Due to limitations imposed by the COVID pandemic and the competitive landscape for myelodysplastic syndrome, this study was unable to enroll a sufficient patient population.

This study will evaluate preliminary safety and efficacy of TP-0184 to treat anemia when administered to adult patients with Revised International Prognostic Scoring System (IPSS-R) low or intermediate risk MDS. The recommended Phase 2 dose (RP2D) will be determined by the maximum tolerated dose (MTD) or maximum administered dose (MAD) in the Phase 1 portion of the study.

Inclusion Criteria:

1. A documented diagnosis of lower risk MDS (IPSS-R Low, Intermediate) according to WHO 2016 classification, de novo or secondary..

2. Bone marrow biopsy and/or aspirate performed pre-dose to assess disease status and available for review prior to full screening review. If the bone marrow biopsy and/or aspirate is nonproductive or nondiagnostic, the procedure must be repeated. Bone marrow biopsy/aspirate performed ≤ 12 weeks prior to baseline will not need to be repeated if results and a minimum of 6 slides are available.

3. Relapse, refractory/resistant, intolerant, or inadequate response to ESA treatment, as defined by the following:

   • Relapse according to IWG 2006
   • Refractory/resistant - documented non-response or response that is no longer maintained to prior ESA-containing regimen, either as single agent or combination (e.g., with G-CSF); ESA regimen must have been either:
   • Recombinant human erythropoietin (rHu EPO) ≥ 500 IU/wk for at least 8 doses or equivalent; OR
   • Darbepoetin alpha ≥ 300 μg Q3W for at least 4 doses or equivalent;
   • Intolerant- documented discontinuation of prior ESA containing regimen, either as single agent or combination (e.g., with G-CSF), at any time after introduction due to intolerance or an adverse event

   Inadequate response - in the absence of transfusions support, patients under ESA treatment for at least 12 weeks that do not show a rise in hemoglobin of greater than equal to 1 g/dl.

4. Patients with 5q deletions are allowed only if they have failed or are intolerant to lenalidomide treatment.

   o Failure or intolerance to lenalidomide defined as clinical and cytogenetic responses to according to the international working group 2006 MDS: (1) absence of response, or (2) bone marrow progression during treatment with or without prior response, or (3) secondary failure (loss of prior hematological response without bone marrow progression), or (4) intolerance (treatment discontinuation due to adverse events, with or without prior response) based on investigator judgement (Prebet 2017). 7

5. Patients previously treated for anemia with or without RBC transfusion support:

   1. Low transfusion burden (LTb), defined as requiring less than 4 red blood cell units in the 8 weeks before treatment (and baseline hemoglobin < 9.0 g/dL),
   2. High transfusion burden (HTb), defined as requiring 4 or more red blood cell units in the 8 weeks before treatment

6. At least 12 weeks of transfusion history immediately preceding the first dose of TP-0184. This transfusion data must include hemoglobin measured prior to transfusion (pre transfusion Hgb).

7. Written, signed consent for trial participation must be obtained from the patient appropriately in accordance with applicable ICH guidelines and local and regulatory requirements prior to the performance of any study specific procedure.

8. Must be ≥18 years of age.

9. Patients with an Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) score ≤ 2.

10. Patients with a life expectancy of ≥3 months (90 days) per the treating investigator.

11. Patients with adequate major organ functions meeting the following criteria on the basis of laboratory data within 28 days (4 weeks) before screening (if multiple data are available, most recent data during the period):

    1. Serum creatinine: ≤1.8 x the upper limit of the normal (ULN) range
    2. Total bilirubin ≤ 1.5 x upper limit of normal (ULN) except in patients with Gilbert's syndrome. Patients with Gilbert's syndrome may enroll if direct bilirubin ≤2.0 x ULN or if the elevated total bilirubin can be attributed to active red blood cell precursor destruction within the bone marrow (i.e., ineffective erythropoiesis). Elevated indirect bilirubin due to post-transfusion hemolysis is allowed.
    3. Aspartate transaminase (AST) and alanine transaminase (ALT): ≤2.5 x ULN

    Left ventricular ejection fraction (LVEF) ≥ 45% by echocardiogram or multigated acquisition (MUGA) scan

12. All previous therapy with ESAs, G-CSF and GM-CSF must be discontinued ≥ 14 days before Cycle 1 Day 1 dosing.

13. Twenty-eight-day (4 weeks) washout period from prior treatment with cytotoxic chemotherapeutic agents, HMAs (hypomethylating agents), ImiDs (immunomodulatory imide drugs), luspatercept and / or investigational drugs before study dosing for the patient begins.

14. Women of childbearing potential (WOCBP) must have a negative serum or urine pregnancy test within 5 days prior to the first dose of TP-0184.

15. Non-fertile or agree to use an adequate method of contraception while on study and for 7 months following the study and have a negative pregnancy test (if female of childbearing potential) and not currently nursing; males agree to use an adequate method of contraception while on study and for 4 months following the study.

16. Patients must be able to comply with the requirements of the entire study and accessible for treatment and follow-up.

17. Patient agrees not to participate in other interventional clinical studies during their participation in this trial, while on study treatment. Patients participating in surveys or observational studies are eligible to participate in this study.

Exclusion Criteria:

1. IPSS-R high or very high risk MDS.

2. Presence of concomitant severe cardiovascular disease; congestive heart failure (CHF), myocardial infarction, angina and/ or uncontrolled cardiac arrhythmia as determined by the investigator within 6 months (180 days) of study onset.

3. Corrected QT interval (using Fridericia's correction formula) of > 465 msec in men and > 480 msec in women.

4. History of stroke, deep venous thrombosis (DVT), pulmonary or arterial embolism within 6 months (180 days) prior to enrollment.

5. Presence of clinically significant anemia due to iron, vitamin B12, or folate deficiencies, or autoimmune or hereditary hemolytic anemia, or gastrointestinal bleeding.

   a. Iron deficiency to be determined by a bone marrow aspirate stain for iron, calculated transferrin saturation (iron/total iron binding capacity) ≤ 20%, or serum ferritin ≤ 15 µg/L.

   b. Iron-chelating agents, except for subjects on a stable or decreasing dose for at least 8 weeks prior to enrollment, are excluded

6. Prior allogeneic or autologous stem cell transplant due to myeloid disease

7. Known history of diagnosis of AML.

8. Use of corticosteroid, except for subjects on a stable or decreasing (no greater than a 10 mg dose of prednisone or equivalent) for ≥ 2 weeks prior to enrollment for medical conditions other than MDS

9. Patients are excluded if there is evidence of autoimmune hemolytic anemia manifested as a corrected reticulocyte count (reticulocyte index) of > 2% with either a positive Coombs' test or over 50% indirect bilirubin.

10. Patients with a recent diagnosis of malignancy are excluded except for those with in situ malignancies treated with curative intent (eg, basal cell carcinoma of the skin, squamous cell carcinoma of the skin, or carcinoma in situ of the cervix). Patients with more advanced malignancies are allowed to enroll, provided they were treated with curative intent and have no evidence of active disease ≥ 2 years prior to Cycle 1 Day 1.

11. Patients requiring systemic antibiotics or antifungals are not eligible until they have completed the prescribed course of antibiotics or antifungals and are clinically stable. Topical antibiotics or antifungals are permitted.

12. Known HIV, active Hepatitis B, and/or active Hepatitis C infection.

13. Patients with clinically active uncontrolled, bleeding in the past month.

14. Thrombocytopenia (platelet count < 50,000/µL [50 x 109/L]).

15. Neutropenia (absolute neutrophil count [ANC] <500 /µL [0.5 x 109/L])

16. Women who are pregnant or breastfeeding.

17. Male patients with partners of childbearing potential who are unwilling to use condoms in combination with a second effective method of contraception during the trial and for 7 months after the last administration of study treatment.

18. Inability to undergo MRI imaging.

19. Parenchymal iron overload by screening MRI.

20. Patients who are unwilling or unable to comply with procedures required in this protocol.

21. Have undergone recent surgery with potential to cause the impairment of gastrointestinal tract absorption or that could cause short bowel syndrome with diarrhea due to malabsorption.

22. Have known hemochromatosis at baseline or a family history of hemochromatosis.

23. Presence of any psychological, familial, sociological or geographical condition that, in the opinion of the investigator, could potentially hinder compliance with the study protocol and follow-up schedule.

24. Patient has any significant medical condition, laboratory abnormality, or psychiatric illness that would prevent the subject from participating in the study.

25. Live vaccines within 14 days prior to first study drug administration. COVID-19 vaccines (non-live) approved by regional health authorities are allowed.

26. Medications that are known strong to moderate CYP3A4 inducers must be discontinued at least 21 days prior to first dose of study drug. Medications that are known strong to moderate CYP3A4 inhibitors must be stopped 21 days (or 5 half-lives, whichever is shorter) prior to the first dose of study drug.

27. Patients who have received medications with known or possible risk of prolonging the QT interval or inducing Torsades de Pointes within the previous 7 days.

The company decided to terminate further development of the TP-0184 program. No patients were enrolled into phase 2.

Serious and Other Adverse Events were assessed from the date of first treatment through 30 days of the last administration of study drug, an average of 4 months. All-Cause Mortality was assessed from the date of first treatment until death or withdrawal of consent, up to 4 months off treatment.

Sponsor's decision to terminate further development of the TP-0184 program. No patients were enrolled into phase 2.