resistance to many 
therapeutic agents. The myeloid leukemia cell-1 (MCL-1) gene is the 
predominant BCL2 family member expressed in primary AML samples. Tumor 
resistance to targeted therapies limits effectiveness of current clinical regimens. 
Overexpression of MCL-1 has been shown to convey resistance to apoptosis 
induced by a number of different treatments, including etoposide, in vitro [4, 5]. 
Other studies have indicated that MCL-1 expression can be induced rapidly in 
response to a number of DNA-damaging agents [6, 7]. 
Alvocidib (flavopiridol), a potent cyclin-dependent kinase (CDK) inhibitor, 
downregulates the expression of MCL-1 through inhibition of CDK 9, which, in 
turn, inhibits tumor growth. Studies have shown that alvocidib suppresses 
MCL-1 expression [8, 9] and acts synergistically with other chemotherapeutic 
agents like daunorubicin. Through use of mitochondrial (BH3) profiling, the 
mechanism by which apoptosis is suppressed in a population of cells can be 
determined. Mitochondrial sensitivity to NOXA BH3 peptides suggests 
dependence on MCL-1 to mediate resistance to apoptosis. Early studies have 
shown that NOXA priming can predict the clinical activity of alvocidib in AML 
patient samples and suggests an important role for MCL-1 activity in predicting 
alvocidib activity. MS1 and TMS1 are alternatives to NOXA that also measure 
MCL-1 dependency in addition to other potential molecular (genetic) targets. 


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1.1.2 
Newly Diagnosed and Previously Untreated AML 
Genetic abnormalities are the prevailing prognostic factors in determining 
response to treatment [10]. A number of studies have investigated the relative 
contribution of genetic and clinical variables to prediction of event-free survival 
(EFS) and overall survival (OS). Results from conventional cytogenetics and 
from certain mutational screenings are now routinely employed in clinical 
practice following recommendations by the European LeukemiaNet group in 
2017.  
The presence of specific genomic aberrations accounts for about two thirds of 
variability in predicting disease response in patients with AML; the remaining 
third is a combination of demographic, clinical, and treatment variables [10]. 
Advances have been made in incorporating these key data into models to aid 
physicians in predicting whether a given set of covariates conveys a longer 
remission or life expectancy compared to another patient with a different set of 
covariates. However, the accuracy of these models in correctly pinpointing the 
likelihood of response hovers around 75%. Along with the need to identify 
additional pretreatment prognostic factors that can address the remaining 
quarter of patients in whom response is likely, there is hope that evaluation of 
post-treatment events such as the presence of minimal residual disease (MRD) 
will further boost the percentage of likely responders.  
There are different methods one can use to assess the presence of MRD, with 
each methodology varying in the proportion of patients to whom it can be applied 
and in its sensitivity to detect MRD. By integrating the evaluation of baseline 
factors together with the assessment of MRD, risk assessment should improve 
to better direct post-remission therapy.  
1.2 Rationale 
Acute myeloid leukemia continues to be one of the highest unmet medical 
needs, due to very short survival from time of diagnosis (median <1 to 2 years). 
Short survival in AML patients is directly correlated with the presence of 
unfavorable cytogenetics and multiple adverse clinical features (age >60, prior 
MDS, treatment-related or secondary AML, FLT3-ITD positivity, and monocytic 
phenotype). Attainment of initial complete remission still remains unachievable 
in approximately 40-60% of AML patients, and progression, rapid relapse and 
short survival are too frequent consequences from currently available, but 
inadequate, antileukemic therapy. 
Tolero has investigated the preclinical combination of alvocidib with agents used 
in the 7+3 regimen. In AML cell lines, single-agent IC50 values of alvocidib, 
cytarabine, and daunorubicin ranged from 2.2 nM to as high as 567 nM in 
viability assays. Apoptosis assays (Caspase-Glo) revealed modest induction 
with single agent cytarabine, and good induction with single agent daunorubicin 
or alvocidib. In combination therapy, however, very strong synergy (ie, a more 
than two-fold enhanced induction of apoptosis) has been observed (or 


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achieved) in some treatment groups. Alvocidib treatment reduced the 
expression of MCL-1 protein and mRNA in a time- and concentration-dependent 
fashion in AML cells. This has also been observed in the 7+3 treatment context. 
In an MV4-11 xenograft model, single-agent treatment with daunorubicin or 
cytarabine resulted in 21.1% and 48.5% tumor growth inhibition (%TGI), 
respectively; whereas treatment with 1.25 mg/kg of alvocidib yielded 60.0% TGI. 
The combination of all three agents—alvocidib, cytarabine and daunorubicin—
resulted in even greater tumor regression with a TGI of 116.2%.  
Tolero’s position remains that the existing AML therapies developed decades 
ago, which remain the standard of care, do not adequately attain sufficiently 
high rates of first CR, long-term remission nor satisfactory survival rates for the 
majority of AML patients.  
 




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2.4 Mechanism of Action 
Alvocidib is a potent cyclin-dependent kinase (CDK) inhibitor with selectivity for 
CDKs 9, 1, 2, 4 and 7 [11, 12, 13]. The greatest inhibition (Ki of 3 nM) was 
observed with CDK 9 [14]. Alvocidib-induced apoptosis results at least in part 
from inhibition of multiple serine-threonine CDKs leading to changes in gene 
expression of critical survival and proliferative genes including BCL-2, myeloid 
cell leukemia-1 (MCL-1) and c-myc [15, 16, 17]. Whereas inhibition of CDK 2 
and CDK 4 contributes to cell cycle arrest in G1 and G2, alvocidib-triggered 
inactivation of the CDK 9/cyclin T complex (also known as PTEF-b) inhibits the 
activating phosphorylation of RNA polymerase 2 and diminishes mRNA 
synthesis [18, 19]. Consequently, alvocidib-treated cells are unable to 
synthesize transcripts encoding polypeptides, such as cyclin D1 and c-myc, 
which are expressed in a cell cycle-dependent manner [20]. 
Inhibition of CDK 9, which is involved in the regulation of transcription by RNA 
polymerase 2, is postulated to be a key event in the inhibition of transcription 
observed following alvocidib treatment. Effects on CDK 9 may be particularly 
relevant to inducing apoptosis in malignant hematopoietic cells [21]. 
These observations, coupled with the ability of alvocidib to kill non-cycling cells, 
suggested that alvocidib might be particularly effective when administered first 
and then followed several days later by cytarabine. Therapeutically achievable 
alvocidib concentrations induced apoptotic cell death in bone marrow leukemic 
blasts in vitro and that alvocidib-treated blast cultures exhibited increased 
sensitivity to the subsequent pro-apoptotic effects of cytarabine relative to either 
agent alone [22]. 
2.5 Preclinical Studies 
2.5.1 
In Vitro/In Vivo Studies 
Alvocidib (2 to 430 nM) demonstrated cyclin-dependent kinase (CDK) selective 
inhibition when tested on a panel of recombinant kinases [11, 12, 13]. In 
particular, CDK 9 is involved in the regulation of transcription by phosphorylating 
ribonucleic acid polymerase II (RNA pol II) and is inhibited to the greatest extent 
(3 nM) [14].  Consistent with the CDK 9 inhibition, alvocidib (50 to 200 nM) 
significantly inhibited the uptake (up to 80%) of [3H]-uridine incorporation into 
total ribonucleic acid (RNA) compatible with inhibition of RNA transcription as a 
primary mechanism of action [23]. 
Alvocidib inhibited the proliferation of cell lines from a large panel of 
histologically distinct hematological and solid tumors at submicromolar 
concentrations ranging from 7 nM (PC3 human prostate) to 182 nM 
(K562 human chronic myelogenous leukemia). Alvocidib also induced dose 
dependent apoptosis in B-cell chronic lymphocytic leukemia (B-CLL) cells at 
drug concentrations ranging from 10 to 100 nM [24, 25]. The induction of 
apoptosis correlated best with depletion of the antiapoptotic proteins myeloid 
cell leukemia-1 (MCL-1) and X-linked inhibitor of apoptosis (XIAP) [15, 17]. 


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Chronic lymphocytic leukemia cells are nonproliferating and dependent on the 
continuous expression of antiapoptotic proteins. As a result, reduction of 
antiapoptotic proteins by alvocidib may in part account for the drug-induced 
apoptotic response. 
Significant antitumor activity was observed in 6 human leukemia xenograft 
models in mice (EOL-1 and ML-2 acute myeloid leukemia [AML], Ramos 
nonHodgkin’s lymphoma, SUDHL-4 follicular lymphoma, HL-60 promyelocytic 
leukemia, and L363 multiple myeloma). In the SUDHL-4 and HL-60 studies, 
optimal activity was observed with daily × 5 bolus intravenous (IV) or 
intraperitoneal administration of 7.5 mg/kg alvocidib that gave peak plasma 
OHYHOVRIȝ0IROORZHGE\DSURJUHVVLYHGHFOLQHWRDSSUR[LPDWHO\Q0LQ
8 hours [26]. In contrast, continuous infusion of alvocidib for 3 days 
demonstrated only modest activity. This infusion resulted in plasma levels of 
approximately 420 nM; these levels exceeded the in vitro 50% inhibitory 
concentration (IC50), 20 to 200 nM, for most cell lines. This observation is 
consistent with the finding that alvocidib binds strongly to plasma proteins. 
These data also indicate that protein binding can be overcome with higher doses 
of alvocidib that achieve micromolar concentrations for short duration. 
Alvocidib has enhanced antitumor activity when combined with standard of care 
agents in nonclinical models of AML. Due to its MCL-1-targeting activity, cells 
treated with alvocidib are in a primed state to undergo apoptosis which can be 
further exploited when followed by an agent known to induce apoptosis. Indeed, 
nonclinical data in AML strongly suggest that cytarabine and mitoxantrone are 
highly synergistic when preceded by alvocidib treatment. These data support 
the clinical regimen combining alvocidib, cytarabine, and mitoxantrone (ACM) 
[27]. 
Another study was designed to model the ‘7+3’ clinical regimen in an animal 
model to determine if alvocidib could enhance the efficacy of cytarabine and 
daunorubicin in the MV-4-11 model for AML. Mice were given two ‘cycles’ of 
alvocidib, cytarabine, and daunorubicin (ACD), in which they were dosed for two 
days with alvocidib, one day with cytarabine and daunorubicin, followed by two 
additional days with cytarabine alone. Following these two treatment cycles, 
tumor volumes and body weights were observed until volumes neared 
1500 mm3. The ACD regimen modeled in this xenograft study demonstrated 
superior efficacy when compared to either cytarabine, daunorubicin, or the 
combination of the two drugs. The full drug combination (ACD) was tolerated 
well at the lower alvocidib dose level (1.25 mg/kg) and tolerated moderately at 
the higher dose level (2.5 mg/kg) with minor body weight loss observed. In the 
ACD regimen, alvocidib significantly enhanced tumor growth inhibition [28]. 
Alvocidib demonstrated only minor activity when evaluated in vivo in various 
solid tumor models. 








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Table 1: Overview of Alvocidib Phase 1 & 2 Clinical Studies in AML  
(In Chronologic Order) 
Study (Reference) 
N 
Treatment Regimen 
Patient Population 
Study 1:  
JHOC J0254/ 
NCI-3170  
Phase 1 FLAM [30] 
Total: 
34 
 
AML: 
26 
 
Alvocidib Bolus 1 hr IV: 
40, 50, 60 mg/m2/d on Days 1-3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on day 9 
Adults median age 54, 
primary refractory, multi-
refractory or relapsed AML 
(26) ALL (7) CML (1)  
Study 2: 
JHOC J0254/ 
NCI-3170  
Phase 2 FLAM [31] 
62 
AML 
Alvocidib Bolus 1 hr IV:  
50 mg/m2/d on Days 1-3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
Adults median age 58, 
primary refractory (13), 
multirefractory (10), relapsed 
(24), newly diagnosed 
secondary AML 
(15) 
Study 3: 
OSU-0479/ 
NCI-6947  
Phase 1 Alvocidib  
Monotherapy [32] 
Total: 
24 
 
AML: 
19 
Alvocidib monotherapy  
dose-escalation, Hybrid regimen: 
20 mg/m2 & 30 mg/m2  
30 mg/m2 & 35 mg/m2 
30 mg/m2 & 50 mg/m2 
40 mg/m2 & 60 mg/m2 
50 mg/m2 & 75 mg/m2 
30 min bolus followed by 4-hr infusion/day 
on Days 1,2,3 
Adults median age 62, 
relapsed or refractory  
non-M3 AML (19), ALL (5) 
Study 4: 
JHOC J0669/ 
NCI-7845  
Phase 2 FLAM [33] 
45 
AML 
Alvocidib Bolus 1hr IV: 50 mg/m2/d Days 1-3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
Adults median age 61, newly 
diagnosed, pathologically 
confirmed, previously 
untreated intermediate/poor 
risk AML 
Study 5: 
JHOC J06133/ 
NCI-7889  
Phase 1 FLAM [34] 
Total: 
55 
 
AML: 
49 
Alvocidib dose-escalation in Hybrid 
regimen 
20 mg/m2 & 30 mg/m2  
25 mg/m2 & 35 mg/m2 
30 mg/m2 & 40 mg/m2 
30 mg/m2 & 50 mg/m2 
30 mg/m2 & 60 mg/m2 
30 mg/m2 & 70 mg/m2 
given as:  
30-min bolus followed by 4-hr infusion/d on 
Days 1,2,3  
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
Adults median age 54, 
pathologically confirmed 
relapsed and refractory AML 
(49), ALL (3), ABL (3) 
 
 
 


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Table 1: 
Overview of Alvocidib Phase 1 & 2 Clinical Studies in AML  
(In Chronologic Order) (cont) 
Study (Reference) 
N 
Treatment Regimen 
Patient Population 
Study 6: 
ECOG 1906  
Phase 2 Randomized 
Trial  
of Carboplatin and 
Topotecan; Alvocidib, 
Mitoxantrone and 
Cytosine Arabinoside; 
and Sirolimus, 
Mitoxantrone, 
Etoposide and 
Cytosine Arabinoside 
for the Treatment of 
Adults With Primary 
Refractory or Initial 
Relapse of AML [35] 
Ongoing follow-up 
AML 
 
Total: 
111  
 
Arm B 
FLAM:
36 
Arm A:  CT 
carboplatin and topotecan IV continuously 
over 24 hours on days  
1-5 
Arm B:  Hybrid FLAM 
Alvocidib: 30 mg/m2 by 30-min bolus 
followed by & 60 mg/m2  
by 4-hr CIV/day on Days 1,2,3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
Arm C:  Sirolimus-MEC 
sirolimus PO QD on days 2-9, mitoxantrone 
hydrochloride IV over 15 minutes QD, 
etoposide IV over 1 hour QD, and Ara-c IV 
over 3 hours QD on Days 4-8 or 5-9 
Adults 18-70 years,  
relapsed or refractory AML 
(36 on FLAM arm);  
median age 58 
Study 7: 
JHOC J0856/ 
NCI-8237 
Phase 2 FLAM [36] 
AML 
78 
Arm A:  Bolus FLAM 
Alvocidib Bolus 1 hr IV:  
50 mg/m2/d on Days 1-3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
Arm B: Hybrid FLAM 
Alvocidib: 30 mg/m2 by 30-min bolus 
followed by 40 mg/m2  
by 4-hr CIV/day on Days 1,2,3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
Adults median age 61, newly 
diagnosed, 
pathophysiologically 
confirmed, previously 
untreated intermediate/poor 
risk AML 
Study 8: 
JHOC J1101/  
NCI-8972  
Randomized  
Phase 2  
FLAM vs 7+3 [37] 
 
AML 
Total: 
165 
 
FLAM: 
109 
 
 
7+3: 
56 
Arm A: Bolus FLAM 
Alvocidib Bolus 1-hr IV:  
50 mg/m2/d on Days 1-3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 given by  
60-120 min IV on Day 9 
 
Arm B:  7+3 
Ara-c: 100 mg/m2/day IV infusion Days 1-7 
Daunorubicin 90 mg/m2 /day IV over 30-60 
minutes Days 1, 2, 3 
Adults median age 60 
(FLAM), newly diagnosed, 
pathologically confirmed, 
previously untreated 
intermediate/poor risk AML 
(including Secondary AML) 
 
 
 


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2.6.2 
Phase 2 Studies in Patients with Newly Diagnosed and Previously 
Untreated AML 
Multiple Phase 2 studies have been conducted using ACM (FLAM) in patients 
with newly diagnosed nonfavorable (ie, high)-risk AML. In most studies, 
nonfavorable-/high-risk AML was defined as disease that was treatment related, 
had secondary AML, or had adverse-risk cytogenetics. A key study was 
NCI-8972 (Table 1) where 165 newly diagnosed poor-risk patients were 
randomized to ACM versus 7+3. The primary endpoint of CR following one 
induction cycle was found to be statistically significant (P=0.08) and in favor of 
ACM-treated patients (70% CR) versus 7+3-treated patients (46% CR).   
Key study parameters are provided in Table 2 followed by summaries of safety 
for each study. 
Table 2: 
Alvocidib/FLAM in Newly Diagnosed Poor-risk AML 
Indication 
(Study) [Ref] 
Phase 
Number of 
Patients 
Total/Evaluable 
Alvocidib Administration 
(other agents) 
Number 
of CRs 
Newly diagnosed poor risk 
acute myelogenous 
leukemia 
(NCI-7845, J0669)  
[33]  
Completed 
 
2 
60/57 
Alvocidib: 50 mg/m2/d by 1hr IV on Days 1-3 
Ara-c: 2 gm/m2/72h by CIV given Days 6-8 
Mitoxantrone: 40 mg/m2 by IV over 60-120 
min on Day 9 
30 CR 
Newly diagnosed poor risk 
acute myelogenous 
leukemia 
(NCI-8237J0856)  
[36]  
Completed 
 
2 
39/39 
 
 
39/39 
Arm A:  Alvocidib 50 mg/m2/d by 1hr IV on 
Days 1-3 
Ara-C:  2 gm/m2/72h by CIV on Days 6-8; 
Mitoxantrone:  40 mg/m2 by IV over 60-120 
min on Day 9 
 
Arm B:  Alvocidib 30 mg/m2 by 30-min 
infusion followed by 40 mg/m2 by 4h infusion 
on Days 1-3;  
Ara-C and mitoxantrone as in Arm A 
 
24 CR 
 
 
29 CR 
Newly diagnosed poor risk 
acute myelogenous 
leukemia 
(NCI-8972, J1101)  
[37]  
Completed 
 
2 
 
109/109 
 
 
56/56 
Randomized study of: 
Arm A:  Alvocidib 50 mg/m2/d by 1hr IV on 
Days 1-3; 
Ara-C: 2 gm/m2/72h by CIV on Days 6-8 
Mitoxantrone: 40 mg/m2 by IV over 60-120 
min on Day 9  
 
Arm B:  7+3 
Ara-c: 100 mg/m2/day by IV infusion on Days 
1-7 
Daunorubicin 90 mg/m2/d by IV over 30-60 
minutes on Days 1-3 
 
76 CR 
 
 
26 CR 
 


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2.6.2.1 Summary of Safety in NCI-7845 (J-0669) FLAM in Newly-diagnosed Poor-
risk AML 
All-grade Tumor Lysis Syndrome was observed in 19/45 (42%), with one patient 
expiring due to disseminated intravascular coagulation (DIC) and multiorgan 
failure. Treatment-related mortality (TRM) at 30 days was observed in 2 patients 
(4%), with one patient each with TLS/DIC/multiorgan failure and fungal infection.  
TRM at 60 days was observed in 2 additional patients (4%), both died from 
sepsis. Adverse events Grade 3 included: 11% GI mucositis, 11% reversible 
SV arrhythmia with sepsis, 7% sepsis, 4% oral mucositis, and 4% diarrhea.  
2.6.2.2 Summary of Safety in NCI-8237 (J-0856) FLAM in Newly-diagnosed Poor-
risk AML 
The rate of all-grade Tumor Lysis Syndrome was equivalent on both arms (9%), 
as well as death from any cause at 60 days (8%, with 3 patients on each arm). 
Adverse events Grade 3 included: 50% febrile neutropenia, 35% infections, 
14% nausea, 6% cardiac-related events, and 6% oral/GI mucositis. 
The time from initiation of therapy to hematologic recovery was similar to 
previous FLAM studies, with median time to ANC over 0.5 × 109/L being 33 days 
(range 22-71 days) and platelets over 50 × 109/L being 30 days (range 
21-80 days) for both arms. 
2.6.2.3 Summary of Safety in NCI-8972 (J-1101) FLAM in Newly-diagnosed Poor-
risk AML 
In this comparison of FLAM vs. 7+3, adverse events were similar in both arms. 
Comparative adverse events Grade 3 included (FLAM, 7+3): febrile 
neutropenia (48%, 45%), infection (35%, 38%), hepatic dysfunction (21%, 
23%), and GI events (11%, 9%). 
Based on previous observations of Tumor Lysis Syndrome in prior AML studies 
of FLAM, preventive measures were included in this study including the use of 
allopurinol, phosphate binder, hydration, and rasburicase was allowed per 
institutional policy for hyperuricemia. The rates of TLS were similar between 
FLAM and 7+3 (FLAM: 8% versus 7+3: 7%). Treatment-related mortality was 
also similar between the arms at 30 days: FLAM: 5% versus 7+3: 2%, or at 
60 days FLAM: 10% versus 7+3: 4%. The majority of early deaths (8/11 
patients) on FLAM were >60 years. 
2.7 Justification for Study Treatment Plan 
Based on the initial data from single-arm Phase 1 and 2 studies as well as 
randomized Phase 2 studies, Tolero is pursuing the development of alvocidib in 
combination with cytarabine and daunorubicin regimen (7+3) in patients with 
newly diagnosed and previously untreated AML. As previously noted, these 
patients have a poor prognosis and new therapeutic options are needed. The 
combination of alvocidib plus cytarabine and daunorubicin is being explored as 
one of the regimens that can be considered for these patients.  


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NOXA binds and deactivates MCL-1. Early studies have suggested that NOXA 
priming can predict the clinical activity of alvocidib in AML patient samples and 
suggests an important role for MCL-1 activity in predicting alvocidib activity. As 
such, Tolero is conducting this Phase 1 study, in part, to explore the ability of 
MCL-1 activity to predict which patients will respond favorably to alvocidib 
treatment when administered along with cytarabine and daunorubicin. Any 
effects of alvocidib on MRD status will also be evaluated. 
While both the bolus as well as hybrid dosing regimens of alvocidib have shown 
substantial activity in patients with AML, the hybrid regimen will be used in this 
study. Clinical data from a randomized study that compared the two dosing 
regimens suggest that the hybrid schedule tends to produce a higher remission 
rate (62% versus 74%) in poor-risk, newly diagnosed AML patients [36].  
We have also observed a high CR rate (39%) with the hybrid regimen in 
relapsed and refractory AML patients (and 92% CR among relapsed-only 
patients) [34]. In addition, the safety profile of the two regimens appears similar, 
though there may be a trend to lower early mortality with the hybrid regimen. In 
these two studies, the incidence of Tumor Lysis Syndrome (TLS) was 9%, and 
treatment-related mortality was 8% and 9%, respectively. 
2.8 Summary of Risk and Benefits 
There have been no clinical studies conducted using alvocidib in combination 
with cytarabine and daunorubicin; however, the safety profile for alvocidib in 
combination with cytarabine and mitoxantrone has been well-described in eight 
clinical studies in patients with AML (see Table 1) and appears to be acceptable 
in patients with nonfavorable disease characteristics. The early observation of 
tumor lysis and the potential for renal failure has resulted in an aggressive 
prophylaxis approach to manage the dramatic lysis of leukemic blasts caused 
by alvocidib. Treatment-related mortality (TRM) for patients treated with 
alvocidib/FLAM is approximately 8-10%, with a range up to 28% in Study 6 in 
relapsed/refractory AML patients (particularly among patients over 60 years 
old). Overall, TRM of alvocidib/FLAM appears to be comparable to other 
therapeutic options including 7+3 and intermediate- and high-dose cytarabine.   
 
 
 


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3. STUDY OBJECTIVES 
Primary Objective: 
x To determine the safety and tolerability including the maximum tolerated 
dose (MTD) and dose-limiting toxicities (DLTs) of alvocidib when 
administered over a range of doses on Days 1-3 followed by 
cytarabine/daunorubicin (7+3) on Days 5-11 in adults with newly diagnosed 
and previously untreated AML 
Secondary Objectives: 
x To observe patients for any evidence of antileukemic activity of alvocidib 
plus 7+3 using the 2017 ELN response criteria  
x To establish the Recommended Phase 2 Dose (RP2D) for future studies 
with alvocidib in combination with 7+3 
Exploratory Objectives: 
x To assess levels of minimal residual disease (MRD) using standardized 
techniques (ie, multiparametric flow cytometry [MPFC] and next generation 
sequencing [NGS]) and evaluate other potential biomarkers including, but 
not limited to, MCL-1 dependency. 


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4. INVESTIGATIONAL PLAN 
4.1 Overall Study Design 
This is an open-label, multicenter, dose-escalation, safety and biomarker 
prediction study of alvocidib followed by 7+3 therapy in adults with newly 
diagnosed and previously untreated AML.  
Induction – Alvocidib and 7+3 
The starting dose of alvocidib will be 20 mg/m2 as a 30-minute intravenous (IV) 
bolus followed by 30 mg/m2 over 4 hours as an IV infusion administered daily 
on Days 1-3 of Induction. Patients will have a one day drug holiday (Day 4) 
before initiation of the 7+3 regimen. Beginning on Day 5, cytarabine will be 
administered as a 100 mg/m2/day continuous IV infusion for seven consecutive 
days (Days 5-11) plus daunorubicin administered at a dosage of 60 mg/m2 via 
IV bolus of up to 15 minutes’ duration on Days 5-7.  
Escalation of the alvocidib dose will follow a standard 3+3 design with sequential 
cohorts of three patients treated with incrementally higher doses of alvocidib 
until a DLT is observed and the MTD is established. Three patients within a 
dose cohort may be enrolled without a waiting period between patients. 
Escalation to the next higher dose level will not occur until all patients within the 
current dose cohort have undergone full safety assessments (including count 
recovery or disease assessment).  
If 1 of 3 patients in a cohort experiences a DLT, up to 3 additional patients will 
be treated at that dose level. If all patients in the expanded cohort have 
undergone full safety assessments (including count recovery or disease 
assessment) with no additional DLTs observed, the alvocidib dose will be 
escalated in a new cohort of 3 patients. If 2 or more of 3-6 patients at a given 
dose level experience a DLT during the first cycle, then the MTD will have been 
exceeded and up to a total of 6 patients will be treated at the previous lower 
dose level. If 0 or 1 of 6 patients experiences a DLT at this previous lower dose 
level, this dose will be declared the MTD. 
7KH07'LVGHILQHGDVWKHGRVHDWZKLFKRISDWLHQWVH[SHULHQFHD'/7
during Cycle 1 with the next higher dose having at least 2 of 3-6 patients 
experiencing a DLT during Cycle 1. 
The period of DLT determination for alvocidib and 7+3 ends at the start of 
consolidation therapy. However, any AEs that occur during Reinduction and 
meet DLT criteria will be taken into consideration when determining whether to 
escalate the dose of alvocidib and when defining the MTD. 
Once the MTD has been established, up to 20 additional patients will be enrolled 
at the MTD level for confirmation of safety as well as additional safety analysis 
and feasibility for determining MRD by dual methods (ie, MPFC and NGS) at a 
central laboratory. 


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Disease Assessment 
On Day 14 (±3 days), unless medically contraindicated, peripheral blood and 
bone marrow samples will be collected for disease assessment including MRD. 
Patients with no evidence of residual leukemia (5% bone marrow blasts plus 
10% cellularity) will be monitored weekly and will undergo response 
assessment at the time of hematologic recovery (ie, absolute neutrophil count 
(ANC) >1000/μL and platelet count >100,000/μL) or Day 50 (±3 days), counted 
from Day 1 of Induction therapy, whichever occurs first. At this time, the patient 
may continue to Consolidation therapy with HiDAC. 
Reinduction – Alvocidib and 5+2 
Patients with evidence of residual leukemia (>5% bone marrow blasts plus 
>10% cellularity) may be eligible for a second induction cycle (or ‘Reinduction’) 
with alvocidib and 5+2 at the discretion of the Investigator. The dose of alvocidib 
will remain the same, but the 7+3 regimen will be changed to 5+2: cytarabine, 
100 mg/m2/day, as a continuous IV infusion on Days 5-9 plus daunorubicin 
administered at a dosage of 45 mg/m2 via IV bolus of up to 15 minutes’ duration 
on Days 5 and 6.  
Should a patient undergo Reinduction therapy, they will be monitored weekly 
and will undergo response assessment at the time of hematologic recovery (ie, 
ANC >1000/μL and platelet count >100,000/μL) or Day 60 (±3 days), counted 
from Day 1 of Induction therapy, whichever occurs first. Upon documented 
hematologic recovery, the patient may continue to Consolidation therapy with 
HiDAC. Additional bone marrow assessments may be obtained per investigator 
discretion. 
Investigators are permitted to administer intrathecal (IT) chemotherapy per 
institutional protocols after Induction (preferably during marrow aplasia), but 
before starting Consolidation therapy. Additional doses of IT chemotherapy may 
be administered after discussion with the Medical Monitor. 
During both Induction and Reinduction, if necessary, care must be taken to 
ensure the patient’s lifetime daunorubicin equivalent does not exceed 
460 mg/m2 (see Appendix G for conversion table) or that their left ventricular 
ejection fraction (LVEF) does not drop below 45%. 
No intra-patient escalation of the alvocidib dose is permitted. 


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Consolidation – HiDAC 
Consolidation therapy with HiDAC may be initiated at the time of hematologic 
recovery or within 90 days of recovery. Consolidation therapy may start before 
complete hematologic recovery after discussion with the Medical Monitor. It is 
not anticipated that all patients will undergo Consolidation therapy. 
The HiDAC regimen will consist of 3 gm/m2 IV every 12 hours on Days 1, 3, and 
5 (a reduced dosage of 1.5 gm/m2 is permitted for patients aged 60 to 65 years) 
(ie, a total of 6 doses over the 3-day regimen). The starting dose of HiDAC may 
be decreased pending discussion between the investigator and Medical 
Monitor.   
Patients who plan to receive chemotherapy-based consolidation should get a 
minimum of two cycles of Consolidation up to a maximum of four cycles. 
Patients proceeding to stem cell transplant for Consolidation should get one 
cycle of Consolidation, if possible, to ensure disease stability while transplant 
plans are being made.  
4.2 Patient Population 
Patients enrolled in this study must be newly diagnosed with previously 
untreated AML excluding those patients with acute promyelocytic leukemia 
(APL-M3) or core-binding factor AML (CBF-AML).  
4.2.1 
Number of Patients 
A sufficient number of patients will be screened in order to obtain up to 
40 eligible and evaluable patients for dosing. Any patient who withdraws from 
the study before completing Induction/Reinduction therapy will be replaced 
unless that patient is withdrawn due to toxicity or has experienced a DLT. 
4.2.2 
Inclusion Criteria 
To be eligible for participation in the study, patients must meet all of the following 
inclusion criteria: 
1. 
%HEHWZHHQWKHDJHVRIDQG\HDUV 
2. 
Have an established, pathologically confirmed diagnoses of AML by 
World Health Organization (WHO) criteria with 20% bone marrow blasts 
based on histology or flow cytometry 
3. 
Be newly diagnosed and previously untreated  
4. 
Have an Eastern Cooperative Oncology Group (ECOG) performance 
VWDWXV36 
5. 
+DYHDVHUXPFUHDWLQLQHOHYHOPJG/ 
6. 
Have 
an 
alanine 
aminotransferase 
(ALT) 
and 
aspartate 
DPLQRWUDQVIHUDVH$67OHYHOWLPHVXSSHUOLPLWRIQRUPDO8/1 


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7. 
+DYH D WRWDO ELOLUXELQ OHYHO  PJG/ XQOHVV VHFRQGDU\ WR *LOEHUW
syndrome, hemolysis, or leukemia) 
8. 
Have a left ventricular ejection fraction (LVEF) >45% by echocardiogram 
(ECHO) or multigated acquisition (MUGA) scan 
9. 
Be nonfertile or agree to use an adequate method of contraception. 
Sexually active patients and their partners must use an effective method 
of contraception associated with a low failure rate prior to study entry, for 
the duration of study participation, and for at least 6 months after the last 
dose of study drug (see Section 4.5.3).  
10. 
Be able to comply with the requirements of the entire study. 
11. 
Provide written informed consent prior to any study related procedure. 
(In the event that the patient is re-screened for study participation or a 
protocol amendment alters the care of an ongoing patient, a new 
informed consent form must be signed.) 
4.2.3 
Exclusion Criteria 
Patients meeting any one of these exclusion criteria will be prohibited from 
participating in this study. 
1. 
Received any previous treatment for AML 
2. 
Diagnosed with APL-M3 or CBF-AML 
3. 
Require 
concomitant 
chemotherapy, 
radiation 
therapy, 
or 
immunotherapy. Hydroxyurea is allowed up to the evening before starting 
(but not within 12 hours) of starting Induction therapy. 
4. 
Received >200 mg/m2 equivalents of daunorubicin (see Appendix G for 
conversion table) 
5. 
Have a peripheral blast count of >30,000/mm3 (may use hydroxyurea as 
in #3 above) 
6. 
Have active central nervous system (CNS) leukemia 
7. 
Have evidence of uncontrolled disseminated intravascular coagulation 
8. 
Have an active, uncontrolled infection 
9. 
Have other life-threatening illness 
10. 
Have other active malignancies or diagnosed with other malignancies 
within the last 6 months, except nonmelanoma skin cancer or cervical 
intraepithelial neoplasia 
11. 
Have mental deficits and/or psychiatric history that may compromise the 
ability to give written informed consent or to comply with the study 
protocol. 
12. 
Are pregnant and/or nursing 


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4.3 Study Treatments 
4.3.1 
Calculation of Dose 
The dosage of study drugs will be recalculated at the beginning of each new 
treatment cycle to reflect changes in the body surface area (BSA) that may have 
occurred but will remain the same for all treatments within a treatment cycle. 
4.3.2 
Study Drug Administration 
Induction – Alvocidib and 7+3  
x Days 1, 2, 3:  Alvocidib at a starting dose of 20 mg/m2 as a 30-minute 
(±10 minutes) IV bolus followed by 30 mg/m2 administered as a 4-hour 
(±15 minutes) IV infusion (this is the starting dose for Cohort 1; see 
Table 3 for assigned alvocidib doses per treatment cohort) 
x Day 4:  Drug-free day 
x Days 5, 6, 7: (7+3) Daunorubicin 60 mg/m2 via IV bolus of up to  
15 minutes’ (±5 minutes) duration each day followed immediately by;   
x Days 5, 6, 7, 8, 9, 10, 11: Cytarabine 100 mg/m2/day via continuous 
24-hour IV infusion (±2 hours for infusion duration each day) 
Reinduction – Alvocidib and 5+2 
Patients with evidence of residual leukemia defined as >5% bone marrow blasts 
plus >10% cellularity, based on the Day 14 (±3 days) bone marrow will be 
eligible to start a second induction cycle (ie, Reinduction) with alvocidib plus 
5+2. The second induction cycle with alvocidib plus 5+2 will be allowed per 
investigator discretion.  
x Days 1, 2, 3:  Alvocidib at same dosage as during Induction 
x Day 4:  Drug-free day 
x Days 5, 6:  (5+2) Daunorubicin 45 mg/m2/day via IV bolus of up to  
15 minutes’ (±5 minutes) duration each day followed immediately by;  
x Days 5, 6, 7, 8, 9: Cytarabine 100 mg/m2/day via continuous IV infusion 
(±2 hours for infusion duration each day)  




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4.3.3.1 Dose Escalation of Alvocidib – Step 1 
Escalation of the alvocidib dose will follow a 3+3 design. Sequential cohorts of 
three patients will be treated with escalated doses until the MTD is established. 
In the absence of DLTs, the dose will be increased incrementally. Three patients 
within a dose cohort may be enrolled without a waiting period between patients. 
Escalation to the next higher dose level will not occur until all patients within the 
current dose cohort have undergone full safety assessments (including count 
recovery or disease assessment).  
If 1 of 3 patients in a cohort experiences a DLT, up to 3 additional patients will 
be treated at that dose level. If all patients in the expanded cohort have 
undergone full safety assessments (including count recovery or disease 
assessment) with no additional DLTs observed, the alvocidib dose will be 
escalated in a new cohort of 3 patients. If 2 or more of 3-6 patients at a given 
dose level experience a DLT during the first cycle, then the MTD will have been 
exceeded and up to a total of 6 patients will be treated at the previous lower 
dose level. If 0 or 1 of 6 patients experiences a DLT at this previous lower dose 
level, this dose will be declared the MTD. 
4.3.3.2 Identifying and Confirming the MTD – Step 2 
7KH07'LVGHILQHGDVWKHGRVHDWZKLFKRISDWLHQWVH[SHULHQFHD'/7
during Cycle 1 with the next higher dose having at least 2 of 3-6 patients 
experiencing a DLT during Cycle 1. 
Any AEs that occur during Reinduction and meet DLT criteria will be taken into 
consideration when determining whether to escalate the dose of alvocidib and 
when defining the MTD. 
Once the MTD has been established, up to 20 additional patients will be enrolled 
at the MTD level for confirmation of safety as well as additional safety analysis 
and feasibility for determining MRD by dual methods (ie, MPFC and NGS) at a 
central laboratory. 
4.4 Management of Toxicities and Dosage Modifications 
Suggested doses of supportive care therapies are provided; however, 
adjustment of the dosages based on the patient’s clinical condition or each 
institution’s standard of care is permitted. 
4.4.1 
Management of Nonhematologic Toxicities 
Adverse events may be treated with concomitant medications, as deemed 
clinically indicated by the Principal Investigator. All concomitant medications 
must be recorded in the source and on the appropriate CRF. 
Adverse events that are moderate to severe in intensity (see Appendix C for 
toxicity grading) and considered possibly or probably related to study drug 
treatments may result in the delay or termination of study treatment in affected 
patients. 


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4.4.1.1 Hyperkalemia and Tumor Lysis Syndrome 
Tumor lysis may occur as part of initial cytoreductive therapy. The most extreme 
form, known as Tumor Lysis Syndrome (TLS), is characterized by 
hyperkalemia, 
hyperuricemia, 
hyperphosphatemia, 
increased 
lactate 
dehydrogenase (LDH), coagulopathy, and a potential cytokine release 
syndrome.  
Mandatory IV hydration with 0.45% NaCl (or similar hydration fluid per 
institutional standard) sterile solution at 100 cc/hour for at least 10 hours prior 
to initiation of the first dose of chemotherapy during Induction (optional for 
subsequent cycles including Reinduction). If, by Day 4, there is no evidence of 
tumor lysis syndrome, the hydration rate can be reduced to a maintenance level.  
Diligent monitoring of urine output frequently to ensure that fluid output equals 
fluid input. If input is greater than output by 10%, administration of diuretics is 
encouraged. Replacement of excessive fluid losses, including from diarrhea, 
should be done unless otherwise clinically indicated. 
x Mandatory allopurinol orally each day of dosing for first cycle to be started 
at same time as initiation of IV hydration  
x Mandatory oral phosphate binder to be started at the same time as 
initiation of IV hydration, unless contraindicated. 
x Evaluation of laboratory indicators of tumor lysis syndrome (TLS) during 
Induction therapy. Evaluation of laboratory indicators of TLS may be 
adjusted for Reinduction and Consolidation therapy based on extent of 
tumor burden. 
o Tumor lysis laboratory evaluations (‘tumor lysis labs’) include 
electrolytes (sodium, potassium, chloride, and carbon dioxide) as 
well as creatinine, calcium, lactate dehydrogenase (LDH), uric 
acid, and phosphorus levels. 
o For patients at high risk for TLS including those with risk scores 
RIDFFRUGLQJWRWKHWDEOHLQAppendix F, those with monocytic 
leukemia phenotype, or those with a history of FLT3 positive AML: 
 Obtain a STAT serum potassium at end of alvocidib 
infusion 
 Strongly recommend serum potassium at 2 hours post end 
of alvocidib infusion as best practice 
 Obtain full TLS panel at 4 hours post end of alvocidib 
infusion 
 If evidence of clinically meaningful TLS, obtain TLS panel 
every 2 hours during the first 24 hours post end of alvocidib 
infusion (LDH levels are recommended to be assessed at 
least once every 24 hours). 


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 If no evidence of clinically meaningful TLS, obtain TLS 
panel every 4 hours during the first 24 hours post end of 
alvocidib infusion (LDH levels are recommended to be 
assessed at least once every 24 hours). 
 If, after the first 24 hours post end of alvocidib infusion, 
there is no evidence of TLS, obtain TLS panel 
approximately every 6 hours for the remainder of alvocidib 
treatment and then every 12 hours after completion of 
alvocidib and during daunorubicin and cytarabine (LDH 
levels are recommended to be assessed at least once 
every 24 hours). 
 Monitor fibrinogen levels at baseline and then as clinically 
indicated. 
 Patients who are determined to be at intermediate- or high-
risk for TLS should be considered for rasburicase 
prophylaxis according to institutional standards 
o For patients NOT at high risk for TLS: 
 During the first 24 hours - Monitor tumor lysis labs at the 
start of alvocidib and approximately every 4 hours. 
Laboratory studies during this period should be run as a 
“STAT” to ensure the results are available in a timely 
manner. 
 If no evidence of TLS during first 24 hours, then monitor 
tumor lysis labs approximately every 6-8 hours for the 
remainder of alvocidib treatment and then every 12 hours 
after the completion of alvocidib and during cytarabine and 
daunorubicin. 
 Monitor fibrinogen levels at baseline and then as clinically 
indicated. 
Risk of TLS and Guidelines for Management of High Risk Patients 
TLS management during treatment with alvocidib was implemented in previous 
studies, which included medical prophylaxis for hyperuricemia, as well as 
aggressive monitoring and management of hyperkalemia and other biochemical 
laboratory abnormalities. Rapid development of hyperkalemia has been of 
particular concern in earlier studies.  While these guidelines are not necessarily 
consistent with specific standard recommendations for the treatment of TLS, 
they are recommended based on previous experience with the treatment of 
patients with alvocidib. These measures resulted in a lower incidence of TLS 
without adverse outcomes.  


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For this reason, investigators are encouraged to follow the recommended 
guidelines below but may follow your own institution’s protocols in determining 
the best treatment for your patients. 
x If potassium levels are increasing to >4.0 mEq/L, patients should receive 
a 30 gm dose of sodium polystyrene sulfonate, unless there are other 
likely causes of hyperkalemia other than TLS or contraindication to its 
use.  
x If potassium levels rise to >5.0 mEq/L, in addition to the 30-gm dose of 
sodium polystyrene sulfonate, patients should also receive 10 units of 
IV rapid-acting insulin and 25 gm (one ampule) of IV dextrose 50%, 
unless there are other likely causes of hyperkalemia other than TLS or 
contraindication to its use. 
x If potassium levels rise to >5.5 mEq/L, patients should be considered for 
emergent intermittent or continuous dialysis. 
x Calcium supplementation should only be given for symptomatic 
hypocalcemia in this setting to avoid renal precipitation of calcium 
phosphate crystals. 
x Patients who develop clinical evidence of cytokine release syndrome or 
who have hyperkalemia requiring dialysis will receive immediate steroid 
therapy with an equivalent of at least 20 mg of IV dexamethasone. 
4.4.1.2 Diarrhea 
If diarrhea occurs during therapy, patients should initiate loperamide (or 
equivalent) 2 mg by mouth every 2 hours during the waking hours. The rapid 
introduction of loperamide (or equivalent) at the first signs of diarrhea is strongly 
encouraged. Once the diarrhea is controlled, the time interval of loperamide 
may be titrated to a frequency that adequately controls the diarrhea.  The 
diarrhea observed with alvocidib almost always resolves following completion 
of therapy, so treatment with loperamide following completion of therapy will not 
be required in most patients. If loperamide (or equivalent) does not control 
diarrhea, cholestyramine (or equivalent) 5 gm orally four (4) times daily may be 
added. For patients developing diarrhea during alvocidib administration, 
subsequent treatments should include a similar diarrhea prophylaxis. If diarrhea 
is not controlled with the above prophylactic regimen and is grade 2 or greater, 
therapy should be held until diarrhea has resolved. Replacement of excessive 
fluid losses should be done unless otherwise clinically indicated. 
4.4.1.3 Nausea/Vomiting 
Antiemetics (ie, 5-hydroxytryptamine [5-HT3] receptor inhibitor or other 
antiemetic medications) are permitted according to standard practices at each 
investigational site.  


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4.4.1.4 Infection Prevention 
Prophylactic antibiotics including levofloxacin (or equivalent) 500 mg orally once 
daily and valacyclovir (or equivalent) 500 mg orally BID each day should be 
administered at the start of chemotherapy. Alternative prophylactic antibiotic or 
antiviral therapy is left to the discretion of the treating physician and according 
to institutional standards. 
Antifungal prophylaxis to be administered according to each institution’s 
standard of care. 
Routine growth factor support is not allowed Day 35 unless otherwise 
discussed with the Medical Monitor. Growth factor support can be given at the 
discretion of the Investigator >Day 35 of Induction/Reinduction therapy in the 
presence of life-threatening infection with ongoing neutropenia. Growth factor 
support during Consolidation therapy may be administered according to each 
institution’s standard of care.  
4.4.2 
Management of Hematologic Toxicities 
Adverse events that are moderate to severe in intensity (see Appendix C for 
toxicity grading) and considered possibly or probably related to study drug 
treatments may result in the termination of study treatment in the affected study 
patient. Such termination should be reviewed with the Sponsor’s Medical 
Monitor at the earliest possible time (see Section 8.5). Following review with the 
Sponsor’s Medical Monitor, the study patient may be permanently withdrawn 
from the study depending upon the nature and severity of the event. 
Adverse events may be treated with concomitant medications, as deemed 
clinically indicated by the Principal Investigator. All concomitant medications 
must be recorded on the appropriate CRF. 
4.4.3 
Dose-limiting Toxicities 
Dose-limiting toxicities (DLTs) for alvocidib and 7+3 will be determined during 
Induction and Reinduction therapy, determined to be at least possibly related 
to study drug and defined as follows based on the NCI CTCAE version 4.03: 
x Any Grade 4 nonhematologic toxicity considered at least possibly 
drug related 
x Any Grade 3 nonhematologic toxicity considered at least possibly drug 
related and that does not resolve to Grade 2 within 48 hours, with the 
following exceptions: 
o Grade 3 diarrhea, mucositis, nausea or vomiting will be 
considered dose-limiting only if resolution to <Grade 2 (including 
use of supportive care) requires more than 7 days 
x *UDGHF\WRSHQLDVODVWLQJ50 days from the start of the cycle in the 
absence of residual leukemia if subject received one cycle of induction 


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x *UDGHF\WRSHQLDVODVWLQJGD\VLQthe absence of residual leukemia 
if subject received 2 cycles of induction 
x Grade 3 or 4 tumor lysis syndrome or related electrolyte disturbances 
(eg, hyperkalemia, hypophosphatemia, hyperuricemia) that do not 
UHVROYHWR*UDGHZLWKLQGD\V 
x *UDGHHOHYDWLRQVLQFUHDWLQLQHWKDWGRQRWUHVROYHWR*UDGHZLWKLQ
7 days 
x $Q\$67DQG$/7HOHYDWLRQ5 ×ULN accompanied by serum bilirubin 
levels >2 ×ULN, regardless of duration 
x Any Grade 5 toxicity that is not clearly and incontrovertibly related to the 
underlying disease or extraneous causes 
x Anorexia, alopecia, fever, neutropenic fever, and infections of any grade 
should not be designated as DLTs since they are known and expected 
toxicities associated with the study drugs.  
4.4.4 
Dose Modifications 
During Induction/Reinduction, there will be no dose reductions for alvocidib or 
cytarabine. Unless an elevation in total bilirubin level is secondary to suspected 
Gilbert syndrome, hemolysis (as reflected by an increase in indirect bilirubin 
level), or hepatic leukemic infiltration, the dose of daunorubicin must be reduced 
by 25% per day per dose if the patient’s total direct bilirubin value is 1.2 mg/dL 
and 3 mg/dL, and must be reduced 50% per day per dose if the patient’s total 
direct bilirubin value is >3 mg/dL on the day of planned daunorubicin 
administration. Bilirubin adjustment should be based on direct measurement. 
Patients with serum creatinine concentrations >3 mg/dL should receive 50% of 
the planned dose. Daunorubicin must be omitted from subsequent cycles if the 
patient’s lifetime daunorubicin equivalent exceeds 460 mg/m2 (see Appendix G 
for conversion table) or their left ventricular ejection fraction (LVEF) drops below 
45%. 
The HiDAC dose may be modified during Consolidation at the discretion 
Investigator.   
4.5 Concomitant Medications and Therapies 
4.5.1 
Previous Therapies 
During Screening, patients will be asked about all medications used during the 
previous 30 days from anticipated first dose. This information will be recorded 
in the source documentation and appropriate CRF along with the diagnosis or 
reason for use. If a branded product is being taken, the generic name should be 
reported, if known.   
Patients will not be enrolled into the study if they have received >100 mg/m2 
equivalents of daunorubicin (see Appendix G for conversion table). 


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4.5.2 
Concomitant Therapies 
Concomitant therapies are any new or existing medications or therapy taken by 
the patient including: 
x Drugs, including but not limited to, prescription, over-the-counter, birth 
control pills/patches/hormonal devices, and homeopathic preparations 
x Nondrug therapies, including but not limited to, thermal/laser/radiation 
procedures, vitamins, herbal medicines/supplements. 
During the Screening process (up to two weeks prior to anticipated first dose of 
study drug), information on all concomitant therapies, medications, and 
procedures will be recorded in the source documents and appropriate CRF 
along with the diagnosis or reason for use.  
Once the patient receives the first dose of study drug, recording of concomitant 
therapies will be limited to any new medication or modification of an existing 
medication taken for treatment of an adverse event (AE). These therapies will 
be recorded in the source documents and appropriate CRF along with the 
diagnosis or reason for use. Those therapies used for the treatment of an 
adverse event are to be linked to an AE and documentation of the AE must also 
be completed (refer to Section 8).   
If a branded product is being taken, the generic name should be reported, if 
known.   
4.5.2.1 Mandated / Permitted Therapies 
Concomitant medications necessary for the health and well-being of the patient 
and that do not interfere with study assessments are permitted during the study 
at the Investigator’s discretion. This includes the use of appropriate medications 
for the treatment of AEs and/or concurrent illnesses under the direction of the 
Principal Investigator. All such therapies must be recorded in the source and on 
the appropriate CRF.  
In patients with rapidly proliferating disease, hydroxyurea may be administered 
up to the evening before starting treatment in either Stage, but not within 
12 hours prior to dosing. 
Investigators are permitted to administer intrathecal (IT) chemotherapy per 
institutional protocols after Induction (preferably during marrow aplasia), but 
before starting Consolidation therapy. Additional doses of IT chemotherapy may 
be administered after discussion with the Medical Monitor. 
Medications and procedures that are mandatory or permitted during the study 
are listed in Section 4.4.1. 


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4.5.2.2 Prohibited Therapies 
The following medications are excluded from concomitant use:  
x Antileukemic 
therapy 
(chemotherapy, 
radiation 
therapy, 
immunotherapy) within the last 3 weeks prior to the first study drug 
administration and during the cycle of study treatment. 
4.5.3 
Birth Control Requirements for Fertile Patients 
Sexually active patients and their partners must use an effective method of 
contraception associated with a low failure rate prior to study entry, for the 
duration of study participation, and for at least 6 months after the last dose of 
study drug. The following are considered effective contraceptives: (1) oral 
contraceptive pill; (2) condom plus spermicide; (3) diaphragm plus spermicide; 
(4) abstinence; (5) patient or partner surgically sterile; (6) patient or partner more 
than 2 years post-menopausal; or (7) injectable or implantable agent/device. 
4.6 Protocol Deviations 
It is expected that this study will be conducted as described in this protocol, 
except for an emergency situation in which the protection, safety and well-being 
of the patient requires immediate intervention, based on the judgment of the 
Principal Investigator (or a responsible, appropriately trained and credentialed 
professional[s] designated by the Principal Investigator). In the event of a 
significant deviation from the protocol due to an emergency, accident or error, 
the Principal Investigator or Designee must contact the Sponsor at the earliest 
possible time by telephone. This will allow an early joint decision to be made as 
to whether or not the patient should continue in the study. This decision will be 
documented in writing by both the Principal Investigator and the Sponsor. 
4.7 Other Precautions 
Dose adjustments for nonhematologic and hematologic toxicities and laboratory 
abnormalities will be made according to Section 4.4.1 and Section 4.4.2, 
respectively. 


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5. ON-STUDY CLINICAL AND LABORATORY EVALUATIONS 
See Appendix A - Schedule of Events  
5.1 Screening (Within 2 Weeks Prior to First Dose of Alvocidib) 
5.1.1 
Within 2 Weeks Prior to First Dose 
x Obtain written informed consent 
x Perform bone marrow biopsy and/or aspiration and collect peripheral 
blood for diagnosis, cytogenetic profiling, MPFC, molecular testing, and 
assessment of other potential biomarkers  
x Record results of molecular testing from bone marrow or peripheral blood 
that was collected as standard of care 
x Collect and document a complete medical history including pathological 
confirmed diagnosis of AML by WHO criteria, confirmation of newly 
diagnosed and previously untreated disease, and all other measures of 
disease and disease symptoms (eg, extramedullary disease) 
x Perform a complete physical examination including height (cm) and 
weight (kg) 
x Assess ECOG PS (Appendix B) 
x Record vital signs (temperature, heart rate, systolic and diastolic blood 
pressures) 
x Perform 12-lead electrocardiogram (ECG) 
x Perform echocardiogram (ECHO) or multigated acquisition (MUGA) scan  
x Perform chest radiograph (may omit, if performed/obtained within 
30 days prior to anticipated first dose) 
x Record all concomitant medications including all prescription drugs, 
nonprescription drugs, and nutritional supplements taken within the past 
2 weeks 
5.1.2 
Within 72 Hours Prior to First Dose of Alvocidib 
Perform the following activities and evaluations within 72 hours prior to 
administration of the first dose of alvocidib: 
x Collect blood for evaluation of laboratory parameters (Appendix D): 
o Hematology 
o Full serum chemistry panel 


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x Collect urine sample for full urinalysis 
x &ROOHFWXULQHRUVHUXPVDPSOHIRUȕ-hCG pregnancy test  
x Record all concomitant medications including all prescription drugs, 
nonprescription drugs, and nutritional supplements 
x Lumbar puncture for those patients with clinical symptoms suspicious of 
central nervous system involvement 
Review all Inclusion/Exclusion criteria and determine if patient has met all 
eligibility criteria for inclusion into the study.  
5.2 Induction – Alvocidib and 7+3 
5.2.1 
Assessments Required Prior to First Dose 
Within 24 hours prior to first dose, patients will be hospitalized to receive 
supportive care measures and should remain hospitalized at least through 
completion of chemotherapy. Patients will be discharged after completion of 
chemotherapy once deemed clinically stable by the investigator.   
5.2.1.1 Induction – At Least 10 Hours Prior to First Dose 
Perform the following procedures at least 10 hours prior to starting Induction 
therapy on Day 1 (unless otherwise stated): 
x Abbreviated physical examination including weight (kg) for calculation of 
body surface area (BSA) (may be performed within 10 hours prior to first 
dose) 
x Assess ECOG PS (Appendix B) (may be performed within 10 hours prior 
to first dose) 
x Initiate supportive care measures at least 10 hours prior to first dose in 
all patients to minimize the likelihood of tumor lysis syndrome: 
o Administer pretreatment IV hydration, oral allopurinol, and oral 
phosphate binder (see Section 4.4.1) (as clinically indicated 
during Reinduction) 
o Diligent monitoring of urine output frequently to ensure that it 
equals fluid input. If input is greater than output by 10%, 
administration of diuretics is encouraged. Replacement of 
excessive fluid losses, including from diarrhea, should be done 
unless otherwise clinically indicated. (To be performed if clinically 
indicated during Reinduction) 
x Record all concomitant medications including all prescription drugs, 
nonprescription drugs, and nutritional supplements taken since 
screening (may be performed within 10 hours prior to first dose) 


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5.2.1.2 Induction, Day 1 – Just Prior to First Dose 
Perform the following procedures just prior to dosing on Day 1: 
x Record vital signs (body temperature, heart rate, systolic and diastolic 
blood pressures) measured 5-15 minutes prior to the initiation of infusion 
following a 5-minute rest 
x Collect blood for evaluation of laboratory parameters (Appendix D):  
o Tumor lysis labs to include electrolytes (sodium, potassium, 
chloride, and carbon dioxide) as well as creatinine, calcium, 
lactate dehydrogenase (LDH), uric acid, and phosphorus levels 
o Coagulation: fibrinogen level 
x &ROOHFWXULQHRUVHUXPVDPSOHIRUȕ-hCG pregnancy test for females of 
child-bearing potential if screening pregnancy test is greater than 
72 hours prior to first dose 
x Record all concomitant medications including all prescription drugs, 
nonprescription drugs, and nutritional supplements 
5.2.2 
Induction, Day 1 – Dosing 
x Monitor tumor lysis labs at the start of alvocidib and throughout the 
treatment cycle according to the schedule outlined in Section 4.4.1.1.  
[Note: there are different blood collection schedules for monitoring of TLS 
labs for patients at high risk of TLS and for those NOT at high risk for 
TLS.]  
x Monitor fibrinogen levels as clinically indicated. 
x Monitor urine output frequently to ensure that it equals fluid input. If input 
is greater than output by 10%, administration of diuretics is encouraged. 
Replacement of excessive fluid losses, including from diarrhea, should 
be done unless otherwise clinically indicated. 
x Administer prophylactic antibiotics and antivirals, and antifungals 
according to Section 4.4.1.4 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 


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5.2.3 
Induction – Daily during Hospitalization for Chemotherapy 
Perform the following procedures daily (or more frequently if clinically indicated) 
while patients are hospitalized for chemotherapy administration: 
x Collect blood for evaluation of laboratory parameters (Appendix D): 
o Hematology 
o Bilirubin, creatinine, alanine aminotransferase (ALT), aspartate 
aminotransferase (AST), alkaline phosphatase (ALP) 
o Tumor lysis labs as outlined in Section 4.4.1.1 (or more frequently 
if clinically indicated)  
o Fibrinogen level (as clinically indicated) 
x Monitor urine output frequently to ensure that it equals fluid input. If input 
is greater than output by 10%, administration of diuretics is encouraged. 
Replacement of excessive fluid losses, including from diarrhea, should 
be done unless otherwise clinically indicated. 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 
5.2.4 
Induction – Weekly after Completion of Chemotherapy Regimen 
Perform the following procedures weekly (approximately every seven days, or 
more frequently if clinically indicated) after patients have completed their 
chemotherapy regimen: 
x Abbreviated physical examination (AE- or symptom-directed exam) 
including weight (kg) 
x Assess ECOG PS (Appendix B) 
x Vital signs (temperature, heart rate, systolic and diastolic blood 
pressures) 
x Collect blood for evaluation of laboratory parameters (Appendix D): 
o Hematology 
o Bilirubin, creatinine, ALT, AST, ALP 
o Tumor lysis labs 
o Fibrinogen level (as clinically indicated) 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 


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5.2.5 
Induction, Day 14 (±3 Days) 
x Collect peripheral blood samples and perform a bone marrow biopsy on 
Day 14 (±3 days), unless medically contraindicated, for disease 
assessment including MRD and other potential biomarkers. Central 
laboratory assessment of MRD is to be done for disease assessment and 
treatment guidance. 
o Patients with no evidence of residual leukemia will be monitored 
weekly (as in Section 5.2.4) until hematologic recovery (go to 
Section 5.2.6) 
o Patients with evidence of residual leukemia (>5% bone marrow 
blasts plus >10% cellularity) may be eligible for a second Induction 
cycle (or ‘Reinduction’) with alvocidib and 5+2 at the discretion of 
the Investigator (go to Section 5.3).  
x 
Assess for AEs 
x 
Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 
5.2.6 
Induction – At Hematologic Recovery or Day 50 (±3 days), Whichever 
Occurs First 
x Patients will undergo response assessment including MRD via peripheral 
blood and bone marrow biopsy samples collected at the time of 
hematologic recovery (ie, absolute neutrophil count [ANC] >1000/μL and 
platelet count >100,000/μL) or Day 50 [±3 days], counted from Day 1 of 
Induction therapy, whichever occurs first. These same samples will also 
be used for assessment of other potential biomarkers. Central laboratory 
assessment of MRD is to be done for disease assessment and treatment 
guidance. If the bone marrow biopsy and/or aspirate is nonproductive or 
not diagnostic, the procedure must be repeated within 7-10 days. 
x Additional bone marrow assessments may be obtained per Investigator 
discretion. 
x 
Assess for AEs, including tumor lysis clinical symptoms 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 


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5.3 Reinduction (if Day 14 [±3 Days] Positive Marrow) 
Patients with evidence of residual leukemia (>5% bone marrow blasts plus 
>10% cellularity) may undergo Reinduction with alvocidib and 5+2 at the 
discretion of the Investigator. Care must be taken to ensure the patient’s lifetime 
daunorubicin equivalent does not exceeds 460 mg/m2 (see Appendix G for 
conversion table) or that their LVEF does not drop below 45%. 
Patients undergoing Reinduction will repeat the assessments in Section 5.2.1 
through Section 5.2.5.  
5.3.1 
Reinduction – At Hematologic Recovery or Day 60 (±3 days), 
Whichever Occurs First 
x Following the second induction cycle (or ‘Reinduction’) of alvocidib and 
5+2, patients will undergo response assessments including MRD via 
peripheral blood and bone marrow biopsy samples collected at the time 
of hematologic recovery (ie, ANC >1000/μL and platelet count 
>100,000/μL) or Day 60 (±3 days), counted from Day 1 of Induction 
therapy, whichever occurs first. These same samples will also be used 
for assessment of other potential biomarkers. Central laboratory 
assessment of MRD is to be done for disease assessment and treatment 
guidance. If the bone marrow biopsy and/or aspirate is nonproductive or 
not diagnostic, the procedure must be repeated within 7-10 days. 
x Additional bone marrow assessments may be obtained per Investigator 
discretion. 
x 
Assess for AEs, including tumor lysis clinical symptoms 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 
5.4 Consolidation – HiDAC 
Consolidation therapy will consist of high-dose cytarabine (HiDAC) initiated at 
the time of hematologic recovery or within 90 days of recovery. Consolidation 
therapy may also be started before complete hematologic recovery after 
discussion with the Medical Monitor. It is not anticipated that all patients will 
undergo Consolidation therapy.  
5.4.1 
Consolidation, Day 1 – Just Prior to First Dose 
Perform the following procedures just prior to dosing on Day 1: 
x Abbreviated physical examination including weight (kg) for calculation of 
body surface area (BSA) 
x Assess ECOG PS (Appendix B) 


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x Record vital signs (temperature, heart rate, systolic and diastolic blood 
pressures) measured 5-15 minutes prior to the initiation of infusion 
following a 5-minute rest 
x Collect blood for evaluation of laboratory parameters (Appendix D):  
o Hematology 
o Full serum chemistry panel 
o Fibrinogen level 
x &ROOHFWXULQHRUVHUXPVDPSOHIRUȕ-hCG pregnancy test for females of 
child-bearing potential  
x Record all concomitant medications including all prescription drugs, 
nonprescription drugs, and nutritional supplements administered in 
conjunction with an AE 
x 
Assess for AEs 
5.4.2 
Consolidation, Day 1 – Dosing 
x Administer recommended prophylactic antibiotics and antivirals, and 
antifungals according to each institution’s standard of care 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 
5.4.3 
Consolidation – Daily during Hospitalization for HiDAC 
Perform the following procedures daily (or more frequently if clinically indicated) 
while patients are hospitalized for chemotherapy administration: 
x Collect blood for evaluation of laboratory parameters (Appendix D): 
o Hematology  
o Bilirubin, creatinine, ALT, AST, ALP 
o Tumor lysis labs (as clinically indicated) 
o Fibrinogen level (as clinically indicated) 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 


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5.4.4 
Consolidation – Weekly after Completion of HiDAC 
Perform the following procedures weekly (approximately every seven days, or 
more frequently if clinically indicated) after patients have completed their 
chemotherapy regimen: 
x Collect blood for evaluation of laboratory parameters (Appendix D): 
o Hematology 
o Bilirubin, creatinine, ALT, AST, ALP 
o Tumor lysis labs (as clinically indicated) 
o Fibrinogen level (as clinically indicated) 
5.4.5 
Consolidation – Response Assessment 
x After Consolidation cycles 2 and 4, patients will undergo response 
assessments including MRD via peripheral blood and bone marrow 
biopsy samples collected at the time of hematologic recovery (ie, ANC 
>1000/μL and platelet count >100,000/μL). These same samples will 
also be used for assessment of other potential biomarkers. Central 
laboratory assessment of MRD is to be done for disease assessment and 
treatment guidance. If the bone marrow biopsy and/or aspirate is 
nonproductive or not diagnostic, the procedure must be repeated within 
7-10 days. 
x Additional bone marrow samples may be requested at the discretion of 
the Investigator. 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE. 
5.4.6 
Consolidation – Cycles 2 through 4 
Patients who plan to receive chemotherapy-based consolidation should get a 
minimum of two cycles of Consolidation up to a maximum of four cycles. 
Patients proceeding to stem cell transplant for Consolidation should get one 
cycle of Consolidation, if possible, to ensure disease stability while transplant 
plans are being made.  
Each cycle will include the assessments listed in Section 5.4.1 through 
Section 5.4.5.  


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5.5 End of Study Assessments 
If, at any time, a patient discontinues study treatment, a visit should be 
scheduled as soon as possible and within 14 days of the last dose of study drug 
or within 14 days of the decision to discontinue study treatment. If the decision 
to withdraw the patient occurs at a regularly scheduled visit, that visit may 
become the End of Study visit rather than having the patient return for an 
additional visit. 
x Complete physical examination including weight (kg) and other 
measures of disease and disease symptoms, eg, extramedullary disease 
x Vital signs (temperature, heart rate, systolic and diastolic blood 
pressures) 
x ECOG PS (Appendix B) 
x Collect blood for evaluation of laboratory studies (Appendix D): 
o Hematology 
o Full serum chemistry panel (as clinically indicated) 
o Fibrinogen level (only required if clinically indicated) 
x Urinalysis 
x Perform bone marrow biopsy and/or aspiration (if not done in the 
preceding 30 days) for determination of disease status including MRD 
and assessment of other potential biomarkers. If the bone marrow biopsy 
and/or aspirate is nonproductive or not diagnostic, the procedure must 
be repeated within 7-10 days. 
x Perform 12-lead ECG (as clinically indicated) 
x Perform ECHO or MUGA scan (as clinically indicated) 
x Assess for AEs 
x Record only those medications (prescription, nonprescription, nutritional 
supplements) administered in conjunction with an AE 
5.6 Follow-up Assessments 
5.6.1 
Safety Follow-up (30 Days Post Last Dose) 
Patients must have a safety evaluation 30 days after the last dose of study drug. 
The following assessments will be performed: 
x Assess for AEs 
o Ongoing AEs must be followed clinically until the event is resolved, 
deemed stable, or the patient starts another treatment for their 
disease 
x Record only those medications (prescription, nonprescription, and 
nutritional supplements) administered in conjunction with an AE, as well 


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as any antineoplastic therapies initiated since discontinuation of study 
drug.  
5.6.2 
Long-term Follow-up (Starting 30 Days Post End of Study out to 
2 Years)  
Additionally, all study patients will be attempted to be contacted by phone, 
if possible, every 6 months to assess for date of death, date of stem cell 
transplant, date of relapse, or continued remission beginning the month 
after the patient completes the End of Study assessments to 24 months 
after Day of First Dose regardless of how many cycles a patient receives. 
When telephone contact is not possible, medical records will serve as the 
surrogate to assess for these outcomes.  
 


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6. OFF-STUDY CRITERIA 
6.1 Withdrawal of Patients 
All patients have the right to withdraw at any time during treatment without 
prejudice. Circumstances may occur under which a patient may be permanently 
removed from the study. The criteria used to justify withdrawal of a study patient 
are described below. 
In the event of a premature withdrawal, the assessments for the End of Study 
visit, as detailed in the Schedule of Activities (see Appendix A), should be 
completed at the time of the withdrawal, wherever possible, including dates of 
remission and death. If the study patient is prematurely withdrawn due to an 
adverse event(s), attempts should also be made to clinically follow the study 
patient until the event is resolved, stable or permanent as determined by the 
Principal Investigator and Sponsor. 
6.2 Reasons for Withdrawal 
A patient may be permanently removed from the study for any of the following 
reasons: 
x Failure to achieve a CR or PR. Patients not demonstrating evidence of 
CRMRD–, CR, CRi, MLFS, or PR after the first cycle of treatment will be 
considered for removal from the study, although with permission of the 
Medical Monitor, induction treatment may continue if clinically indicated 
and provided there is no evidence of *rade 3 toxicity considered at 
least possibly related to alvocidib.  
x An excessive Grade 3-4 toxicity without a response to treatment or 
occurrence of any other adverse event, concurrent illness or laboratory 
abnormality which, in the opinion of the Principal Investigator, warrants 
the patient’s permanent withdrawal  
x Patient noncompliance, defined as refusal or inability to adhere to the 
study schedule; 
x At the request of the patient, Principal Investigator, the Sponsor, or 
regulatory authority;  
x Patient is lost to follow-up;  
x Patient becomes pregnant while on study;  
x Patient begins another treatment for their disease; or 
x Patient death 


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6.3 Follow-up for Patients Withdrawn from Study 
Patients withdrawn from the study with an ongoing adverse event must be 
followed clinically until the event is resolved, deemed stable or permanent by 
the PI, or the patient starts another treatment for their disease. A stable adverse 
event is defined as an event that is not expected to change in nature, severity 
or frequency. See Section 8.4 through Section 8.8 for reporting of adverse 
events. The pregnancy of any patient, or patient’s partner, will be followed via 
monthly telephone calls until the birth of the child to term to record any birth 
defects/abnormalities. 


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7. CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS 
7.1 Safety Endpoints 
Through escalation of the dosage of alvocidib, the MTD and any DLTs will be 
defined. Safety and tolerability will also be assessed by analyzing the incidence 
rates of treatment-emergent adverse events summarized within treatment 
groups at the MedDRA preferred term and primary system organ class levels. 
Similar summaries will be made for subsets of AEs such as (1) those judged by 
the Investigator to be related to study treatment, and (2) serious adverse events 
(SAEs).  
The multivariate analysis and risk score prediction model by Montesinos and 
colleagues [38] will be used to assess the potential for development of TLS (see 
Appendix F). 
Other routine safety assessments (eg, clinical laboratory parameters and vital 
signs) will be summarized by shift tables and treatment group using mean, 
standard deviation, median, minimum and maximum changes from baseline 
values. 
Mortality (all causes) at 30 and 60 days will also be calculated. 
7.2 Efficacy Endpoints 
Since the primary objective of this study is to determine safety and tolerability 
including of alvocidib when administered over a range of doses followed by 
cytarabine/daunorubicin (7+3) in adults with newly diagnosed and previously 
untreated AML, a formal efficacy analysis is not appropriate. However, any 
objective response to treatment will be determined using the remission 
definitions detailed in the 2017 European LeukemiaNet Recommendations in 
AML 
[10] 
after 
Induction 
(or 
Reinduction) 
(definitions 
provided 
in 
Section 11.3.2).  
 


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8. ADVERSE EVENTS 
8.1 Definitions 
An adverse event (AE) is defined as any untoward medical occurrence 
associated with the use of a drug in humans, whether or not considered drug 
related. An AE can therefore be any unfavorable and unintended sign (including 
an abnormal laboratory finding), symptom, or disease temporally associated 
with the use of a drug, whether or not related to the drug product.) 
Suspected adverse reaction means any adverse event for which there is a 
reasonable possibility that the drug caused the adverse event. For the purposes 
of IND safety reporting, ‘reasonable possibility’ means there is evidence to 
suggest a causal relationship between the drug and the adverse event. 
Unexpected adverse event or unexpected suspected adverse reaction: An 
adverse event or suspected adverse reaction is considered unexpected if it is 
not listed in the current Investigator’s Brochure or is not listed at the specificity 
or severity that has been observed; or, is not consistent with the risk information 
described in the general investigational plan (clinical study protocol). 
Toxicities will be assessed according to the NCI CTCAE, version 4.03 (see 
Appendix C). When the NCI CTCAE grade is not available, the investigator will 
use the following toxicity grading: mild, moderate, severe, life-threatening or 
fatal.    
GRADE 1 – Mild: 
Transient or mild discomfort; no limitation in 
activity; no medical intervention/therapy 
required. 
GRADE 2 – Moderate: 
Mild to moderate limitation in activity – 
some assistance may be needed; no or 
minimal medical intervention/therapy 
required. 
GRADE 3 – Severe: 
Marked limitation in activity, some 
assistance usually required; medical 
intervention/therapy required, 
hospitalizations possible. 
GRADE 4 – Life Threatening: 
Extreme limitation in activity, significant 
assistance required; life threatening 
(immediate risk of death); significant 
medical intervention/therapy required, 
hospitalization or hospice care probable. 
GRADE 5 – Fatal: 
Results in death. 


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8.2 Causality 
Relationship of the adverse event (AE) to the study drug should be defined as 
follows:  
Unrelated: 
AE is clearly not related to the investigational agent(s) 
Unlikely: 
AE is doubtfully related to the investigational agent(s) 
Possible: 
AE may be related to the investigational agent(s) 
Probable: 
AE is likely related to the investigational agent(s) 
Definite: 
AE is clearly related to the investigational agent(s) 
8.3 Serious Adverse Events 
A serious adverse event (SAE) is defined as any experience that suggests a 
significant hazard, contraindication, side effect, or precaution.  An SAE includes: 
x Any death, or  
x Any life-threatening event (ie, the patient is at immediate risk of death 
from the event as it occurred), or 
x Any event that is persistently, significantly, severely or permanently 
disabling, or requires intervention to prevent such disability, or 
x Any event which requires inpatient hospitalization or prolongs 
hospitalization, or 
x Any congenital abnormality/birth defect, or 
x Any medically significant event that may jeopardize the patient or may 
require intervention to prevent one of the other outcomes listed above. 
In addition, any adverse event which results in termination of the patient from 
study will be considered a potentially serious adverse event and must be 
reported to the Sponsor as described in Section 8.4. 
Bone marrow suppression and associated complications are expected events 
during leukemia therapy and are part of the treatment process (marrow 
emptying of leukemic cells). Therefore, hospitalization or prolongation of 
hospitalization for myelosuppression and associated complications directly 


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related to the myelosuppression, such as fever, infections and bleeding, will not 
be reported as serious adverse events (SAEs), but will be reported as adverse 
events on the adverse event case report form and will be summarized in the 
updated and final reports. Anemia and thrombocytopenia will not be reported as 
an SAE. Prolonged bone marrow suppression (as defined by the NCI toxicity 
criteria specific for leukemia, ie, bone marrow cellularity <5% on day 42 or later 
(6 weeks) from start of therapy without evidence of leukemia) or the unexpected 
nature, 
severity 
or 
frequency 
of 
myelosuppression, 
anemia, 
and 
thrombocytopenia or an associated complication will be reported as an SAE.  
8.4 Eliciting and Reporting Adverse Events 
All adverse events, regardless of severity, which occur during the study, will be 
documented in the study progress notes, and the “Adverse Event” case report 
form will be completed. This includes both serious and non-serious events. 
Adverse events occurring from the time of the first dose will be captured. 
All adverse events noted by study staff or volunteered by study patients at any 
time will be recorded. The Principal Investigator or a qualified designated staff 
physician will conduct clinical assessments of all patients at each scheduled 
clinic visit.  In addition, patients will be queried about any adverse symptoms 
they have experienced since the previous study visit. In order to avoid bias in 
eliciting events, suggestive questioning of the patients shall not occur.  
Record a laboratory abnormality as an AE if it is associated with clinical 
sequelae or requires a therapeutic intervention. For both non-laboratory and 
laboratory abnormalities capture only the highest grade of an event using 
Start/Stop dates of the longest duration of the AE not the longest duration of the 
highest grade. If worst grade is captured on a lab drawn between visits, enter 
the lab under Unscheduled Evaluations. Additional details are provided in the 
electronic case report form (eCRF) Completion Guidelines. 
Adverse events will be reported and described in terms of intensity, seriousness 
and causality, based on the Principal Investigator’s judgment using protocol-
defined definitions. Necessary counter measures will also be reported on the 
appropriate case report form used to collect concomitant medications. 
8.5 Serious Adverse Events and/or Adverse Events Requiring Discontinuation 
of Study Drug 
Any serious adverse event (SAE) or unexpected AE NCI CTCAE Grade 3 that 
occurs during this study and up to 30 days after discontinuation of study drug 
must be reported to the Study Medical Monitor within 24 hours of the Principal 
Investigator’s awareness of the event, whether or not this reaction is considered 
to be associated with use of the investigational drug.  
In addition, the occurrence of any AE leading to permanent discontinuation of 
study drug must also be reported to the Sponsor within 24 hours of the Principal 
Investigator’s awareness of the event.   


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Serious adverse events must be scanned and emailed to the Sponsor/Study 
Medical Monitor.  
 
It is expected that the Principal Investigator will provide or arrange appropriate 
supportive care for the study patient. A patient experiencing a serious adverse 
event(s) should be followed clinically until the event is resolved, deemed stable 
or permanent, or the patient starts another treatment for their disease. All 
telephone and scanned/emailed reports must be followed with a written Serious 
Adverse Event (SAE) report form within 24 hours of the Principal Investigator’s 
awareness of serious adverse events and nonserious events which required 
discontinuation of study drug.  
The (SAE) report form should be completed and signed by the Principal 
Investigator, scanned, and sent by email to the Sponsor as described above. 
The SAE Report Form is distinct and separate from the adverse event form 
included in the case report form. 
Grades for all SAEs and AEs, regardless of whether they trigger expedited 
reporting or not, must still be captured by the CRF. 
8.6 Follow-up of Adverse Events 
Adverse events, which are identified on the last scheduled visit, must be 
recorded on the AE CRF page and reported to the Sponsor according to the 
procedures outlined in Section 8.4.  
Patients with unresolved previously reported adverse events or new adverse 
events identified on the last scheduled visit should be followed by the Principal 
Investigator until the events resolve, are deemed stable or permanent, or the 
patient starts another treatment for their disease. Resolution means the patient 
has returned to his/her baseline state of health or the Principal Investigator does 
not expect any further improvement or worsening of the adverse event. The 
Principal Investigator should continue to report any significant follow-up 
information to the Sponsor up to the point the event has resolved. Any adverse 
events reported by the patient to the Principal Investigator which occur after the 
last scheduled visit, and are determined by the Principal Investigator to be 
reasonably associated with the use of the study drug or meet the criteria of a 
reportable adverse event as described above, should be reported to the 
Sponsor. 


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Patients withdrawn from the study with an ongoing adverse event must be 
followed clinically until the event is resolved, deemed stable or permanent, or 
the patient starts another treatment for their disease. A stable adverse event is 
defined as an event, which is not expected to change in nature, severity, or 
frequency. The Principal Investigator should continue to report any significant 
follow-up information to the Sponsor. 
8.7 Patient Deaths 
Every effort will be made in the case of patients who die to determine the cause 
of death. Information regarding a patient who dies more than 30 days after 
receiving study drug may be recorded on a Death Report Form (no SAE report 
is required). An SAE report is recorded only if the event leading up to the 
patient’s death began within 30 days of the last administration of study drug. 
The Death Report Form is distinct and separate from the adverse event form 
included in the case report form. 
8.8 Reporting Adverse Events to the Regulatory Authorities 
The Sponsor will be responsible for reporting adverse events to the FDA as 
described in 21 CRF Section 312.32 (IND Safety Reports) and to other 
Regulatory Authorities according to local regulations. 
In addition, the Principal Investigator is required by FDA regulations to notify the 
IRB promptly of all unexpected SAEs occurring at the investigator’s study site. 
The Principal Investigator is also required by FDA regulations to forward the IRB 
all IND Safety Reports received from the sponsor. 
The Sponsor will also report SAEs in compliance with local regulatory 
requirements. 


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9. STUDY DRUG MANAGEMENT 
9.1 Study Drug 
The investigational study drug, alvocidib, will be provided to the Principal 
Investigator by the Sponsor or designee. 
Alvocidib is supplied for parenteral administration as a sterile, nonpyrogenic, 
injectable, clear pale yellow to yellow-colored, 10 mg/mL solution, which is 
packaged in glass vials fitted with coated rubber closures crimped with an 
aluminum seal and light blue plastic cap. Each vial contains 50 mg of alvocidib 
(calculated with reference to the active moiety). The fill volume has been 
established to ensure removal of 5 mL. The pH of the solution ranges between 
2.7 and 3.3. The solution contains the following excipients: water for injection, 
glacial acetic acid, and sodium hydroxide (as needed to reach the targeted pH).  
Cytarabine and daunorubicin, approved pharmaceutical products, will be 
provided by commercially available sources. 
9.2 Study Drug Dispensing and Accountability 
Alvocidib will be provided by the Sponsor to study centers as an investigational 
drug. The label and package for the drug product will be prepared in accordance 
with current regulatory requirements. The Investigator or designee will inventory 
and acknowledge receipt of all shipments of study drugs. The study drugs must 
be kept in a locked area with access restricted to designated study personnel.   
An accurate and current accounting of the dispensing of the study drugs for 
each patient will be maintained on an ongoing basis by a member of the study 
site staff in a drug accountability log or equivalent document and will be verified 
by the sponsor’s study monitor. All drug supplies, including unused study drug, 
must be accounted for. A final inventory of the total amount of drug received at 
each study site against the amount used and returned must be recorded in the 
study drug accountability log or an equivalent document. Inventory and 
dispense records must be readily available for inspection by the study monitor 
and/or auditor, and open to government inspection at any time. Study drug 
destruction will be handled by the sites of open/used vials. Unopened study drug 
vials should be returned to the Sponsor or Courante (CRO) at the end of the 
study only after full drug accountability has been completed by the study 
monitor.  


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9.3 Preparation and Administration 
Alvocidib is to be diluted with either 0.9% Sodium Chloride Injection, USP, or 
5% Dextrose Injection, USP, prior to infusion, providing solutions of 0.09 to 
1.0 mg/mL alvocidib. The diluted solution should be administered according to 
treatment schedule provided in Section 4.3.2.  
Cytarabine (Ara-c), using the 2-gm vial, may be reconstituted with 20 mL of 
Bacteriostatic Water for Injection with Benzyl Alcohol 0.945% w/v added as 
preservative. The resulting solution contains 100 mg of cytarabine per mL. 
Administer according to treatment schedule in Section 4.3.2. 
Daunorubicin Hydrochloride Injection, 5 mg/mL, is available as a deep red 
sterile liquid. The desired dose is withdrawn into a syringe containing 10 mL to 
15 mL of 0.9% Sodium Chloride Injection, USP, and then injected into the tubing 
or side-arm in a rapidly flowing IV infusion of 5% Dextrose Injection, USP, or 
0.9% Sodium Chloride Injection, USP. Daunorubicin hydrochloride should not 
be administered mixed with other drugs or heparin. Administer according to 
treatment schedule in Section 4.3.2.  
Both cytarabine and daunorubicin are approved pharmaceutical products. 
Complete instructions and training on the proper preparation and administration 
of all study drugs will be provided to study sites in the Pharmacy Manual. 
9.4 Storage at Study Center 
x Alvocidib should be stored at USP controlled room temperature (ie, 20°C to 
25°C [68°F to 77°F]) with permitted excursions between 2°C to 30°C (36°F 
to 86°F).  
x Cytarabine (Ara-c) should be stored between 15° to 30°C (59° to 86°F).  
x Daunorubicin (daunorubicin hydrochloride injection) should be stored at 
room temperature, 15° to 30°C (59° to 86°F) for up to 24 hours. Contains no 
preservative. Discard unused portion.  
9.5 Compliance 
Study drugs will be administered by trained staff at the treatment site(s).  


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10. RECORD MANAGEMENT 
10.1 Data Collection 
The Investigator must maintain required records for all study subjects. Case 
report forms are used to record clinical study data and are an integral part of the 
study and subsequent reports. Data for this study will be recorded in the 
subject’s source document and into an electronic Case Report Form (eCRF) 
system that must be kept current to reflect patient status during each part of the 
study. Patients are not to be identified by name on the eCRF. Appropriately 
coded identification (site number, patient identification number, and patient 
initials) should be used. 
Electronic CRFs are not to be used as source documents. Investigators must 
keep accurate separate records (other than the Case Report Forms) of all 
subjects’ visits, being sure to include all pertinent study related information. A 
statement should be made indicating that the subjects have been enrolled in 
this clinical study and have provided written Informed Consent. Any adverse 
events must be thoroughly documented. Results of any diagnostic tests 
conducted during the study should also be included in the source 
documentation.   
All data should be recorded completely and promptly in the eCRFs as soon after 
the visit as possible, but no later than 5 days. All queries are to be answered 
within 3 days of query date.   
The Principal Investigator will allow the Sponsor or its representative, or an 
appropriate representative of the regulatory authorities to inspect study 
documents (eg, consent forms, drug distribution forms, IRB approval) and 
pertinent hospital or clinic records for confirmation of data throughout the study 
period. 
10.2 Source Document Maintenance 
Source documents are defined as the results of original observations and 
activities of a clinical investigation. Source documents may include, but are not 
limited to, hospital medical records, study progress notes, consent forms, 
computer printouts, laboratory data and recorded data from automated 
instruments. All source documents produced in this study will be maintained by 
the Principal Investigator and made available for inspection by representatives 
of the Sponsor or the Regulatory Authorities. The original signed informed 
consent form for each participating patient shall be filed with the records kept 
by the Principal Investigator with a copy filed in the patient’s medical records, 
and a copy given to the patient. 
A source document is an original record of information, also known as source 
data, which is necessary for the reconstruction and evaluation of a clinical trial. 
The purpose of source documents is to provide proof of a participant’s 
existence, confirm that protocol-related procedures were completed and 


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conducted per protocol and to verify that data reported in the study CRFs are 
accurate.  
Source documents at a clinical trial site may be maintained in paper or electronic 
format and typically contain the types of information below.  If electronic source 
documents are used, sponsor and study monitors will be given access to verify 
study data.  
Source documents can include, but are not limited to: 
x Notes from clinic physicians, nurses, and other study staff 
x Reports of procedures and tests 
x Flow sheets, checklists, and worksheets 
x Subject diaries, study calendars 
x Pharmacy records, accountability logs, shipping receipts 
x Study notes or memos to file 
x Documented telephone calls, emails, faxes 
x Hospital admission forms and discharge summaries 
x Sponsor/site-generated study source document templates 
Source documents must meet five fundamental principles of data quality 
(“ALCOA”).  They must be: 
x Attributable – The data originator is identified. If data needs to be 
amended, the amender is identified. 
x Legible – The source document must be readable.  If handwritten, black 
or blue ink must be used, never pencil. 
x Contemporaneous – The document must be signed and dated when the 
information is first recorded, with any updates or corrections noted in real 
time as well. 
x Original – The document must be the first place the information is 
recorded. 
x Accurate – The information must be error-free, and any conflicts with 
data recorded elsewhere must be reconciled. 


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10.3 Record Maintenance 
The Investigator must retain a comprehensive and centralized filing system of 
all clinical study-related documentation that is suitable for inspection by the 
Sponsor and representatives of regulatory authorities.  
The Investigator must retain essential study documents (as specified in 
Section 8 of ICH-GCP and as required by the applicable regulatory 
requirements) until at least 2 years after the last approval of a marketing 
application. Patient files and other source data (including copies of protocols, 
CRFs, original reports of test results, agent-dispensing logs, correspondence, 
records of informed consent, and other documents pertaining to the conduct of 
the trial) must be kept for the maximum period of time permitted by the 
institution. 
No trial document will be destroyed without prior written agreement between the 
Sponsor and the Investigator. Should the Investigator wish to assign the trial 
records to another party or move them to another location, written agreement 
must be obtained from the Sponsor. 
The Principal Investigator shall take responsibility for maintaining adequate and 
accurate hard-copy source documents of all observations and data generated 
during this study, including any data clarification forms (DCF’s) received from 
the Sponsor. Such documentation is subject to inspection by the Sponsor and 
the FDA or other Regulatory Authorities. 
10.4 Study Center File Management 
It will be the responsibility of the Principal Investigator to assure that the study 
file at the center is maintained.  The study file for this protocol will contain, but 
will not be limited to, the information listed below: 
x Investigator’s Brochure (all versions provided during the study period.) 
x Final study protocol. 
x Protocol amendments (if applicable). 
x Original informed consent form (blank). 
x Revised informed consent forms and/or all addenda (if applicable). 
x Copy of signed FDA Form(s) 1572 
x Curricula Vitae and medical licenses of Principal Investigator and 
Subinvestigators. 
x Financial Disclosure Form of Principal Investigator and Subinvestigators 
(if applicable). 


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x DHHS Number for IRB, or other documentation of IRB compliance with 
FDA regulation (US sites). 
x Documentation of IRB/IEC approval of protocol, consent form, any 
protocol amendments and any consent form revisions. 
x Annual IRB/IEC updates and approvals. 
x All correspondence between the Principal Investigator, IRB/IEC and 
Sponsor or Sponsor’s representative relating to study conduct. 
x Copies of all 7-day and 15-day Safety Reports submitted to the 
Regulatory 
Authorities 
(provided 
by 
Sponsor) 
and 
IRB/IEC 
correspondence documenting their submission. 
x Laboratory certifications. 
x Normal laboratory value ranges for tests required by the protocol for all 
laboratories that are utilized. 
x CRA monitoring log. 
x List of signatures and Delegation of Authority for all study personnel 
x Drug invoices for both receipt and return of study drug, as well as drug 
inventory/accountability records. 


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11. STATISTICAL ANALYSIS  
A brief overview of the statistical analysis plan is presented below. Complete 
details of the planned analysis will be documented in a full Statistical Analysis 
Plan, which will be finalized before locking the study database. 
11.1 Statistical Methods 
Statistical analyses will be performed using SAS software version 9.4 or higher. 
In general, data summaries will be compiled by alvocidib dose level and overall 
and will include the mean, standard deviation, median, minimum and maximum 
values for continuous data; the median, 25th and 75th percentiles, minimum and 
maximum values for time-to-event endpoints; and the number and percentage 
of patients in each category for categorical data. Pointwise 95% confidence 
intervals (CI) will also be estimated for the mean (continuous data), median 
(time-to-event endpoints) or percentage of patients (categorical data). 
Baseline value of a characteristic is defined as the last measured value prior to 
the first dose of alvocidib. 
11.2 Sample Size 
Given the design and primary objectives of this study, the sample size will be 
determined by the guidelines governing dose escalation/de-escalation and the 
identification of DLTs. As a result, the final sample size is not fixed and will not 
be determined by consideration of inferential analyses conducted via statistical 
hypothesis testing. It may be anticipated that the study sample size will be up to 
40 patients. This is based on observing DLTs in 2 of 3 patients enrolled at the 
fourth dose level (Cohort 4) and declaring the third dose level as the MTD 
(3 patients each in the first and second dose levels, 6 patients in the third dose 
level during dose escalation, 3 patients at the fourth dose level, and an 
additional 20 patients at the third dose level for confirmation of safety as well as 
additional safety analysis and feasibility for determining MRD by dual methods 
[ie, MPFC and NGS] at a central laboratory). However, the actual number of 
patient enrolled may be slightly more or less depending on the actual pattern 
and frequency of DLTs. 
11.3 Data Analyses 
The MTD is defined as the largest dose for which fewer than 33% of patients 
experience a DLT. The MTD will be estimated by the highest alvocidib dose for 
which the empirical incidence of DLT during Cycle 1 was less than 33% in 
combination with 7+3. 


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Incidence rates of treatment-emergent adverse events will be summarized 
within treatment group at the MedDRA preferred term and primary system organ 
class levels. Similar summaries will be made for subsets of AEs such as 
(1) those judged by the Investigator to be related to study treatment, and (2) 
serious adverse events (SAEs). 
Other routine safety assessments (eg, clinical laboratory parameters and vital 
signs) will be summarized by standard deviation, median, minimum and 
maximum observed values and changes from baseline values.  
The multivariate analysis and risk score prediction model by Montesinos and 
colleagues [38] will be used to assess the potential for development of TLS (see 
Appendix F). 
11.3.1 
Demographics and Baseline Characteristics 
Demographics and baseline characteristics will be summarized by alvocidib 
dose level and overall using descriptive statistics and confidence intervals. 
11.3.2 
Efficacy Analyses 
Objective response to treatment will be determined using the remission 
definitions detailed in the 2017 European LeukemiaNet Recommendations in 
AML [10] after Induction/Reinduction (for those patients not achieving a CR after 
Cycle 1) (see Appendix E). 
x CRMRD- = CR without MRD 
x CR = Complete Remission (including patients with morphologic CR who 
are MRD+ and cytogenetic and/or molecular marker positive) 
x CRi = CR with incomplete hematologic recovery 
x MLFS = Morphologic leukemia-free state 
x PR = Partial Remission 
x SD = Stable Disease 
x PD = Progressive Disease 
The numbers of overall complete remissions (patients with a best objective 
response of CRMRD, CR, CRi or MLFS), and overall remissions (patients with a 
best objective response of CRMRD, CR, CRi, MLFS or PR) will be summarized 
by observed rates and estimated 95% CIs. If there are sufficient numbers of 
patients achieving remissions for an analysis to be informative, logistic 
regression will be used to model the probability of achieving a remission as a 
function of the total alvocidib daily dose level (bolus dose amount + infusion 
dose amount) and biomarker prediction endpoints (eg, MRD). 


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Kaplan-Meier time-to-event analyses will be conducted on overall survival, 
relapse-free survival and duration of remission. Mortality (all causes) at 30 and 
60 days will also be calculated. Cox proportional hazards models will be fit to 
these time-to-event endpoints with the total alvocidib daily dose level (bolus 
dose amount + infusion dose amount) and biomarker prediction endpoints (eg, 
MRD) serving as independent variables in the model. 
Additional exploratory analyses may be performed to assist the sponsor in 
planning future studies. 
11.3.3 
Biomarker Prediction Endpoint Analyses 
Summary of baseline biomarker values will include within– and between–
treatment-arm descriptive statistics. If there are sufficient numbers of patients 
achieving remissions for an analysis to be informative, a logistic regression 
model will be fit to examine the relationship between baseline results and other 
potential biomarkers (including, but not limited to, MCL-1 dependency) and the 
independent binary variables complete remissions and overall remissions 
during the study. In addition, area under the curve (AUC) and 95% CI will be 
calculated (by alvocidib dose level) for the trapezoidal receiver operating 
characteristic curve. This value will quantify the ability of certain biomarkers 
(including, but not limited to, MCL-1 dependency) to predict complete/overall 
remissions. 
11.3.4 
Safety Analyses 
The following safety analyses will be performed on all patients who receive at 
least one dose of study drug. 
x Adverse Events = Reported adverse event (AE) terms will be mapped 
to MedDRA preferred terminology. All reported events will appear in AE 
listings, however only treatment-emergent adverse events will be 
summarized. A treatment-emergent adverse event (TEAE) is an AE that 
starts or increases in severity any time after the first administration of any 
study drug up to 30 days following the last administration of any study 
drug. AE severity will be rated by the investigator according to NCI 
CTCAE version 4.03.  
x Clinical Laboratory Assessments = Laboratory test results measured 
on a continuous scale and changes from baseline values will be 
summarized by visit and within alvocidib dose level using mean, standard 
deviation, median, minimum and maximum values. Categorical test 
results will be summarized within alvocidib dose level using shift tables. 
Additionally, for tests where NCI CTCAE, version 4.03, severity criteria 
are specified, NCI CTCAE severity grades will be summarized in shift 
tables. 


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x Vital Signs = Vital signs and changes from baseline values will be 
summarized by visit and within alvocidib dose level using mean, standard 
deviation, median, minimum and maximum values. 


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12. PROTOCOL AMENDMENTS 
Any permanent change to the protocol must be handled as a protocol 
amendment. Protocol amendments will be written by the Sponsor. All protocol 
amendments must be submitted in writing to the Institutional Review Board 
(IRB)/Independent Ethics Committee (IEC), and the Principal Investigator must 
await IRB/IEC approval of the amendments before implementing the changes. 
However, a protocol change that is intended to eliminate an apparent immediate 
hazard to patients may be implemented immediately and the IRB/IEC is to be 
notified within five (5) days. The Sponsor should also be notified by telephone 
as soon as possible, ideally before the amendment is implemented and 
definitely within 5 days. The Sponsor will submit protocol amendments to the 
Regulatory Authorities. 
When an amendment to the protocol substantially alters the study design and/or 
increases the potential risk to the patient, the currently approved written 
informed consent form will require similar modification and IRB/IEC approval. In 
such cases, repeat written informed consent will be obtained from patients 
currently enrolled in the study before expecting continued participation. 


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13. MONITORING 
Prior to enrolling any participants, a study initiation visit (SIV), including protocol 
training, will be conducted for the study center. A Study Manual of Procedures 
will be provided to each clinical site. A record of site personnel training will be 
maintained by the site onsite training logs. 
Clinical Research Associates (CRAs) and other applicable personnel will 
receive training prior to study initiation about the disease, applicable Standard 
Operating Procedures (SOPs), the protocol and other study-specific items. 
Team organization, communication, and operational issues will also be 
discussed. 
The conduct of the study will be closely monitored by representatives (Clinical 
Research Associates “CRAs” or study monitors) of the Sponsor or designee, to 
verify adherence to the Protocol, ICH GCP guidelines, and applicable 
regulations. The CRA will verify eCRF entries by comparing them with 
Sponsor/site-generated source documents, hospital, clinic, office and/or study 
records which will be made available for this purpose. CRAs will monitor the 
study as outlined in the Monitoring Plan prepared for the study. 
During the study, CRAs will visit the clinical sites to assess and assure 
satisfactory enrollment rate, data recording, and maintenance of required 
regulatory documentation, drug accountability, and compliance with the 
protocol.  CRAs will also be able to monitor the data remotely. The Investigator 
will ensure that all requested materials, including subject charts, eCRFs, source 
documents, laboratory records, and drug inventory records, will be available to 
the CRA. At the end of the study, a closeout visit (COV) will be performed.   
The Investigator will allow Sponsor’s representatives, designee and/or and any 
regulatory agency to have direct access to all study records, eCRFs, 
corresponding subject medical records, test product dispensing records and test 
product storage area, and any other documents considered source 
documentation. The Investigator also agrees to assist the representative, if 
required. 


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14. AUDITING 
The study is conducted under the sponsorship of Tolero Pharmaceuticals, Inc, 
in compliance with the applicable international and local regulatory 
requirements as well as applicable ICH guidelines, Helsinki (1964, 1975, 1983, 
1989, 1996, 2000, 2002, 2004, 2008, 2013) and in respect of the Sponsor or 
designee’s SOPs for study conduct and monitoring. 
Audits may be carried out by Sponsor representatives, and inspection may be 
performed by regulatory authorities’ inspectorate or IRBs/IECs before, during, 
or after the study. The Investigator will allow and assist Sponsor’s 
representatives and any regulatory agency to have direct access to all study 
records, eCRFs, subject medical records, study product dispensing records and 
study product storage area, study facilities, and any other documents 
considered source documentation.   
For the Audit(s) performed by, or on behalf of, Sponsor’s auditors, audit 
certificate(s) will be provided by Quality Assurance. 


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15. ETHICS AND RESPONSIBILITY 
15.1 Principal Investigator’s Responsibilities 
The Principal Investigator shall ensure that all work and services described 
herein, or incidental to those described herein, shall be conducted in 
accordance with the highest standards of Good Clinical Practice (GCP). The 
Principal Investigator shall administer the investigational drug only to patients 
under his/her personal supervision, or under the supervision of any Sub-
Investigator(s) responsible to him/her, who are identified on the Form FDA 
1572/Regulatory Authorities approval form. The Principal Investigator will 
provide copies of the study protocol, amendments, and investigational brochure 
to all Sub-Investigators, Pharmacists, or other staff responsible for study 
conduct. 
With the exception of eliminating an immediate hazard to a subject, the 
Investigator should not deviate from the protocol or implement any changes 
without written prior approval from Sponsor and prior review and documented 
approval/favorable opinion from the IRB/IEC of an amendment. 
Change(s) which involve(s) only logistical or administrative changes are 
authorized. The Investigator should document and explain any deviation from 
the protocol. 
The Investigator is responsible for adequate and safe medical care of subjects 
during the trial and for ensuring that appropriate medical care and relevant 
follow-up procedures are maintained after the trial. Any additional data from 
these follow-up procedures must be documented and available to Sponsor who 
will determine whether or not the data need to be documented in the case report 
forms. 
15.2 Informed Consent 
It is the ethical and legal responsibility of the Principal Investigator to ensure 
that each patient considered for inclusion in this study is given a full explanation 
of the protocol, in a language in which the patient is fluent, and in which the 
patient will clearly understand. This shall be documented on a written informed 
consent form, which shall be approved by the same IRB/IEC responsible for 
approval of this protocol. Each informed consent form shall include the elements 
required by local regulations. The Sponsor will draft this document in 
consultation with the Principal Investigator. The Principal Investigator agrees to 
obtain written approval of the consent form from the Sponsor prior to submission 
to the IRB/IEC. 
Once the appropriate essential information has been provided to the patient and 
fully explained by the Principal Investigator (or his/her qualified Designee) and 
it is felt that the patient understands the implications of participating in the study, 
the IRB/IEC-approved consent form shall be signed by the patient, a witness 
(when appropriate) and the Principal Investigator. Written informed consent will 


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be obtained from each patient prior to any study-related procedures (including 
any pre-treatment procedures) that are performed. The patient shall be given a 
copy of the informed consent form when signed; the original shall be kept on file 
by the Principal Investigator and a second copy shall be placed in the patient’s 
medical chart.  
15.3 Institutional Review Board/Independent Ethics Committee 
This protocol and all amendments will be reviewed and approved by the 
Institutional or Independent Review Board(s) or Independent Ethics 
Committee(s) charged with this responsibility at the study center. Notification in 
writing of approval must come from the Chairman or the Secretary of the 
IRB/IEC meeting minutes where this protocol and associated informed consent 
form were discussed. The Principal Investigator shall not participate in the 
decision, and, if an IRB/EC member, the written approval must indicate such 
non-participation. The Principal Investigator shall submit status reports to the 
IRB/IEC no less frequently than annually (when applicable).  
The IRB/IEC must be notified by the Principal Investigator in writing of the 
interruption and/or completion of the study; the Principal Investigator must 
promptly report to the IRB/IEC all changes in research (protocol amendments) 
and will not make such changes without IRB/IEC approval, except where 
necessary to eliminate apparent immediate hazards to human patients. In these 
cases, the IRB/IEC must be notified within five days of the change. The Principal 
Investigator will promptly report to the IRB/IEC all unanticipated problems 
involving risk to patients or others. The Principal Investigator is required to 
maintain an accurate and complete record of all written correspondence to, and 
received from the IRB/IEC, and must agree to share all such documents and 
reports with the Sponsor. 


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16. CONFIDENTIALITY 
The existence of this clinical study is confidential and should not be discussed 
with persons outside of the study.  The Investigator shall hold confidential, and 
not disclose directly or indirectly to any third party other than those persons 
involved in the study who have a need to know, the protocol, the data arising 
out of the study, and any other information related to the study or to Tolero’s 
products or research programs that is provided by Tolero to you (the 
“Confidential Information”).  All such persons must be instructed not to further 
disseminate this information to others.  Investigator shall not use the 
Confidential Information for any purpose other than the study.  The foregoing 
obligations of confidence and non-use assumed by you shall not apply to: (a) 
information which at the time of disclosure is in the public domain; (b) 
information which thereafter lawfully becomes part of the public domain other 
than through disclosure by or through you; (c) information which, as evidenced 
by your written records, was known by you prior to Tolero’s disclosure; (d) 
information which is lawfully disclosed to you by a third party not under any 
obligation of confidence to Tolero; or (e) information which is required to be 
disclosed by law or government regulatory agency, provided reasonable 
advance notice of such disclosure is given to Tolero.  
All information generated in this study must be considered highly confidential 
and must not be disclosed to any persons not directly concerned with the study, 
without written permission from the Sponsor. However, authorized drug 
regulatory officials and the Sponsor’s representatives will be allowed full access 
to the records.   
Patients will be identified only by initials and assigned a patient number. Their 
full names may, however, be made known to a drug regulatory agency or other 
authorized official if necessary.  
All data and discoveries arising out of the study, patentable or non-patentable, 
shall be the sole property of Tolero, Inc. 
In signing this protocol, Investigator agrees to the release of the data from this 
study and acknowledges the above confidentiality and publication policy.  The 
provisions of this Statement shall survive the completion of the study.  
Clinical information will not be released without the written permission of the 
patient, except as necessary for monitoring by the Sponsor or the Regulatory 
Authorities, or as required by law. 


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17. NONPROTOCOL RELATED RESEARCH 
The Sponsor has a legal responsibility to report fully to regulatory authorities all 
the results of administration of investigational drugs. No investigative 
procedures other than those in this protocol shall be undertaken on the enrolled 
patients without the agreement of the IRB/IEC and the Sponsor’s medical 
monitor. 


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18. PUBLICATIONS 
The publication policy for the study will be described in the clinical study 
agreement. To avoid disclosures that could jeopardize proprietary rights, the 
investigator agrees to give Tolero Pharmaceuticals, Inc, the right to review all 
manuscripts, abstracts, and presentations related to this study prior to their 
submission for publication or presentation. Tolero may use these data now and 
in the future for presentation or publication at Tolero’s discretion or for 
submission to government regulatory agencies.  
Authorship among Investigators generally will be based on the extent of 
significant contribution, including scientific and clinical, to the publication. 
 
 


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33. Karp JE, Blackford A, Smith BD, et al. Clinical activity of sequential 
flavopiridol, cytosine arabinoside, and mitoxantrone for adults with newly 
diagnosed, poor-risk acute myelogenous leukemia. Leuk Res 2010;34:877–
882. (Study No. J0669 / NCI7845). 
34. Karp JE, Smith BD, Resar LS, et al. Phase 1 and pharmacokinetic study of 
bolus-infusion flavopiridol followed by cytosine arabinoside and mitoxantrone 
for acute leukemias. Blood 2011;117:3302–3310. (Phase 1 Study No. 
J06133 / NCI7889). 
35. Litzow MR, Wang XV, Carroll MP, et al. Randomized Phase II Trial of Three 
Novel Regimens for Relapsed/ Refractory Acute Myeloid Leukemia (AML) 
Demonstrates Encouraging Results with a Flavopiridol-Based Regimen: 
Results of Eastern Cooperative Oncology Group (ECOG) Trial E1906. Proc 
ASH: Blood 2014 #3742. 
36. Karp JE, Garrett-Mayer E, Estey EH, et al. Randomized phase II study of two 
schedules of flavopiridol given as timed sequential therapy with cytosine 
arabinoside and mitoxantrone for adults with newly diagnosed, poor-risk 
acute myelogenous leukemia. Haematologica 2012;97:1736–1742. 
37. Zeidner JF, Foster MC, Blackford AL, et al. Randomized multicenter phase 
2 study of flavopiridol (alvocidib), cytarabine, and mitoxantrone (FLAM) 
versus cytarabine/daunorubicin (7+3) in newly diagnosed acute myeloid 
leukemia. Haematologica 2015;100(9):1172–1179. (Phase 2 Study No. 
J1101/NCI-8972). 
38. Montesinos P, Lorenzo I, Martín G, et al. Tumor lysis syndrome in patients 
with acute myeloid leukemia: identification of risk factors and development 
of a predictive model. Haematologica 2008;93(1):67–74. 
 




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b 
Vital signs to include: temperature, heart rate, systolic and diastolic blood pressures 
c 
May omit if performed/obtained within 30 days prior to anticipated first dose 
d 
See Appendix D – Laboratory Tests  
e 
&ROOHFWXULQHRUVHUXPVDPSOHIRUȕ-hCG pregnancy test for females of child-bearing potential 
f 
Diligent monitoring of urine output frequently to ensure that it equals fluid input. If input is greater than output by 10%, administration of diuretics 
is encouraged. Replacement of excessive fluid losses, including from diarrhea, should be done unless otherwise clinically indicated. 
g 
Toxicities will be assessed according to the NCI CTCAE, version 4.03 (See Appendix C). When the NCI CTCAE grade is not available, the 
investigator will use the following toxicity grading: mild, moderate, severe, life-threatening or fatal. 
h 
Bone marrow biopsy and/or aspiration and peripheral blood collected for diagnosis, cytogenetic profiling, MPFC, molecular testing, and 
assessment of other potential biomarkers.  
i 
Including all prescription and nonprescription medications and nutritional supplements taken within the past 2 weeks 
j 
Including all prescription and nonprescription medications and nutritional supplements taken since screening 
k 
May be conducted within 10 hours prior to first dose 
l 
Mandatory IV hydration with 0.45% NaCl (or similar hydration fluid per institutional standard) sterile solution at 100 cc/hour for at least 10 hours 
prior to initiation of first dose during Cycle 1 (optional for subsequent cycles) (Section 4.4.1.1). If, by Day 4, there is no evidence of tumor lysis 
syndrome, the hydration rate can be reduced to a maintenance level.  Mandatory allopurinol orally each day of dosing for first cycle to be started 
at same time as initiation of IV hydration.  Mandatory oral phosphate binder to be started at the same time as initiation of IV hydration, unless 
contraindicated. 
m Measured 5-15 minutes prior to the initiation of infusion following a 5-minute rest 
n 
Required if screening pregnancy test was performed greater than 72 hrs prior to first dose 
o 
To include only those medications (prescription, nonprescription, nutritional supplements) administered in conjunction with an AE  
p 
Only required if clinically indicated 
q 
Abbreviated physical examination (AE- or symptom-directed exam) 
r 
Bone marrow biopsy and peripheral blood sample collected, unless medically contraindicated, for disease assessment including MRD and 
assessment of other potential biomarkers. Central laboratory assessment of MRD is to be done for disease assessment and treatment guidance. 
Patients with no evidence of residual leukemia will be monitored weekly (as in Section 5.2.4) until hematologic recovery (Section 5.2.6). Patients 
with evidence of residual leukemia (>5% bone marrow blasts plus >10% cellularity) may be eligible for a second Induction cycle (or ‘Reinduction’) 
with alvocidib and 5+2 at the discretion of the Investigator (Section 5.3). 
s 
Response assessment to include MRD via peripheral blood and bone marrow biopsy samples collected at the time of hematologic recovery (ie, 
absolute neutrophil count [ANC] >1000/μL and platelet count >100,000/μL) or Day 50 [±3 days], counted from Day 1 of Induction therapy, 
whichever occurs first. These same samples will also be used for assessment of other potential biomarkers. Central laboratory assessment of 
MRD is to be done for disease assessment and treatment guidance. If the bone marrow biopsy and/or aspirate is nonproductive or not diagnostic, 
the procedure must be repeated within 7-10 days. Additional bone marrow assessments may be obtained per Investigator discretion.  
t 
Including tumor lysis clinical symptoms 
u 
Complete physical examination including height (cm) and weight (kg) 
v 
Record results of molecular testing from bone marrow or peripheral blood that was collected as standard of care  
w 
Collect blood for evaluation of serum bilirubin, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline 
phosphatase (ALP) levels 
 




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j 
Measured 5-15 minutes prior to the initiation of infusion following a 5-minute rest 
k 
Only required if clinically indicated 
l 
Or more frequently if clinically indicated 
m Abbreviated physical examination (AE- or symptom-directed exam). 
n 
Collect blood for evaluation of serum bilirubin, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline 
phosphatase (ALP) levels 
o 
Following Reinduction, response assessment to include MRD via peripheral blood and bone marrow biopsy samples collected at the time of 
hematologic recovery (ie, absolute neutrophil count [ANC] >1000/μL and platelet count >100,000/μL) or Day 60 [±3 days], counted from Day 1 
of Induction therapy, whichever occurs first. These same samples will also be used for assessment of other potential biomarkers. Central 
laboratory assessment of MRD is to be done for disease assessment and treatment guidance. If the bone marrow biopsy and/or aspirate is 
nonproductive or not diagnostic, the procedure must be repeated within 7-10 days. Additional bone marrow assessments may be obtained per 
Investigator discretion.  
p 
Including tumor lysis clinical symptoms. 
 
 
 
 
 
 




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h 
Toxicities will be assessed according to the NCI CTCAE, version 4.03 (see Appendix C).  When the NCI CTCAE grade is not available, the 
investigator will use the following toxicity grading: mild, moderate, severe, life-threatening or fatal 
i 
Measured 5-15 minutes prior to the initiation of infusion following a 5-minute rest 
j 
Abbreviated physical examination (AE- or symptom-directed exam). 
k 
After Cycle 2 and Cycle 4, assess response including MRD via peripheral blood and bone marrow biopsy samples collected at the time of 
hematologic recovery (ie, absolute neutrophil count [ANC] >1000/μL and platelet count >100,000/μL). These same samples will also be used 
for assessment of other potential biomarkers. Central laboratory assessment of MRD is to be done for disease assessment and treatment 
guidance. If the bone marrow biopsy and/or aspirate is nonproductive or not diagnostic, the procedure must be repeated within 7-10 days. 
Additional bone marrow assessments may be obtained per Investigator discretion.  
l 
If, at any time, a patient discontinues study treatment, a visit should be scheduled as soon as possible and within 14 days of the last dose of 
study drug or within 14 days of the decision to discontinue study treatment. If the decision to withdraw the patient occurs at a regularly scheduled 
visit, that visit may become the End of Study visit rather than having the patient return for an additional visit. 
m Complete physical examination including measures of disease and disease symptoms, eg, extramedullary disease. 
n 
Perform bone marrow biopsy and/or aspiration (if not done in the preceding 30 days) for determination of disease status including MRD and 
assessment of other potential biomarkers. If the bone marrow biopsy and/or aspirate is nonproductive or not diagnostic, the procedure must be 
repeated within 7-10 days. 
o 
Patients must have a safety evaluation 30 days after the last dose of study drug to assess any ongoing AEs and to record concomitant 
medications administered with an AE, as well as any antineoplastic therapies initiated since discontinuation of study drug.  
p 
Record only those medications (prescription, nonprescription, and nutritional supplements) administered in conjunction with an AE, as well as 
any antineoplastic therapies initiated since discontinuation of study drug. 
q 
Ongoing AEs must be followed clinically until the event is resolved, deemed stable, or the patient starts another treatment for their disease. 
r 
Collect blood for evaluation of serum bilirubin, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline 
phosphatase (ALP) levels 
s 
All study patients will be attempted to be contacted by phone, if possible, every 6 months to assess for date of death, date of stem 
cell transplant, date of relapse, or continued remission beginning the month after the patient completes the End of Study assessments 
to 24 months after Day of First Dose regardless of how many cycles a patient receives. When telephone contact is not possible, 
medical records will serve as the surrogate to assess for these outcomes. 
 
 
 


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APPENDIX B – ECOG PERFORMANCE STATUS SCALE 
 
ECOG PERFORMANCE STATUS* 
Grade ECOG 
0 
Fully active, able to carry on all pre-disease performance without 
restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to 
carry out work of a light or sedentary nature, e.g., light house work, 
office work 
2 
Ambulatory and capable of all selfcare but unable to carry out any work 
activities. Up and about more than 50% of waking hours 
3 
Capable of only limited selfcare, confined to bed or chair more than 
50% of waking hours 
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to 
bed or chair 
5 
Dead 
Oken MM, Creech RH, Tormey DC, et al. Toxicity And Response Criteria Of The Eastern Cooperative 
Oncology Group. Am J Clin Oncol 1982;5:649-655. 
Available at: http://www.ecog.org/general/perf_stat.html 
*The ECOG Performance Status is in the public domain therefore available for public use. To duplicate 
the scale, please cite the reference above and credit the Eastern Cooperative Oncology Group, Robert 
Comis, MD, Group Chair. 
 
 


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APPENDIX C – NCI COMMON TERMINOLOGY CRITERIA FOR ADVERSE EVENTS  
View the National Cancer Institute’s Common Terminology Criteria for Adverse 
Events v4.03 (NCI CTCAE) electronically at the following Web site:  
https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE 4.03/CTCAE 4.03 2010-06-
14 QuickReference 8.5x11.pdf 
The Study Manual includes a copy of the NCI CTCAE.  
 
 


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APPENDIX D – LABORATORY TESTS 
Hematology 
x 
CBC with manual differential 
x 
Platelet Count 
 
Note:  A manual differential is the preferred method and is 
required on each day that the assessment is done.  Automated 
differentials may be used for subsequent differentials performed 
on the same day. 
Full Serum 
Chemistry 
x 
Blood urea nitrogen (BUN) 
x 
Phosphorus 
x 
Magnesium 
x 
Lactate dehydrogenase (LDH) 
x 
Creatinine 
x 
Uric acid 
x 
Total protein 
x 
Albumin 
x 
Calcium 
x 
Glucose 
 
x 
Total bilirubin 
x 
Alkaline phosphatase (ALP) 
Aspartate aminotransferase 
(AST) 
x 
Alanine aminotransferase 
(ALT) 
x 
Electrolytes  
o Sodium 
o Potassium 
o Chloride  
o Carbon dioxide 
(bicarbonate) 
Tumor Lysis Labs 
x 
Phosphorus 
x 
Uric acid 
x 
Electrolytes (sodium, 
potassium, chloride, and 
carbon dioxide)  
x 
LDH* 
x 
Creatinine 
x 
Calcium 
Coagulation 
x 
Fibrinogen 
 
Urinalysis 
x 
Color 
x 
Specific gravity 
x 
pH 
x 
Bilirubin 
x 
Ketones 
x 
Glucose 
x 
Occult Blood (Hemoglobin) 
x 
Leukocyte esterase 
x 
Protein 
x 
Urobilinogen 
x 
Nitrites 
 
Microscopic 
x 
White blood cells (WBCs) 
x 
Red blood cells (RBCs) 
x 
Casts, crystals, bacteria 
Cardiac Tests 
x 
12-lead Electrocardiogram 
(ECG) 
 
x 
Echocardiogram (ECHO) or 
Multigated Acquisition 
(MUGA) scan 
Biomarker Tests 
x 
Minimal residual disease (MRD) using standardized techniques 
(ie, multiparametric flow cytometry [MPFC] and next generation 
sequencing [NGS]) and other potential biomarkers including, but 
not limited to, MCL-1 dependency 
Other Tests 
x 
Pregnancy test (urine or serum 
GHWHUPLQDWLRQRIȕ-hCG in 
females of childbearing 
potential) 
x 
Chest radiograph  
*Recommended every 24 hours in patients receiving alvocidib. 
 


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APPENDIX E – RESPONSE CRITERIA 
(2017 EUROPEAN LEUKEMIANET RECOMMENDATIONS) 
 
*Including patients with morphologic CR who are MRD+ and cytogenetic and/or molecular marker positive. 
 
 
*






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APPENDIX F – MULTIVARIATE ANALYSIS AND RISK SCORE PREDICTION MODEL FOR DEVELOPMENT OF TUMOR 
LYSIS SYNDROME IN AML 
 
 
CTLS = clinical tumor lysis syndrome; LDH = lactate dehydrogenase;  
ULN = upper limit of normal; WBC = white blood cells 
*Patients with an overall score of 2 will be considered at high risk for  
development of TLS in this study.  
 
 
Source: Montesinos P, Lorenzo I, Martín G, et al. Haematologica 2008;93(1):67–74. 
*


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APPENDIX G – ASSESSMENT OF PRIOR AND CUMULATIVE 
ANTHRACYCLINE/ANTHRACENEDIONE EXPOSURE* 
 
 
 
 

SAP_001.pdf: 
STATISTICAL ANALYSIS PLAN 
Study Title: 
A Phase 1, Open-label, Dose-escalation, Safety 
and Biomarker Prediction Study of Alvocidib and 
Cytarabine/Daunorubicin (7+3) in Patients with 
Newly Diagnosed Acute Myeloid Leukemia (AML) 
Protocol Number: 
TPI-ALV-101 
IND Number: 
057729 
Study Drug: 
Alvocidib (test agent; formerly flavopiridol) in 
combination with Ara-C (cytarabine) and 
mitoxantrone 
Phase of Development: 
Phase 1 
Sponsor: 
Sumitomo Dainippon Pharma Oncology, Inc. 
3900 North Traverse Mountain Blvd, Suite 100 
Lehi, UT USA 84043 
Date of SAP: 
28 July 2019 (Version 1.0) 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-101 
 
28 July 2019 
Sumitomo Dainippon Pharma Oncology 
 
2 | 27 
Table of Contents 
1. 
Synopsis .................................................................................................................. 4 
2. 
Abbreviations ........................................................................................................... 5 
3. 
Definitions ................................................................................................................ 7 
4. 
Introduction .............................................................................................................. 8 
4.1. Study Endpoints ................................................................................................. 8 
4.2. Statistical Objectives .......................................................................................... 9 
5. 
Sample Size ........................................................................................................... 10 
6. 
Treatment Assignment ........................................................................................... 10 
7. 
Statistical Methods ................................................................................................. 10 
7.1. Analysis Populations ........................................................................................ 10 
7.2. Missing Values ................................................................................................. 11 
7.3. Visit Windows ................................................................................................... 11 
7.4. Interim Analysis ................................................................................................ 11 
7.5. Patient Disposition ........................................................................................... 12 
7.6. Baseline Characteristics ................................................................................... 12 
7.7. Study Drug Exposure ....................................................................................... 12 
7.8. Efficacy Endpoints ............................................................................................ 13 
7.8.1. 
Remission Rates ....................................................................................... 13 
7.8.2. 
Progression-Free Survival ......................................................................... 13 
7.8.3. 
Overall Survival ......................................................................................... 14 
7.8.4. 
Relapse-Free Survival Following CR ......................................................... 15 
7.8.5. 
Complete Remission Duration ................................................................... 15 
7.8.6. 
ECOG Performance Status ....................................................................... 16 
7.9. Biomarker ......................................................................................................... 16 
7.10. Safety Endpoints .............................................................................................. 17 
7.10.1. 30- and 60-Day Mortality ........................................................................... 17 
7.10.2. Adverse Events ......................................................................................... 17 
7.10.3. Classification of Tumor Lysis Syndrome .................................................... 18 
7.10.4. Clinical Laboratory Parameters ................................................................. 18 
7.10.5. Neutrophil Recovery .................................................................................. 19 
7.10.6. Platelet Recovery ...................................................................................... 19 


Statistical Analysis Plan 
 
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Sumitomo Dainippon Pharma Oncology 
 
3 | 27 
7.10.7. Concomitant Medication Use ..................................................................... 19 
8. 
Adverse Event and Medication Coding Dictionaries............................................... 20 
9. 
Summary Tables .................................................................................................... 20 
10. References ............................................................................................................. 23 
 
List of Tables 
Table 1. 
Study Endpoints ............................................................................................. 8 
Table 2. 
Cairo-Bishop Definition of Laboratory Tumor Lysis Syndrome ..................... 18 
Table 3. 
Planned Summary Tables ............................................................................ 20 
 
List of Appendices 
Appendix 1. 
Criteria for Grading Severity of Clinical Tumor Lysis Syndrome ............. 24 
Appendix 2. 
Sample Table Template ......................................................................... 25 
 
 


Statistical Analysis Plan 
 
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Protocol TPI-ALV-101 
 
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Sumitomo Dainippon Pharma Oncology 
 
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1. Synopsis 
Protocol Title: 
A Phase 1, Open-label, Dose-escalation, Safety and Biomarker Prediction Study of 
Alvocidib and Cytarabine/Daunorubicin (7+3) in Patients with Newly Diagnosed Acute 
Myeloid Leukemia (AML) 
Study Design: 
Open label, multicenter, 3+3 cohort dose escalation of alvocidib for induction therapy 
combined with 7+3 cytarabine and daunorubicin, followed by optional reinduction with 
alvocidib combined with 5+2 cytarabine and daunorubicin and/or up to 4 cycles of 
consolidation therapy with high-dose cytarabine (HiDAC) 
Study Populations: 
Patients with newly diagnosed, previously untreated AML excluding acute promyelocytic 
leukemia or core-binding factor AML 
Induction Therapy (alvocidib with 7+3): 
x Alvocidib on Days 1-3 
x 20-mg/m2 IV bolus followed by 30-mg/m2 IV infusion over 4 hours, or 
x 30-mg/m2 IV bolus followed by 40-mg/m2 IV infusion over 4 hours, or 
x 30-mg/m2 IV bolus followed by 50-mg/m2 IV infusion over 4 hours, or 
x 30-mg/m2 IV bolus followed by 60-mg/m2 IV infusion over 4 hours 
x Cytarabine 100 mg/m2/day continuous IV infusion on Days 5-11 
x Daunorubicin 60-mg/m2 IV bolus on Days 5-7 
Optional Reinduction Therapy (alvocidib with 5+2): 
x Alvocidib on Days 1-3 at the same dose used for induction 
x Cytarabine 100 mg/m2/day continuous IV infusion on Days 5-9 
x Daunorubicin 60-mg/m2 IV bolus on Days 5-6 
Optional Consolidation Therapy (HiDAC up to 4 cycles): 
x Cytarabine 3 g/m2 IV q12h on Days 1, 3 and 5 for a total of 6 doses 
x A reduced dose of 1.5 g/m2 IV q12h was permitted for patients ш60 years old 
Sample Size: 
A sufficient number of patients to complete a standard 3+3 cohort dose escalation for up 
to 4 dose levels plus up to 20 additional patients enrolled at the maximum tolerated 
dose (MTD) of alvocidib 
Analysis Populations: 
Intent-to-treat (primary for efficacy), safety, per-protocol 


Statistical Analysis Plan 
 
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Response Assessments: 
Local review of bone marrow and blood test results by the investigator at the study 
center where patient is enrolled to classify response to treatment following to European 
LeukemiaNet (ELN) criteria1 
Missing Values: 
Missing values will not be replaced by imputed values. Patients who do not supply bone 
marrow for response assessment are counted among those not achieving remission. 
Missing time-to-event endpoints will be censored using standard rules detailed below. 
Interim Analysis: 
No interim analyses. Ongoing review of clinical data performed as required for dose 
escalation/de-escalation decisions 
Efficacy Endpoints: 
CR rate (primary endpoint), combined CR rate, combined remission rate, stem cell 
transplant rate, overall survival, progression-free survival, relapse-free survival, CR 
duration 
Safety Endpoints: 
30- and 60-day survival, adverse events, time to neutrophil recovery, time to platelet 
recovery, prevalence of tumor lysis syndrome, clinical laboratory parameters, vital signs  
Statistical Methods: 
Descriptive statistics (including 95% confidence intervals) within and across alvocidib 
dose levels 
2. Abbreviations 
Standard abbreviations (e.g., AML = acute myeloid leukemia and mg = milligrams) are 
omitted intentionally. 
AE 
Adverse Event 
AML 
Acute Myeloid Leukemia 
ANC 
Absolute Neutrophil Count 
ATC 
Anatomical and Therapeutic Class 
AUC 
Area Under Curve 
BM 
Bone Marrow 
BSA 
Body Surface Area 
CI 
Confidence Interval 
CM 
Ara-C (Cytarabine) and Mitoxantrone 
CMH 
Cochran-Mantel-Haenszel (test) 
CR 
Complete Remission 


Statistical Analysis Plan 
 
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CRi 
Complete Remission with Incomplete Blood Count Recovery 
CTCAE 
Common Terminology Criteria for Adverse Events 
DDE 
Drug Dictionary Enhanced 
DLT 
Dose-Limiting Toxicity 
DSMB 
(Independent) Data Safety Monitoring Board 
ECOG 
Eastern Cooperative Oncology Group (performance status) 
ELN 
European LeukemiaNet 
HiDAC 
High-Dose Cytarabine 
HR 
Hazards Ratio 
ITT 
Intent-to-Treat (patient population) 
IWG 
International Working Group 
KM 
Kaplan-Meier (survivor function estimate) 
LR 
Logistic Regression 
MedDRA 
Medical Dictionary for Regulatory Activities 
MRD– 
Minimal Residual Disease Negative 
MTD 
Maximum Tolerated Dose 
OS 
Overall Survival 
PBSC 
Peripheral Blood Stem Cells 
PFS 
Progression-Free Survival 
PH 
Proportional Hazards (model) 
PR 
Partial Remission 
PT 
(MedDRA) Preferred Term 
RFS 
Relapse-Free Survival 
ROC 
Receiver Operating Characteristic (curve) 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SCT 
Stem Cell Transplant/Transplantation 
SMQ 
Standardized MedDRA Query 
SOC 
(MedDRA) System Organ Class 
TEAE 
Treatment Emergent Adverse Event 
TLS 
Tumor Lysis Syndrome 
WHO 
World Health Organization 


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3. Definitions 
Standard statistical terminology (e.g., type-1 error rate and significance level) is omitted 
intentionally. Efficacy endpoints are defined in Section 4.1 below (see Table 1). 
Baseline Value: last measured value prior to the first dose of study drug 
Combined CR: response assessment of CR or CRi 
Combined Remission: response assessment of CR, CRi or PR 
Cycle 1: period of time from the first dose of study drug until the start of study drug in 
cycle 2 or the start of alternative AML therapy other than supportive measures such as 
blood product transfusions (hence a patient whose first response assessment in cycle 1 
is a CRi is considered to have achieved CR if neutrophils and platelets recover prior to 
initiation of cycle 2 or alternative AML therapy) 
Combined CR Rate: percentage of patients who achieve a combined CR following 
treatment with alvocidib 
Combined Remission Rate: percentage of patients who achieve a combined remission 
following treatment with alvocidib 
CR Rate: percentage of patients who achieve a CR following treatment with alvocidib 
(see section 7.8.1) 
Dose-Limiting Toxicity: Refer to the study protocol for the specific conditions and events 
that qualify as a dose-limiting toxicity (DLT) 
Intent-to-Treat Population: all patients enrolled in the study regardless of whether they 
actually received study drug and regardless of whether evidence is found indicating they 
failed to meet study inclusion/exclusion criteria or had other protocol violations (see 
section 7.1) 
Minimal Residual Disease Negative: Absence of gene fusion transcripts using 
standardized techniques such as multiparametric flow cytometry or next generation 
sequencing 
Neutrophil Recovery: Absolute neutrophil count 1x109/L following the administration of 
study drug 
Per-Protocol Population: The subset of safety patients who either (a) have at least one 
response assessment on study, or (b) die prior to their first scheduled response 
assessment; however, patients are excluded from the per-protocol population if they 
have an important protocol deviation, such as when evidence is found indicating they 
failed to meet any study inclusion/exclusion criterion (see section 7.1) 
Platelet Recovery: Platelet count 100x109/L following the administration of study drug 
Prestudy: Occurrence prior to the first administration of study drug 
Safety Population: The subset of intent-to-treat patients who received at least one dose 
or partial dose of study drug (see section 7.1) 
Shift Table: two-way frequency table pairing baseline value with the most extreme post-
baseline result 


Statistical Analysis Plan 
 
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Sumitomo Dainippon Pharma Oncology 
 
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Study Drug: alvocidib, Ara-C (cytarabine) and mitoxantrone 
Treatment Failure: failing to achieve a CR, CRi or PR following induction therapy (see 
section 7.8.2) 
4. Introduction 
This Statistical Analysis Plan (SAP) details the planned methodology for summarizing 
data collected in the clinical study conducted under Tolero, Inc. protocol TPI-ALV-101. 
The current version of the study protocol is Amendment 6 dated 14-JUN-2019. Future 
protocol amendments (if any) will be reviewed to assess whether the changes 
necessitate modification of this SAP. 
Since the study protocol is a companion document to this SAP, aspects in the protocol 
unrelated to statistical issues (e.g., patient eligibility criteria, descriptions of clinical 
materials, and criteria for defining treatment failure, response to treatment and disease 
relapse) are not repeated here. 
4.1. Study Endpoints 
Statistical analysis and/or summarization is planned for the following study endpoints. 
Complete details on how endpoints are calculated and compared across treatment arms 
are presented in the subsections below. A key to abbreviated terms appears in Section 
2. 
Table 1. 
Study Endpoints 
Primary Efficacy Endpoint 
x CR Rate: percentage of patients who achieve a CR as assessed by the 
investigator following treatment with alvocidib 
Secondary Efficacy Endpoints (not listed in order of importance) 
x CRMRD– Rate: percentage of patients who achieve a CR and test negative for 
minimal residual disease (MRD) using standardized techniques such as 
multiparametric flow cytometry or next generation sequencing 
x Combined CR Rate: percentage of patients achieving a combined CR (CR or 
CRi) following treatment with alvocidib 
x Combined Remission Rate: percentage of patients achieving a combined 
remission (CR, CRi or PR) following treatment with alvocidib 
x Overall Survival: time from the date of first dose (Day 1) until death from any 
cause 
x Progression-Free Survival: time from the date of first dose (Day 1) until (a) 
treatment failure, (b) relapse after combined remission (CR, CRi or PR), or (c) 
death from any cause, whichever occurs first 
x Relapse-Free Survival Following CR (defined only for patients who achieve a 
CR during the study): time from the date of CR (Day 1) until (a) relapse after 
CR, or (b) death from any cause, whichever occurs first 


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Table 1. 
Study Endpoints 
x Relapse-Free Survival Following Combined CR (defined only for patients who 
achieve a combined CR during the study): time from the earliest date of 
combined CR (Day 1) until (a) relapse after combined CR, or (b) death from 
any cause, whichever occurs first 
x Relapse-Free Survival Following Combined Remission (defined only for 
patients who achieve a combined remission during the study): time from the 
earliest date of combined remission (Day 1) until (a) relapse after combined 
remission, or (b) death from any cause, whichever occurs first 
x CR Duration (defined only for patients who achieve a CR during the study): 
time from the date of CR (Day 1) until relapse after CR 
x Combined CR Duration (defined only for patients who achieve a combined CR 
during the study): time from the earliest date of combined CR (Day 1) until 
relapse after combined CR 
x Combined Remission Duration (defined only for patients who achieve a 
combined remission during the study): time from the earliest date of combined 
remission (Day 1) until relapse after combined remission  
x Stem Cell Transplant Rate: percentage of patients proceeding directly to stem 
cell transplantation within 90 days after their last dose of study drug 
Safety Endpoints (not listed in order of importance) 
x 30- and 60-Day Mortality 
x Adverse Event Incidence Rates 
x Time to neutrophil recovery 1x109/L 
x Time to platelet recovery 100x109/L 
x Presence and Severity of Tumor Lysis Syndrome 
x Clinical Laboratory Parameters 
x Vital Signs 
Other Endpoints 
x Concomitant Medication Usage Rates 
 
4.2. Statistical Objectives 
The statistical objectives are threefold: 
1. To define a maximum tolerated dose of alvocidib administered with cytarabine 
and daunorubicin in newly diagnosed AML patients 
2. To describe the safety and efficacy of alvocidib administered with cytarabine and 
daunorubicin in newly diagnosed AML patients 


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3. To model the relationship between baseline MCL-1 dependence and response to 
treatment with alvocidib administered with cytarabine and daunorubicin 
5. Sample Size 
The sample size for this study is not predetermined. The number of patients enrolled 
depends on the occurrence and pattern of DLTs. 
6. Treatment Assignment 
Cohorts of 3 patients are assigned a dose of alvocidib according to standard 3+3 dose 
escalation/de-escalation rules. All patients receive the same, standard doses of 
cytarabine and daunorubicin. 
7. Statistical Methods 
Analyses will be performed using SAS statistical software. Default estimation methods 
in version 9.4 of SAS are always used unless an alternative is specified below. Data 
summaries will include the mean, standard deviation, median, minimum and maximum 
values for continuous data; the median, 25th and 75th percentiles, minimum and 
maximum values for time-to-event endpoints; and the number and percentage of 
patients in each category for categorical data. Pointwise 95% confidence intervals (CI) 
will also be estimated for the mean (continuous data), median (time-to-event endpoints) 
or percentage of patients (categorical data). 
In general, data values will be obtained directly from the clinical database (e.g., birth 
date, treatment dates, AML relapse date and death date). Derivations for certain values 
not collected explicitly in the database are explained in relevant sections below (e.g., 
age and treatment failure date, sections 7.6 and 7.8.2, respectively). In some instances, 
it is beyond the scope of this SAP to explain schemes for patient classifications and 
data derivations (e.g., classifying patients in cytogenetic risk group according to 
published criteria). These details will be expounded in the clinical study report. 
Durations of time expressed in months (e.g., times-to-event endpoints) will be reported 
in proportional “months” according to the formula 
months =
12
365.25 × days 
Baseline value of a characteristic is defined as the last measured value prior to the first 
dose of study drug. 
7.1. Analysis Populations 
The intent-to-treat (ITT) patient population includes all patients enrolled in the study 
regardless of whether they actually received study drug and regardless of whether 
evidence is found indicating they failed to meet study inclusion/exclusion criteria or had 
other protocol violations. When the ITT patient population is analyzed, patients are 
grouped according to their assigned alvocidib dose regardless of actual dose received. 
The ITT patient population is the analysis population for the primary analyses of efficacy 
endpoints. 


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The safety patient population is the subset of ITT patients who received at least one 
dose of study drug. When the safety patient population is analyzed, patients are 
grouped according to the actual alvocidib dose received. The safety patient population 
is the analysis population for all analyses of safety data. 
The per-protocol patient population is the subset of safety patients who either (a) have 
at least one response assessment on study, or (b) die prior to their first scheduled 
response assessment. However, patients are excluded from the per-protocol patient 
population if they have an important protocol deviation, such as when evidence is found 
indicating they failed to meet any study inclusion/exclusion criterion. When the per-
protocol patient population is analyzed, patients are grouped according to their assigned 
alvocidib dose regardless of actual dose received. The per-protocol population is used 
for sensitivity (secondary, supportive) analyses of efficacy endpoints. 
Each of the patient populations listed above may be further subdivided for certain 
analyses (e.g., by age, race or gender) to assess whether certain subpopulations 
benefited from treatment with alvocidib more than others or if certain subgroups 
experienced greater toxicity from exposure to alvocidib. 
 
7.2. Missing Values 
In general, missing values will not be replaced by imputed values. 
x Patients who, for any reason, do not supply bone marrow for response 
assessment are counted among those not achieving remission 
x Patients missing a time-to-event endpoint will have their value censored 
according to the rules set forth below (see sections 7.8.2 to 7.8.5) 
Exceptions to the general rule of not replacing missing values are planned for the 
following items. 
x The first day of the month will be used for a missing day component of a partial 
birthdate, and January will be substituted for a missing birth month (these 
substitutions are relevant only for calculating a patient’s age) 
x Partial start and end dates for adverse events will be replaced by calendar dates 
that maximize the duration of the adverse event (see section 7.10.2) 
7.3. Visit Windows 
Visit windows are not relevant for analyzing efficacy endpoints since these endpoints 
are either binary outcomes over the entire study period (e.g., CR rate) or measured on a 
continuous time scale (e.g., OS and PFS). Some safety assessments are summarized 
over time and within-cycle visit windows will be used (e.g., clinical laboratory 
parameters; see section 7.10.4). 
7.4. Interim Analysis 
No interim analyses are planned. However, ongoing review of clinical data was 
performed during patient accrual and follow-up as required for dose escalation/de-
escalation decisions. 


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7.5. Patient Disposition 
The numbers of patients enrolled (ITT population), dosed (safety population) and 
included in the per-protocol population will be summarized by frequency counts within 
and across alvocidib dose levels. Time on study will be summarized as a continuous 
variable (mean, standard deviation, median, minimum and maximum values). Reasons 
for discontinuation will be summarized as a categorical variable (number and 
percentage of patients in each category). Relevant data supporting these summaries 
will be listed by patient within alvocidib dose level. 
7.6. Baseline Characteristics 
Patient age in years on the date of the first dose of alvocidib will be calculated by 
dividing the number of days since birth (Day 1) by 365.25. If body surface area (BSA) 
expressed in m2 is missing in the study database, then it will be calculated using the 
formula6 
BSA = ඨW × H
3600  
where W is the patient’s weight in kg and H is the patient’s height in cm. 
Summaries of baseline characteristics will include descriptive statistics appropriate for 
continuous, time-to-event and categorical variables within and across alvocidib dose 
levels (see section 7). Separate summaries will be produced for the ITT, safety and per-
protocol patient populations. 
Baseline characteristics include demographic data (e.g., age, sex, race, ethnicity, 
height, weight and BSA); AML history (e.g., clinical onset of AML [de novo AML, prior 
MDS or prior leukemogenic therapy], time since AML diagnosis, peripheral blood and 
bone marrow blast percentages, cytogenetic risk group, frontline AML therapy and 
response to frontline AML therapy [see section 6]); MCL-1 dependence; and other 
medical history (e.g., baseline ECOG performance status, hemoglobin, leukocyte and 
platelet counts, and blood chemistry parameters assessing liver and kidney function). 
Reported medical history terms will be mapped to Medical Dictionary for Regulatory 
Activities (MedDRA) preferred terminology and then summarized within and across 
alvocidib dose levels by incidence rates for each MedDRA primary system organ class 
(SOC) and preferred term (PT). Optionally, depending on the perceived relevance, 
prestudy medications will mapped to terminology in the World Health Organization 
(WHO) Drug Dictionary Enhanced (DDE) and then summarized within and across 
alvocidib dose levels by usage rates for each WHO DDE anatomical and therapeutic 
class (ATC) and preferred (i.e., standardized) drug name. Relevant data supporting 
these summaries will be listed by patient within alvocidib dose level. 
7.7. Study Drug Exposure 
Patients’ total exposures to study drugs and average exposures per treatment cycle will 
be calculated and summarized within and across alvocidib dose levels by the mean, 
standard deviation, median, minimum and maximum values. Numbers of treatment 
cycles received will be summarized as a continuous variable (by the mean, standard 


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deviation, median, minimum and maximum values) and as a categorical variable (by the 
number and percentage of patients in each category). Reasons for noncompliance with 
protocol-specified dosing schedules will be summarized as a categorical variable. 
Relevant data supporting these summaries (including actual infusion durations and 
expected doses based on BSA calculated from a patient’s latest reported height and 
weight) will be listed by patient within alvocidib dose level. 
7.8. Efficacy Endpoints 
Relevant data supporting efficacy analyses will be listed by patient within alvocidib dose 
level. 
7.8.1. Remission Rates 
The primary efficacy endpoint is CR rate as assessed by the investigator following 
treatment with alvocidib. Patients who, for any reason, do not supply bone marrow for 
response assessment are counted among those not achieving remission. 
Summary statistics will include the number and percentage of patients rated as not 
achieving CR due to not providing a bone marrow biopsy/aspirate, proportion of patients 
who achieve a CR and exact 95% CI estimated without stratification. Between–
treatment-arm statistics will include the Mantel-Haenszel odds ratio and 95% CI 
estimated with stratification. 
A standard logistic regression (LR) model will be estimated relating the probability of 
achieving CR as a function of baseline MCL-1 dependence. Results will be presented 
graphically as follows. Patients will be divided into groups according to which range of 
values their baseline MCL-1 dependence falls: 
(0%-d1), (d1-d2), (d2-d3), …, (d8-d9), (d9-100%) 
where d1,…,d9 are deciles for baseline MCL-1 dependence regardless of treatment arm. 
Empirical CR rates will be calculated for patients within each range and plotted 
alongside CR probabilities estimated from the LR model. 
 
Other remission rates (e.g., combined CR rate and combined remission rate) will be 
summarized similar to CR rate. 
7.8.2. Progression-Free Survival 
PFS time is defined for all patients and is measured from the date of first dose (Day 1) 
until (a) treatment failure, (b) relapse after combined remission, or (c) death from any 
cause, whichever occurs first. 
Treatment failure is defined as failing to achieve a combined remission following 
induction therapy. The date of treatment failure is defined by the earliest bone marrow 
collection following the first induction attempt regardless of whether the patient received 
a second induction attempt (unless the second induction resulted in a combined 
remission in which case “treatment failure” does not apply). 
Additional rules for defining PFS time are: 


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x A patient found to have relapsed after missing one or more scheduled response 
assessments will have his PFS time end on the scheduled date for the first 
missed response assessment following the last confirmation of combined 
remission 
x A patient who misses the first scheduled response assessment and who never 
achieves combined remission will have his PFS time end on the scheduled date 
for the first response assessment (unless the patient died before this date) 
Patients enrolled subsequent to protocol amendment 6 were scheduled to be followed 
for 2 years following the end-of-study visit, whereas patients enrolled prior to protocol 
amendment 6 were followed for only 30 days following the end-of-study visit unless they 
reconsented to the amendment-6, 2-year follow-up period. The definition of PFS time 
and the following rules for censoring PFS time apply to all patients regardless of follow-
up duration. 
Rules for censoring PFS time are: 
x A patient with PFS continuing as of the date he is lost to follow-up will have his 
PFS time censored on the date of his last response assessment 
x A patient with PFS continuing as of the database lock will have his PFS time 
censored on the date of his last response assessment 
Summary statistics will include the number and percentage of censored PFS times, 
quartile PFS times, 95% CIs for the quartile PFS times, and KM “survival” percentages10 
with 95% CIs at select milestone times (e.g., 6, 12 and 18 months). 
7.8.3. Overall Survival 
OS time is defined for all patients and is measured from the date of first dose (Day 1) 
until death from any cause. Patients enrolled subsequent to protocol amendment 6 were 
scheduled to be followed for 2 years following the end-of-study visit, whereas patients 
enrolled prior to protocol amendment 6 were followed for only 30 days following the 
end-of-study visit unless they reconsented to the amendment-6, 2-year follow-up period. 
The definition of OS time and the following rules for censoring OS time apply to all 
patients regardless of follow-up duration. 
Rules for censoring OS time are: 
x A patient with OS continuing as of the date he is lost to follow-up will have his OS 
time censored on the date of his last assessment of any type 
x A patient with OS continuing as of the database lock will have his OS time 
censored on the date of his last assessment of any type 
Summary statistics will include the number and percentage of censored OS times, 
quartile OS times, 95% CIs for the quartile OS times, and KM survival percentages with 
95% CIs at select milestone times (e.g., 6, 12 and 18 months). 


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7.8.4. Relapse-Free Survival Following CR 
RFS time is defined only for patients who achieve a CR during the study and is 
measured from the date of CR (Day 1) until (a) relapse after CR, or (b) death from any 
cause, whichever occurs first. 
An additional rule for defining RFS time is: 
x A patient found to have relapsed after missing one or more scheduled response 
assessments will have his RFS time end on the scheduled date for the first 
missed response assessment following the last confirmation of CR 
Patients enrolled subsequent to protocol amendment 6 were scheduled to be followed 
for 2 years following the end-of-study visit, whereas patients enrolled prior to protocol 
amendment 6 were followed for only 30 days following the end-of-study visit unless they 
reconsented to the amendment-6, 2-year follow-up period. The definition of RFS time 
and the following rules for censoring RFS time apply to all patients regardless of follow-
up duration. 
Rules for censoring RFS time are: 
x A patient with RFS continuing as of the date he is lost to follow-up will have his 
RFS time censored on the date of his last response assessment 
x A patient with RFS continuing as of the database lock will have his RFS time 
censored on the date of his last response assessment 
Summary statistics will include the number and percentage of patients who achieve a 
CR, the number and percentage of censored RFS times, quartile RFS times, 95% CIs 
for the quartile RFS times, and KM “survival” percentages with 95% CIs at select 
milestone times (e.g., 6, 12 and 18 months). 
Two endpoints analogous to relapse-free survival following CR will be analyzed using 
similar methods. 
x Relapse-Free Survival Following Combined CR (defined only for patients who 
achieve a combined CR during the study): time from the earliest date of 
combined CR (Day 1) until (a) relapse after combined CR, or (b) death from any 
cause, whichever occurs first 
x Relapse-Free Survival Following Combined Remission (defined only for patients 
who achieve combined remission during the study): time from the earliest date of 
combined remission (Day 1) until (a) relapse after combined remission, or (b) 
death from any cause, whichever occurs first 
Response categories included in “combined CR” and “combined remission” are 
delineated in Section 3. 
7.8.5.  Complete Remission Duration 
CR duration is defined only for patients who achieve a CR during the study and is 
measured from the date of CR (Day 1) until relapse. 
An additional rule for defining CR duration is: 


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x A patient found to have relapsed after missing one or more scheduled response 
assessments will have his CR duration end on the scheduled date for the first 
missed response assessment following the last confirmation of CR 
Patients enrolled subsequent to protocol amendment 6 were scheduled to be followed 
for 2 years following the end-of-study visit, whereas patients enrolled prior to protocol 
amendment 6 were followed for only 30 days following the end-of-study visit unless they 
reconsented to the amendment-6, 2-year follow-up period. The definition of CR duration 
and the following rules for censoring CR duration apply to all patients regardless of 
follow-up duration. 
Rules for censoring CR duration are: 
x A patient who dies while in remission will have his CR duration censored on the 
date of death 
x A patient in remission on the date he is lost to follow-up will have his CR duration 
censored on the date of his last response assessment 
x A patient in remission on the database lock will have his CR duration censored 
on the date of his last response assessment 
Summary statistics will include the number and percentage of patients who achieve a 
CR, the number and percentage of censored CR durations, quartile CR durations, 95% 
CIs for the quartile CR durations, and KM “survival” percentages with 95% CIs at select 
milestone times (e.g., 6, 12 and 18 months). 
Two endpoints analogous to CR duration will be analyzed using similar methods. 
x Combined CR Duration (defined only for patients who achieve a combined CR 
during the study): time from the earliest date of combined CR (Day 1) until 
relapse after combined CR 
x Combined Remission Duration (defined only for patients who achieve combined 
remission during the study): time from the earliest date of combined remission 
(Day 1) until relapse after combined remission 
Response categories included in “combined CR” and “combined remission” are 
delineated in Section 3. 
7.8.6. ECOG Performance Status 
ECOG performance status will be summarized within and across alvocidib dose levels 
using shift tables. 
7.9. Biomarker 
The biomarker in this study is MCL-1 dependence measured by mitochondrial sensitivity 
to NOXA BH3 peptides. Relevant data supporting analyses of MCL-1 dependence will 
be listed by patient within alvocidib dose level. Summary of baseline biomarker values 
will include descriptive statistics appropriate for continuous variables (see section 7.6). 
An LR model will be fit to examine the relationship between baseline MCL-1 
dependence and the independent binary variable CR for newly diagnosed AML patients 
receiving ACM. In addition, area under the curve (AUC) will be calculated (by treatment 


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arm) for the trapezoidal receiver operating characteristic (ROC) curve. This value will 
quantify the ability of MCL-1 dependence to predict CR.11 Ninety-five percent CIs will be 
calculated by assuming estimated AUC follows a normal distribution. 
AUC
෣± zଵିఈଶ
Τ  SEAUC 
where the standard error SEAUC is calculated by the jackknife method.12 Similar 
analyses will be conducted for combined CR and combined remission. 
7.10. 
Safety Endpoints 
Summaries of safety endpoints will include data collected from the safety patient 
population. Relevant data supporting safety analyses will be listed by patient within 
alvocidib dose level. 
7.10.1.  30- and 60-Day Mortality 
Estimates of 30- and 60-day mortality and their pointwise 95% CIs will be derived from 
KM curves for OS by treatment arm (see section 7.8.3). 
7.10.2. Adverse Events 
Reported adverse event (AE) terms will be mapped to MedDRA preferred terminology. 
AEs suggestive of tumor lysis syndrome (TLS) will be flagged based in the standardized 
MedDRA query (SMQ) for TLS. All reported events will appear in AE listings, however 
only treatment-emergent adverse events will be summarized. A treatment-emergent 
adverse event (TEAE) is an AE that starts or increases in severity any time after the first 
administration of any study drug up to 30 days following the last administration of any 
study drug. AE severity was rated by the investigator according to Common 
Terminology Criteria for Adverse Events (CTCAE) version 4.03 criteria.13 
A high-level safety summary will display the numbers of patients within and across 
alvocidib dose levels who experience one or more AEs in each of the following 
categories:  
x All TEAEs regardless of severity or presumed relationship to study drug 
x TEAEs judged related to study drug 
x All TLS SMQ TEAEs 
x TLS SMQ TEAEs judged related to study drug 
x Treatment-emergent serious adverse events (SAEs) 
x TEAEs leading to a delay in the administration of study drug 
x TEAEs leading to a reduction in the protocol-specified dose of study drug 
x TEAEs leading to discontinuation of study drug 
x TEAEs leading to withdrawal from the study 
x TEAEs leading to death 
The base summary of TEAEs will show incidence rates for each MedDRA primary SOC 
and/or PT by highest reported CTCAE severity grade and overall. A separate summary 


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will be produced each of the AE subsets listed above. Additional AE summaries may be 
produced using safety data from subsets of patients and/or characterized using 
additional SMQs. 
Partial start and end dates for adverse events will be replaced by calendar dates that 
maximize the duration of the adverse event. The following steps will be followed. 
For a partial start date: 
1. Replace a missing month with January 
2. Replace a missing calendar day with the first of the month 
3. If the replacement date is prior to the first dose of study drug, then set the 
adverse event start date equal to the date of the first dose 
For a partial end date: 
1. Replace a missing month with December 
2. Replace a missing calendar day with the last day of the month 
The replacement date for a missing end date may exceed end of the adverse event 
reporting period specified in the study protocol. 
An end date will not be estimated for adverse events marked continuing at the end of 
the study. 
7.10.3. Classification of Tumor Lysis Syndrome 
Cairo-Bishop definitions for laboratory TLS and clinical TLS will be used to diagnose 
and grade TLS.14 Patients are classified as experiencing laboratory TLS if they have 
any two or more serum values of uric acid, potassium, phosphorus and/or calcium 
shown in Table 2 within 3 days before or 7 days after the initiation of study drug. 
Table 2. 
Cairo-Bishop Definition of Laboratory Tumor Lysis Syndrome 
Laboratory Parameter 
Criteria 
Uric Acid 
ȝPRO/RULQFUHDVHIURPEDVHOLQH 
Potassium 
PPRO/RULQFUHDVHIURPEDVHOLQH 
Phosphorus 
PPRO/RULQFUHDVHIURPEDVHOLQH 
Calcium 
1.75 mmol/L or 25% decrease from baseline 
 
Diagnosis of clinical TLS requires the presence of laboratory TLS and elevated serum 
creatinine levels, cardiac arrhythmia and/or seizures. Criteria for grading the severity of 
clinical TLS are presented in Appendix 1. 
The numbers of patients experiencing laboratory TLS and the various severities of 
clinical TLS will be summarized within and across alvocidib dose levels. 
7.10.4. Clinical Laboratory Parameters 
Within-cycle patient minimum and maximum laboratory values (and changes from 
baseline) for analytes measured on a continuous scale will be summarized within and 
across alvocidib dose levels using descriptive statistics appropriate for continuous 
variables (see section 7.6). Ordinal categorical test results will be summarized within 


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and across alvocidib dose levels using shift tables. Additionally, for tests where CTCAE 
[version 4.03] severity criteria are specified, CTCAE severity grades will be summarized 
in shift tables. 
7.10.5. Neutrophil Recovery 
Time to neutrophil recovery is defined for all patients and is measured from the date of 
first dose (Day 1) until the first day the absolute neutrophil count (ANC) is 1x109/L for 
14 consecutive days. It is assumed that the ANC remains above the threshold value of 
1x109/L unless there is evidence that it did not. Therefore, a patient with ANC 1x109/L 
on Day 45 and without another assessment for >14 days will have a time to neutrophil 
recovery of 45 days. 
Rules for censoring time to neutrophil recovery are: 
x A patient with ANC <1x109/L as of the date he is lost to follow-up will have his 
time to neutrophil recovery censored on the date of his last assessment of any 
type 
x A patient with ANC <1x109/L as of the database lock will have his time to 
neutrophil recovery censored on the date of his last assessment of any type 
Summary statistics will include the number and percentage of censored times to 
neutrophil recovery, quartile times to neutrophil recovery, 95% CIs for the quartile times 
to neutrophil recovery, and KM “survival” percentages with 95% CIs at select milestone 
times (e.g., 42, 49 and 56 days). 
7.10.6. Platelet Recovery 
Time to platelet recovery is defined for all patients and is measured from the date of first 
dose (Day 1) until the first day the platelet count is 100x109/L for 14 consecutive days. 
It is assumed that the platelet count remains above the threshold value of 100x109/L 
unless there is evidence that it did not. Therefore, a patient with platelet 100x109/L on 
Day 60 and without another assessment for >14 days will have a time to platelet 
recovery of 60 days. 
Rules for censoring time to platelet recovery are: 
x A patient with platelet count <100x109/L as of the date he is lost to follow-up will 
have his time to platelet recovery censored on the date of his last assessment of 
any type 
x A patient with platelet count <100x109/L as of the database lock will have his time 
to platelet recovery censored on the date of his last assessment of any type 
Summary statistics will include the number and percentage of censored times to platelet 
recovery, quartile times to platelet recovery, 95% CIs for the quartile times to platelet 
recovery, and KM “survival” percentages with 95% CIs at select milestone times (e.g., 
49, 56 and 63 days). 
7.10.7. Concomitant Medication Use 
Optionally, depending on the perceived relevance, concomitant medications will 
mapped to terminology in the WHO DDE and then summarized within and across 


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alvocidib dose levels by usage rates for each level-1 ATC term and preferred (i.e., 
standardized) drug name. 
8. Adverse Event and Medication Coding Dictionaries 
The MedDRA and WHO DD versions (editions) that will be used to standardize medical 
terminology are not known at this time, but both will be recent editions published within 
2 years before the date the first patient is enrolled into the study and the versions used 
will be documented in the clinical study report. 
9. Summary Tables 
Suggested titles for summary tables to be included in the clinical study report are shown 
in Table 3. The actual table titles may be altered as needed for stylistic consistency and 
to support text in the clinical study report. In addition, some tables listed below may be 
combined under a single title. A blueprint for the general format of these tables is 
presented in Appendix 2. 
Table 3. 
Planned Summary Tables 
 
Summary Table [comments] 
Patient Population 
ITT 
Safety 
Per-
Protocol 
Patient Disposition 
X 
 
 
Screening and Demographic Information 
X 
 X  
 X  
AML History 
X 
 X  
 X  
Genetic Mutations 
X 
 X  
 X  
Medical History 
 X  
 X  
 X  
Pre-Existing Medical Conditions 
 X  
 X  
 X  
Relevant Prestudy Medications 
 X  
 X  
 X  
Study Drug Exposure 
 X  
 X  
 X  
Complete Remission Rates – Independent 
Hematologists Review [repeat as needed for 
subgroup analyses] 
X 
 
 X  
Complete Remission Rates – Local Investigator 
Review [repeat as needed for subgroup analyses] 
X 
 
 X  
Combined CR and Combined Remission Rates – 
Independent Hematologists Review [repeat as needed 
for subgroup analyses] 
 X  
 
 X  
Combined CR and Combined Remission Rates – 
Local Investigator Review [repeat as needed for 
subgroup analyses] 
 X  
 
 X  
Progression-Free Survival [repeat as needed for 
subgroup analyses] 
 X  
 
 X  
Progression-Free Survival Censoring at Transplant 
[repeat as needed for subgroup analyses] 
 X  
 
 X  
Overall Survival [repeat as needed for subgroup 
analyses] 
X 
 
 X  


Statistical Analysis Plan 
 
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Protocol TPI-ALV-101 
 
28 July 2019 
Sumitomo Dainippon Pharma Oncology 
 
21 | 27 
 
Summary Table [comments] 
Patient Population 
ITT 
Safety 
Per-
Protocol 
Relapse-Free Survival Following CR [repeat as 
needed for subgroup analyses] 
 X  
 
 X  
Relapse-Free Survival Following CR Censoring at 
Transplant [repeat as needed for subgroup analyses] 
 X  
 
 X  
Relapse-Free Survival Following Combined CR 
[repeat as needed for subgroup analyses] 
 X  
 
 X  
Relapse-Free Survival Following Combined CR 
Censoring at Transplant [repeat as needed for 
subgroup analyses] 
 X  
 
 X  
Relapse-Free Survival Following Combined 
Remission [repeat as needed for subgroup analyses] 
 X  
 
 X  
Relapse-Free Survival Following Combined 
Remission Censoring at Transplant [repeat as needed 
for subgroup analyses] 
 X  
 
 X  
Complete Remission Duration [repeat as needed for 
subgroup analyses] 
 X  
 
 X  
Complete Remission Duration Censoring at 
Transplant [repeat as needed for subgroup analyses] 
 X  
 
 X  
Combined Complete Remission Duration [repeat as 
needed for subgroup analyses] 
 X  
 
 X  
Combined Complete Remission Duration Censoring at 
Transplant [repeat as needed for subgroup analyses] 
 X  
 
 X  
Combined Remission Duration [repeat as needed for 
subgroup analyses] 
 X  
 
 X  
Combined Remission Duration Censoring at 
Transplant [repeat as needed for subgroup analyses] 
 X  
 
 X  
Stem Cell Transplant Rates 
 X  
 
 X  
ECOG Performance Status Shift Table 
 X  
 
 X  
30- and 60-Day Mortality 
 
X 
 
Numbers of Patients with Adverse Events 
 
X 
 
Treatment-Emergent Adverse Events: Incidence 
Rates by MedDRA System Organ Class 
 
X 
 
Treatment-Emergent Adverse Events: Incidence 
Rates by MedDRA Preferred Term 
 
X 
 
Treatment-Emergent Adverse Events Judged Related 
to Study Drug: Incidence Rates by MedDRA System 
Organ Class 
 
 X  
 
Treatment-Emergent Adverse Events Judged Related 
to Study Drug: Incidence Rates by MedDRA Preferred 
Term 
 
X 
 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-101 
 
28 July 2019 
Sumitomo Dainippon Pharma Oncology 
 
22 | 27 
 
Summary Table [comments] 
Patient Population 
ITT 
Safety 
Per-
Protocol 
Treatment-Emergent Adverse Events in the 
Standardized MedDRA Query for Tumor Lysis 
Syndrome: Incidence Rates by MedDRA Preferred 
Term 
 
 X  
 
Treatment-Emergent Adverse Events in the 
Standardized MedDRA Query for Tumor Lysis 
Syndrome Judged Related to Study Drug: Incidence 
Rates by MedDRA Preferred Term 
 
 X  
 
Serious Adverse Events: Incidence Rates by MedDRA 
System Organ Class 
 
 X  
 
Serious Adverse Events: Incidence Rates by MedDRA 
Preferred Term 
 
X 
 
Serious Adverse Events Judged Related to Study 
Drug: Incidence Rates by MedDRA System Organ 
Class 
 
 X  
 
Serious Adverse Events Judged Related to Study 
Drug: Incidence Rates by MedDRA Preferred Term 
 
 X  
 
Treatment-Emergent Adverse Events Leading to a 
Delay in the Administration of Study Drug: Incidence 
Rates by MedDRA Preferred Term 
 
 X  
 
Treatment-Emergent Adverse Events Leading to a 
Reduction in the Protocol-Specified Dose of Study 
Drug: Incidence Rates by MedDRA Preferred Term 
 
 X  
 
Treatment-Emergent Adverse Events Leading to 
Discontinuation of Study Drug: Incidence Rates by 
MedDRA Preferred Term 
 
 X  
 
Treatment-Emergent Adverse Events Leading to 
Withdrawal from the Study: Incidence Rates by 
MedDRA Preferred Term 
 
 X  
 
Fatal Adverse Events: Incidence Rates by MedDRA 
Preferred Term 
 
X 
 
Tumor Lysis Syndrome Incidence Rates During Cycle 
1 by Maximum Cairo-Bishop Severity Grade 
 
X 
 
Tumor Lysis Syndrome Incidence Rates During Study 
by Maximum Cairo-Bishop Severity Grade 
 
 X  
 
Clinical Laboratory Test Results and Changes from 
Baseline 
 
 X  
 
Clinical Laboratory Test Result Shift Tables 
 
 X  
 
Vital Signs and Changes from Baseline 
 
 X  
 
Concomitant Medications 
 
 X  
 
 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-101 
 
28 July 2019 
Sumitomo Dainippon Pharma Oncology 
 
23 | 27 
10. References 
1. Dohner H, Estey E, Grimwade D, et al. Diagnosis and Management of AML in 
Adults; 2017 ELN Recommendations from an International Expert Panel. Blood. 
Jan 26 2017;129:424-447. 
2. O’Brien PC, Fleming TR. A Multiple Testing Procedure for Clinical Trials. 
Biometrics. 1979;35:549-556. 
3. Grimwade D, Walker H, Oliver F, et al. The Importance of Diagnostic 
Cytogenetics on Outcome in AML: Analysis of 1,612 Patients Entered Into the 
MRC AML 10 Trial. Blood. Oct 1 1998;92:2322-2333. 
4. Yue L. Testing Multiple Secondary Endpoints in Confirmatory Comparative 
Studies – A Regulatory Perspective. Presented at: 2nd Annual AdvaMed 
Statistical Issues for Medical Devices and Diagnostics; April 29, 2009; Bethesda, 
MD. Available at: http://www.advamedmtli.org/download/File/
Statistics_April_2009/Yue_lilly_pres.pdf. Accessed February 5, 2015. 
5. Koch GG, Gansky SA. Statistical Considerations for Multiplicity in Confirmatory 
Protocols. Drug Information J. 1996;30:523-533. Available at: http://
ferran.torres.name/download/shared/general/Multiplicity%20dj302612.pdf. 
Accessed February 5, 2015. 
6. Mosteller RD. Simplified Calculation of Body-Surface Area. N Engl J Med. 
1987;317:1098 
7. Mantel N, Haenszel W. Statistical Aspects of Analysis of Data from Retrospective 
Studies of Disease. J Natl Cancer Inst. 1959;22:719-748. 
8. SAS Institute Inc. 2010. Base SAS® 9.2 Procedures Guide: Statistical 
Procedures, Third Edition. Cary, NC: SAS Institute Inc. 
9. Cohen J. A Coefficient of Agreement for Nominal Scales. Educ Psychol Meas. 
1960;20:37-46. 
10. Kaplan EL, Meier P. Nonparametric Estimation from Incomplete Observations. J 
Am Stat Assoc. 1958;53:457-481. 
11. Pierceall WE, Lena R, Medeiros BC, et al. Mcl-1 Dependence Predicts Response 
to Vorinostat and Gemtuzumab Ozogamicin in Acute Myeloid Leukemia. Leuk 
Res. 2014;38:564-568. 
12. Efron B, Stein C. The Jackknife Estimate of Variance. Annals Stat. 1981;9:586-
596. 
13. Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. U.S. 
Dept of Health and Human Services, National Institutes of Health, National 
Cancer Institute; May 28, 2009 (v4.03 June 14, 2010). Available at: http://evs.nci.
nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf. 
Accessed February 16, 2015. 
14. Cairo MS, Bishop M. Tumor Lysis Syndrome: New Therapeutic Strategies and 
Classification. Br J Haematol. 2004;127:3-11. 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-201 
 
28 July 2019 
 
 
 
Sumitomo Dainippon Pharma Oncology 
 
24 | 27 
Appendix 1. Criteria for Grading Severity of Clinical Tumor Lysis Syndrome 
 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Renal 
Creatinine 
1.5 x ULN 
Creatinine 
>1.5-3.0 x ULN 
Creatinine 
>3.0-6.0 x ULN 
Creatinine 
>6.0 x ULN 
Death 
Cardiac 
Arrhythmia 
Intervention not 
indicated 
Non-urgent medical 
intervention indicated 
Symptomatic and 
incompletely controlled 
medically or controlled 
with device (e.g., 
defibrillator) 
Life-threatening (e.g., 
arrhythmia associated 
with CHF, hypotension, 
syncope, shock) 
Death 
Seizure 
— 
One brief generalized 
seizure; seizure(s) well 
controlled by 
anticonvulsants or 
infrequent focal motor 
seizures not interfering 
with activities of daily 
living 
Seizure in which 
consciousness is 
altered; poorly 
controlled seizure 
disorder; with 
breakthrough 
generalized seizures 
despite medical 
intervention 
Seizures of any kind 
which are prolonged, 
repetitive or difficult to 
control (e.g., status 
epilepticus, intractable 
epilepsy) 
Death 
Clinical TLS requires one or more clinical manifestations (renal, cardiac, neuro) along with criteria for laboratory TLS 
Maximal clinical manifestation defines the severity grade 
ULN = upper limit of normal; 114.4 and 105.6 ȝmol/L will be used for males and females, respectively, if ULN is not available for an institution 
 
 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-201 
 
28 July 2019 
 
 
 
Sumitomo Dainippon Pharma Oncology 
 
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Appendix 2. Sample Table Template 
Tolero Pharmaceuticals ALV-101 
Table X.X 
Page 1 of 327 
Patient Disposition 
(Intent-to-Treat Population) 
 
 
Alvocidib 
20/30 mg/m² 
(N=3) 
Alvocidib 
30/40 mg/m² 
(N=3) 
Alvocidib 
30/50 mg/m² 
(N=3) 
Alvocidib 
30/60 mg/m² 
(N=13) 
Study 
Total 
(N=22) 
 
 
 
 
 
 
Study Center 
  Columbia University Medical Center              
3 (100%) 
1 (33.3%) 
0 
2 (15.4%) 
6 (27.3%) 
  University of North Carolina                    
0 
2 (66.7%) 
3 (100%) 
7 (53.8%) 
12 (54.5%) 
  Johns Hopkins University                        
0 
0 
0 
4 (30.8%) 
4 (18.2%) 
 
 
 
 
 
 
Country 
  United States                                   
3 (100%) 
3 (100%) 
3 (100%) 
13 (100%) 
22 (100%) 
 
 
 
 
 
 
Protocol Version 
  Amendment 2                                     
1 (33.3%) 
0 
0 
0 
1 (4.5%) 
  Amendment 3                                     
2 (66.7%) 
3 (100%) 
3 (100%) 
0 
8 (36.4%) 
  Amendment 4                                     
0 
0 
0 
13 (100%) 
13 (59.1%) 
 
 
 
 
 
 
Safety Analysis Population 
  Yes                                             
3 (100%) 
3 (100%) 
3 (100%) 
13 (100%) 
22 (100%) 
 
 
 
 
 
 
Response Evaluated Analysis Population 
  Yes                                             
3 (100%) 
3 (100%) 
3 (100%) 
13 (100%) 
22 (100%) 
 
 
 
 
 
 
Alvocidib and 7+3 Induction 
  Yes                                             
3 (100%) 
3 (100%) 
3 (100%) 
13 (100%) 
22 (100%) 
 
[a] Number of weeks from the first dose of alvocidib to withdrawal from study 
Source: Data Extract ddmmmyy; SAS (v9.4) ddmmmyy at hh:mm 
 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-201 
 
28 July 2019 
 
 
 
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Tolero Pharmaceuticals ALV-101 
Table X.X 
Page 2 of 327 
Patient Disposition 
(Intent-to-Treat Population) 
 
 
Alvocidib 
20/30 mg/m² 
(N=3) 
Alvocidib 
30/40 mg/m² 
(N=3) 
Alvocidib 
30/50 mg/m² 
(N=3) 
Alvocidib 
30/60 mg/m² 
(N=13) 
Study 
Total 
(N=22) 
 
 
 
 
 
 
Alvocidib and 5+2 Reinduction 
  Yes                                             
0 
1 (33.3%) 
0 
1 (7.7%) 
2 (9.1%) 
  No                                              
3 (100%) 
2 (66.7%) 
3 (100%) 
12 (92.3%) 
20 (90.9%) 
 
 
 
 
 
 
HiDAC Consolidation Cycles 
  0                                               
1 (33.3%) 
2 (66.7%) 
1 (33.3%) 
9 (69.2%) 
13 (59.1%) 
  1                                               
1 (33.3%) 
0 
0 
3 (23.1%) 
4 (18.2%) 
  2                                               
0 
0 
1 (33.3%) 
1 (7.7%) 
2 (9.1%) 
  3                                               
1 (33.3%) 
0 
1 (33.3%) 
0 
2 (9.1%) 
  4                                               
0 
1 (33.3%) 
0 
0 
1 (4.5%) 
 
 
 
 
 
 
Weeks on Study[a] 
  Mean (S.D.)                                     
19.7 (13.8) 
15.0 (11.0) 
15.0 (8.1) 
8.1 (3.6) 
13.6 (9.1) 
  Median                                          
17.7 
9.4 
14.4 
9.0 
10.0 
  Min, Max                                        
7.0, 34.4 
7.9, 27.6 
7.3, 23.4 
3.9, 12.3 
3.9, 34.4 
 
 
 
 
 
 
Primary Reason Patient was Withdrawn from the Study 
  Completed the Study                             
2 (66.7%) 
2 (66.7%) 
1 (33.3%) 
2 (15.4%) 
7 (31.8%) 
  Death                                           
0 
0 
0 
1 (7.7%) 
1 (4.5%) 
  Relapsed Disease (following remission)          
0 
0 
1 (33.3%) 
1 (7.7%) 
2 (9.1%) 
  Lack of Efficacy (failure to achieve remission) 
0 
1 (33.3%) 
1 (33.3%) 
1 (7.7%) 
3 (13.6%) 
  Unknown                                         
1 (33.3%) 
0 
0 
0 
1 (4.5%) 
  Missing                                         
0 
0 
0 
8 (61.5%) 
8 (36.4%) 
 
[a] Number of weeks from the first dose of alvocidib to withdrawal from study 
Source: Data Extract ddmmmyy; SAS (v9.4) ddmmmyy at hh:mm 


Statistical Analysis Plan 
 
Version 1.0 
Protocol TPI-ALV-201 
 
28 July 2019 
 
 
 
Sumitomo Dainippon Pharma Oncology 
 
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Tolero Pharmaceuticals ALV-101 
Table X.X 
Page 3 of 327 
Patient Disposition 
(Intent-to-Treat Population) 
 
 
Alvocidib 
20/30 mg/m² 
(N=3) 
Alvocidib 
30/40 mg/m² 
(N=3) 
Alvocidib 
30/50 mg/m² 
(N=3) 
Alvocidib 
30/60 mg/m² 
(N=13) 
Study 
Total 
(N=22) 
 
 
 
 
 
 
Poststudy Bone Marrow Transplant 
  Yes                                             
1 (33.3%) 
1 (33.3%) 
1 (33.3%) 
0 
3 (13.6%) 
  No                                              
2 (66.7%) 
2 (66.7%) 
2 (66.7%) 
13 (100%) 
19 (86.4%) 
 
[a] Number of weeks from the first dose of alvocidib to withdrawal from study 
Source: Data Extract ddmmmyy; SAS (v9.4) ddmmmyy at hh:mm