Is prioritization the best way to treat hepatitis C? Vicente Soriano Infectious Diseases Unit La Paz University Hospital Madrid, Spain

Is prioritization the best way to treat hepatitis C? Vicente Soriano Infectious Diseases Unit La Paz University Hospital Madrid, Spain

Disclosures Advisory boards and speaker s bureau for: Gilead, Merck, Jannsen and Abbott.

HCV Treatment should be prioritized Treatment Indicated All naive and experienced pts with liver disease Prioritized Pts with fibrosis (F3) or cirrhosis (F4) including compensated cirrhosis HIV coinfection, HBV coinfection Indication for liver transplantation HCV recurrence after transplantation Extra-hepatic manifestations Debilitating fatigue Risk of transmitting HCV Justified Deferred Not recommended Pts with moderate fibrosis (F2) Pts with no or mild (F0-F1) disease and no extra-hepatic manifestations Pts with limited life expectancy due to non-liver comorbidities EASL Guidelines 2015. http://www.easl.eu/medias/cpg/hepc-2015/full-report.pdf.

DAA prioritization debate Cons: Prevent progression to advanced liver disease, and risk for developing HCC Ameliorate extrahepatic manifestations and reduce non-liver-related morbidity and deaths DAA are safer and more effective in patients with null-mild liver than advanced hepatic fibrosis. Wide HCV-Ab screening and transmission prevention strategies would be less incentivated if asymptomatic carriers are not treated Pros: Focus therapy in those more in need Reduce and/or defer costs Avoid drug-related adverse events of current DAAs Protection from HCV re-infection in persons engaged in high-risk behaviors (i.e., MSM)

Cumulative incidence of HCC (%) Decreased risk of HCC after SVR, but the risk is not ZERO 1,0 0,8 Non-SVR SVR Log-rank : p < 0.0001 0,6 3 yrs 5 yrs 0,4 0,2 0 13,6 % 21,8 % 1,9 % 3,3 % 0 12 24 36 48 60 72 Time after SVR (months) 84 Non-SVR SVR 747 (17) 678 (33) 585 (36) 444 (19) 341 (15) 239 (11) 136 (9) 65 482 (1) 464 (5) 420 (2) 348 (1) 272 (3) 208 (3) 140 (1) 62 Nahon et al, EASL 2015, Abs. P0328 5

Patients after 5 years (%) Liver transplant requirement by SVR 20 18 16 14 12 10 8 6 4 2 0 General: 1 study n=108 Avg. FU=4.2 years 2.2% Cirrhotic: 2 studies n=1,046 Avg. FU=7.7 years 7.3% HIV/HCV: 2 studies n=2,039 Avg. FU=4.9 years 0% 0.2% 0.6% 2.7% General Cirrhotic Co-infected SVR No SVR

Clinical spectrum of chronic HCV disease Liver disease: Cirrhosis Hepatocellular carcinoma Lymphoproliferative disorders: Mixed cryoglobulienmia Monoclonal gammapathies B-cell lymphoma Rheumatic diseases: Sicca syndrome Poliarthritis Extra-hepatic organ damage: Atherosclerosis & Cardiovascular disease Kidney disease Insulin resistance & Diabetes Bone disease Neuropsychiatric abnormalities Mucocutaneous conditions: porphyria cutanea tarda, lichen, psoriasis Soriano et al. Antivir Ther 2015

B-cell syndromes in chronic hepatitis C HCV replication B-cell Antibody disorders B-cell proliferation Mixed Cryoglobulinemia Monoclonal Gammapathies Non-Hodgkin Lymphomas

Causes of death in patients with chronic hepatitis C (REVEAL-HCV). HCV Ab-pos vs HCV Ab-neg - 23,820 adults followed for a mean of 16.2 years - 1,095 HCV Ab+ (4%) - 69% of HCV Ab+ were HCV-RNA pos - 2,394 deaths during the study period All causes death 1.9 Liver-related Liver cancer Cirrhosis Extrahepatic Cancers* Cardiovascular 1.3 1.4 1.5 5.4 // 12.5 21.6 Kidney 2.8 *esophagus, prostate & thyroid Adjusted hazard ratio Lee et al. J Infect Dis 2012; 206: 469-77.

Complications halted with universal treatment of chronic hepatitis C 1. Hepatic disease progression. 2. Direct extra-hepatic manifestations (lymphoproliferative disorders, kidney, skin). 3. Indirect extra-hepatic complications (heart, diabetes, dislipidemia, neuropsychiatric symptoms). 4. Liver toxicity of meds. 5. Transmission.

Impact of antiviral therapy on HCV extrahepatic outcomes Comparison of pegifn-rbv treated and untreated matched (1:2) chronic HCV patients. 3.3-years mean follow in Taiwan during 2003-2010. Calculated 8-year cumulative incidence. % p<0.001 93.3 84.4 Treated (n=12,384; >90% treated >16w) Untreated (n=24,768) p<0.001 0.15 1.32 p=0.027 2.21 2.96 p=0.001 1.31 1.76 p=0.816 0.57 0.49 Survival End-stage renal disease Acute coronary syndrome Ischemic stroke Autoimmune catastrophe Hsu et al. Gut 2015; 64:495-503.

Classification of recommended DAA (2016) NS3 protease inhibitors NS5A inhibitors Nucleos(t)ide polymerase inhibitors Non-nucleoside polymerase inhibitors Simeprevir Asunaprevir Paritaprevir Grazoprevir Ledipasvir Daclatasvir Ombitasvir Elbasvir Velpatasvir Sofosbuvir Beclabuvir Dasabuvir Squares record co-formulations or co-packaged medications. Velpatasvir will soon replace ledipasvir.

Current DAA limitations Limited efficacy & Resistance Safety Cost

Predictors of DAA failure Baseline On-treatment Cirrhosis Genotype 3 RAVs Prior interferon failure Elevated serum HCV-RNA IFNL4 unfavorable AA ethnicity HIV (?) Drug adherence Drug interactions Side effects

Estimated clearance time for RAVs selected upon treatment failure RAVs (%) 10% days months years Benitez et al. Exp Op Pharmacother 2016

Anecdotal SAEs with DAA Bradyarrithmias (and syncope) Pulmonary arterial hypertension Lung toxicity Hepatotoxicity Photosensitivity Hyperbilirubinemia Lactic acidosis Hypoglycemia in diabetics on insulin Hepatitis B reactivation Herpesvirus reactivation Rapid HCV drop Fontaine et al. NEJM 2015; 373: 1886-8. Ahmad et al. Hepatology 2015; 62: 409-16. Dyson et al. J Hepatol 2016; 64: 234-8. Soriano et al. Hepatology 2016; 63:2065-6. Stine et al. Dig Dis Sci 2015; 60: 1031-5. Welker et al. J Hepatol 2016; 64: 790-9. Shibata et al. Hepatology 2016; 63: 2063-4. Helmers et al. Mayo Clin Proc 2015; 90: 1294-7. Renard et al. Chest 2016; 149: e69-73. Soriano et al. Antivir Ther 2016; 21: 91-2. Perello et al. Clin Gastroenterol Hepatol (in press)

HBV reactivation during DAA for hep C * Collins et al. Clin Infect Dis 2016 Ende et al. J Med Case Rep 2015 Takayama et al. Hepatol Res 2016 *De Monte J Clin Virol 2016

DAA World Prices

Wholesale acquisition cost versus estimated production cost for DAAs Hill A et al. Clin Infect Dis 2014;58:928-36.

Beker, Algeria Pharma5, Morocco Mylan, India

REDEMPTION-1 First study with generic DAAs Generic DAAs evaluated for quality using HPLC and mass spectroscopy Consecutive patients enrolled via the fixhepc website http://fixhepc.com https://gp2u.com.au Freeman J et al. EASL 2016. LB03.

REDEMPTION-1 400 patients worldwide enrolled

REDEMPTION-1

Summary Hepatitis C is a systemic disease that involves liver damage and extrahepatic complications. Once the patient is ready to start and the medication is accesible/affordable, there is no scientific basis to defer DAA therapy. The benefits of universal DAA treatment translates in lower liver disease, lower extrahepatic morbidity and less transmissions.