23 ε Γηεκερίδα Ιογελώλ Ηπαηηηίδωλ Β θαη C «Ση. Χαηδεγηάλλες» 30 θαη 31 Ιαλοσαρίοσ 2016

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1 23 ε Γηεκερίδα Ιογελώλ Ηπαηηηίδωλ Β θαη C «Ση. Χαηδεγηάλλες» 30 θαη 31 Ιαλοσαρίοσ 2016

2 Λεηηοσργηθή θαη Ιοιογηθή Ιαζε ηες Χρολίας Ηπαηίηηδας Β: Παρόλ θαη Μέιιολ Σηέθαλος Χαηδεγηάλλες Οκόηηκος Καζεγεηής Παζοιογίας ΔΚΠΑ

3 Functional and Virological Cure of Chronic Hepatitis B: Present and Future Stephanos J. Hadziyannis MD Emeritus Professor of Medicine University of Athens

4 The Term Cure and its Meaning in CHB Historically, in the treatment of CHB the term cure has been avoided, since the persistence of cccdna, the transcriptional template of HBV, in the nucleus of hepatocytes, even in individuals with serological markers of resolved infection, poses a lifelong risk for reactivation of the infection. However, HBsAg loss with sustained HBV DNA suppression and normal ALT levels persistently off therapy has been considered as the closest to cure outcome of CHB and has been referred under various terms including Immunological Cure, Functional Cure and Virological Cure. On the other hand, it has been realized that a Complete or Absolute Virological Cure with eradication of the HBV from the host, including its cccdna from the nuclei of hepatocytes, is not achievable by current therapies but, probably, it could be reached by some new treatment modalities.

5 Definitions of HBV Cure HBsAg Anti-HBs Viraemia cccdna Functional Cure + + Complete Cure +

6 A Further Clarification Literally the term Functional cure implies that the patient s life expectancy becomes the same as that of an individual who has resolved his HBV infection and has achieved virological cure without therapy. But since such an outcome cannot be measured over short time, the term apparent virological cure is considered as more appropriate for a sustained off therapy HBsAg loss. (Antiviral Res (1): 27 34)

7 In the present review the terms Functional and Virological (or complete) cure of chronic HBV infection are applied to stable off-drug suppression of HBV viraemia and HBs antigenaemia with normalization of ALTs and of other laboratory tests and with the suggestion that such a cure should be the goal of future therapies in all patients with chronic hepatitis B.

8 In the context of the above I have added a table of Operational Definitions of medically attainable cures (Antiviral Res (1): 27 34)

9 This presentation is aiming at reviewing: Current, developing and experimental therapies targeting viral and host factors and pathways previously not accessible to intervention. Such therapeutic approaches may lead to HBsAg loss and to apparent virological cures in the near term and to absolute cures upon long term follow-up.

10 But First a Reminder on CHB and its Therapy Up to the mid 1960s almost nothing was known for chronic viral liver disease. Then the HBsAg and the HBV itself were discovered and chronic liver disease due to HBV proved a major public health problem worldwide. In the 1980s the molecular biology and the replication cycle of HBV were elucidated Then in 1990 the first treatment modality with interferon alpha was approved From 2000 treatment efforts have expanded over the years to NAs. However, since 2008 the treatment landscape has remained practically the same

11 Viral Entry Uncoating Nuclear import Repair Assembly & budding cccdna ER HBsAg Transcription Export Positive strand synthesis Removal of pregenome kb RNA /2.1 kb RNA Translation Negative strand synthesis Encapsulation Nassal M, et al. J Viral Hepat. 1996;3:217. Ganem D, et al. Fields Virology. 4th ed. Philadelphia: Lippincott-Raven Publishers; 2000:2923.

12 Furthermore, the hepatitis Delta was discovered in 1977 and in the years that followed 5% to 10% of chronic HBV carriers were also found to be chronically infected with HDV, with delta virions being produced in co-infected hepatocytes, along with HBV particles and being coated with the envelope proteins of the helper HBV and containing an inner ribonucleoprotein (RNP) consisting of the HDV RNA genome and of HDV-encoded proteins (next figure)

13 A schematic representation of the life cycles of both ΗΒV and ΗDV in the same hepatocyte

14 . The HDV RNA can replicate to very high levels in the nuclei of hepatocytes, leading to the production of HDV RNPs that can egress only in the presence of HBV envelope proteins and after assembly of HDV virions. The latter can subsequently infect human hepatocytes using the same entry pathway as the one used by HBV to propagate infection. HBV/HDV coinfection significantly worsens the course of the liver disease.

15 But First a Reminder Up to the mid 1960s almost nothing was known for chronic viral liver disease. Then the HBsAg and the HBV itself were discovered and chronic liver disease due to HBV proved a major public health problem worldwide. In the 1980s the molecular biology and the replication cycle of HBV were elucidated In 1990 the first treatment modality with interferon alpha was approved and From 2000 treatment efforts have expanded over the years to NAs. However, since 2008 the treatment landscape has remained practically the same

16 The same treatment landscape up tο January 2016 Peginterferon alpha-2a Lamivudine Entecavir Tenofovir Interferon alfa-2b Adefovir Telbivudine

17 From 2008 to Jan Clinical studies of the efficacy of long term NAs Discontinuation of long therapies in CHB particularly in the HBeAg-negative type Combination of IFN with NAs and add of IFN on NAs. Two new NAs Βesifovir and Tenofovir Alafenamide (TAF) promissing superiority compared to the current first choice NAs Εntecavir και Tenofovir in terms of safety and long-term efficacy. But currently stand far away from such a target (J Hepatol 2015, 62:505-7) Efforts for development of new drugs and combinations against old and new HBV targets

18 But prior to this a note on a couple of new data on TDF (2015 AASLD (Abstr.1997 and 2004). Confirm its high efficacy (100%) at the end of 5 th year of therapy but with renal events in 7.5% of the patients and with an average 12,5% loss of bone mineral density Indicate that reduced TDF dosage is as effective as standard dosing while being less costly and conferring a protective effect for renal function And with these observations, therefore, pointing out to studies of long-term NUC therapy with reduced doses of TDF probably including also comparison with ENT

19 But what can be achieved even with the safest and of lowest cost long-term anti-hbv therapies? Suppression but not elimination of HBV Only low rates of HBsAg loss and only partial reversion of liver necroinflammation and fibrosis Decrease but not elimination of the risk for development of HCC Thus we are looking hopefully forward to future therapies that may eradicate HBV, reverse completely liver damage and prevent cirrhosis and HCC

20 New Therapies Under Development Aiming at Functional and Virological HBV Cure

21 Prospects for HBV cure They are based on recent advances in the understanding of the complex biology of CHB that are actually leading to the design and development of new, experimental therapies targeting host and viral factors and pathways. These developments are expected to lead to functional cures in the near term and to absolute or complete virological cures upon long-term follow-up.

22 The closed covalent circular DNA of HBV depicted in linear form and showing positions of the direct repeats (DR) 1 and 2, and the polyadenylation signal (An)

23 A note for the previous figure: The transcripts with the open reading frames they contain and which encode for the surface proteins (L, M, S), polymerase (P), X and precore proteins are indicated as boxes. HBeAg is derived following the proteolytic processing of the precore protein. The various RNA transcripts terminate at the common polyadenylation signal

24 Viral Life Cycle and Target Stages (From Baltayannis and Karayiannis J V Hep. 2014)

25 Therapeutic Perspectives Α Targeting the Virus 1. Entry of ΗΒV (and of HDV) in the hepatocytes by the ΝΤCP receptor: Sodium Taurocholate Co-transporting Polypeptide) as Mircludex-Β (a synthetic lipopeptide derived from the ηο pre-s1 domain of the envelope protein of HBV).Ttargeting specifically NTCP, demonstrated to block effectively HBV infection in vitro and in vivo 2. Assembly/encapsidation of the virush Eteroaryldihydropyrimidines, phenylpropenamides, AT Excretion of HBsAg nitazoxanide, tizoxanide, new inhibitors triazolopyrimidine 4. Envelopment of capsids Rep 9AC hampers the excretion of HBsAg SVPs without affecting the excretion of infectious particles of the virus 5. At the ccdna level: Neutralization/suspension/disruption/ rejection/epigenetic silencing zinc-finger nucleases (ZFNs), disubstituted sulfonamides (DSS), termed CCC-0975 and CCC-0346, CRISPR/Cas9 6. At the level of messenger mrna of the virus RNA-i

26 Highlights of a 2015 Review by HBV Experts from USA, Australia and China (Antiviral Research, Sept. 2015;121:97-108) Current drugs such as NUCs and IFN often fail to reduce levels of viral antigens responsible for immune system exhaustion. RNA interference (RNAi) is a powerful, natural pathway that could be harnessed to reduce viral transcripts and antigenaemia. Tremendous progress in conferring drug-like properties onto synthetic RNAi triggers has been made. RNAi-based drugs are likely to be a cornerstone of therapies with curative intent for chronic hepatitis B in the future

27 Therapeutic Perspectives: B Targeting the host TLR agonists GS-9620, a per os administered agonist of TLR-7 Cytokines IL-7 and IL-21 may exert a beneficial action in CHB Programmed cell death-1/programmed death ligand-1 Tregs Therapeutic vaccinations

28 Breakdown of Proteins that Inhibit Apoptosis of HBV Infected Hepatocytes A new drug named Birinapant (TetraLogic Pharmac.) triggers proteins, known as inhibitors of apoptosis (IAPs) that prevent infected cells from self-destructing. Preclinical models have shown that targeting IAPS allows infected cells to die while not harming uninfected cells. This drug, used in conjunction with an existing treatment for hepatitis B, has the potential to cure functionally chronic hepatitis B.

29 Potential Agents Against HBV

30 Emerging drugs against hepatitis B

31 Some References on Potential Anti-HBV Agents

32 And Also Some Suggestion for Further Reading: Mirjam B Zeisel et al.towards an HBV Cure. State-of-the-art and Unresolved Questions. Gut. 2015;64(8): E.R. Verrier et al :Hepatol A targeted functional RNA interference screen has uncovered glypican 5 as an entry factor for hepatitis B and D viruses. Virus glypican 5 interactions may also play a role in the pathogenesis of virus-induced liver disease and cancer. These findings advance our understanding of virus cell entry and open new avenues for curative therapies. CL, Yang HC, Kao JH. Hepatitis B virus: new therapeutic perspectives. Liver Int Jan;36 Suppl 1:85-92.

33 SUMMARY To the historical term of immunological cure of HBV the new ones of functional and virological cure have now emerged defined by stable offtherapy negative HBsAg and HBV DNA and normal ALT. At the same time major advances in basic research of hepatitis B virology and of CHB have contributed to the development of new treatment approaches targeting new viral and host factors and pathways.

34 And A Final Wish The Arc of a Medical Triumph is a recent title that has been applied to the potential conquering of Viral Hepatitis C by new therapies with DAAs Let us hope that a similar triumph soon follows also in the treatment of Viral Hepatitis B and that functional and complete cures become a therapeutic reality for all CHB patients.

35

36 Conclusion On the basis of extensive research on the HBV lifecycle and virus-host interactions, several new agents focusing on viral and host targets are under development aiming to cure HBV. Agents targeting cccdna, such as engineered site-specific nucleases and RNA interference therapeutics could eliminate cccdna or silence cccdna transcription. Inhibitors of HBV nucleocapsid assembly suppress capsid formation and prevent synthesis of HBV DNA. The HBV entry inhibitor, Myrcludex-B, has been shown to effectively inhibit amplification of cccdna as well as the spread of intrahepatic infection. Agents targeting host factors that enhance innate and adaptive immune responses, including the lymphotoxin-β receptor agonist, toll-like receptor agonist, immune checkpoint inhibitors and adenovirus-based therapeutic vaccine, could play a critical role in the elimination of HBV-infected cells With all of these promising approaches, we hope to reach the ultimate goal of a cure to HBV in the near future

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