Need to Assess HCV Resistance to DAAs: Is it Useful and When?

Need to Assess HCV Resistance to DAAs: Is it Useful and When? Stéphane Chevaliez French National Reference Center for Viral Hepatitis B, C and delta Department of Virology & INSERM U955 Henri Mondor Hospital University of Paris-Est Créteil, France

Patient Case Age/gender 54 years, male HCV diagnosed 2013 Route of transmission Injectable drugs Genotype 1a (VERSANT HCV Genotype 2.0) Fibrosis stage Complications Concomitant diseases Associated treatment HCV RNA levels Previous HCV treatment Cirrhosis (Fibroscan 27 kpa) Child-Pugh A5 Obesity (BMI 30.2 kg/m2) None 5.4 Log IU/mL (Abbott RealTime HCV) pegifn/rbv (relapse)

Will you Prescribe an HCV Resistance Testing Prior to Treatment? 1. Yes 2. No

Systematic Resistance Testing Prior to First-Line Therapy is NOT Recommended Pawlotsky JM., Gastroenterology 2016;151:70-86; EASL recommendations on treatment of hepatitis C 2016., J Hepatol 2016, in press.

No need to Perform Systematic HCV Resistance Testing at Baseline Clinical reasons In clinical trials and in the real-world setting, most patients achieve an SVR Presence of RASs has limited impact on SVR except in some subgroups of patients (cirrhotic, treatmentexperienced and genotypes 1a and 3) Patients who failed to a first course of DAA therapy can be successfully retreated following guidelines Virological reasons No commercially standardized methods are available

No need to Perform Systematic HCV Resistance Testing at Baseline Clinical reasons In clinical trials and in the real-world setting, most patients achieve an SVR Presence of RASs has limited impact on SVR except in some subgroups of patients (cirrhotic, treatmentexperienced and genotypes 1a and 3) Patients who failed to a first course of DAA therapy can be successfully retreated following guidelines Virological reasons No commercially standardized methods are available

In the Real-World, Most Patients Achieve an SVR

Most Patients Achieve an SVR with All-oral DAAs (Genotype 1) 100 80 S V R ( % ) 60 40 20 1921 1995 1504 1595 199 200 4911 5390 1015 1152 3718 4068 2056 2363 0 96,3 94,3 99,5 91,1 88,1 91,4 87 AUBE US Veterans R HCV- TARGET TRIO Health Terrault et al., Gastroenterology 2016;151(6):1131-1140.Tapper et al., J Viral Hepat 2017;24(1):22-27; Flisiak et al., Aliment Pharmacol Ther 2016;44(9):946-956; Backus et al., Aliment Pharmacol Ther 2016;44(4):400-10; Backus et al., Hepatology 2016;64(2):405-14; McCombs et al., EASL 2016;abstract LB510.

SVR in Genotype 1 Patients Treated with SOF/LDV for 8 Weeks S V R 1 2 ( % ) 119 123 251 263 150 154 69 70 97 95 97 99 100 98 97 103 103 47 48 638 658 Post hoc analysis: patients qualified = Treatment-naïve, no cirrhosis, HCV RNA 6 million IU/mL ** Per protocol analysis *** ITT analysis Buggisch P, et al. EASL 2016, Abstract. SAT-242.

Presence of RASs Has Limited Impact on Antiviral Response

Impact of RASs on Virological Responses (LOD 15%) 3,2 91,7 p<.001 10,9 89,1 p<.063 9,2 90,8 p<.001 S V R ( % ) No RASs RASs 1416 1445 117 130 462 468 54 57 1880 1915 177 193 98 90 98,7 94,7 98,2 91,7 SOF/LDV±RBV for 6-24 weeks Sarrazin et al., Gastroenterology 2016;151(3):501 512.

Impact of RASs on Virological Responses (LOD 1%) NS5A RASs NS5B RASs 36 64 7 93 No RASs RASs 100 S V R ( % ) 637 643 373 380 251 251 73 75 70 70 162 162 225 231 38 43 43 43 72 72 28 28 20 20 22 22 Overall 99 95 99G1 100 100 G2 100 97G3 88 100 G4 100 100 G5 100 G6 SOF/VEL for 12 weeks Hézode et al., EASL 2016;Abstract 216.

Impact of RASs on Virological Responses (LOD 15%) No RASs RASs 0,9 10 1 87 No RASs NS3 RAS NS5A RAS NS5B RAS S V R ( % ) 390 410 4 4 269133 276138 351 57 361 59 365 375 43 45 388 399 97100 9796 97 97 9796 97 97 7 8 PTV/r+OMB+DSV±RBV for 12-24 weeks Sarrazin et al., EASL 2016, Abstract LB503.

Methods Available to Determine Resistance Profile

Tests Available in Europe? No commercially standardized test are available Except for the detection of NS3 Q80K RAS (Polymorphism kit, Clonit srl, Milan)1 Only homebrew population sequencing based methods for NS3pro, NS5A domain I and NS5B NGS-based tests are currently in development Sentosa SQ HCV Genotyping Assay (VELA Diagnostics)2 1Vicenti et al., J Clin Virol. 2016;76:20-3; 2Poon et al., AASLD 2015.

Features Sentosa SQ HCV Genotyping Assay HCV RNA level >1000 IU/mL Serum or plasma specimens accepted Time to obtain results 48 hours HCV genome 342 Core C 915 E1 1491 Structural proteins Envelop e E2 2580 2769 NS2/3 proteas e NS2 3420 NS3 5313 5477 5ʹ UTR P7 NS4A NS3 NS5A NS5B Serine protease Helicas e Protease cofactor NS4B 6258 Non-structural proteins NS5A 7601 RNAdependent RNApolymerase NS5B 9375 3ʹ XR

How Will you Treat? 1. Sofosbuvir + Ledipasvir ± RBV for 12/24 weeks 2. Sofosbuvir + Velpatasvir ± RBV for 12/24 weeks 3.Paritaprevir/r + Ombitasvir + Dasabuvir ± RBV for 12/24 weeks 4. Grazoprevir + Elbasvir ± RBV for 12/16 weeks 5. Sofosbuvir + Daclatasvir ± RBV for 12/24 weeks EASL recommendations on treatment of hepatitis C 2016., J Hepatol 2016, in press.

Patient Case First treatment received in May 2014 SOF + DCV for 12 weeks Day 0 Week 4 Week 8 Week 12 (EoT) Follow-up week 4 Follow up week 12 HCV RNA levels 5.4 Log IU/mL 1.1 Log IU/mL <1.08 Log UI/mL, Target not detected <1.08 Log UI/mL, Target not detected 5.55 Log IU/mL 5.15 Log IU/mL

Patient Case First treatment received in May 2014 SOF + DCV for 12 weeks Day 0 Week 4 Week 8 Week 12 (EoT) HCV RNA levels 5.4 Log IU/mL 1.1 Log IU/mL <1.08 Log UI/mL, Target not detected <1.08 Log UI/mL, Target not detected Relapse

Patient Case RASs post-daa treatment (population sequencing 20-30%) None NS3 NS5 A M28T None NS5 B

M28T RAS Confer a High Level of Resistance to NS5A Inhibitors EC50 (pm) Ledipasvir Daclatasvir Ombitasvir Pibrentasvir GT1a GT1b

Selection of NS5A RAS in Patients Who Fail to Achieve an SVR

Treatment Failures Were Associated with Selection of RASs Ledipasvir1 Ombitasvir2 Elbasvir3 Populations Treatment groups N G1 Rx-naïve and -exp. G1/4 Rx-naïve and -exp. G2 Rx-exp. G1/4/6 Rx-naïve and -exp. SOF/LDV±RBV 8, 12 or 24 Wks 2D or 3D±RBV 8, 12 or 24 Wks GZR/ELB±RBV 12 Wks Virologic Failure NS5A RAS at failure 1952 37 (1.9%) 29 (78%) 2652 82 (3.1%) 73 (89%) 1492 47 (3.1%) 42 (89%) Velpatasvir4 G1/2/3/4/5/6 Rxnaïve and -exp SOF/VEL±RBV 12 or 24 Wks 1623 35 (2.1%) 29 (83%) Daclatasvir5 G1/2/3/4 Rxnaïve and -exp SOF+DCV±RBV 8, 12, 16 or 24 Wks 616 33 (5.4%) 24 (73%) Pibrentasvir 4 G1/2/3/4 Rxnaïve and -exp GLE/PIB 8, 12 Wks 843 5 (0.6%) 1ION-1, -2, -3 2PEARL-I, -II, -III, -IV, AVIATOR, TURQUOISE-I, SAPPHIRE-II 3C-SUFFER, C-EDGE, C-SALVAGE, C-WORTHY 4ASTRAL-1, -2, -3, -4 5ALLY-2, -3, AI4444040 4ENDURANCE-1, -2, -3, -4

Persistence of NS5A RASs in Patients Who Fail to Achieve an SVR

Long-term Persistence of NS5A RASs In G1- Patients who Failed to GZR-containing Regimens All NS5A RASs All NS5A RASs Days Post-Treatment Lahser et al., AASLD 2016;Abstract 61.

Will you Retreat this Patient? 1. Yes 2. No

What is Recommended for Patients Who Fail DAA Therapy? For patients who failed IFN-free DAA combination therapies, EASL and AASLD guidelines recommend the following: Switching to a different DAA class Adding RBV to the treatment Treating for a longer duration AASLD/IDSA HCV Guidance Panel., Hepatology 2015;62(3):932-54; EASL Recommendations on Treatment of Hepatitis C J Hepatol 2016; Sep 12. pii: S0168-8278(16)30489-5. doi: 10.1016/j.jhep.2016.09.001.

How Will you Retreat? 1. Sofosbuvir + Ledipasvir + RBV for 24 weeks 2. Sofosbuvir + Velpatasvir + RBV for 24 weeks 3.Sofosbuvir + Paritaprevir/r + Ombitasvir + Dasabuvir + RBV for 24 weeks 4. Sofosbuvir + Grazoprevir + Elbasvir + RBV for 16/24 weeks 5. Sofosbuvir + Simeprevir + RBV for 24 weeks

SOF/SMV for 12 weeks in Patients Who Failed Prior DCV-based Therapy Patients with SVR12 (%) 2 patients relapsed 86,7 14/16 Hézode et al., Hepatology 2016;63(6):1809-16.

SOF/SMV for 12 weeks in Patients Who Failed Prior DCV-based Therapy Patients with SVR12 (%) Relapse 86,7 14/16 4/4 10/12 100 83 Hézode et al., Hepatology 2016;63(6):1809-16.

SOF/SMV for 12 weeks in Patients Who Failed Prior DCV-based Therapy Patients with SVR12 (%) Relapse 86,7 14/16 100 75 8/8 6/8 Hézode et al., Hepatology 2016;63(6):1809-16.

3D Combination plus SOF for 12-24 Weeks in Patients who Failed Prior DAA Regimen Patients with SVR12 (%) 21/22 13/14 6/6 2/2 95 93 100 100 Poordad et al,. EASL 2016;Abstract 156. without cirrhosis with cirrhosis

GZR/ELB plus SOF and RBV for 16-24 Weeks in Patients who Failed Prior DAA Regimen 7,7 With NS5A RASs 92,3 0 0 8 15 23 25 31 54 83 77 92 100 100 100 100 100 N=26 Pts (20 G1 & 6 G4) de Ledinghehn et al., AASLD 2016; Abst. LB-18 16 Weeks 24 Weeks

Patient Case Second treatment received in January 2015 SOF + SMV + RBV for 24 weeks In September 2015, SVR12 achieved Patient is cured!

Conclusions Systematic HCV resistance testing prior to first-line treatment is NOT recommended SVR rates are >90%, however some relapses can occur, especially when treatment is suboptimal Patients who failed to a first course of DAA therapy can be successfully retreated following guidelines Cure of infection does not mean cure of disease (cirrhotics), and these patients