This is a phase 1b/2 study to evaluate the safety and efficacy of metronomic combination
therapy in subjects with with CD20-positive NHL who have progressed on or after rituximab
Treatment will be administered in 2 phases, an induction and a maintenance phase, as
described below. Subjects will continue induction treatment for up to 1 year or until they
experience progressive disease (PD) or experience unacceptable toxicity (not correctable with
dose reduction), withdraw consent, or if the Investigator feels it is no longer in the
subject's best interest to continue treatment. Those who have a complete response (CR) in the
induction phase will enter the maintenance phase of the study. Subjects may remain on the
maintenance phase of the study for up to 1 year. Treatment will continue in the maintenance
phase until the subject experiences PD or unacceptable toxicity (not correctable with dose
reduction), withdraws consent, or if the Investigator feels it is no longer in the subject's
best interest to continue treatment.
1. Age ≥ 18 years.
2. Able to understand and provide a signed informed consent that fulfills the relevant
IRB or Independent Ethics Committee (IEC) guidelines.
3. Histologically confirmed relapsed CD20-positive NHL with progression on or within 6
months after rituximab therapy.
4. Eastern Cooperative Oncology Group (ECOG) performance status of 0 to 2.
5. Have at least 1 measurable lesion of ≥ 1.5 cm.
6. Must have a recent tumor biopsy specimen obtained following the conclusion of the most
recent anti-cancer treatment. If a historic specimen is not available, the subject
must be willing to undergo a biopsy during the screening period.
7. Must be willing to provide blood samples, and, if considered safe by the Investigator,
a tumor biopsy specimen at 8 weeks after the start of treatment.
8. Ability to attend required study visits and return for adequate follow-up, as required
by this protocol.
9. Agreement to practice effective contraception for female subjects of child-bearing
potential and non-sterile males. Female subjects of child-bearing potential must agree
to use effective contraception for up to 1 year after completion of therapy, and
non-sterile male subjects must agree to use a condom for up to 4 months after
1. History of persistent grade 2 or higher (CTCAE Version 4.03) hematologic toxicity
resulting from previous therapy.
2. Within 5 years prior to first dose of study treatment, any evidence of other active
malignancies or brain metastasis except controlled basal cell carcinoma; prior history
of in situ cancer (eg, breast, melanoma, cervical); prior history of prostate cancer
that is not under active systemic treatment (except hormonal therapy) and with
undetectable prostate-specific antigen (PSA) (< 0.2 ng/mL).
3. Serious uncontrolled concomitant disease that would contraindicate the use of the
investigational drug used in this study or that would put the subject at high risk for
4. Systemic autoimmune disease (eg, lupus erythematosus, rheumatoid arthritis, Addison's
disease, autoimmune disease associated with lymphoma).
5. History of organ transplant requiring immunosuppression.
6. History of or active inflammatory bowel disease (eg, Crohn's disease, ulcerative
7. Requires whole blood transfusion to meet eligibility criteria.
8. Inadequate organ function, evidenced by the following laboratory results:
1. White blood cell (WBC) count < 2,000 cells/mm3.
2. Absolute neutrophil count < 1,500 cells/mm3.
3. Platelet count < 100,000 cells/mm3.
4. Total bilirubin greater than the upper limit of normal (ULN; unless the subject
has documented Gilbert's syndrome).
5. Aspartate aminotransferase (AST [SGOT]) or alanine aminotransferase (ALT [SGPT])
> 2.5 × ULN (> 5 × ULN in subjects with liver metastases).
6. Alkaline phosphatase levels > 2.5 × ULN (> 5 × ULN in subjects with liver
metastases, or >10 × ULN in subjects with bone metastases).
7. Serum creatinine > 2.0 mg/dL or 177 μmol/L.
8. International normalized ratio (INR) or activated partial thromboplastin time
(aPTT) or partial thromboplastin time (PTT) >1.5 × ULN (unless on therapeutic
9. Uncontrolled hypertension (systolic > 150 mm Hg and/or diastolic > 100 mm Hg) or
clinically significant (ie, active) cardiovascular disease, cerebrovascular
accident/stroke, or myocardial infarction within 6 months prior to first study
medication; unstable angina; congestive heart failure of New York Heart Association
grade 2 or higher; or serious cardiac arrhythmia requiring medication.
10. Dyspnea at rest due to complications of advanced malignancy or other disease requiring
continuous oxygen therapy.
11. Positive results of screening test for human immunodeficiency virus (HIV), hepatitis B
virus (HBV), or hepatitis C virus (HCV).
12. Current chronic daily treatment (continuous for > 3 months) with systemic
corticosteroids (dose equivalent to or greater than 10 mg/day methylprednisolone),
excluding inhaled steroids. Short-term steroid use to prevent IV contrast allergic
reaction or anaphylaxis in subjects who have known contrast allergies is allowed.
13. Known hypersensitivity to any component of the study medication(s).
14. Subjects taking any medication(s) (herbal or prescribed) known to have an adverse drug
reaction with any of the study medications.
15. Concurrent or prior use of a strong CYP3A4 inhibitor (including ketoconazole,
itraconazole, posaconazole, clarithromycin, indinavir, nefazodone, nelfinavir,
ritonavir, saquinavir, telithromycin, voriconazole, and grapefruit products) or strong
CYP3A4 inducers (including phenytoin, carbamazepine, rifampin, rifabutin, rifapentin,
phenobarbital, and St John's Wort) within 14 days before study day 1.
16. Concurrent or prior use of a strong CYP2C8 inhibitor (gemfibrozil) or moderate CYP2C8
inducer (rifampin) within 14 days before study day 1.
17. Participation in an investigational drug study or history of receiving any
investigational treatment within 14 days prior to screening for this study, except for
testosterone-lowering therapy in men with prostate cancer.
18. Assessed by the Investigator to be unable or unwilling to comply with the requirements
of the protocol.
19. Concurrent participation in any interventional clinical trial.
20. Pregnant and nursing women.