Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Afdhal N, Reddy KR, Nelson DR, et al. Ledipasvir and sofosbuvir for previously treated HCV genotype 1 infection. N Engl J Med 2014;370: DOI: /NEJMoa (PDF updated April 17, 2014.)

2 Contents ION-2 Principal Investigators... 3 Statistical Hypothesis for the Primary Efficacy Endpoint... 4 Figure S1. Algorithm for Prior Treatment Response Categorization... 5 Table S1. Reasons for Screen Failure... 6 Figure S2. Patient Disposition Study Assessments... 8 Criteria for Determining Treatment Duration for Group Table S2. Bonferroni-Adjusted Confidence Intervals for the Pairwise Differences in SVR12 Rates Table S3. Sustained Virologic Response by Subgroups Table S4. Proportion of Patients with ALT >ULN at Baseline Who Had ALT Normalization During Treatment 13 Table S5. Baseline Characteristics of Patients with Virologic Relapse after Treatment Exact Logistic Regression Analysis for Evaluating Associations between Baseline Characteristics and SVR Table S6: Univariate Exact Logistic Regression in Assessing Factors Associated with SVR Table S7: Final Exact Logistic Regression Model Identifying Factor(s) Associated with SVR Table S8. Contingency Table of Cirrhosis Status and Treatment Duration with SVR Figure S3. Mean HCV RNA by Presence or Absence of Baseline NS5A Resistance-Associated Variants Figure S4. Proportion of Patients with HCV RNA <LLOQ by Presence or Absence of Baseline NS5A Resistance-Associated Variants Table S9. Proportion of Patients with HCV RNA <25 IU/mL during Treatment by Cirrhosis Status Table S10. SVR12 by Early Viral Response and Cirrhosis Status Table S11. Platelets and Change from Baseline by Visit Table S12. Albumin and Change from Baseline by Visit Page 2

3 ION-2 Principal Investigators Nezam Afdhal, Avanish Aggarwal, Sanjeev Arora, Leslie Bank, Kimberly Beavers, Nicholaos Bellos, Michael Bennett, David Bernstein, Thomas Boyer, Robert Brown Jr, Mario Chojkier, Christopher Christensen, James Cooper, Adrian Di Bisceglie, Richard Elion, Robert Emslie, Kyle Etzkorn, Gregory Everson, Steven Flamm, Todd Frederick, Bradley Freilich, Michael Galambos, Joseph Galati, Reem Ghalib, Norman Gitlin, Stuart Gordon, David Hassman, Trevor Hawkins, Robert Herring, Federico Hinestrosa, Charles Howell, Ira Jacobson, Marcelo Kugelmas, Paul Kwo, Jacob Lalezari, Eric Lawitz, Claudia Martorell, Anthony Mills, Ronald Nahass, David Nelson, Mindie Nguyen, Keyur Patel, Paul Pockros, Gary Poleynard, John Poterucha, John Poulos, David Pound, Ronald Pruitt, Bruce Rashbaum, Natarajan Ravendhran, K. Rajender Reddy, Robert Reindollar, Peter Ruane, Vinod Rustgi, Michael Ryan, Eugene Schiff, Thomas Sepe, Aasim Sheikh, Mitchell Shiffman, Coleman Smith, Mark Sulkowski, Hugo Vargas, Kimberly Workowski, David Wyles, Ziad Younes 3

4 Statistical Hypothesis for the Primary Efficacy Endpoint The 4 primary statistical hypotheses of the study were that the SVR12 rates in each of the 4 treatment groups of the study would be higher than the adjusted historical SVR null rate of 25%. The 25% null SVR rate was derived from the historical data as follows: 1) For treatment experienced subjects (eg, PEG+RBV) receiving a PI-based triple therapy regimen, a historical retreatment SVR rate of approximately 65% was calculated from the telaprevir (REALIZE study) and boceprevir (RESPOND-2 study) data after adjusting for the expected proportion of subjects with cirrhosis (approximately 20%) in this study. The weighted average of the telaprevir and boceprevir data provided an estimate of SVR rate to be approximately 69% in noncirrhotic subjects and 50% in cirrhotic subjects. The retreatment SVR rate for the historical control in this study (ie, a patient population of 80% noncirrhotics and 20% cirrhotics) was then calculated to be approximately 65% (ie, % %); 2) For subjects who have had failed treatment with a PI + PEG+ RBV retreatment options are currently lacking. A conservative retreatment SVR rate of 5% was therefore used. In this study, the expected proportion of subjects having had prior treatment with a PI+PEG+RBV was approximately 50%. A 35% null SVR rate was obtained after averaging a 65% retreatment SVR control rate for treatment experienced subjects (eg, PEG+RBV) being retreated with PI+PEG+RBV (current SOC)and a 5% SVR control rate for subjects who failed prior treatment of a PI+PEG+RBV, if retreated with a PI+PEG+RBV. In addition, we allowed a discount of 10 percentage points in efficacy due to the expected improved safety profile and significantly shorter duration associated with the treatment, which resulted in a null SVR rate for this study of 25%. 4

5 Figure S1. Algorithm for Prior Treatment Response Categorization 5

6 Table S1. Reasons for Screen Failure Of the 551 patients screened, 110 were screen failures (four patients failed for more than one reason) Screen failure patients who did not meet criteria Inclusion criteria 31 Lab parameters at screening: ALT 10xULN, AST 10xULN, Hgb 12 g/dl (M) & 11 g/dl (F), Platelets 50,000/uL, INR 1.5, Albumin 3 g/dl, Direct bilirubin 1.5xULN, HbA1c 8.5%, Creatinine clearance 60 ml /min, INR 1.5 ULN 10 Cirrhosis determination: a) Cirrhosis is defined as any one of the following: i) Liver biopsy showing cirrhosis (e.g., Metavir score = 4 or Ishak score 5), ii) FibroTest score of > 0.75 AND an AST: platelet ratio index (APRI) of > 2 during Screening b) Absence of cirrhosis is defined as any one of the following: i) Liver biopsy within 2 years of Screening showing absence of cirrhosis, ii) FibroTest score of 0.48 AND APRI of 1 during Screening c) In the absence of a definitive diagnosis of presence or absence of cirrhosis by the above criteria, a liver biopsy is required; liver biopsy results will supersede blood test results and be considered definitive. 5 Liver imaging within 6 months of Baseline/Day 1 to exclude hepatocellular carcinoma is required in patients with cirrhosis 3 Prior virologic failure after treatment with a pegylated interferon (PEG) and ribavirin (RBV) regimen, including those who have failed treatment with a NS3/4A protease inhibitor (PI) plus PEG/RBV regimen. Subjects must not have discontinued prior therapy due to an adverse event. 2 Willing and able to provide written informed consent 2 HCV RNA 10 4 IU/mL at Screening 1 HCV genotype 1a, 1b, or mixed 1a/1b at Screening as determined by the Central Laboratory. 1 Not pregnant or nursing 1 Subject must be of generally good health, with the exception of chronic HCV infection Exclusion criteria 8 Clinically-relevant drug abuse within 12 months of screening. 2 History of clinically-significant illness or any other major medical disorder that may interfere with treatment, assessment, or compliance with the protocol 1 Chronic liver disease of a non-hcv etiology 1 Prohibited concomitant medication Screen failure patients who did meet criteria Reason for non-enrollment 3 Subject withdrew consent 16 Study enrollment closed 27 Other 6

7 Figure S2. Patient Disposition 551 screened 110 screen failures 64 did not meet eligibility criteria 16 due to close of enrollment period 3 withdrew consent 27 due to other reasons 441 randomized 1 randomized patient was never dosed 440 randomized and treated 109 were assigned to receive SOF + LDV for 12 weeks N = were assigned to receive SOF + LDV + RBV for 12 weeks N = were assigned to receive SOF + LDV for 24 weeks N = were assigned to receive SOF + LDV + RBV for 24 weeks 109 completed treatment 111 completed treatment 107 completed treatment 110 completed treatment 109 included in the efficacy and safety analyses 111 included in the efficacy and safety analyses 109 included in the efficacy and safety analyses 111 included in the efficacy and safety analyses 7

8 Study Assessments HCV genotype and subtype were determined using the Siemens VERSANT HCV Genotype INNO-LiPA 2.0 assay. IL28B genotype was determined by PCR amplification and sequencing of the rs single-nucleotide polymorphism. On-treatment assessments included laboratory testing, serum HCV RNA, vital signs, electrocardiography, and symptom-directed physical examinations. All adverse events were recorded and graded according to a standardized scale (see Appendix 3 of study protocol, available at NEJM.org). Plasma samples for viral sequence analysis were collected at Baseline/Day 1 and every subsequent visit (as appropriate). Patients with virologic failure underwent resistance testing. Analyses of samples for HCV NS5A and NS5B substitutions at baseline and virologic failure time points were conducted. DDL Diagnostics Laboratory (Rijswijk, The Netherlands, EU) performed amplification and population sequencing, and WuXi Apptec (Shanghai, China) performed deep sequencing assays to identify treatment-emergent virologic resistance. 8

9 Criteria for Determining Treatment Duration for Group 1 The duration of treatment for the first group depended on emerging results from the LONESTAR trial (clinicaltrials.gov number NCT ). One treatment group in LONESTAR was made up of patients who had previously received unsuccessful treatment with a protease-inhibitor regimen (50% of whom could have cirrhosis). This group received 12 weeks of treatment with the sofosbuvir-ledipasvir fixed-dose combination. If at least 75% of those patients had HCV RNA <LLOQ 4 weeks after the end of treatment, patients randomized in the present study to receive sofosbuvir-ledipasvir for the pending treatment duration (ie12 or 24 weeks) in the current study would stop treatment with sofosbuvir-ledipasvir after 12 weeks; if not, they would continue to 24 weeks. The rate of sustained virologic response in the group of 19 patients receiving sofosbuvirledipasvir in the LONESTAR trial was 95% (18 of 19 patients). 1 Therefore, patients in group 1 of ION-2 stopped treatment after 12 weeks. 1. Lawitz E, Poordad FF, Pang PS, et al. Sofosbuvir and ledipasvir fixed-dose combination with and without ribavirin in treatment-naïve and previously treated patients with genotype 1 hepatitis C virus infection (LONESTAR): an open-label, randomised, phase 2 trial. Lancet 2014;383:

10 Table S2. Bonferroni-Adjusted Confidence Intervals for the Pairwise Differences in SVR12 Rates SOF/LDV SOF/LDV + RBV SOF/LDV SOF/LDV + RBV 12 Weeks 12 Weeks 24 Weeks 24 Weeks (N = 109) (N = 111) (N = 109) (N = 111) SVR12 102/109 (93.6%) 107/111 (96.4%) 108/109 (99.1%) 110/111 (99.1%) 95% CI 87.2% to 97.4% 91.0% to 99.0% 95.0% to 100.0% 95.1% to 100.0% SOF/LDV 12 weeks vs SOF/LDV + RBV 12 weeks Prop Diff -2.7% (99.17% CI) (-12.4%, 7.0%) SOF/LDV 24 weeks vs SOF/LDV + RBV 24 weeks Prop Diff -0.04% (99.17% CI) (-7.6%, 7.5%) SOF/LDV 12 weeks vs SOF/LDV 24 weeks Prop Diff -5.5% (99.17% CI) (-14.6%, 3.6%) SOF/LDV + RBV 12 weeks vs SOF/LDV + RBV 24 weeks Prop Diff -2.7% (99.17% CI) (-11.0%, 5.5%) SOF/LDV 12 weeks vs SOF/LDV + RBV 24 weeks Prop Diff -5.5% (99.17% CI) (-14.6%, 3.6%) SOF/LDV + RBV 12 weeks vs SOF/LDV 24 weeks Prop Diff -2.8% (99.17% CI) (-11.1%, 5.5%) 10

11 Table S3. Sustained Virologic Response by Subgroups 11

12 Table S3. Sustained Virologic Response by Subgroups (continued) 12

13 Table S4. Proportion of Patients with ALT >ULN at Baseline Who Had ALT Normalization During Treatment 13

14 Table S5. Baseline Characteristics of Patients with Virologic Relapse after Treatment 12-Week Treatment Group Age (years) Race Sex HCV Genotype HCV RNA (log 10 IU/mL) Platelets ( 10 3 /µl) IL28B Cirrhosis (yes/no) Baseline NS5A RAV (yes/no) Prior Treatment Prior Treatment Response SOF-LDV 64 White M 1b CT Yes No PI+Peg-IFN+RBV Relapse/ Breakthrough SOF-LDV 62 White M 1b CT Yes No Peg-IFN+RBV Null Responder SOF-LDV 64 White M 1a CT Yes No PI+Peg-IFN+RBV Relapse/ Breakthrough SOF-LDV 61 White M 1b CT No Yes Peg-IFN+RBV Null Responder SOF-LDV 58 White F 1a CT No Yes PI+Peg-IFN+RBV Non-Responder SOF-LDV 57 White F 1a CT No Yes PI+Peg-IFN+RBV Relapse/ Breakthrough SOF-LDV 54 White M 1a CT No Yes Peg-IFN+RBV Non-Responder: Partial Responder SOF-LDV+RBV 60 White M 1a TT Yes Yes PI+Peg-IFN+RBV Non-Responder SOF-LDV+RBV 65 White M 1a CT Yes No Peg-IFN+RBV Relapse/ Breakthrough SOF-LDV+RBV 63 Black M 1a CT Yes No PI+Peg-IFN+RBV Non-Responder SOF-LDV+RBV 60 White M 1a CT Yes Yes Peg-IFN+RBV Relapse/ Breakthrough 14

15 Exact logistic regression analysis for evaluating associations between baseline characteristics and SVR12 Univariate exact logistic regression analysis was performed to assess the relationship between sustained virologic response and 15 baseline demographic and clinical factors: treatment with or without RBV, 12 or 24 weeks of treatment, age (<65 or 65 years old), sex, race (black or non-black), ethnicity (Hispanic/Latino or not Hispanic/Latino), HCV genotype (1a or 1b), cirrhosis (yes or no), response to prior HCV therapy (relapse/breakthrough or non-responder), prior HCV therapy (PEG+RBV or PI+PEG+RBV), baseline HCV RNA viral load (<800,000 IU/mL or 800,000 IU/mL), BMI (<30 or 30 kg/m 2 ), IL28B alleles (CC or non-cc), GGT, and platelets (<125 or /µl ). Factors found to be significant according to in the univariate analysis (p value <0.05) were then evaluated in a multivariate exact logistic regression model using a forward selection procedure to identify the factors most predictive of sustained virologic response. Factors found to be significant (p value <0.05) using this forward selection procedure were included in the final exact logistic regression analysis. Table S6. Univariate Exact Logistic Regression in Assessing Factors Associated with SVR12 Variable Odds Ratio 95% Confidence Limit 2-Sided P Value Treatment: with ribavivin (0.468, 6.524) Treatment: 24 weeks (1.226, ) Age group (years): < (0.025, 7.939) Sex: female (0.643, ) Race: black (0.248, ) Ethnicity: Hispanic or Latino (0.313, Infinity) HCV genotype: 1a (0.195, 4.484) Cirrhosis: no (1.386, ) Response to prior HCV therapy: relapse/breakthrough (0.419, 5.433) Prior HCV therapy: PEG+RBV (0.296, 3.837) Baseline HCV RNA (IU/mL): <800, (0.221, ) Baseline BMI (kg/m 2 ): ( ) IL28B: CC (0.247, ) Baseline GGT (U/L) (continuous) (0.994, 1.003) Baseline platelets ( 10 3 /µl): (1.269, )

16 Table S7. Final Exact Logistic Regression Model Identifying Factor(s) Associated with SVR12 Variable Odds Ratio 95% Confidence Limit 2-Sided P Value Cirrhosis: no (1.406, ) Treatment: 24 weeks (1.243, ) Table S8. Contingency Table of Cirrhosis Status and Treatment Duration with SVR12 Cirrhosis Treatment Duration Yes SVR12 yes 81 7 no No 12 weeks weeks Note: The exact 95% CI of SVR12 rate is based on the Clopper-Pearson method. SVR12 Rate (95% CI) 92.1% (84.3%, 96.7%) 98.3% (96.3%, 99.4%) 95.0% (91.2%, 97.5%) 99.1% (96.8%, 99.9%) 16

17 Figure S3. Mean HCV RNA by Presence or Absence of Baseline NS5A Resistance-Associated Variants Pooled analysis of all randomized patients in all four treatment groups who received at least 1 dose of study drug. One subject without baseline NS5A data is excluded. Error bars are constructed using 1 standard deviation from the mean. 17

18 Figure S4. Proportion of Patients with HCV RNA <LLOQ by Presence or Absence of Baseline NS5A Resistance-Associated Variants Pooled analysis of all randomized patients in all four treatment groups who received at least 1 dose of study drug. One subject without baseline NS5A data is excluded. 18

19 Table S9. Proportion of Patients with HCV RNA <25 IU/mL during Treatment by Cirrhosis Status 19

20 Table S9. Proportion of Patients with HCV RNA <25 IU/mL during Treatment by Cirrhosis Status (continued) 20

21 Table S10. SVR12 by Early Viral Response and Cirrhosis Status 21

22 Table S11. Platelets and Change from Baseline by Visit 22

23 Table S12. Albumin and Change from Baseline by Visit 23