Massimo Puoti Dept. of Infectious Diseases AO Ospedale Niguarda Cà Granda

Innovative strategies in viral hepatitis : : and/or free regimens

10th International Workshop on HIV & Hepatitis Co-, 12 - 13 June 2014 Paris, France. Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens

• Directly Acting Antivirals nomenclature • Rationale for IFN free Regimens • Strategies • based regimens • Multi-target sofosbuvir free regimens

Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens

• Directly Acting Antivirals nomenclature • Rationale for IFN free Regimens • Strategies • Sofosbuvir based regimens • Multi-target sofosbuvir free regimens

HCV targets for therapy

Receptors binding “entry inhibitors” And endocytosis mAbs anti-E2/CD81, PRO 206 Ezetimibe Transport and release miRNA ISIS 14803 (antisense) Fusion and AVI- 4066 (antisense) Inhibitors of decapsidation Heptazyme (ribozyme) viral VGX-410C (small molecules IRES (+) RNA Trasltion Virion assembly assembly and inhibitor) TT 033 (sIRNA) eIF2α phosphorilation inhibitors: relaese : Nitazoxanide Celgosivir NS5A I Translation and processing of polyprotein Protease inhibitors RNA replication Replication

inhibitors: •NS5B NS2–NS3 •NNI, protease NS3 protease Drugs active on viral enzymes • NI Drugs active on host cell enzymes •NS5A I •Ciclophyllin B C E1 E2 p7 NS2 NS3 4A NS4B NS5A NS5B

Core Membrane Serine protease RNA-dipendent RNA domain polymerase 1. Lindenbach BD & Rice CM. Unravelling replication from genome to function. Nature 2005;Moradpour D and Penin F. Curr Top Microbiol Immunol 2013 36 Protease Inhibitors (-PREVIR) HCV Polymerase Inhibitors (-BUVIR)

 Nucleos(t)ide inhibitors (NI) - - Sofosbuvir  Non-nucleoside inhibitors (NNI) = allosteric inhibitors A Thumb I e.g. B Thumb II e.g. lomibuvir, C Palm I e.g. D E Palm II e.g. nesbuvir, tegobuvir

Bartenschlager R et al. Nat Rev Microbiol 2013;11:482-496. See also Scheel TK and Rice CM. Nat Med 2013;19:837-849. HCV Nonstructural Protein 5A

Bartenschlager R et al. Nat Rev Microbiol 2013;11:482-496

HCV NS5A Inhibitors (-ASVIR)

Prototype: Other examples: , ACH2928, ACH3102, AZD7295, BMS824393, GS5816, GSK2336805, , MK8742, PPI668, …

Gao M et al. Nature 2010;465:96-100. Reviewed in Bartenschlager R et al. Nat Rev Microbiol 2013;11:482-496, Pawlotsky JM. J Hepatol 2013;59:375-382, and Gao M. Curr Opin Virol 2013;3:1-7.

HCV: Probability of the presence of viral variants Hepatitis C virus: ~9600 nucleotides Error rate during replication: ~10-4 – 10-5 per copied nucleotide Viral turnover: ~1012 virions produced every day

Probability of Number of virions Number of all Number of Fraction of all generation after with nucleotide possible nucleotide possible mutants one round of change(s) produced nucleotide change created per day replication per day mutants 0 91% 9.1 x 1011 1 8.7% 8.7 x 1010 2.9 x 104 1 2 0.4% 4.2 x 109 4.1 x 108 1 3 0.001% 1.3 x 108 4.0 x 1012 3.4 x 10-5

- HCV genome ~ 9600 nucleotides; the average number of changes per genome is 0.096 per replication cycle - Before treatment, a new virion has a probability of 91% to carry an unmutated genome and 8.7% to carry one substitution

Not all variants survive - Dead mutations (variants that can not replicate) - Immune sensitive mutations (variants eliminated by the immune system)

Rong L, et al, Sci Transl Med 2010;2:30ra32; Neumann AU, et al. Science 1998;282:103–7 Domingo E, et al. Viral Hepatitis Rev 1996;2:247–61; Cuevas JM, et al. J Virol 2009;83:5760–4 Emergence of Pre-existing Resistant Variants During Treatment with DAA

Drug Potency Baseline HCV RNA Viral breakthrough

Intracellular drug concentrations IC50 of mutant viruses Resistance N of Mutations needed to reduce IC50 Barrier  X Fitness of mutant virusesX X X

HCV RNA X X X X X

Before Treatment Time on Treatment with DAA Alone

Resistant virus Sensitive virus DAA Classes and Subclasses

Drug Class Subclass Potency Resistance Barrier Protease 1st Generation first wave i.e. Medium- Low inhinbitors / Low (-PREVIR) 1st Generation 2nd wave i.e. Medium Low //Asunapre vir ABT450/r 2nd Generation High High except MK5172 ABT 493 HCVG3 NS5a Inhibitor 1st Generation High Medium- High (-ASVIR) Daclatasvir, Ledipasvi,r except HCV G3 & Ombitasvir 1a

2nd Generation High High MK 8742 GS 5816 ABT530 NN Polymerase Dasabuvir GS 9669 Low- Low Inhibitors Deleobuvir BMS 791325 Medium Nucleos/tides 1st Generation: Mericitabine Low High Polymerase 2nd Generation : Sofosbuvir High Lower High inhibitors in HCV G1b (-BUVIR) and 3

CONSEQUENCES OF HCV VARIABILITY AT POPULATION LEVEL: HCV GENOTYPES HCV protein variability

47% amino acid of 46.1% amino acid of HCV PROTEASE NS3 are 54.8% amino acid of HCV POLYMERASE HCV NS5A are conserved among All HCV- NS5B are conserved among All HCV- conserved among All genotypes genotypes HCV-genotypes Amino acid variability: Amino acid variability: 0% <1% 1-5% 5-10% 10-25% >25% 0% <1% 1-5% 5-10% 10-25% >25%

Cento et al., PLoS ONE 2012 Love et al., J Vir 2009 Di Maio et al., submitted 2013 DAA Classes and Subclasses: antiviral potency and resistance barrier according to HCV genotype Drug Class Subclass 1 b 1a 2 3 4

1st Generation first wave i.e. Telaprevir/Boceprevir     

st nd Protease inhinbitors 1 Generation 2 wave i.e. (-PREVIR) Faldaprevir/Simeprevir      2nd Generation MK5172 ABT 493      1st Generation Daclatasvir Ledipasvir      NS5a Inhibitor Ombitasvir (-ASVIR) 2nd Generation MK 8742 GS 5816 ABT 530      NN Polymerase Dasabuvir Deleobuvir Inhibitors      (-BUVIR) Nucleos/tides 2nd Generation : Sofosbuvir Polymerase inhibitors      (-BUVIR) 14  High  Moderate  Low Very low Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens

• Directly Acting Antivirals nomenclature • Rationale for IFN free Regimens • Strategies • Sofosbuvir based regimens • Multi-target sofosbuvir free regimens

Combo with PEGIFN + RBV of Telaprevir, Boceprevir, Simeprevir, Faldaprevir

Potent IFNα-ribavirin effect

1

0 DAA Monotherapy

IU/mL) Wild-type, sensitive HCV

10 -1 Triple Combo

-2 Resistant HCV -3

Median HCV RNA change HCV RNA Median -4 from baseline (log

-5

Time on treatment Combo with PEGIFN + RBV + non anchor drugs i.e. Telaprevir, Boceprevir, Simeprevir, Faldaprevir

Weak IFNα-ribavirin effect

1

Wild-type, sensitive HCV 0 DAA Monotherapy IU/mL)

10 -1 Predictive Triple Combo role of RVR -2 and Response Guided Resistant HCV Therapy -3

Median HCV RNA change HCV RNA Median -4 from baseline (log

-5

Time on treatment Combo with PEGIFN & RBV + anchor drug (Sofosbuvir)

Any IFNα-ribavirin effect

1

0 Anchor drug monother

IU/mL) Wild-type, sensitive HCV

10 -1 Triple Combo No Predictive role of RVR -2 No Response guided Resistant HCV -3 therapy

Median HCV RNA change HCV RNA Median -4 from baseline (log

-5

Time on treatment Attain study: Telaprevir vs Simeprevir with PEGIFN + R in non responders to PEGIFN + Ribavirin

Reddy KR et al APASL 2014 Retreatment of HCV Genotype-1 Infected Patients Who Failed Prior Therapy with Peg-interferon + Ribavirin Plus 1 or 2 Other Direct- Acting Antiviral Agents with Sofosbuvir

Pol S et al EASL 2014 Contraindications to and Ribavirin Side effects: IFN free vs IFN containing

Sofosbuvir For Treatment of Chronic Hepatitis C Infection Antiviral Drugs Advisory Committee Meeting Briefing Document 25 October 2013 Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens • Key messages • PEGIFN based therapies: • Weak PEGIFN activity  Lack of efficacy • Insufficient results in cirrhosis and PEGIFN experienced • Contraindications  restriction of access to treatment • Side effects  low patients motivations, tolerability and adherence

Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens

• Directly Acting Antivirals nomenclature • Rationale for IFN free Regimens • Strategies • Sofosbuvir based regimens • Multi-target sofosbuvir free regimens

Genetic barrier to resistance can be sufficient with one anchor drug + Ribavirin according to genotype sensitivity to anchor drug Baseline

Sofosbuvir + Ribavirin

Anchor drug

Sensitive virus Resistant virus Sofobuvir + Ribavirin in HCV G2-4

29

31

60

100

105

27

11

177

Gane D et al. AASLD 2011 Jacobson IM et al. NEJM 2013 Zeuzem et al. The Liver Congress 2013 abstr. 1085 Ruane PJ, et al. AASLD 2013 #1090 Sofosbuvir + Ribavirin in HCV G1

11

148

38

121

159

Sovaldi SPC Cosmos Study Sofosbuvir + Simeprevir + RBV for 12-24 w: ITT SVR 12

24 92 63 95 All 87 94 80 90

12 W 14 93 14 93

12 W + R 27 93 27 96

16 24 w 100 15 93

30 24 w +R 24 93 79

0 20 40 60 80 100 F3-F4 naives F3-F4 Exp F3-F4 all F0-F2 exp

Sulkowsky MS et al EASL 2014; Lawitz E et al EASL 2014 AI444-040 study Daclatasvir + Sofosbuvir + RBV:

SVR12 primary endpoint (mITT) for treatment-naive patients

HCV GT1G1 HCVGT2 G2 HCVGT3 G3 a a

Patients, % Patients, Patients, % Patients, HCV RNA

A C E G H DCV + SOF DCV + SOF ± LIb SOF, DCV DCV DCV DCV ± RBV RBV DCV + SOF + SOF + SOF + SOF + SOF + RBV + RBV

24 weeks 12 weeks 24 weeks

• SVR12 rates were 98% in GT1a and 100% in GT1b c • SVR24 rates ranged from 93–100% in GT1, and 88–100% in GT2/3 aLI,One lead patient in; LLOQ had missing= lower datalimit atof postquantitation treatment (25 week IU/mL), 12 but mITT, achieved modified SVR24, intent and to one treat who was lost to follow-up after achieving SVR4 bLI (lead in) with SOF was not included in subsequent trials c93% and 88% were the percentage for the lead in arm.

Sulkowski et al. N Engl J Med 2014;370:211–21. AI444-040 study: SVR12 primary endpoint (mITT) for GT1 patients who have experienced PI failure

a

Patients, % Patients, HCV RNA

21 19 21 20

I J DCV + SOF DCV + SOF + RBV 24 weeks

• End of treatment (EOT) responses were 100%, with or without RBV

a One patient with missing data at post treatment week 12, who achieved SVR24

Sulkowski et al. N Engl J Med 2014;370:211–21. The ION studies: LDV + SOF ± RBV in HCV GT 1

ION-11 ION-22 ION-33 Naive EXP No cirrhosis

99 97 98 99 99 99 100 94 96 93 95 94

80

60 RBV-free With RBV 40

20 Patients achieving SVR achieving SVR (%) Patients 211/ 211/ 212/ 215 102/ 107 108/ 110 202/ 201/ 206/ 214 217 217 / 109 / 109 / 215 216 216 0 217 111 111 12-wk 24-wk 12-wk 24-wk 8-wk 12-wk • LDV + SOF achieved high SVR12 rates with or without RBV • SVR12 rates were similar if patients were categorised by GT (GT 1a: 92–100%, GT 1b: 87–100%) or by cirrhosis (cirrhotic: 82–100%, non-cirrhotic: 95–100%)

1. Afdhal N, et al. N Engl J Med 2014;ePub ahead of print; 2. Afdhal N, et al. N Engl J Med LDV, ledipasvir 2014;ePub ahead of print; 3. Kowdley KV, et al. N Engl J Med 2014;ePub ahead of print. Ledipasvir and Sofosbuvir for Untreated HCV Genotype 1 Infection: Treatment Discontinuations, Adverse Events, and Hematologic Abnormalities.

Afdahl A et al. NEJM 2014 SOF/LDV in patients who failed Sofosbuvir + Ribavirin

SOF/RBV 17 relapsers (SPARE Study) Hypothesis: combining SOF with a second DAA may effectively suppress HCV replication and improve odds of achieving SVR

Wk 0 Wk 12 48 week follow up

SOF/LDV (400/90mg) n = 14 NIAID SYNERGY STUDY SVR 12

3 participants did not participate -1 developed hepatocellular cancer -1 opted for telaprevir triple therapy -1 declined participation Osinusi A et al. EASL 2014 Treatment Response On SOF/LDV of SOF/RBV failures

n / N 14/14 14/14 14/14 14/14 14/14 14/14 Osinusi A et al. EASL 2014 Sofosbuvir + Ledipasvir +….. reducing treatment duration adding more drugs

Kohli A et al CROI 2014 Sofo + GS5816 (2nd gen NS5AI) FDC: one pill fits all?

Everson GT et al EASL 2014 Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens • Sofosbuvir based IFN free regimens: • Sofosbuvir + Ribavirin • Effective in HCV G2-4 • 12 w in HCV G2 24 week in HCV G3 & 4 • Execption HCV G3 experienced cirrhotics • Low efficacy in HCV G1  somewhat more is needed • Sofosbuvir + PI/NS5a • Universal efficacy wity Simeprevir in a small Phase II study in HCV G1 Optimal duration ? Is ribavirin needed? • Universal efficacy with Daclatasvi in HCV G1, 2, 3 Optimal Duration? Is Ribavirin needed ? • Sofosbuvir + Ledipasvir • Large Phase IIII study: 12 w in cirrhotics 8 weeks in non cirrhotics No difference between naives and experienced • Ribavirin is not needed  les side effects • Effective in Sofosbuvir experienced • 12 weeks Ribavirin free schedule is insufficient in CTP B cirrhosis • + PI/NNPOLi treatment for only 6 weeks • Sofosbuvir + GS5816  one pill for all

Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens

• Directly Acting Antivirals nomenclature • Rationale for IFN free Regimens • Strategies • Sofosbuvir based regimens • Multi-target sofosbuvir free regimens

Genetic barrier to resistance can be increased in HCV G1 by combination drug regimens No relationship with IFN sensitivity no IFN related side effects

Baseline

NN-NS5B in + NS5A + PI + RBV

Anchor drug

Sofosbuvir + NS5A / PI + RBV

Sensitive virus Resistant virus SAPPHIRE-I: GT1, treatment-naive, non-cirrhotic patients Treated with 3D + RBV for 12 w SVR12 rates by HCV GT1 subtype

Treatment-naive, non-cirrhotic

SVR12 (%) SVR12

n 455 307 148 N 473 322 151

1 GT1a patient experienced virologic failure; 7 patients relapsed; •Error bars: 95% CI. • Feld JJ, et al. New Engl J Med 2014; 370:1594–1603. PEARL-III: GT1b, treatment-naive, non-cirrhotic patients treated with 3D + RBV SVR12 rates

Treatment-naive, non-cirrhotic

SVR12 (%) SVR12

n 209 207 N 210 209

* 1 patient with virologic rebound – emergence of NS5A Y93H; † 2 patients were lost to follow-up, but subsequently achieved an• SVR24; Error bars: 95% CI. • Ferenci P, et al. EASL 2014. Abstract 1299 [late breaker poster]. SAPPHIRE-II: GT1, treatment-experienced, non-cirrhotic patients treated with 3D + RBV SVR12 rates by HCV GT1 subtype and by prior P/R response

SVR12 (%) SVR12 (%) SVR12

n 286 166 119 n 82 65 139 N 297 173 123 N 86 65 146

† One patient achieved SVR12, but was •unable to be subgenotyped; Error bars: 95% CI. • Zeuzem S, et al. New Engl J Med 2014; 370:1604–1614. PEARL-II: HCV GT1b, treatment-experienced, non- cirrhotic patients – SVR12 rates

GT1b Treatment-experienced, non-cirrhotic

SVR12 (%) SVR12

n 85 91 N 88 91

• AbbVie press release 2014 [Accessed 21-03-14]. ABT450/r + Ombitasvir + RBV in HCV G4

Hezode C et al. EASL 2014 Safety of Ribavirin free treatment DCV + ASV+ BMS791325

Everson GT et al CROI 2014 DCV + ASV+ BMS791325

Everson GT et al CROI 2014 Genetic barrier to resistance can be increased in HCV G1 by combination drug regimens according to HCV subtype 2nd gen NS5A + 2nd gen PI HCV G1a

Baseline

HCV G1b

Anchor drug

Sensitive virus Resistant virus 2nd generation PI + 2nd Generation NS5A I Phase II studies with MK5172 + MK 8742 Innovative strategies in viral hepatitis : Hepatitis C: Interferon and/or Ribavirin free regimens • Key messages • 3D Combos • 3 D Abbvie 12 weeks in non cirrhotics with Ribavirin in HCV G1a , maybe 24 weeks in cirrhotics • 2D Abbvie 12 w w/o Ribavirin in HCVG4 non cirrhotics • BMS promising results from phase II study • 2° Generation PI + 2° Generation NS5aI • Impressibve results from phase II study in HCV G1 even in difficult to treat patients • Potential one pilll for all schedule •