Conditions: Sickle Cell Disease
Keywords: Plerixafor Leukapheresis Mobilization Stem Cells Sickle Cell Disease
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 15
Healthy volunteers: no

Brief summary:
The constitution of blood relies upon hematopoietic stem cells (HSCs), which stay in the bone marrow and differentiate to all lineages of peripheral blood cells. HSC transplantation is the only curative option currently available for sickle cell disease (SCD) patients either via allogeneic HSC transplantation or HSC-targeted gene therapy. Granulocyte-colony stimulating factor (G-CSF)- mobilized HSCs are frequently utilized in the adult setting of HSC transplantation because of the faster hematologic recovery as compared to bone marrow. As an autologous HSC source for gene therapy, bone marrow harvest has been generally employed since G-CSF has been prohibitive in SCD patients due to granulocyte stimulation and the associated reports of vaso-occlusive crises, multi-organ failure, and death. However, when bone marrow harvest is used, the amounts of collected cells are limited and anesthesia is required. In order to obtain HSCs in large numbers without anesthesia, patients will undergo mobilization followed by large volume apheresis. Plerixafor is an alternative treatment for mobilization without direct stimulation to granulocytes, and it is theoretically applicable for SCD patients. The primary endpoint of this study is to obtain sufficient amounts of HSCs collected from the peripheral blood in SCD patients after plerixafor

mobilization with an acceptable safety profile. The harvested products will be stored as backup for patients undergoing gene therapy as well as allogeneic HSC transplantation.

Detailed description:
The constitution of blood relies upon hematopoietic stem cells (HSCs), which stay in the bone marrow and differentiate to all lineages of peripheral blood cells. HSC transplantation is the only curative option currently available for sickle cell disease (SCD) patients either via allogeneic HSC transplantation or HSC-targeted gene therapy. Granulocyte-colony stimulating factor (G-CSF)- mobilized HSCs are frequently utilized in the adult setting of HSC transplantation because of the faster hematologic recovery as compared to bone marrow. As an autologous HSC source for gene therapy, bone marrow harvest has been generally employed since G-CSF has been prohibitive in SCD patients due to granulocyte stimulation and the associated reports of vaso-occlusive crises, multi-organ failure, and death. However, when bone marrow harvest is used, the amounts of collected cells are limited and anesthesia is required. In order to obtain HSCs in large numbers without anesthesia, patients will undergo mobilization followed by large volume apheresis. Plerixafor is an alternative treatment for mobilization without direct stimulation to granulocytes, and it is theoretically applicable for SCD patients. The primary endpoint of this study is to obtain sufficient amounts of HSCs collected from the peripheral blood in SCD patients after plerixafor mobilization with an acceptable safety profile. The harvested products will be stored as backup for patients undergoing gene therapy as well as allogeneic HSC transplantation.

Arms:
arm 1: Plerixafor at a single dose of 240 microgram/kg

Interventions: intervention 1: Plerixafor
Intervention descriptions: intervention 1: Single-dose subcutaneous administration of plerixafor (Mozobil®) at 240 μg/kg

Protocol document:
Prot_SAP_001.pdf: 
 
 Protocol with Statistical Analysis Plan Cover Page:   
 
Official Title: 
Peripheral blood stem cell collection for sickle cell disease (SCD) patients using 
plerixafor 
NCT number: 
 
NCT03226691 
Document Type:  
Protocol with Statistical Analysis Plan (SAP)  
Document Date: 
February 7, 2019 
 


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Clinical Research Project 
February 7, 2019 
 
 
 
 
 
 
 
 
 
 
Drug Name: Plerixafor 
 
 
 
 
 
 
 
 
 
 
IND/IDE: FDA Exemption 
Closed to accrual: February 7, 2019 
 
Title: Peripheral blood stem cell collection for sickle cell disease (SCD) patients using plerixafor 
 
Abbreviated Title: Plerixafor Mobilization 
 
Other identifying words: plerixafor, leukapheresis, mobilization, stem cells, sickle cell disease 
 
Principal Investigator: John Tisdale MD, MCHB, NHLBI* 
 
Lead Associate Investigator: Naoya Uchida MD, MCHB, NHLBI* 
 
Associate Investigators: 
 
Matthew Hsieh MD, MCHB, NHLBI* 
Courtney Fitzhugh MD, SB, NHLBI* 
Wynona Coles RRT, MCHB, NHLBI 
Katherine Roskom RN, MSN, OCD, NHLBI 
Swee Lay Thein MD, SB, NHLBI 
Susan Leitman MD, OCRTME, CC 
Thomas Hughes PharmD, CC 
David Stroncek MD, CPS/DTM, CC 
Tiffani Taylor PA-C, MCHB, NHLBI* 
Donna Chauvet, NP, NHLBI* 
Stephanie Helwing, RN, NHLBI 
Sara Hauffe, RN, NHLBI, OCD 
Neal Jeffries, Ph.D., Statistician, OBR, NHLBI 
Julia Varga, RN, BScN, MN 
 
Non-NIH Collaborators: 
Joanne Swanson, Sanofi Genzyme Corporation 
 
Madhusudan V. Peshwa, Ph.D. 
Chief Scientific Officer 
Executive Vice President, Cellular Therapies 
22 Firstfield Road, Suite 110 
Gaithersburg, MD 20878 
Phone: (301) 944-1641 
Email: mvpeshwa@maxcyte.com 
 
 
Bill Lundberg, MD 
CSO CRISPR Therapeutics 
CRISPR Therapeutics  
610 Main Street 
Cambridge, MA 02139 
Phone: (617) 319- 9180 


17-H-0124 
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Prafulla Bhad 
Novartis Institute for Biomedical Research 
250 Massachusetts Ave, 
Cambridge, MA 02139 
Phone +1 617 871 5443 
Mobile +1 617 335 0972 
prafulla.bhad@novartis.com  
 
Kenneth M. Huttner, MD PhD 
Bioverativ 
225 Second Ave 
Waltham, MA 02451 
Ken.huttner@bioverativ.com 
Mobile: 617.325.3878 
 
KaiHsin Chang, PhD.  
 
 
           Editas Medicine 
 
 
 
 
 
 
           11 Hurley Street 
 
 
 
 
 
 
           Cambridge, MA 02141 
 
 
 
 
 
 
           kaihsin.chang@editasmed.com 
 
 
 
 
 
 
           Mobile: 617.401.9000 
 
Donald B. Kohn, M.D. 
 
 
 
Kohn Lab- Zule Romero  
610 Charles E. Young Drive 
Terasaki Life Science Building #3162 
Los Angeles, CA  90095 
617-291-3007  
 
 
Subjects of study:  
 
Number  
 
 
Sex 
 
Age range  
Patients 
 
15 
 
 
 
Either  
18 and above 
 
 
 
 
 
 
Project involves ionizing radiation? No 
Project uses “Durable Power of Attorney”? No 
Off site project? No 
Multi-institutional project? Yes 
 
Study Site: 
Principal Investigator: 
National Heart Lung and Blood Institute, NIH 
FWA00005897 
(Data Coordinating Center) * 
John Tisdale MD, MCHB, NHLBI 
BG10 RM 9N112 
10 Center Dr.  
Bethesda, MD 20814 
301-402-6497 
johntis@mail.nih.gov 
St. Jude Children’s Research Hospital 
(FWA00004775) 
As of January 18, 2019, this site is consider 
closed to accrual  
Akshay Sharma, MBBS 
262 Danny Thomas Place 
Memphis, TN 38105 
(901)595-3300 
Akshay.Sharma@stjude.org 


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Precis: 
 
The constitution of blood relies upon hematopoietic stem cells (HSCs), which stay in the bone 
marrow and differentiate to all lineages of peripheral blood cells. HSC transplantation is the only 
curative option currently available for sickle cell disease (SCD) patients either via allogeneic HSC 
transplantation or HSC-targeted gene therapy. Granulocyte-colony stimulating factor (G-CSF)-
mobilized HSCs are frequently utilized in the adult setting of HSC transplantation because of the 
faster hematologic recovery as compared to bone marrow. As an autologous HSC source for gene 
therapy, bone marrow harvest has been generally employed since G-CSF has been prohibitive in 
SCD patients due to granulocyte stimulation and the associated reports of vaso-occlusive crises, 
multi-organ failure, and death. However, when bone marrow harvest is used, the amounts of 
collected cells are limited and anesthesia is required. In order to obtain HSCs in large numbers 
without anesthesia, patients will undergo mobilization followed by large volume apheresis. 
Plerixafor is an alternative treatment for mobilization without direct stimulation to granulocytes, 
and it is theoretically applicable for SCD patients. The primary endpoint of this study is to obtain 
sufficient amounts of HSCs collected from the peripheral blood in SCD patients after plerixafor 
mobilization with an acceptable safety profile. The harvested products will be stored as backup for 
patients undergoing gene therapy as well as allogeneic HSC transplantation. 
 
 


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Table of Contents 
1.0 
Introduction and Background ......................................................................................................... 5 
2.0 
Objectives ........................................................................................................................................... 6 
3.0 
Scientific and Clinical Justification ................................................................................................. 7 
4.0 
Study Design ...................................................................................................................................... 8 
5.0 
Eligibility Assessment ....................................................................................................................... 8 
6.0 
Treatment Plan ................................................................................................................................ 11 
7.0 
Sample Collection, Storage, and Biospecimen and Data Management Plan ............................. 12 
8.0 
Biostatistical Considerations .......................................................................................................... 15 
9.0 
Data Safety and Monitoring Plan .................................................................................................. 16 
10.0 Human Subjects Protections .......................................................................................................... 23 
11.0 Investigator Administrative Requirements .................................................................................. 25 
12.0 Compensation .................................................................................................................................. 27 
13.0 Reimbursement for Travel ............................................................................................................. 27 
14.0 Pharmaceuticals .............................................................................................................................. 27 
15.0 References ........................................................................................................................................ 29 
Appendix I .................................................................................................................................................. 31 
 
 
 
 
 
 


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1.0 
Introduction and Background 
 
Sickle cell disease (SCD) is the first disease to be described at the molecular level and has long 
been targeted for treatment at the molecular level. The disease is associated with significant 
morbidity and early mortality, with the most recent estimates of median lifespan only into the 40s. 
SCD affects one of every 600 African Americans in the United States alone, with around 100,000 
Americans with the disease, but in Africa, an estimated 300,000 births per year are affected by 
SCD.1 This orphan disease is historically underserved, and represents an area of significant health 
disparity. 
 
β-globin is an essential component of hemoglobin, and a specific mutation (20A>T) of β-globin 
distinguishes SCD. The mutated β-globin leads to hemoglobin polymerization upon 
deoxygenation in areas of low oxygen tension. As a result, patients develop recurrent pain crisis, 
anemia, infections, acute chest syndrome, and neurologic events, as well as sudden death as the 
most serious consequences of this disease.2 In addition, iron overload due to chronic transfusion 
increases morbidity and mortality in SCD patients. The medical costs of this disease are 
enormous, with estimates of $40,000 per patient per year (year 2000 figures) for chronic red cell 
transfusion and chelation alone, and rising costs with age at $231,000 per year in total costs for 
adults due to accumulating end organ damage have recently been described.3 
 
Red cell transfusions are commonly used to treat patients with SCD. Red cells are infused as 
needed to treat symptoms of anemia, acute and severe complications such as acute chest 
syndromes and strokes, or before elective surgeries. Red cell transfusions can also be given at 
timed interval (also known as chronic transfusion therapy) to decrease the incidence of stroke in 
pediatric patients with abnormal trans-cranial Doppler velocities (internal carotid or middle 
cerebral artery velocity >200 cm/s).4 While transfusions can prevent further neurologic events in 
patients at risk, iron overload is common, resulting in significant end-organ toxicity. Thus, iron 
chelation has become an important part in the care of patients with SCD.  
 
Hydroxyurea, the one and only FDA approved drug for this disease, results in a significant 
reduction in the number of pain crisis per year and a decreased frequency of acute chest 
syndrome,5 and has become the treatment of choice for many individuals with SCD. 
Unfortunately, neither red cell transfusions nor hydroxyurea is curative, nor do they appear to 
reverse established end-organ damage. Hydroxyurea has been suggested to improve survival in 
patients with SCD.6 However, life expectancy remains significantly shortened compared to the 
national average with that of an affected male being 47 years versus the national average of 72.7  
 
The only established cure for patients with SCD is allogeneic bone marrow transplantation, and 
the procedure was initially only applied in children.8-10 In adults, the higher burden of accumulated 
end-organ damage would be expected to result in higher transplantation associated mortality and 
morbidity.8,11,12 Recently, we established allogeneic hematopoietic stem cell (HSC) transplantation 
for adult SCD patients, the vast majority of whom meet disease severity entry criteria, by using 
reduced intensity conditioning.13,14 This strategy can cure more than 90% of transplanted SCD 
patients; however, it requires an HLA-matched sibling donor (without SCD) that can be found for 
~10% of patients, leaving 90% of patients with SCD without a curative option. 
 
We are developing both haploidentical allogeneic and autologous HSC-targeted gene therapy for 
SCD patients who lack an HLA-matched sibling donor. Though we have seen success in around 


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Date: February 7, 2019 
6
half of the patients undergoing haploidentical allogeneic transplants, rejection rates remain high, 
and prolonged cytopenias have been observed in some SCD patients after rejection prompting us 
to require back up harvests for all patients on this experimental protocol. In addition, we are 
developing gene therapy approaches which utilize the patients’ own HSC.  With gene therapy, 
harvested HSC products are immunomagnetically purified for the CD34+ HSC population, and the 
purified HSCs are genetically modified to correct the β-globin gene in ex vivo culture by gene 
addition using lentiviral vectors. The genetically modified autologous HSCs are subsequently 
infused after conditioning. Our initial patients treated with a gene therapy approach have required 
multiple bone marrow harvests to proceed to transplantation on this protocol which also requires 
back up bone marrow harvesting. 
 
Peripheral blood is the current preferred source for HSCs in both autologous and allogeneic 
transplant applications. Mobilization of HSCs into the circulation can be achieved by the 
administration of granulocyte-colony stimulating factor (G-CSF) and/or plerixafor, allowing the 
collection of bone marrow derived HSCs from the peripheral blood by apheresis.15,16 The 
mobilized product can be further enriched for the primitive progenitor population by CD34+ cell 
selection. However, G-CSF leads to intolerable adverse effects in SCD patients including vaso-
occlusive crisis, multi-organ failure, and even death, probably due to granulocyte stimulation 
associated with G-CSF.17-21  
 
Plerixafor is an alternative treatment for HSC mobilization. Plerixafor is an inhibitor of the 
CXCR4 chemokine receptor and blocks binding of its cognate ligand, stromal cell-derived factor-
1α (SDF-1α). The CXCR4 and SDF-1α play an important role in the homing of human HSCs to 
the marrow compartment, and the CXCR4 can help to anchor HSCs to the bone marrow 
matrix.22,23 Treatment with plerixafor resulted in elevations in circulating HSCs, and human 
CD34+ cells mobilized by plerixafor were capable of engraftment with long-term repopulating 
capacity.24 Plerixafor can theoretically be applied safely to SCD patients, since it mobilizes HSCs 
into the peripheral blood without direct stimulation of granulocytes.22,25  
 
Therefore, we sought to evaluate the use of plerixafor to mobilize HSCs in SCD patients. Since 
our initial publication demonstrating the efficacy of allogeneic transplantation in adults with 
severe SCD, interest in curative approaches has increased substantially. We have screened more 
than 750 individuals with SCD at the NIH Clinical Center, and performed transplantation in over 
75 SCD patients at our single center. We continue to see 3 new patient screens per week for 
consideration for protocol entry in our clinical trials testing allogeneic and autologous transplant 
strategies in this disorder. In this pilot trial, we seek to address one of the major limitations 
moving forward for autologous gene transfer/editing approaches – autologous HSC harvesting. 
The ability to safely and reliably collect HSCs in SCD could transform our approach to this 
devastating disease, meeting a significant unmet need. 
 
 
2.0 
Objectives 
 
To obtain sufficient amounts of HSCs collected from the peripheral blood in SCD patients after 
plerixafor mobilization without serious adverse events. 
 
2.1.Determine the safety profile associated with plerixafor administration in SCD. (Appendix) 


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2.2.Determine the number of CD34+ cells/kg of body weight achievable with plerixafor mobilization 
in SCD 
2.3.Compare both the CD34+ cell/kg yield and side effects among SCD individuals 
 
3.0 
Scientific and Clinical Justification 
 
Harvest of HSCs is required for both allogeneic HSC transplantation and autologous HSC-targeted 
gene therapy. Our efforts to develop curative therapies for SCD span this spectrum of modalities, 
but our efforts are encumbered by the relative contraindication of G-CSF usage in SCD, and thus 
the most utilized method for HSC collection.  The availability of a safe, noninvasive means for 
HSC harvest from individuals with SCD would accelerate efforts at developing HSC based 
approaches, and mobilization with plerixafor could fill this void.   Thus, the current work seeks to 
determine the safety of plerixafor mobilization in individuals with SCD undergoing experimental 
transplantation procedures with haploidentical HSC donors, gene-modified autologous HSCs, or 
other allogeneic transplant protocol where prolonged cytopenia is expected. 
 
In patients transplanted on our haploidentical transplantation protocol to date, 5 of 21 patients with 
SCD did not recover their platelet counts to >50k/uL by 100 days’ post-transplant. Because of the 
risk of intracerebral hemorrhage in patients with SCD and severe thrombocytopenia, backup 
collection of autologous HSCs by bone marrow harvesting is now routinely performed in SCD 
patients undergoing haploidentical transplantation.  Additionally, gene therapy applications 
targeting autologous HSCs require bone marrow harvesting in SCD subjects, and the experimental 
nature of this work requires back up harvesting.  The need for back up HSCs on these existing 
protocols demands that patients undergo a bone marrow harvest procedure with the associated 
risks.  This protocol will therefore be offered to patients with SCD enrolling on to our 
haploidentical transplantation and gene therapy studies as an alternative to bone marrow harvest 
for collection of autologous HSCs. 
 
The risks of plerixafor administration in SCD patients are not known. However, G-CSF 
administration was reported to induce vaso-occlusive crisis during mobilization in several SCD 
patients, likely due to granulocyte expansion associated with G-CSF.17,19-21,26 Tragically, one SCD 
patient developed multi-organ failure and death after G-CSF mobilization despite close monitoring 
during the 5 day mobilization.19 The risks of plerixafor administration, in contrast, are expected to 
acceptable. Plerixafor has a different mechanism of action and acts by blocking CXCR4 to directly 
interfere with binding between HSCs and bone marrow niche, while G-CSF markedly increases 
bone marrow cellularity with granulocyte expansion to permit egress of HSCs to peripheral 
blood.27 The different mechanism of plerixafor results in less bone marrow expansion, less 
granulocyte stimulation, and lower peak of leukocyte counts than G-CSF.17,22,25,27,28 Plerixafor 
effects are brief, with only one time injection at one day, while G-CSF requires injection for 5 
days. Bone pain is minimal after a single dose of plerixafor, as compared to very common with 5-
6 days of G-CSF.24 
 
After single plerixafor administration (240 μg/kg) in patients with hematological malignancies, 
67% of patients (16/24) achieved sufficient amounts of CD34+ cells (≥2.0x10e6 CD34+ cells/kg) 
without complication, while a second administration and apheresis was required to obtain a 
sufficient CD34+ cell yield in 21% of patients (5/24).24 In addition, a higher dose (480 μg/kg) of 
plerixafor administration in healthy volunteers resulted in greater amounts of HSC mobilization 
without severe adverse events, as compared to the standard dose (240 μg/kg).29 


17-H-0124 
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8
 
As compared to these strategies, bone marrow harvest does not require drug administration for 
mobilization. However, bone marrow harvesting requires anesthesia (similar to surgery), which 
significantly increases risks of SCD-related complications.30  
 
Following HSC mobilization, apheresis is required for HSC collection. The risks of apheresis are 
expected to be less than marrow harvest, since apheresis in SCD patients is established for red 
blood cell exchange. In contrast to simple transfusion, risks of apheresis also include hypovolemia 
or circulatory overload, citrate toxicity with hypocalcemia, infection, and hematoma or thrombosis 
at the site of catheter placement.31-33 In our current open and active gene therapy protocol, 14-H-
0155, the first 4 patients required at least 2 marrow harvests. When repeat HSC mobilization and 
collection is needed, the risks can be additive, and thus the risk to benefit ratio appears to favor 
apheresis.  
 
Table 1. abbreviated list of adverse events with apheresis or marrow harvest 
HSC collection by apheresis 
HSC collection by bone marrow harvest 
• Central venous catheter placement (all 
patients)  
• Toxicity from citrate containing 
anticoagulant; hypocalcemia (in 20% of 
patients) 
• 4-6 hours of apheresis (in all patients) 
• Hypovolemia or circulatory volume overload 
(in 20% of patients) 
• Hematoma from central venous catheter 
(<10%) 
• General anesthesia, about 2 hours (in all 
patients) 
• Inpatient management of postoperative pain 
(in all) 
• Large intravascular volume shift, about 1-
1.5 liters of marrow are aspirated, replaced 
by equal or greater volume of supportive IV 
fluid (in all) 
• Hematoma (in 20%) 
• Infection (10%) 
 
 
4.0 
Study Design 
 
This is a single cohort phase I study to determine the safety of plerixafor mobilization and 
apheresis in SCD patients. With amendment C, this protocol becomes a multi-institute study with 
the inclusion of St. Jude Children’s Research hospital as a participating site. 
 
At Participating Site: 
For St. Jude Children’s Research Hospital, see Appendix II for site-specific protocol changes and 
activities.  
 
5.0 
Eligibility Assessment 
 
SCD patients who are age 18 or greater and: (a) are to enroll on a clinical trial with curative intent 
in which a backup bone marrow harvest is required (e.g. allogeneic HSCT), or (b) are willing to 
donate hematopoietic stem cell collection for future gene therapy/gene editing study, are eligible 
for study entry. Patients who are not receiving long-term transfusion therapy will receive 
prophylactic red cell exchange prior to plerixafor administration to target the fraction of 
hemoglobin S <30% to reduce the incidence of vaso-occlusive crisis and other sickle related 
complications. Patients on red cell transfusions can either maintain on transfusions or undergo a 
modified exchange (e.g. mini-exchange) prior to plerixafor. Hydroxyurea treatment should be 


17-H-0124 
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Date: February 7, 2019 
9
stopped at least 2 weeks before mobilization, since the washout period is important for bone 
marrow recovery to reduce the myelosuppressive effects of hydroxyurea.34,35  
 
Plerixafor may have adverse effects on a fetus in utero. Furthermore, it is not known if Plerixafor 
has transient adverse effects on the composition of sperm.  
 
For this trial, male subjects will be considered of non-reproductive potential if they have 
azoospermia (whether due to having had a vasectomy or due to an underlying medical condition).  
 
Female subjects will be considered of non-reproductive potential if they are either:  
 
postmenopausal (defined as at least 12 months with no menses without an alternative medical 
cause; in women < 45 years of age a high follicle stimulating hormone (FSH) level in the 
postmenopausal range may be used to confirm a post-menopausal state in women not using 
hormonal contraception or hormonal replacement therapy. In the absence of 12 months of 
amenorrhea, a single FSH measurement is insufficient.);  
 
OR  
 
have had a hysterectomy and/or bilateral oophorectomy, bilateral salpingectomy or bilateral tubal 
ligation/occlusion, at least 6 weeks prior to screening;  
 
OR  
 
has a congenital or acquired condition that prevents childbearing.  
 
Female and male subjects of reproductive potential must agree to avoid becoming pregnant or 
impregnating a partner, respectively, while receiving study drug by complying with one of the 
following contraception regimens if sexually active:  
 
Single method (one of the following is acceptable):  
• intrauterine device (IUD)  
• vasectomy of a female subject’s male partner  
• contraceptive rod implanted into the skin  
Combination method (requires use of two of the following):  
• diaphragm with spermicide (cannot be used in conjunction with cervical cap/spermicide) 
• cervical cap with spermicide (nulliparous women only)  
• contraceptive sponge (nulliparous women only)  
• male condom or female condom (cannot be used together)  
• hormonal contraceptive: oral contraceptive pill (estrogen/progestin pill or progestin-only pill), 
contraceptive skin patch, vaginal contraceptive ring, or subcutaneous contraceptive injection  
 
Subjects should be informed that taking the study medication may involve unknown risks to the 
fetus (unborn baby) if pregnancy were to occur during the study. All patients must agree to an 
effective method of contraception while on study treatment and for at least 3 months following 
Plerixafor treatment (including both female patients of child-bearing potential and male patients 
with partners of child-bearing potential). Effective birth control includes: a) birth control pills, 
depot progesterone, or an intrauterine device plus one barrier method, or b) two barrier methods. 


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Effective barrier methods are: male and female condoms, diaphragms, and spermicides (creams or 
gels that contain a chemical to kill sperm). For patients using a hormonal contraceptive method, 
information about any interaction of Plerixafor with hormonal contraceptives is not known.. If 
there is any question that a subject of childbearing potential will not reliably comply with the 
requirements for contraception, that subject should not be entered into the study. 
 
All patients will be evaluated first with a medical history and physical examination. Baseline 
laboratory tests include: 
• complete blood count and differential 
• hemoglobin analysis 
• blood chemistry studies (electrolytes and liver and renal function tests) 
• ABO blood typing 
• serological tests for syphilis (RPR) 
• hepatitis B and C (HBsAg, Anti-HCV) 
• HIV (anti-HIV 1/2) 
• HTLV-I/II (anti-HTLV-I/II) 
• abdominal ultrasound (baseline) 
• other relevant tests that investigators consider important to establish a complete medical 
history will be performed 
• All female patients of childbearing age will be required to undergo a serum or urine 
pregnancy test. 
 
 
5.1 
Inclusion criteria: 
 
5.1.1. SCD patients who are 18 or older, and  (a) planned to enroll in an active allogeneic 
HSCT study where back-up autologous HSCs are needed; OR (b) are eligible for an 
allogeneic HSCT study [i.e. have the same disease severity as group (a), but no 
active allogeneic HSCT study is available], and are willing to donate autologous 
HSCs for a future gene therapy, gene editing, or allogeneic HSCT study. 
5.1.2. Adequate renal function: serum/plasma creatinine <1.5 mg/dL. 
5.1.3. Adequate liver function: direct bilirubin and ALT <5 times the upper limit of 
normal range. 
5.1.4. Blood counts: WBC >3,000/mm3, granulocytes >1,000/mm3, 
hemoglobin>7.0g/dL, platelets>150,000/mm3. 
5.1.5. Female patients of childbearing age should have a negative serum pregnancy test 
within one week of beginning plerixafor administration, have had a hysterectomy, 
post-menopausal, or absence of a menses for over a year. 
5.1.6. Meets NIH Department of Transfusion Medicine (DTM) eligibility criteria for 
blood component donation for in vitro research use (negative serologic tests for 
syphilis, hepatitis B and C, HIV, and HTLV-1). 
5.1.7. Ability to give informed consent to participate in the protocol. 
5.1.8 Female and male individuals of reproductive potential must agree to one of the 
contraceptive regimens stated above if sexually active 
5.2 
Exclusion criteria: 
 


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Date: February 7, 2019 
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5.2.1. Pregnancy. Female patients of childbearing age should have a negative serum 
pregnancy test within one week of beginning plerixafor administration, except 
those that have had a hysterectomy, post-menopausal, or an absence of a menses 
for over a year. 
5.2.2. Active viral, bacterial, fungal, or parasitic infection. 
5.2.3. History of cancer, excluding squamous carcinoma of the skin and cervical 
carcinoma in situ. 
5.2.4. Active and painful splenomegaly or splenomegaly (size greater than upper limit of 
normal) determined by ultrasound. 
5.2.5. Allergy to plerixafor. 
 
At Participating Site: 
For St. Jude Children’s Research Hospital, see Appendix II for site-specific protocol changes and 
activities. 
 
6.0 
Treatment Plan  
 
At NIH 
6.1 
Prophylactic red blood cell exchange or simple red cell transfusions will be given to 
patients prior to plerixafor administration targeting HbS <30% to reduce the incidence of 
vaso-occlusive crisis and other events that may be associated with high hemoglobin S 
levels. Hydroxyurea treatment should be stopped at least 2 weeks before mobilization, 
since the washout period is important for bone marrow recovery after myelosuppressive 
effects of hydroxyurea.34,35 
 
6.2 
Patients undergoing HSC mobilization will be admitted on a telemetry medical unit. They 
will then receive a single-dose subcutaneous administration of plerixafor (Mozobil®) at 
240 μg/kg. (If the CD34+ cell yields are not sufficient for a minimal target dose in each 
protocol, a second plerixafor administration can be performed at the same dose for 
mobilization and apheresis the following day.)  
 
 
 
6.3 
Patients will be monitored continuously by telemetry. Leukapheresis will start 
approximately 4-12 hours after plerixafor is given. Mononuclear cells will be collected 
using an automated cell separator or apheresis device. Whole blood is withdrawn from one 
venipuncture site at a rate of 60-80 mL/min and then conveyed to the separator. If IV 
access is inadequate, central lines will be inserted prior to apheresis. Leukapheresis will be 
performed by the Apheresis Unit under supervision of the medical staff of the Department 
of Transfusion Medicine at the NIH Clinical Center with periodic EKG monitoring, or in a 
nursing unit where continuous cardiac monitoring (telemetry) can start with plerixafor 
administration and through the apheresis procedure. 
 
6.4 
After successful blood withdrawal, blood is separated into cells and plasma by 
centrifugation. The light density mononuclear cells are collected into a component bag, and 
the remaining cells and plasma are re-infused into the patient via a second venipuncture 
site. Acid Citrate Dextrose formula A (ACD-A) is used as the anticoagulant at a whole 
blood to anticoagulant ratio of 13:1. Prophylactic intravenous calcium infusions are used in 
all procedures. Maximal extracorporeal blood volume during the procedure ranges from 


17-H-0124 
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Date: February 7, 2019 
12
300-400 mL. Sufficient volumes of blood will be processed to obtain target CD34+ cells of 
2.0x10e6 CD34+ cells/kg (minimum of 1.5x10e6 cells/kg). 
 
6.5 
The harvested peripheral blood apheresis products will be cryopreserved using a controlled 
rate freezer. All excess cells beyond 2.0x10e6 CD34+ cells/kg will be available for 
immediate CD34+ cell selection and freezing for research testing cell culture, lentiviral 
transduction, gene editing, and xenotransplantation. 
 
6.6 
After successful mobilization and stem cell collection, patients will remain in the hospital 
for 1-3 days to monitor for side effects. The total inpatient duration is about 1 week. 3-10 
days after discharge from hospital, patients will be evaluated in outpatient clinic. 
Laboratory and other testing will be obtained as clinically indicated. 
 
6.7 
Additional blood samples may be drawn before plerixafor administration, 2 hours after 
plerixafor, when starting apheresis, and at the end of apheresis to study CD3, CD34, and 
total nucleated cell counts.  The total amount of blood to be drawn including the screening 
labs will adhere to the policy for adult patients. 
 
6.8 
Patients will complete this study 10 days after the last dose of plerixafor, and be taken off 
this protocol. 
 
At Participating Site: 
For St. Jude Children’s Research Hospital, see Appendix II for site-specific protocol changes and 
activities. 
 
7.0 
Sample Collection, Storage, and Biospecimen and Data Management Plan 
 
At NIH 
7.1 
Data management 
 
The PI will be responsible for overseeing entry of data into a password-protected electronic system 
that complies with NIH security standards and NHLBI DIR policy, and for ensuring data accuracy, 
consistency and timeliness of entry. The PI, associate investigators, research nurses, and/or a 
contracted data manager will assist with the data management efforts. All human subject 
personally identifiable information (PII) eligibility and consent verification will be recorded in 
conformity with DIR policy. Primary and final analyzed data will have unique codes so that 
research data can be attributed to an individual human subject participant. 
 
7.2 
Intended use 
 
Blood samples and data collected and stored for research purposes will be used to study alternative 
stem cell selection strategies and culture techniques. Research samples will be stored indefinitely 
in NIH freezers. Patient clinical data will be protected and tracked using standard operating 
procedures in the medical record department. The IRB will be notified if research samples are 
unintentionally destroyed or lost. 
 
 
7.3 
End of study procedures 


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13
 
Data will be stored in a password-protected database in conformity with NHLBI DIR policy or in 
a publicly accessible research repository until they are no longer of scientific value. Data may be 
destroyed only when permitted by the clinical director and approved by the IRB. 
 
7.4 
Loss or destruction of data 
 
Should the research team become aware that a major breech in our plan to protect research subject 
confidentiality and trial data has occurred, the clinical director and IRB will be notified. 
 
7.5 
Data sharing and future use of data 
 
Research data may be shared with qualified non-collaborator recipients following publication of 
the primary research results after removal of PII and IRB approval. Future research use of data not 
defined in the research protocol may occur only after IRB review and approval or an exemption 
from the NIH Office of Human Subjects Research Protections (OHSRP). Refusal of a research 
subject participant to permit future use of data--other than required in the protocol or by the FDA--
will be honored. Limitations in data sharing and future use of data due to contractual obligations 
(e.g., CRADAs) or intellectual property proceedings (such as patent filings) will be honored. 
 
7.6 
Future use of biospecimens 
  
After analyzing the biospecimens for primary research purposes as described in the protocol, 
remaining samples suitable for future research must be stored in manner that conforms with DIR 
policy (such as BSI) or in a publicly accessible research biospecimen repository following IRB or 
OHSRP approval. Biospecimens may be destroyed only when permitted by the clinical director 
and approved by the IRB.  
Any future research use of biospecimens not defined in the protocol in which NHLBI investigators 
are engaged in research (e.g., they are undertaking research activities and hold the key that 
identifies research subjects) requires IRB review and approval. Coded biospecimens (NHLBI 
investigators hold the key that identifies research subjects) to be shared outside of NIH for future 
research use requires IRB review and approval (for research collaborations) or submission of a 
determination to OHSRP (for non-collaborative research), and an executed transfer agreement. 
Unlinked biospecimens (no key to identify research subjects exists) to be shared outside of NIH 
for future research use requires submission of a determination to OHSRP and an executed transfer 
agreement. There are a few types of biospecimens that do not require IRB or OHSRP approval for 
future research use outside of NIH, such as specimens from deceased individuals (refer to OHSRP 
SOP5, Appendix 1 for complete list); an executed transfer agreement is required in these special 
cases.  Refusal of a research subject participant to allow for future use of identifiable 
biospecimens--other than required in the protocol or for appropriate regulatory purposes --will be 
honored. 
 
Transmission of Data to Outside Investigators: 
Coded samples and data may also be sent to our collaborators for analysis. No samples or data 
collected on this study will be sent outside NIH without prior IRB approval and fully executed 
material transfer agreement (MTA).  
 


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14
Collaborators include Madhusudan V. Peshwa, Ph.D., MaxCyte, Inc. and Dr. Bill Lundberg, 
CRISPR Therapeutics Director, will receive de-identified excess CD34+ cells to conduct 
preclinical studies aimed at genetically modifying hematopoietic stem cells as a treatment for 
sickle cell disease. These studies will be performed in vitro only and will not be returned to 
patients.  
 
Collaborator include Prafulla Bhad, with Novartis Institute for Biomedical Research, will receive 
the bone marrow and peripheral blood sample from sickle cell patients to demonstrate 
comparability between the results obtained from processing of healthy volunteer bone marrow 
hematopoietic stem and progenitor cells obtained from healthy donor bone marrow derived HSPC 
and those from the sickle cell disease patient bone marrow. They will also get the available 
mobilized peripheral blood CD34+ samples from Dr. Tisdale for similar comparability studies.   
 
Collaborator, Kenneth M. Huttner, with Bioverativ, may receive the bone marrow and mobilized 
peripheral blood sample from sickle cell patients for ZFN-editing testing. Bioverativ will be 
investigating gene expression characteristics of these populations. All data derived by Bioverativ 
from the NIH-sourced CD34+ stem cells that relates to stem cell editing will be shared with the 
NIH SCD research teams.   
 
Collaborator, KaiHsin Chang, with Editas Medicine, may receive peripheral blood, leukocytes, 
and CD34+ cells from sickle cell patients.  Editas is developing genome editing strategies to use 
CRISPR/Cas9 to introduce mutations in DNA that are associated with reactivation of fetal 
hemoglobin or to correct the mutation in the beta-globin gene that causes sickle cell disease.  
 
Collaborator, Donald B. Kohn, M.D., with UCLA, may receive CD34 cells to perform gene 
editing to correct the sickle cell mutation and will assay in both culture and xenografted mice. 
 
7.7 
Loss or destruction of data/samples 
 
Should we become aware that a major breech in our plan for tracking and storage of samples has 
occurred, the IRB will be notified. 
 
7.8 
Publication Policy 
 
Given the research mandate of the NIH, subject data including the results of testing and responses 
to treatment will be entered into an NIH-authorized and controlled research database. Any future 
research use will occur only after appropriate human subject protection institutional approval such 
as prospective NIH IRB review and approval or an exemption from the NIH Office of Human 
Subjects Research Protections (OHSRP).  Data will not be sent outside the NIH without IRB 
notification and an executed MTA or CTA. 
 
7.9 
Privacy and Confidentiality 
 
All efforts, within reason, will be made to keep subjects’ protected health information (PHI) and 
private identifiable information (PII) private.  Using or sharing (“disclosure”) such data must 
follow federal privacy rules.  Under certain circumstances, the United States Office of Human 
Research Protections (OHRP), and the NIH Intramural Institutional Review Board (IRB), will be 


17-H-0124 
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Date: February 7, 2019 
15
able to inspect and copy confidential study-related records which identify participants by name.  
Therefore, absolute confidentiality cannot be guaranteed.  
 
At Participating Site: 
For St. Jude Children’s Research Hospital, see Appendix II for site-specific protocol changes and 
activities. 
 
8.0 
Biostatistical Considerations 
 
8.1 
Sample size  
 
This is a pilot study of safety of plerixafor mobilization in SCD.  This study will accrue a 
maximum of 15 SCD patients at plerixafor 240 μg/kg and safety will be determined by successful 
accrual without reaching stopping rules.   
 
8.2 
Stopping rules 
 
Death and life-threatening adverse events: Drug dosing in further participants will be held 
pending IRB review, if any subject develops any grade IV or V (death) adverse events (Common 
Terminology Criteria for Adverse Events [CTCAE] version 4.0 or equivalent, see 
http://ctep.cancer.gov/reporting/ctc.html) considered possibly or definitely related to plerixafor 
within 10 days of administration of the drug. 
 
Non-pain crisis related events: The allowance of a 20% rate for grade III AEs (attributable to 
plerixafor) is reasonable, given that 30-40% of participant’s experience headaches or GI 
symptoms after plerixafor and a minority of these adverse events might lead to a grade III AE. 
Drug dosing in further participants will be held pending IRB review, if stopping rules are met in 
Table 2. Both pain crisis and acute chest syndrome are considered in a separate set of stopping 
rules below.  
 
We examined the performance of the stopping rule against a range of true non-pain grade III (or 
higher) AE probabilities – between 10% and 50%. This range was chosen to span plausible AE 
rates based on clinical experience. The probability of concluding whether the regimen is unsafe (or 
safe) was determined by the percentage of 100,000 simulated trials in which the stopping rule 
boundary was reached (or not reached) for a given AE probability. Each simulated trial involved 
generating 15 dichotomous (yes/no) AE outcomes with the given AE probability and it was 
determined if the cumulative count of AEs reached the stopping boundary. The boundary was 
chosen after considering a range of different possible combinations of sample sizes and stopping 
boundaries. This boundary was selected because the performance balances a strong probability of 
stopping the trial when the true AE rate is too high (30% or more) and allowing the trial to 
continue when the AE rate is relatively low (less than 20%). 
 
Table 2 – Stopping rule: Stop if 2 non-pain grade 3 or higher AEs observed in first 5 individuals, 4 
AEs after evaluating 6-10 individuals, or 5 AEs after evaluating 11-15 individuals 
True, Unknown AE 
probability 
Probability Conclude Safe 
Probability Conclude Unsafe 
0.50 
0.04 
0.96 
0.40 
0.14 
0.86 


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16
0.30 
0.37 
0.63 
0.20 
0.67 
0.33 
0.15 
0.81 
0.19 
0.10 
0.91 
0.09 
 
 
Pain crisis related events: Pain crisis is excluded from the criteria of grade III, while acute chest 
syndrome is included as grade III or IV. We anticipate up to a rate of 40% for pain crisis 
(attributable to plerixafor). This rate reflects that among the patients with SCD that have 
undergone allogeneic HSCT at our center, approximately 30-35% have chronic pain requiring 
chronic opioid usage and had frequent hospitalizations for pain at baseline. This prevalence is 
similar to the sickle cell center in Milwaukee, where 34 of 115 patients had 5-11 hospitalizations 
per year and 17 patients had ≥12.36 Additionally, all the patients in our current gene therapy study 
(14-H-0155) had at least 4-5 days of hospitalization after marrow harvest, indicating that pain 
induced by the harvest procedure is substantial in all patients.  The pain from plerixafor would be 
expected to be lower.  Thus, we define pain crisis for this protocol to be (1) duration of 
hospitalization for the entire HSC collection (e.g. from plerixafor to discharge) to be more than 4 
days due to pain that is considered to be sickle related crisis; or (2) hospitalization for pain crisis 
after discharge from the initial HSC collection and within 10 days of the final plerixafor dose; or 
(3) escalation in pain treatment (e.g. from oral to IV narcotics administration or from as needed 
doses of IV to PCA narcotics).. 
 
Hence drug dosing in further participants will be held pending IRB review, if stopping rules are 
met in Table 3. 
 
Table 3 – Stopping rule: Stop if 3 pain AEs (defined above) observed in first 5 individuals, 5 AEs 
after evaluting 6-10 individuals, or 6 AEs after evaluating 11-15 individuals. 
True, Unknown AE 
probability 
Probability Conclude Safe 
Probability Conclude Unsafe 
0.60 
0.03 
0.97 
0.50 
0.13 
0.87 
0.40 
0.36 
0.64 
0.30 
0.66 
0.34 
0.20 
0.90 
0.10 
 
 
The boundaries for pain AEs were determined in a manner similar to the boundary for grade III 
AEs. Participants will be dosed sequentially, with no overlap during the 10-day monitoring period, 
(including hospital admission to clinic visit post-stem cell collection) to allow assessment of 
adverse events in each participant before proceeding to the next. If stopping rules are met at 240 
ug/kg, dose reduction may be proposed at that time.  
 
 
9.0 
Data Safety and Monitoring Plan 
 
 
The side effects of plerixafor mobilization and apheresis should be less than that of G-CSF, which 
are well described and vast experience with the procedure in both normal volunteers and family 
donors exists in the Clinical Center. In addition, we will evaluate for vaso-occlusive crisis for SCD 


17-H-0124 
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Date: February 7, 2019 
17
patients, for which vast experience also exists in the Clinical Center. Grade 3 and higher AEs and 
SAEs will be collected from the start of first dose of plerixafor administration to 10 days after the 
last dose of plerixafor. For subjects enrolled at the NIH, AEs and SAEs outside of this window of 
time will be tracked on the natural history protocol (04-H-0161), screening protocol (08-H-0156), 
or transplant protocol (03-H-0170, 14-H-0077, 17-H-0069). 
 
 
9.1 
Safety Monitoring 
 
At NIH 
Principal Investigator: Accrual will be monitored by the principal investigator who will 
provide oversight, and will monitor accrual and safety data. The investigator and/or 
associate investigators will make study documents readily available for inspection by the 
local IRB, and the NHLBI Office of the Clinical Director staff for confirmation of the 
study data. 
 
NIH Intramural IRB:  Accrual and safety data will also be monitored and reviewed 
annually by the IRB. Prior to implementation of this study, the protocol and the proposed 
patient consent and assent forms will be reviewed and approved by the properly constituted 
Institutional Review Board (IRB) operating according to 45 CFR 46. This committee will 
approve all amendments to the protocol or informed consent and conduct continuing 
annual review so long as the protocol is open to accrual or sample and/or data analysis 
continues. 
 
NHLBI DSMB: The NHLBI Data and Safety Monitoring Board (DSMB) will review the 
protocol, progress report, accrual, efficacy and safety data at six- or twelve-month intervals 
as scheduled. All AEs and SAEs observed during the clinical trial and for which there is a 
relationship with the use of plerixafor, or the conduct of the study will be reported to the 
DSMB at the regularly scheduled DSMB meeting. The DSMB may recommend early 
termination of the study for considerations of safety and efficacy. 
 
 
9.2 
Adverse events Definitions 
 
Adverse Event (AE): Any untoward medical occurrence in a human subject, including any 
abnormal sign (e.g., abnormal physical exam or laboratory finding), symptom, or disease, 
temporally associated with the subject’s participation in the research, whether or not 
considered related to the subject’s participation in the research.  
 
Serious adverse events (SAEs): defined by federal regulations and include events which  
• Are fatal or life threatening  
• Result in significant or persistent disability  
• Require or prolong inpatient hospitalization  
• Result in a congenital anomaly or neoplasm  
• Result from an overdose  
• Are other conditions which in the judgment of the PI represent a significant hazard  
 
Serious event: An event is serious if it meets the definition of a serious adverse event 
(above) or if it requires immediate corrective action by a PI and/or IRB to protect the 
safety, welfare or rights of subjects. 
 


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Date: February 7, 2019 
18
Unanticipated Problem (UP): Any incident, experience, or outcome that meets all of the 
following criteria:  
1. 
unexpected in terms of nature, severity, or frequency in relation to 
a. 
the research risks that are described in the IRB-approved research protocol 
and informed consent document; Investigator’s Brochure or other study 
documents; and  
b.  
the characteristics of the subject population being studied; and  
 
2. 
related or possibly related to participation in the research; and  
 
3. 
places subjects or others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was previously known or 
recognized.  
 
Unanticipated Problem that is not an Adverse Event: An unanticipated problem that does 
not fit the definition of an adverse event, but which may, in the opinion of the investigator, 
involves risk to the subject, affect others in the research study, or significantly impact the 
integrity of research data. For example, report occurrences of breaches of confidentiality, 
accidental destruction of study records, or unaccounted-for study drug.  
 
Protocol Deviation (PD): Any change, divergence, or departure from the IRB approved 
research protocol. 
 
Non-compliance: The failure to comply with applicable NIH HRPP policies, IRB 
requirements, or regulatory requirements for the protection of human research. 
Noncompliance may be further characterized as: 
 
1. Serious non-compliance: Non-compliance that: 
a. Increases risks, or causes harm, to participants. 
b. Decreases potential benefits to participants. 
c. Compromises the integrity of the NIH HRPP. 
d. Invalidates the study data. 
2. Continuing non-compliance: Non-compliance that is recurring. An example may be 
a pattern of non-compliance that suggests a likelihood that, absent an intervention, non-
compliance will continue. Continuing noncompliance could also include a failure to 
respond to IRB requests to resolve previous allegations of non-compliance. 
3. Minor (non-serious) non-compliance: Non-compliance that, is neither serious nor 
continuing. 
 
 
9.3 
Adverse event assessment 
 


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Date: February 7, 2019 
19
For both serious and non-serious adverse events, the investigator must determine both the intensity 
of the event and the relationship of the event to plerixafor administration. The investigator should 
record what action, if any, was taken to the planned administration of the investigational product 
due to the AE (i.e., discontinuation, modification, or interruption of the treatment). 
 
Intensity will be assessed by the investigator using the NCI CTCAE, version 4.0. If the adverse 
event is not included in the CTCAE, then the investigator is to determine the intensity of the 
adverse event according to the following criteria: 
Grade 
Definition 
Mild (Grade 1) 
The AE is noticeable to the subject, but does not interfere 
with routine activity. 
Moderate (Grade 2) 
The AE interferes with routine activity, but responds to 
symptomatic therapy or rest. 
Severe (Grade 3) 
The AE significantly limits the subject’s ability to perform 
routine activities despite symptomatic therapy. 
Life-threatening (Grade 4) 
The subject is at immediate risk of death. 
Death (Grade 5) 
Death 
 
If the intensity (grade) changes within a day, the maximum intensity (grade) should be recorded. 
 
Relationship will be determined by the investigator according to the criteria that follow. 
Relationship of adverse events to plerixafor will be determined after the start of plerixafor 
infusion: 
Investigator 
Assessment 
Definition 
Classification for 
Reporting Purposes 
Not Related 
Exposure to the drug product did not occur, or 
the occurrence of the AE is not reasonably 
related in time, or the AE is considered 
unlikely to be related to the drug product. 
 
 
 
Not Related 
Unlikely Related 
The study treatment and the AE were not 
closely related in time, and/or the AE could be 
explained more consistently by causes other 
than exposure to the drug product. 
Possibly Related 
The study treatment and the AE were 
reasonably related in time, and the AE could be 
explained equally well by causes other than 
exposure to the drug product. 
 
 
 
Related 
Definitely Related 
The study treatment and the AE were 
reasonably related in time, and the AE was 
more likely explained by exposure to the drug 
product than by other causes, or the drug 
product was the most likely cause of the AE. 
 
9.4 
NIH Intramural-IRB and CD Reporting 
Note: All IRB reportable events will be submitted by the coordinating center (NHLBI). Participating sites 
will submit those events to the NHLBI study coordinator, who will, in turn submit them to the IRB via an 
NIH Problem Report Form within the timeframes specified below. 
 
 


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20
9.4.1 Serious Events 
 
Reports to the IRB and CD:  
The PI must report serious UPs and serious PDs to the IRB and CD as soon as possible but not 
more than 7 days after the PI first learns of the event using the NIH Problem Report Form.  
 
Reports to the IRB Chair and CD:  
The PI must report all SAEs that do not meet the definition of UP to the IRB Chair and CD not 
more than 14 days after the PI first learns of the event using the NIH Problem Report Form. 
 
9.4.2. Non-serious Events  
 
Reports to the IRB and CD:  
The PI must report all UPs that are not serious to the IRB and CD, and PDs that are not serious to 
the IRB, not more than 14 days after the PI first learns of the event using the NIH Problem Report 
Form. 
 
Non-serious protocol deviations that result from normal subject scheduling variations or technical 
issues associated with sampling that does not impact the health of the subject or the interpretation 
of the study data will not be reported. 
  
9.4.3 Deaths  
The PI must report all deaths to the CD and IRB as soon as possible, but not more than 7 days 
after the PI first learns of the event. 
 
We will not track subjects after stem cell donation. However, deaths and SAE will be reported 
through the primary transplant protocol. 
 
9.4.4 Pregnancy 
We will discuss the available options with patients who become pregnant during this study, and 
refer them for the appropriate consult or service. 
 
9.5 
Reports at the time of continuing IRB review 
  
At continuing review, the PI will provide to the IRB a summary of:  
• All UPs  
• All PDs  
• All AEs and SAEs grade 3 and higher will be collected from the start of first dose of plerixafor 
administration to 10 days after the last dose of plerixafor.  (except for those granted a waiver of 
reporting)  
 
Note: If, while preparing the continuing review, the PI identifies a greater frequency or level of 
severity of expected adverse events than was previously identified in the protocol or 
investigational brochure (IB), these should be reported separately as a UP. If such an observation 
occurs before the time of continuing IRB review, it should be reported to the IRB and CD as a UP 
in the time frames noted above, and summarized at the time of continuing review. 
 
9.6 
 Reporting to Sanofi  


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Date: February 7, 2019 
21
 
9.6.1 Adverse Event Definition 
 
An AE is any untoward medical occurrence associated with the use of the investigational product 
(active or placebo drug, biologic, or device) in a clinical investigation patient, which does not 
necessarily have a causal relationship with the investigational product. An AE can, therefore, be 
any unfavorable and unintended symptom, sign, disease or condition, or test abnormality whether 
or not considered related to the investigational product.  
 
AEs may include, but are not limited to: 
• Subjective or objective symptoms spontaneously offered by the patient and/or observed by 
the investigator or medical staff 
• Clinically significant laboratory abnormalities 
• A significant worsening of the patient’s condition from study entry 
• Disease signs and symptoms and/or laboratory abnormalities existing prior to the use of the 
study treatment that resolve but then recur after treatment 
• Disease signs and symptoms and/or laboratory abnormalities existing prior to the use of the 
study treatment which increase in frequency, intensity, or a change in quality after 
treatment 
9.6.2 
Adverse Event Reporting 
Adverse events will be graded according to CTCAE version 4(see section 9.3).  Reference safety 
information to assess expectedness for Investigators will be IB. All adverse events except those 
clearly attributable to the underlying disease will be reported, including definitely, probably and 
possibly related. Both Serious and Non-Serious Adverse Events will be clearly noted in source 
documentation and listed on study specific Case Report Forms (CRFs).  The Protocol Director 
(PD) or designee will assess each Adverse Event (AE) to determine whether it is unexpected 
according to the Informed Consent, Protocol Document, or Investigator’s Brochure, and related to 
the investigation. 
 
9.6.3 
Serious Adverse Events (SAEs) Definition 
 
A SAE is any adverse event that results in any of the following outcomes: 
Death 
• 
A life-threatening experience 
• 
Requires inpatient hospitalization or prolongs existing hospitalization 
• 
A persistent or significant disability/incapacity 
• 
A congenital anomaly/birth defect 
• 
Important medical events that may jeopardize the patient and may require medical or 
surgical intervention to prevent 1 of the outcomes listed above 
 
Hospitalizations that occur under the following circumstances are not considered to be SAEs: 
• were planned before entry into the clinical study; 
• are for elective treatment of a condition unrelated to the studied indication or its   
treatment; 
• occur on an emergency or outpatient basis and do not result in admission (unless fulfilling 
the criteria above), are part of the normal treatment or monitoring of the studied indication 
and not associated with any deterioration in condition. 
 
9.6.4 
Serious Adverse Events (SAEs) Reporting 


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Date: February 7, 2019 
22
All Serious Adverse Events (SAEs) will be tracked for 30 days or until resolution, or until the end 
of study (10 days after last dose of the study treatment).  
 
SAEs, CTCAE Grade 3 and above, and all subsequent follow-up reports will be reported to the 
Safety Monitoring Committee (DSMC) using the study specific CRF regardless of the event’s 
relatedness to the investigation. Following review by the DSMC, events meeting the IRB definition 
of ‘Unanticipated Problem’ will be reported to the IRB using eProtocol within 10 working days of 
DSMC review, or within 5 working days for deaths or life-threatening experiences. 
 
SAEs, within 24 hours (US) or one business day (EU) of first knowledge of such serious adverse 
event, will need to notify Sanofi via fax, attention Sanofi Pharmacovigilance (PV), 908-203-7783 
(US) or via email at: USPVmailbox@sanofi-aventis.com.   Additionally, the Investigator will 
transmit to Sanofi PV an information copy of any such report sent to the governing regulatory 
authority, prior to or at the time of authority filing. The Investigator will make available to Sanofi 
promptly such records as may be necessary and pertinent to investigate any such expedited adverse 
event, if specifically requested by Sanofi. 
 
Furthermore, the Investigator will inform Sanofi of the following: 
• Any events that result in protocol amendments for safety reasons, as well as any safety 
related regulatory action such as a clinical hold of the Research; 
• Any pregnancies occurring in patients who are exposed to the Product in connection with 
the Research.  
• In addition, the Investigator will notify Sanofi within 24 hours (US) or one business day 
(EU) of first knowledge of any Product complaints (communication of dissatisfaction that 
alleges deficiencies related to the identity, quality, durability, effectiveness, safety, 
labeling, purity, stability, and appearance) by fax to 508-661-8771 (US)  or Sanofi 
Customer Services Europe, +31 (0)35 699 1222.  
• The Investigator will also inform Sanofi within 1 business day of becoming aware of any 
actions from any authority that may affect the performance of the Research  
 
Safety reporting rules are to be complied with, according to current PV specifications (QGSD-
007589).  Sponsor is to provide Sanofi with: results relevant to final diagnosis of any SAE; routine 
transmission of any overdose with plerixafor; periodic reports; study report must contain section 
with safety review and conclusion –to be reviewed by Sanofi before finalization. 
 
9.6.5 
Pregnancy Reporting 
 
The Investigator will inform Sanofi PV within 24 hours of the Investigator’s first knowledge of 
pregnancy in a female patient or the female partner of a male patient at any time after the first dose 
of Plerixafor.  Pregnant female patient(s) must not receive additional study treatment.  The 
pregnancy will be followed until the outcome is known (i.e., delivery, elective termination, 
spontaneous abortion).  The Investigator will obtain follow-up information no later than two 
months after the gestational period to obtain maternal, fetal, and neonatal outcome and any other 
relevant information.  If the pregnancy results in the birth of a child, additional follow-up 
information may be requested.  The Investigator must complete as much information as possible on 
the relevant Pregnancy Notification Forms (PNF) A and B, and fax the forms to the Sanofi 
Genzyme PV. 


17-H-0124 
PI: John F. Tisdale MD 
Date: February 7, 2019 
23
 
10.0 
Human Subjects Protections 
 
 
10.1 
Rationale for Subject Selection 
 
Subjects will be recruited through the Clinical Center Volunteer Office and through our 
clinic referrals. Accrual will be based solely upon protocol entry criteria and no selection 
will be based upon gender, race, or age (in those 18 years or greater in age).  
 
10.2 
Participation of children 
Children are excluded from protocol entry as the study poses more than minimal risk 
without the prospect of direct clinical benefit. 
 
10.3 
 Risks in relation to benefits 
As of February 7, 2019, this study is now closed to new subject accrual and continues in 
data analysis only and the level of risk is now minimal. 
 
For adult research participants level of risk is greater than minimal risk with no prospect of 
direct benefit but likely to yield generalizable knowledge about the subject’s disorder or 
condition (45 CFR 46.406). Patients may withdraw from study at any time. 
 
 
10.4 
Rationale for the Exclusion of Pregnant Women 
 
The participation in the study may lead to a risk to the fetus. For those reasons, we are 
excluding pregnant women. During screening, any prospective subject who reports being 
pregnant will be excluded from participating. In addition, we will measure serum or urine 
beta-HCG in women for childbearing age. Any subjects found to be pregnant will be 
excluded from this study. 
 
10.5 
Informed Consent Processes and Procedures 
 
 
At NIH 
Each participant will receive an oral and written explanation of the goals, procedures, and 
risks of this study.  The Principal Investigator and those Associate Investigators who are 
listed on the cover page of the protocol with an asterisk next to their name may obtain 
informed consent from research participants.  Consent will be obtained at the NIH Clinical 
Center.  The original, signed informed consent document will be placed in the medical 
record, and the subject will receive a signed copy of the informed consent document. 
 
At participating site: 
After the study has been fully explained, written informed consent will be obtained from 
the subject or his/her legal representative prior to study participation. The method of 
obtaining and documenting the informed consent and the contents of the consent will 
comply with ICH-GCP and all applicable regulatory requirement(s).  
 
 
 
10.6 
Conflict of Interest 
 


17-H-0124 
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24
This is a covered protocol. The Principal Investigator assured that each associate 
investigator listed on the protocol title page received a copy of the NIH’s Guide to 
preventing conflict of interest.  No initial or subsequent members of the research team 
reported a potential conflict of interest. The National Institutes of Health reviews NIH staff 
researchers at least yearly for conflicts of interest. The following link contains details on 
this process http://ethics.od.nih.gov/forms/Protocol-Review-Guide.pdf.  You may ask your 
research team for additional information or a copy of the Protocol Review Guide. This 
protocol may have investigators who are not NIH employees. Non-NIH Investigators are 
expected to adhere to the principles of the Protocol Review Guide but are not required to 
report their personal financial holdings to the NIH. 
 
10.7 
Risk and discomforts 
 
10.7.1. Plerixafor: 
 
Plerixafor is an inhibitor of the CXCR4 chemokine receptor and blocks binding of its 
cognate ligand, stromal cell-derived factor-1α (SDF-1α). The CXCR4 and SDF-1α are 
recognized to play an important role in the homing of human HSCs to the marrow 
compartment, and the CXCR4 can help to anchor HSCs to the marrow matrix, including 
SDF-1α. Treatment with plerixafor resulted in leukocytosis and elevations in circulating 
HSCs, and the plerixafor-mobilized CD34+ cells were capable of engraftment with long-
term repopulating capacity. The plerixafor blocks CXCR4 to directly interfere binding 
between HSCs and bone marrow niche, while G-CSF markedly increases bone marrow 
cellularity with granulocyte expansion to permit egress of HSCs to peripheral blood.27 The 
different mechanism of plerixafor results in less bone marrow expansion, less granulocyte 
stimulation, and lower peak of leukocyte counts than G-CSF.17, 22, 25, 27, 28 
 
Common (≥10%) side effects: 
[Plerixafor and G-CSF] The most common adverse reactions reported were diarrhea 
(37%), nausea (34%), fatigue (27%), injection site reactions (34%), headache (22%), 
arthralgia (13%), dizziness (11%), and vomiting (10%). 
 
34% of patients had mild to moderate injection site reactions at the site of subcutaneous 
administration of plerixafor. These included erythema, hematoma, hemorrhage, induration, 
inflammation, irritation, pain, paresthesia, pruritus, rash, swelling, and urticarial.  
 
[Plerixafor only] Adverse events were similar, including lightheadedness (44%); nausea, 
bloating, or flatulence (36%); injection site discomfort or warm sensation (28%); perioral 
paresthesia, loose stools, or diaphoresis (20%); and headache (16%).24 A recent study for 
a single administration of plerixafor revealed mild-moderate facial paresthesia (26%) and 
mild arrhythmia including sinus tachycardia (56%), premature ventricular contraction 
(21%), and sinus bradycardia (7%)37. 
 
Less common (1-10%) side effects: 
Other adverse reactions that occurred in < 5% of patients but were reported as related to 
plerixafor during HSC mobilization and apheresis included abdominal pain, hyperhidrosis, 
abdominal distention, dry mouth, erythema, stomach discomfort, malaise, hypoesthesia 
oral, constipation, dyspepsia, and musculoskeletal pain. 


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Rare (<1%) side effects: 
Mild to moderate allergic reactions were observed in less than 1% of patients within 
approximately 30 min after plerixafor administration. Symptoms generally responded to 
treatments (e.g., antihistamines, corticosteroids, hydration or supplemental oxygen) or 
resolved spontaneously. Severe side effects including anaphylaxis have been reported in 
patients receiving plerixafor. 
 
Vasovagal reactions, orthostatic hypotension, and/or syncope can occur following 
subcutaneous injections (<1%). The majority of these events occurred within 1 hour of 
plerixafor administration. Because of the potential for these reactions, appropriate 
precautions should be taken. 
 
Other side effects may include thrombocytopenia, splenic enlargement (potential for 
rupture), fever, bone pain, anorexia, insomnia, muscle pain, and infusion related reaction.  
 
SCD specific side effects: 
Recent reports document the provocation of vaso-occlusive crisis by G-CSF administration 
in individuals with SCD.19, 20, 26 The risks of plerixafor in SCD are not known, but are 
expected be less than G-CSF, since it mobilizes HSCs without direct stimulation to 
granulocytes. 
 
10.7.2. Risks related to apheresis: 
 
Adverse reactions related to apheresis include lightheadedness, nausea, and pre-syncope 
due to vasovagal reactions and cutaneous paresthesia due to ACD-A, a calcium chelating 
anticoagulant. Vasovagal reactions are managed by postural manipulation and volume 
administration. Paresthesia are treated by slowing the rate of the anticoagulant infusion, 
increasing the rate of calcium replacement, or temporarily interrupting the procedure. 
Since patients with SCD would have a red cell exchange previously, the risk of apheresis 
for HSC collection are expected to be similar. 
 
10.7.3 Other potential risks: 
 
Anemia may occur from repeated blood sampling and leukapheresis. This can be prevented 
by initial screening and red blood cell exchange. Pain and bruising can result from needle 
sticks. Thrombocytopenia (platelet count <150,000/uL) can be expected in 10-20% of 
subject’s post-apheresis. When observed, thrombocytopenia is usually moderate, self-
limited, and clinically insignificant. Although the implications are not clear, splenic 
enlargement occurs in individuals undergoing standard mobilization for stem cell 
collection.38,39 This enlargement is transient, resolving in 3-4 days. 
 
11.0 
Investigator Administrative Requirements 
 
11.1Good Clinical Practice 
The study will be conducted in accordance with the International Conference on Harmonization 
(ICH) E6 (Guideline for Good Clinical Practice), the ethical principles that have their origin in the 
Declaration of Helsinki, Title 21 of the Code of Federal Regulations, Parts 50 (Protection of 


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Date: February 7, 2019 
26
Human Subjects), and 56 (Institutional Review Boards), and other appropriate regulatory 
requirement(s). The Investigator will be thoroughly familiar with plerixafor as described in the 
protocol. Essential clinical documents will be maintained to demonstrate the validity of the study 
and the integrity of the data collected. Regulatory files should be established at the beginning of the 
study, maintained for the duration of the study and retained according to the appropriate 
regulations. 
 
11.2 IRB Submissions 
The site IRB/IEC and other appropriate institutional regulatory bodies will review all appropriate 
study documentation in order to safeguard the rights, safety, and well-being of the subjects. The 
protocol, informed consent, safety updates, annual progress reports, and any revisions to these 
documents will be provided to the IRB/IEC and other appropriate institutional regulatory bodies by 
the Investigator. 
 
11.3 Subject Information and Informed Consent 
After the study has been fully explained, written informed consent will be obtained from the 
subject or his/her legal representative prior to study participation. The method of obtaining and 
documenting the informed consent and the contents of the consent will comply with ICH-GCP and 
all applicable regulatory requirement(s). 
 
11.4 Subject Confidentiality 
In order to maintain subject privacy, all CRFs, accountability records, study reports, and 
communications will identify the subject by initials and the assigned subject number. The 
Investigator will grant monitor(s) and auditor(s) from the NIH Principal Investigator or his 
designee and regulatory authority(ies) access to the subject’s original medical records for 
verification of data gathered on the CRFs and to audit the data collection process. The subject’s 
confidentiality will be maintained and will not be made publicly available to the extent permitted 
by the applicable laws and regulations. 
 
11.5 Protocol Compliance 
The Investigator will conduct the study in compliance with the protocol provided by the NIH 
Principal Investigator, and given approval/favorable opinion by the IRB/IEC and other appropriate 
institutional regulatory bodies. Modifications to the protocol should not be made without 
agreement of both the Investigator and the NIH Principal Investigator. Changes to the protocol will 
require written IRB/IEC and other appropriate institutional regulatory body approval/favorable 
opinion prior to implementation, except when the modification is needed to eliminate an immediate 
hazard(s) to subjects. The IRB/IEC may provide, if applicable regulatory authority(ies) permit, 
expedited review and approval/favorable opinion for minor change(s) in ongoing studies that have 
the approval /favorable opinion of the IRB/IEC and other appropriate institutional regulatory 
bodies. The NIH Principal Investigator will submit all protocol modifications to the regulatory 
authority(ies) in accordance with the governing regulations. 
When immediate deviation from the protocol is required to eliminate an immediate hazard(s) to 
subjects, the Investigator will contact the NIH Principal Investigator, if circumstances permit, to 
discuss the planned course of action. Any departures from the protocol must be fully documented 
in the CRF and source documentation. 
 
11.6 Direct Access to Source Data 


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27
Monitoring and auditing procedures developed by the NIH Principal Investigator will be followed, 
in order to comply with GCP guidelines. 
Regulatory authorities, the IRB/IEC and other appropriate institutional regulatory bodies, and/or 
the NIH Principal Investigator may request access to all source documents, CRFs, and other study 
documentation for on-site audit or inspection. Direct access to these documents must be guaranteed 
by the Investigator, who must provide support at all times for these activities. 
 
11.7 Case Report Form Completion 
CRFs will be completed for each study subject. It is the Site Principal Investigator’s responsibility 
to ensure the accuracy, completeness, and timeliness of the data reported in the subject’s CRF. 
Source documentation supporting the CRF data should indicate the subject’s participation in the 
study and should document the dates and details of study procedures, AEs, and subject status.  The 
Investigator will have access to an NHLBI-approved database to enter CRF data electronically.   
 
12.0 
Compensation 
 
 
Participants will not be compensated for participating in this study. 
 
 
13.0 
Reimbursement for Travel 
 
 
Reimbursement for travel will be in accordance with NHLBI travel policy reimbursement for food 
and lodging will be consistent with NIH and NHLBI guidelines. 
 
14.0 
Pharmaceuticals 
 
• Plerixafor (Sanofi), Mozobil® 
 
Plerixafor is available from the Clinical Center pharmacy in single-use clear glass vials containing 
24 mg plerixafor in 1.2 mL vials (20 mg/mL). It is formulated as a sterile, preservative-free, clear, 
colorless to pale yellow, and isotonic solution for subcutaneous injection. The quantitative 
composition (per vial) is: 
 
 
Plerixafor 
 
 
 
24 mg 
 
Sodium chloride 
 
 
5.9 mg 
 
Water for injection (qs ad) to  
1.2 mL 
 
(adjusted to a pH of 6.0 to 7.5 with hydrochloric acid and with sodium hydroxide) 
 
Storage: The intact vials of plerixafor should be stored at 25°C (77°F); excursions permitted to 15-
30°C (59-86°F). 
 
Stability: The expiration date is indicated on the label. Do not use it after the expiration date. 
 
Off-Label Use of Drugs 
Plerixafor will be used beyond the indications specified in the Prescriber Information. These Off-
Label uses will comply with prevailing community standards.  
 
The use of these drugs for this protocol meets the requirements for exemption from the 
Investigational New Drug regulations, 21 CFR 312, specifically:  


17-H-0124 
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Date: February 7, 2019 
28
1. The investigational drug is lawfully marketed in the United States  
2. The investigation is not intended to be reported to the FDA as a well-controlled study in 
support of a new indication for use of the drug product  
3. The investigation is not intended to support a significant change in advertising to an 
existing lawfully marketed prescription drug product  
4. The investigation does not involve a route of administration or dosage level or other factor 
that significantly increases the risks (or decreases the acceptability of the risks) associated 
with the use of the drug product.  
5. The investigation will be conducted in compliance with the requirements for institutional 
review set forth in FDA regulations 21 CFR 56, and requirements for informed consent as 
set forth in FDA regulations 21 CFR 50 
6. The investigation will be conducted in compliance with FDA regulations 21 CFR 312.7: 
Promotion and charging for investigational drugs. 
 
 
 


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29
 
15.0 
References 
 
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Neuropsychol Rev. Dec 2001;11(4):179-196. 
2. 
Brown RT, Davis PC, Lambert R, Hsu L, Hopkins K, Eckman J. Neurocognitive functioning and 
magnetic resonance imaging in children with sickle cell disease. J Pediatr Psychol. Oct-Nov 
2000;25(7):503-513. 
3. 
Powars DR, Chan LS, Hiti A, Ramicone E, Johnson C. Outcome of sickle cell anemia: a 4-decade 
observational study of 1056 patients. Medicine (Baltimore). Nov 2005;84(6):363-376. 
4. 
Adams RJ, McKie VC, Hsu L, et al. Prevention of a first stroke by transfusions in children with 
sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med. 
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5. 
Charache S, Terrin ML, Moore RD, et al. Effect of hydroxyurea on the frequency of painful crises 
in sickle cell anemia. Investigators of the Multicenter Study of Hydroxyurea in Sickle Cell 
Anemia. N Engl J Med. May 18 1995;332(20):1317-1322. 
6. 
Steinberg MH, Barton F, Castro O, et al. Effect of hydroxyurea on mortality and morbidity in 
adult sickle cell anemia: risks and benefits up to 9 years of treatment. JAMA. Apr 2 
2003;289(13):1645-1651. 
7. 
Rodgers GP, Dover GJ, Noguchi CT, Schechter AN, Nienhuis AW. Hematologic responses of 
patients with sickle cell disease to treatment with hydroxyurea. N Engl J Med. Apr 12 
1990;322(15):1037-1045. 
8. 
Walters MC, Patience M, Leisenring W, et al. Bone marrow transplantation for sickle cell disease. 
N Engl J Med. Aug 8 1996;335(6):369-376. 
9. 
Vermylen C, Cornu G, Ferster A, et al. Haematopoietic stem cell transplantation for sickle cell 
anaemia: the first 50 patients transplanted in Belgium. Bone Marrow Transplant. Jul 1998;22(1):1-
6. 
10. 
Bernaudin F, Socie G, Kuentz M, et al. Long-term results of related myeloablative stem-cell 
transplantation to cure sickle cell disease. Blood. Oct 1 2007;110(7):2749-2756. 
11. 
Platt OS, Guinan EC. Bone marrow transplantation in sickle cell anemia--the dilemma of choice. 
N Engl J Med. Aug 8 1996;335(6):426-428. 
12. 
Kalinyak KA, Morris C, Ball WS, Ris MD, Harris R, Rucknagel D. Bone marrow transplantation 
in a young child with sickle cell anemia. Am J Hematol. Apr 1995;48(4):256-261. 
13. 
Hsieh MM, Kang EM, Fitzhugh CD, et al. Allogeneic hematopoietic stem-cell transplantation for 
sickle cell disease. N Engl J Med. Dec 10 2009;361(24):2309-2317. 
14. 
Hsieh MM, Fitzhugh CD, Weitzel RP, et al. Nonmyeloablative HLA-matched sibling allogeneic 
hematopoietic stem cell transplantation for severe sickle cell phenotype. JAMA. Jul 2 
2014;312(1):48-56. 
15. 
Anderlini P, Rizzo JD, Nugent ML, Schmitz N, Champlin RE, Horowitz MM. Peripheral blood 
stem cell donation: an analysis from the International Bone Marrow Transplant Registry (IBMTR) 
and European Group for Blood and Marrow Transplant (EBMT) databases. Bone Marrow 
Transplant. Apr 2001;27(7):689-692. 
16. 
Lane TA. Allogeneic marrow reconstitution using peripheral blood stem cells: the dawn of a new 
era. Transfusion. Jul 1996;36(7):585-589. 
17. 
Fitzhugh CD, Hsieh MM, Bolan CD, Saenz C, Tisdale JF. Granulocyte colony-stimulating factor 
(G-CSF) administration in individuals with sickle cell disease: time for a moratorium? 
Cytotherapy. 2009;11(4):464-471. 


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Date: February 7, 2019 
30
18. 
Abboud M, Laver J, Blau CA. Granulocytosis causing sickle-cell crisis [letter]. Lancet. 
1998;351(9107):959. 
19. 
Adler BK, Salzman DE, Carabasi MH, Vaughan WP, Reddy VV, Prchal JT. Fatal sickle cell crisis 
after granulocyte colony-stimulating factor administration. Blood. May 15 2001;97(10):3313-
3314. 
20. 
Grigg AP. Granulocyte colony-stimulating factor-induced sickle cell crisis and multiorgan 
dysfunction in a patient with compound heterozygous sickle cell/beta+ thalassemia. Blood. Jun 15 
2001;97(12):3998-3999. 
21. 
Kamble RT, Tin UC, Carrum G. Successful mobilization and transplantation of filgrastim 
mobilized hematopoietic stem cells in sickle cell-hemoglobin C disease. Bone Marrow Transplant. 
Jun 2006;37(11):1065-1066. 
22. 
Liles WC, Broxmeyer HE, Rodger E, et al. Mobilization of hematopoietic progenitor cells in 
healthy volunteers by AMD3100, a CXCR4 antagonist. Blood. Oct 15 2003;102(8):2728-2730. 
23. 
Broxmeyer HE, Orschell CM, Clapp DW, et al. Rapid mobilization of murine and human 
hematopoietic stem and progenitor cells with AMD3100, a CXCR4 antagonist. J Exp Med. Apr 18 
2005;201(8):1307-1318. 
24. 
Devine SM, Vij R, Rettig M, et al. Rapid mobilization of functional donor hematopoietic cells 
without G-CSF using AMD3100, an antagonist of the CXCR4/SDF-1 interaction. Blood. Aug 15 
2008;112(4):990-998. 
25. 
Hendrix CW, Collier AC, Lederman MM, et al. Safety, pharmacokinetics, and antiviral activity of 
AMD3100, a selective CXCR4 receptor inhibitor, in HIV-1 infection. J Acquir Immune Defic 
Syndr. Oct 1 2004;37(2):1253-1262. 
26. 
Abboud M, Laver J, Blau CA. Granulocytosis causing sickle-cell crisis. Lancet. Mar 28 
1998;351(9107):959. 
27. 
Bonig H, Papayannopoulou T. Hematopoietic stem cell mobilization: updated conceptual 
renditions. Leukemia. Jan 2013;27(1):24-31. 
28. 
Bendall LJ, Bradstock KF. G-CSF: From granulopoietic stimulant to bone marrow stem cell 
mobilizing agent. Cytokine Growth Factor Rev. Aug 2014;25(4):355-367. 
29. 
Pantin JM, Tian X, Hsieh MM, et al. High Dose Plerixafor Is Safe and Mobilizes Higher Numbers 
of CD34+ Cells Compared with Standard Dose Plerixafor. Blood. 2012-11-16 00:00:00 
2012;120(21):585-585. 
30. 
Koshy M, Weiner SJ, Miller ST, et al. Surgery and anesthesia in sickle cell disease. Cooperative 
Study of Sickle Cell Diseases. Blood. Nov 15 1995;86(10):3676-3684. 
31. 
Kim HC. Red cell exchange: special focus on sickle cell disease. Hematology Am Soc Hematol 
Educ Program. Dec 5 2014;2014(1):450-456. 
32. 
Marques MB, Singh N, Reddy VV. Out with the bad and in with the good; red cell exchange, 
white cell reduction, and platelet reduction. J Clin Apher. Aug 2014;29(4):220-227. 
33. 
Jeng MR, Feusner J, Skibola C, Vichinsky E. Central venous catheter complications in sickle cell 
disease. Am J Hematol. Feb 2002;69(2):103-108. 
34. 
Yannaki E, Papayannopoulou T, Jonlin E, et al. Hematopoietic stem cell mobilization for gene 
therapy of adult patients with severe beta-thalassemia: results of clinical trials using G-CSF or 
plerixafor in splenectomized and nonsplenectomized subjects. Mol Ther. Jan 2012;20(1):230-238. 
35. 
Yannaki E, Karponi G, Zervou F, et al. Hematopoietic stem cell mobilization for gene therapy: 
superior mobilization by the combination of granulocyte-colony stimulating factor plus plerixafor 
in patients with beta-thalassemia major. Hum Gene Ther. Oct 2013;24(10):852-860. 
36. 
Koch KL, Karafin MS, Simpson P, Field JJ. Intensive management of high-utilizing adults with 
sickle cell disease lowers admissions. Am J Hematol. Mar 2015;90(3):215-219. 


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37. 
Pantin J, Purev E, Tian X, et al. Effect of high-dose plerixafor on CD34+ cell mobilization in 
healthy stem cell donors: results of a randomized crossover trial. Haematologica. Mar 
2017;102(3):600-609. 
38. 
Stroncek D, Shawker T, Follmann D, Leitman SF. G-CSF-induced spleen size changes in 
peripheral blood progenitor cell donors. Transfusion. May 2003;43(5):609-613. 
39. 
Stroncek DF, Dittmar K, Shawker T, Heatherman A, Leitman SF. Transient spleen enlargement in 
peripheral blood progenitor cell donors given G-CSF. J Transl Med. Jul 21 2004;2(1):25. 
 
Appendix I 
 
Individuals with sickle cell disease, after plerixafor mobilization and apheresis for stem cell collection 
 
Date(s) of plerixafor injections: 
 
Date(s) of apheresis: 
 
Narcotics offered: yes or no  
 
Narcotics taken: yes or no, if yes, state for what kind of pain 
 
CTCAE (common toxicity criteria for adverse events v 4.0, 
http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf) 
 
 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 
5 
Fever (pg 56) 
38.0-39.0C 
100.4-102.2 F 
>39.0-40.0 C 
102.3-104 F 
>40 (>104F) for 24 
hrs or less 
>40C (>104F) 
for >24 hrs 
Death  
Fatigue (pg 56) 
Relieved by 
rest 
Fatigue not 
relieved by 
rest; 
limiting 
instrumental 
ADL 
Fatigue not relieved 
by rest, limiting self-
care ADL 
 
 
Rash, papulo-
pustular, not 
acne (pg 79) 
<10% body 
surface area 
10-30% 
>30% 
>30%, extensive 
superinfection, 
need IV 
antibiotics 
Death  
Rash, pustular 
(pg 82) 
 
localized 
Need IV antibiotics or 
antimicrobials 
 
 
Pruritus (pg 
184) 
Mild or 
localized 
(topical 
treatment) 
Intense, 
widespread, 
skin changes 
from 
scratching 
Intense, widespread, 
skin changes from 
scratching, limiting 
self-care; oral steroids 
or immune-
suppressive therapy 
 
 
Rash, 
acneiform (pg 
184) 
<10% body 
surface area 
10-30% 
>30%, limiting self-
care, local 
superinfection, oral 
antibiotics 
>30%, extensive 
superinfection, 
need IV 
antibiotics 
Death  


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Rash, maculo-
papular (pg 
185) 
<10% body 
surface area 
10-30% 
>30%, limiting self-
care 
 
 
Injection site 
reaction (pg 58) 
Tender +/- 
warmth, 
redness, or 
itching 
Pain, edema, 
phlebitis 
Ulceration or 
necrosis, severe tissue 
damage, operative 
intervention indicated 
Life-threatening, 
urgent 
intervention 
Death  
Nausea (pg 46) 
Loss of 
appetite, no 
change in 
eating habits 
Decrease oral 
intake, no 
weight loss 
Tube feeding, TPN, 
or hospitalization 
 
 
Vomiting (pg 
54) 
1-2 episodes 
(separated by 
5 min) in 24 
hrs 
2-5 episodes in 
24 hrs 
6 or more episodes in 
24 hrs, tube feeding, 
TPN, or 
hospitalization 
Life threatening, 
urgent 
intervention 
Death  
Anorexia (pg 
114), similar to 
nausea 
Loss of 
appetite, no 
change in 
eating habits 
Decrease oral 
intake, no 
weight loss 
Tube feeding, TPN, 
or hospitalization 
Life threatening, 
urgent 
intervention 
Death  
Insomnia (pg 
144) 
Mild difficulty 
falling asleep, 
staying asleep 
or waking up 
early 
Moderate 
difficulty 
Severe difficulty 
 
 
Dizziness (pg 
131) 
Mild 
unsteadiness 
or 
sensation of 
movement 
Moderate 
Severe  
 
 
Presyncope (pg 
137) 
 
Present (near 
fainting) 
 
 
 
Syncope (pg 
139) 
 
 
Fainting, orthostatic 
collapse 
 
 
Abdominal 
pain (pg 28) 
Mild 
Moderate, 
limiting 
instrumental 
ADL 
Severe, limiting self-
care 
 
 
Bone pain, 
specify where, 
including back, 
hips, or other 
joints (pg 120) 
Mild  
Moderate, 
limiting 
instrumental 
ADL 
Severe, limiting self-
care 
 
 
Headache (pg 
133) 
Mild  
Moderate, 
limiting 
instrumental 
ADL 
Severe, limiting self-
care 
 
 


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Myalgia, 
muscle pain (pg 
124) 
Mild  
Moderate, 
limiting 
instrumental 
ADL 
Severe, limiting self-
care 
 
 
IV site or 
infusion related 
reaction (pg 57) 
Mild, infusion 
not 
interrupted, no 
intervention 
Interrupted, 
but prompt 
response to 
treatment 
Prolonged, recurrence 
of symptoms, or 
hospitalization 
Life threatening 
Death  
Pharyngitis (pg 
81) 
 
Localized, 
local treatment 
IV antimicrobials, 
radiologic or 
operative intervention 
Life threatening 
Death  
 
 
 


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Appendix II-As of January 18, 2019, this site is considered closed to accrual but open to follow-up 
St. Jude Children’s Research Hospital site-specific protocol changes and activities 
 
The following changes and clarifications are requested for St. Jude Children’s Research Hospital. 
 
Section 3.0 Scientific and clinical justification 
This research protocol (Plerixafor mobilization) will be offered to adult patients with SCD (ages 18 to 25) 
to assess feasibility and success of plerixafor mobilization and harvest of mobilized peripheral blood HSCs 
for future use in transplantation or gene therapy trials. At St. Jude, currently there are no open haploidentical 
hematopoietic stem cell transplant (HSCT) or gene therapy studies for children with SCD. However, for 
adults with SCD, a haploidentical bone marrow transplant research study is open and enrolling patients at 
UT/Methodist Hospital in Memphis. St. Jude participants may wish to enroll in a haploidentical HSCT or 
gene therapy trial following participation in the current study. Until then, their HSCs will be cryopreserved. 
All excess cells beyond 3.0x10e6 CD34+ cells/kg will be  used for research and to develop various 
therapeutic approaches for sickle cell disease, including gene therapy, gene editing, drug discovery and 
development and other novel approaches to increase fetal hemoglobin as discussed in section 7.2.  
 
Section 5.0 Eligibility assessment 
Eligibility criteria will be as described in the NIH parent protocol except where noted. At St. Jude, SCD 
patients who are between the ages of 18 and 25 and are willing to donate hematopoietic stem cell collection 
for future gene therapy/gene editing study are eligible for study entry (criteria (b) of the parent protocol). 
Due to St. Jude being a pediatric hospital, participants will need to be no older than 25 to enroll at St. Jude. 
There are no clinical trials with curative intent open at St. Jude currently.  In the future, if and when such 
trials become available, these subjects will be offered participation in those trials and the harvested HSCs 
will be used in those trials if the subjects so desire. Additionally, should any of these adult participants 
undergo haploidentical HSCT at UT/Methodist Hospital, their remaining unmanipulated HSCs will be 
made available for clinical purposes as needed, as back-up in case of graft failure or rejection, just like in 
the parent protocol at NIH/NHLBI. 
 
Patients on chronic red cell transfusion therapy or chronic erythrocytapheresis therapy will be eligible. 
 
Patients will need to have a working central line for access in order to be eligible for this protocol. 
 
Section 5.1 Inclusion criteria 
5.1.1 At St Jude, Inclusion criteria will be as described in NIH parent protocol 5.0 part (b).  
 
Section 6.0 Treatment plan 
6.1 Only one dose of Plerixafor will be administered and only one HSC apheresis will be performed at St. 
Jude irrespective of the CD34+ cell yield. 
6.2 Leukapheresis will be performed in the Apheresis unit by the Apheresis team at St. Jude. 
6.3 All excess cells beyond 3.0x10e6 CD34+ cells/kg will be used for sickle cell disease research at St Jude 
as described in 7.2 below.  
6.4 Due to St. Jude Children’s Research Hospital being a pediatric facility, if a participant experiences a 
prolonged complication as a result of participating in the protocol, he or she will be transferred to an adult 
hospital. An adult intensive care provider will be identified to serve as a liaison between St. Jude Children’s 
Research Hospital and the adult hospital should a transfer need to take place. The intensive care unit at St. 
Jude Children’s Research Hospital has agreed to accept adult participants from this protocol and will only 


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initiate a transfer to an adult hospital should the participant require a prolonged stay or develop multiple 
organ dysfunction. 
 
Section 7.0 Sample Collection, Storage and Biospecimen and Data Management Plan 
7.1 Data management 
Data will be entered by the study coordinator in the Clinical Trial Management team within the Department 
of Hematology through electronic Case Report Forms provided by the sponsor.  
 
St. Jude may share samples from the excess of 3.0x10e6 CD34+ cells/kg collected for research purposes in 
a de-identified manner. 
 
7.2 Intended Use 
At the time of collection, all excess cells beyond 3.0x10e6 CD34+ cells/kg will be allocated for research 
purposes and stored (coded and de-identified) in a research lab at St. Jude in the Department of Hematology.  
These HSCs will be used primarily for gene-editing studies to demonstrate comparability and efficacy of 
gene-editing in bone marrow-derived and peripheral blood-derived hematopoietic stem and progenitor cells 
obtained from those with SCD. The remaining cells will be stored at St. Jude in the Human Application Lab 
and will be available for clinical purposes if needed in the future. In the future, if a participant receives a 
curative therapy (stem cell transplant, gene editing, etc) and does not require these stored cells as backup, 
or expires, then the remaining stored clinical samples will be used for research.  
 
7.8 Publication Policy:  
Primary objectives are to determine the safety and efficacy of Plerixafor for mobilizing HSCs—data related 
to these objectives will be shared with Dr. Tisdale at the NHLBI. Data arising from laboratory studies of 
bone marrow and mobilized patient HSCs belongs to St. Jude investigators and will be shared with outside 
investigators at the discretion of St. Jude investigators. 
 
7.9 Privacy and Confidentiality 
Study codes will be used in place of an identifier, such as a medical record number. The list containing the 
study number and the medical record number will be maintained in a locked file and will be retained 
indefinitely. Samples will be handled and processed by Tissue Resources at St. Jude by trained personnel 
used to handling human specimens and with strict procedures for protecting participant confidentiality.  De-
identified samples will only be forwarded to the Hematology research lab. 
 
The medical records of study participants may be reviewed by the NHLBI, St. Jude IRB, FDA, or clinical 
research monitors only.  
 
Section 8.0 Biostatistical Consideration 
8.1 St. Jude will enroll up to 4 participants.  
 
Section 9.0 Data Safety and Monitoring Plan 
9.1 Safety Monitoring 
St. Jude PIs and study team are responsible for ensuring protocol compliance.  100% of eligibility checklists 
and consents will be reviewed for accuracy and completeness by the Eligibility Coordinators.  Continuing 
reviews by the IRB and CT-SRC will occur at least annually 
 
The NHLBI and the NHLBI Data Coordinating Center will be responsible for monitoring the St. Jude site. 
 


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9.4 NIH Intramural IRB and CD Reporting 
St. Jude PI will report AEs to the NHLBI in time of submission of protocol to the NIH Intramural IRB for 
continuing review.  St. Jude PI will report all SAEs to Dr. Tisdale within 72 hours of learning about the 
event. 
 
Section 11.0 Compensation 
Subjects at St Jude will receive $250 per inpatient stay day up to $750 and $50 per outpatient clinic visit to 
compensate them for wage losses due to time away from their jobs during study participation, for a max of 
$800 per participant.