HCV Therapies: The Last challenges 12th Paris Hepatology Conference 14th January Stefan Zeuzem, MD University Hospital, Frankfurt, Germany

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1 HCV Therapies: The Last challenges 2th Paris Hepatology Conference 4th January 209 Stefan Zeuzem, MD University Hospital, Frankfurt, Germany

2 Disclosures Advisory boards: AbbVie, Gilead Sciences, Intercept, and Janssen Speaker: AbbVie, Gilead Sciences, and Merck Sharp & Dohme

3 Challenge No. Omit Discrepencies between (Inter)national Guidelines

4 Treatment-Naive Genotype 3 Patients with compensated cirrhosis AASLD & IDSA Glecaprevir/Pibrentas vir x 2 weeks Sofosbuvir/Velpatasvi r x 2 weeks AASLD/IDSA: HCV Guidance. on January 03,209 EASL Glecaprevir/Pibrentasvi r x 2 weeks The combination of Sofosbuvir/Velpatasvir is not recommended in treatment-naive... patients with compensated (ChildPugh A) cirrhosis EASL Recommendations on Treatment of Hepatitis C 208. J Hepatol (208), jhep

5 Challenge No. 2 Shorten (Inter)national Guidelines

6 Size of International Guidelines AASLD/IDSA: 265 pages; EASL 5 pages Short guidelines for practioners needed: 2 pangenotypic regimen (dose, duration) Protease inhibitor contraindicated in patients with decompensated cirrhosis, sofosbuvir not licensed in CDK-4/5 App available to check for potential DDI For special populations contact/refer to specialist (children, decompensated cirrhosis/transplant evaluation, HCC)

7 Challenge No. 3 Drug-Drug interactions

8 Important drug-drug interactions* (DDI) of dual antiviral combinations DDI Sofosbuvir + Ledipasvir Sofosbuvir + Velpatasvir Grazoprevir + Elbasvir Glecaprevir + Pibrentasvir Amiodaron, anticonvulsants, antacids, PPI (high dose), rifampicin, St John s Worth, statins Amiodaron, anticonvulsants, antacids, PPI (high dose), rifampicin, efavirenz, St John s Worth, statins Dabigatran, anticonvulsants, antimycotics, bosentan, St John s Worth, atazanavir, darunavir, lopinavir, u.a., efavirenz, statins, ciclosporin, modafinil Dabigatran, anticonvulsants, rifampicin, ethinylestradiol, St John s Worth, atazanavir, darunavir, efavirenz, statins, ciclosporin, omeprazol *HEP Drug Interactions, University of Liverpool: *HEP Mobile Apps (Apple, Android) But some challenges remain with e.g. anticonvulsants, herbal preparations, etc.

9 Challenge No. 4 TreaTment of Patients with CKD stage-4/5 and decompensated Cirrhosis

10 SOF/VEL for 2 weeks is safe and effective in patients undergoing dialysis n (%) or mean (range) Age (years) SOF/VEL N=59 60 (33 9) Male 35 (59) White 3 (53) BMI (kg/m2) HCV genotype a/b/other 2 3 4/6/indeterminate 26 (7 39) 25 (42) 3 (22)/ (9)/ (2) 7 (2) 6 (27) 4 (7)/2 (3)/5 (9) Compensated cirrhosis 7 (29) IL28B CC genotype 23 (39) HCV RNA (log0 IU/mL) 5.8 (3. 7.7) Prior treatment experience 3 (22) Type of dialysis Hemodialysis Peritoneal dialysis 54 (92) 5 (8) Duration of dialysis (years) Prior renal transplant 7.3 (0 40) 9 (32) Borgia S, et al. AASLD 208, San Francisco, USA. #LB-5 SVR2 (%) Baseline demographics Patients, n (%) SOF/VEL N=59 Virologic failure Relapse 2 (3) 2 (3) Other (2) Safety, n (%) AE Grade 3 AE Serious AE Treatment discontinuation due to AE Death Grade 3/4 laboratory abnormality AEs in 0% patients Headache Fatigue Nausea Vomiting Insomnia SOF/VEL N=59 47 (80) 7 (2) (9) 0 2 (3) 25 (42) 0 (7) 8 (4) 8 (4) 8 (4) 6 (0) No Grade 3 or serious AEs were treatment related

11 Challenge No. 5 TreaTment of Patients with decompensated cirrhosis with Transplant option

12 Consensus Statement for Treatment of Patients with Decompensated Cirrhosis Recommendation 2. We suggest that HCV-infected patients with decompensated cirrhosis with CTP Class B and/or MELD less than 20 on the waiting list for liver transplantation, who are without refractory portal hypertensive symptoms or other conditions requiring more immediate transplantation, should be treated with antiviral therapy. Recommendation 2.2 We suggest that HCV-infected patients with advanced decompensated cirrhosis (MELD 30) or those who are expected to undergo liver transplantation within 3 months should not undergo antiviral therapy. Recommendation 2.3 We suggest that HCV-infected patients with decompensated cirrhosis with intermediate MELD scores and/or low MELD scores but refractory portal hypertensive complications who are on the waiting list be offered treatment with antiviral therapy selectively. Terrault et al., International Liver Transplantation Society Consensus Statement on Hepatitis C Management in Liver Transplant Candidates. Transplantation 207; 0:

13 Delisting of liver transplant candidates with chronic HCV infection after viral eradication: Outcome after delisting Child-Pugh score 42 patients listed for decompensated cirrhosis without HCC treated with DAAs 38/42 patients (26.8%) delisted due to clinical improvement Median (IQR) f/u from start of Tx = 28 months, from delisting = 5 months 37/38 delisted patients alive 2 pts were relisted for clinical re-decompensation (MELD at relisting were 6 and 5) At start of therapy Delisting area Variable HR 95% CI p-value Δ MELD at 2 wks <0.000 BL MELD < >20 Ref <0.000 <0.000 Belli LS, et al. EASL 207, Amsterdam. #PS-063 Belli LS, et al., J Hepatol 206;65: Child-Pugh score MELD score At last update MELD score pt 2 pts 3 pts

14 Challenge No. 6 TreaTment of Patients with decompensated cirrhosis without Transplant option

15 ASTRAL-4: SOF/VEL for HCV in Patients with Decompensated Cirrhosis SOF/VEL n=90 SVR2 SOF/VEL + RBV n=87 SVR2 SVR2 SOF/VEL n=90 Wk 0 Wk 2 94 SVR24 rates (%) Wk BT Relapse LTFU Death / 90 Wk / 87 79/ 90 60/ 68 65/ 68 67/ 7 7/ 4 / 3 6/ 2 G2: 4/4 G4: 4/ G2: 4/4 G4: 2/2 G2: 4/4 G4: 2/2 G6: / - Curry MP, et al., N Engl J Med 205;373:268-28

16 Clinical Benefits of SVR with SOF/VEL in Changes in CPT and MELD Scores from Baseline. Decompensated Cirrhotic Patients 3 / 267 pts (5%)with MELD > 6 Curry MP et al., N Engl J Med 205;373:

17 Challenge No. 7 Transplantation of HCV positive Organs

18 Transplantation of hepatitis C-positive solid organ allografts into hepatitis C-negative recipients Transplantation of HCV-positive organ into HCV-negative recipient Regimen and timing at physicians discretion Virologic response after initiation of DAA therapy Liver Heart Patients transplanted, n 54 0 Patients started on DAA therapy, n Age, years Male, n Time on waitlist, days Time on waitlist after consenting to receive HCV organs, days Treatment regimen, daily x 2 weeks LDV 90 mg and SOF 400 mg GLE 00 mg and PIB 40 mg VEL 00 mg and SOF 400 mg Time from transplant to initiation of DAA Patients (%) Kidne y Kidney 4 weeks after DAA initiation Menon K, et al. AASLD 208, San Francisco, USA. #LB-9 Liver EO T Heart SVR2

19 Determine if preemptive pangenotypic DAAs prevent chronic HCV development in HCV-negative cardiac transplant recipients receiving HCV-infected donor hearts Patients offered HCV-positive donor heart given preemptive GLE/PIB st dose prior to transplant 8-week course post-transplant No drug reactions or interactions have necessitated a lapse or cessation of therapy Pre-transplant wait time HCV protocol:.5 days (IQR 5 35) Standard wait list: 3 days (IQR ) NAT, nucleotide acid testing; POD, post-operative day Bethea E, et al. AASLD 208, San Francisco, USA. #7 Patient case number Preemptive, pan-genotypic DAA therapy in cardiac transplantation from HCV-positive donor to HCV-negative recipient SVR 24 SVR SVR 2 NAT+ NAT- All NAT+ recipients achieved viral suppression by POD 9 Median donor VL 3 million IU/mL Median peak recipient VL 500 IU/mL All HCV RNA tests after initial viral suppression remain undetectable Week post-transplant Preemptive administration of GLE/PIB results in prevention of chronic HCV infection in HCV-negative cardiac transplant recipients receiving HCV-infected donor hearts This strategy has the potential to decrease heart transplant wait times and improve post-transplant outcomes

20 Challenge No. 8 NON-responders to SOF/VEL/VOX

21 Number of virologic failures Rare genotypes tend to select multiple NS5A RAS after DAA failure e g 0 2c 2i 3b 2 3 NS5A RAS 4b 4c 4 4d 5 4g 6 4o 4r V ir o lo g ic f a ilu r e s w it h R A S in r e s p e c ti v e g e n o t y p e s (% ) A real world resistance profile of virologic failures collected from an international collaboration (SHARED) High frequency of S282T mutation in G4 failures Ga Gb G3 G4 22,6 3,2 2,9 2,9 9,6,7 6,5,9,5 0,6 4,6 3,2,0,0 NS5B amino acid RAS patterns are unique among genotypes New RAS were observed in real-world clinics Rare genotypes tend to select multiple RAS 20% of the G4 patients selected NS5B S282T after failing SOFregimens (confers 2- to 8-fold reduced drug susceptibility to SOF in HCV replicons) Howe A, et al. AASLD 208, San Francisco, USA. #204

22 Challenge No. 9 HCV Treatment in patients with HCC, BCLC stage B / C

23 A meta-analysis of the risk of HCC occurrence following SVR to IFN or DAAs IFN DAA 2.96 ( ).4 ( ) HCC occurrence rate (/00 PY) HCC occurrence rate (/00 PY) Meta regression of HCC occurrence Unadjusted RR Adjusted RR 95% CI P-value Average follow-up Average age DAA treatment Waziry R, et al. J Hepatol 207;67:204 2 RR: risk ratio

24 A meta-analysis of the risk of HCC recurrence following SVR to IFN or DAAs IFN DAA 2.6 ( ) 9.2 (7.8.8) HCC recurrence rate (/00 person-years) HCC recurrence rate (/00 PY) Meta regression of HCC reccurrence Unadjusted RR Adjusted RR 95% CI P-value Average follow-up Average age DAA treatment Waziry R, et al. J Hepatol 207;67:204 2

25 Consensus Statement for Management of Patients with Decompensated Cirrhosis and HCC Recommendation 3. We suggest that HCV-infected patients with decompensated cirrhosis and HCC, who are not expected to undergo liver transplantation within a short time (3-6 months), should be treated with antiviral therapy. Recommendation 3.2 We suggest that HCV-infected patients with decompensated cirrhosis and HCC, who are expected to undergo liver transplantation within a short time (3-6 months), should not be treated with antiviral therapy. Paucity of data, therefore pragmatic approach Primary benefit is prevention of waitlist drop off due to worsening decompensation, Potentially lower SVR rates Potentially more aggressive tumor growth Terrault et al., International Liver Transplantation Society Consensus Statement on Hepatitis C Management in Liver Transplant Candidates. Transplantation 207; 0:

26 Challenge No. 0 HCC surveillance in patients with SVR

27 Risk-based HCC surveillance strategies based on risk prediction models in patients who received antiviral treatment for HCV.00 SVR 0.95 No SVR 0.90 SVR 0.85 No cirrhosis with SVR No cirrhosis with no SVR Cirrhosis with SVR Cirrhosis with no SVR Years after start of HCV treatment No SVR 7 8 Probability free from HCC diagnosis Probability free from HCC diagnosis Current HCC screening strategy is to screen all cirrhotics regardless of SVR status, but not to screen non-cirrhotics Study aimed to develop and internally validate models to estimate HCC risk after antiviral treatment 45,80 veterans who started HCV antivirals Followed until Jun 207 for HCC occurrence, Predicted vs observed survival free of HCC diagnosis for Cirrhosis and no SVR Cirrhosis and SVR 297 incident HCCs No cirrhosis and no SVR 2 3 No cirrhosis and SVR Ioannou G, et al. AASLD 208, San Francisco, USA. #94 Ioannou G, et al., J. Hepatol. 208;69: Years after start of HCV treatment Observed Predicted Low risk Medium risk High risk 2 3

28 Risk-based HCC surveillance strategies based on risk prediction models in patients who received antiviral treatment for HCV HCC risk prediction models that can be used to estimate HCC risk in patients with HCV 80 days after antiviral treatment Web-based tool Input: Cirrhosis, SVR, age, gender, BMI, race/ethnicity, platelets, albumin, AST, ALT, GT, INR, hemoglobin (prior to DAA values) Key drivers: Age, platelets, AST/ ALT Categorize 3-year risk as low (<% per year), medium ( 3% per year), or high (>3% per year) Ioannou G, et al. AASLD 208, San Francisco, USA. #94 Ioannou G, et al., J. Hepatol. 208;69: Cirrhosis Yes Yes Yes No No No SVR No Yes Yes No No Yes Age Albumin AST ALT Platelet yr HCC risk 25.9 %.6 %. % 7.0 % 0.6 % 0.3 % Screening recommended Screening not recommended Screening/not screening with overlapping HCC risk Theoretically not screen low risk regardless of cirrhosis status

29 Challenge No. Diagnosis rates, linkage to care, access to daas

30 HCV treatment: linkage to care Enhanced HCV screening and diagnosis Expanded models of HCV treatment and care Specific strategies for highly marginalised patients National HCV strategies and political leadership Removal of restrictions on access to DAA therapy Increased and broadened HCV prescribers

31 Challenge No. 2 Vaccine Development

32 Total Viremic HCV Infections Countries Responsible for 80% of Global Infections Insert reference Gower, E., Estes C., Hindman, S., Razavi-Shearer, K., Razavi, H., Global epidemiology and genotype distribution of the hepatitis C virus. Journal of Hepatology (204)

33 WHO global health sector HCV strategy Prevention targets 90% of infants have HBV birth dose vaccination 00% of blood donations screened 90% have access to safe injections 5 x Increase in the number of sterile needles and syringes provided per injecting drug user per year Testing targets 90% of people aware of infection Treatment targets 80% of patients treated 90% of HCV patients cured World Hepatitis Alliance. Available at: WHO. Draft global health sector strategy on viral hepatitis, Available at: news-events/strategy /draft_global_health_sector_strategy_viral_hepatitis_3nov.pdf?ua= (Both accessed February 207) WHO: World Health Organization

34 Conclusions Several challenges remain in small populations. Most likely that these populations disappear faster than the challenges are solved e.g. patients with decompensated cirrhosis Some challenges remain in large populations e.g. HCC surveillance after SVR Some challenges are key to reduce the burden of disease in geographic regions and populations Diagnosis rates, linkage to care, and access to DAAs One challenge to indeed eliminate HCV globally Vaccine development

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