Phase Ib/II Investigator Initiated Study of the IDH1-mutant inhibitor ivosidenib (AG120) with the BCL2 inhibitor venetoclax +/- azacitidine in IDH1-mutated hematologic malignancies

This phase Ib/II trial studies the side effects and best dose of venetoclax and how well
it works when given together with ivosidenib with or without azacitidine, in treating
patients with IDH1-mutated hematologic malignancies. Venetoclax and ivosidenib may stop
the growth of cancer cells by blocking some of the enzymes needed for cell growth. Drugs
used in chemotherapy, such as azacitidine, work in different ways to stop the growth of
cancer cells, either by killing the cells, by stopping them from dividing, or by stopping
them from spreading. Giving ivosidenib and venetoclax with azacitidine may work better in
treating patients with hematologic malignancies compared to ivosidenib and venetoclax
alone.

Inclusion Criteria:

1. Age > 18 years.

2. ECOG performance status of < 2.

3. IDH1-R132 mutated disease status as assessed by local laboratory. 2HG-producing IDH1
variants outside of R132 (i.e. R100) may be eligible after discussion with the PI.

4. Relapsed/refractory AML, or treatment-naïve patients with AML who are not eligible
for standard induction chemotherapy. Patients with high-risk MDS, MDS/MPN or MPN
(defined as > 10% bone marrow blasts, or intermediate or high risk by IPSS, R-IPSS
or D-IPSS) that have failed standard therapy may also be eligible after discussion
with the PI.

5. Adequate hepatic function (direct bilirubin < 2 x ULN, ALT and/or AST < 3x ULN)
unless deemed to be related to underlying leukemia.

6. Adequate renal function including creatinine clearance > 30 ml/min based on the
Cockcroft-Gault equation.

7. Willing and able to provide informed consent

8. In the absence of rapidly proliferative disease, the interval from prior treatment
to time of initiation will be at least 7 days for cytotoxic or non-cytotoxic
(immunotherapy) agents.

9. Male subjects must agree to refrain from unprotected sex and sperm donation from
initial study drug administration until 90 days after the last dose of study drug.

Exclusion Criteria:

1. Patients with known allergy or hypersensitivity to ivosidenib or venetoclax.

2. Patients who have previously received either ivosidenib or venetoclax.

3. Patients with any concurrent uncontrolled clinically significant medical condition
including infection, laboratory abnormality, or psychiatric illness, which could
place the patient at unacceptable risk of study treatment.

4. The use of other chemotherapeutic agents or anti-leukemic agents is not permitted
during study with the following exceptions (1) intrathecal chemotherapy for
prophylactic use or for controlled CNS leukemia. (2) use of hydroxyurea and/or one
dose of cytarabine (up to 2 g/m2) for patients with rapidly proliferative disease is
allowed before the start of study therapy and for the first four weeks on therapy.

5. Patients receiving concomitant strong CYP3A inducers (avasimibe, carbamazepine,
phenytoin, rifampin, rifabutin, St. John's wort) within 3 days of start of study
therapy.

6. Patients with active graft-versus-host-disease (GVHD) status post stem cell
transplant (patients without active GVHD on chronic suppressive immunosuppression
and/or phototherapy for chronic skin GVHD are permitted after discussion with the
PI).

7. Patients with any severe gastrointestinal or metabolic condition which could
interfere with the absorption of oral study medications.

8. Patients with a concurrent active malignancy under treatment.

9. QTc interval using Fridericia's formula (QTcF) > 450 msec. Bundle branch block and
prolonged QTc interval are permitted after discussion with the PI.

10. Known active hepatitis B (HBV) or Hepatitis C (HCV) infection or known HIV
infection.

11. Subject has a white blood cell count > 25 x 10⁹/L. (Note: Hydroxyurea is permitted
to meet this criterion.)

12. Nursing women, women of childbearing potential (WOCBP) with positive urine pregnancy
test, or women of childbearing potential who are not willing to maintain adequate
contraception a. Appropriate highly effective method(s) of contraception include
oral or injectable hormonal birth control, IUD, and double barrier methods (for
example a condom in combination with a spermicide).