Conditions: Non-Hodgkin's Lymphoma Hodgkin's Lymphoma Multiple Myeloma Hematopoietic Stem Cells
Keywords: Non-Hodgkin's lymphoma Hodgkin's lymphoma Multiple myeloma Hematopoietic stem cells
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 31
Healthy volunteers: no

Brief summary:
This research study is evaluating a drug called meloxicam to see if it provides a benefit to people receiving Autologous Hematopoietic Stem Cell Transplantation (AHSCT).

The participant is currently scheduled to receive an AHSCT, which is a procedure that removes blood-forming stem cells (cells from which all blood cells develop) from the body. These stem cells are stored and later given back to the participant by a process called apheresis. This is a standard procedure to treat certain blood diseases such as lymphoma and multiple myeloma. However the use of meloxicam with this procedure is considered investigational.

Meloxicam is a non-steroidal anti-inflammatory drug (NSAID) which is given to decrease fever, swelling and pain that may come with inflammation. It has been approved by the FDA for the treatment of arthritis however it has not been approved for use in people receiving AHSCT.

This study will compare the combination of meloxicam with a drug called G-CSF (also called neupogen), to the combination of G-CSF with an agent that has no medicine (placebo). G-CSF is a substance that causes blood stem cells to change or increase in number when given to people undergoing AHSCT. The researchers would like to learn if giving meloxicam in combination with G-CSF to people before they undergo AHSCT will increase the number of stem cells available in the blood to collect and make the collection process easier.

Detailed description:
After the screening procedures confirm that the participant is eligible to participate in the research study:

Because no one knows which of the study options is best, the participant will be "randomized" into one of the study groups:

* G-CSF with meloxicam
* G-CSF with placebo (pills with no medicine)

Randomization means that the participants are put into a group by chance. It is like flipping a coin. Neither the participant nor the research doctor will choose what group the participant will be in. The participant will have an equal chance of being placed in any group.

\- Study Drug (meloxicam or placebo): If the participant takes part in this research study, the participant will be given a study drug-dosing diary. The study drug will come as a pill that the participant will take by mouth daily for 5 days, starting 6 days (Day -6) before the participant is scheduled to undergo the first apheresis procedure (Day 0) and continuing until 2 days before apheresis (Day -2). The participant will take meloxicam or placebo for a total of 5 days. The diary will also include special instructions for taking the study drug(s).

-G-CSF: All participants receive G-CSF as an injection under the skin (subcutaneous) in the clinic, daily starting 4 days (Day -4) before the first apheresis procedure (Day 0). The participant will continue to receive G-CSF for 3 days after apheresis.

\- Apheresis: The participant may receive up to 4 apheresis procedures, depending on how their body reacts to the stem cell mobilization. The participant will receive either meloxicam or placebo in combination with G-CSF on Days -6 to -2 as described above.

Clinical Exams: While the participant is receiving this procedure, the participant will have regular physical exams and they will be asked specific questions about any problems that they might be having. The participant will also have blood tests every day to look at how their bone marrow is recovering, to give possible transfusional support, and how to see how their liver and kidneys are functioning.

Planned Follow-up: The investigators would like to keep track of the participant's medical condition for the rest of their life. The investigators would like keep track of the participant's medical condition for 6 months after the study to see how they are doing.

Arms:
arm 1: GCSF + Placebo Patients in this group will receive GCSF 10 ug/kg s.c. daily, beginning 4 days prior to the 1st apheresis \[days -4, -3, -2, -1\] and continued on daily GCSF for a total of 4 apheresis or until ≥ 5 x 10\^6 CD34+ cells/kg are collected. They will also receive oral placebo for 5 days on days -6 through -2. Patients will undergo apheresis for 300 minutes to achieve approximately 3 to 4 whole blood volumes processed. This is a standard institutional protocol for autologous HSPC collection at the MGH. arm 2: B. GCSF + meloxicam:

Patients in this group will be treated with meloxicam and GCSF in an approximate two-day staggered dose schedule as described in our preclinical studies. Meloxicam will be given orally at a dose of 15 mg/day for 5 days (days -6 through -2). GCSF at 10 ug/kg/day subcutaneously will be started on day -4 and continued daily for a total of 4 apheresis or until ≥ 5 x 10\^6 CD34+ cells/kg are collected.

Interventions: intervention 1: GCSF intervention 2: meloxicam intervention 3: Placebo
Intervention descriptions: intervention 1: None intervention 2: None intervention 3: None

Protocol document:
Prot_SAP_000.pdf: 
NSAIDs to mobilize hematopoietic stem cells 
 September 28, 2016 
Protocol Version Date:  September 28, 2016 
NCT #: NCT02003625
Local Protocol #: 13-195 
Title: Non-steroidal anti-inflammatory drugs (meloxicam) to mobilize 
hematopoietic stem cells: A Phase II randomized trial 
Study Chair: Bimalangshu R. Dey, MD, PhD 
Co-Chair : David Scadden, MD. 
Co-Investigators: Karen Ballen, MD, Yibin Chen, MD, Steven McAfee, MD, Thomas Spitzer, 
MD;  
Lab Investigators Pavan Bendapudi, MD, Jonathan Hoggatt, PhD., Robert Maker, MD. 
Statistician: Beow Yeap, PhD., 
Schema 
Diseases: 
Non-Hodgkin’s 
lymphoma,  
Hodgkin’s lymphoma 
Multiple myeloma. 
Drugs: 
G-CSF
meloxicam
 Stratify   
R
A
  N
  D
Patients  
O
M
I
Z
E
Treatment 
  ARM A: G-CSF  
   (days -4 through until 
   Stem cell collection 
       Complete ) + placebo 
(days -6 through -2) (mulitple 
myeloma patients may 
optionally receive 
cyclophosphamide on day -
12) 
 ARM B: G-CSF (days -4 
through until stem cell 
collection complete) + 
meloxicam (days -6 through -2) 
(mulitple myeloma patients may 
optionally receive 
cyclophosphomide on day -12)  
Day 0: First day of apheresis 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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TABLE OF CONTENTS 
1. 
OBJECTIVES .................................................................................................................................................... 1 
1.1 
Study Design ............................................................................................................................................... 1 
1.2 
Primary Objectives ..................................................................................................................................... 1 
1.3 
Secondary Objectives ................................................................................................................................. 1 
2. 
BACKGROUND  AND  SIGNIFICANCE ...................................................................................................... 1 
2.3 
Rationale .................................................................................................................................................... 1 
2.4 
Correlative Studies Background ................................................................................................................. 7 
3. 
PARTICIPANT SELECTION .......................................................................................................................... 9 
3.1 
Eligibility Criteria ...................................................................................................................................... 9 
3.2 
Exclusion Criteria .................................................................................................................................. 10 
4. 
REGISTRATION PROCEDURES ................................................................................................................ 10 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ..................................................................... 10 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ................................................................. 11 
5. 
TREATMENT PLAN ...................................................................................................................................... 11 
5.1 
Agent Administration .............................................................................................................................. 12 
5.2 
General Concomitant Medication and Supportive Care Guidelines ........................................................ 13 
5.3 
Duration of Therapy .................................................................................................................................. 13 
5.4 
Duration of Follow Up ............................................................................................................................. 13 
5.5 
Criteria for Removal from Study .............................................................................................................. 13 
6. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS .................................... 13 
6.1 
Anticipated Toxicities ............................................................................................................................... 14 
7. 
DRUG FORMULATION AND ADMINISTRATION ................................................................................. 15 
7.1 
[Meloxicam] ............................................................................................................................................. 15 
8. 
CORRELATIVE/SPECIAL STUDIES .......................................................................................................... 16 
9. 
STUDY CALENDAR ...................................................................................................................................... 18 
10. 
ADVERSE EVENT REPORTING REQUIREMENTS .......................................................................... 18 
10..1 
Definitions ................................................................................................................................................ 19 
10.2 
Procedures for AE and SAE Recording and Reporting ............................................................................ 20 
10.3 
Reporting Requirements ........................................................................................................................... 21 
10.4 
Reporting to the Institutional Review Board (IRB) ................................................................................... 22 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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10.5 
Reporting to Hospital Risk Management .................................................................................................. 22 
10.6 
Monitoring of Adverse Events and Period of Observation ....................................................................... 22 
11. 
DATA AND SAFETY MONITORING ..................................................................................................... 23 
11.1 
Data Reporting ......................................................................................................................................... 23 
11.2 
Safety Meetings ......................................................................................................................................... 23 
11.3 
Monitoring ................................................................................................................................................ 24 
12. 
REGULATORY CONSIDERATIONS ..................................................................................................... 24 
12.1 
Protocol Review and Amendments ........................................................................................................... 24 
12.2 
Informed Consent ..................................................................................................................................... 24 
12.3 
Ethics and Good Clinical Practice (GCP) ............................................................................................... 25 
12.4 
Study Documentation ................................................................................................................................ 25 
12.5 
Records Retention ..................................................................................................................................... 26 
13. 
STATISTICAL CONSIDERATIONS ....................................................................................................... 26 
14. 
PUBLICATION PLAN ............................................................................................................................... 26 
15. 
REFERENCES ............................................................................................................................................ 26 
16. 
APPENDICES ................................................................................................................................................. 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
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1 
1. OBJECTIVES 
 
We hypothesize that patients in the meloxicam group (G-CSF + meloxicam) will have higher 
numbers of CD34+ cells (above 1.5 fold) in the apheresis product collected on the first day, will 
require fewer apheresis sessions to achieve  4 x 10^6 CD34+ cells/kg for multiple myeloma 
patients and >2 x 10^6 CD34+ cells/kg for lymphoma patients compared to patients in G-CSF + 
placebo group and will have faster neutrophil and platelet engraftment compared to patients 
transplanted with HSC graft mobilized with G-CSF + placebo. 
 
 
1.1 
Study Design 
 Patients eligible for AHSCT will be randomized to receive G-CSF + placebo (Arm A) or G-CSF 
+ meloxicam (Arm B) for their stem cell mobilization.  Patients who will have <10/l CD34+ cells 
in the peripheral blood will be declared as “poor mobilizers” and be rescued with Plerixafor and 
G-CSF. 
 
1.2 
Primary Objectives 
 
1. Determine if meloxicam in conjunction with G-CSF leads to increased numbers of circulating 
CD34+ cells on the first day of apheresis compared to G-CSF + placebo.  
 
2. Determine how many apheresis sessions are required to collect  4 x 10^6 CD34+ cells/kg 
for multiple myeloma patients and >2 x 10^6 CD34+ cells/kg for lymphoma patients in the G-
CSF + meloxicam group compared to the G-CSF group. 
  
 
1.3 
Secondary Objectives 
 
1.  To determine that meloxicam is safe when used in combination with G-CSF for stem cell 
mobilization. 
 
2. The time to neutrophil and platelet engraftment after AHSCT.   
 
3.  To evaluate transfusion support (number of red blood cells and platelet transfusions needed 
prior to red blood cell and platelet engraftment). 
 
4.  Proportion of patients failing stem cell mobilization. 
 
 
2. BACKGROUND 
 
 
2.1 
Rationale 
 
Autologous hematopoietic stem cell (HSC) transplantation plays an important role in the 
treatment of many hematologic malignancies and some pediatric cancers.  The utility of current 
mobilization regimens which use cytokines (G-CSF) after chemotherapy (chemomobilization) or 
cytokine(s) (e.g. G-CSF) alone, is limited by failure to mobilize adequate numbers of CD34+ 


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2 
cells in up to 40% of selected patient population.  Plerixafor (AMD 3100, a CXCR4 antagonist) 
in combination with G-CSF has recently been used as a rescue with (second) successful 
mobilization of HSC in approximately 63% of these patients, which still leaves a large number of 
patients without an adequate HSC graft for their potentially curative autologous HSC 
transplantation.  In addition, current strategies have differing HSC yields, safety considerations, 
resource utilization and costs.  Novel agents are clearly needed that will adequately mobilize 
HSC with  few or no toxicities, thereby improving patient outcomes.  Here, we propose to 
demonstrate that oral meloxicam, an inexpensive, well-tolerated, and widely available non-
steroidal anti-inflammatory drug (NSAID), can be a safe and effective stem cell mobilizing agent.  
Recently, we have shown in a mouse model that meloxicam increases egress of hematopoietic 
progenitor cells (HPC) and the phenotypic HSC-enriched populations Sca-1+ c-Kit+ lineage- 
(SKL) or the highly purified CD150+ CD48- (SLAM) SKL populations [Nature in press].  When 
baboons were mobilized with a standard clinical regimen of G-CSF, or the combination of G-
CSF + meloxicam, in all cases meloxicam resulted in increased numbers of circulating CD34+ 
cells compared to G-CSF alone, and in addition, meloxicam treatment on its own also resulted 
in significant HSC/HPC mobilization.  In healthy human volunteers, short-term meloxicam 
treatment resulted in significant increases in CD34+ cells.  The inhibition of PGE2 signaling 
which is an important positive regulator of HSC CXCR4 and HSC homing to the niche, appears 
to be one (reduced CXCR4 levels) of the main mechanisms of NSAID-induced HSC 
mobilization and this is a cyclooxygenase (COX) pathway specific effect. Staggered 
administration of meloxicam and G-CSF allowed for restored CXCR4 levels but maintaining 
enhanced HSC mobilization and, in transplantation models HSC grafts collected this way 
resulted in significant enhancement in hematopoietic engraftment. Meloxicam inhibits both 
COX-1 and COX-2 and when compared to other dual inhibitors it has much less inhibition of 
platelet aggregation.  In this proposal, we will address the hypothesis that oral meloxicam - an 
inexpensive, well-tolerated, and widely available non-steroidal anti-inflammatory drug (NSAID), 
can be a safe and effective stem cell mobilizing agent.  These studies have the potential to lead 
to the establishment of a novel drug, that is widely available, affordable, easy to administer, 
safe, yet effective in predictably mobilizing CD34+ cells for both autologous and allogeneic HSC 
transplantation. 
 
BACKGROUND AND SIGNIFICANCE 
Factors limiting clinical AHSCT.   Autologous hematopoietic stem cell (HSC) transplantation 
(AHSCT) provides hematopoietic support after high dose chemotherapy and is the standard of 
care for patients with multiple myeloma, chemosensitive relapsed/refractory Hodgkin’s disease, 
high- or intermediate-grade non-Hodgkin lymphoma (NHL) and relapsed/refractory germ cell 
tumor [1-3].  AHSCT is also used as a salvage treatment in follicular lymphoma and recent data 
suggest that more than10-year disease-free survival is possible after high-dose chemotherapy 
and AHSCT [4].  In addition, AHSCT may lead to long-term progression-free survival in patients 
with mantle cell lymphoma, when used as part of front-line treatment in first remission [5]. 
 
The numbers of CD34+ cells play an important role in the success of AHSCT.  Higher HSC doses 
are associated with faster neutrophil (>0.5 x 109/l) and faster platelet engraftment (plt count >20 x 
109/l) and reduction in the need of supportive measures such as blood product transfusions and 
prophylactic antibiotics [6, 7].  Other factors that influence the HSC mobilization and, therefore, the 
success of AHSCT include patient age, gender, degree of exposure to previous chemotherapy 
and irradiation, disease characteristics such as bone marrow involvement and previous 
mobilization attempts [8].  Unsuccessful initial HSC mobilization often leads to expensive 
additional mobilization attempts and may preclude ASHCT altogether [9-12].  
 


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3 
Today, the two most common HSC mobilization regimens use cytokines (G-CSF) alone or 
cytokines (G-CSF) after chemotherapy (chemomobilization).  While cytokine alone can mobilize 
adequate HSC, the addition of a myelosuppressive chemotherapy followed by cytokine 
mobilization increases HSC numbers by a factor of 2.5 [11] and can reduce the number of 
apheresis required for targeted HSC collection.  The use of chemotherapy in chemomobilization is 
associated with variable rates of complications due to neutropenia and thrombocytopenia and, 
therefore leads to increased resource use, hospitalization, transfusions and the use of antibiotic 
therapy [13, 14].  In addition, the variation in chemotherapeutics and individual responses to 
chemomobilization often results in unpredictable/irregular collection schedules that increase 
resource utilization [15]. Current HSC mobilization regimens also have high failure rates, failing to 
mobilize sufficient HSC to proceed to AHSCT in 5-30% of patients, necessitating additional 
mobilization attempts or precluding transplantation [16, 17]. 
 
Biology of HSC Mobilization. There has been significant recent advances in specific cellular 
and 
molecular 
mechanisms 
governing 
the 
interactions 
between 
HSC 
and 
BM 
microenvironment, i.e., HSC/niche interactions. The HSC niche is represented by stromal cells, 
endothelial cells, osteoblasts and other matrix components such as collagens, fibronectins and 
proteoglycans.  HSCs express a variety of cell surface receptors, specifically adhesion 
molecules, namely lymphocyte function-associated Ag-1 (LFA-1), very late Ag-4 (VLA-4) and 
Mac-1, the chemokine receptors CXCR4 and CXCR2, the cell surface glycoproteins CD44 and 
CD62L and the tyrosine kinase receptor c-kit [18, 19]. The BM stroma contains stromal cell-
derived factor-1 (SDF-1), CXC chemokine GRO-, vascular cell adhesion molecule-1 (VCAM-
1), kit ligand, P-selectin glycoprotein ligand-1 (PSGL-1) and hyaluronic acid, all of which are 
ligands for HSC adhesion molecules/receptors [18, 19].  Inhibition of these receptor-ligand 
interactions results in HSC and HPC egress from the bone marrow [20, 21].  Human 
hematopoietic progenitor cells (HPC) and their precursors, including the majority of HSCs, 
express the CD34 antigen, despite the available evidence that CD34- cells may have 
multilineage reconstitution capacity [22, 23].  Therefore, the CD34 surface marker is commonly 
used as a marker for HSC/HPC collection.  The target dose of CD34+ cells ranges from a 
minimum of 2.0 x 106 CD34+ cells/kg to an optimal dose of 5.0 x 106 CD34+ cells/kg [12, 24-26].  
The numbers of CD34+ cells are positively correlated with the pace of neutrophil and platelet 
engraftment following AHSCT.  Higher CD34+ cell doses are more beneficial for patients with 
myeloma and NHL, with a few studies reporting improvement in overall survival in myeloma 
patients [27, 28].  
 
G-CSF. Under G-CSF stimulation, myeloid cells release active neutrophil serine proteases 
cathepsin G and neutrophil elastase along with stromal metalloproteinase-9.  This results in 
cleavage/degradation of the adhesion molecules VCAM-1, c-kit, CXCR4 and SDF-1 and in 
release of CD34+ cells [29-32].  G-CSF is the most commonly used HSC mobilizing agent.  
When G-CSF alone is used for mobilization of CD34+ cells, it is given at doses varying from 10 
ug/kg s.c. daily to 32 ug/kg s.c. daily, beginning at least 4 days before the first apheresis 
session and continued until the last apheresis session (Neupogen, filgrastim [package insert]. 
Amgen Inc.: Thousand Oaks, CA, 1991-2006) [32].  In many patients with myeloma and 
malignant lymphoma, mobilization with G-CSF alone results in suboptimal CD34+ cell yields, 
with “mobilization failures”, defined as CD34+ cell yields of <2 x 106/kg, in up to 30% of patients.  
Moskowitz et al reported that G-CSF mobilization alone yielded significantly fewer CD34+ cells 
and was inferior to mobilization with chemotherapy + G-CSF (1.5 x 106/kg vs. 6.7 x 106/kg) [33].  
 
G-CSF with chemotherapy. It has been speculated that treatment with cyclophosphamide (CY) 
and G-CSF have a synergistic effect on protease release in marrow microenvironment, because 
when administered individually, both CY and G-CSF enhance the release of neutrophil 


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4 
proteases that cleave the adhesion molecules CXCR4, SDF-1 and c-kit [34]. Besides CY, some 
of the other chemotherapeutics chosen from the salvage regimens, that are used in conjunction 
with G-CSF for HSC mobiliozation are ICE (ifosfamide, carboplatinum, etoposide), high-dose 
cytarabine, DHAP and ESHAP (etoposide, cytarabine, methylyprednisolone and cisplatinum), 
etc.  Salvage chemotherapy followed by G-CSF is widely used for mobilization of CD34+ cells 
because the addition of suppression of the bone marrow to G-CSF results in higher HSC yields 
with fewer apheresis sessions needed to collect the targeted CD34+ cell dose, which may result 
in better patient outcomes [35, 36].  While chemotherapy has been noted to reduce the risk of 
tumor-contaminated cell collections, it has not been proven yet that the cytoreductive effects of 
chemomobilization confer any survival benefit to the patients [37, 38]. 
 
The effect of chemomobilization is highly variable and CD34+ cell egress peaks 10-18 days 
after administration of chemotherapy which generally correlates with rebound of white cell count 
after a chemotherapy-induced nadir [39].  Following chemomobilization, the length of time 
before the number of CD34+ cells peaks differs substantially between patients resulting in 
unpredictable collection schedules [11, 15, 40].  White cell and CD34+ cell counts, on 
occasions, must be monitored over the course of many days to determine when to initiate the 
collection.  Besides, the gains of adding chemotherapy to a G-CSF mobilization regimen may be 
offset by the increased risk of complications, including higher risk of infection, hospitalizations, 
the need for transfusion and antibiotic therapy, greater resource utilization with considerably 
higher cost overall [13, 35]. 
 
Plerixafor (AMD 3100). AMD 3100 is a selective and reversible inhibitor of CXCR4 and disrupts 
its interaction with SDF-1, thereby releasing HSC into the peripheral blood [41].  Plerixafor in 
combination with G-CSF has been shown to predictably enhance the numbers of circulating 
CD34+ cells [compared to G-CSF alone group, median increase of 4.4 fold in lymphoma 
patients and 3- to 3.5 fold in myeloma patients] [42]. In a study on poor mobilizers, collections of 
 2x 106 CD34+ cells/kg after administration of G-CSF (10 g/kg s.c. daily, with apheresis 
initiated on day 5, continued until the collection is complete or declared “failed”) and plerixafor 
(240 g/kg s.c. daily, beginning on the evening of day 4, continued every evening until collection 
is complete or declared “failed”) were achieved in 60.3% of patients with NHL, 71.4% of patients 
with myeloma and 76.5% of patients with Hodgkin lymphoma [43].  Perixafor is establishing its 
recognition as a potential HSC mobilizing agent.  However, this is an expensive drug, needs 
hospital visits for the injections and it has adverse side effects such as diarrhea, nausea, 
vomiting and injection-site erythema/edema. 
 
PRELIMINARY STUDIES: Despite significant advances in specific cellular or molecular 
mechanisms governing HSC/niche interactions, little is understood about regulatory function 
within the intact mammalian hematopoietic niche. Recently, we and others described a positive 
regulatory role for the lipid mediator 
Prostaglandin E2 (PGE2) on HSC function 
ex vivo [44,45]. However, to date, the 
function of PGE2 produced endogenously 
in mammalian niches in regulation of 
hematopoiesis is unknown. Given the 
known roles of PGE2 on HSC and the 
abundance of clinically used compounds 
that alter PGE2 signaling, particularly 
nonsteroidal 
anti-inflammatory 
drugs 
(NSAIDs), we sought to determine the 
Figure 2. Meloxicam enhances HPC and HSC mobilization.  
(a) Colony forming units and (b) phenotypically defined HSC in 
the peripheral blood of mice treated with G-CSF or the 
combination of G-CSF and Meloxicam. Data are mean ± SEM 3 
individual epxeriments, of 5 mice per group, per experiment, 
each assayed individually. ***P<0.001. 


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5 
role of endogenous PGE2 on systemic niche-HSC regulation. 
NSAIDs increase hematopoietic stem and progenitor cell egress  
Mice were treated with the prototypical 
NSAID indomethacin (50 g/mouse) for 
4 days to reduce endogenous PGE2 
production. Treatment resulted in a 
significant increase in hematopoietic 
progenitor cells (CFU-GM) in peripheral 
blood [46] (Figure 1a), that was not 
accompanied by an increase in total 
white blood cell count (not shown), 
which likely accounts for lack of previous 
detection of this observation despite 
decades of clinical NSAID use. No 
increase in HPC egress was seen in 
mice treated with the lipoxygenase 
inhibitor 
baicalein 
(Figure 
1a), 
suggesting a cyclooxygenase (COX) pathway specific effect. When indomethacin was co-
administered with the clinically used mobilizing agent granulocyte-colony stimulating factor (G-
CSF), significant enhancement (~2 fold) in HPC mobilization resulted (Figure 1a, right panel). 
NSAIDs with varying COX-1- and COX-2-selectivity demonstrated significant mobilization with 
indomethacin, aspirin, ibuprofen, and meloxicam (Figure 1b). Meloxicam inhibits both COX-1 
and COX-2 within the bone marrow microenvironment and when compared to other dual 
inhibitors it has a reduced incidence of gastrointestinal discomfort [47] and inhibition of platelet 
aggregation [48]. Therefore, meloxicam was used in the majority of the described studies below, 
and is our choice for clinical study in this proposal. Meloxicam, similar to indomethacin, 
increased egress of HPC  (Figure 2, left panel) and the phenotypic HSC-enriched populations 
Sca-1+ c-kit+ lineage- (SKL) or the highly purified CD150+ CD48- (SLAM) SKL populations 
(Figure 2, right panel). 
 
Enhanced hematopoietic engraftment with G-CSF + NSAID mobilized grafts  We then 
explored the hematopoietic engraftment potential of an NSAID-mobilized graft.  Despite 
significant increases in phenotypic HSC and functional HPC in the graft, two early attempts at 
transplant did not show a significant effect on HSC engraftment (data not shown). Since we had 
previously shown that PGE2 signaling was an important positive regulator of HSC CXCR4 
expression and HSC homing to the niche 1, we hypothesized that while there was an increase in 
HSC/HPC yield in NSAID grafts, CXCR4 expression might be reduced, accounting for apparent 
lack of enhancement in engraftment. To test this hypothesis we used a simple treatment 
regimen modification, staggering the administration of NSAID and G-CSF to allow for 
hematopoietic mobilization and restoration of normal endogenous PGE2 signaling pathways 
before transplant (Figure 3a).  As hypothesized, CXCR4 levels were significantly lower on G-
CSF mobilized HSC/HPC after NSAID treatment, while staggered administration allowed for 
restored receptor levels (Figure 3b), while maintaining enhanced HSC mobilization (Figure 3c).  
Using these novel dosing strategies, we competitively transplanted mobilized grafts from G-
CSF-mobilized mice, or non-staggered and staggered G-CSF + meloxicam treated mice.  
Staggered NSAID administration along with G-CSF resulted in a significant enhancement in LT-
HSC engraftment as measured by enhanced chimerism and competitive repopulating unit 
frequency in the G-CSF + NSAID mobilized graft (Figure 3d).  In addition to long-term 
engraftment, early recovery of blood cell counts, particularly neutrophils and platelets, is 
important to reduce the duration of neutropenia and thrombocytopenia associated with 
Figure 1. NSAIDs mobilize hematopoietic stem  and 
progenitor cell (a) CFU-GM mobilization by indomethacin, G-CSF 
and combination treatment (n=5 mice per group) (b) Fold increase 
in CFU-GM over G-CSF  with NSAIDs with varying COX-1 and 
COX-2 selectivity; SC-560 (SC), valeryl salicylate (V), 
indomethacin (IN), aspirin (A), ibuprofen (IB), meloxicam (M), 
licofelone (L), celecoxib (C), valdecoxib (VC) and NS-398 (NS). X 
± SEM of 5 mice/group, each assayed individually.*P<0.05;


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6 
G-CSF
G-CSF + Meloxicam
0
1
2
3
4
5
6
0
4
8
12 16 20 24 28
Neutrophils (K/µl)
90
P<0.05
Days Post-Transplant
50%
100%
0
200
400
600
800
1000
1200
0
4
8
12 16 20 24 28
Platelets (K/µl)
90
P<0.05
Days Post-Transplant
50%
100%
G-CSF
G-CSF + Meloxicam
G-CSF
G-CSF + Meloxicam
0
1
2
3
4
5
6
0
4
8
12 16 20 24 28
Neutrophils (K/µl)
90
P<0.05
Days Post-Transplant
50%
100%
0
200
400
600
800
1000
1200
0
4
8
12 16 20 24 28
Platelets (K/µl)
90
P<0.05
Days Post-Transplant
50%
100%
0
200
400
600
800
1000
1200
0
4
8
12 16 20 24 28
Platelets (K/µl)
90
P<0.05
Days Post-Transplant
0
200
400
600
800
1000
1200
0
4
8
12 16 20 24 28
Platelets (K/µl)
90
P<0.05
0
200
400
600
800
1000
1200
0
4
8
12 16 20 24 28
Platelets (K/µl)
90
P<0.05
Days Post-Transplant
50%
100%
Figure 4. Recovery of ANC (left) and platelets (right) in irradiated 
mice after non-competitive transplant of PB cells mobilized by G-CSF 
or G-CSF plus Meloxicam (2 day stagger). Counts were monitored for 
90 days post-transplant. Data presented as X±SEM; n=5 mice /group 
bled on alternate 4 day cycles. 
myeloablative conditioning regimens and subsequent transplant related morbidity and mortality 
[49-51].  Increasing the number of HSC/HPC contained within a hematopoietic graft has been 
demonstrated to reduce the time necessary for neutrophil and platelet recovery [52].  When 
grafts were transplanted non-competitively, G-CSF plus staggered co-administration of 
meloxicam resulted in a 4-day faster recovery of both neutrophils (Figure 4, left panel) and 
platelets (Figure 4, right panel) compared to G-CSF alone.  Competitive secondary 
transplantation confirmed sustained LT-HSC activity in these mice with full multi-lineage 
reconstitution 36 weeks post-transplant (data not shown). These results  
clearly demonstrate that endogenous 
PGE2 signaling is required for HSC 
niche retention and robustly define a 
novel therapeutic mobilization strategy 
with NSAIDs that significantly enhances 
hematopoietic transplantation efficiency 
and efficacy. Our proposed studies will 
utilize this novel NSAID dosing strategy 
to enhance hematopoietic mobilization. 
 
Non-human primates and healthy 
volunteers 
mobilize 
after 
NSAID 
treatment  To confirm the NSAID 
mediated hematopoietic effects in higher 
species, 4 baboons were mobilized with 
a standard clinical regimen of G-CSF, or 
the combination of G-CSF + meloxicam in a crossover design (Figure 5a).  While individual 
baboon response to G-CSF varied, similar to what is seen in humans, in all cases meloxicam 
treatment resulted in increased numbers of CD34+ cells (Figure 5b) and CFU-GM (Figure 5c) in 
b
%  of C on trol M F I of C X C R 4  o n  S K L  C ells
Control
G-CSF
G-CSF + NSAID (No Stagger)
G-CSF + NSAID (1 Day Stagger)
G-CSF + NSAID (2 Day Stagger)
*
*
50
60
70
80
90
100
110
120
b
%  of C on trol M F I of C X C R 4  o n  S K L  C ells
Control
G-CSF
G-CSF + NSAID (No Stagger)
G-CSF + NSAID (1 Day Stagger)
G-CSF + NSAID (2 Day Stagger)
*
*
50
60
70
80
90
100
110
120
%  of C on trol M F I of C X C R 4  o n  S K L  C ells
Control
G-CSF
G-CSF + NSAID (No Stagger)
G-CSF + NSAID (1 Day Stagger)
G-CSF + NSAID (2 Day Stagger)
Control
G-CSF
G-CSF + NSAID (No Stagger)
G-CSF + NSAID (1 Day Stagger)
G-CSF + NSAID (2 Day Stagger)
*
*
50
60
70
80
90
100
110
120
**
*
SKL x 
10
SLAM
SKL 
Absolute Number / ml Blood
**
*
SKL x 
10
SLAM
SKL 
Absolute Number / ml Blood
c
Figure 3. Enhanced engraftment in G-CSF + NSAID mobilized 
grafts (a) A 4-day regimen of meloxicam (MXC) was given 
concurrently with G-CSF for 4 days or staggered 1 or 2 days to allow 
for restoration of PGE2 signaling. (b) Mean fluorescence intensity (MFI) 
of CXCR4 by flow cytometry on PB SKL cells from mice treated with 
NSAID plus G-CSF, concurrently or staggered. mean±SEM; 5 
mice/group, each assayed individually. * P<0.05. (c) Assessment of 
SKL and SLAM SKL cells in PB from mice treated with meloxicam plus 
G-CSFin a 48 hour staggered regimen. mean±SEM; 4 mice/group, 
each assayed individually. * P<0.05.  (d) Chimerism (left) and 
competitive repopulating units CRU (right) 36 weeks after limiting 
dilution competitive transplants of peripheral blood mononuclear cells 
(PBMC)from mice treated with G-CSF, G-CSF plus Meloxicam with no 
stagger, or G-CSF plus Meloxicam with a 1 or 2 day stagger. 
d
0
1
2
3
CRU per 2x106 PBMC
*
*
0
5
10
15
20
25
30
35
G-CSF
G + M (No stagger)
G + M (1 day stagger)
G + M (2 day stagger)
% Chimerism PBMC
1:1
2:1
3:1
4:1
PBMC to Competitor BM 
Ratio
*
*
*
*
*
d
0
1
2
3
CRU per 2x106 PBMC
*
*
0
5
10
15
20
25
30
35
G-CSF
G + M (No stagger)
G + M (1 day stagger)
G + M (2 day stagger)
% Chimerism PBMC
1:1
2:1
3:1
4:1
PBMC to Competitor BM 
Ratio
*
*
*
*
*
0
1
2
3
CRU per 2x106 PBMC
*
*
0
1
2
3
CRU per 2x106 PBMC
*
*
0
5
10
15
20
25
30
35
G-CSF
G-CSF
G + M (No stagger)
G + M (No stagger)
G + M (1 day stagger)
G + M (1 day stagger)
G + M (2 day stagger)
G + M (2 day stagger)
% Chimerism PBMC
1:1
2:1
3:1
4:1
PBMC to Competitor BM 
Ratio
*
*
*
*
*
G-CSF
G-CSF
G-CSF
G-CSF
Bleed
MXC
MXC
MXC
MXC
No Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
2 Day Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
1 Day Stagger
Vehicle
Vehicle
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
a
G-CSF
G-CSF
G-CSF
G-CSF
Bleed
MXC
MXC
MXC
MXC
No Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
2 Day Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
1 Day Stagger
Vehicle
Vehicle
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
G-CSF
G-CSF
G-CSF
G-CSF
G-CSF
G-CSF
G-CSF
G-CSF
Bleed
Bleed
MXC
MXC
MXC
MXC
No Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
No Stagger
Vehicle
Vehicle
Vehicle
Vehicle
MXC
MXC
MXC
MXC
2 Day Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
2 Day Stagger
Vehicle
Vehicle
Vehicle
Vehicle
MXC
MXC
MXC
MXC
1 Day Stagger
Vehicle
Vehicle
MXC
MXC
MXC
MXC
MXC
MXC
MXC
MXC
1 Day Stagger
Vehicle
Vehicle
Vehicle
Vehicle
Day 1
Day 2
Day 3
Day 4
Day 4
Day 5
Day 6
a


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
7 
peripheral blood. In addition, as seen in mice, meloxicam treatment on its own resulted in 
significant HSC/HPC mobilization compared to baseline levels (Figures 5 d,e).  In healthy 
human volunteers, short-term meloxicam treatment resulted in significant increases in CD34+ 
cells (Figure 5f), determined using the ISHAGE procedure [53], and functionally defined HPC 
(Figures 5 g, h and i), matching hematopoietic egress seen with meloxicam treatment in 
baboons and mice. Thus, short-term endogenous PGE2 inhibition, closely resembling current 
clinical NSAID treatment, results in a previously unappreciated increase in stem and progenitor 
cells in the peripheral blood. 
 
G-CSF 
(10µg/kg)
G-CSF (10µg/kg) + 
Meloxicam (0.1 mg/kg)
G-CSF 
(10µg/kg)
G-CSF (10µg/kg) + 
Meloxicam (0.1 mg/kg)
2 Week 
Washout
a
15 mg 
Meloxicam
5 Days
Pre
Post
0
2
4
6
8
28
48
68
CD34+ / ml blood x 102
Pre
Post
0
1
2
3
4
5
7.5
11.5
15.5
19.5
23.5
CFU-GM / ml blood x 102
Pre
Post
0
2
4
6
8
10
12
14
16
18
20
22
BFU-E / ml blood x 102
Pre
Post
0
1
2
3
4
10
14
18
22
CFU-GEMM /ml blood x 102
Pre
Post
2.05±0.6 Fold ↑
P=0.043
1.03±0.1 Fold ↑
P=NS
3.21±0.7 Fold ↑
P=0.021
f
g
h
i
3.60±0.9 Fold ↑
P=0.004
CD34+ Cells / mL x 104
CFU-GM / mL x 103
0
0.5
1
1.5
2
2.5
3
3.5
4
G-CSF
G+ Mel
0
2
4
6
8
10
0.5
1
1.5
2
2.5
3
3.5
0
Pre
Post
CD34+ Cells / mL x 103
0
50
100
150
200
250
Pre
Post
CFU-GM / mL Blood
b
c
d
e
4.58±1.78 Fold ↑
P=0.027
G-CSF G+ Mel
2.07±0.12 Fold ↑
P<0.01
5.22±0.61 Fold ↑
P=0.033
2.73±0.94 Fold ↑
P=0.028
 
 
 
 
 
  
2.2 
Correlative Studies Background 
 
Characterize the hematopoietic stem and progenitor cells mobilized by meloxicam. 
There is increasing evidence that grafts collected after different mobilization methods differ in 
CD34 subclasses and immune cell content, which may have important clinical impact on 
transplant outcome, although further studies are still required [54,55]. In preclinical studies, 
grafts mobilized by chemokine agonists/antagonists contain populations of more immature 
HSPC with enhanced engraftment potential compared to G-CSF alone [54,56,57]. 
Administration of myeloid progenitor cells has also shown utility as a bridging therapy in animal 
models. Co-administration of purified common myleoid progenitor cells (CMP) and granulocyte 
Figure 5.  Non-human primates and healthy human 
volunteers mobilize HSC/HPC in response to NSAID 
treatment. 
a, Four baboons were mobilized with G-CSF or G-CSF 
+ Meloxicam in a cross-over design and b, CD34
+ cells 
and c, CFU-GM in peripheral blood determined.  d, 
CD34
+ cells and e, CFU-GM in peripheral blood 
determined pre- and post- 5 days of meloxicam alone 
treatment in baboons. Seven healthy human volunteers 
were treated with 15 mg/day p.o. for 5 days, and were 
assessed for f, CD34
+ cells; g, CFU-GM; h, BFU-E, and 
i, CFU-GEMM pre- and post-treatment.  Statistics 
represent paired, two-tailed t-test. 
 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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8 
macrophage progenitor cells 
(GMP) with HSC showed 
enhanced reconstitution of tissue 
myeloid cells and protection from 
fungal and bacterial infections 
[58], and  significantly improved 
survival in mice receiving lethal 
doses of radiation [59]. Therefore, 
not only are the absolute numbers 
of CD34+ cells important in 
determining post-transplant 
outcome, but the functional 
repertoire of stem and progenitor 
cells, as well as their mature 
counterparts, also substantially 
contribute.  We have recently demonstrated that treatment with NSAIDs alone or in combination 
with G-CSF results in an increase in functionally defined myeloid progenitors both in bone 
marrow and in peripheral blood (preliminary data and [46]). Intriguingly, morphologic and 
microscopic analysis of myeloid hematopoietic colonies from mice mobilized with G-CSF vs. G-
CSF plus NSAIDs showed a marked shift in multi-centric and monocytic colony formation 
(Figure 6), with many colonies exceeding the field of view (40X) in size (not shown). Histological 
analysis revealed that these colonies were primarily monocytic, and are highly reminiscent of 
multipotent, high proliferative potential colony forming cells (HPP-CFC) [60].  
While functional studies 
demonstrated an 
increase in CFU-GM in 
bone marrow following 
NSAID treatment, 
immunophenotypic 
studies by flow cytometry 
did not show an increase 
in HSC or other HPC 
populations, despite 
clear increases in their 
colony forming ability 
and enhanced long-term 
repopulating ability. 
These results suggest 
that perhaps a 
qualitatively more robust 
progenitor population 
was mobilized by 
NSAIDs. To answer this 
question we performed 
extensive functional and 
immunophenotypic 
analysis of bone marrow 
of control vs. NSAID 
treated mice [46] (Figure 
7). The striking findings 
Granulocyte-Macrophage Progenitor Cells
(GMP)/2 femurs x 103 (Gate 4)
50
100
150
200
250
300
350
CFU per 500 CMP
M-CSF
5
10
15
20
CFU per 500 CMP
SCF + GM-CSF
**
20
40
60
80
100
CFU per 500 GMP
SCF + GM-CSF
50
100
150
200
250
300
350
CFU per 500 GMP
M-CSF
50
100
150
200
250
300
c
d
e
f
g
h
Megakaryocyte-Erythroid Progenitor Cells 
(MEP)/2 femurs x 103 (Gate 2)
20
40
60
80
100
120
NS
**
**
**
***
Common Myeloid Progenitor Cells
(CMP)/2 femurs x 103 (Gate 3)
20
40
60
80
100
120
140
160
180
NS
a
b
Vehicle
Meloxicam
SLAM SKL cells /2 femurs x 103 (Gate 1)
NS
1
2
3
4
5
Sca-1+IL7R
FCRll/lll
CD34
c-Kit
Gated on Linneg
c-Kit
CD150
CD48
Sca-1
1
2
3
4
Gated on Linneg
Granulocyte-Macrophage Progenitor Cells
(GMP)/2 femurs x 103 (Gate 4)
50
100
150
200
250
300
350
CFU per 500 CMP
M-CSF
5
10
15
20
CFU per 500 CMP
SCF + GM-CSF
**
20
40
60
80
100
CFU per 500 GMP
SCF + GM-CSF
50
100
150
200
250
300
350
CFU per 500 GMP
M-CSF
50
100
150
200
250
300
c
d
e
f
g
h
Megakaryocyte-Erythroid Progenitor Cells 
(MEP)/2 femurs x 103 (Gate 2)
20
40
60
80
100
120
NS
Megakaryocyte-Erythroid Progenitor Cells 
(MEP)/2 femurs x 103 (Gate 2)
20
40
60
80
100
120
NS
**
**
**
***
Common Myeloid Progenitor Cells
(CMP)/2 femurs x 103 (Gate 3)
20
40
60
80
100
120
140
160
180
NS
a
b
Vehicle
Meloxicam
Vehicle
Meloxicam
SLAM SKL cells /2 femurs x 103 (Gate 1)
NS
1
2
3
4
5
SLAM SKL cells /2 femurs x 103 (Gate 1)
NS
1
2
3
4
5
Sca-1+IL7R
FCRll/lll
CD34
c-Kit
Gated on Linneg
c-Kit
CD150
CD48
Sca-1
1
2
3
4
Gated on Linneg
Sca-1+IL7R
FCRll/lll
CD34
c-Kit
Gated on Linneg
c-Kit
CD150
CD48
Sca-1
1
2
3
4
Gated on Linneg
Figure 7. Representative FACS gating of bone marrow SLAM SKL cells (gate 1), MEP 
(gate 2), CMP (gate 3) and GMP. a, SLAM SKL, b, MEP, c, CMP  and f, GMP cell number  
between vehicle and meloxicam treated mice (n=4 mice/group, each assayed individually). 
CMPs were sorted and plated in d, GM-CSF 10 ng/ml) + SCF (50 ng/ml) or e, M-CSF (2 
ng/ml); GMPs were sorted and plated in g, GM-CSF + SCF or h, M-CSF. CFU per 500 cells 
determined (n=10 plates per treatment and condition group).  *P<0.05, **P<0.01, 
***P<0 001; unpaired two-tailed t-test All error bars represent X ± s e m
G-CSF
G-CSF + NSAID
G-CSF
G-CSF + NSAID
Figure 6. Representative 
CFU-GM colonies from G-
CSF and G-CSF + NSAID 
mobilized mice. Mice were 
mobilized with a 4 day regimen 
of G-CSF or G-CSF + 
indomethacin. Shown on left 
are prototypical colonies found 
in blood mobilized by G-CSF 
and on the right various non-
prototypical colonies found in 
PB of mice mobilized by G-
CSF with NSAID. This 
representation is not inclusive 
of all colonies present, but 
highlights distinct colony types 
not normally seen in cultures of 
PB mobilized by G-CSF alone. 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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This document is confidential. Do not disclose or use except as authorized. 
9 
were 1) phenotypic analysis showed no increase in SLAM SKL (highly purified LT-HSC), 
phenotypically defined CMP, or phenotypically defined myelo-erythroid progenitors (MEP), with 
a ~2-fold increase in phenotypically defined GMP; 2) flow cytometry sorted GMP from NSAID 
treated mice showed 2-fold enhanced colony formation on an equal cell number basis 
compared to GMP from control mice (Figure 7g,h), and in addition, 3) flow cytometry sorted 
CMP from NSAID treated mice showed 2-fold enhanced colony formation on an equal cell 
number basis compared to control CMP (Figure 7d,e). These data clearly demonstrate that 
NSAIDs increase the proliferative potential or proliferative program of both CMP and GMP, 
resulting in the mobilization of a qualitatively different progenitor subset. In our patient 
populations mobilized with meloxicam, we hypothesize that the CD34+ cells will be qualitatively 
different than those mobilized with G-CSF + placebo.  
 
 
3. PARTICIPANT SELECTION 
 
Patients with Hodgkin’s disease, non-Hodgkin lymphoma and multiple myeloma for whom 
AHSCT is an appropriate therapeutic strategy, will be the study population for this trial. 
Standard inclusion and exclusion criteria will be followed.  In the randomized arm A, 
patients will receive G-CSF + placebo for the mobilization of their HSPC. Patients in arm 
B will receive G-CSF + meloxicam.  
 
 
Eligibility tests for patients on BMT protocols must be completed within 42 days of 
registration, unless otherwise stated.  
 
 
3.1 
Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study: 
  
   
3.1.1 
Patients with hematologic malignancies for whom autologous stem cell        
transplantation is deemed clinically appropriate:  
 
3.1.2 
Inclusion criteria  
3.1.2.1 .   Non-Hodgkin’s lymphoma, or Hodgkin’s lymphoma either in a CR1 or 
refractory/relapsed   with  chemosensitive disease in a CR or PR.  
 
                     3.1.2.2..  Multiple myeloma in first or second remission.  Patients with CR or PR 
will be eligible for this protocol.  
3.1.2.2    Ages 18-75 years 
3.1.2.3     ECOG performance status of 0, 1, or 2. 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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10 
3.1.2.4     Ability to understand and the willingness to sign a written informed   
consent 
3.1.2.5   Patients on NSAIDs will be eligible only when they are off NSAIDs for 14 
days. 
 
3.2 
Exclusion Criteria 
 
Participants who exhibit any of the following conditions at screening will not be eligible 
for admission into the study. 
 
3.2.1 
Cardiac disease: symptomatic congestive heart failure or RVG, active angina 
pectoris, or uncontrolled hypertension. Participants may not be receiving any other 
study agents. 
 
3.2.2 Pulmonary disease: severe chronic obstructive lung disease, or symptomatic 
restrictive lung disease.   
 
3.2.3 Renal disease: serum creatinine > 2.0 mg/dl. 
 
3.2.4 
Hepatic disease:  SGOT or SGPT > 3 x normal; serum bilirubin >2.0 mg/dl that is 
not due to Gilbert’s syndrome or hemolysis  
 
3.2.5 
Uncontrolled infection. 
 
3.2.6 
Pregnancy or lactation. 
 
3.2.7 
Patients with NSAIDs allergies, known lactose allergy, a history of recent GI bleed 
(less than 2 weeks), and those who are on therapeutic dose anticoagulants will be 
excluded from this protocol. 
 
3.2.8 
Known CNS lymphoma. 
 
  
 
4. REGISTRATION PROCEDURES 
 
  
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) central registration system. Registration must 
occur prior to the initiation of therapy. Any participant not registered to the protocol 
before treatment begins will be considered ineligible and registration will be denied.  
 
A member of the study team will confirm eligibility criteria and complete the 
protocol-specific eligibility checklist. 
  
Following registration, participants may begin protocol treatment. Issues that 
would cause treatment delays should be discussed with the Principal Investigator. If 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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This document is confidential. Do not disclose or use except as authorized. 
11 
a participant does not receive protocol therapy following registration, the participant’s 
protocol status must be changed. Notify the QACT Registrar of participant status 
changes as soon as possible. 
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 
5:00 PM Eastern Standard Time.  
   
The registration procedures are as follows: 
 
1. 
Obtain written informed consent from the participant prior to the performance of 
any study related procedures or assessments. 
 
2. 
Complete the protocol-specific eligibility checklist using the eligibility 
assessment documented in the participant’s medical/research record. To be 
eligible for registration to the study, the participant must meet each 
inclusion and exclusion criteria listed on the eligibility checklist. 
  
Reminder: Confirm eligibility for ancillary studies at the same time as eligibility 
for the treatment study. Registration to both treatment and ancillary studies 
will not be completed if eligibility requirements are not met for all studies. 
  
3. 
Fax the eligibility checklist(s) and all pages of the consent form(s) to the 
QACT at 
 
  
Exception: DF/PCC Affiliate sites must fax the entire signed consent form 
including HIPAA Privacy Authorization and the eligibility checklist to the 
Network Affiliate Office. The Network Affiliate Office will register the participant 
with the QACT. 
  
4. 
The QACT Registrar will (a) validate eligibility, (b) register the participant on 
the study, and (c) randomize the participant when applicable. 
  
5. 
The QACT Registrar will send an email confirmation of the registration and/or 
randomization to the person initiating the registration immediately following 
the registration and/or randomization. 
  
 
 
5. TREATMENT PLAN  
 
Treatment will be administered on both an outpatient and inpatient basis. Expected toxicities 
and potential risks as well as dose modifications for G-CSF and Meloxicam are described in 
Section 6 (Expected Toxicities and Dosing Delays/Dose Modification). No investigational or 
commercial agents or therapies other than those described below may be administered with 
the intent to treat the participant’s malignancy. 
 
All patients will sign an informed consent and register through the Dana Farber 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
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12 
QACT.  The day of 1st apheresis will be regarded as day 0.  Patients in whom the 
numbers of CD34+ cells in the peripheral blood are <10/ul, will be declared as 
“poor mobilizers” and they will be rescued with plerixafor. 
The patients will be randomized into two main arms as follows ( A & B).  There will 
also be further randomization according to the type of the disease, i.e., malignant 
lymphoma vs. multiple myeloma. 
 
A.  G-CSF Alone (+ placebo):  Patients in this group will receive G-CSF 10 ug/kg s.c. 
daily, beginning 4 days prior to the 1st apheresis [days -4, -3, -2, -1] and continued on 
daily G-CSF for a total of 4 apheresis or until   4 x 10^6 CD34+ cells/kg for multiple 
myeloma patients or >2 x 10^6 CD34+ cells/kg for lymphoma patients are collected.  
They will also receive oral placebo for 5 days on days -6 through -2. Patients will undergo 
apheresis for 300 minutes to achieve approximately 3 to 4 whole blood volumes 
processed.  This is a standard institutional protocol for autologous HSPC collection at the 
MGH.  Multiple myeloma patients opting for mobilization with cyclophosphomide will have 
cyclophosphomide on day -12.  
 
B.  G-CSF + meloxicam:  Patients in this group will be treated with meloxicam and G-CSF in an 
approximate two-day staggered dose schedule as described in our preclinical studies.  
Meloxicam will be given orally at a dose of 15 mg/day for 5 days (days -6 through -2).  G-CSF at 
10 ug/kg/day subcutaneously will be started on day -4 and continued daily for a total of 4 
apheresis or until   4 x 10^6 CD34+ cells/kg for multiple myeloma or >2 x 10^6 CD34+ cells/kg 
for lymphoma patients are collected. Multiple myeloma patients opting for mobilization with 
cyclophosphomide will have cyclophosphomide on day -12.     
 
Any patient in any of the above groups who has <10/ul circulating CD34+ cells on day 0 
(poor mobilizer) will be started on daily (evening) plerixafor at 240 ug/kg/day s.c. as a 
rescue, will undergo apheresis on day +1 if circulating CD34+ cells are  10/ul and be 
continued on daily G-CSF + plerixafor for a total of 4 apheresis or until  4 x 10^6 CD34+ 
cells/kg are collected for multiple myeloma patients and > 2 x 10^6 CD34+ cells/kg for 
lymphoma patients.  Patients who have < 10/L CD34+ cells on day +1 after the plerixafor 
on day 0 will come off the study. 
 
 
 
 
 
5.1 Agent Administration  
 
 
5.1.1 Meloxicam: Patients will receive meloxicam 15 mg by mouth daily for 5 days on 
days -6 through -2.  Please see below “safety concerns of meloxicam”. 
 
5.1.2 G-CSF(Neupogen, Granix, filgrastim, tbo-filgrastim): Patients will receive G-CSF 
10 ug/kg/day S.C. The dose of G-CSF is based on actual body weight. The dose of 
G-CSF may be rounded as follows:  Patients < 65 kg, receive 600 mcg, patients ≥ 
65<80 kg, receive 780 mcg, patients ≥ 80<96 kg, receive 900 mcg, patients ≥ 
96<110 kg, receive 1080 mcg, patients ≥110kg receive 1200 mcg. The G-CSF is 
used to mobilize stem cells. G-CSF is commercially available. 
5.1.3 Placebo: Patients in Arm A will receive oral placebo for 5 days on days -6 through -
2. 
5.1.4 Cyclophosphamide: Optional and only for multiple myeloma patients. Patients will 
receive cyclophosphamide 2000 mg/m2 intravenously once a day for stem cell 


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13 
mobilization on day -12. Mesna and intravenous hydration be given in conjunction 
for hemorrhagic cystitis prophylaxis per institutional standard.   
 
 
 
 
5.2 
General Concomitant Medication and Supportive Care Guidelines 
 
 
A.   Access to vessels.  Pheresis will be obtained either via an indwelling central venous 
catheter (Hickman pheresis), a temporary venous catheter, or peripheral access. 
 
B.   Patients will receive standard supportive care for stem cell transplant patients according to 
institutional guidelines. 
 
C.   Transfusions: Transfusion practices will follow institutional guidelines.  All blood products 
will be irradiated and leukoreduced.  
 
D.   Management of infections. Principles of infection prophylaxis and treatment will vary 
according to the spectrum of organisms and their antibiotic sensitivity and concurrent 
infection management practices and/or antibiotic clinical trial participation.  
 
 
 
5.3 
Duration of Therapy 
Patients will receive meloxicam or placebo daily for 5 days, on days -6 through -2 along with daily 
G-CSF starting on day -4. G-CSF will be continued for a total of four sessions of apheresis or until 
 4 x 106 CD34+ cells/kg for multiple myeloma patients or >2 x 10^6 CD34+ cells/kg for lymphoma 
patients is collected.  Multiple myeloma patients opting for mobilization with additional 
cyclophosphomide will start on day -12. The patients, who on day 0 are declared to be poor 
mobilizers, will be rescued with Plerixafor/G-CSF.   
 
5.4 
Duration of Follow Up  
 
Participants will be followed for 6 months after autogeneic transplantation or until death 
whichever occurs first. If participants are removed from study, they will be followed for 
survival until 6 months after SCT or until death, whichever occurs first. Participants 
removed from study for unacceptable adverse events will be followed until resolution 
or stabilization of the adverse event. Participants who experience relapse of disease 
will be followed at the discretion of the treating physician.  
 
5.5 
Criteria for Removal from Study  
 
Participants will be removed from study for death, relapsed or progressive disease, 
discretion of PI or treating physician, or withdrawal of consent. In the event of unusual 
or life-threatening complications, participating investigators must immediately notify the 
Principal Investigator: Bimalangshu Dey, MD, 
  
 
6. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
 
 


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No dose delays or modifications are allowed. Toxicity assessments will be done using the 
CTEP Active Version of the NCI Common Terminology Criteria for Adverse Events (CTCAE) 
which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
If possible, symptoms should be managed symptomatically. In the case of toxicity, 
appropriate medical treatment should be used (including anti-emetics, anti-diarrheals, etc.). 
 
All adverse events experienced by participants will be collected from the time of the first 
dose of study treatment, through 30 days after the last apheresis session. .  Additionally all 
serious infection or bleeding events post transplant should be collected through day 100 
post transplant.  Participants continuing to experience toxicity at the off study visit may be 
contacted for additional assessments until the toxicity has resolved or is deemed 
irreversible. 
  
 
6.1 
Anticipated Toxicities 
  
Meloxicam: 
 Non-steroidal 
anti-inflammatory 
drugs 
(NSAIDs) 
have 
been 
associated with adverse effects such as peptic ulcers, gastritis, and 
bleeding.  Meloxicam is a selective inhibitor of cyclooxygenase 2 
(COX-2), inhibiting this enzyme with approximately six times the 
potency of COX-1.  Originally approved in 2000, meloxicam has a 
long track record and a favorable side effect profile.  Trials in healthy 
volunteers showed that this agent did not prolong the bleeding time 
or affect platelet aggregation in contrast to other NSAIDs tested such 
as nabumetone and indomethacin [69,70].  Data from these studies 
suggest that even at supratherapeutic doses, meloxicam shows 
relatively low inhibition of thromboxane A2, the eicosanoid that is 
responsible for platelet aggregation and maintenance of the bleeding 
time.  With regard to the potential gastrointestinal side effects of 
NSAIDs, these almost always occur in the context prolonged use at 
high doses ; as we will be using the standard dose of meloxicam for 
a total of 5 days, GI adverse events are highly unlikely.  Additionally, 
at least one large-scale cohort study that followed 13,000 patients on 
meloxicam for three months found only a 0.8% rate of GI adverse 
events [71] 
 
G-CSF: 
Rare anaphylactic reactions with the first dose; bone pain at sites of active 
marrow with continued administration. Local reactions at injection sites. 
Constitutional symptoms, increased alkaline phosphatase, LDH, uric acid; 
worsening of pre-existing inflammatory conditions. Please refer to the 
package insert for a complete listing of all toxicities. 
 
Cyclophosphamide: 
 
Alopecia, nausea, vomiting, leukopenia, amenorrhea, cardiomyopathy, 
Stevens-Johnson 
syndrome, 
hemorrhagic 
cystitis, 
azospermia, 


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oligozoospermia, interstitial pneumonia, infections, and rare cases of toxic 
epidermal necrolysis. Please refer to the package insert for a complete listing 
of all toxicities. 
 
 
7. DRUG FORMULATION AND ADMINISTRATION  
 
7.1.1 Meloxicam: in arm B, patients will receive meloxicam 15 mg by mouth daily for 5 
days on days -6 through -2.  Please see below “safety concerns of meloxicam”. 
7.1.1.1 Availability: Meloxicam tablets are commercially available and will be used 
in the compounding of meloxicam capsules.  Pharmacy will be ensuring the 
blinding and distributing of both placebo and study drug (meloxicam) 
among the participating patients. "Blinding" will ensure accurate 
assessments of the toxicities of the "study drug" arm [G-CSF + meloxicam].  
7.1.1.2 Preparation: Meloxicam will be compounded into a capsule formation in 
order to ensure the blind.  Missed and/or vomited doses should not be 
made up.  Meloxicam can be taken with or without food.  Capsules should 
be swallowed whole and not crushed, chewed or dissolved.   
7.1.1.3 Administration: oral 
 
7.1.2 Placebo: In arm A, patients will receive placebo by mouth daily for 5 days on 
Days -6 through -2. 
 
Study staff will provide pharmacy with a fund number to purchase and blind study 
drug.  The compounding pharmacy will blind active drug and provide a 
matching placebo.  The placebo will be composed of lactose in a gelatin 
capsule.  The pharmacy will dispense the blinded study drug to subjects 
free of charge. 
 
7.1.3 G-CSF(Neupogen, Granix, filgrastim, tbo-filgrastim): Patients will receive G-CSF 
10 ug/kg/day S.C. The dose of G-CSF is based on actual body weight. The dose of 
G-CSF may be rounded as follows:  Patients < 65 kg, receive 600 mcg, patients 
≥65<80 kg, receive 780 mcg, patients ≥80<95 kg, receive 900 mcg, patients 
≥96<110 kg, receive 1080 mcg, patients ≥110kg receive 1200 mcg. The G-CSF is 
used to mobilize stem cells. G-CSF is commercially available. 
 
7.1.3.1 Availability 
 
Commercially available in single use vials containing 480 mcg/vial (300 mcg/ml, 
1.6 mg/vial). 
Should be stored at 2-8oC (do not freeze and do not shake) and is stable for at 
least 1 year at this temperature. 
 
7.1.3.2 Preparation 


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Refer to the FDA approved package insert for complete product information. 
  
7.1.3.3 Administration 
 
Filgrastim or tbo-filgrastim will be given by subcutaneous injection at 10 g/kg/d; 
patient or other caregiver will be instructed on proper injection technique 
 
7.1.4 Cyclophosphamide: Optional and only for multiple myeloma patients. Patients will 
receive cyclophosphamide 2000 mg/m2 intravenously once a day for stem cell 
mobilization on day -12. 
The chemical name is 2-[bis(2-chloroethyl)amino]tetrahydro-2H-1,3,2-
oxazaphosphorine 2-oxide monohydrate. The molecular formula is 
C7H15Cl2N2O2P•H2O. The molecular weight is 279.1. Cyclophosphamide is a 
nitrogen mustard alkylating agent. Following 
intravenous administration, the elimination half-life of cyclophosphamide ranges 
from 4.1 to 16 hours. There is extensive hepatic metabolism, as 
cyclophosphamide is a prodrug that is converted by hepatic microsomal enzymes 
(cytochrome P450 mixed-function oxidase) to the active form. Specifically, the 
activation pathway of cyclophosphamide involves CYP2B6, CYP2C9 and 
CYP3A4 isoenzymes. CYP3A4 also catalyzes the inactivation of 
cyclophosphamide to dechloroethylcyclophosphamide. Metabolites include 4-
hydroxycyclophosphamide, aldophosphamide, phosphoramide mustard (believed 
to be the active antineoplastic metabolite of cyclophosphamide), acrolein 
(believed to cause hemorrhagic cystitis), and a number of inactive metabolites. 
Excretion of cyclophosphamide is exclusively by the kidney; however, due to the 
non-ionized nature of the intact drug, renal tubular reabsorption is avid, resulting 
in a large fraction of the dose being eliminated by hepatic metabolism. 
   
7.1.4.1 Availability 
Cyclophosphamide is commercially available and supplied as a lyophilized 
powder which is compatible in 0.9% sodium chloride or 5% dextrose in 
glass or polyolefin containers and is incompatible with aluminum. 
Reconstituted solutions of lyophilized cyclophosphamide are chemically 
and physically stable for 24 hours at room temperatures or for 6 days in the 
refrigerator. Specific temperatures are not provided by the manufacturer.  
7.1.4.2 Preparation 
Cyclophosphamide will be prepared per institutional standards.  
7.1.4.3 Administration 
Cyclophosphamide will be given intravenously once a day at 2000 mg/m2. 
 
 
8. CORRELATIVE/SPECIAL STUDIES  


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Characterize the hematopoietic stem and progenitor cells mobilized by meloxicam. 
      Our scientific studies clearly demonstrate the importance of defining and characterizing the 
cellular content and function of grafts mobilized following the novel regimen of G-CSF + 
meloxicam.  1 10 mL EDTA tube of blood will be sampled from patients at the following 
timepoints: baseline prior to initiating meloxicam or placebo (day -6), and on day 0 (first 
apheresis day), and on subsequent days of apheresis if no additional mobilization rescue is 
given. The following assays will be performed on blood samples: 1) CD34+ cells will be 
quantified by flow-cytometry using the ISHAGE protocol [53] as performed routinely in our 
clinic; 2) Functionally defined hematopoietic progenitors (CFU-GM, CFU-GEMM and BFU-
E).  Assays will be performed using methylcellulose media with 30% HI-FCS, 1 U/ml Epo, 50 
ng rhSCF and 10 ng rhGM-CSF, and CFU-GM, BFU-E and CFU-GEMM quantified after 7 
days incubation at 37oC, in 5% CO2, 5% O2 in humidified air, as we have previously 
described (Figure 5 and_ENREF_40 [46]).  
 
            In addition to the above analysis, the sample collected on the first day of apheresis will also 
be assessed for content of 1) Total CD34+ cells and the most primitive subset CD34+CD38-
CD90+CD45RA-CD49f+ [64-68] 2) CXCR4 expression on CD34+ cells; ; and 3) immune cell 
subsets by flow-cytometry. Immune cell subsets to be analyzed include B (CD19+) cells, NK 
(CD3-CD56+) cells, total T cell subsets (CD3+CD4+CD8-, CD3+CD4-CD8+), and Treg cells 
(CD45+CD25+FOXP3+). Also, for CD4+ and CD8+ T cells, we will determine the proportion of 
naïve cells (CD45RA+CD27+), CD45RA-expressing effector memory cells (CD45RA+CD27-), 
central memory (CD45-CD27+CD62L+) cells, effector memory type I cells (CD45RA-
CD27+CD62L-), and effector memory type II cells (CD45RA-CD27-) cells. As dendritic cell 
(DC) content of the graft may also impact on outcome of allogeneic HCT, we will also 
evaluate the plasmacytoid (Lin-DR+CD11c-CD123+) and myeloid (Lin-DR+CD11c+CD123-) DC 
mobilized.  
 


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9. 
 STUDY CALENDAR 
 
  
10. ADVERSE EVENT REPORTING REQUIREMENTS 
 
 
Pre- 
Study 
Day 
-12 
Day 
-6 
Day 
-5 
Day  -
-4 
Day 
-3 
Day 
-2 
Day 
-1 
Day
0 
Day 
1-27 
Day 
+37 
Day5 
100 
post 
Day 
1805 
Informed consent 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 G-CSF 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
 
 
Meloxicam or placebo 
 
 
 
X 
 
X
 
X
 
X
 
X
 
 
 
 
 
 
Cyclophosphomide8 
 
X 
 
 
 
 
 
 
 
 
 
 
 
History, Physical Exam 
X 
 
 
X 
 
 
 
 
 
 
   X
 
    X 
 
    X 
 
       X 
 
Physical exam (Ht, Wt, 
BSA, VS) 
X1 
 
X 
 
 
 
 
 
X 
 
 
 
    X 
 
 
       X 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
CBC w/diff, plts3 
X 
 
X 
 
 
 
 
 
X
X 
X 
X 
X
 
Chemistry panel2 
X 
 
 
 
 
 
 
 
 
 
 
X
 
Serum Hcg 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Flow cytometry 
 
 
X 
 
 
 
 
 
X 
   X 
X 
 
 
Adverse event 
evaluation6 
 
 
       X---------------------------------------------------------------------------------------------X 
 
 
Disease assessment as 
per SOC for disease 
X 
 
 
Research samples4 
  
 
    X 
 
 
 
 
 
 
    X 
 
     X 
 
     X 
 
 
 
1.  Height, weight and BSA required only at pre-study visit. 
2.  Chemistry panel must include: creatinine, bilirubin, SGOT, SGPT 
3.   Daily CBC after AHSCT until ANC> 500 th/cmm and PLT > 20 th/cumm (transfusion 
independent), for 3 consecutive days. 
4.  1 10 mL EDTA tube of blood at D-6, D0, D+1, D+2, D+3 
5.  Day 100 and 180 assessments  refer to post SCT 
6. Formal toxicity assessments to be documented at days -6, 0, 3 and                                            
day 100 post stem cell infusion. 
7.  Days 1, 2, and 3 required if insufficient cells collected on day 0. 
8. Cyclophosphomide optional for multiple myeloma patients only and not applicable for 
lymphoma patients.   


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10.1 Definitions 
10.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or 
experience that develops or worsens in severity after starting the first dose of 
study treatment or any procedure specified in the protocol, even if the event is 
not considered to be related to the study.  
 
Abnormal laboratory values or diagnostic test results constitute adverse events 
only if they induce clinical signs or symptoms.  
10.1.2 Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that:  
 
Results in death 
 
Is life-threatening. Life-threatening means that the person was at 
immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction which hypothetically might have caused death had it 
occurred in a more sever form. 
 
Requires or prolongs inpatient hospitalization (i.e., the event required at 
least a 24-hour hospitalization or prolonged a hospitalization beyond the 
expected length of stay). Hospitalization admissions and/or surgical 
operations scheduled to occur during the study period, but planned prior 
to study entry are not considered SAEs if the illness or disease existed 
before the person was enrolled in the trial, provided that it did not 
deteriorate in an unexpected manner during the trial (e.g., surgery 
performed earlier than planned). 
 
Results in persistent or significant disability/incapacity. Disability is 
defined as a substantial disruption of a person’s ability to conduct normal 
life functions. 
 
Is a congenital anomaly or birth defect; or 
 
Is an important medical event when, based upon appropriate medical 
judgment, it may jeopardize the participant and require medical or 
surgical intervention to prevent one of the outcomes listed above. 
Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home; blood 
dyscrasias or convulsions that do not result in inpatient hospitalization, or 
the development of drug dependency or drug abuse. 
 
Events not considered to be serious adverse events are hospitalizations for: 
 
routine treatment or monitoring of the studied indication, not associated 
with any deterioration in condition, or for elective procedures 
 
elective or pre-planned treatment for a pre-existing condition that did not 
worsen 
 
emergency outpatient treatment for an event not fulfilling the serious 
criteria outlined above and not resulting in inpatient admission 
 
respite care 
 


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10.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
10.1.3.1 
Expected adverse event 
 
Expected adverse events are those that have been previously identified 
as resulting from administration of the agent. For the purposes of this 
study, an adverse event is considered expected when it appears in the 
current adverse event list, the Investigator’s Brochure, the package 
insert or is included in the informed consent document as a potential 
risk.   
 
Refer to Section 6.1 for a listing of expected adverse events 
associated with the study agent(s). 
10.1.3.2 
Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered 
unexpected when it varies in nature, intensity or frequency from 
information provided in the current adverse event list, the Investigator’s 
Brochure, the package insert or when it is not included in the informed 
consent document as a potential risk.   
10.1.4 Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event 
and the study treatment. Attribution will be assigned as follows: 
 
 Definite – The AE is clearly related to the study treatment. 
 Probable – The AE is likely related to the study treatment. 
 Possible – The AE may be related to the study treatment.  
 Unlikely - The AE is doubtfully related to the study treatment. 
 Unrelated - The AE is clearly NOT related to the study treatment. 
10.2 Procedures for AE and SAE Recording and Reporting 
 
Participating investigators will assess the occurrence of AEs and SAEs at all 
participant evaluation time points during the study.  
 
All AEs and SAEs whether reported by the participant, discovered during questioning, 
directly observed, or detected by physical examination, laboratory test or other means, 
will be recorded in the participant’s medical record and on the appropriate study-
specific case report forms.  
 
The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0. 
A copy of the CTCAE version 4.0 can be downloaded from the CTEP website at: 
 


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 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
10.3 Reporting Requirements 
 
10.3.1 Serious Adverse Event Reporting 
 
All serious adverse events that occur after the initial dose of study treatment, 
during treatment, or within 30 days of the last dose of treatment must be reported 
to the DF/HCC Overall Principal Investigator on the local institutional SAE form. 
This includes events meeting the criteria outlined in Section 11.1.2, as well as the 
following: 
 
 
Grade 2 (moderate) and Grade 3 (severe) Events – Only events that are 
unexpected and possibly, probably or definitely related/associated with 
the intervention. 
 
 
All Grade 4 (life-threatening or disabling) Events – Unless expected AND 
specifically listed in the protocol as not requiring reporting. 
 
 
All Grade 5 (fatal) Events – When the participant is enrolled and actively 
participating in the trial OR when the event occurs within 30 days of the 
last study intervention.  
 
Note: If the participant is in long term follow up, report the death at the time of 
continuing review.  
 
Grade 4 (life threatening) events are not required to be reported as SAEs if 
they are expected events related to stem cell transplantation. These include 
neutropenia, neutropenic fever within 14 days of transplantation, oral 
mucositis, thrombocytopenia, minor bleeding episodes (e.g. epistaxis), 
infections in the first 100 days of transplantation (e.g. pneumonia, line sepsis, 
cellulitis). 
 
Participating investigators must report each serious adverse event to the 
DF/HCC Overall Principal Investigator as soon as possible, but not later than 10 
days of learning of the occurrence. In the event that the participating investigator 
does not become aware of the serious adverse event immediately (e.g., 
participant sought treatment elsewhere), the participating investigator is to report 
the event within 10 days after learning of it and document the time of his or her 
first awareness of the adverse event. Report serious adverse events by 
telephone, email or facsimile to: 
 
 
 
  
 
 
 
  
 
 
 
 
 


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10.3.2 Non-Serious Adverse Event Reporting  
 
Non-serious adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms. Grade 2 and higher adverse 
events will be captured.  
10.4 Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the 
DFCI Office for Human Research Studies (OHRS). 
 
Other investigative sites should report serious adverse events to their respective IRB 
according to the local IRB’s policies and procedures in reporting adverse events. A 
copy of the submitted institutional SAE form should be forwarded to: 
 
 
 
[DF/HCC Overall Principal Investigator]  
 
 
 
[telephone #]  
 
 
 
[email]   
 
 
[fax#] 
 
The DF/HCC Principal Investigator will submit SAE reports from outside institutions to 
the DFCI Office for Human Research Studies (OHRS) according to DFCI IRB policies 
and procedures in reporting adverse events.  
10.5 Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any subject 
safety reports or sentinel events that require reporting according to institutional policy. 
10.6 Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered 
from initiation of study intervention, throughout the study, and within 30 days of the last 
study intervention should be followed to their resolution, or until the participating 
investigator assesses them as stable, or the participating investigator determines the 
event to be irreversible, or the participant is lost to follow-up. The presence and 
resolution of AEs and SAEs (with dates) should be documented on the appropriate 
case report form and recorded in the participant’s medical record to facilitate source 
data verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, 
and/or monitoring visit to obtain additional case details deemed necessary to 
appropriately evaluate the SAE report (e.g., hospital discharge summary, consultant 
report, or autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might 
reasonably be related to participation in this study. Participating investigators should 
notify the DF/HCC Overall Principal Investigator and their respective IRB of any 
unanticipated death or adverse event occurring after a participant has discontinued or 
terminated study participation that may reasonably be related to the study.   


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11. DATA AND SAFETY MONITORING 
 
11.1 Data Reporting 
11.1.1 Method  
The QACT will collect, manage, and monitor data for this study.  
11.1.2 Data Submission  
The schedule for completion and submission of case report forms (paper or 
electronic) to the QACT is as follows: 
 
 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration with QACT 
On Study Form 
Within 30 days of registration 
Baseline Assessment Form 
Within 30 days of registration 
Treatment Form 
Within 30 days of the last day of the cycle 
Adverse Event Report Form 
Within 30 days of the last day of the cycle 
Response Assessment Form 
Within 30 days of the completion of the cycle 
required for response evaluation 
Off Treatment/Off Study Form
Within 14 days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Form 
Within 30 days of the protocol defined follow 
up visit date or call 
 
11.2 Safety Meetings 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor 
toxicity and accrual data from this trial. The committee is composed of clinical 
specialists with experience in oncology and who have no direct relationship with the 
study. Information that raises any questions about participant safety will be addressed 
with the Principal Investigator and study team. 
 


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The DSMC will meet quarterly and/or more often if required to review toxicity and 
accrual data.  Information to be provided to the committee may include:  up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or 
higher unexpected adverse events that have been reported; summary of all deaths 
occurring within 30 days for Phase I or II protocols; for gene transfer protocols, 
summary of all deaths while being treated and during active follow-up; any response 
information; audit results, and a summary provided by the study team. Other 
information (e.g. scans, laboratory values) will be provided upon request.  
 
11.3 Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of 
potential audits or inspections, including source data verification, by representatives 
designated by the DF/HCC Overall Principal Investigator (or Protocol Chair) or 
DF/HCC. The purpose of these audits or inspections is to examine study-related 
activities and documents to determine whether these activities were conducted and 
data were recorded, analyzed, and accurately reported in accordance with the 
protocol, institutional policy, Good Clinical Practice (GCP), and any applicable 
regulatory requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence 
to protocol requirements. Monitoring will begin at the time of participant registration 
and will continue during protocol performance and completion.  
 
12. REGULATORY CONSIDERATIONS 
 
12.1 Protocol Review and Amendments 
This protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit participants) 
and any other necessary documents must be submitted, reviewed and approved by 
a properly constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be 
approved by the IRB prior to implementation. Any changes in study conduct must be 
reported to the IRB. The DF/HCC Overall Principal Investigator (or Protocol Chair) 
will disseminate protocol amendment information to all participating investigators.  
All decisions of the IRB concerning the conduct of the study must be made in 
writing. 
12.2 Informed Consent 
 
All participants must be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision 
about their participation in this study. The formal consent of a participant, using 
the IRB approved consent form, must be obtained before the participant is 
involved in any study-related procedure. The consent form must be signed and 


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dated by the participant or the participant’s legally authorized representative, and 
by the person obtaining the consent. The participant must be given a copy of the 
signed and dated consent document. The original signed copy of the consent 
document must be retained in the medical record or research file.  
12.3 Ethics and Good Clinical Practice (GCP) 
This study is to be conducted according to the following considerations, which 
represent good and sound research practice: 
 
E6 Good Clinical Practice: Consolidated Guidance 
www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM129515.pdf  
 
US Code of Federal Regulations (CFR) governing clinical study conduct and 
ethical principles that have their origin in the Declaration of Helsinki 
o Title 21 Part 11 – Electronic Records; Electronic Signatures 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr11_02.html 
o Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html  
o Title 21 Part 54 – Financial Disclosure by Clinical Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html  
o Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr56_02.html  
o Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html  
 
State laws 
 
DF/HCC research policies and procedures        
http://www.dfhcc.harvard.edu/clinical-research-support/clinical-research-unit-
cru/policies-and-procedures/  
It is understood that deviations from the protocol should be avoided, except when 
necessary to eliminate an immediate hazard to a research participant. In such 
case, the deviation must be reported to the IRB according to the local reporting 
policy.  
12.4 Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each 
research participant. This information enables the study to be fully documented and 
the study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are 
not limited to hospital records, clinical charts, laboratory and pharmacy records, 


NSAIDs to mobilize hematopoietic stem cells 
 
 
 September 28, 2016 
 
 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
26 
recorded data from automated instruments, microfiches, photographic negatives, 
microfilm or magnetic media, and/or x-rays.  
12.5 Records Retention 
 
All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  
 
13. STATISTICAL CONSIDERATIONS  
 
A sample size of 15 patients per group provides 90% power to detect a 1.5 fold increase in the 
number of circulating CD34+ cells on the first day of apheresis with the addition of meloxicam 
compared to G-CSF + placebo. The fold change is defined as the difference between group 
means that is expressed as a multiple of the standard deviation assumed to be common in both 
groups. A two-sided Mann-Whitney test is used at a 1% level, under the assumption of a normal 
distribution for the number of circulating CD34+ cells. The Mann-Whitney test will also be used 
to compare the number of apheresis sessions required to collect ˜ 5 x 10^6 CD34+ cells/kg 
between the patient groups.  To show that meloxicam-treated patients will need 1  less 
apheresis session to achieve  ˜5 x 10^6 CD34+ cells/kg, 50 patients in each group will be 
required to achieve 81% power at a one-sided 10% alpha level, assuming an average of two 
sessions will be required to collect ˜5 x 10^6 CD34+ cells/kg in G-CSF-treated patients.  The 
time to neutrophil or platelet engraftment will estimated by the Kaplan-Meier method and the 
difference between groups compared by the logrank test. Cell population numbers and HPC in 
peripheral and apheresis products will be summarized respectively by the median, mean and 
standard deviation.  In peripheral blood, the difference in cell types following meloxicam and G-
CSF mobilization relative to baseline will be compared to the change following G-CSF alone 
using the Mann-Whitney test or two-sample t-test.   The proportion of patients failing stem cell 
mobilization will be a secondary comparison between the two groups. Fisher's exact test will be 
used to explore the effect of adding meloxicam but will have limited power.  
 
 
14. PUBLICATION PLAN 
  
The outcomes of the study including the correlative science studies will be analyzed and 
hopefully be presented at the professional clinical and scientific meetings.  The results will then 
be submitted to peer reviewed journals for publication. 
 
15. REFERENCES  
 
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Fu, S. and J. Liesveld, Mobilization of hematopoietic stem cells. Blood Rev, 2000. 14(4): 
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Pavone, V., et al., Poor mobilization is an independent prognostic factor in patients with 
malignant lymphomas treated by peripheral blood stem cell transplantation. Bone 
Marrow Transplant, 2006. 37(8): p. 719-24. 
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have improved survival in autologous stem cell transplantation for lymphoid 
malignancies. Bone Marrow Transplant, 2007. 40(5): p. 437-41. 
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O'Shea, D., et al., Predictive factors for survival in myeloma patients who undergo 
autologous stem cell transplantation: a single-centre experience in 211 patients. Bone 
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Toor, A.A., et al., Favourable results with a single autologous stem cell transplant 
following conditioning with busulphan and cyclophosphamide in patients with multiple 
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Vermeulen, M., et al., Role of adhesion molecules in the homing and mobilization of 
murine hematopoietic stem and progenitor cells. Blood, 1998. 92(3): p. 894-900. 
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Heissig, B., et al., Recruitment of stem and progenitor cells from the bone marrow niche 
requires MMP-9 mediated release of kit-ligand. Cell, 2002. 109(5): p. 625-37. 
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Levesque, J.P., et al., Characterization of hematopoietic progenitor mobilization in 
protease-deficient mice. Blood, 2004. 104(1): p. 65-72. 
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Levesque, J.P., et al., Mobilization by either cyclophosphamide or granulocyte colony-
stimulating factor transforms the bone marrow into a highly proteolytic environment. Exp 
Hematol, 2002. 30(5): p. 440-9. 
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Moskowitz, C.H., et al., Factors affecting mobilization of peripheral blood progenitor cells 
in patients with lymphoma. Clin Cancer Res, 1998. 4(2): p. 311-6. 
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mobilized with granulocyte-colony-stimulating factor alone and chemotherapy followed 
by granulocyte-colony-stimulating factor. Transfusion, 2006. 46(2): p. 193-8. 
35. 
Desikan, K.R., et al., Comparable engraftment kinetics following peripheral-blood stem-
cell infusion mobilized with granulocyte colony-stimulating factor with or without 
cyclophosphamide in multiple myeloma. J Clin Oncol, 1998. 16(4): p. 1547-53. 
36. 
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filgrastim mobilization of hematopoietic progenitor cells for rescue in autologous 
transplantation. Blood, 2001. 98(7): p. 2059-64. 
37. 
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growth factors for mobilization of peripheral blood progenitor cells. Curr Opin Hematol, 
2000. 7(3): p. 191-6. 
38. 
Dingli, D., et al., Cyclophosphamide mobilization does not improve outcome in patients 
receiving stem cell transplantation for multiple myeloma. Clin Lymphoma Myeloma, 
2006. 6(5): p. 384-8. 
39. 
Demirer, T., C.D. Buckner, and W.I. Bensinger, Optimization of peripheral blood stem 
cell mobilization. Stem Cells, 1996. 14(1): p. 106-16. 
40. 
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and granulocyte colony-stimulating factor in multiple myeloma patients is reliable and 
cost effective. Bone Marrow Transplant, 2003. 31(2): p. 99-103. 


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gamma receptor-deficient mice. J Immunol, 2001. 167(8): p. 4686-92. 
42. 
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progenitor cell mobilization is superior to G-CSF alone. Blood, 2005. 106(5): p. 1867-74. 
43. 
Calandra, G., et al., AMD3100 plus G-CSF can successfully mobilize CD34+ cells from 
non-Hodgkin's lymphoma, Hodgkin's disease and multiple myeloma patients previously 
failing mobilization with chemotherapy and/or cytokine treatment: compassionate use 
data. Bone Marrow Transplant, 2008. 41(4): p. 331-8. 
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hematopoietic stem cell homing, survival, and proliferation. Blood 113, 5444 (2009). 
45.  T. E. North, W. Goessling, C. R. Walkley, C. Lengerke, K. R. Kopani, et al., Prostaglandin 
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46.  J. Hoggatt, K.S. Mohammad, P. Singh, A.F. Hoggatt, B.R. Chitteti, et al. Differential stem 
and progenitor cell trafficking by prostaglandin E2. Nature, (2013), in press. 
47.  M. Ahmed, D. Khanna, and D. E. Furst, Meloxicam in rheumatoid arthritis. Expert. Opin. 
Drug Metab Toxicol. 1, 739 (2005). 
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49.  S. L. Gerson, G. H. Talbot, S. Hurwitz, B. L. Strom, E. J. Lusk, et al., Prolonged 
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50.  K. M. Taylor, S. Jagannath, G. Spitzer, J. A. Spinolo, S. L. Tucker, et al., Recombinant 
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51.  P. A. Pizzo, Granulocytopenia and cancer therapy. Past problems, current solutions, future 
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sibling bone marrow transplantation. Blood 99, 2726 (2002). 
53.  D. R. Sutherland, L. Anderson, M. Keeney, R. Nayar, and I. Chin-Yee, The ISHAGE 
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54.  S. Fruehauf, M. R. Veldwijk, T. Seeger, M. Schubert, S. Laufs, et al., A combination of 
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55.  E. Jantunen and S. Fruehauf, Importance of blood graft characteristics in auto-SCT: 
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56.  J. Hoggatt and L. M. Pelus, Hematopoietic stem cell mobilization with agents other than G-
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59.  V. K. Singh, J. Christensen, O. O. Fatanmi, D. Gille, E. J. Ducey, et al., Myeloid 
progenitors: a radiation countermeasure that is effective when initiated days after 
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61.  P. Schroeter, A. Sablotzki, and D. Riemann, CD13 and CD10 expression of granulocytes 
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64.  C. M. Baum, I. L. Weissman, A. S. Tsukamoto, A. M. Buckle, and B. Peault, Isolation of a 
candidate human hematopoietic stem-cell population. Proc. Natl. Acad. Sci. U. S. A 89, 
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65.  M. Bhatia, J. C. Wang, U. Kapp, D. Bonnet, and J. E. Dick, Purification of primitive human 
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human hematopoietic cells with SCID-repopulating activity. Nat. Med. 4, 1038 (1998). 
67.  R. Majeti, C. Y. Park, and I. L. Weissman, Identification of a hierarchy of multipotent 
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68.  F. Notta, S. Doulatov, E. Laurenti, A. Poeppl, I. Jurisica, et al., Isolation of single human 
hematopoietic stem cells capable of long-term multilineage engraftment. Science 333, 218 
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69.   H.M.Rinder, J.B.Tracey, M. Souhrada, C.Wang, R.P.Gagnier, et al.  Effects of meloxicam 
on platelet functionin healthy adults: a randomized, double-blind, placebo-controlled trial. 
J. Clin. Pharmacol. 42, 881(2002) 
70.   D.J.van Kraaij, A.H.Hovestad-Witterland, M. de Metz, E.J.Vollaard. A comparison of the 
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CONFIDENTIAL 
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31 
Appendix A: Performance Status Criteria 
 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Description 
Percent 
Description 
0 
Normal activity. Fully active, able 
to carry on all pre-disease 
performance without restriction. 
100 
Normal, no complaints, no 
evidence of disease. 
90 
Able to carry on normal activity; 
minor signs or symptoms of 
disease. 
1 
Symptoms, but ambulatory. 
Restricted in physically strenuous 
activity, but ambulatory and able to 
carry out work of a light or 
sedentary nature (e.g., light 
housework, office work). 
80 
Normal activity with effort; 
some signs or symptoms of 
disease. 
70 
Cares for self, unable to carry on 
normal activity or to do active 
work. 
2 
In bed < 50% of the time. 
Ambulatory and capable of all self-
care, but unable to carry out any 
work activities. Up and about more 
than 50% of waking hours. 
60 
Requires occasional assistance, 
but is able to care for most of 
his/her needs. 
50 
Requires considerable assistance 
and frequent medical care. 
3 
In bed >50% of the time. Capable 
of only limited self-care, confined 
to bed or chair more than 50% of 
waking hours. 
40 
Disabled, requires special care 
and assistance. 
30 
Severely disabled, 
hospitalization indicated. Death 
not imminent. 
4 
100% bedridden. Completely 
disabled. Cannot carry on any self-
care. Totally confined to bed or 
chair. 
20 
Very sick, hospitalization 
indicated. Death not imminent. 
10 
Moribund, fatal processes 
progressing rapidly.  
5 
Dead. 
0 
Dead. 
 


NSAIDs to mobilize hematopoietic stem cells 
 September 28, 2016 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
 
 
32 
Appendix B: Lab Manual 
 
The following research samples will be collected: 
 10 mL EDTA tube of blood at D-6, D0, D+1, D+2, D+3 
 
Sample Handling: 
Samples should be received by the lab within 24 hours of collection and should be sent 
ambient. 
 
Sample labeling: 
Samples should be labeled with pt initials, pt ID number, Study number (13-195), sample 
time point, date and time obtained.  
 
Samples with Sample Submission Form to be sent to: 
 
 
 
 


NSAIDs to mobilize hematopoietic stem cells 
 September 28, 2016 
CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
 
 
33 
 
Protocol 13-195 
Non-steroidal anti-inflammatory drugs (meloxicam) to mobilize hematopoietic stem cells: A 
Phase II randomized trial 
 
Sample Submission Form 
 
Date: ____________  
Initials:_____________________ PT ID #:________________________________ 
16. MRN: ___________________ 
          
 
 
 
 
 
 
 
 
 
Sample Information 
 
1. Sample type: _____________________________ 
2. Sample time point: _________________________ 
3. Date sample obtained: ______________________ 
4. Relation to G-CSF administration (circle one):  PRE/  POST 
5. WBC (attach a copy of CBC report if available): __________________ 
6. Sample sent out by: ________________________ Date: __________ 
7. FedEx tracking # or Skycom Job #: ______________________________ 
 


 
 
 
OTHER MEDICATIONS TAKEN 
 
If you take a daily medication (prescribed or otherwise), please use one 
line per drug and indicate the start and stop dates under the “Date(s) 
Taken” section (i.e., 6/2/09-6/5/09).  
 
Drug Name 
Dose 
Dates Taken 
Reason Taken 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study Participant Initials __________ Date __________ 
 
 
FOR OFFICE USE 
 
Staff Initials:  
 
Date Dispensed:     
Date Returned:  
 
# pills/caps/tabs dispensed:  
# pills/caps/tabs returned:  
# pills/caps/tabs that should have been taken:  
 
Discrepancy Notes: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
            Participant Identifier: _______________________ 
            Protocol # 13-195 
            Your MD_____________________  Phone___________________  
            Your RN______________________ Phone___________________ 
 
 
            STUDY DRUG  INSTRUCTIONS: 
 
Study Drug: Meloxicam/Placebo 
 
How Often: You will take each dose  daily for 5 days  starting 6 
days (Day -6) before you are scheduled to undergo the first apheresis 
procedure (Day 0) and continuing until 2 days before apheresis (Day 
-2).   
 
 
SPECIAL INSTRUCTIONS: 
 Meloxicam/Placebo can be taken with or without food.   
 Tablets should be swallowed whole and not crushed, chewed or 
dissolved.   
 Missed and/or vomited doses should not be made up.  If you 
forget to take a dose or vomit after a dose, please wait until the 
next scheduled dose. 
 
Study Participant  
Self-Administration 
Study Drug Diary 
Dana-Farber/Harvard Cancer Center 


DOSING LOG                                             SYMPTOMS/SIDE EFFECTS 
 
 
CYCLE 
X 
Meloxicam/Placebo 
For each dose take : X pills/capsules/tablets 
 
Please indicate the date, time, amount taken and any 
comments.  
 
Please record any side effects experienced during this cycle. Include 
the date the particular symptom started and when it ended. Please 
evaluate the severity of the symptom according to the following scale: 
 
Mild: Awareness of sign or symptom; easily tolerated and did not 
affect ability to perform normal daily activities. Symptom did not 
require medication or therapeutic intervention. 
 
Moderate: Significant discomfort which interfered with ability to 
perform normal daily activities. Symptom was easily resolved with at 
home medication or simple therapeutic intervention. 
 
Severe: Marked discomfort with an inability to carry out normal daily 
activities. Symptom required new medication and/or therapeutic 
intervention in order to resolve.  
 
Please Note: The severity should reflect the most severe level 
experienced during the time period.  
 
 
Date 
Amount Taken 
Comments 
 
AM dose 
 
Ex: 
6/1/09 
8am - 1 
Vomited AM dose 
 
Day -6 
 
 
 
 
-5 
 
 
 
 
-4 
 
 
 
 
-3 
 
 
 
 
-2 
 
 
 
 
-1 
 
 
 
 
Day 0 
 
 
 
 
1 
 
 
 
 
2 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
Symptom 
Start Date 
End Date 
Severity 
13 
 
 
 
 
 
 
 
 
14 
 
 
 
 
 
 
 
 
15 
 
 
 
 
 
 
 
16 
 
 
 
 
 
 
 
 
17 
 
 
 
 
 
 
 
 
18 
 
 
 
 
 
 
 
 
19 
 
 
 
 
 
 
 
 
20 
 
 
 
 
 
 
 
 
21 
 
 
 
 
 
 
 
 
22 
 
 
 
 
 
 
 
 
23 
 
 
 
 
 
 
 
 
24 
 
 
 
 
 
 
 
 
25 
 
 
 
 
 
 
 
 
26 
 
 
 
 
 
 
 
 
27 
 
 
 
 
 
 
 
 
28