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Elbasvir and Grazoprevir for Chronic Hepatitis C Genotypes 1 and 4

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Elbasvir and Grazoprevir for Chronic Hepatitis C Genotypes 1 and 4 Expert Review of Clinical Pharmacology ISSN: 1751-2433 (Print) 1751-2441 (Online) Journal homepage: http://www.tandfonline.com/loi/ierj20 Elbasvir and grazoprevir for chronic hepatitis C genotypes 1 and 4 Mohamed El Kassas, Tamer Elbaz, Yasmeen Abd El Latif & Gamal Esmat To cite this article: Mohamed El Kassas, Tamer Elbaz, Yasmeen Abd El Latif & Gamal Esmat (2016): Elbasvir and grazoprevir for chronic hepatitis C genotypes 1 and 4, Expert Review of Clinical Pharmacology, DOI: 10.1080/17512433.2016.1233813 To link to this article: http://dx.doi.org/10.1080/17512433.2016.1233813 Accepted author version posted online: 07 Sep 2016. Published online: 26 Sep 2016. Submit your article to this journal Article views: 19 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ierj20 Download by: [T&F Internal Users], [Priti Nagda] Date: 18 October 2016, At: 05:00 EXPERT REVIEW OF CLINICAL PHARMACOLOGY, 2016 http://dx.doi.org/10.1080/17512433.2016.1233813 DRUG PROFILE Elbasvir and grazoprevir for chronic hepatitis C genotypes 1 and 4 Mohamed El Kassasa, Tamer Elbazb, Yasmeen Abd El Latifc and Gamal Esmatb aEndemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt; bEndemic Hepatogastroenterology, Faculty of Medicine, Cairo University, Cairo, Egypt; cTropical Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt ABSTRACT ARTICLE HISTORY Introduction: During the last few years, treatment of hepatitis C virus (HCV) revolutionized with the Received 16 June 2016 appearance of direct antiviral agents especially for patients with HCV genotypes 1 and 4 infections. Accepted 5 September 2016 Elbasvir (NS5A inhibitor) and grazoprevir (NS3/4A protease inhibitor) are newly developed drugs that Published online 26 are presented in fixed dose combination tablets. September 2016 Areas covered: This review covers the mechanism of action, pharmacokinetic and pharmacodynamics KEYWORDS properties, clinical uses, safety and efficacy of elbasvir/grazoprevir in managing a wide variety of easy HCV; genotype 1; genotype and difficult to treat populations (such as presence of cirrhosis, treatment experienced, co-infection 4; elbasvir and grazoprevir with HIV and patients with inherited blood disorders). Expert commentary: Elbasvir/grazoprevir combination showed great efficacy with high rates of sus- tained virological response rates in genotypes 1 and 4 HCV infection. In addition, it retained a good safety profile and is generally well tolerated. 1. Introduction in selected genotypes including genotype 1. However, the approval of the NS5B drug, sofosbuvir, changed the map of Chronic hepatitis C virus (HCV) infection represents a world- HCV management. USA and/or Europe approvals included wide health problem due to its major drastic sequelae that different drug combinations as sofosbuvir/ledipasvir fixed- result from end-stage liver disease which may end up with dose combination, sofosbuvir/daclatasvir, sofosbuvir/simepre- liver transplantation. It carries a possibility of malignancy vir, and ritonavir-boosted paritaprevir/ombitasvir/dasabuvir development (hepatocellular carcinoma) certainly on top of [9,10]. One of the recently approved combinations was that liver cirrhosis [1]. Six major genotypes (1–6) and more than 50 produced by Merck Company marketed under the name of subtypes of HCV have been described with clear geographical Zepatier™. This combination includes elbasvir (EBR, NS5A inhi- distribution [2]. This variation in genotypes represents an bitor) and grazoprevir (GZR, NS3/4A inhibitor) [11]. It has been obstacle in developing a standard pan-genotypic treatment, US FDA approved for treatment of adult patients chronically and hence, the global trends in HCV genotype prevalence are infected with HCV genotypes 1 or 4 [12]. EBR and GZR have a to be considered in treatment options and guidelines. high barrier to resistance as well as a good spectrum of Genotype 1 is the most prevalent genotype worldwide with activity against many common resistant-associated variants more than half of the global HCV cases and shows a particular (RAVs). Even more, different clinical trials conducted for this higher prevalence in western developed countries [3]. HCV combination hit difficult frontiers such as patients coinfected genotype 4 is predominant in Africa and the Middle East with HIV, patients with hepatic or renal impairment, and region where it represents more than 90% of detected HCV patients with inherited blood disorders (IBLD). genotypes in a country with a very high seroprevalence of HCV like Egypt [4]. In the past and till recent years, pegylated interferon-based 2. Pharmacokinetic and pharmacodynamic therapy represented the mainstay treatment for chronic HCV. properties However, it was associated with suboptimal cure rates and a Both EBR and GZR are delivered as a fixed-dose combination poorly tolerated safety profile [5]. Cirrhotic patients were tablet that is taken once daily regardless to food intake. Peak always considered to be difficult to treat due to low sustained plasma concentration reaches 3 h for EBR and 2 h for GZR. virologic response (SVR) rates and higher incidence of serious Both bind to plasma proteins at a rate of 99.9% for EBR and adverse events (SAEs) [6,7]. 98.8% for GZR [13]. They are partially eliminated by oxidative During the pegylated interferon-based treatment era, both metabolism and they have no circulating metabolites that HCV genotypes 1 and 4 were considered to be the most hard- could be detected in human plasma. Both are primarily to-treat genotypes [8]. The emergence of new directly acting excreted by feces and just less than 1% is excreted in urine [1]. antiviral agents (DAAs) from the protease group (telaprevir As regards antimutant potency and antiviral pressure, GZR and boceprevir) has markedly improved the treatment results showed potency against many protease-resistant mutants CONTACT Mohamed El Kassas [email protected] Endemic Medicine Department, Faculty of Medicine, Helwan University, Helwan, Egypt © 2016 Informa UK Limited, trading as Taylor & Francis Group 2 M. EL KASSAS ET AL. observed in previous studies. GZR maintains its potency with Table 1. The main drug–drug interactions for elbasvir/grazoprevir combination. continued dosing while retaining high plasma and hepatic con- Drug Class Reasons for interactions centrations without cellular toxicities [14,15]. Studies showed a Phenytoin Antiepileptic agents CYP3A inducers mean maximum viral load reduction equivalent to 5.38 and Carbamazepine Rifampin Antibiotic 5.22 log10 in genotypes 1 and 3 infections, respectively [16]. Efavirenz Antiretrovirals In patients with hepatic decompensation, EBR area under Atazanavir OATP inhibitors the curve (AUC) showed unaltered plasma concentration– Lopinavir Darunavir time in non-HCV patients who had mild-to-severe liver Tipranavir impairment. This differed with GZR. Different degrees of Cuclosporins Immunosupressants hepatic impairment in non-HCV-infected patients were asso- ciated with progressively higher AUC in direct relation to Table 2. degree of hepatic severity and as compared to persons with Safety of elbasvir/grazoprevir in clinical trials. normal hepatic function [13]. In advanced liver disease, Occurrence of serious adverse CYP3A4 that is responsible for drug metabolism (including Trial Study population events (%) metabolism of GZR) is usually affected and so leads to C-WORTHY [29,30] HIV confection, genotype 1 3 increased exposure to the drug. Also, efflux and uptake C-SALVAGE [27,28] Previous DAA failure; non- 5.1 transporters may show upregulation and downregulation, cirrhotic and compensated cirrhosis, genotype 1 respectively. Downregulation of organic anion transporting C-SALT [31] Cirrhosis with decompensation, 13.3 polypeptide (OATP) uptake transporters in advanced liver genotype 1 disease will decrease the uptake of GZR from the circulation C-SURFER [33] Advanced kidney disease 15.6 C-EDGE [34] Non-cirrhotic and compensated 3 to the hepatocytes with subsequent increase of its plasma cirrhosis, genotypes 1, 4, 6 concentration. Other related factors include decreased pre- DAA: Directly acting antiviral agent. systemic metabolism due to portal shunting (therefore bypassing the liver) and the decreased production of pro- teins (including the binding proteins) with a subsequent The main drug–drug interactions for EBR/GZR combination are increase of free unbound drugs leading to toxicity [17–20]. outlined in Table 1. For these safety reasons, it is not generally recommended to treat HCV-infected patients who are Child–Pugh class B or higher with EBR/GZR regimen. As compared to AUC in patients without severe renal 3. Safety issues impairment, AUC is 10% and 25% higher in dialysis-dependent Many phase II and III clinical trials discussed the safety profile subjects for GZR and EBR, respectively. Also, AUC is 40% and of EBR/GZR combination in a large group of various patient 46% higher in non-dialysis-dependent patients for GZR and populations [26–36]. Generally, this combination was found to EBR, respectively [1]. In patients with severe renal impairment be safe and tolerable with varying prevalence of adverse or patients on dialysis, no clinically important changes or need events according to the study population (Table 2). The most to dose adjustment was recorded while treating chronic HCV common adverse events were headache, fatigability, nausea, by
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