4.11. diet/activity/other considerations
11.13. confidentiality

Subject names will not be supplied to Merck, Incyte or its designee if applicable. Only the subject number and subject's initials will be recorded in the CRF, where permitted; if the subject's name appears on any other document (e.g., laboratory report), it must be obliterated on the copy of the document to be supplied to the sponsor or its designee. Study findings stored on a computer will be stored in accordance with local data protection laws. The subjects will be informed that representatives of the sponsor or its designee, IRB or IEC, or regulatory authorities may inspect their medical records to verify the information collected, and that all personal information made available for inspection will be handled in strictest confidence and in accordance with local data protection laws.
4.11. diet/activity/other considerations
12. statistics considerations 12.1. statistical

This is a single-stage study for the doublet epacadostat and pembrolizumab. A 6-month PFS of 20% was observed using single agent pembrolizumab and is the basis for the null hypothesis of the present study (Bang, abstract 4001, GI ASCO 2015). We will enroll 30 patients over 18 months and follow patients for at least 6 months. This design has 80% power to reject a 20% PFS rate, if the true PFS is 39%. Calculation based on binomial probabilities with a one-sided significance of 10%. The level of significance for the primary endpoint in Phase 2 is one-sided 10%, which is deemed acceptable for a proof-of-concept study.  
12.2. **Safety Analyses**
4.11. diet/activity/other considerations
12.2.1. analysis plan

The analysis will be done on the intent to treat population and patients who drop out will be censored at the point of last follow up. The primary endpoint of the study is 6-month Progression-free survival (PFS), which is defined as number of days from the first day of taking study dose to the earlier of death or disease progression by RECIST v1.1 for solid tumors. Median PFS will be estimated using the Kaplan-Meier method.
4.11. diet/activity/other considerations
12.3. secondary analyses

Secondary efficacy analysis will be conducted for the efficacy evaluable population. Secondary endpoints and analyses are as follows: To evaluate response rate (RR). Response will be determined by RECIST v1.1 for solid tumors. The 95% exact CI for the RR will be estimated using the Clopper-Pearson method. For objective responders, the duration of response is the time from the first objective response contributing to an objective response, to the first objective response of PD (by RECIST v1.1) occurring after the first objective response contributing to the objective response. To evaluate overall survival (OS). Time-to-event data will be analyzed by the Kaplan-Meier method, treating subjects with no observed death or progression as censored at their last date known to be alive. For the OS analysis, the nonparametric Kaplan-Meier method will be used to estimate the survival time distribution and the median survival. To assess the safety and tolerability of epacadostat in combination with pembrolizumab. AEs will be coded by the MedDRA, and incidences will be tabulated by preferred term and system organ class for all events, related events, and events ≥ Grade 3. Severity of AEs will be based on the CTCAE v5 scale as indicated. Quantitative safety variables and their changes from baseline (laboratory, vital signs) will be summarized with descriptive statistics. Clinically significant abnormal values will be flagged and tabulated based on predefined criteria. Exposure will be analyzed by describing dose intensity, which is defined as the dose-received divided by the dose planned over a given time interval. This will be done by cycle as well as overall cycles received for epacadostat and pembrolizumab. For each cycle, incidences of dose reductions and cycle delays will also be tabulated, by reason for the reduction or delay. The percentage of subjects  
  
 with any delay and/or reduction will also be calculated. Clinical Laboratory Tests. The clinical laboratory data will be analyzed using summary statistics (e.g., means and frequencies), and no formal statistical comparisons among the treatments are planned. In addition, distributions of key laboratory parameters (including hemoglobin, neutrophils, and platelets) will be plotted over time; these values will also be classified into CTCAE toxicity grades and tabulated. Descriptive statistics and mean change from baseline will be determined for vital signs at each assessment time. Vital sign results will be reviewed for clinically notable abnormalities.
4.11. diet/activity/other considerations
12.4. sample size

We will enroll 30 patients over 18 months and follow patients for at least 6 months.
4.11. diet/activity/other considerations
12.5. criteria for future studies

If the sample size is justified by precision only, state the outcomes that constitute success. If the protocol is part of a sequence of studies, state the statistical criteria that will be applied. If this is a pilot study, state what result would convince you to begin a fully powered study.
4.11. diet/activity/other considerations
13. references

1. Bang, Y., et al., *Relationship between PD-L1 expression and clinical outcomes in* patients with advanced gastric cancer treated with the anti-PD-1 monoclonal antibody pembrolizumab (MK-3475) in KEYNOTE-012. J Clin Oncol 33, 2015 (suppl; abstr 4001), 2015.  
2. Torre, L.A., et al., *Global cancer statistics, 2012.* CA Cancer J Clin, 2015. 65(2): p. 87108.  
3. Siegel, R.L., K.D. Miller, and A. Jemal, *Cancer statistics, 2015.* CA Cancer J Clin, 2015.  
65(1): p. 5-29.  
4. Parfitt, J.R., Z. Miladinovic, and D.K. Driman, *Increasing incidence of adenocarcinoma* of the gastroesophageal junction and distal stomach in Canada -- an epidemiological study from 1964-2002. Can J Gastroenterol, 2006. 20(4): p. 271-6.  
5. Wagner, A., *Chemotherapy for advanced gastric cancer.* Cochrane Database Syst Rev, 2005: p. CD004064.  
6. Fuchs, C.S., et al., Ramucirumab monotherapy for previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (REGARD): an international, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet, 2014. 383(9911): p. 31-9.  
7. Wilke, H., et al., *Ramucirumab plus paclitaxel versus placebo plus paclitaxel in patients* with previously treated advanced gastric or gastro-oesophageal junction adenocarcinoma (RAINBOW): a double-blind, randomised phase 3 trial. Lancet Oncol, 2014. 15(11): p. 1224-35.  
8. Herbst, R., et al., A study of MPDL3280A, an engineered PD-L1 antibody in patients with locally advanced or metastatic tumors. J Clin Oncol 31, 2013 (suppl; abstr 3000).  
9. Ralph, C., et al., Modulation of lymphocyte regulation for cancer therapy: a phase II trial of tremelimumab in advanced gastric and esophageal adenocarcinoma. Clin Cancer Res, 2010. 16(5): p. 1662-72.  
10. Disis, M.L., *Immune regulation of cancer.* J Clin Oncol, 2010. 28(29): p. 4531-8. 11. Talmadge, J.E., M. Donkor, and E. Scholar, *Inflammatory cell infiltration of tumors:*
Jekyll or Hyde. Cancer Metastasis Rev, 2007. 26(3-4): p. 373-400.  
12. Usubutun, A., et al., *Prognostic factors in renal cell carcinoma.* J Exp Clin Cancer Res, 1998. 17(1): p. 77-81.  
13. Hiraoka, N., *Tumor-infiltrating lymphocytes and hepatocellular carcinoma: molecular* biology. Int J Clin Oncol, 2010. 15(6): p. 544-51.  
14. Nobili, C., et al., *Prolonged survival of a patient affected by pancreatic adenocarcinoma* with massive lymphocyte and dendritic cell infiltration after interleukin-2 immunotherapy. Report of a case. Tumori, 2008. 94(3): p. 426-30.  
15. Hodi, F.S. and G. Dranoff, *The biologic importance of tumor-infiltrating lymphocytes.* J
Cutan Pathol, 2010. **37 Suppl 1**: p. 48-53.  
16. Kloor, M., *Lymphocyte infiltration and prognosis in colorectal cancer.* Lancet Oncol, 2009. 10(9): p. 840-1.  
17. Hillen, F., et al., *Leukocyte infiltration and tumor cell plasticity are parameters of* aggressiveness in primary cutaneous melanoma. Cancer Immunol Immunother, 2008. 57(1): p. 97-106.  
  
  
  
18. Lee, H.E., et al., Prognostic implications of type and density of tumour-infiltrating lymphocytes in gastric cancer. Br J Cancer, 2008. 99(10): p. 1704-11.  
19. Leffers, N., et al., Prognostic significance of tumor-infiltrating T-lymphocytes in primary and metastatic lesions of advanced stage ovarian cancer. Cancer Immunol Immunother, 2009. 58(3): p. 449-59.  
20. Nishimura, H., T. Honjo, and N. Minato, *Facilitation of beta selection and modification* of positive selection in the thymus of PD-1-deficient mice. J Exp Med, 2000. 191(5): p. 891-8.  
21. Liotta, F., et al., *Frequency of regulatory T cells in peripheral blood and in tumourinfiltrating lymphocytes correlates with poor prognosis in renal cell carcinoma.* BJU Int, 2011. 107(9): p. 1500-6.  
22. Godin-Ethier, J., et al., Indoleamine 2,3-dioxygenase expression in human cancers:
clinical and immunologic perspectives. Clin Cancer Res, 2011. 17(22): p. 6985-91.  
23. Mellor, A.L. and D.H. Munn, *IDO expression by dendritic cells: tolerance and* tryptophan catabolism. Nat Rev Immunol, 2004. 4(10): p. 762-74.  
24. Munn, D.H. and A.L. Mellor, Indoleamine 2,3-dioxygenase and tumor-induced tolerance. J Clin Invest, 2007. 117(5): p. 1147-54.  
25. Mellor, A.L., et al., Cutting edge: induced indoleamine 2,3 dioxygenase expression in dendritic cell subsets suppresses T cell clonal expansion. J Immunol, 2003. 171(4): p. 1652-5.  
26. Frumento, G., et al., *Tryptophan-derived catabolites are responsible for inhibition of T*
and natural killer cell proliferation induced by indoleamine 2,3-dioxygenase. J Exp Med, 2002. 196(4): p. 459-68.  
27. Fallarino, F., et al., The combined effects of tryptophan starvation and tryptophan catabolites down-regulate T cell receptor zeta-chain and induce a regulatory phenotype in naive T cells. J Immunol, 2006. 176(11): p. 6752-61.  
28. Zou, W., *Regulatory T cells, tumour immunity and immunotherapy.* Nat Rev Immunol, 2006. 6(4): p. 295-307.  
29. Munn, D.H., et al., *Prevention of allogeneic fetal rejection by tryptophan catabolism.*
Science, 1998. 281(5380): p. 1191-3.  
30. Uyttenhove, C., et al., *Evidence for a tumoral immune resistance mechanism based on* tryptophan degradation by indoleamine 2,3-dioxygenase. Nat Med, 2003. 9(10): p. 126974.  
31. Muller, A.J., et al., *Inhibition of indoleamine 2,3-dioxygenase, an immunoregulatory* target of the cancer suppression gene Bin1, potentiates cancer chemotherapy. Nat Med, 2005. 11(3): p. 312-9.  
32. Huang, L., et al., Dendritic cells, indoleamine 2,3 dioxygenase and acquired immune privilege. Int Rev Immunol, 2010. 29(2): p. 133-55.  
33. Weinlich, G., et al., *Decreased serum tryptophan concentration predicts poor prognosis* in malignant melanoma patients. Dermatology, 2007. 214(1): p. 8-14.  
34. Munn, D.H., et al., Expression of indoleamine 2,3-dioxygenase by plasmacytoid dendritic cells in tumor-draining lymph nodes. J Clin Invest, 2004. 114(2): p. 280-90.  
35. Okamoto, A., et al., *Indoleamine 2,3-dioxygenase serves as a marker of poor prognosis* in gene expression profiles of serous ovarian cancer cells. Clin Cancer Res, 2005. 11(16): p. 6030-9.  
36. Brandacher, G., et al., *Prognostic value of indoleamine 2,3-dioxygenase expression in*  
  
  
colorectal cancer: effect on tumor-infiltrating T cells. Clin Cancer Res, 2006. 12(4): p. 1144-51.  
37. Ino, K., et al., *Indoleamine 2,3-dioxygenase is a novel prognostic indicator for* endometrial cancer. Br J Cancer, 2006. 95(11): p. 1555-61.  
38. Nakamura, T., et al., Expression of indoleamine 2, 3-dioxygenase and the recruitment of Foxp3-expressing regulatory T cells in the development and progression of uterine cervical cancer. Cancer Sci, 2007. 98(6): p. 874-81.  
39. Witkiewicz, A., et al., Expression of indoleamine 2,3-dioxygenase in metastatic pancreatic ductal adenocarcinoma recruits regulatory T cells to avoid immune detection. J Am Coll Surg, 2008. 206(5): p. 849-54; discussion 854-6.  
40. Hamid, O., et al., Association of baseline and on-study tumor biopsy markers with clinical activity in patients (pts) with advanced melanoma treated with ipilimumab. J Clin Oncol 27:15s, 2009 (suppl; abstr 9008), 2009.  
41. Robert, C., et al., *Ipilimumab plus dacarbazine for previously untreated metastatic* melanoma. N Engl J Med, 2011. 364(26): p. 2517-26.  
42. Hodi, F.S., et al., *Improved survival with ipilimumab in patients with metastatic* melanoma. N Engl J Med, 2010. 363(8): p. 711-23.  
43. Topalian, S.L., et al., Safety, activity, and immune correlates of anti-PD-1 antibody in cancer. N Engl J Med, 2012. 366(26): p. 2443-54.  
44. Hamid, O., et al., Safety and tumor responses with lambrolizumab (anti-PD-1) in melanoma. N Engl J Med, 2013. 369(2): p. 134-44.  
45. Wolchok, J.D., et al., Guidelines for the evaluation of immune therapy activity in solid tumors: immune-related response criteria. Clin Cancer Res, 2009. 15(23): p. 7412-20.  
46. Quezada, S.A. and K.S. Peggs, *Exploiting CTLA-4, PD-1 and PD-L1 to reactivate the* host immune response against cancer. Br J Cancer, 2013. 108(8): p. 1560-5.  
47. Curran, M.A., et al., PD-1 and CTLA-4 combination blockade expands infiltrating T cells and reduces regulatory T and myeloid cells within B16 melanoma tumors. Proc Natl Acad Sci U S A, 2010. 107(9): p. 4275-80.  
48. Selby, M., et al., *Antitumor activity of concurrent blockade of immune checkpoint* molecules CTLA-4 and PD-1 in preclinical models. J Clin Oncol 31, 2013 (suppl; abstr 3061), 2013.  
49. *Yervoy [package insert]. Princeton, NJ: Bristol-Myers Squibb, 2012.* 50. Holmgaard, R.B., et al., *Indoleamine 2,3-dioxygenase is a critical resistance mechanism* in antitumor T cell immunotherapy targeting CTLA-4. J Exp Med, 2013. 210(7): p. 1389402.  
51. Spranger, S., et al., *Up-regulation of PD-L1, IDO, and T(regs) in the melanoma tumor* microenvironment is *driven by CD8(+) T cells.* Sci Transl Med, 2013. 5(200): p. 200ra116.  
52. Gibney, G., et al., *Preliminary results from a phase 1/2 study of INCB024360 combined* with ipilimumab (ipi) in patients (pts) with melanoma. J Clin Oncol 32:5s, 2014 (suppl; abstr 3010), 2014.  
53. Robert, C., et al., *Nivolumab in previously untreated melanoma without BRAF mutation.*
N Engl J Med, 2015. 372(4): p. 320-30.  
54. Robert, C., et al., *Pembrolizumab versus Ipilimumab in Advanced Melanoma.* N Engl J
Med, 2015. 372(26): p. 2521-32.  
55. Garon, E.B., A.S. Balmanoukian, and O. Hamid, *Preliminary clinical safety and activity*  
  
  
of MK-3475 monotheraly for the treatment of previously treated patients with non-small cell lung cancer. J Thorac Oncol; 8(suppl 2): S364 (anstr MO18.02).  
56. Garon, E.B., et al., *Pembrolizumab for the treatment of non-small-cell lung cancer.* N
Engl J Med, 2015. 372(21): p. 2018-28.  
57. Muro, K., et al., *Relationship between PD-L1 expression and clinical outcomes in* patients (Pts) with advanced gastric cancer treated with the anti-PD-1 monoclonal antibody pembrolizumab (Pembro; MK-3475) in KEYNOTE-012. J Clin Oncol 33, 2015 (suppl 3; abstr 3).  
58. Boyer, E.W. and M. Shannon, *The serotonin syndrome.* N Engl J Med, 2005. 352(11): p.  
1112-20.
4.11. diet/activity/other considerations
14. appendices

14.1. Appendix A: Participant Eligibility Checklist  
| Protocol Title:                                                                                                                        | Phase                          | II   | Study   | Of   | Epacadostat   | (INCB024360)   | With   |
|----------------------------------------------------------------------------------------------------------------------------------------|--------------------------------|------|---------|------|---------------|----------------|--------|
| Pembrolizumab (MK-3475) In Metastatic Or Unresectable  Gastroesophageal Junction And Gastric Adenocarcinoma  Requiring Paired Biopsies |                                |      |         |      |               |                |        |
| Protocol Number:                                                                                                                       | IRB-40823 / GI0015             |      |         |      |               |                |        |
| Principal Investigator:                                                                                                                | George A. Fisher, Jr., MD, PhD |      |         |      |               |                |        |
| I. Subject Information: Subject Name/ID: Gender: Male                                                                                  | Female                         |      |         |      |               |                |        |
4.11. diet/activity/other considerations
ii. inclusion/exclusion criteria

| Yes                | No                                                                                                                                                                                                                        | Supporting Documentation*   |
|--------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------|
| Inclusion Criteria |                                                                                                                                                                                                                           |                             |
| 1.                 | Age ≥ 18 years of age on day of signing informed  consent                                                                                                                                                                 |                             |
| 2.                 | Be willing and able to provide written informed consent  for the study                                                                                                                                                    |                             |
| 3.                 | Histologically or cytologically confirmed  adenocarcinoma of the distal esophagus,  gastroesophageal junction or stomach, including patients  with HER2+ disease - Distal esophagus is defined as within 5 cm of the  GEJ |                             |
| 4.                 | Patients must have metastatic or unresectable disease,  including those with HER2+ disease                                                                                                                                |                             |
| 5.                 | Must have progressed on at least one line of prior  therapy for metastatic disease, or be intolerant to that  therapy if they have not progressed; for HER2+ disease  patients should have received prior trastuzumab     |                             |  
| 6.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Life expectancy of ≥ 12 weeks                                                                                                                   |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------|
| 7.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Have a performance status of 0 or 1 (ECOG)                                                                                                      |
| 8.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Have measurable disease per RECIST v1.1 assessed  within 4 weeks prior to study entry                                                           |
| 9.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Tumor deemed amenable to biopsy by core for  metastatic site or endoscopic biopsy for primary tumor (for both before and on-treatment biopsies) |
| 10. Patient must be willing to undergo 2 biopsies - before  and on-treatment, provided the procedure is not deemed  high-risk and is clinically feasible.  11. Demonstrate adequate organ function within 7 days  before treatment initiation, as defined below: - Absolute neutrophil count ≥ 1500 /mcL - Platelets ≥ 100,000 /mcL - Hemoglobin ≥ 9 g/dL or ≥ 5.6 mmol/L without  transfusion or EPO dependency (within 7 days of  assessment) - Serum creatinine ≤ 1.5 x ULN or measured  creatinine clearance ≥ 60 mL/min (for subjects that  have creatinine levels > 1.5 x ULN) - Total bilirubin ≤ 1.5 x ULN or direct bilirubin ≤  ULN - AST and ALT ≤ 2.5 x ULN (for subjects that have  liver metastases, ≤ 5 x ULN) - Albumin ≥ 2.5 mg/dL - INR or PT ≤ 1.5 x ULN (if subjects are on  anticoagulation therapy, PT/INR must be within  therapeutic range) - aPTT ≤ 1.5 x ULN (if subjects are on  anticoagulation therapy, PT/INR must be within  therapeutic range) 12. Female subject of childbearing potential should have a  negative urine or serum pregnancy within 3 days prior to  receiving the first dose of study medication. If the urine  test is positive or cannot be confirmed negative, a serum  pregnancy test will be required 13. Female subjects of childbearing potential must be  willing to use an adequate method of contraception |                                                                                                                                                 |  
  
  
| starting with the date of consent through 120 days after  the last dose of study medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 14. Male subjects of childbearing potential must agree to  use an adequate method of contraception starting with  the date of consent through 120 days after the last dose  of study medication 15. Must be able to swallow pills Exclusion Criteria 1. Is currently participating and receiving study therapy or  has participated in a study of an investigational agent  and received study therapy or used an investigational  device within 4 weeks of the first planned dose of  treatment  2. Has known hypersensitivity to pembrolizumab and/or  epacadostat or any of their excipients 3. Has had a prior anti-cancer monocloncal antibody  within 4 weeks prior to day 1 or who has not recovered  (i.e., ≤ grade 1 or to baseline) from AEs due to agents  administered more than 4 weeks earlier.  - Denosumab for treatment for bone metastases is  allowed 4. Has had prior chemotherapy, targeted small molecule  therapy, or radiation therapy within 2 weeks prior to  study day 1 or who has not recovered (i.e., ≤ grade 1 or  to baseline) from AEs due to previously administered  agents - Subjects with ≤ grade 2 neuropathy are an  exception to this criterion and may qualify for  the study - If subjects have received major surgery, they  must have recovered adequately from surgery prior to starting therapy 5. Patients who have been treated on any Merck-sponsored  pembrolizumab containing gastric cancer pivotal trial  will require prior authorization by Merck in order to  enroll in this study 6. Prior therapy with IDO-inhibitors 7. Has active autoimmune disease that has required |  
  
  
| systemic treatment in the past 2 years (i.e., with use of  disease modifying agents, corticosteroids, or  immunosuppressive drugs). - Replacement therapy (e.g., thyroxine, insulin, or  physiologic corticosteroid replacement therapy  for adrenal or pituitary insufficiency etc.) is not  considered a form of systemic treatment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |                                                                                                                                                                                                                                                                                         |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 8.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Has known history of, or any evidence of active, noninfectious pneumonitis                                                                                                                                                                                                                                                                                         |
| 9.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  | Has received a live vaccine within 30 days of planned  start of therapy - Seasonal influenza vaccines for injection are  generally inactivated flu vaccines and are  allowed; however intranasal influenza vaccines  (e.g., FluMist®) are live attenuated vaccines and  are NOT allowed |
| 10. Has known active central nervous system (CNS)  metastases and/or carcinomatous meningitis - Subjects with previously treated brain metastases  may participate provided they are stable (without  evidence of progression by imaging for at least 4  weeks prior to the first dose of study treatment  and any neurologic symptoms have returned to  baseline), have no evidence of new or enlarging  brain metastases, and are not using steroids for at  least 7 days prior to study treatment - Carcinomatous meningitis is excluded regardless  of clinical stability - Patient with prior CNS metastases treated w/  prior RT will also need: A. 2 months off RT  before starting study or 4 weeks following XRT  if MRI is stable and the patient is off steroids, B.  Baseline MFI with no edema., and C. stable for  at least 8 weeks. 11. Has known additional malignancy that is progressing or  requires active treatment - Exceptions include: basal cell carcinoma of the  skin, squamous cell carcinoma of the skin, or in  situ cervical cancer that has undergone  potentially curative therapy |                                                                                                                                                                                                                                                                                         |  
  
  
| 12. Has active infection requiring systemic therapy 13. Has a known history of active TB (bacillus tuberculosis) 14. Has known active Hepatitis B (e.g., HBsAg reactive) or  Hepatitis C (e.g., HCV RNA [qualitative] detected  15. Has a diagnosis of immunodeficiency or is receiving  systemic steroid therapy or any other form of  immunosuppressive therapy within 7 days prior to the  first dose of study treatment 16. Has a known history of Human Immunodeficiency  Virus (HIV) (HIV 1/2 antibodies) 17. Is pregnant or breastfeeding, or expecting to conceive or  father children within projected duration of the study,  starting with pre-screening or screening visit through  120 days after the last dose of study treatment 18. Has had Monoamine oxidase inhibitors within 21 days  before screening 19. Has any history of serotonin syndrome after receiving 1  or more serotonergic drugs 20. Has presence of a gastrointestinal condition that may  affect drug absorption 21. Use of systemic corticosteroids 22. Has history or presence of an abnormal ECG which, in  the investigator's opinion, is clinically significant.  QTcF > 480 ms or presence of a Left Bundle Branch  Block (LBBB). If the QRS duration > 120ms, the JTc  can be used in place of the QTcF, The JTc must be <  340 ms. 23. Has history or current evidence of any condition,  therapy, or laboratory abnormality that might confound  the results of the study, interfere with the subjects  participation for the full duration of the study, or is not  in the best interest of the subject to participate, in the  opinion of the investigator 24. Has known psychiatric or substance abuse disorders that  would interfere with cooperation with the requirements  of the study 25. Has known allergy or reaction to any component of  either study drug or formulation components   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|  
  
  
*All subject files must include supporting documentation to confirm subject eligibility.  
  
 The method of confirmation can include, but is not limited to, laboratory test results, radiology test results, subject self-report, and medical record review.
4.11. diet/activity/other considerations
iii. statement of eligibility

By signing this form of this study, I verify that this subject is [ eligible / **ineligible**] for participation in the study. This study is approved by the Stanford Cancer Institute Scientific Review Committee, the Stanford IRB, and has finalized financial and contractual agreements as required by Stanford School of Medicine's Research Management Group.  
Treating Physician Signature: Date:  
| Printed Name:   |
|-----------------|  
Secondary Reviewer Signature: Date:  
| Printed Name:   |
|-----------------|  
| Study Coordinator Signature:   | Date:   |
|--------------------------------|---------|
| Printed Name:                  |         |  
14.2. **APPENDIX B:** INFORMATION REGARDING EFFECTIVENESS OF
contraceptive methods
for subjects participating in the

The following methods have been determined to be more than 99% effective (< 1% failure rate per year when used consistently and correctly and are permitted under this Protocol for use by the subject and his/her partner:
- Complete abstinence from sexual intercourse - Double barrier methods:
− Condom with spermicide in conjunction with use of an intrauterine device
− Condom with spermicide in conjunction with use of a diaphragm
- Birth control patch or vaginal ring - Oral, injectable, or implanted contraceptives - Surgical sterilization (tubal ligation or vasectomy)
contraceptive methods
14.3. appendix c eastern cooperative

Performance Status  
| Grade                                                                                                                                                                                                                                        | Description                                                                                                                                                                                 |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| 0                                                                                                                                                                                                                                            | Normal activity. Fully active, able to carry on all pre-disease  performance without restriction. Symptoms, but ambulatory. Restricted in physically strenuous                              |
| 1                                                                                                                                                                                                                                            | activity, but ambulatory and able to carry out work of a light or  sedentary nature (e.g., light housework, office work). In bed <50% of the time. Ambulatory and capable of all self-care, |
| 2                                                                                                                                                                                                                                            | but unable to carry out any work activities. Up and about more than  50% of waking hours.                                                                                                   |
| 3                                                                                                                                                                                                                                            | In bed >50% of the time. Capable of only limited self-care, confined  to bed or chair more than 50% of waking hours.                                                                        |
| 4                                                                                                                                                                                                                                            | 100% bedridden. Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair.                                                                                                                                                                                             |
| 5                                                                                                                                                                                                                                            | Dead.                                                                                                                                                                                       |
| *As published in Am. J. Clin. Oncol.:                                                                                                                                                                                                        | Oken, M.M., Creech, R.H., Tormey, D.C.,                                                                                                                                                     |
| Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And Response  Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655,  1982. The Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair. |                                                                                                                                                                                             |  
14.4. **APPENDIX D:** PROHIBITED MONOAMINE OXIDASE INHIBITORS AND  
  
  
DRUGS ASSOCIATED WITH SIGNIFICANT MONOAMINE OXIDASE
INHIBITORY ACTIVITY  
| Drugs Associated With           |                                                                                                                                                                                                                                                                                                           |                                                     |
|---------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------------------------------------------|
| Monoamine Oxidase Inhibitors    | Significant Monoamine                                                                                                                                                                                                                                                                                     | UGT1A9 inhibitor                                    |
| Oxidase Inhibitory Activity     |                                                                                                                                                                                                                                                                                                           |                                                     |
| Hydrazines (example phenelzine) | Meperidine                                                                                                                                                                                                                                                                                                | acitretin, amitriptyline,                           |
| Isocarboxazid                   | Linezolid                                                                                                                                                                                                                                                                                                 | androsterone, cyclosporine,  dasatinib, diclofenac, |
| Tranylcypromine                 | Methylene blue                                                                                                                                                                                                                                                                                            | diflunisal, efavirenz, erlotinib,                   |
| Brofaromine                     | estradiol (17-beta), flutamide,                                                                                                                                                                                                                                                                           |                                                     |
| Rasagiline                      | geftinib, gemfibrozil,                                                                                                                                                                                                                                                                                    |                                                     |
| Selegiline                      | glycyrrhetinic acid  glycyrrhizin, imatinib,  imipramine, ketoconazole,  linoleic acid, mefenamic acid,  mycophenolic acid, niflumic  acid, nilotinib, phenobartital,  phenylbutazone, phenytoin,  probenecid, propofol,  quinidine, ritonavir,  Sorafenib, sulfinpyrazone,  valproic acid, and verapmil. |                                                     |  
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appendix e publication on serotonin
14.3. appendix c eastern cooperative

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CURRENT CONCEPTS
appendix e publication on serotonin
the serotonin syndrome

Edward W. Boyer, M.D., Ph.D., and Michael Shannon, M.D., M.P.H.  
From the Division of Medical Toxicology, Department of Emergency Medicine University of Massachusetts, Worcester
(E.W.B.), and the Program in Medical Tox icology Division of Emergency Medicine, Children's Hospital, Boston (E.W.B., M.S.)  
| Address reprint requests to Dr. Boyer at   |            |
|--------------------------------------------|------------|
| IC Smith Bldg, Children's Hospital, 300    |            |
| Longwood Ave., Boston, MA 02115, or at     |            |
| edward.boyer@tch.harvard. edu              |            |
| This article (10.1056/ NEJMra041867) was   |            |
| updated on October 21, 2009 at NEJM.org.   |            |
| N Engl J Med 2005;352:1112-203             |            |
| Copyright © 2005 Man                       | ACA SOCIAL |  
| able condition.   |
|-------------------|  
¶ HE SEROTONIN SYNDROME IS A POTENTIALLY LIFE-THREATENING AD-
verse drug reaction that results from therapeutic drug use, intentional self-poisoning, or inadvertent interactions between drugs. Three features of the serotonin syndrome are critical to an understanding of the disorder. First, the serotoning syndrome is not an idiopathic drug reaction; it is a predictable consequence of excess serotonergic agonism of central nervous system (CNS) receptors and peripheral serotonergic receptors.¹ ,² Second, excess serotonin produces a spectrum of clinical findings. 3 Third, clinical manifestations of the serotonin syndrome range from barely perceptible to lethal. The death of an 18-year-old patient named Libby Zion in New York City more than 20 years ago, which resulted from coadminstration of meperidine and phenelzine, remains the most widely recognized and dramatic example of this prevent-
appendix e publication on serotonin
definition and epidemiology

The seroton in syndrome is often describedas a dinical triad of mental-status changes, autonomichyperactivity, and neuromuscularabnormalities, but not all of these findings are consistently present in all patients with the disorder (Fig. 1). 5,6 Signs of excess serotonin range from tremor and diarrhea in mild cases to delirium, neuromuscular rigidity, and hyperthermia in life-threatening cases. The difficulty for clinicians is that mild symptoms may be easily overlooked, and an inadvertent increase in the dose of the causative agent or the addition of a drug with proserotonergic effects may provoke a dramatic clinical deterioration.  
The incidence of the serotonin syndrome is thought to mirror the increasing number of proserotonergic agents being used in clinical practice. 7 In 2002, the Toxic Exposure Surveillance System, which receives case descriptions from office-based practices, inpatient settings, and emergency departments, reported 26,733 incidences of exposure to selective serotonin-reuptake inhibitors (SSRIs) that caused significant toxic effects in 7349 persons and resulted in 93 deaths. 8,9 The assessment of the serotonin syndrome in therapeutic drug dosing has relied on post-marketing surveillance studies, one of which identified an incidence of 0.4 case per 1000 patient-months for patients who were taking nefazodone. 10 Performing a rigorous epidemiologic assessment of the serotonin syndrome, however, is difficult, since more than 85 percent of physicians are unaware of the serotonin syndrome as a dinical diagnosis. 20 The syndrome occurs in approximately 14 to 16 percent of persons who overdose on SSRIs. 8 Although the seroton in syndrome has occurred in a broad range of clinical environments, several barriers limit the ability of clinicians to diagnose the condition. First, the syndrome may be missed because ofits protean manifestations. Clinicians and patients may dismiss symptoms such as tremor with diarrhea or hypertension as inconsequential or unrelated to drug therapy; anxiety and akathisia may be misattributed to the patient's mental state. 5,10 Second, a strict application of the diagnostic criteria proposed N ENGLJ MED 352;11  WWW.NEJM.ORG   MARCH 17, 2005.  
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by Sternbach potentially rules out what are now recognized as mild, early, or subacute cases of the disorder. 1,11 Third, clinicians cannot diagnose a condition of which they are unaware, even though the serotonin syndrome is not rare and has been identified in patients of all ages, including the elderly, children, and newborn infants. 10 , 12 -14 A striking number of drugs and drug combinations have been associated with the serotonin syndrome (Table 1). These include monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, SSRIs, opiate analgesics, over-the-counter cough medicines, antibiotics, weight-reduction agents, antiemetics, antimigraine agents, drugs of abuse, and herbal products; the withdrawal of medications has also been associated with the syndrome. 1,4,12,15-23 Asingle therapeutic dose of an SSRI has caused the serotonin syndrome. 12 Moreover, the addition of drugs that inhibit cytochrome isoforms CYP2D6 and CYP3A4 to therapeutic SSRI regimens has been associated with the condition. 16,24,25 Administration of serotonergic agents with in five weeks after the discontinuation of fluoxetine therapy has produced a drug interaction culminating in the serotonin syndrome, presumably the result of the demethylation offluoxetine to norfluoxetine, a serotonergic metabolite with a longer serum half-life than its parent compound. 13 Specific drugs, such as MAOIs that are irreversible or nonselective or that inhibit monoamine oxidase subtype A, are strongly associated with severe cases of the syndrome, especially when these agents are used in combination with meperidine, dextromethorphan, SSRIs, or methylenedioxymethamphetamine (MDMA, or "ecstasy"). 4,8,15,26,27
appendix e publication on serotonin
m a n i f

The serotonin syndrome encompasses a range of clinical findings. Patients with mild cases may be afebrile but have tachycardia, with a physical examination that is notable for autonomic findings such as shivering, diaphoresis, or mydriasis (Fig. 2). The neurologic examination may reveal intermittent tremor or myoclonus, as well as hyperreflexia.  
A representative example of a moderate case of the serotonin syndrome involves such vital-sign abnormalities as tachycardia, hypertension, and hyperthermia. A core temperature as high as 40°C is common in moderate intoxication. Common features of the physical examination are mydriasis, hyperactive bowel sounds, diaphoresis, and normal  
  
Manifestations of the serotonin syndrome range from mild to life-threatening. The vertical arrows suggest the approximate point at which clinical findings initially appear in the spectrum of the disease, but all findings may not be consistently present in a single patient with the serotonin syndrome. Severe signs may mask other clinical findings. For example, muscular hypertonicity can overwhelm tremor and hyperreflexia.  
skin color. Interestingly, the hyperreflexia and clonus seen in moderate cases may be considerably greater in the lower extremities than in the upper extremities; patellar deep-tendon reflexes often demonstrate clonus for several seconds after a single tap of the tendon, whereas the brachioradialis reflex is only slightly increased. Patients may exhibit horizontal ocular clonus. Changes in mental status include mild agitation or hypervigilance, as well as slightly pressured speech. Patients may easily startle or adopt a peculiar head-turning behavior characterized by repetitive rotation of the head with the nck held in moderate extension.  
In contrast, a patient with a severe case of the serotonin syndrome may have severe hypertension and tachycardia that may abruptly deteriorate into frank shock. Such patients may have agitated delirium as well as muscular rigidity and hypertonicity.  
Again, the increase in musde tone is considerably greater in the lower extremities. The muscle hyperactivity may produce a core temperature of more than 41.1°C in life-threatening cases. Laboratory abnormalities that occur in severe cases include metabolic acidosis, rhabdomyolysis, elevated levels of serum aminotransferase and creatinine, seizures, renal failure, and disseminated intravascular coagulopathy. Many of these abnormalities arise, however, as a consequence of poorly treated hyperthermia.  
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| Table 1. Drugs and Drug Interactions Associated with the Serotonin             |
|--------------------------------------------------------------------------------|
| Syndrome,                                                                      |
| Drugs associated with the serotonin syndrome                                   |
| Selective serotonin-reuptake inhibitors: sertraline, fluoxetine, fluvoxamine,  |
| paroxetine, and citalopram                                                     |
| Antidepressant drugs: trazodone, nefazodone, buspirone, clomipramine,          |
| and venlafaxine                                                                |
| Monoamine oxidase inhibitors: phenelzine, moclobemide, clorgiline,             |
| and isocarboxazid                                                              |
| Anticonvulsants: valproate                                                     |
| Analgesics: meperidine, fentanyl, tramadol, and pentazocine                    |
| Antiemetic agents: ondansetron, granisetron, and metoclopramide                |
| Antimigraine drugs: sumatriptan                                                |
| Bariatric medications: sibutramine                                             |
| Antibiotics: linezolide (a monoamine oxidase inhibitor) and ritonavir          |
| (through inhibition of cytochrome P-450 enzyme isoform 3A4)                    |
| Over-the-counter cough and cold remedies: dextromethorphan                     |
| Drugs of abuse: methylenedicxymethamphetamine (MDMA, or "ecstasy"),            |
| lysergic acid diethylamide (LSD), 5-methoxydiisopropyltryptamine ("foxy        |
| methoxy"), Syrian rue (contains harmine and harmaline, both                    |
| monoamine oxidase inhibitors)                                                  |
| Dietary supplements and herbal products: tryptophan, Hypeticum perforatum      |
| (St. John's wort), Panax ginseng (ginseng)                                     |
| Other: lithium                                                                 |
| Drug interactions associated with severe serotonin syndrome                    |
| Zoloft, Prozac, Sarafem, Luvox, Paxil, Celexa, Desyrel, Serzone, Buspar, Anaf- |
| ranil, Effexor, Nardil, Manerix, Marplan, Depakote, Demerol, Duragesic,        |
| Sublimaze, Ultram, Talwin, Zofran, Kytril, Reglan, Imitrex, Meridia, Redux,    |
| Pondimin, Zyvox, Norvir, Parnate, Tofranil, Remeron                            |
| Phenelzine and meperidine                                                      |
| Tranylcypromine and imipramine                                                 |
| Phenelzine and selective serotonin-reuptake inhibitors                         |
| Paroxetine and buspirone                                                       |
| Linezolide and citalopram                                                      |
| Moclobemide and selective serotonin-reuptake inhibitors                        |
| Tramadol, venlafaxine, and mirtazapine                                         |  
To better delineate the signs and symptoms that define the serotonin syndrome, the clinical findings in 2222 consecutive cases of self-poisoning with serotonergic drugs were rigorously assessed on the basis of information from a detailed toxicology registry. 2 These findings were then compared with the
"gold standard," the assignment of a diagnosis of the serotonin syndrome by a medical toxicologist. 2 The clinical findings that had a statistically significant as sociation with the diagnosis of the syndrome were primarily neuromuscular, including hyperreflexia, inducible clonus, myoclonus, ocular clonus, spontaneous clonus, peripheral hypertonicity, and shivering. 2 Autonomic derangements were tachycardia on admission, mydriasis, diaphoresis, and the presence of bowel sounds and diarmea. 2 Abnormalities in mental status that were significantly associated with the serotonin syndrome were agitation and delirium. 2 Hyperthermia that was a caused by muscular hypertonicity, defined in this study as a temperature of more than 38°C, was not as strongly associated with the diagnosis of the serotonin syndrome but occurred in severely intoxicated patients. 2 The onset of symptoms is usually rapid, with clinical findings often occurring within minutes after a change in medication or self-poisoning. 28 Approximately 60 percent of patients with the serotonin syndrome present within six hours after initial use of medication, an overdose, or a change in dosing. 28 Patients with mild manifestations may present with subacute or chronic symptoms, whereas severe cases may progress rapidly to death. The serotonin syndrome is not believed to resolve spontaneously as long as precipitating agents continue to be administered.
appendix e publication on serotonin
pathophysiology and molecular mechanisms

Serotonin is produced by the decarboxylation and hydroxylation of L -tryptophan. Its quantity and actions are tightly regulated by a combination of reuptake mechanisms, feedback loops, and metabolizing enzymes (Fig. 3). Serotonin receptors are divided into seven 5-hydroxytryptamine (5-HT)
families (5-HT 1 to 5-HT 7 ), several of which have multiple members (e.g., 5-HT 1A , 5-HT 1B , 5-HT 1C, 5-HT 1 D , 5-HT 1 E , and 5-HT 1 B ). Further structural and operational diversity is achieved by allelic polymorphisms, splice variants, receptor isoforms, and the formation of receptor heterodimers. 29 Serotonergic neurons in the CNS are found primarily in the midline raphe nuclei, located in the brain stem from the midbrain to the medulla. 30 The rostral end of this system assists in the regulation of wakefulness, affective behavior, food intake, thermoregulation, migraine, emesis, and sexual behavior. 30 The neurons of the raphe in the lower pons and medulla participate in the regulation of nociception and motor tone. 30 In the periphery, the serotonin system assists in the regulation of vascular tone and gastrointestinal motility. 30 No single receptor appears to be responsible for the development of the serotonin syndrome, although several lines of evidence converge to suggest that agonism of 5-HT 2A receptors contributes substantially to the condition. 31 -35 Additional subtypes of serotonin receptors, such as 5-HT 1 A, may contribute through a pharmacodynamic interaction in which increased synaptic concentrations of serotonin agonist saturate all receptor subtypes. Noran englj med 352;11  www.nejm.org   march 17, 2005.  
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drenergic CNS hyperactivity may play a critical role, since the degree to which CNS norepine phrine concentrations are increased in the serotonin syndrome maycorrelatewiththeclinicaloutcome3335,36Other neurotransmitters, including N -methyl- D -aspartate (NMDA) receptor antagonists and y-aminobutyric acid (GABA), may affect the development of the syndrome, but the role of these agents is less clear. 33,37 Dopaminergic receptors have been implicated, but this association may arise from pharmacodynamic interactions, direct interactions between serotonin and dopamine receptors, other mechanisms, or a misdiagnosis of the serotonin syndrome as the neuroleptic malignant syndrome. 26,33,38,39
appendix e publication on serotonin
diagnosis

No laboratory tests confirm the diagnosis of the serotonin syndrome. Instead, the presence of tremor, donus, or akathisia without additional extrapyramidal signs should lead dinicians to consider the diagnosis, which must be inferred from the patient's history and physical examination. When obtaining the patient's history, clinicians should inquire about the use of prescription and over-thecounter drugs, illicit substances, and dietary supplements, since all of these agents have been implicated in the development of the serotonin syndrome. The evolution of symptoms and their rate of changeshould also be reviewed. Physical examination should include a focused assessment of deep-tendon reflexes, clonus, and muscle rigidity, in addition to an evaluation of the size and reactivity of the pupils, the dryness of the oral mucosa, the intensity of bowel sounds, skin color, and the presence or absence of diaphoresis.  
Although several diagnostic criteria have been developed, we prefer the decision rules described in Figure 4.2,11,14,40 These rules, when compared with the original diagnostic criteria, are simpler, more sensitive (84 percent vs. 75 percent), and more specific (97 percent vs. 96 percent) for diagnosing the serotonin syndrome. 1 -2 Clonus (inducible, spontanous, and ocular) is the most important finding in establishing the diagnosis of the serotonin syndrome 2 , 27 , 41 Clinicians should always be aware N ENGL J MED 352:11   www.nejm.org   march 17, 2005 Stanford University Medical Center  
  
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Serotonin is produced in presynaptic neurons by hydroxylation and decarboxylation of L -tryptophan. Serotonin is then incorporated into vesicles, where it resides until it is needed for neurotransmission. After axonal stimulation, serotonin is released into the intrasynaptic space; presynaptic serotonin receptors function as a feedback loop to inhibit exocytosis of vesicles (shown in red).  
Serotonin then binds to postsynaptic receptors to effect neurotransmission.  
A reuptake mechanism returns serotonin to the cytoplasm of the presynaptic neuron, where it is reintroduced into vesicles. Serotonin is then metabolized by monoamine oxidase subtype A to hydroxyindoleacetic acid.  
that hyperthermia and hypertonicity occur in lifethreatening cases, but muscle rigidity may mask the highly disting us hing findings of clonus  and hyperreflexia and therefore doud the diagnosis. 241 The differential diagnosis includes anticholinergic poisoning, malignant hyperthermia, and the neuroleptic malignant syndrome, each of which can be readily distinguished from the serotonin syndrome on dinical grounds and on the basis of the medication history (Table 2). Patients with the anticholinergic syndrome have normal reflexes and show the "toxidrome" of mydriasis; agitated delirium; dry oral mucosa; hot, dry, erythematous skin; urinary retention; and an absence of bowel sounds.  
Hyperactive bowel sounds - along with neuromuscular abnormalities, diaphoresis, and normal skin color - distinguish the serotonin syndrome from the anticholinergic toxidrome. 2 Malignant hyperthermia is a pharmacogenetic disorder characterized by increasing concentrations of end-tidal carbon dioxide, hypertonicity, hyperthermia, and metabolic acidosis. The disorder occurs within minutes after exposure to inhalational anesthetic agents. 43 On physical examination, the skin is often mottled, with cyanotic areas contrasting with patches of bright red flushing. *3 The rigor mortis–like rigidity of skeletal muscles and hyporeflexia that are seen in malignant hyperthermia further distinguish this condition from the serotonin syndrome. 53 The neuroleptic malignant syndrome is an idiopathic reaction to dopamine antagonists, a condition that is defined by a slow onset, bradykinesia or akinesia, "lead pipe" muscular rigidity, hyperthermia, fluctuating consciousness, and autonomic instability. 44 Signs and symptoms of the neuroleptic malignant syndrome typically evolve during several days, in contrast to the rapid onset and hyperkinesia of the serotonin syndrome. Knowledge of the precipitating drug also helps in distinguishing between dopamine antagonists syndromes:
produce bradykinesia, whereas serotonin agonists produce hyperkinesia. 55
appendix e publication on serotonin
management

Management of the serotonin syndrome involves the removal of the precipitating drugs, the provision of supportive care, the control of agitation, the administration of 5-HT A antagonists, the control of autonomic instability, and the control of hyperthermia. 45 Many cases of the serotonin syndrome typically resolve within 24 hours after the initiation of therapy and the discontinuation of serotonergic drugs, but symptoms may persist in patients taking drugs with long elimination half-lives, active metab1116 N ENGL J MED 352:11   www.nejm.org    march 17, 2005  
  
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olites, or a protracted duration of action. Supportive care, comprising the administration of intravenous fluids and correction of vital signs, remains a mainstay of therapy. However, an abrupt deterioration in the condition of a patient who has been conservatively treated indicates the need for an immediate, aggressive response. 1,2,45 The intensity of therapy depends on the severity of illness. Mild cases (e.g., with hyperreflexia and tremor but no fever) can usually be managed with supportive care, removal of the precipitating drugs, and treatment with benzodiazepines. Moderately ill patients should have all cardiorespiratory and thermal abnormalities aggressively corrected and may benefit from the administration of 5-HT 2 A
antagonists. Hyperthermic patients (those whose temperature is more than 41.1°C) are severely ill and should receive the above therapies as well as immediate sedation, neuromuscular paralysis, and orotracheal intubation.  
Control of agitation with benzodiazepines is essential in the management of the serotonin syndrome, regardless of its severity. Benzodiazepines such as diazepam improve survival in animal models and blunt the hyperadrenergic component of the syndrome. 37,45 Physical restraints are ill-advised and may contribute to mortality by enforcing isometric muscle contractions that are associated with severe lactic acidosis and hyperthermia. 46 If physical restraints are used, they must be rapidly replaced with chemical sedation.  
Pharmacologically directed therapy involves the N ENGL J MED 352:11   www.nejm.org   march 17, 2005  
  
N ENGL J MED 352:11   www.nejm.org    march 17, 2005 administration of 5-HT A antagonists. 7:45 Cyproheptadine is the recommended therapy for the serotonin syndrome, although its efficacy has not been rigorously established. 7:45 Treatment of the serotonin syndrome in adults may require 12 to 32 mg of the drug during a 24-hour period, a dose that binds 85 to 95 percent of scrotonin receptors. 47 Clinicians should consider an initial dose of 12 mg of cyproheptadine and then 2 mg every two hours if symptoms continue. Maintenance dosing involves the administration of 8 mg of cyproheptadine every six hours. Cyproheptadine is available only in oral form, but tablets may be crushed and adm inistered by nasogastric tube. Atypical antipsychotic agents with 5-HT 2A –antagonist activity may be beneficial in treating the serotonin syndrome. The sublin gual administration of 10 mg of olanzapine has been used successfully, but its efficacy has not been rigorously determined. 48 Clinicians desiring a parenteral agent should consider the intramuscular administration of 50 to 100 mg of chlorpromazine. 45 Even though chlorpromazine is an outdated therapy that has been replaced in psychiatric practice by newer agents, its use may nonetheless be considered in severe cases. 45 Control of autonomic instability involves stabilization offluctuating pulse and blood pressure. Hypotension arising from MAOI interactions should be treated with low doses of direct-acting sympathomimetic amines (e.g., norepinephrine, phenylephrine, and epinephrine). Direct agonists do not require intracellular metabolism to generate a vasoactive amine, but their concentration in the synapse is regulated by catecholamine-O-methyl transferase. Indirect agents such as dopamine are metabolized to epinephrine and norepinephrine.  
Under normal conditions, monoamine oxidase limits the intracellular concentration of these metabolites. When inhibited, however, monoamine oxidase cannot control the amount of epinephrine and norepinephrine produced, and an exaggerated hemodynamic response may ensue. Patients in whom hypertension and tachycardia develop, either as a result of pressor therapy or from poisoning itself, should be treated with short-acting agents such as nitroprusside and esmolol.  
Control of hyperthermia involves eliminating excessive musde activity. Although benzodiazepines have a beneficial effect in moderate cases, in severely ill patients with hyperthermia (a temperature of more than 41.1°C) immediate paralysis should be induced with nondepolarizing agents such as ve-
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curonium, followed by orotracheal intubation and Antagonist therapy with the use of cyproheptaventilation. Clinicians should avoid succinylcholine dine and chlorpromazine may have unintended efbecause of the risk of arrhythmia from hyperkalefects. The dosage of cyproheptadine used to treat the mia associated with rhabdomyolysis. Recent case serotonin syndrome may cause sedation, but this reports have shown that premature termination of effect is a goal of therapy and should not deter clineuromuscular paralysis was associated with a renicians from using the drug. Chlorpromazine is an outmoded drug that has been associated with secrudescence of hyperthermia. 49 There is no role for antipyretic agents in the management of the serovere orthostatic hypotension and has been thought to aggravate hyperthermia. Patients who require tonin syndrome; the increase in body temperature is due to muscular activity, not an alteration in the acute parenteral therapy for the serotonin syndrome hypothalamic temperature set point.  
are often hypertensive and are not ambulatory, so Potential pitfalls for clinicians include misdiagthat the risk of orthostatic hypotension is mininosis of the serotonin syndrome, a failure to commized. Hyperthermia in response to neuroleptic prehend its rapidity of progression, and adverse efadministration is an idiopathic response; the norfects of pharmacologically directed therapy. The mal outcome is hypothermia. Nonetheless, chlordiagnosis may be clouded by the presence of severe promazine should not be administered to a patient musclerigiditythatobscuresmyoclonusandhyperwith hypotension or the neuroleptic malignant synreflexia. If the correct diagnosis is not obvious, a drome, since the drug could potentially exacerbate prudent course is to withhold antagonist therapy dinical findings.  
and provide aggressive supportive care, sedation with benzodiazepines, and, if necessary, intubation PREVENTION
and paralysis. 7 Because of the speed with which the condition of patients declines, physicians should The serotonin syndrome can be avoided by a comanticipate the need for aggressive therapy before bination of pharmacogenomic research, the educaclinical indications are reached.  
tion of physicians, modifications in prescribing Therapies such as propranolol, bromocriptine, practices, and the use of technological advances.  
and dantrolene are not recommended. 7,45 Propran-
The application of pharmacogenomic principles olol, a 5-HT 1 A antagonist with a long duration of accan potentially protect patients at risk for the syntion, may cause hypotension and shock in patients drome before the administration of serotonergic with autonomic instability. Furthermore, propraagents. Once toxicity occurs, consultation with a nolol can abolish tachycardia that can be used to medical toxicologist, a dinical pharmacology serdetermine the duration and effectiveness of theravice, or a poison-control center can identify proseropy. ² Bromocriptine, a dopamine agonist, and tonergic agents and drug interactions, assist clinidantrolene are not useful therapies; case reports cians in anticipating adverse effects, and provide citing their use probably involved a misdiagnosis valuable clinical decision-making experience. The of another condition as the serotonin synavoidance of multidrug regimens is critical to the drome. 7,35,45 Bromocriptine has been implicated prevention of the serotonin syndrome. If multiple in the development of the serotonin syndrome, and agents are required, however, computer-based orits use in patients in whom the neuroleptic maligdering systems and the use of personal digital assistants can detect drug interactions and decrease nant syndrome is misdiagnosed may worsen serotonergic signs. 27,50 According to one report, the reliance on memory in drug ordering. Post-marketadm inistration of bromocriptine and dantrolene to ing surveillance linked to physician education has a patient with the serotonin syndrome caused an been proposed to improve awareness of the scrotoabrupt increase in temperature, culminating in n syndrome. 11 death. 39 This finding is supported by the observa-
Supported in part by a grant from the National Institute on Drug Abuse (DA-14929, to Dr. Boyer).  
tion that dantrolene has no effect on survival in animal models. 34 , 35  
| R E F E R E N C E S                     |                                                                                           |                                        |
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| 1. Sternbach H. The serotonin syndrome. | nin Toxicity Criteria: simple and accuratedi- fects of tryptophan in patients receiving a |                                        |
| Am J Psychiatry 1991;148:705-13.        | agnostic decision rules for serotonin toxici-                                             | monoamine oxidase inhibitor. Neurology |
| 2. Dunkley EJ, Isbister GK, Sibbritt D, | ty. QJM 2003;96:635-42.                                                                   | 1960;10:1076-8.                        |
| Dawson AH, Whyte IM. The Hunter Seroto- | 3. Oates JA, Sjoerdsma A. Neurologic ef-                                                  | 4. Asch DA, Parker RM. The Libby Zion  |  
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the serotonin syndrome, and serotonergic neurotoxicity. Pharmacol Biochem Behav 2002;71:837-44. 16. Lee DO, Lee CD. Serotonin syndrome in a child associated with erythromycin and sertraline. Pharmacotherapy 1999;19:89417. Gardner MD, Lynd LD. Sumatriptan contraindications and the sexotonin syndrome. Ann Pharmacother 1998;32:33-8. 18. Giese SY, Neborsky R, Semanin syndrome; potential consequences of Meridia combined with demerol or fentanyl. Plast Reconstr Surg 2001;107:293-4. 19. DeSilva KE, Le Flore DB, Marston BJ, Rimland D. Serotonin syndrome in HIV-
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CURRENT CONCEPTS
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| a potential combination for severe adverse   |
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| Ractions. J Psychoactive Drugs 1998;30:      |
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Hemke C, Mann K. Serotonin syndrome as a result of finonetine in a patient with tramadol abuse plasma level-correlated symptomatology J Clin Psychopharmacol 2002; nt 5-HT2A receptors using antisense oligo-  
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35. Nisijima K, Yoshino T, Yui K, Kamh S.  
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| 3. Nisijima K, Shioda K, Yoshino T, Takano   |
| K, Kato S. Memantine, an NMDA antago-        |
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47. Kapur S, Zipursky RB, Jones C, Wilson AA, DaSilva JD, Houle S. Cyproheptadine:
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N ENGL J MED 352:11   www.nejm.org    march 17, 2005
appendix e publication on serotonin
14.6. appendix f administration of

Administration of pembrolizumab will be witnessed by the investigator and/or site staff. The total volume of study treatment infused will be compared to the total volume prepared to determine compliance with each dose administered. On day 1 of every cycle subjects will receive a 200 mg flat dose of pembrolizumab on an every3-week schedule; this is 2 vials of 100 mg/4mL per infusion. Intrasubject dose escalation of pembrolizumab is not permitted.  
Formulation and administration instructions for pembrolizumab are provided below.  
- Pembrolizumab infusion solutions should be prepared in 0.9% Sodium Chloride Injection, USP (normal saline) or 5% Dextrose Injection, USP (5% dextrose) and the final concentration of Pembrolizumab in the infusion solutions should be between 1.0 mg/mL and 10.0 mg/mL.  
- Pembrolizumab SHOULD NOT BE MIXED WITH OTHER RECONSTITUTION
DILUENTS.  
- Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Discard the drug product vial if extraneous particulate matter other than translucent to white proteinaceous particles are observed.  
- Do not use Pembrolizumab if discoloration is observed. - DO NOT SHAKE OR FREEZE THE VIAL(S). - DO NOT ADMINISTER THE PRODUCT AS AN [INTRAVENOUS (IV) PUSH OR
BOLUS].  
- DO NOT COMBINE, DILUTE OR ADMINISTER THE PRODUCT AS AN INFUSION
WITH OTHER MEDICINAL PRODUCTS.  
Preparation of Infusion Solution
- Aseptic technique must be strictly observed throughout the preparation procedure preferably in a biologic safety cabinet or hood since no anti-microbial preservative is present in the solutions.  
- Equilibrate required number of Pembrolizumab vials to room temperature  
  
  
- Choose a suitable infusion bag size so that the following conditions are met:
o Concentration of Pembrolizumab is between 1.0 mg/mL and 10.0 mg/mL
o The infusion volume to bag capacity ratio should not be less than 0.3. In other words, the bag must be filled to at least 30% of its capacity.  
- Choose a suitable infusion bag material. The bag may be empty or it may contain normal saline The following infusion bag materials are compatible with Pembrolizumab:
- PVC plasticized with DEHP
- Non-PVC (polyolefin)
- EVA
- PE lined polyolefin
*Contact Sponsor for materials not listed above
- Calculate the volume of Pembrolizumab and normal saline required to prepare the infusion
(admixture) bag Volume of Pembrolizumab (mL) = required dose amount (mg) / 25.0 (mg/mL) Volume of normal saline = total infusion volume - volume of Pembrolizumab from above
- If a bag pre-filled with normal saline is being used, remove the excess volume of normal saline using a sterile syringe (Polypropylene, latex-free) attached to a suitable needle. Keep in consideration the excess bag fill volume as well as the volume of reconstituted Pembrolizumab to be added to the bag to prepare the infusion solution.  
- If an empty bag is being used, withdraw the necessary volume of normal saline from another appropriate bag and inject into the empty bag. Keep in consideration the volume of reconstituted Pembrolizumab to be added to the bag to prepare the infusion solution.  
- Withdraw the required volume of Pembrolizumab from the vial(s) (up to 4 mL from each  
  
  
vial) using a sterile syringe attached to a suitable needle. The vial(s) may need to be inverted to remove solution.  
Volume of Pembrolizumab (mL) = required dose amount (mg) / 25.0 (mg/mL)
Note: If it is necessary to use several vials, it is advisable to withdraw from several vials into a suitable size single use syringe using a new needle for each vial.  
- Add the required Pembrolizumab into the infusion IV bag containing normal saline and gently invert the bag 10-15 times to mix the solution.  
Infusion Instructions
- Pembrolizumab infusions should be administered over a period of 30 minutes, with a window of -5 and +10 minutes, using an infusion pump. A central catheter is not required for infusion; however if a subject has a central venous catheter in place, it is recommended that it be used for the infusion. The following infusion set materials are compatible with Pembrolizumab:
o PVC Infusion set that is plasticized using DEHP
o PVC and tri-(2-ethylhexyl) trimellitate (TOTM) infusion set o Polyethylene lined PVC infusion set o PVC Infusion set that is plasticized using Di-2-ethylhexyl Terephthalate (DEHT)
o Polyurethane set
- A sterile, non-pyrogenic, low-protein binding 0.2 to 5 µm in-line-filter made of polyethersulfone (PES) must be used during administration to remove any adventitious particles. If the infusion set does not contain 0.2 to 5 µm in-line filter, it is recommended to use 0.2 to 5 µm add-on filter which may contain an extension line (Note: the materials of the extension line and filter should be as mentioned above).  
- Attach the infusion line to the pump and prime the line, either with normal saline (at least 25 mL) or with infusion solution as per local SOP, before starting the infusion.  
- Infuse Pembrolizumab over approximately 30 minutes, with a window of -5 and +10  
  
  
  
minutes, through a peripheral line or indwelling catheter.  
o Whenever possible, the lowest infusion rate should be used that will allow completion of the infusion within the 30 minutes o Maximum rate of infusion should not exceed 6.7 mL/min. through a peripheral line or indwelling catheter. However, when it is necessary to infuse a larger volume (i.e. 250 mL), the flow rate may go as high as 10 mL/mL (maximum) in order to keep the infusion within the window as defined above.  
- Use 30 mL normal saline to flush the infusion line at the end of infusion. If institutional guidelines do not allow the flushing of the infusion line at the completions of the infusion, please prepare excess volume of drug/diluent admixture solution that is required to make up for the volume of the dosing solution lost in the infusion line. For example if a subject is receiving 100 mL IV infusion and it is known that 18mL will be left in the infusion line since the line is not flushed, the pharmacist should prepare 118 mL of drug/diluent admixture solution in a 200 mL bag to make sure that the 100 mL will be delivered to the subject.  
- DO NOT CO-ADMINISTER OTHER DRUGS THROUGH THE SAME INFUSION LINE.  
- UNUSED INFUSION SOLUTION FOR INJECTION SHOULD NOT BE USED FOR
ANOTHER INFUSION OF THE SAME SUBJECT OR DIFFERENT SUBJECT.  
- Discard any unused portion left in the vial, as the product contains no preservative.  
Stanford University Medical Center  
  
A NATIONAL CANCER INSTITUTE-DESIGNATED CANCER CENTER  
  
14.7.
appendix g temperature and light
epacadostat

Temperature Excursion Report Form After completion, email this page together with the Site Temperature Log or TempTale downloaded data immediately to the tempex@incyte.com mailbox and copy the following Sponsor contacts:  Jennifer Kelley (ikelley@incyte.com), Jennifer Davis
( jdavis@incyte.com ) and Mark Goetz ( mgoetz@incyte.com )
appendix g temperature and light
incyte

PAREXEL
1. To be filled out by INVESTIGATIONAL CENTER STAFF:
In the event of temperature excursion during storage of study drug at your investigational center, please complete all fields INC8024360 bottles: Store at room temperature (15-30°C)
MK-3475 vink; Store between 2-8 Degrees Celsius | Reconstituted if not used immediately should be stored between 2-8 Degrees Celsius up to 20 hours and allowed to equilibrate to room temperature prior to subsequent use. MK-3475 solutions may be stored at room temperature for a cumulative time of up to 4 hours. This includes room temperature storage of reconstituted or liquid MK-3475 solution in vials, room temperature  
  
Based on the information provided please evaluate the temperature excursion data provided and confirm
whether the affected product can be used / must be discarded.  
  
IMPORTANT PXL CRA: Please ensure that response from sponsor is filed along with this Form in Investigator Site File and in PMED
217153_Temperature_Excursion_Form_V3.0 version date: 25Jun15    page 1 of 1   /  Incyte Corporation. / INCB 24360-202
appendix g temperature and light
14.8. appendix h definition of

14.8.1. Definition Of Tumor Response Using Irrc  
The sum of the products of diameters at tumor assessment using the irRC for progressive disease incorporates the contribution of new measurable lesions. Each net percentage change in tumor burden per assessment using irRC criteria accounts for the size and growth kinetics of both old and new lesions as they appear.
appendix g temperature and light
14.8.2. definition of index lesions

- **irComplete Response (irCR):** Complete disappearance of all index lesions. This category encompasses exactly the same subjects as "CR" by the mWHO criteria.  
- **irPartial Response (irPR):** Decrease, relative to baseline, of 50% or greater in the sum of the products of the two largest perpendicular diameters of all index and all new measurable lesions (i.e., percentage change in tumor burden). Note: the appearance of new measurable lesions is factored into the overall tumor burden, but does not automatically qualify as progressive disease until the SPD increases by ≥ 25% when compared to SPD at nadir.  
- **irStable Disease (irSD):** Does not meet criteria for irCR or irPR, in the absence of progressive disease.  
- **irProgressive Disease (irPD):** At least 25% increase percentage change in tumor burden (i.e., taking sum of the products of all index lesions and any new lesions) when compared to SPD at nadir.  
14.8.3. **Definition of Non-Index Lesions Response Using irRC**
- **irComplete Response (irCR):** Complete disappearance of all non-index lesions. This category encompasses exactly the same subjects as "CR" by the mWHO criteria.  
- **irPartial Response (irPR) or irStable Disease (irSD):** non-index lesion(s) are not considered in the definition of PR, these terms do not apply.  
- **irProgressive Disease (irPD):** Increases in number or size of non-index lesion(s)
does not constitute progressive disease unless/until the percentage change in tumor burden increases by 25% (i.e., the SPD at nadir of the index lesions increases by the required amount).  
14.8.4. **Impact of New Lesions on irRC**
New lesions in and by themselves do not qualify as progressive disease. However their contribution to total tumor burden is included in the SPD which in turn feeds into the irRC criteria for tumor response. Therefore, new non-measurable lesions will not discontinue any  
  
 subject from the study.  
14.8.5. **Definition of Overall Response Using irRC**
Overall response using irRC will be based on these criteria:
- **Immune-Related Complete Response (irCR):** Complete disappearance of all tumor lesions (index and nonindex together with no new measurable/unmeasurable lesions) for at least 6 weeks from the date of documentation of complete response.  
- **Immune-Related Partial Response (irPR):** The sum of the products of the two largest perpendicular diameters of all index lesions is measured and captured as the SPD baseline. At each subsequent tumor assessment, the sum of the products of the two largest perpendicular diameters of all index lesions and of new measurable lesions are added together to provide the Immune Response Sum of Product Diameters (irSPD). A decrease, relative to baseline of the irSPD compared to the previous SPD baseline, of 50% or greater is considered an irPR.  
- **Immune-Related Stable Disease (irSD):** irSD is defined as the failure to meet criteria for immune complete response or immune partial response, in the absence of progressive disease.  
- **Immune-Related Progressive Disease (irPD):** It is recommended in difficult cases to confirm PD by serial imaging. Any of the following will constitute progressive disease:
o At least 25% increase in the sum of the products of all index lesions over baseline SPD calculated for the index lesions.  
o At least a 25% increase in the sum of the products of all index lesions and new measurable lesions (irSPD) over the baseline SPD calculated for the index lesions.  
| 14.8.6.               | Immune-Related Response Criteria Definitions Percent change in  tumor burden  (including  measurable new  lesions when present)   |      |     |                |      |
|-----------------------|-----------------------------------------------------------------------------------------------------------------------------------|------|-----|----------------|------|
| NonIndex  Lesion                       |                                                                                                                                   |      |     |                |      |
| Definition            |                                                                                                                                   |      |     |                |      |
| Index  Lesion         |                                                                                                                                   |      |     |                |      |
| Definition            | New                                                                                                                               |      |     |                |      |
| Measurable  Lesions   | New                                                                                                                               |      |     |                |      |
| Unmeasurable  Lesions | Overall  irRC  Response                                                                                                           |      |     |                |      |
| Complete              | Complete                                                                                                                          | No   | No  | -100%          | irCR |
| Response              | Response                                                                                                                          |      |     |                |      |
| Partial               | Any                                                                                                                               | Any  | Any | > -50%         | irPR |
| Response              | <-50% to <+25%                                                                                                                    | irSD |     |                |      |
| >+25%                 | irPD                                                                                                                              |      |     |                |      |
| Stable                | Any                                                                                                                               | Any  | Any | <-50% to <+25% | irSD |
| Disease               | >+25%                                                                                                                             | irPD |     |                |      |
| Progressive           | Any                                                                                                                               | Any  | Any | >+25%          | irPD |
| Disease               |                                                                                                                                   |      |     |                |      |
appendix g temperature and light
14.8.7. immune-related best overall response

irBOR is the best confirmed irRC overall response over the study as a whole, recorded between the date of first dose until the last tumor assessment before subsequent therapy (except for local palliative radiotherapy for painful bone lesions) for the individual subject in the study. For the assessment of irBOR, all available assessments per subject are considered. irCR or irPR determinations included in the irBOR assessment must be confirmed by a second (confirmatory) evaluation meeting the criteria for response and performed no less than 6 weeks after the criteria for response are first met.