Treating HCV Genotype 2 & 3 - PDF Free Download

Treating HCV Genotype 2 & 3 3rd Workshop on HCV Therapy Advances, Rome 14.12.2013 Christoph Sarrazin Klinikum der J. W. Goethe-Universität Frankfurt am Main, Germany

HCV Genotypes 2 & 3 Laurel and Hardy

Geographical distribution and prevalence Genotype 2 and 3 in Europe Canada Norway Germany Sweden Czech Republic Poland Russia UK Hungary France Portugal HCV Prevalence <1% 1-1,9% 2-2,9% >3% unknown Spain Switzerland Italy Greece Israel Romania Turkey Cornberg et al. Liver International 2011; Suppl 2:30-60

Geographical distribution and prevalence Genotype 2 and 3 Global Syria Iraq Iran Pakistan China Korea Lebanon Japan Egypt Taiwan Jordan Saudi Arabia India Thailand HCV Prävalenz <1% 1-1,9% 2-2,9% >3% Nicht untersucht Vietnam Australia Sievert et al. Liver International 2011; Suppl 2:61-80

Summary distribution and clinical features Genotype 2 and 3 Genotype 2 Approx. 8% of HCV infections globally High prevalence in - Italy - Korea - Japan - Taiwan Genotype 3 Approx. 10% of HCV infections globally High prevalence in - Pakistan - India - Thailand - Europe - Australia HCV associated NHL? Hepatic steatosis Faster fibrosis progression? Ferri et al., Autoimmun Rev 2007; Bochud et al., J Hepatol 2009, Probst et al., J Viral Hepatitis 2011

Treatment options Genotype 2 and 3 Country specific availability / approval and coverage by health insurance - PEG-Interferon alfa and ribavirin - Boceprevir / Telaprevir - Sofosbuvir, Simeprevir / Faldaprevir - Future drugs

Treatment options Genotyp 2/3 PEG-Interferon alfa and Ribavirin (treatment naive) PEG-IFN-α plus Ribavirin (24 weeks) 120 100 80 97 92 76 76 82 71 93 78 SVR (%) 60 40 Genotype 2 Genotype 3 20 0 Dalgard et al. Mangia et al. Shiffman et al. Zeuzem et al. Dalgard et al., Hepatology 2008; Mangia et al., NEJM 2005; Shiffman et al., NEJM 2007; Zeuzem et al., J Hepatol 2004

Treatment options Genotyp 2/3 PEG-Interferon alfa and Ribavirin (treatment naive) Meta-Analysis of 8 studies with PEG-IFN-α plus Ribavirin (12-16 versus 24 weeks in RVR patients irresp. of baseline viral load) SVR (%) 100 90 80 70 60 50 40 30 20 10 0 83 84 84 86 Genotype 2 Genotype 3 12-16 weeks (RVR) 24 weeks (RVR) Andriulli et al., Alim Pharm Ther 2008

Treatment options Genotyp 2/3 PEG-Interferon alfa and Ribavirin (treatment naive) Meta-Analysis of 8 studies with PEG-IFN-α plus Ribavirin (non-rvr patients with 24 weeks of treatment) 24 weeks (non-rvr) SVR (%) 100 90 80 70 60 50 40 30 20 10 0 62 46 Genotype 2 Genotype 3 Genotype 2 Genotype 3 Andriulli et al., Alim Pharm Ther 2008

Treatment options Genotyp 2/3 PEG-Interferon alfa and Ribavirin (treatment naive) Extension of treatment duration in non-rvr patients? N-Core Study design CHC G2/3 patients on PegIFN alfa- 2a/ RBV RVR: continue treatment outside the study Non-RVR: enrolled in the study n=400 n=235 STOP n=160 PegIFN alfa-2a/ RBV n=160 48 week follow-up n=95 n=93 24 week follow-up 0 4 8 12 24 48 72 Entry into study at week 8 if no RVR Randomization of patients without RVR, but with undetectable HCV RNA or 2-log drop in HCV RNA from baseline at week 12

Treatment options Genotyp 2/3 PEG-Interferon alfa and Ribavirin (treatment naive) SVR24 (% of patients) 80 73 70 63 61 60 52 52 54 50 40 30 20 10 0 ITT (n=188) PP (n=176) SC (n=153) Odds ratio 0.68 0.63 0.44 PegIFN 2a/RBV 24 weeks PegIFN 2a/RBV 48 weeks SC population: Significantly higher SVR24 rates with 48 weeks vs. 24 weeks of PegIFN 2a/RBV 95% CI 0.38 1.21 0.35 1.16 0.22 0.89 p value 0.1934 0.1461 0.0231 CI = confidence interval; ITT = intent-to-treat; PP = per protocol; SC = study completer; SVR24 = sustained virologic response 140 days after end of treatment. Cheinquer H et al. AASLD 2012; #156 (S271A)

Treatment options Genotyp 2/3 PEG-Interferon alfa and Ribavirin (Relapser/NR) EPIC-3 Study: relapser / non-responder to (PEG)IFN + ribavirin 48 weeks PEG-IFN plus Ribavirin 100 90 80 SVR (%) 70 60 50 40 59 55 61 46 30 20 10 0 Genotype 2 (n=75) Genotype 3 (n=292) GT2/3 Relapser GT2/3 Non- Responder Poynard et al., Gastroenterology 2009

Telaprevir Genotype 2 Genotype 3 Median HCV RNA decline (log 10 IU/ml) A Genotype 2 0,0-1,0-2,0-3,0-3,65-4,0-5,0-4,83-5,51-6,0-6,0 Baseline 2 3 4 7 12 15 Telaprevir monotherapy Time (days) Median HCV RNA decline (log 10 IU/ml) B 0,0-1,0-2,0-3,0-4,0-5,0 Genotype 3-6,0-6,0 Baseline 2 3 4 7 12 15 Time (days) -0,54 Telaprevir monotherapy -4,72-4,85 Telaprevir monotherapy Telaprevir plus Peg-IFN/RBV Peg-IFN/RBV Foster et al. Gastroenterology 2011; 141: 881-889

Boceprevir Antiviral activity of Boceprevir monotherapy in genotype 2/3 Silva et al. J Hepatol 2013

Telaprevir and Boceprevir Mean maximum log10 HCV RNA decline during mono-therapies 7-14 days HCV RNA log10 decline 6 5 4 3 2 1 0 4,4 2,1 3,9 1,4 1,7 0,5 0,9 GT 1 GT 2 GT 3 GT 4 GT 5 GT 6 Telaprevr 750mg TID; Reesink et al., Gastro 2006, Foster et al., Gastro 2011, Benhamou et al., EASL 2009 Boceprevir 400mg TID (current dose 800mg TID); Sarrazin et al., Gastroenterology 2007; Silva et al., APASL 2011 no data

Telaprevir and Boceprevir Rescue treatment in patients with incomplete virologic response viral load log 10 decline 7 6 5 4 3 2 1 Case: 45 years female 80kg (BMI 26) Genotype 3 F4 (cirrhosis) treatment-naive PEG-2a 180 plus 1200 Riba 0 1 2 3 4 5 6 7 8 Treatment week

Telaprevir and Boceprevir Rescue treatment in patients with incomplete virologic response Add-on Boceprevir 3x800mg per die viral load log 10 decline 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Case: 45 years female 80kg (BMI 26) Genotype 3 F-3 fibrosis treatment-naive PEG-2a 180 plus 1200 Riba Treatment week

Telaprevir and Boceprevir Rescue treatment in patients with incomplete virologic response HCV Genotype Fibrosis Metavir IL28B* Pre-Tx Status Protease- Inhibitor Viral load PI baseline Virological response 2a 4 CT Relapse Telaprevir 6400 SVR 2a 2 CT Partial-NR Telaprevir 46300 Relapse 3a 4 CC Naive Boceprevir 20500 SVR 3a 2 CT Naive Boceprevir 320 SVR 3a 4 CT Naive Boceprevir 1120 BT 3a 4 CT Relapse Boceprevir 1250 Relapse 3a 4 CC Naive Boceprevir 125 SVR *rs12979860

Sofosbuvir Monotherapy: antiviral activities EC50 (µm) GT1b con1 GT1a H77 GT2a JFH-1 GT1b/ 2a J6 GT1b/ 2b pt GT1b/ 3a pt SOF 0.048 0.044 0.037 0.0047 0.020 0.016 Median HCV RNA change from baseline (log IU/mL) 0-1 -2-3 -4-5 0 1 2 3 4 5 6 7 Days PSI-7977 400 mg QD In HCV GT2/3 (ELECTRON) PSI-7977 400 mg QD In HCV GT1 (NUCLEAR) 1 Lam et al., AAC 2012; Gane et al., AASLD 2011; Lawitz et al., EASL 2011

Sofosbuvir + Riba: IFN-intolerant tx-naive (Positron) 100 92 94 No cirrhosis Cirrhosis 80 68 SVR12 (%) 60 40 21 20 0 85/92 16/17 57/84 3/14 GT 2 GT 3 100% on tx response, no viral break-through, failure = relapse No resistance (deep and phenotypic) Jacobson et al., EASL 2013; #61 and NEJM 2013

Sofosbuvir plus Riba vs. PEG/R tx-naive (Fission) SOF + RBV Peg-IFN + RBV SVR12 (%) 100 80 60 40 98 82 91 62 61 71 34 30 20 0 58/59 44/54 10/11 8/13 89/145 99/139 13/38 11/37 No cirrhosis Cirrhosis No cirrhosis Cirrhosis GT 2 GT 3 Gane et al., EASL 2013; #5 and NEJM 2013

Sofosbuvir plus Ribavirin in tx-experienced (Fusion) SOF + RBV 12 weeks SOF + RBV 16 weeks 100 80 96 100 60 78 100 80 63 61 SVR12 (%) 60 40 60 40 37 19 20 20 0 25/26 23/23 6/10 7/9 14/38 25/40 5/26 14/23 No cirrhosis Cirrhosis 0 No cirrhosis Cirrhosis GT 2 GT 3 Gane et al., EASL 2013 and NEJM 2013

Sofosbuvir plus Ribavirin 12 vs. 24 wks. (Valence) Genotype 2/3, tx-naive and Non-Responder: Extension of treatment duration in GT3 patients Zeuzem et al., AASLD 2013; 1085

Sofosbuvir plus Ribavirin 12 vs. 24 wks. (Valence) Genotyp 2/3, Tx-naive and Non-Responder: Extension of treatment duration in genotype 3 patients Zeuzem et al., AASLD 2013; 1085

Sofosbuvir+ PEG + Riba: tx-experienced (Lonestar 2) Genotyp 2/3, Re-treatment (85% BT or Relapse), 50% F4, n=47 Sofosbuvir 400mg QD plus PEG-2a + Riba for 12 weeks 120 SVR12 (%) 100 80 60 40 96 100 93 83 83 83 all no cirrhosis cirrhosis 20 0 22/23 20/24 Genotype 2 Genotype 3 Relapse 2 1 1 Lawitz et al., AASLD 2013; LB4

Sofosbuvir + Riba +/- PEG: Adverse events Overall safety Hematolog ic abnormalit ies Patients, n (%) SOF + RBV n=207 Placebo n=71 AEs 185 (89) 55 (78) Serious AEs 11 (5) 2 (3) Treatment disc. due to AEs 4 (2) 3 (4) Hemoglobin <10 g/dl 15 (7) 0 Hemoglobin <8.5 g/dl 2 (1) 0 Absolute neutrophil count <750/mm 3 0 1 (1) Platelets <50,000/mm 3 0 2 (3) Preferred term, n (%) SOF + RBV n=207 Placebo n=71 p-value* Fatigue 91 (44) 17 (24) 0.003 Nausea 46 (22) 13 (18) 0.614 Headache 43 (21) 14 (20) 1.00 Insomnia 39 (19) 3 (4) 0.002 Pruritus 23 (11) 6 (9) 0.655 Anemia 27 (13) 0 <0.001 Jacobson et al., EASL 2013; #61

Simeprevir Genotype 1: -3.8 log decline -2.73 log -0 log -3.52 log -2.19 log Moreno et al., J Hepatol 2012

Faldaprevir Potentcy of BI 201335 (Faldaprevir), telaprevir, and boceprevir against NS3-NS4A proteins of differnt HCV genotypes White et al., AAC 2010

Sofosbuvir: FDA approval Dec. 13

Future drugs NS3 Protease-Inhibitors MK-5172 (activity against genotype 3 at toxic doses only) NS5A-Inhibitors: Daclatasvir (lower activity against GT3 versus GT1) Ledipasvir (in vitro low activity against GT3) ABT-267 (in vitro lower activity against GT3 versus GT1) GS-5816 (improved activity against GT3) Non-nucleoside Polymerase-Inhibitors no clinical data Nucleoside Polymerase-Inhibitors several compounds in phase 1/2 (VX-135, IDX-20963, ACH3422)

Summary Different geographical distribution of genotypes (GT) 2 and 3 Countries with high prevalence of GT 2 or 3 (>30%) PEG-Interferon plus ribavirin for 12-16 weeks in patients with RVR (without cirrhosis, <45 years and BMI <30) PEG-Interferon plus ribavirin for 48 weeks in non- RVR and previous Rel/NR patients? Rescue treatment with Boceprevir / Telaprevir? Sofosbuvir plus Ribavirin for 12 weeks in genotype 2 Sofosbuvir plus Ribavirin for 24 weeks in genotype 3 (Sofosbuvir + Riba + PEG for 12 weeks?) No efficacy / data for Simeprevir and Faldaprevir

HCV Genotypes 2 & 3 Laurel and Hardy