Repurposed drugs to improve haematological responses in Myelodysplastic Syndromes

1. Provision of written informed consent 2. Age ≥ 18 years and able to give informed consent 3. Diagnosis of Myelodysplastic Syndrome with an IPSS-R score of less than or equal to 3.5 4. Haematological parameters: 1) Mean Haemoglobin < 100 g/l over 16 weeks (pre transfusion) OR 2) Mean Platelets < 100 x 109/L over 16 weeks + evidence of bleeding (assessed using the ISTH Bleeding Assessment Tool) OR 3) Mean neutrophils < 1.0 x 109/L over 16 weeks + history of infection (the requirement for antimicrobial therapy and hospital admissions associated with infection) 5. No response to Erythroid Stimulating Agents (ESAs) OR have ceased to respond to ESAs OR are Predicated not to Respond to ESAs by current UK guidelines (NB Patients with thrombocytopenia and/or neutropenia, without anaemia, are eligible as they are predicated not to respond). 6. ECOG performance status 0-3 7. Expected survival > 12months

1. Abnormal liver function (if patient has Gilbert’s syndrome, then abnormal direct Bilirubin is an exclusion) 2. Cockcroft Gault CrCl < 20ml/min 3. Current systemic treatment for low risk MDS 4. History of Allogeneic Bone Marrow Transplant 5. History of having received ESAs and/or G-CSF in the past 16 weeks 6. Currently receiving statin medication for Secondary Prophylaxis of Cardiovascular Disease, Cerebrovascular, or Peripheral Vascular disease (Please note patients receiving statin medication for Primary Prophylaxis of Cardiovascular Disease – i.e. the patient has no prior history of Ischaemic Heart Disease or Cerebrovascular Disease - can still be entered, please see section 1.4 Statin use) 7. Currently receiving fibrate medications 8. Currently receiving sodium valproate, carbamazepine or phenytoin for treatment of epilepsy 9. Prior cytotoxic chemotherapy or hypomethylating agents for AML/MDS (e.g. azacitidine) 10. Concurrent active malignancy requiring treatment 11. History of any Androgen Dependent Tumour (patients with Prostate Cancer are Excluded when a biopsy proven diagnosis of Prostate Cancer has been made OR their PSA is known to be elevated OR they are on active treatment for Prostate Cancer, including hormonal therapy). 12. Currently receiving Vitamin K-Antagonist Anticoagulation (though patients receiving DOACs (direct oral anticoagulants) can be included) 13. History of Venous Thrombo-Embolism (VTE) 14. Cardiac Failure NYHA Class III or IV 15. Women of childbearing potential, pregnant or lactating 16. The physician or patient consider VBaP or danazol to be inappropriate for the patient 17. Known HIV 18. Abnormally high CK level 19. Presence of isolated del 5q 20. Acute Porphyria 21. Contraindications to any of the trial medications or known hypersensitivity to any of the investigational products (see Appendix C for contraindications) 22. Previous randomisation in the REPAIR-MDS trial 23. Participation in a clinical trial of an investigational medicinal product in the last 16 weeks