Supplementary Appendix

Transcription

1 Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Ferenci P, Bernstein D, Lalezari J, et al. ABT-45/r ombitasvir and dasabuvir with or without ribavirin for HCV. N Engl J Med 214;37: DOI: 1.156/NEJMoa142338

2 Table of Contents Investigators... 3 PEARL-III and PEARL-IV Eligibility Criteria... 4 Randomization Methods... 5 Blinding... 6 Collection of Samples for HCV RNA Measurement... 6 HCV RNA Measurement... 6 Virologic Failure Criteria... 6 Resistance Testing... 7 Noninferiority and Superiority Analyses... 7 Sample Size... 9 Ranked Efficacy Endpoint Analyses... 9 Logistic Regression Analyses... 1 Figure S1. PEARL-IV Flow Diagram Figure S2. PEARL-III Flow Diagram Figure S4. Mean Hemoglobin and Bilirubin Values Over Time Table S1. Reasons for Failing to Meet Study Eligibility Table S2. Fibrosis Scoring Table S3. PEARL-IV Adverse Events Occurring in 5% of Patients or with P values Table S4. PEARL-III Adverse Events Occurring in 5% of Patients or with P values Table S5. Treatment-Emergent Serious Adverse Events During the Treatment Period Table S6. Maximum Post-Baseline Liver Function Test Values, no. (%) Table S7. Potentially Clinically Significant Laboratory Abnormalities, no. (%) References

3 ABT-45 was identified as a lead compound by AbbVie and Enanta Pharmaceuticals. ABT-45 is a nonstructural protein 3 (NS3)/ nonstructural protein 4A (NS4A) protease inhibitor, Ombitasvir is a nonstructural protein 5A (NS5A) inhibitor. Dasabuvir is a nonstructural protein 5B (NS5B) non-nucleoside polymerase inhibitor. ABT-45: (2R,6S,12Z,13aS,14aR,16aS)-N-(cyclopropylsulfonyl)-6-{[(5-methylpyrazin-2- yl)carbonyl]amino}-5,16-dioxo-2-(phenanthridin-6-yloxy)- 1,2,3,6,7,8,9,1,11,13a,14,15,16,16atetradecahydrocyclopropa[e]pyrrolo[1,2- a][1,4]diazacyclopentadecine-14a(5h)-carboxamidehydrate ritonavir: [5S-(5R*,8R*,1R*,11R*)]-1-Hydroxy-2-methyl-5-(1-methylethyl)-1-[2-(1-methylethyl)-4- thiazolyl]-3,6-dioxo-8,11-bis(phenylmethyl)-2,4,7,12-tetraazatridecan-13-oic acid, 5-thiazolylmethyl ester Ombitasvir (ABT-267): dimethyl N,N'-{[(2S,5S)-1-(4-tert-butylphenyl)pyrrolidene-2,5-diyl]-bis-{[(4,1- phenyleneazanediyl)carbonyl][(2s)-pyrrolidine-2,1-diyl]}[(2s)-3-methyl-1-oxobutane-1,2- diyl])}biscarbamate Dasabuvir (ABT-333): N-(6-{3-tert-butyl-5-[2,4-dioxo-3,4-dihydropyrimidin-1(2H)-yl]-2- methoxyphenyl}naphthalen-2-yl)methanesulfonamide 2

4 Investigators PEARL-III investigators included: Austria: P Ferenci, M Gschwantler, A Maieron Belgium: S Bourgeois, JP Mulkay, C Moreno, F Nevens, H Van Vlierberghe Hungary: J Gervain, F Szalay Israel: Y Baruch, Z Ben-Ari, Y Lurie Italy: M Puoti, G Rizzardini, E Villa Poland: E Janczewska, W Mazur, I Olszok Portugal: FA Calinas, R Sarmento e Castro, R Tato Marinho Romania: FA Caruntu, M Curescu, S Rugina Russian Federation: V Chulanov, M Maevskaya, AA Yakovlev Spain: JL Calleja Panero, M Diago Madrid, R Planas Vila, M Romero Gomez United States: L Balart, D Bernstein, TD Box, I Crespo, P Enayati, S Lidofsky, VA Luketic, P Mantry, TC Marbury, A Nyberg, LM Nyberg, V Patel, BL Pearlman, RK Reddy, BG Yangco, Z Younes PEARL-IV investigators included: Canada: F Bredeek, C Cooper, P Cote, M Elkhashab, D Longpre, A Ramji, E Tam, D Wyles United Kingdom: R Aspinall, A Brown, M Cramp, J Dusheiko, D Foxton, M Foxton, M Priest, S Ryder United States: M Bennett, D Bernstein, BR Bhandari, TD Box, M Davis, M Eisner, J Fessel, B Freilich, J Gathe, D Geenen, S Green, J Hanje, J Hanson, T Hassanein, R Herring, Z Kayali, N Kemmer, W King, J Lalezari, P Manos, R Nahass, G Oguchi, O Osiyemi, S Overcash, M Ramgopal, D Rausher, R Ravinuthala, F Rhame, J Rodriguez, P Ruane, V Rustgi, T Sepe, M Saag, J Santoro, N Tsai, Z Younes, Z Younossi, J Yozviak 3

5 PEARL-III and PEARL-IV Eligibility Criteria Main Inclusion: 1. Male or female between 18 and 7 years of age, inclusive, at time of Screening. 2. Female who is: Not of childbearing potential, defined as: o postmenopausal for at least 2 years prior to screening (defined as amenorrheic for longer than 2 years, age appropriate, and confirmed by a follicle-stimulating hormone [FSH] level indicating a postmenopausal state), or o surgically sterile (defined as bilateral tubal ligation, bilateral oophorectomy or hysterectomy), or has a vasectomized partner, or o practicing total abstinence from sexual intercourse (minimum 1 complete menstrual cycle), or o sexually active with female partners only. of childbearing potential and sexually active with male partner(s) currently using at least one effective method of birth control at the time of screening and two effective methods of birth control while receiving study drugs (as outlined in the patient informed consent or other patient information documents), starting with Study Day 1 and for 7 months after stopping study drug as directed by the local ribavirin label. (Note: Hormonal contraceptives, including oral, topical, injectable or implantable varieties, may not be used during administration of study drugs). 3. Sexually active males must be surgically sterile or have male partners only or if sexually active with female partner(s) of childbearing potential must agree to practice two effective forms of birth control (as outlined in the patient information and consent form or other patient information documents) throughout the course of the study, starting with Study Day 1 and for 7 months after stopping study drug or as directed by the local ribavirin label. 4. Patient has never received antiviral treatment for hepatitis C infection. 5. Body Mass Index (BMI) is from 18 to < 38 kg/m2 at the time of Screening. BMI is calculated as weight measured in kilograms (kg) divided by the square of height measured in meters (m). 6. Chronic HCV infection as defined by one of the following: Positive for anti-hcv antibody (Ab) or HCV RNA at least 6 months before Screening, and positive for HCV RNA and anti-hcv Ab at the time of Screening; or Positive for anti-hcv Ab and HCV RNA at the time of Screening with a liver biopsy consistent with chronic HCV infection (or a liver biopsy performed prior to enrollment with evidence of chronic hepatitis C disease). 7. Screening laboratory result indicating HCV genotype 1a infection for PEARL-IV, or genotype 1b infection for PEARL-III. 8. Per local standard practice, documented results of one of the following: Liver biopsy within 24 months prior to or during screening demonstrating the absence of cirrhosis, e.g., a Metavir score of 3 or less or an Ishak score of 4 or less; or Screening FibroTest score of.72 and Aspartate Aminotransferase to Platelet Ratio Index (APRI) 2; or 4

6 Screening FibroScan result of < 9.6 kpa; (Patients with a non-qualifying FibroTest/APRI or FibroScan may only be enrolled if they have a qualifying liver biopsy within 24 months prior to or during screening.) 9. Patient has plasma HCV RNA level > 1, IU/mL at Screening. Main Exclusion: 1. Recent (within 6 months prior to study drug administration) history of drug or alcohol abuse that could preclude adherence to the protocol. 2. Positive test result for Hepatitis B surface antigen (HBsAg) or anti-human immunodeficiency virus antibody (HIV Ab). 3. HCV genotype performed during screening indicates more than 1 subtype or co-infection with any other genotype. 4. History of uncontrolled seizures, uncontrolled diabetes as defined by a glycated hemoglobin (hemoglobin A1C) level > 8.5% at the Screening visit, active or suspected malignancy or history of malignancy (other than basal cell skin cancer or cervical carcinoma in situ) in the past 5 years. 5. Any current or past clinical evidence of cirrhosis such as ascites or esophageal varices, or prior biopsy showing cirrhosis, e.g., a Metavir score of >3 or Ishak score of > Screening laboratory analyses showing any of the following abnormal laboratory results: Alanine aminotransferase (ALT) > 5 upper limit of normal (ULN) Aspartate aminotransferase (AST) > 5 ULN Calculated creatinine clearance (using Cockcroft-Gault method) < 6 ml/min Albumin < Lower limit of normal (LLN) Prothrombin time/international normalized ratio (INR) > 1.5. Patients with a known inherited blood disorder and INR > 1.5 may be enrolled with permission of the AbbVie Study Designated Physician Hemoglobin < LLN Platelets < 12, cells per mm 3 Absolute neutrophil count (ANC) < 15 cells/μl (< 12 cells/µl for patients of African descent who are black) Indirect bilirubin > 1.5 ULN and direct bilirubin > ULN Randomization Methods At the screening visit, patients were assigned a unique patient number through the use of Interactive Response Technology (IRT). For patients who did not meet the study selection criteria, the site personnel contacted the IRT system and identified the patient as a screen failure. Enrolled patients retained their patient number, assigned at the Screening Visit, throughout the study. For enrollment of eligible patients into the study, the site utilized the IRT system in order to receive unique study drug bottle/kit numbers and a unique randomization number. The randomization number 5

7 was used only by the Sponsor for loading the treatment assignments into the database. The study drug kit numbers and randomization numbers were assigned according to schedules computer-generated before the start of the study by the AbbVie Statistics Department. Contact information and user guidelines for IRT use were provided to each site. Upon receipt of study drugs, the site acknowledged receipt in the IRT system. Blinding Treatment assignment was to remain blinded to the investigator, patient, and sponsor. During the Treatment Period, ABT-45/r/ombitasvir and dasabuvir were provided as tablets. Ribavirin and matching placebos were provided as capsules and were identical in appearance. During the treatment period, measures to prevent implicit unblinding by laboratory results were used. Specifically, the results of hemoglobin and hematocrit were blinded to the investigator, patient and sponsor until the post-treatment week 12 or premature discontinuation visit, unless criteria for virologic failure or relevant predefined toxicity were met, in which case the relevant laboratory data were unblinded to the investigator, patient, and sponsor. Collection of Samples for HCV RNA Measurement Plasma samples for HCV RNA measurement were obtained at screening. Additional samples for HCV RNA measurement were obtained during the double-blind period on day 1 and during the double-blind period at scheduled visits every 1-2 weeks through the final treatment visit or premature discontinuation. Following administration of the last dose of study drug, samples for HCV RNA measurement were collected at post-treatment weeks 2, 4, 8, 12, 24, 36, and 48 or at the time of premature discontinuation of study. Plasma samples were also collected at screening to assess HCV genotype and subtype using the Versant HCV Genotype Inno-LiPA Assay, version 2. or higher (LiPA; Siemens Healthcare Diagnostics, Tarrytown, NY), and for IL28B rs haplotype analysis. HCV RNA Measurement Plasma HCV RNA levels was determined for each sample collected by the central laboratory using the Roche COBAS TaqMan real-time reverse transcriptase-pcr (RT-PCR) assay v2.. The lower limit of detection (LLOD) is 15 IU/mL and the LLOQ (lower limit of quantification) is 25 IU/mL. Virologic Failure Criteria The following criteria were considered evidence of virologic failure leading to discontinuation of study drug for individual patients: Confirmed increase from nadir in HCV RNA (defined as 2 consecutive HCV RNA measurements > 1 log1 IU/mL above nadir) at any time point during treatment; Failure to achieve HCV RNA < LLOQ by Week 6; 6

8 Confirmed HCV RNA LLOQ (defined as two consecutive HCV RNA measurements LLOQ) at any point during treatment after HCV RNA < LLOQ. If any of the above criteria were met, the patient was to discontinue study treatment. Patients who completed the treatment with HCV RNA < LLOQ at the end of treatment and who had a confirmed HCV RNA LLOQ (defined as 2 consecutive HCV RNA measurements LLOQ) in the posttreatment period were considered to have relapsed. Resistance Testing For resistance testing, HCV viral RNA was extracted from samples obtained at baseline and at the time of virologic failure. The target genes were amplified by RT-PCR and then nested PCR using primers appropriate for subtype 1a or 1b sequences encoding NS3/4A protease, NS5A, and NS5B polymerase. The nested PCR amplification product was used as the template for DNA sequencing of the population of amplified molecules, performed under GLP (Good Laboratory Practice) conditions in a CLIA (Clinical Laboratories Improvement Amendments)-certified reference laboratory. The DNA sequence from each baseline sample was translated into amino acid sequence and compared to the appropriate reference sequence (1a-H77 or 1b-Con1) in order to identify pre-existing resistance-associated variants. The DNA sequence from each post-baseline sample was translated into amino acid sequence and compared to the sequence from the corresponding baseline sample to identify resistance-associated amino acid variants that emerged as a result of treatment. Each translated amino acid sequence from samples obtained at the time of virologic failure was compared to the sequence from the corresponding pretreatment sample in order to identify those amino acid variants that emerged or became enriched during direct-acting antiviral agent treatment. Noninferiority and Superiority Analyses Historical SVR rates, as reported in the telaprevir US Prescribing Information (USPI) 1 for telaprevir plus pegifn and ribavirin treatment in various groups of treatment-naïve patients from the ADVANCE and ILLUMINATE trials are presented in the table below. For genotype 1a-infected patients, the upper bound of the 95% confidence interval (CI) was 75%, representing a threshold relevant to the overall population enrolled in PEARL-IV. For the regimen to be considered superior to the historical SVR rate for telaprevir, the lower bound of the 95% CI for the SVR rate was required to exceed the upper confidence bound of the historical SVR rate for telaprevir-based therapy presented in the table below (i.e., 75%). To be considered noninferior to the historical SVR rate for telaprevir, a noninferiority margin of 1.5% was used. Thus, noninferiority to the historical SVR rate for telaprevir based therapy was met if the lower bound of the 95% CI for the SVR rate was greater than the upper confidence bound of the SVR rate for telaprevir-based therapy minus 1.5% (i.e., 65%). The 2-sided 95% confidence intervals were created using the normal approximation to the binomial. 7

9 For genotype 1b-infected patients, the upper bound of the 95% confidence interval (CI) was 84%, representing a threshold relevant to the overall population enrolled in PEARL-III. For the regimen to be considered superior to the historical SVR rate for telaprevir, the lower bound of the 95% CI for the SVR rate was required to exceed the upper confidence bound of the historical SVR rate for telaprevir-based therapy presented in the table below (i.e., 84%). To be considered noninferior to the historical SVR rate for telaprevir, a noninferiority margin of 1.5% was used. Thus, noninferiority to the historical SVR rate for telaprevir based therapy was met if the lower bound of the 95% CI for the SVR rate was greater than the upper confidence bound of the SVR rate for telaprevir-based therapy minus 1.5% (i.e., 73%). The 2-sided 95% confidence intervals were created using the normal approximation to the binomial. 8

10 Estimated SVR Rates for Telaprevir plus pegifn and Ribavirin Therapy in Treatment-naïve Patients with Genotype 1a or 1b Telaprevir Studies ADVANCE T12/PR n/n (%) ILLUMINATE T12/PR n/n (%) Meta-Analysis % [95% CI] Treatment-naïve GT1a patients 162/217 (75) 273/388 (7) 72 [68, 75] Treatment-naïve GT1b patients 119/142 (84) 112/149 (75) 8 [75, 84] GT1a, genotype 1a; GT1b, genotype 1b To test noninferiority of each study placebo group to its corresponding group with ribavirin, the 2-sided 95% confidence interval for the difference in SVR12 rates (placebo group minus ribavirin group) was calculated using the normal approximation to the binomial distribution. If the lower bound of the 2- sided 95% confidence interval for the difference was above the noninferiority margin of -1.5%, the regimen with placebo was considered noninferior to the regimen with ribavirin. Sample Size PEARL-IV planned to enroll 3 patients in a 1:2 ratio to the DAA combination regimen with ribavirin or placebo for ribavirin (1 patients randomized to active drug + ribavirin and 2 patients randomized to active drug + placebo). Randomization was stratified by IL28B genotype (CC vs. non-cc). Based on a 2- sided significance level of.5, and an underlying SVR12 rate of 9% or higher in the treatment group receiving ribavirin and 85% or higher in the treatment group without ribavirin, a sample size of 1 patients for the treatment group receiving ribavirin and 2 patients in for the group without ribavirin provided > 95% power to demonstrate noninferiority of each regimen to the historical SVR rate for telaprevir plus pegifn and ribavirin therapy (75%), and it provided > 9% power to demonstrate superiority of each regimen to the historical SVR rate for telaprevir plus pegifn and ribavirin therapy (75%). No adjustment for dropout was applicable because patients without data at Post-Treatment Week 12 (after imputing) were considered as failures for SVR12. PEARL-III planned to enroll 4 patients in a 1:1 ratio to the DAA combination regimen with ribavirin or placebo for ribavirin (2 patients randomized to active drug + ribavirin and 2 patients randomized to active drug + placebo). Randomization was stratified by IL28B genotype (CC vs. non-cc). Based on a 2- sided significance level of.5, and an underlying SVR12 rate of 92% or higher in each arm, a sample size of 2 patients per treatment group provided > 95% power to demonstrate noninferiority each regimen to the historical SVR rate for telaprevir plus pegifn and ribavirin therapy (84%), and it provided > 9% power to demonstrate superiority of each regimen to the historical SVR rate for telaprevir plus pegifn and ribavirin therapy (84%). The planned sample size provided >95% to demonstrate noninferiority of the regimen with placebo to the regimen with ribavirin, based on a -1.5% noninferiority margin. Ranked Efficacy Endpoint Analyses PEARL-IV and PEARL-III had the same primary efficacy endpoints: 9

11 1) noninferiority of the SVR12 rate in placebo-containing treatment groups to the historical rate for telaprevir plus pegylated interferon and ribavirin; and 2) noninferiority of the SVR12 rate in ribavirin-containing treatment groups to the historical rate for telaprevir plus pegylated interferon and ribavirin. Secondary efficacy endpoints included: 3) the percentage of patients with a decrease in hemoglobin from, at, or above the lower limit of normal to below the lower limit of normal at the end of treatment comparing the ribavirincontaining group to the placebo-containing group; 4) superiority of SVR12 rate in ribavirin-containing treatment group to the historical rate for telaprevir plus pegifn and ribavirin in corresponding population; 5) superiority of SVR12 rate in placebo-containing treatment group to the historical rate for telaprevir plus pegifn and ribavirin in corresponding population; 6) noninferiority of placebo-containing treatment group to ribavirin-containing treatment group In order to control the Type I error rate at.5, a fixed-sequence testing procedure 2 was used to proceed through the primary and secondary efficacy endpoints in the order shown below for each study. PEARL-IV: 1, 2, 3, 4, 5, 6 PEARL-III: 1, 2, 6, 3, 4, 5 Other secondary endpoint analyses not included in the fixed-sequence testing procedure were the percentage of patients in each treatment group with on-treatment virologic failure (including failure to suppress and rebound) and post-treatment relapse. Logistic Regression Analyses A stepwise logistic regression was performed to determine independent predictors of SVR12 using all ITT patients irrespective of treatment group. Pre-specified subgroup variables below were tested as predictors in this model, with the exception of HOMA-IR and IP-1 as many patients were missing these values. Baseline HCV RNA, age, and body-mass index were entered as continuous variables. Significance level for entering predictors into and removing predictors from the model was.1. HCV genotype 1 subtype (1a, non-1a); IL28B genotype (CC or non-cc) Sex (male or female); Age (< 55 or 55 years) Birth year (< 1945, 1945 to 1965, > 1965); Race (Black or non-black); Ethnicity (Hispanic or Latino, Not Hispanic or Latino); 1

12 Geographic Region (North America, Europe, or Australia/New Zealand) and Country (as appropriate); BMI (< 3 or 3 kg/m 2 ); Baseline HCV RNA levels (< 8, or 8, IU/mL); Baseline IP-1 (< 6 or 6 ng/l); Baseline HOMA-IR (< 3 or 3 mu mmol/l 2 ); Baseline fibrosis stage (F F1, F2, or F3); History of Diabetes (yes/no); History of Depression or Bipolar Disorder (yes/no); History of Bleeding Disorders (yes/no); Former injection drug user (yes/no); RBV dose modifications (yes/no). 11

13 Figure S1. PEARL-IV Flow Diagram. Treatment-naïve patients with chronic HCV genotype 1a infection were assessed for eligibility and randomized to receive either ABT-45/r/ombitasvir and dasabuvir with ribavirin or placebo during the treatment period. Some patients reported multiple reasons for exclusion from the trial or for early treatment discontinuation. 12

14 Figure S2. PEARL-III Flow Diagram. Treatment-naïve patients with chronic HCV genotype 1b infection were assessed for eligibility and randomized to receive either ABT-45/r/ombitasvir and dasabuvir with ribavirin or placebo during the treatment period. Some patients reported multiple reasons for exclusion from the trial. 13

15 Log1 HCV RNA IU/mL Log1 HCV RNA IU/mL On Treatment Failures Week Relapsers Week LLOQ LLOD LLOQ LLOD Figure S3. HCV RNA Levels for Patients With Virologic Failure Within PEARL-IV. Seven GT1a patients experienced on treatment virologic failure (rebound), and 11 patients relapsed following end of treatment and before the 12-week follow-up. The treatment period is denoted by gray shading. Horizontal dashed lines depict the lower limit of detection (LLOD) and lower limit of quantitation (LLOQ). 14

16 A 16 Hemoglobin Over Time Hemoglobin, g/dl PT4 Week Group 1A RBV Group 1A PBO Group 1B RBV Group 1B PBO B 25 Total Bilirubin Over Time Bilirubin, µmol/l PT4 Week Figure S4. Mean Hemoglobin and Bilirubin Values Over Time. Mean hemoglobin values for treatment groups in the genotype 1a and 1b study (A), and mean total bilirubin values (B) of the safety population (all patients receiving at least one dose of study drug) are plotted over time during the treatment period and for the week-4 post-treatment follow-up (PT4). 15

17 Table S1. Reasons for Failing to Meet Study Eligibility # OF SCREEN INCLUSION CRITERIA FAILURES PEARL-IV PEARL-III 1 Male or female between 18 and 7 years of age, inclusive, at time of Screening. 12 Females must have negative results for pregnancy tests performed: at Screening by serum specimen within 35 days prior to initial study drug administration, and at Baseline (prior to dosing) by urine specimen 1 1 Patient has never received antiviral treatment for hepatitis C infection. 1 2 Patients must be able to understand and adhere to the study visit schedule and all other protocol requirements. 2 6 Body Mass Index (BMI) is from 18 to < 38 kg/m2 at the time of Screening. BMI is calculated as weight measured in kilograms (kg) divided by the square of height measured in meters (m). 2 3 Chronic HCV infection prior to study enrollment. Chronic HCV infection is defined as one of the following: Positive for anti-hcv antibody (Ab) or HCV RNA at least 6 months before Screening, and positive for HCV RNA and anti-hcv Ab at the time of Screening; or Positive for anti-hcv Ab and HCV RNA at the time of Screening with a liver biopsy consistent with chronic HCV infection (or a liver biopsy performed prior to enrollment with evidence of chronic hepatitis C disease) Screening laboratory result indicating HCV GT 1a (PEARL-III) or GT 1b (PEARL-IV) infection Per local standard practice, documented results of one of the following: Liver biopsy within 24 months prior to or during screening demonstrating the absence of cirrhosis, e.g., a Metavir score of 3 or less or an Ishak score of 4 or less; or Screening FibroTest score of.72 and Aspartate Aminotransferase to Platelet Ratio Index (APRI) 2; or Screening FibroScan result of < 9.6 kpa; (Patients with a non-qualifying FibroTest/APRI or FibroScan may only be enrolled if they have a qualifying liver biopsy within 24 months prior to or during screening.) 8 9 Patient has plasma HCV RNA level > 1, IU/mL at Screening. # OF SCREEN EXCLUSION CRITERIA FAILURES 1 Use of any herbal supplements (including milk thistle) within 2 weeks or 1 half-lives of the respective supplement (if known), whichever is longer, prior to the first dose of study drugs 1 History of severe, life-threatening or other significant sensitivity to any drug. 3 2 Recent (within 6 months prior to study drug administration) history of drug or alcohol abuse that could preclude adherence to the protocol. 1 1 HCV genotype performed during screening indicates more than 1 subtype or coinfection with any other genotype. 2 Positive test result at screening for Hepatitis B surface antigen (HBsAg) or anti-human immunodeficiency virus antibody (HIV Ab). 2 3 Use of any medication not allowed per the protocol, as well as those that are contraindicated for ritonavir and ribavirin, within 2 weeks prior to study drug administration or 1 half-lives (if known), whichever is longer Positive result of a urine drug screen at the Screening Visit for opiates, barbiturates, 16

18 amphetamines, cocaine, benzodiazepines, phencyclidine, propoxyphene, or alcohol, with the exception of a positive result associated with documented short-term use or chronic stable use of a prescribed medication in that class. 3 4 Clinically significant abnormalities, other than HCV infection, based upon the results of a medical history, physical examination, vital signs, laboratory profile and a 12-lead electrocardiogram (ECG) that make the patient an unsuitable candidate for this study in the opinion of the investigator. 2 5 History of uncontrolled seizures, uncontrolled diabetes as defined by a glycated hemoglobin (hemoglobin A1C) level > 8.5% at the Screening Visit, or an active or suspected malignancy or history of malignancy (other than basal cell skin cancer or cervical carcinoma in situ) in the past 5 years. 3 2 Any current or past clinical evidence of cirrhosis such as ascites or esophageal varices, or prior biopsy showing cirrhosis, e.g., a Metavir score > 3 or an Ishak score > Screening laboratory analyses showing any of the following abnormal laboratory results: ALT > 5 Upper limit of normal (ULN) AST > 5 ULN Calculated creatinine clearance (using Cockcroft-Gault method) < 6 ml/min Albumin < Lower limit of normal (LLN) Prothrombin time/international normalized ratio (INR) > 1.5. Patients with a known inherited blood disorder and INR > 1.5 may be enrolled with permission of the AbbVie Study-Designated Physician Hemoglobin < LLN Platelets < 12, cells per mm3 Absolute neutrophil count (ANC) < 15 cells/μl (< 12 cells/μl for patients of black/african descent) Indirect bilirubin > 1.5 ULN and direct bilirubin > ULN 1 Any cause of liver disease other than chronic HCV infection, including but not limited to the following: Hemochromatosis Alpha-1 antitrypsin deficiency Wilson's disease Autoimmune hepatitis Alcoholic liver disease Nonalcoholic steatohepatitis Drug-related liver disease 4 4 Clinically significant abnormal ECG, or ECG with QT interval corrected for heart rate (QTc) using Fridericia's correction formula (QTcF) > 45 msec at Screening or Study Day 1 (prior to dosing). 1 Consideration by the investigator, for any reason, that the patient is an unsuitable candidate to receive ombitasvir, dasabuvir, ABT-45, ritonavir or RBV. 1 Current enrollment in another clinical study, previous enrollment in this study, or previous use of any investigational or commercially available anti-hcv agents including previous exposure to telaprevir, boceprevir, ABT-45, ombitasvir, dasabuvir or RBV. (Patients who previously participated in trials of investigational anti-hcv agents may be enrolled if they can produce documentation that they received only placebo.) Concurrent participation in a non-interventional, epidemiologic, or registry trials may be permitted with the approval of the AbbVie Study-Designated Physician. 1 Uncontrolled clinically significant cardiac, respiratory (except mild asthma), hepatic (except HCV-related disease), gastrointestinal, hematologic or psychiatric disease or disorder, or any uncontrolled medical illness. 17

19 Table S2. Fibrosis Scoring Baseline Fibrosis Stage, Metavir Equivalents Liver Biopsy Metavir or Batts-Ludwig or Knodell or IASL or Scheuer Score Liver Biopsy Ishak Score FibroScan (kpa) FibroTest F-F1 or 1, 1, or 2 <8.8 <.48 F2 2 3 >8.8 to < to.58 F3 (or higher) 3 (or higher) 4 (or higher) >9.6 >.59 Baseline fibrosis stage is defined based on liver biopsy findings, FibroScan scores, or FibroTest scores available. Fibrosis stage was determined by a single score in patients with multiple scores available. If biopsy results were present, they were used to categorize the patient, regardless of the FibroScan/FibroTest score. Similarly, if a FibroScan score was present along with a FibroTest score, then the FibroScan score was used to categorize the patient. 18

20 Table S3. PEARL-IV Adverse Events Occurring in 5% of Patients or with P values.1 HCV Genotype 1a MEDDRA 16. PREFERRED TERM Antiviral Regimen with Ribavirin N = 1 Antiviral Regimen without Ribavirin N = 25 P Value n % n % Fatigue 46 (46.) 72 (35.1).8 Headache 25 (25.) 58 (28.3) Nausea 21 (21.) 28 (13.7) Insomnia 17 (17.) 16 (7.8).2 Diarrhea 14 (14.) 33 (16.1) Pruritus 1 (1.) 12 (5.9) Arthralgia 9 (9.) 5 (2.4).2 Dizziness 8 (8.) 13 (6.3) Irritability 8 (8.) 14 (6.8) Blood bilirubin increased 7 (7.) <.1 Dyspnea exertional 7 (7.) 1 (.5).2 Anemia 6 (6.).1 Dry skin 6 (6.) 2 (1.).2 Upper respiratory tract infection 6 (6.) 8 (3.9) Back pain 5 (5.) 12 (5.9) Cough 5 (5.) 12 (5.9) Dyspepsia 5 (5.) 5 (2.4) Rash 5 (5.) 1 (4.9) Gastroesophageal reflux disease 4 (4.) 1 (.5).4 Rash pruritic 4 (4.).1 Reticulocyte count increased 4 (4.).1 Feeling jittery 3 (3.).4 Memory impairment 1 (1.) 14 (6.8).3 P value for comparisons between treatment groups using fisher s exact test. Only P values.1 are presented. 19

21 Table S4. PEARL-III Adverse Events Occurring in 5% of Patients or with P values.1 MEDDRA 16. PREFERRED TERM Antiviral Regimen with Ribavirin N = 29 HCV Genotype 1b Antiviral Regimen without Ribavirin N = 21 P value n % n % Headache 51 (24.3) 49 (23.4) Fatigue 45 (21.4) 48 (23.) Pruritus 25 (11.9) 11 (5.3).2 Nausea 23 (11.) 9 (4.3).2 Asthenia 22 (1.5) 11 (5.3).7 Cough 19 (9.) 5 (2.4).5 Insomnia 19 (9.) 7 (3.3).2 Anemia 14 (6.7) 1 (.5) <.1 Dyspepsia 14 (6.7) 9 (4.3) Rash 12 (5.7) 8 (3.8) Abdominal pain upper 11 (5.2) 6 (2.9) Diarrhea 9 (4.3) 13 (6.2) Upper respiratory tract infection 9 (4.3) 2 (1.).6 Hyperbilirubinemia 7 (3.3) 1 (.5).7 Jaundice 7 (3.3) 1 (.5).7 Nasopharyngitis 3 (1.4) 1 (4.8).5 Arthritis 4 (1.9).6 P value for comparisons between treatment groups using fisher s exact test. Only P values.1 are presented. 2

22 Table S5. Treatment-Emergent Serious Adverse Events During the Treatment Period Reasonable Treatment Group Serious Adverse Event Possibility of Relation to DAA? Led to Study Discontinuation? Genotype 1a Pancreatitis a Yes No Antiviral Regimen Anemia No a No with Ribavirin Small intestinal obstruction No No Genotype 1a Antiviral Regimen without Ribavirin Diverticulitis No Yes Coronary artery disease No No Genotype 1b Atrial fibrillation No No Antiviral Regimen with Ribavirin Nepthrolithiasis No No Epididymitis No No Arthritis c Yes No Genotype 1b Intraductal proliferative breast lesion No No Antiviral Regimen without Ribavirin Uterine polyp No No Myalgia No No a Patient with family and personal history of pancreatitis. Assessed by the investigator to be related to ribavirin. c Led to hospitalization; the event was ongoing at the end of study and no definitive etiology was established. Relationship to DAAs was determined by the investigator. DAA, direct-acting antiviral agent 21

23 Table S6. Maximum Post-Baseline Liver Function Test Values, no. (%) PEARL-IV (Genotype 1a) PEARL-III (Genotype 1b) Antiviral Antiviral Antiviral Regimen with Ribavirin (N = 1) Regimen without Ribavirin (N = 25) Antiviral Regimen with Ribavirin (N = 21) Regimen without Ribavirin (N = 29) Hemoglobin Grade 1 Grade 2 Grade 3 Grade 4 Alanine aminotransferase Grade 1 Grade 2 Grade 3 Grade 4 Aspartate aminotransferase Grade 1 Grade 2 Grade 3 Grade 4 Alkaline phosphatase Grade 1 Grade 2 Grade 3 Grade 4 Total bilirubin Grade 1 Grade 2 Grade 3 Grade 4 48 (48.) 3 (3.) 1 (1.) 11 (11.) 1 (1.) 17 (17.) 1 (1.) 6 (6.) 21 (21.) 19 (19.) 3 (3.) 15 (7.3) 36 (17.6) 6 (2.9) 1 (.5) 35 (17.1) 3 (1.5) 19 (9.3) 12 (5.9) 12 (5.9) 1 (.5) 112 (53.3) 18 (8.6) 1 (.5) 29 (13.8) 4 (1.9) 2 (1.) 28 (13.3) 1 (.5) 2 (9.5) 41 (19.5) 29 (13.8) 12 (5.7) 13 (6.2) 45 (21.5) 24 (11.5) 21 (1.) 21 (1.) 8 (3.8) 1 (.5) 22

24 Table S7. Potentially Clinically Significant Laboratory Abnormalities, no. (%) PEARL-IV (Genotype 1a) PEARL-III (Genotype 1b) Antiviral Antiviral Regimen Antiviral Regimen without Regimen without Ribavirin with Ribavirin Ribavirin (N = 25) (N = 21) (N = 29) Antiviral Regimen with Ribavirin (N = 1) Hemoglobin <8 g/dl 1 (1.) 1 (.5) Platelet count <5 x 1 9 /L 1 (.5) White blood count <2 x 1 9 /L >2 x 1 9 /L 1 (1.) 1 (1.) 1 (.5) Total neutrophils <1 x 1 9 /L 2 (1.) 1 (.5) Lymphocytes <.5 x 1 9 /L 1 (1.) Eosinophils >5 x 1 9 /L Activated partial thromboplastin 1 (.5) time >2 X ULN International normalized ratio 2 (1.) 1 (.5) 2 (1.) >2 x ULN Alanine aminotransferase > 5 x 1 (.5) 2 (1.) ULN and 2 x baseline Aspartate aminotransferase >5 x ULN and 2 x baseline Alkaline phosphatase >1.5 x ULN 1 (.5) 1 (.5) Total bilirubin 2 x ULN 8 (8.)* 5 (2.4) 25 (11.9)*** 3 (1.4) Creatinine µmol/l 1 (1.) 2 (1.) 3 (1.4) Calculated creatinine clearance <5 ml/min 1 (1.) 2 (1.) 3 (1.4) Triglycerides >5.7 mmol/l 3 (1.5) 2 (1.) 2 (1.) * and *** denotes statistically significant differences comparing intra-study groups at the.5 and.1 levels, respectively. 23

25 References 1. Incivek (telaprevir) film coated tablets: US prescribing information. Cambridge, MA: Vertex Pharmaceuticals Inc, 213. (Accessed at Aug 2, 213.). 2. Westfall PH, Krishen A. Optimally weighted, fixed sequence and gatekeeper multiple testing procedures. J Stat Plan Inference 21;99: