A Study of Oral Nuvisertib (TP-3654) in Patients with Myelofibrosis

Patients must meet all of the following inclusion criteria to be eligible:

Nuvisertib (TP-3654) Monotherapy Arm:

• Confirmed pathological diagnosis of primary myelofibrosis (PMF) or post-PV-MF/post-ET- MF and intermediate or high-risk primary or secondary MF

• Previously treated with JAK inhibitor(s) and is intolerant, resistant, refractory or has lost response to the JAK inhibitor(s) or is ineligible to be treated with JAK inhibitor

• Fulfill the following clinical laboratory parameters:

• Platelet count ≥ 25 x 10^9 /L, without assistance of growth factors or platelet transfusions

• ANC ≥ 1 x 10^9/L without assistance of granulocyte growth factors

• Peripheral blood blast count < 5%

• ECOG performance status ≤ 1

• Life expectancy ≥ 6 months

• Adequate renal function

• Adequate hepatic function

• Adequate coagulation function

• Splenomegaly (spleen volume of ≥ 450 cm3 by MRI or CT scan) within 2 weeks prior to Cycle 1 Day 1.

• Dose escalation: At least 2 symptoms measurable (score ≥ 1) using the MF-SAF

• Dose expansion: At least 2 symptoms measurable with each score of ≥ 3 or a total average score of ≥ 10 per MFSAF

Nuvisertib (TP-3654) + Ruxolitinib Arm:

• Confirmed pathological diagnosis of PMF or post-PV-MF/post ET- MF and intermediate or high-risk primary or secondary MF

• On ruxolitinib treatment for ≥ 6 months, and on a stable dose of ruxolitinib (5 to 25 mg BID) for ≥ 8 weeks prior to the first dose of nuvisertib, but has either lost response or had a suboptimal or plateau in response

• Fulfills the following clinical laboratory parameters:

• Platelet count ≥ 50 × 10^9/L (without assistance of growth factors or platelet transfusions)

• ANC ≥ 1 × 109/L without assistance of granulocyte growth factors

• Peripheral blood blast count < 5% at screening

• Adequate renal function

• Adequate hepatic function

• Adequate coagulation function

• Splenomegaly (spleen volume of ≥ 450 cm3 by MRI/CT scan) within 2 weeks prior to Cycle 1 Day 1

• At least 2 symptoms measurable with each score ≥ 3 or a total average score of ≥ 10 per MFSAF v4.0

• ECOG performance status ≤ 1

• Life expectancy ≥ 6 months

Nuvisertib (TP-3654) + Momelotinib Arm

• Confirmed pathological diagnosis of PMF or post-PV-MF/post ET-MF and intermediate or high-risk primary or secondary MF

• Previously treated with an approved JAK inhibitor (except momelotinib) for PMF or Post-PV/ET MF for ≥ 12 weeks, or ≥ 4 weeks if JAK inhibitor therapy was complicated by a transfusion requirement of ≥ 4 units of red blood cells in 8 weeks, or Grade 3/4 AEs of thrombocytopenia, anemia, or hematoma

• Fulfills the following clinical laboratory parameters:

• Anemic, defined as Hb <10 g/dL or requiring RBC transfusion at baseline

• Platelet count ≥ 50 × 109/L (without assistance of growth factors or platelet transfusions)

• ANC ≥ 1 × 109/L without assistance of granulocyte growth factors

• Peripheral blood blast count < 5% at screening

• Adequate renal function

• Adequate hepatic function

• Adequate coagulation function

• Splenomegaly (spleen volume of ≥ 450 cm3 by MRI/CT scan) within 2 weeks prior to Cycle 1 Day 1

• At least 2 symptoms measurable with each score of ≥ 3 or a total average score of ≥ 10 per MFSAF v4.0

• ECOG performance status ≤ 1

• Life expectancy ≥ 6 months

Patients meeting any one of these exclusion criteria will be prohibited from participating in this study:

Nuvisertib (TP-3654) Monotherapy Arm:

• Received previous systemic antineoplastic therapy or any experimental therapy within 2 weeks or 5 half-lives, whichever is longer, prior to Cycle 1 Day 1. Hydroxyurea or anagrelide are allowed up to 24 hours prior to Cycle 1 Day 1).

• Major surgery within 4 weeks prior to Cycle 1 Day 1 and/or not recovered adequately from from surgery prior to first dose.

• Splenic irradiation within 6 months prior to Screening or prior splenectomy.

• Prior allogeneic stem cell transplant within the last 6 months.

• Eligible for allogeneic bone marrow or stem cell transplantation.

• Unresolved Grade ≥ 2 non-hematological toxicity related to prior treatment

• History of symptomatic congestive heart failure, or myocardial infarction, or uncontrolled arrhythmia within 6 months prior to Cycle 1 Day 1; left ventricular ejection fraction (LVEF) < 45% by echocardiogram within 4 weeks prior to Cycle 1 Day

• Corrected QT interval > 480msec.

• Prior or concurrent malignancy that could interfere with the investigational regime.

• Known history of chronic liver disease, e.g. portal hypertension or any of its complications, cirrhosis, Child-Pugh C, auto-immune hepatitis, alpha-1 anti-trypsin deficiency, Wilson's disease, etc.

• Active, uncontrolled bacterial, viral, or fungal infections, requiring systemic antimicrobial within 1 week prior to Cycle 1 Day 1.

• Chronic active or acute viral hepatitis A, B, or C infection (testing for hepatitis B and C are required)

• Exhibited allergic reactions or sensitivity to nuvisertib, or similar compound.

• Medical condition or GI tract surgery that could impair absorption or result in short bowel syndrome with diarrhea.

• Systemic steroid therapy (>10 mg daily prednisone or equivalent) within 1 week prior to the first dose of study treatment (note: topical, inhaled, nasal, and ophthalmic steroids are not prohibited).

• Known clinically significant anemia due to iron, vitamin B12, or folate deficiencies, or autoimmune or hereditary hemolytic anemia, or thalassemia, or severe GI bleeding.

• Pregnant or breastfeeding

• Currently receiving any other investigational agent.

Nuvisertib (TP-3654) + Ruxolitinib Arm:

• Received previous systemic antineoplastic therapy (other than ruxolitinib) or any other experimental therapy within 2 weeks or 5 half-lives, whichever is longer, prior to Cycle 1 Day 1 (Note: Prior treatment with nuvisertib is not allowed. Hydroxyurea or anagrelide are allowed up to 24 hours prior to Cycle 1 Day 1).

• Received systemic steroid therapy (>10 mg daily prednisone or equivalent) within 1 week prior to Cycle 1 Day 1 (Note: Topical, inhaled, nasal, and ophthalmic steroids are not prohibited)

• Known allergic reactions or sensitivity to nuvisertib, or similar compound.

• Splenic irradiation within 6 months prior to Screening or prior splenectomy

• Prior allogeneic stem cell transplant within the last 6 months (Note: Patients who have relapsed after 6 months post-transplant and do not have active GVHD are eligible).

• Eligible for allogeneic bone marrow or stem cell transplantation (Note: Patients who are not willing to undergo transplantation or for whom a suitable donor is not available are considered as transplant ineligible.)

• Major surgery within 4 weeks prior to Cycle 1 Day 1 and/or have not recovered adequately prior to first dose.

• Active, uncontrolled bacterial, viral, or fungal infections, requiring parenteral antimicrobial within 1 week prior to Cycle 1 Day 1

• Chronic active or acute viral hepatitis A, B, or C infection (testing for hepatitis B and C are required)

• Known history of chronic liver disease (eg, portal hypertension or any of its complications, cirrhosis, Child-Pugh C, auto-immune hepatitis, alpha-1 anti-trypsin deficiency, Wilson's disease, etc) (Note: Abnormal liver morphology at baseline imaging may require additional testing, as needed).

• Unresolved Grade ≥ 2 non-hematological adverse events related to prior treatment (stable Grade 2 conditions may be permitted in consultation with the Sponsor)

• History of myocardial infarction or symptomatic congestive heart failure or uncontrolled arrhythmia within 6 months prior to Cycle 1 Day 1; LVEF <45% by echocardiogram within 4 weeks prior to Cycle 1 Day 1

• Corrected QTcF of > 480 msec

• Prior or concurrent malignancy that could interfere with the safety or efficacy assessment of the study intervention

• History of a medical condition or GI tract surgery that could impair absorption or could result in short bowel syndrome with diarrhea

• Known clinically significant anemia due to iron, vitamin B12, or folate deficiencies, or autoimmune or hereditary hemolytic anemia, or thalassemia, or severe GI bleeding

• Pregnant or breastfeeding

Nuvisertib (TP-3654) + Momelotinib Arm:

• Received previous systemic antineoplastic therapy or any experimental therapy within 2 weeks or 5 half-lives, whichever is longer, prior to Cycle 1 Day 1 (Notes: Prior treatment with momelotinib or nuvisertib is not allowed; in patients with ongoing JAK inhibitor therapy, ie, ruxolitinib, at screening, JAK inhibitor therapy must be tapered over a period of at least 1 week. Patients on a low dose of ruxolitinib (eg, 5 mg QD) may have a reduced taper period or no taper; hydroxyurea or anagrelide are allowed up to 24 hours prior to Cycle 1 Day 1).

• Received systemic steroid therapy (>10 mg daily prednisone or equivalent) within 1 week prior to Cycle 1 Day 1 (Note: Topical, inhaled, nasal, and ophthalmic steroids are not prohibited).

• Known allergic reactions or sensitivity to nuvisertib, momelotinib, or any structurally similar drug, or to any component of the formulations of either study intervention

• Splenic irradiation within 6 months prior to screening or prior splenectomy

• Prior allogenic stem cell transplant within the last 6 months (Note: Patients who have relapsed after 6 months post-transplant and do not have active GVHD are eligible).

• Eligible for allogeneic bone marrow or stem cell transplantation (Note: Patients who are not willing to undergo transplantation or for whom a suitable donor is not available are considered as transplant ineligible).

• Major surgery within 4 weeks prior to Cycle 1 Day 1 and/or have not recovered adequately from surgery prior to first dose.

• Active, uncontrolled bacterial, viral, or fungal infections, requiring parenteral antimicrobial within 1 week prior to Cycle 1 Day 1

• Chronic active or acute viral hepatitis A, B, or C infection (testing for hepatitis B and C are required)

• Known history of chronic liver disease (eg, portal hypertension or any of its complications, cirrhosis, Child-Pugh C, auto-immune hepatitis, alpha-1 anti-trypsin deficiency, Wilson's disease, etc) (Note: Abnormal liver morphology at baseline imaging may require additional testing, as needed)

• Unresolved Grade ≥ 2 non-hematological adverse events related to prior treatment (stable Grade 2 conditions may be permitted in consultation with the Sponsor)

• Presence of Grade ≥ 2 peripheral neuropathy

• History of myocardial infarction or symptomatic congestive heart failure or uncontrolled arrhythmia within 6 months prior to Cycle 1 Day 1; LVEF < 45% by echocardiogram within 4 weeks prior to Cycle 1 Day 1

• Corrected QTcF of > 480 msec

• Prior or concurrent malignancy that could interfere with the safety or efficacy assessment of the study intervention

• History of a medical condition or GI tract surgery that could impair absorption or could result in short bowel syndrome with diarrhea

• Known clinically significant anemia due to iron, vitamin B12, or folate deficiencies, or autoimmune or hereditary hemolytic anemia, or thalassemia, or severe GI bleeding

• Pregnant or breastfeeding