Informations générales (source: ClinicalTrials.gov)
A Phase 1/2, Open-Label, Dose-Escalation, Safety, Pharmacokinetic, and Pharmacodynamic Study of Oral Nuvisertib (TP-3654) in Patients With Intermediate or High-Risk Primary or Secondary Myelofibrosis
Interventional
Phase 1/Phase 2
Sumitomo Pharma America, Inc. (Voir sur ClinicalTrials)
décembre 2019
avril 2030
05 juin 2025
This study is a Phase 1/2, multicenter, dose-escalation, open-label trial to assess
safety, tolerability, pharmacokinetics and pharmacodynamics of nuvisertib (TP-3654) in
patients with intermediate or high-risk primary or secondary MF.
Etablissements
| Les établissements d'Île-de-France dont les données sont issues de ClinicalTrials.gov Origine et niveau de fiabilité des données | |||||
|---|---|---|---|---|---|
| CLCC INSTITUT GUSTAVE ROUSSY | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| Les établissements sans correspondance certaine dans le répertoire FINESS dont les données sont issues de ClinicalTrials.gov Origine et niveau de fiabilité des données | |||||
| Centre Hospitalier Lyon Sud - 69495 - Lyon - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| Centre Hospitalier Universitaire D'Amiens - 80054 - Amiens - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| CHU Angers - 9000 - Angers - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| Hospital Saint Louis - 75010 - Paris - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| Hospitalier Universitaire (CHU) de Nice - Hopital de l'Archet - 06200 - Nice - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| Institut de cancerologie du Gard - 30029 - Nimes - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
| Institut de cancerologie du Gard - Nimes - France | SMPA Investigative Site | Contact (sur clinicalTrials) | |||
Critères
Tous
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
1.
- 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
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
1.
- 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