2044 Background: Gaseous hydrogen sulfide (H 2 S), a by-product of cysteine metabolism, inhibits the growth of glioblastoma (GBM) cells and impairs GBM progression in mice. Likewise, H 2 S generation and sulfhydration are decreased in human GBM specimens as compared to non-tumor controls. Thus, boosting H 2 S production is a novel strategy for GBM treatment. Suppression of thyroid hormone (TH) signaling increases endogenous production of H 2 S. We hypothesize that methimazole-induced hypothyroidism will enhance the efficacy of chemotherapy in WHO grade 4 gliomas by boosting H 2 S production capacity (HPC) within the tumor. The goal of this trial is to provide proof of concept that suppression of TH signaling, via methimazole and subsequent augmentation of H 2 S synthesis and signaling, is feasible in patients with WHO grade 4 gliomas (G4G). Methods: This modified phase 1/2 study evaluates the safety and efficacy of methimazole + chemotherapy with pharmacodynamic correlates in patients with progressive G4G. The main objective is a 10% increase in HPC and a 1.5-fold increase in peripheral blood sulfhydration signaling (SS). Patients who are planned for a clinically-indicated resection receive pre-op (5-7 days) and post-op methimazole with the addition of investigator’s choice of chemotherapy 1 month after starting post op methimazole. Patients receive methimazole + chemotherapy until progression. Resected tumor will be assayed for HPC and for proteins relevant to H 2 S production. Peripheral blood lead-acetate assays for HPC and SS are obtained at baseline, pre-op, intra-op, post-op, before the addition of chemotherapy, and before each cycle of methimazole + chemo. Key eligibility criteria: progressive G4G for whom a clinically-indicated resection is planned, and normal thyroid function with no history of thyroid disease. Patients may have had unlimited prior regimens including bevacizumab. Results: To date six patients (4 male) ages 49-59 years have enrolled. At all time points tested post-methimazole treatment relative to baseline age/sex matched no-methimazole control patients, there were significant increases in plasma H 2 S production capacity (table). Conclusions: In this early cohort, it appears methimazole treatment in recurrent GBM patients enhances HPC on a systemic level. Next steps will be to measure sulfide signaling and sulfhydration alterations in patient tumor samples. The protocol is being modified to allow earlier addition (2 weeks) of post-op chemotherapy. Clinical trial information: NCT05607407 . [Table: see text]