Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak)

Transcription

1 HEPATITIS WEB STUDY HEPATITIS C ONLINE Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) Prepared by: Sophie Woolston, MD and David H. Spach, MD Last Updated: December 29, 2014

2 OMBITASVIR-PARITAPREVIR-RITONAVIR + DASABUVIR Background and Dosing

3 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) Approval Status: FDA approval on December 19, 2014 Indication: Genotype 1 chronic HCV infection, including compensated cirrhosis Class & Mechanism - Ombitasvir (ABT-267): NS5A inhibitor - Paritaprevir (ABT-450): NS3/4A serine protease inhibitor - Ritonavir: HIV protease inhibitor used as pharmacologic booster - Dasabuvir (ABT-333): Non-nucleoside NS5B polymerase inhibitor Tablets: Ombitasvir-Paritaprevir-Ritonavir (fixed dose 12.5/75/50 mg) Dasabuvir: 250 mg Dose: 2 tablets Ombitasvir-Paritaprevir-Ritonavir once daily (am) with food plus Dasabuvir 1 tablet twice daily with food Adverse Effects (AE): fatigue, pruritus, and insomnia Cost: $83,319 for 12-week course Source: Viekira Pak Prescribing Information. AbbVie Inc.

4 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) Indications and Usage Patient Populations Treatment* Duration GT1a, without cirrhosis GT1a, with cirrhosis GT1b, without cirrhosis GT1b, with cirrhosis Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir + Ribavirin Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir + Ribavirin Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir + Ribavirin 12 weeks 24 weeks** 12 weeks 12 weeks *Follow the genotype 1a dosing recommendations in patients with an unknown genotype 1 subtype or with mixed genotype 1 infection. **Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir + ribavirin for 12 weeks may be considered for some patients based on prior treatment history Source: Viekira Pak Prescribing Information. AbbVie Inc.

5 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) Contraindications Decompensated cirrhosis Concomitantly taking medications that are: - highly dependent on CYP3A for clearance, - strong inducers of CYP3A and CYP2C8, or - strong inhibitors of CYP2C8 Known hypersensitivity to ritonavir Source: Viekira Pak Prescribing Information. AbbVie Inc.

6 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) Estimated Medication Cost for Therapy Estimated Cost of Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir Duration of Treatment Estimated Cost* 12 Weeks (without ribavirin) $83, Weeks (without ribavirin) Unknown *Estimated cost based on Wholesaler Acquisition Cost in United States

7 Drugs Contraindicated for Use with Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir Drug Class Alpha1-adrenoreceptor antagonist Anticonvulsants Antihyperlipidemic agent Antimycobacterial Ergot derivatives Ethinyl estradiol-containing products Herbal Product HMG-CoA Reductase Neuroleptics Non-nucleoside reverse transcriptase inhibitor Phosphodiesterase-5 (PDE5) inhibitor Sedatives/hypnotics Drug(s) within Class that are Contraindicated Alfuzosin HCL Carbamazepine, phenytoin, phenobarbital Gemfibrozil Rifampin Ergotamine, dihydroergotamine, ergonovine, methylergonovine Ethinyl estradiol-containing medications such as combined oral contraceptives St. John s Wort (Hypericum perforatum) Lovastatin, simvastatin Pimozide Efavirenz Sildenafil when dosed as Revatio for the treatment of pulmonary arterial hypertension (PAH) Triazolam; Orally administered midazolam Source: Viekira Pak Prescribing Information. AbbVie Inc.

8 Drugs Contraindicated for Use with Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir Drug Class Drug(s) within Contraindicated Class Clinical Comments Alpha1-adrenoreceptor antagonist Anticonvulsants Antihyperlipidemic agent Antimycobacterial Ergot derivatives Ethinyl estradiol-containing products Herbal Product Alfuzosin HCL Carbamazepine, phenytoin, phenobarbital Gemfibrozil Rifampin Ergotamine, dihydroergotamine, ergonovine, methylergonovine Ethinyl estradiol-containing medications such as combined oral contraceptives St. John s Wort (Hypericum perforatum) Source: Viekira Pak Prescribing Information. AbbVie Inc. Potential for hypotension. Ombitasvir, paritaprevir, ritonavir and dasabuvir exposures may decrease leading to a potential loss of activity for HCV therapy Increase in dasabuvir exposures by 10-fold which may increase the risk of QT prolongation. Ombitasvir, paritaprevir, ritonavir and dasabuvir exposures may decrease leading to a potential loss of HCV therapeutic activity. Acute ergot toxicity characterized by vasospasm and tissue ischemia has been associated with co-administration of ritonavir and ergonovine, ergotamine, dihydroergotamine, or methylergonovine. Potential for ALT elevations Ombitasvir, paritaprevir, ritonavir and dasabuvir exposures may decrease leading to a potential loss of HCV therapeutic activity. HMG-CoA Reductase Lovastatin, simvastatin Potential for myopathy including rhabdomyolysis. Neuroleptics Pimozide Potential for cardiac arrhythmias. Non-nucleoside reverse transcriptase inhibitor Phosphodiesterase-5 (PDE5) inhibitor Sedatives/hypnotics Efavirenz Sildenafil when dosed as REVATIO for the treatment of pulmonary arterial hypertension (PAH) Triazolam Orally administered midazolam Co-administration of efavirenz based regimens with paritaprevir, ritonavir plus dasabuvir was poorly tolerated and resulted in liver enzyme elevations. There is increased potential for sildenafil-associated adverse events such as visual disturbances, hypotension, priapism, and syncope. Triazolam and orally administered midazolam are extensively metabolized by CYP3A4. Coadministration of triazolam or orally administered midazolam with VIEKIRA PAK may cause large increases in the concentration of these benzodiazepines. The potential exists for serious and/or life threatening events such as prolonged or increased sedation or respiratory depression.

9 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) +/- RBV Summary of Key Phase 3 Studies SAPPHIRE-I: GT1 (a & b), Treatment-Naïve, without cirrhosis - Ombitasvir-paritaprevir-ritonavir + dasabuvir + RBV x 12 weeks PEARL-III: GT1b, Treatment-Naïve, without cirrhosis - Ombitasvir-paritaprevir-ritonavir + dasabuvir +/- RBV x 12 weeks PEARL-IV: GT1a, Treatment-Naïve, without cirrhosis - Ombitasvir-paritaprevir-ritonavir + dasabuvir +/- RBV x 12 weeks SAPPHIRE-II: GT1 (a & b), Treatment-Experienced, without cirrhosis - Ombitasvir-paritaprevir-ritonavir + dasabuvir + RBV x 12 weeks PEARL-II: GT1b, Treatment-Experienced, without cirrhosis - Ombitasvir-paritaprevir-ritonavir + dasabuvir +/- RBV x 12 week TURQUOISE II: GT1 (a & b), Treatment-Naïve & Experienced, with cirrhosis - Ombitasvir-paritaprevir-ritonavir + dasabuvir + RBV x 12 or 24 weeks

10 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir (Viekira Pak) +/- RBV Summary of Key Studies in Special Populations TURQUOISE-I: GT1 (a & b), HIV Coinfection, Treatment Naïve/Experienced - Ombitasvir-paritaprevir-ritonavir + dasabuvir + RBV x 12 or 24 weeks CORAL-I: GT1 (a & b), Post-Liver Transplantation Recipients - Ombitasvir-paritaprevir-ritonavir + dasabuvir + RBV x 24 weeks

11 Phase 3 Treatment Naïve Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-I Feld JJ, et al. N Engl J Med. 2014;370:

12 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Design SAPPHIRE-I: Features Design: Phase 3, randomized, double-blind, placebo-controlled trial evaluating safety and efficacy of ombitasvir-paritaprevir-ritonavir and dasabuvir + ribavirin for 12 weeks in treatment-naïve patients with chronic hepatitis C virus genotype 1 Setting: International at 79 sites in North America, Europe, and Australia Entry Criteria - Chronic HCV infection with genotype 1a or 1b - Treatment-naïve - Age Plasma HCV RNA greater than 10,000 IU/mL - Absence of cirrhosis - Absence of coinfection with HBV or HIV Primary End-Point: SVR12 Source: Feld JJ, et al. N Engl J Med. 2014;370:

13 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Study Regimens Week Double blind Group A N = 473 Ombitasvir-Paritaprevir- RTV + Dasabuvir + Ribavirin SVR12 Open label (data pending) Group B N = 158 Placebo Ombitasvir-Paritaprevir- RTV + Dasabuvir + Ribavirin SVR12 RTV = Ritonavir Drug Dosing Ombitasvir-Paritaprevir-Ritonavir (25/150/100 mg once daily) + Dasabuvir: 250 mg twice daily Ribavirin (RBV): weight-based and divided bid (1000 mg/day if < 75 kg or 1200 mg/day if 75 kg) Source: Feld JJ, et al. N Engl J Med. 2014;370:

14 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Baseline Characteristics Baseline Characteristic Group A (N=473) Group B (N=158) Age (years), Mean Male sex % Race (%) White Black Other Source: Feld JJ, et al. N Engl J Med. 2014;370: Body Mass Index (Mean) HCV genotype (%) 1a 1b IL28B CC genotype, (%) HCV RNA, log 10 IU/ml Fibrosis score F

15 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Results SAPPHIRE-I: SVR12 in Group A, by Genotype 1 Subtype Patients (%) with SVR / / /151 All GT-1a GT-1b Source: Feld JJ, et al. N Engl J Med. 2014;370:

16 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Results SAPPHIRE-I: SVR12 in Group A, Fibrosis Score Patients (%) with SVR /363 66/70 37/40 F0-F1 F2 F3 Fibrosis Score Source: Feld JJ, et al. N Engl J Med. 2014;370:

17 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Adverse Events During Double-Blind Phase NUTRINO: SVR 12 by Group Event Liver A = 3D + Disease RBV (N=473) Group B = Placebo (N=158) Any adverse event (%) Any adverse event leading to discontinuation of study drug (%) Any serious adverse event (%) Grade 3 or 4 lab abnormality (%) Alanine aminotransferase Aspartate aminotransferase Alkaline phosphatase 0 0 Total bilirubin Hemoglobin 0 0 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin Source: Feld JJ, et al. N Engl J Med. 2014;370:

18 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin in GT1 SAPPHIRE-I Study: Conclusions Conclusions: In previously untreated patients with HCV genotype 1 infection and no cirrhosis, a 12-week multitargeted regimen of ABT-450/r ombitasvir and dasabuvir with ribavirin was highly effective and was associated with a low rate of treatment discontinuation. Note: ABT-450/r = Paritaprevir-Ritonavir Source: Feld JJ, et al. N Engl J Med. 2014;370:

19 Phase 3 Treatment Naïve Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV Ferenci P, et al. N Engl J Med. 2014;370:

20 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Study Design PEARL-III and PEARL-IV: Features Design: Two phase 3, randomized, open-label trials evaluating safety and efficacy of ombitasvir-paritaprevir-ritonavir + dasabuvir +/- ribavirin for 12 weeks in treatment-naïve patients with chronic HCV GT 1b (PEARL-III) or 1a (PEARL- IV) Setting: International (PEARL-III at 53 sites and PEARL-IV at 50 sites) Entry Criteria - Chronic HCV infection with genotype 1a or 1b - Treatment-naïve - Age Plasma HCV RNA greater than 10,000 IU/mL - Absence of cirrhosis - Absence of coinfection with HBV or HIV Primary End-Point: SVR12 Source: Ferenci P, et al. N Engl J Med. 2014;370:

21 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Study Regimens Week HCV Genotype 1a n = 100 3D + Ribavirin SVR12 n = 205 3D + Placebo SVR12 HCV Genotype 1b n = 210 3D+ Ribavirin SVR12 n = 209 3D + Placebo SVR12 3D = Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir Drug Dosing 3D = Ombitasvir-Paritaprevir-Ritonavir (25/150/100 mg once daily) + Dasabuvir: 250 mg twice daily Ribavirin (RBV): weight-based and divided bid (1000 mg/day if < 75kg or 1200 mg/day if 75kg) Source: Ferenci P, et al. N Engl J Med. 2014;370:

22 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Baseline Characteristics Baseline Characteristic 3D + RBV (n=100) Genotype 1a 3D (n=205) 3D + RBV (n=210) Genotype 1b 3D (n=209) Age, years Male sex (%) BMI kg/m Race (%) White Black Other IL28B CC (%) Metavir F3 (%) 16.0% 18.5% 10.5% 9.6% HCV RNA log 10 IU/ml D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin Source: Ferenci P, et al. N Engl J Med. 2014;370:

23 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Results Patients with SVR12 (%) / / / /209 3D + RBV 3D 3D + RBV 3D Genotype 1a Genotype 1b 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir RBV = Ribavirin Source: Ferenci P, et al. N Engl J Med. 2014;370:

24 Event Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Adverse Events 3D + RBV (n=100) GT1a Source: Ferenci P, et al. N Engl J Med. 2014;370: D (n=205) 3D + RBV (n=210) GT1b 3D (n=209) Any adverse event % Any serious adverse event % Common adverse events: Headache % Fatigue % Pruritus % Nausea % Insomnia % Diarrhea % Laboratory abnormalities (%): Hemoglobin < 10 g/dl Total bilirubin > 3x ULN D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin

25 Event Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Adverse Events 3D + RBV (n=100) GT1a Source: Ferenci P, et al. N Engl J Med. 2014;370: D (n=205) 3D + RBV (n=210) GT1b 3D (n=209) Any adverse event % Any serious adverse event % Common adverse events: Headache % Fatigue % Pruritus % Nausea % Insomnia % Diarrhea % Laboratory abnormalities (%): Hemoglobin < 10 g/dl Total bilirubin > 3x ULN D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin

26 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1 PEARL-III and PEARL-IV: Conclusions Conclusions: Twelve weeks of treatment with ABT-450/r ombitasvir and dasabuvir without ribavirin was associated with high rates of sustained virologic response among previously untreated patients with HCV genotype 1 infection. Rates of virologic failure were higher without ribavirin than with ribavirin among patients with genotype 1a infection but not among those with genotype 1b infection. Note: ABT-450/r = Paritaprevir-Ritonavir Source: Ferenci P, et al. N Engl J Med. 2014;370:

27 Phase 3 Treatment Experienced Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II Zeuzem S, et al. N Engl J Med. 2014;370:

28 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II: Study Design SAPPHIRE-II: Features Design: Phase 3, randomized, open-label trial evaluating safety and efficacy of ombitasvir-paritaprevir-ritonavir and dasabuvir + ribavirin for 12 weeks in treatment-experienced patients with chronic HCV genotype 1 Setting: 76 sites in Australia, North America, and Europe Entry Criteria - Chronic HCV infection with genotype 1 - Prior treatment experience with peginterferon plus ribavirin - Age Plasma HCV RNA greater than 10,000 IU/mL - Absence of cirrhosis - Absence of coinfection with HBV or HIV Primary End-Point: SVR12 Source: Zeuzem S, et al. N Engl J Med. 2014;370:

29 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II: Regimens Week Double blind Active N = 297 Ombitasvir-Paritaprevir-RTV and Dasabuvir + Ribavirin SVR12 Open label (data pending) Placebo N = 97 Placebo Ombitasvir-Paritaprevir-RTV and Dasabuvir + Ribavirin SVR12 RTV = Ritonavir Drug Dosing Ombitasvir-Paritaprevir-Ritonavir (25/150/100 mg once daily) + Dasabuvir: 250 mg twice daily Ribavirin (RBV): weight-based and divided bid (1000 mg/day if < 75kg or 1200 mg/day if 75kg) Source: Zeuzem S, et al. N Engl J Med. 2014;370:

30 Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir + RBV in GT1 SAPPHIRE-II Study: Baseline Characteristics Baseline Characteristic 3D + RBV (n=297) Placebo Arm (n=97) Age (years), Mean Male sex % Race (%) White Black Asian Body Mass Index (Mean) HCV genotype (%) 1a 1b Source: Zeuzem S, et al. N Engl J Med. 2014;370: IL28B CC genotype, (%) Type of Prior Response Relapse Partial Response Null Response HCV RNA, log 10 IU/ml (mean) Fibrosis score F2 or F3 (%) D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin

31 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II: Results SAPPHIRE-II: Results by Genotype 1 Subtype Patients (%) with SVR / / /123 All GT-1a GT-1b Source: Zeuzem S, et al. N Engl J Med. 2014;370:

32 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II: Results SAPPHIRE-II: Results by Prior Treatment Response Patients (%) with SVR /297 82/86 65/65 139/146 All Prior Relapse Prior Partial Response Prior Null Response Source: Zeuzem S, et al. N Engl J Med. 2014;370:

33 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II Study: Key Adverse Events Event 3D + RBV (n=297) Placebo (n=97) Any adverse events % Any serious adverse event % Common adverse events: Headache % Fatigue % Nausea % Asthenia % Insomnia % Pruritus % Diarrhea % Dyspnea % Cough % Myalgia % Abnormalities in laboratory values of grade 3 or 4 % Alanine aminotransferase Total bilirubin D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin Source: Zeuzem S, et al. N Engl J Med. 2014;370:

34 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 SAPPHIRE-II: Conclusions Conclusions: Rates of response to a 12-week interferon-free combination regimen were more than 95% among previously treated patients with HCV genotype 1 infection, including patients with a prior null response. Source: Zeuzem S, et al. N Engl J Med. 2014;370:

35 Phase 3 Treatment Experienced Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II Andreone P, et al. Gastroenterology. 2014;147:

36 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Study Design PEARL-II: Features Design: Phase 3, randomized, open-label trial evaluating safety and efficacy of 3D (ombitasvir-paritaprevir-ritonavir + dasabuvir) with or without ribavirin for 12 weeks in treatment-experienced patients with chronic HCV GT 1b Setting: 43 international sites Entry Criteria - Chronic HCV infection with genotype 1b - Prior treatment experience with peginterferon plus ribavirin - Age Plasma HCV RNA greater than 10,000 IU/mL - Absence of cirrhosis - Absence of coinfection with HBV or HIV Primary End-Point: SVR12 Source: Andreone P, et al. Gastroenterology. 2014;147:

37 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Regimens Week n = 91 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + Ribavirin SVR12 n = 95 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir SVR12 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir Drug Dosing Ombitasvir-Paritaprevir-Ritonavir (25/150/100 mg once daily) + Dasabuvir: 250 mg twice daily Ribavirin (RBV): weight-based and divided bid (1000 mg/day if < 75kg or 1200 mg/day if 75kg) Source: Andreone P, et al. Gastroenterology. 2014;147:

38 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Baseline Characteristics Baseline Characteristic 3D + RBV (n=91) 3D (n=95) Age (years), Mean Male sex % Race (%) White Black Source: Andreone P, et al. Gastroenterology. 2014;147: Body Mass Index (Mean) Previous Response to PEG + RBV Null responder Partial responder Relapser IL28B Non-CC genotype, (%) HCV RNA, log 10 IU/ml (mean) Fibrosis score F3 (%) D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin

39 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Results PEARL-II: SVR 12 Rates* Patients (%) with SVR /88 91/91 3D + RBV 3D *Primary endpoint by intention-to-treat analysis 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Andreone P, et al. Gastroenterology. 2014;147:

40 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Results by Prior Treatment Response PEARL-II: Results by Prior Treatment Response Patients (%) with SVR D + RBV 3D /88 91/91 29/31 32/32 24/25 26/26 32/32 33/33 Overall Null Responder Partial Responder Relapser 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Andreone P, et al. Gastroenterology. 2014;147:

41 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Treatment-Emergent Adverse Effects Event 3D + RBV (n=91) 3D (n=95) Any Treatment Emergent Adverse Effect % Any serious Treatment Emergent Adverse Effect % Common Treatment Emergent Adverse Events: Fatigue % Headache % Nausea % Insomnia % Pruritus % Diarrhea % Asthenia % Anemia % Blood bilirubin level increased % Rash % Laboratory abnormalities (%): Hemoglobin (< lower limit of normal at end of treatment) Total bilirubin > 3x ULN D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin Source: Andreone P, et al. Gastroenterology. 2014;147:

42 Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir +/- RBV in GT1b PEARL-II: Conclusions Conclusions: The interferon-free regimen of ABT-450, ritonavir, ombitasvir, and dasabuvir, with or without ribavirin, produces a high rate of SVR12 in treatment-experienced patients with HCV genotype 1b infection. Both regimens are well tolerated, as shown by the low rate of discontinuations and generally mild adverse events. Note: ABT-450 = Paritaprevir Source: Andreone P, et al. Gastroenteroly. 2014;147:

43 Phase 3 Treatment Naïve and Treatment Experienced Compensated Cirrhosis Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in GT1 TURQUOISE-II Poordad F, et al. N Engl J Med. 2014;370:

44 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Study Design TURQUOISE-II: Features Design: Phase 3, randomized, open-label trial evaluating safety and efficacy of 3D (ombitasvir-paritaprevir-ritonavir & dasabuvir) + ribavirin for 12 or 24 weeks in treatmentnaïve and experienced patients with chronic HCV GT 1 and compensated cirrhosis Setting: 78 sites in North America and Europe Entry Criteria - Chronic HCV infection with genotype 1 - Treatment-naïve or previously treated with peginterferon + RBV - Age Plasma HCV RNA greater than 10,000 IU/mL - Cirrhosis (Metavir >3, Ishak score >4 or Fibroscan 14.6 kpa) - Cirrhosis is compensated (Child-Pugh score <7 at screening) - Absence of coinfection with HBV or HIV Primary End-Point: SVR12 Source: Poordad F, et al. N Engl J Med. 2014;370:

45 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Regimens Week Group A N = 208 3D + Ribavirin SVR12 Group B N = 172 3D + Ribavirin SVR12 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir Drug Dosing Ombitasvir-Paritaprevir-Ritonavir (25/150/100 mg once daily) + Dasabuvir: 250 mg twice daily Ribavirin (RBV): weight-based and divided bid (1000 mg/day if < 75kg or 1200 mg/day if 75kg) Source: Poordad F, et al. N Engl J Med. 2014;370:

46 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Results TURQUOISE II: SVR12 by Genotype 1 Subtype Patients (%) with SVR D + RBV x 12 Weeks D + RBV x 24 Weeks / / / /121 67/68 50/51 Overall GT1a GT1b 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Poordad F, et al. N Engl J Med. 2014;370:

47 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Results TURQUOISE II: SVR12 Based on Prior Treatment Patients (%) with SVR D + RBV x 12 Weeks 3D + RBV x 24 Weeks /86 70/74 28/29 23/23 17/18 13/13 65/75 59/62 No Prior Treatment Prior Relapser Partial Responder Null Responder 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Poordad F, et al. N Engl J Med. 2014;370:

48 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Results for GT1a TURQUOISE II: Genotype 1a SVR12 Based on Prior Treatment Patients (%) with SVR D + RBV x 12 Weeks D + RBV x 24 Weeks /64 52/56 14/15 13/13 11/11 10/10 40/50 39/42 No Prior Treatment Prior Relapser Partial Responder Null Responder 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Poordad F, et al. N Engl J Med. 2014;370:

49 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Results for GT1b TURQUOISE II: Genotype 1b SVR12 Based on Prior Treatment 100 3D + RBV x 12 Weeks 3D + RBV x 24 Weeks Patients (%) with SVR No Prior Treatment Prior Relapser Partial Responder Null Responder /22 18/18 14/14 10/10 6/7 3/3 25/25 20/20 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Poordad F, et al. N Engl J Med. 2014;370:

50 Event 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Adverse Effects Source: Poordad F, et al. N Engl J Med. 2014;370: D + RBV x 12 weeks (n=208) 3D + RBV x 24 weeks (n=172) Any adverse event (%) Adverse event leading to stopping study drug (%) Any serious adverse event Most common adverse event Fatigue (%) Headache (%) Nausea (%) Pruritis (%) Insomnia (%) Diarrhea (%) Asthenia (%) Rash (%) Irritability (%) Anemia (%) Dyspnea (%) D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin

51 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Adverse Effects Lab Abnormalities 3D + RBV x 12 weeks (n=208) 3D + RBV x 24 weeks (n=172) Alanine aminotransferase, grade 3 or 4 6 (2.9) 0 Aspartate aminotransferase, grade 3 or 4 1 (0.5) 0 Alkaline phosphatase, grade 3 or Total bilirubin, grade 3 or 4 28 (13.5) 9 (5.2) Hemoglobin Grade 1 Grade 2 Grade 3 Grade (49.5) 12 (5.8) 2 (1.0) 1 (0.5) 97 (56.4) 18 (10.5) 1 (0.6) 0 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Poordad F, et al. N Engl J Med. 2014;370:

52 3D + Ribavirin in GT1 and Compensated Cirrhosis TURQUOISE-II: Conclusions Conclusions: In this phase 3 trial of an oral, interferon-free regimen evaluated exclusively in patients with HCV genotype 1 infection and cirrhosis, multitargeted therapy with the use of three new antiviral agents and ribavirin resulted in high rates of sustained virologic response. Drug discontinuations due to adverse events were infrequent. Source: Poordad F, et al. N Engl J Med. 2014;370:

53 Phase 2 Treatment Naïve and Treatment Experienced HIV Coinfection 3D (Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir) + RBV in GT1 TURQUOISE-I Wyles D, et al. 65 th AASLD. 2014: Abstract 1939.

54 3D + Ribavirin for HCV-HIV Coinfection and GT1 TURQUOISE-I: Part 1 Study Design TURQUOISE-I: Features Design: Multipart, phase 2/3, randomized, open-label trial evaluating safety and efficacy of 3D (ombitasvir-paritaprevir-ritonavir and dasabuvir) plus ribavirin for 12 or 24 weeks in treatment-naïve and experienced patients with chronic HCV GT 1 and HIV coinfection, including patients with cirrhosis Setting: Multicenter study in United States and Puerto Rico Entry Criteria - Chronic HCV infection with genotype 1 and HIV coinfection - Treatment-naïve or previously treated with peginterferon + ribavirin - Age Plasma HCV RNA greater than 10,000 IU/mL - Child-Pugh A cirrhosis permitted - CD4 count 200 cells/mm 3 (or CD4% 14) and HIV RNA level <40 copies/ml - Receiving atazanavir- or raltegravir-based regimen Primary End-Point: SVR12 Source: Wyles D, et al. 65 th AASLD. 2014: Abstract 1939.

55 3D + Ribavirin for HCV-HIV Coinfection and GT1 TURQUOISE-I: Part 1 Study Regimens Week N = 31 3D + Ribavirin SVR12 N = 32 3D + Ribavirin SVR12 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir Drug Dosing Ombitasvir-Paritaprevir-Ritonavir (25/150/100 mg once daily) and Dasabuvir: 250 mg twice daily Ribavirin (RBV): weight-based and divided bid (1000 mg/day if < 75kg or 1200 mg/day if 75kg) Source: Wyles D, et al. 65 th AASLD. 2014: Abstract 1939.

56 3D + Ribavirin for HCV-HIV Coinfection and GT 1 TURQUOISE-I: Patient Population Baseline Characteristic 12-Week Arm (n=31) Source: Wyles D, et al. 65 th AASLD. 2014: Abstract Week Arm (n=32) Age (years), Mean Male sex % Black Race (%) Cirrhosis (%) HCV genotype (%) 1a 1b HCV RNA, log 10 IU/ml (mean) IL28B non-cc genotype, (%) Previous Response to PEG + RBV Naïve Relapse Partial response Null response CD4 Count, cells/mm 3 (mean)

57 3D + Ribavirin for HCV-HIV Coinfection and GT 1 TURQUOISE-I: Part 1 Results TURQUOISE-I: SVR Rates (to date) 100 3D + RBV x 12 Weeks 3D + RBV x 24 Weeks Patients (%) with SVR SVR4 SVR /31 30/32 29/31 29/32 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = Ribavirin Source: Wyles D, et al. 65 th AASLD. 2014: Abstract 1939.

58 3D + Ribavirin for HCV-HIV Coinfection and GT 1 TURQUOISE-I: Part 1 Results Details of Five Patients NOT Achieving SVR 12 One patient in 12-week arm withdrew consent prior to finishing treatment; had undetectable HCV RNA at week 10 One patient in 12-week arm had virologic relapse at week 4 post treatment; had new resistant HCV variants at 3 viral targets (D168V in NS3/4A, M28T in NS5A, and S556G in NS5B) One patient in 24-week arm had virologic breakthrough during treatment; had new resistant HCV variants at 3 viral targets (R155K in NS3/4A, Q30R in NS5A, and S556G in NS5B) Two patients in 29/31 24-week 30/32 arm achieved early SVR 29/31 but appeared 29/32 to be reinfected with GT1a isolate distinct from baseline HCV isolate; both patients had engaged in high-risk sexual activity post treatment Source: Wyles D, et al. 65 th AASLD. 2014: Abstract 1939.

59 Phase 2 Treatment Naïve and Treatment Experienced Liver Transplantation Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Kwo PY, et al. N Engl J Med. 2014;371:

60 3D + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Trial: Study Design CORAL-I: Features Design: Phase 2, open-label, single-arm trial evaluating safety and efficacy of 3D (ombitasvir-paritaprevir-ritonavir + dasabuvir) + ribavirin x 24 weeks in liver transplant recipients with recurrent HCV GT 1 Setting: International Entry Criteria - Chronic HCV infection with genotype 1 - Liver transplantation due to HCV at least 12 months prior - Treatment-naïve after transplantation - Pre-transplant treatment with peginterferon + ribavirin allowed - Age Metavir score F2 confirmed by liver biopsy Use of Immunosuppressants - Receiving stable immunosuppressant regimen (tacrolimus or cyclosporin) - Tacrolimus or cyclosporin dose based on phase I pharmacokinetic study - Prednisone at dose 5 mg/day permitted but not use of mtor inhibitors Primary End-Point: SVR12 Source: Kwo PY, et al. N Engl J Med. 2014;371:

61 3D + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Trial: Regimen Week N = 34 3D + Ribavirin SVR12 3D = Ombitasvir-Paritaprevir-Ritonavir + Dasabuvir Drug Dosing Ombitasvir-Paritaprevir-Ritonavir- (25/150/100 mg once daily) + Dasabuvir: 250 mg twice daily Ribavirin (RBV): dosing managed per investigator discretion; most patients received mg/day Source: Kwo PY, et al. N Engl J Med. 2014;371:

62 3D + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Trial: Baseline Characteristics Baseline Characteristic 3D + Ribavirin (n=34) Age (years), Mean 59.6 Male sex no. (%) 27 (79) Race no. (%) White Black Multiple Source: Kwo PY, et al. N Engl J Med. 2014;371: (85) 4 (12) 1 (3) Body Mass Index (kg/m 2 ) Mean 29.7 HCV genotype no. (%) 1a 1b 29 (85) 5 (15) IL28B, non-cc genotype no. (%) 26 (76) HCV RNA, log 10 IU/ml 6.6 Fibrosis stage (%) F0 F1 F2 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin 6 (18) 13 (38) 15 (44)

63 3D + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Trial: Results HCV RNA < 25 IU/ml(%) /34 34/34 33/34 33/34 33/34 Week 4 Week 24 SVR4 SVR12 SVR24 On Treatment After Treatment Source: Kwo PY, et al. N Engl J Med. 2014;371:

64 3D + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Trial: Adverse Events Adverse Event Occurring in > 15% of the 34 Patients Receiving 3D + RBV Event N (%) Any adverse event 33 (97) Fatigue 17 (50) Headache 15 (44) Cough 11 (32) Anemia 10 (29) Diarrhea 9 (26) Insomnia 9 (26) Asthenia 8 (24) Nausea 8 (24) Muscle spasms 7 (21) Rash 7 (21) Back pain 6 (18) Dizziness 6 (18) Peripheral edema 6 (18 Rhinorrhea 6 (18) 3D = Ombitasvir-Paritaprevir-Ritonavir and Dasabuvir; RBV = ribavirin Source: Kwo PY, et al. N Engl J Med. 2014;371:

65 3D + RBV in Liver Transplant Recipients with Recurrent HCV GT1 CORAL-I Trial: Conclusions Conclusions: Treatment with the multitargeted regimen of ombitasvir- ABT-450/r and dasabuvir with ribavirin was associated with a low rate of serious adverse events and a high rate of sustained virologic response among liver-transplant recipients with recurrent HCV genotype 1 infection, a historically difficult-to-treat population. Note: ABT-450/r = Paritaprevir-Ritonavir Source: Kwo PY, et al. N Engl J Med. 2014;371:

66 This slide deck is from the University of Washington s C Online and Web Study projects. C Online Web Study Funded by a grant from the Centers for Disease Control and Prevention.