4 th HCV Therapy Advances Meeting Paris, December 12-13, 14 Pivotal New England Journal of Medicine papers 14 Phase 3 Trial data Stefan Zeuzem, MD University of Frankfurt Germany
Disclosures Consultancies: Abbvie, BMS, (Boehringer Ingelheim), Gilead, (Idenix), Janssen, Merck, Novartis, (Roche), Santaris, (Vertex) Honoraria for lectures: Abbvie, BMS, (Boehringer Ingelheim), Gilead, Janssen, Merck, (Roche)
Phase III Trials of IFN-free Regimens: Genotype 1 Sofosbuvir + Ledipasvir ± RBV Ion-1: TN ± cirrhosis; 12 vs. 24 wks Ion-2: TE (incl. PIfailure), ± cirrhosis; 12 vs. 24 wks Ion-3: TN w/o cirrhosis; 8 vs. 12 wks Paritaprevir/r + Ombitasvir + Dasabuvir ± RBV Sapphire-I: TN w/o cirrhosis; 12 wks Sapphire-II: TE w/o cirrhosis; 12 wks Turquoise-II: TN and TE ± cirrhosis; 12 vs. 24 wks Pearl-II, -III, IV: ± RBV
ION-1: SOF/LDV ± RBV in GT1 tx-naive patients Overall GT1a GT1b 99,5 99,3,,,, 99,1,,,, 97,1 8 SVR12 (%) 4 n N 211 212 141 142 SOF/LDV 12 weeks SOF = 4 mg/day; LDV = 9 mg/day; RBV = or 1 mg/day. Subgroup results do not include patients who withdrew consent or who were lost to follow-up. Error bars: 95% CI. 66 66 211 211 143 143 67 67 SOV/LDV + RBV 12 weeks 212 214 143 143 SOV/LDV 24 weeks 66 68 215 215 141 141 71 71 SOF/LDV + RBV 24 weeks Afdhal N, et al. N Engl J Med. 14;37:1889-98
ION-1: SVR12 by Presence of Cirrhosis Absence of Cirrhosis Cirrhosis 97 99 97 8 SVR12 (%) 4 179/179 32/33 178/178 33/33 181/182 31/32 179/179 36/36 LDV/SOF LDV/SOF + RBV LDV/SOF LDV/SOF + RBV Error bars represent 95% confidence intervals 12 Weeks 24 Weeks Afdhal N, et al. N Engl J Med. 14;37:1889-98
ION-1: Reasons for Not Achieving SVR Patients, n (%) LDV/SOF n=214 12 Weeks 24 Weeks LDV/SOF+RBV n=217 LDV/SOF n=217 LDV/SOF+RBV n=217 SVR12 211 (99) 211 (97) 212 (98) 215 (99) Breakthrough 1 (<1) Relapse 1 (<1) 1 (<1) Lost to Follow-Up 2 (<1) 4 (2) 2 (<1) 2 (<1) Withdrew Consent 2 (<1) 1 (<1) Single on-treatment breakthrough was due to non-adherence Two of 865 subjects (.23%) had post-treatment relapse Both had NS5A-resistant variants at baseline and at relapse 16% of all subjects had NS5A RAVs at baseline, with 96% achieving SVR Afdhal N, et al. N Engl J Med. 14;37:1889-98
ION-3: SOF/LDV ± RBV in GT1 tx-naive patients Overall GT1a GT1b 94, 93, 97,7 93,1 95,5 95,4 94,8 97,7 92,4 8 SVR12 (%) 4 SOF = 4 mg/day; LDV = 9 mg/day; RBV = or 1 mg/day. * One patient achieved SVR12, but was not subgenotyped. Error bars: 95% CI. n N 2 215 159 171 SOF/LDV* 8 weeks 42 43 1 216 159 172 42 44 SOV/LDV + RBV 8 weeks 6 216 163 172 SOV/LDV 12 weeks 43 44 Kowdley KV, et al. N Engl J Med. 14;37:1879-88
ION-3: Reasons for Not Achieving SVR 8 Weeks 12 Weeks Patients, n (%) LDV/SOF n=215 LDV/SOF + RBV n=216 LDV/SOF n=216 SVR12 2 (94) 1 (93) 6 (95) Breakthrough Relapse 11 (5) 9 (4) 3 (1) Lost to Follow-Up 1 (<1) 5 (2) 7 (3) Withdrew Consent 1 (<1) 1 (<1) All virologic failures were due to relapse (n=23) 9 subjects had baseline RAVs, 8 subjects with no RAVs, 6 subjects with new RAVs 18% of subjects had baseline NS5A RAVs, and 9% achieved SVR12 Kowdley KV, et al. N Engl J Med. 14;37:1879-88
ION-3: LDV/SOF ± RBV Safety Summary Patients, n (%) LDV/SOF 8 Weeks n=215 LDV/SOF + RBV 8 Weeks n=216 LDV/SOF 12 Weeks n=216 AEs 145 (67) 165 (76) 149 (69) Grade 3 4 AEs 2 (<1) 8 (4) 7 (3) Death Grade 3 4 laboratory abnormality 7 (3) 18 (8) 16 (7) Hemoglobin <1 g/dl 11 (5) 1 (<1) Hemoglobin <8.5 g/dl SAEs occurred in 4 (2%) of LDV/SOF 8 weeks, 1 (<1%) of LDV/SOF+RBV 8 weeks, and 5 (2%) of LDV/SOF 12 weeks Treatment D/C due to AEs occurred in of LDV/SOF 8 weeks, 1 (<1%) of LDV/SOF+RBV 8 weeks, and 2 (1%) of LDV/SOF 12 weeks Kowdley KV, et al. N Engl J Med. 14;37:1879-88
ION-3: Adverse Events ( 5% in Any Arm) Preferred term, n (%) LDV/SOF 8 wk n=215 LDV/SOF + RBV 8 wk n=216 LDV/SOF 12 wk n=216 Overall 145 (67) 165 (76) 149 (69) Fatigue 45 (21) 75 (35) 49 (23) Headache 3 (14) 54 (25) 33 (15) Nausea 15 (7) 38 (18) 24 (11) Insomnia 11 (5) 26 (12) 15 (7) Irritability 3 (1) 29 (13) 9 (4) Diarrhea 15 (7) 13 (6) 9 (4) Arthralgia 9 (4) 11 (5) 16 (7) Constipation 9 (4) 13 (6) 8 (4) Dizziness 6 (3) 13 (6) 9 (4) Rash 3 (1) 19 (9) 5 (2) Pruritus 2 (<1) 16 (7) 5 (2) Cough 3 (1) 12 (6) 7 (3) Anemia 2 (<1) 17 (8) 2 (<1) Muscle Spasms 3 (1) 11 (5) 6 (3) Dyspnea 11 (5) 1 (<1) Kowdley KV, et al. N Engl J Med. 14;37:1879-88
ION-2: SOF/LDV ± RBV in GT1 tx-experienced pts Overall GT1a GT1b 93,6 95,3 96,4 95,5 99,1 98,8 87, 99,1 98,9 8 SVR12 (%) 4 n N 12 19 SOF = 4 mg/day; LDV = 9 mg/day; RBV = or 1 mg/day. * One patient achieved SVR12, but was not subgenotyped. Error bars: 95% CI. 82 86 SOF/LDV 12 weeks 23 17 111 84 88 23 23 SOV/LDV + RBV 12 weeks 18 19 84 85 SOV/LDV 24 weeks 24 24 11 111 87 88 23 23 SOF/LDV + RBV 24 weeks Afdhal N, et al. N Engl J Med. 14;37:1483-93
ION-2: SVR12 in PegIFN+RBV vs. PI+PegIFN+RBV Failures Failed PegIFN+RBV Failed Protease Inhibitor + PegIFN+RBV 93 94 96 97 98 98 8 SVR12 (%) 4 4/43 62/66 45/47 62/64 58/58 49/5 58/59 51/51 LDV/SOF LDV/SOF + RBV LDV/SOF LDV/SOF + RBV 12 Weeks 24 Weeks Error bars represent 95% confidence intervals Afdhal N, et al. N Engl J Med. 14;37:1483-93
ION-2: SVR12 - Absence of Cirrhosis vs. Cirrhosis Absence of Cirrhosis Cirrhosis 95 86 99 99 82 8 SVR12 (%) 4 83/87 19/22 89/89 18/22 86/87 22/22 88/89 22/22 LDV/SOF LDV/SOF + RBV LDV/SOF LDV/SOF + RBV Error bars represent 95% confidence intervals 12 Weeks 24 Weeks Afdhal N, et al. N Engl J Med. 14;37:1483-93
ION-2: Reasons for Not Achieving SVR Patients, n (%) LDV/SOF n=19 12 Weeks 24 Weeks LDV/SOF+RBV n=111 LDV/SOF n=19 LDV/SOF+RBV n=111 SVR12 12 (94) 17 (96) 18 (99) 11 (99) Breakthrough 1 (<1) Relapse 7 (6) 4 (4) Lost to Follow-Up Withdrew Consent 1* (<1) Single on-treatment breakthrough was due to documented non-adherence 11 subjects had virologic failure were due to relapse 6 subjects had baseline RAVs, 5 subjects with no RAVs 14% of subjects had NS5A RAVs at baseline, with 89% achieving SVR * One patient withdrew consent after the post-treatment Week 4 visit, at which HCV RNA < 25 IU/mL Afdhal N, et al. N Engl J Med. 14;37:1483-93
Ledipasvir / Sofosbuvir FDC label (GT 1) Patient population US Label EU Label Treatment-naive w/o cirrhosis Treatment-naive with cirrhosis Treatmentexperienced w/o cirrhosis Treatmentexperienced with cirrhosis Decompensated cirrhosis 12 wks 8 wks (> 6 MIU/mL HCV RNA) 12 wks 8 wks may be considered in TN pts Practical recommendation (Germany) 8 wks (low VL) 12 wks (> 6 MIU/mL HCV RNA) 12 wks 24 wks* 12 wks + RBV 12 wks 12 wks 24 wks should be considered for TE pts with uncertain subsequent tx options 12 wks 24 wks 24 wks* 12 wks + RBV --- 24 weeks + RBV 24 wks ± RBV *12 weeks may be considered for pts deemed at low risk for clinical progression and who have subsequent tx options
Phase III Trials of IFN-free Regimens: Genotype 1 Sofosbuvir + Ledipasvir ± RBV Ion-1: TN ± cirrhosis; 12 vs. 24 wks Ion-2: TE (incl. PIfailure), ± cirrhosis; 12 vs. 24 wks Ion-3: TN w/o cirrhosis; 8 vs. 12 wks Paritaprevir/r + Ombitasvir + Dasabuvir ± RBV Sapphire-I: TN w/o cirrhosis; 12 wks Sapphire-II: TE w/o cirrhosis; 12 wks Turquoise-II: TN and TE ± cirrhosis; 12 vs. 24 wks Pearl-II, -III, IV: ± RBV
SAPPHIRE-I: HCV GT1 treatment-naive patients Treatment-naive 96,2 95,3 98, SVR12 (%) 8 4 3D + RBV x 12 wks 3D: co-formulated Paritaprevir/ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid n N 455 473 37 322 148 151 Overall GT1a GT1b RBV: -1 mg/d Error bars: 95% CI. Feld JJ, et al. N Engl J Med. 14;37:1594-3
SAPPHIRE-I: Breakthrough and Relapse Rates 3D + RBV Event, n/n (%) (N=473) SVR12 455/473 (96.2) Virologic failure Breakthrough 1/473 (.2) Relapse 7/463 (1.5) Prematurely discontinued study drug* 7/473 (1.5) Lost to follow-up after completion of treatment 3/473 (.6) *Patients (n=7) who prematurely discontinued without breakthrough; 2 due to adverse events, 5 withdrew consent/ lost to follow-up. Feld JJ, et al. N Engl J Med. 14;37:1594-3
SAPPHIRE-I: AEs Occurring in >1% of Patients Event, n (%) 3D + RBV (N=473) Placebo (N=158) P Value Any AE 414 (87.5) 116 (73.4) <.5 Fatigue 164 (34.7) 45 (28.5) NS Headache 156 (33.) 42 (26.6) NS Nausea 112 (23.7) 21 (13.3) <.5 Pruritus 8 (16.9) 6 (3.8) <.5 Insomnia 66 (14.) 12 (7.6) <.5 Diarrhea 65 (13.7) 11 (7.) <.5 Asthenia 57 (12.1) 6 (3.8) <.5 Rash 51 (1.8) 9 (5.7) NS Adverse events (AEs) were generally mild. Feld JJ, et al. N Engl J Med. 14;37:1594-3
SAPPHIRE-I: Laboratory Abnormalities 3D + RBV Event, n (%) (N=469) ALT >5X ULN 4 (.9) AST >5X ULN 3 (.6) Alkaline phosphatase >5X ULN Total bilirubin >3X ULN 13 (2.8) Hemoglobin <1-8. g/dl 27 (5.8) <8.-6.5 g/dl <6.5 g/dl No cases consistent with Hy s law Elevations in total bilirubin were mainly transient and predominantly indirect bilirubin 1 patient received EPO; no patient was transfused Ribavirin dose was modified due to AE(s) in 26 (5.5%) 3D + RBV recipients Feld JJ, et al. N Engl J Med. 14;37:1594-3
SAPPHIRE-II: HCV GT1 tx-experienced patients Treatment-experienced 96,3 96, 96,7 SVR12 (%) 8 4 3D + RBV x 12 wks 3D: co-formulated Paritaprevir/ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid n N 286 297 166 173 119 123 Overall* GT1a GT1b RBV: -1 mg/d * One patient achieved SVR12, but was unable to be subgenotyped. Error bars: 95% CI. Zeuzem S, et al. N Engl J Med. 14;37:14-141
SAPPHIRE-II: HCV GT1 tx-experienced patients Treatment-experienced 95,3, 95,2 SVR12 (%) 8 4 3D + RBV x 12 wks 3D: co-formulated Paritaprevir/ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid n N 82 86 Prior relapse 65 65 Prior partial response 139 146 Prior null response RBV: -1 mg/d Error bars: 95% CI. Zeuzem S, et al. N Engl J Med. 14;37:14-141
SAPPHIRE-II: SVR12 and Reasons for Non-Response All Patients (N=297) SVR12, n/n (%) 286/297 (96.3) Virologic failure, n Prior Relapsers (N=86) 82/86 (95.3) No patient had breakthrough and 2.4% of patients had a relapse All relapses occurred 2-8 weeks post-treatment Prior Partial Responders (N=65) 65/65 () Prior Null Responders (N=146) 139/146 (95.2) Breakthrough Relapse 7 1 6 Prematurely discontinued study drug,* n 4 3 1 *Patients (n=4) who prematurely discontinued without breakthrough; 3 due to adverse events, 1 withdrew consent during week 11 Zeuzem S, et al. N Engl J Med. 14;37:14-141
PEARL-II and -III: Paritaprevir/r + Ombitasvir + Dasabuvir ± RBV GT1b naive, 12 weeks (PEARL-III) GT1b experienced, 12 weeks (PEARL-II) 99,5 99. 96,6 8 8 SVR12 (%) 4 4 9 21 RBV 7 9 No RBV Co-formulated paritaprevir/ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid RBV: -1 mg/d 85 88 RBV 91 91 No RBV Ferenci P, et al. N Engl J Med. 14;37:1983-92 Andreone P, et al. Gastroenterology. 14;147:359-365
PEARL-IV: Paritaprevir/r + Ombitasvir + Dasabuvir ± RBV for 12 weeks in GT1a treatment-naive patients 97. 9,2 SVR12 (%) 8 4 Co-formulated paritaprevir/ ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid RBV: -1 mg/d 97 RBV 185 5 No RBV Ferenci P, et al. N Engl J Med. 14;37:1983-92
TURQUOISE-II: SVR12 rates in HCV GT1 treatmentnaive and experienced cirrhotic patients 8 88.6 94.2 98.5 3D + RBV 12-week arm 24-week arm SVR12, % Patients 4 3D: co-formulated paritaprevir/ ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid RBV: -1 mg/d 124/14 114/121 67/68 51/51 GT 1a GT 1b Poordad F, et al. N Engl J Med. 14;37:1973-82
TURQUOISE-II: SVR12 Rates by Prior Treatment Response in HCV Subtype 1a 8 92.2 92.9 93.3 8. 92.9 3D + RBV 12-week arm 24-week arm SVR12, % Patients 4 3D: co-formulated paritaprevir/ ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid RBV: -1 mg/d 59/64 52/56 14/15 13/13 Naïve Prior Relapse Response 11/11 1/1 4/5 39/42 Prior Partial Response HCV Subtype 1a Prior Null Response Poordad F, et al. N Engl J Med. 14;37:1973-82
TURQUOISE-II: SVR12 Rates by Prior Treatment Response in HCV Subtype 1b 8 85.7 3D + RBV 12-week arm 24-week arm SVR12, % Patients 4 3D: co-formulated paritaprevir/ ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid RBV: -1 mg/d 22/22 18/18 25/25 / Naïve Prior Relapse Response 6/7 3/3 14/14 1/1 Prior Partial Response HCV Subtype 1b Prior Null Response Poordad F, et al. N Engl J Med. 14;37:1973-82
TURQUOISE-II: SVR12 Rates by Surrogates of Portal Hypertension and Hepatic Function 8 88.9 97. 92.6 95.7 84. 88.9 92.9 96.8 3D + RBV 12-week arm 24-week arm SVR12, % Patients 4 3D: co-formulated paritaprevir/ ritonavir/ombitasvir, 15 mg/ mg/25 mg qd; dasabuvir, 25 mg bid RBV: -1 mg/d 4/45 32/33 151/163 133/139 < Baseline Platelet Count (x1 9 /L) 21/25 16/18 17/183 149/154 <35 35 Baseline Serum Albumin Count (g/l) Poordad F, et al. N Engl J Med. 14;37:1973-82
TURQUOISE-II: Patients Not Achieving SVR12 Event, n/n (%) 12-Week Arm 24-Week Arm Patients not achieving SVR12 17/8 (8.2) 7/172 (4.1) Premature discontinuation 4/8 (1.9) 3/172 (1.7) Adverse event, n 4 1 Withdrew consent/other, n 2 Virologic failure Breakthrough 1/8 (.5) 3/172 (1.7) Relapse through PTW12 12/3 (5.9)* 1/164 (.6)** *7/12 were GT1a null responders. **Significant difference. Virologic failure occurred in 17/38 patients (4.5%) 15 of these patients had at least 1 resistance-associated variant at the time of virologic failure D168V (NS3) and Q3R (NS5A) seen most frequently in GT1a-infected patients The significance and persistence of these variants are under investigation Poordad F, et al. N Engl J Med. 14;37:1973-82
TURQUOISE-II: Chemical and Hematologic Abnormalities 12-Week Arm (N=8) 24-Week Arm (N=172) ALT >5x ULN (%) 2.9 Total bilirubin >3x ULN (%) 13.5 5.2 Hemoglobin (%) <1 g/dl 7.2 11. <8. g/dl 1.4.6 ALT elevation Asymptomatic, transient, and improved or resolved with ongoing study drug dosing Bilirubin elevation Transient, predominantly indirect, no discontinuations due to hyperbilirubinemia Hemoglobin decrease Managed with reduction of ribavirin dose in 34 patients (8.9%) ULN: upper limit of normal. Poordad F, et al. N Engl J Med. 14;37:1973-82
SVR rates in liver transplant recipients with recurrent HCV G1 infection receiving ABT-45/r/ombitasvir + dasabuvir + RBV 3D + RBV (N=34) 8 4 97,1 97,1 97,1 RVR EOTR SVR4 SVR12 SVR24 (Week 4) (Week 24) Due to interactions between calcineurin inhibitors (CNIs) and study regimen, modified dosing was advised Tacrolimus:.5 mg QW or.2 mg every 3 days; cyclosporine: 1/5 the daily pre-study dose QD No acute or chronic rejection 1 d/c due to AEs; 2x SAEs 5 patients (14.7%) received EPO Kwo et al., NEJM 14 SVR12 SVR24 Day Week 24 To Week 72 CORAL-1: Efficacy results Patients (%) 34/34 34/34 33/34 33/34 33/34 Baseline demographics 3D + RBV (N=34) Median time since transplantation 39.5 months Male (%) 79.4 Mean age (years) 59.6 Fibrosis stage F/F1/F2 (%) 17.6/38.2/44.1 IL28B non-cc 76.5 HCV subtype G1a/G1b (%) 85.3/14.7 Mean HCV RNA (log 1 IU/mL) 6.6 Immunosuppression TAC/CSA (%) 85.3/14.7 Mean CrCl (ml/min) 9.5 Mean ALT (U/L) 78.9 Mean AST (U/L) 63.9 Mean GGT (U/L) 17.3 No lab abnormalities, except 2 x elevated bilirubin at a single time point No virologic breakthrough One pt had virologic relapse (post-treatment day 3) High RVR and SVR rates in F 2 patients Well-tolerated CNI dosing was manageable using PK guidance established in prior DDI study in volunteers Antiviral therapy may benefit patients before acceleration of fibrosis
Putative Label of Paritaprevir/r + Ombitasvir + Dasabuvir ± Ribavirin Patient population Treatment-naive w/o cirrhosis Treatment-naive with cirrhosis Recommended schedule HCV-1a for 12 weeks with RBV HCV-1b for 12 weeks w/o RBV 12 weeks with RBV Treatment-experienced w/o cirrhosis Treatment-experienced with cirrhosis HCV-1a for 12 weeks with RBV HCV-1b for 12 weeks w/o RBV (?) 12 weeks with RBV 24 weeks in HCV-1a prior NR
Other Studies in Patients Infected with HCV-1
SVR12 rates for daclatasvir (DCV) + SOF ± RBV in GT 1 GT 1 (82% GT 1a), Rx-naïve N=82: DCV + SOF ± RBV for 12 weeks* GT1 (8% GT 1a), prior PI non-responder N=41: DCV + SOF ± RBV for 24 weeks* Proportion of patients (%) 8 4 95 Proportion of patients (%) 8 4 95 41/41 39/41 DCV + SOF DCV + SOF + RBV Category 1 Category 2 DCV + SOF DCV + SOF + RBV *DCV mg once daily, SOF 4 mg once daily ± RBV /1 mg/day 21/21 19/ Sulkowski MS, et al. N Engl J Med 14;37:211 21
COSMOS Cohort 2: SVR12 primary endpoint (ITT population) SVR12 Non-VF* Relapse Proportion of patients (%) 8 4 2/3 2/27 1/14 7% 7% 7% 93% % 93% 93% 94% 28/3 16/16 25/27 13/14 82/87 3/87 2/87 SMV/SOF + RBV SMV/SOF SMV/SOF + RBV SMV/SOF SMV/SOF±RBV 24 weeks 12 weeks Overall 3% 2% *Patients who did not achieve SVR12 for reasons other than virological failure Lawitz E, et al. Lancet 14 ITT: intent-to-treat; SMV: simeprevir; VF: virological failure
COSMOS Cohort 2: SVR12 by GT 1 subtype and baseline NS3 Q8K polymorphism * GT 1b GT 1a without Q8K GT 1a with Q8K 93 88 88 95 96 Proportion of patients (%) 8 4 6/6 11/11 11/11 4/4 7/7 4/4 5/5 13/14 7/8 3/3 7/8 3/3 18/18 38/4 25/26 SMV/SOF + RBV SMV/SOF SMV/SOF + RBV SMV/SOF SMV/SOF±RBV 24 weeks 12 weeks Overall *Excluding patients who discontinued for non-virological reasons Lawitz E, et al. Lancet 14
COSMOS Cohort 2: SVR12 by METAVIR score * F3 fibrosis F4 fibrosis Proportion of patients (%) 8 4 94 91 98 86 95 16/16 12/12 6/6 9/9 15/16 1/11 7/7 6/7 44/45 37/39 SMV/SOF + RBV SMV/SOF SMV/SOF + RBV SMV/SOF SMV/SOF±RBV 24 weeks 12 weeks Overall *Excluding patients who discontinued for non-virological reasons Lawitz E, et al., Lancet 14
HALLMARK-DUAL: SVR12 With Daclatasvir + Asunaprevir in GT1b HCV SVR12, % (n/n) Treatment naive Null responders Partial responders All IFN ineligible/intolerant Advanced fibrosis/cirrhosis with thrombocytopenia Daclatasvir ( mg qd) + Asunaprevir ( mg bid) x 24 weeks 9 (182/3) 82 (98/119) 81 (68/84) 82 (192/235) 73 (56/77) Breakthrough: 9 (4%) treatment naive, 26 (13%) nonresponders, (9%) IFN ineligible/intolerant Relapse: 5 (3%) treatment naive, 7 (4%) nonresponders, 12 (6%) IFN ineligible/intolerant 28 of 73 patients with NS5A-L31 and/or Y93 variants at baseline achieved SVR12 Manns M, et al. Lancet 14; Jul 26 epub ahead of print
HALLMARK-DUAL: Adverse Events Serious AEs* occurred in 6% treatment-naive pts, 5% nonresponders and 7% IFN ineligible-intolerant pts AE leading to discontinuation in 3%, 1% and 1%, respectively Grade 3/4 hemoglobin < 9 g/l in,.5% and, respectively Grade 3/4 ALT > 5 x ULN in 3%, 2% and 2%, respectively Grade 3/4 AST > 5 x ULN in 3%, 1% and 1%, respectively Grade 3/4 total bilirubin > 2.5 x ULN in.5%, and 1%, respectively *1 patient with confirmed Gilbert s syndrome met laboratory but not clinical criteria for potential druginduced liver injury. Patient had grade 3 increased hepatic enzymes and grade 4 ALT abnormality. Patient completed treatment and achieved SVR12. Most commonly ALT/AST elevations that resolved off treatment (7 patients, 6 of 7 achieved SVR12). Manns M, et al. Lancet 14; Jul 26 epub ahead of print
Other Studies in Patients Infected with HCV-2 or 3
VALENCE Efficacy : SVR12 SVR4 (%) 8 4 n/n = Overall Treatment Naive Treatment Experienced 93 68/ 73 84 21/ 25 Overall 97 29/ 3 93 86/ 92 2/ 2 92 12/ 13 No Cirrhosis Cirrhosis 91 3/ 33 12 Wks SOF + RBV in GT2 24 Wks SOF + RBV in GT3 85 85/ 88 7/ 8 27/ 45 No Cirrhosis Cirrhosis Zeuzem S, et al., NEJM 14
Conclusions Two IFN-free regimen will be / are approved for HCV genotype 1 infected patients in IV/14 I/15 Response to previous (IFN-based) therapy will be less relevant Cirrhosis (more granular differentiated) and potentially baseline HCV RNA are expected to remain as baseline predictors for SVR Main differentiation between regimens SVR and safety in patients with advanced disease Drug-drug interactions Treatment options for cirrhotic patients, patients with renal impairment and those infected with HCV- 3 need further refinement