Direct acting anti-virals: the near future

Direct acting anti-virals: the near future Heiner Wedemeyer Hannover Medical School Germany

Will IFN-free treatment be possible in the near future?

Interferon-free regimens to treat hepatitis C What should be the goal of interferon-free treatment regimens: Sustained suppression of viral replication or cure of HCV infection? Can chronic HCV infection be cured without interferon alpha? Which DAA combinations have already been studied in clinical trials? What will be the major challenges for interferon-free treatment regimens?

Interferon-free regimens to treat hepatitis C What should be the goal of interferon-free treatment regimens: Sustained suppression of viral replication or cure of HCV infection?

HCV HIV HCV HBV

Immune Control of HCV Is Possible! Spontaneous clearance of acute hepatitis C in 10%-50% of cases HCV-specific T-cell responses are associated with recovery from acute hepatitis C

Vaccine Development for Hepatitis C Virus infection Torresi, Johnson & Wedemeyer, J Hepatol 2011

Immune Control of HCV Is Possible! Spontaneous clearance of acute hepatitis C in 10%-50% of cases HCV-specific T-cell responses are associated with recovery from acute hepatitis C Interferon alpha monotherapy is highly effective if HCV infection is treated early

Early Treatment with Interferon alpha Monotherapy Leads to Cure in 9/10 Patients with Acute Hepatitis C Jaeckel E et al. N Engl J Med. 2001;345:1452-1457. Wiegand J et al. Hepatology. 2006;43:250-256. No Late Relapse! Wiegand J et al. Hepatology. 2004;40:98-107. Quality of T cell responses is associated with treatment response Wiegand J et al. Antiviral Therapy 2007

Long-Term follow-up after treatment of chronic hepatitis C: Long-term SVR in >98% of cases!

Can chronic HCV infection be cured without interferon alpha?

HCV Cure by treatment with a PI + Pol.Inh. 3 Chimps 4 weeks combination MK7009 + MK0608 8 weeks monotherapy MK7009 1 Chimp with Sustained Virological Response! D. Olsen et al., Antimicrob Agents Chemother. 2011

Patel & Heathcote, GUT 2010

BMS-790052 + BMS-650032: AI447011 AI447011: phase IIa study of BMS-790052 plus BMS-650032, with or without PegIFN/RBV, for 24 weeks in HCV genotype-1 null responders A n=11 Cure of HCV-infection w/o IFNa!! BMS-790052 60 mg QD + BMS-650032 600 mg BID Follow-up SVR12 4/11 B n=10 BMS-790052 60 mg QD + BMS-650032 600 mg BID + PR Follow-up 10/10 Week 24 48 72 Lok A, et al. EASL 2011. Abstract 1356

Can HCV be cured in the absence of a functional immune system?

PI + low dose Pol-Inh PI + Pol-Inh + IFNa Ohara et al., J Hepatol 2011

PI + low dose Pol-Inh PI + Pol-Inh + IFNa Ohara et al., J Hepatol 2011

PI + high dose Pol-Inh = Cure w/o IFNa in immunodeficient mice! Ohara et al., J Hepatol 2011

DAA combinations in clinical trials

Combination of Danoprevir and RG7128 Protease inhibitor and nuc-pol-inh. Treatment duration: 14 Days Gane et al., Lancet 2010

IFN-free DAA combination therapies Entry-Inhibitors TLR-Agonists Therapeutic Vaccine Other IFNs PEG-IFN lambda Ribavirin NS5A-Inhibitors Protease- Inhibitors Cyclophillin Inhibitors Polymeraseinhibitors NI NNI

DAAs against HCV in clinical development Protease-Inhibitors 2nd wave vs. 2nd generation Polymerase Inhibitors Non-nucleos(t)ides Polymerase Inhibitors nucleos(t)ides NS5A Inhibitors Cyclophilin Inhibitors Potency Pan-genotype efficacy Resistance Barrier Potency Pan-genotype efficacy Resistance Barrier Potency Pan-genotype efficacy Resistance Barrier Potency Pan-genotype efficacy Resistance Barrier Potency Pan-genotype efficacy Resistance Barrier +++ +/++ +/++ +-++ + (-) + (-) +-+++ +++ ++/+++ +++ +/++ +/++ +/++ +++ ++

Individualized Treatment in 2018?

Individualized Treatment in 2014????

Interferon-free Combination Treatment Protease Inhi. Nukl. Polym. Inh. Non-Nuc NS5A Inhib Cyclophilin Inhibitors Protease Inhi. Mericitabine Danoprevir Several trials +/-RBV (e.g. BI, Gilead) Several trials (e.g. BMS 790052 BMS 650032) Nukl. Polym. Inhib. PSI 7977 + PSI 938 PSI 7977 BMS790052 Non-Nuc NS5A Inh Ribavirin PSI 7977 + RBV Alisporivir + RBV

Non-Nucs + Protease inhibitors

Protease inhibitor GS 9256 + non-nuc-pol. Inhibitor tegobuvir Zeuzem et al., Hepatology 2011

Protease inhibitor GS 9256 + non-nuc-pol. Inhibitor tegobuvir + RBV Zeuzem et al., Hepatology 2011

Protease inhibitor GS 9256 + non-nuc-pol. Inhibitor tegobuvir + RBV + IFN Zeuzem et al., Hepatology 2011

28 days of treatment with BI 201335 (Prot. Inh) + BI 207127 (NNI) + Ribavirin 100000000 10000000 1000000 100000 10000 1000 100 0 4 8 12 16 20 24 28 32 36 40 44 Treatment day BI 207127 600 mg/ BI 201335/RBV BI 201335/ PegIFN/RBV Zeuzem et al., Gastroenterology 2011

SOUND C2 Study: BI 207127 + BI 201335 + RBV SVR data for 16 weeks of treatment Proportion of patients (%) 100 80 60 40 20 0 73 400 mg TID 600 mg TID 100 100 93 94 11/15 17/17 14 a /15 73 17/17 11/15 16 b /17 RVR EoT SVR Zeuzem et al., AASLD 2011, LB Poster

SOUND C2 Study: BI 207127 + BI 201335 (+ RBV) IL28B and week 12 response

NS5A inhibitor + Protease inhibitor

BMS-790052 + BMS-650032: AI447011 AI447011: phase IIa study of BMS-790052 plus BMS-650032, with or without PegIFN/RBV, for 24 weeks in HCV genotype-1 null responders A n=11 B n=10 Cure of HCV-infection w/o IFNa!! BMS-790052 60 mg QD + BMS-650032 600 mg BID No Cure in 7/11 patients!!! BMS-790052 60 mg QD + BMS-650032 600 mg BID + PR Follow-up Follow-up SVR12 4/11 10/10 Week 24 Genotype 1a: cure in 2/9 patients Genotype 1b: cure in 2/2 patients Lok A, et al. EASL 2011. Abstract 1356 48 72

BMS-790052 + BMS-650032 10 Japanese patients all infected with HCV genotype 1b all null responder to prior IFN-based treatment 24 weeks of treatment 790052 (60mg once daily) 650032 (600/200 mg twice daily) 9 patients completed treatment: 9/9 SVR12 1 patient stopped after 2 weeks: SVR Chayama et al., Hepatology 2011 (epub ahead of print)

Cyclophilin inhibitor + RBV Pawlotsky et al., AASLD 2011, LB Poster

VITAL-1: Treatment arms ALV loading* RVR at W4 W12 W24 SVR12 SVR24 W6 ALV 1000 mg RVR ALV 1000 mg QD ALV 600 mg + RBV Continue on IFNfree or add-on IFN No RVR ALV 600 mg QD + PegIFN/RBV RVR ALV 600 mg + RBV No RVR ALV 600 mg + PegIFN/RBV Main objective: Proportion HCV RNA negative ALV 1000 mg QD ALV 600 mg QD + RBV ALV 800 mg QD + RBV ALV 800 mg + RBV RVR ALV 800 mg + RBV Effect of add-on IFN treatment No RVR ALV 600 mg + PegIFN/RBV ALV 600 mg + PegIFN RVR ALV 600 mg + PegIFN No RVR ALV 600 mg + PegIFN/RBV Exploratory: Safety of PegIFN-based treatment PegIFN + RBV PegIFN + RBV *Loading dose: ALV 600 mg BID for 1 week; RVR by LOQ (<25 IU/mL) after 4 weeks of treatment 39

Up to 50 half of patients on IFN-free treatment achieve undetectable RNA at week 6 Beyond Week 4, HCV RNA negative rates increase with IFN-free therapy ALV+RBV show higher responses Longer duration of ALV IFN-free treatment could achieve higher proportion with undetectable HCV RNA Viral response by <LOQ; Analysis for patients who had Week 12 HCV RNA assessment, patients with HCV RNA assessments missing at Week 12 are excluded 40

ALV IFN-free treatment is successful in maintaining HCV RNA negative response to Week 12 RVR patients on IFN free treatment Non-RVR patients with add-on IFN from week 6 IFN-free week 12 results: ALV100 26%; ALV800R 37%; ALV600R 41% Add-on IFN to non-rvr patients shows rapid response Viral response by <LOQ; Analysis for patients who had Week 12 HCV RNA assessment, 41

Nucleos(t)ide Polym. Inhibitor + Protease Inhibitor

Combination of Danoprevir and RG7128 Protease inhibitor and nuc-pol-inh. Treatment duration: 14 Days Gane et al., Lancet 2010

Nucleos(t)ide Polym. Inhibitor + RBV

Ed Gane et al., AASLD 2011

PSI 7977 100% cure in HCV Genotyp 2/3 Patients!! Ed Gane et al., AASLD 2011

Challenges?

Challenges for IFN-free treatment regimens Resistance (difference between genotype 1a vs. 1b!) Pan-genotype activity how long to treat? 8w vs. 12w vs. 16w. vs. 24w vs. xx vs. maintenance therapy

Challenges for IFN-free treatment regimens Resistance (difference between genotype 1a vs. 1b!) Pan-genotype activity how long to treat? Drug-Drug interactions

Challenges for IFN-free treatment regimens Resistance (difference between genotype 1a vs. 1b!) Pan-genotype activity how long to treat? Drug-Drug interactions Toxicity Anämie Rash

Challenges for IFN-free treatment regimens Resistance (difference between genotype 1a vs. 1b!) Pan-genotype activity how long to treat? Drug-Drug interactions Toxicity Drug burden / adherence to therapy

Challenges for IFN-free treatment regimens Resistance (difference between genotype 1a vs. 1b!) Pan-genotype activity how long to treat? Drug-Drug interactions Toxicity Drug burden / adherence to therapy role of host genes, decompensated liver disease, liver transplantation, dialysis, costs, substance user,.

Treatment of Hepatitis C 2011 2014/5