Interferon-free HCV Therapy for Those with HIV: Ready for Prime Time?

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David Wyles, MD, of UC San Diego AntiViral Research Center, presents "Interferon-free HCV Therapy for Those with HIV: Ready for Prime Time?"

David Wyles, MD, of UC San Diego AntiViral Research Center, presents "Interferon-free HCV Therapy for Those with HIV: Ready for Prime Time?"

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  • 1. The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission. AIDS CLINICAL ROUNDS
  • 2. Interferon-free HCV therapy for those with HIV: Ready for Prime Time? David L. Wyles, MD Associate Professor of Medicine
  • 3. USPHTF update
  • 4. Burden of liver disease in the US US Burden of Disease Collaborators. JAMA 2013.
  • 5. Benefits of SVR in HIV/HCV cirrhotics Mira JA. CID 2013. Hepatic Decompensation All-cause Mortality
  • 6. Wait, what about telaprevir and boceprevir?
  • 7. Wait, what about telaprevir and boceprevir? • Approved for HCV monoinfection May 2011 – Off label use in co-infection • Issues: – Tolerability – Drug-drug interactions – Dosing – Potency
  • 8. 74 75 0 20 40 60 80 100 HIV/HCV ADVANCE TVR P/R Phase2 studies of TVR and BOC in HCV/HIV • Adverse events consist with mono-infected studies • Ongoing Phase 3 Studies: VX11-950-115 and ACTG 5294 Sulkowski MS. Annals Int Med 2013. Jacobson IM. NEJM 2011. Sulkowski MS. Lancet ID 2013. Poordad F. NEJM 2011. 28/38 63 68 0 20 40 60 80 100 HIV/HCV SPRINT-2 BOC P/R 40/64 SVR24(ITT)
  • 9. TVR in prior IFN failures - ANRS HC 26 • Prior failures with >12 weeks Peg/RBV • Null cirrhotics excluded Cotte L. CROI 2013.
  • 10. TVR in prior IFN failures - ANRS HC 26 • 88% HCV RNA undetectable at week 16 61% with grade 3/4 anemia, epo use, transfusion or RBV dose reduction Cotte L. CROI 2013.
  • 11. • 63% HCV RNA <15 IU/mL at week 16 BOC in prior IFN failures - ANRS HC 27 Poizot-Martin I. CROI 2013.
  • 12. NEW AGENTS IN COMBINATION WITH IFN FOR CO-INFECTION
  • 13. New agents with PEG/RBV for HCV/HIV Simeprevir- study C212 HAART: RAL, RPV, MVC, or T-20 (no PIs or EFV) HCV: 82% 1a, F3-F4: 21% Dieterich D. CROI 2013.
  • 14. New agents with PEG/RBV for HCV/HIV Faldaprevir: phase III STARTVerso 4 HCV gt1, treatment naïve or relapse – 78% 1a; 17% F4 – 47% RAL-based HAART Dieterich D. CROI 2013. EFV DRV/r ATV/r RAL MVC
  • 15. LESSON: IFN-BASED DAA HCV THERAPIES LEVEL THE PLAYING FIELD FOR CO-INFECTED PATIENTS But…tolerability is an issue in the real-world, at least for telaprevir based regimens.
  • 16. UCSD experience Cachay E. AIDS 2013.
  • 17. 50% SVR4 rate with 9/12 having attained SVR12 Cachay E. AIDS 2013.
  • 18. Anticipated DAA approvals in 2013 • Simeprevir November 2013 – NS3 Protease Inhibitor • Potent but relatively low barrier to resistance – 150mg PO QD • Well tolerated • CYP3A4 substrate – Likely indication: • Combination with PEG/RBV for GT1 HCV – 12 weeks SMV with 24-48 weeks of PEG/RBV (RGT) – Treatment naïve and experienced
  • 19. Simeprevir phase 3 data 80 79 50 37 0 20 40 60 80 100 QUEST1 PROMISE All P/R/pbo 1a 1b F4 Jacobson I. EASL 2013. Lawitz E. EASL 2013. SVR12(%) RGT eligible: • 85% QUEST1: 91% SVR • 93% PROMISE: 83% SVR Good safety profile: • 3% discontinuation due to AE • 9% elevated bilirubin
  • 20. • Sofosbuvir December 2013 – NS5B nucleotide polymerase inhibitor • Very potent and extremely high barrier to resistance – 400mg PO QD • Well tolerated • Low drug-drug interaction potential – Not a CYP450 substrate or inhibitor – Likely indications: • Combination with PEG/RBV for GT1 (?4-6) HCV – 12 weeks SOF/P/R – Naïve only?? • SOF/RBV for GT2 and ?GT3? – 12 weeks for GT2 naïve or non-responders » Cirrhosis? – ?16 or 24 weeks for GT3 Anticipated DAA approvals in 2013
  • 21. Neutrino study: Sofosbuvir + PEG/RBV • IFN naïve • 89% gt1 • 17% cirrhosis SOF 400 QD + Peg2a + RBV 12 weeks SVR 12 N=327 GT 1,4,5,6 90 80 87 87 0 20 40 60 80 100 Combined gt1 gt 4, 5, 6 Cirrhosis AA IL28 T SVR12(%) 2% stopped due to AEs Lawitz E. NEJM 2013.
  • 22. FISSION: Treatment naïve genotype 2/3 • IFN naïve – 73% gt3 – 20% cirrhosis SOF 400 QD + RBV 1000/1200 24 weeks SVR 12N=256 N=243 Peg2a + RBV 800 SVR 12 67 97 56 47 67 78 63 38 0 20 40 60 80 100 Combined gt2 gt3 cirrhosis SOF/RBV P/R Lawitz E. NEJM 2013. SOF arm: 1% discontinued due to AEs P/R: 11% discontinued due to AEs
  • 23. FUSION: Treatment experienced GT 2/3 SOF 400 QD + RBV 1000/1200 12/16 weeks SVR 12N=103 N=98 SOF 400 QD + RBV 1000/1200 SVR 12 50 86 30 60 19 73 94 62 78 61 0 20 40 60 80 100 GT2 GT3 F4 GT2 F4 GT3 SVR12(%)– 75% relapsers – 34% cirrhosis Jacobson I. NEJM 2013. SOF 12wk: 1 subject discontinued 12wk: 5% SAEs; 16 wk: 3% SAEs
  • 24. Status of IFN-free Therapies for GT1 • Key players – Sofosbuvir + NS5A • FDC: SOF/Ledipasvir- phase 3 • SOF + Daclatasvir – ABT-450/r + ABT-267 + ABT-333 +/- RBV- phase 3 – ASN + DCV + BMS-325 for 12 or 24 weeks • GT1 naïve: 94% SVR12 Everson G. AASLD 2012. • Limited data or applications – ASU + DCV – 1b only • Proof of concept for IFN free. Lok A. NEJM 2011. • 77% SVR24 1b null or IFN ineligible. Suzuki F. EASL 2012 – FDV + BI-7027 (deleobuvir) – 1b only • SOUNDC-2: 1b- 85% SVR12 1a- 43% SVR12 Zeuzem S. EASL 2012 • SOUNDC-3: 1b- 95% SVR12 1a/CC- 17% SVR12 Zeuzem S. APASL 2013. – Many others with more limited data
  • 25. IFN-free: boosted PI based Kowdley K. EASL 2013. SVR12(ITT) 96 878983 24 week duration did not improve response for naïve or experienced.
  • 26. How short is too short? King M. CROI 2013.
  • 27. ELECTRON: Sofosbuvir/Ledipasvir plus Ribavirin SOF + RBV (Null) SOF + RBV (Naïve) n=10 n=25 Wk 0 4 8 12 10% 84% Genotype 1 SVR12 Add second potent DAA Ledipasvir: NS5A antagonist SOF + LDV + RBV (Null) SOF + LDV + RBV (Naïve) n=9 n=25 Wk 0 4 8 12 100% 100% Gane E. CROI 2013. Sulkowski M. AASLD 2012. Results replicated with SOF + DCV +/- RBV for 12-24 weeks : 100% SVR12 (N=112)
  • 28. How short can you go: LONESTAR • Being evaluated in the phase 3 ION-3 study – SOF/LDV 8 weeks – SOF/LDV + RBV 8 weeks – SOF/LDV 12 weeks Gilead press release May 2, 2013. Clinicaltrials.gov: NCT01851330.
  • 29. Initial lessons from IFN-sparing treatment 1. Cure happens 2. Interferon sensitivity still matters 3. Genotype/subtype matters 4. Ribavirin matters 5. Resistance happens 6. Duration matters 7. Potency/resistance threshold trumps 2-6 Dave Thomas. CROI 2013.
  • 30. Key questions for IFN-free DAA therapies in those with HIV • Will efficacy mirror HCV moninfection? – As it has with IFN + DAAs • How limiting with drug-drug interactions be? – Particularly for those with long-standing HIV • Complex HAART regimens • More likely to have advanced liver fibrosis and/or prior treatment failure • Will tolerability be equally good? • When can we use them?!
  • 31. Sofosbuvir drug interaction potential • Low potential for interactions – Not a CYP450 substrate or inhibitor – Low protein binding – Rapid hepatic uptake after oral dosing – Major metabolite: GS-331007 • ~90% of systemic exposure following SOF dosing – Substrate for Pgp and BCRP (NOT an inhibitor) • GS-331007 is not a substrate for Pgp or BCRP
  • 32. Sofosbuvir and HIV ARVs Kirby B. #1877. AASLD 2012.
  • 33. Sofosbuvir monotherapy in HCV/HIV clinicaltrials.gov Rodriguez-Torres M. ICAAC 2012. SOF/RBV GT 2/3 studies underway
  • 34. Simeprevir drug interactions • CYP3A4 substrate – Mild intestinal CYP3A4 inhibitor • No significant interaction: TDF, RAL, RPV Ouwerkerk-Mahadevan S. IDSA 2012.
  • 35. Daclatasvir drug interactions • Substrate of Pgp and CYP3A4 – Moderate Pgp inhibitor • ATV/r- DCV 20mg: AUCt: 0.70, C24: 1.21 – 30mg (est): AUCt: 1.05, C24: 1.83 • EFV- DCV 120mg: AUCt: 1.37, C24: 0.83 – 90mg (est): AUCt: 1.03, C24: 0.62 • TDF- DCV 60mg: AUCt: 01.10, C24: 1.17 Phase3 trial using these adjusted doses ongoing: NCT01471574 Bifano M. CROI 2012.
  • 36. OFF LABEL IFN-FREE PRESCRIBING IN 2014?
  • 37. HCV Therapeutics Timeline 1995 2000 20102005 2015 1989 HCV identified Consensus IFN IFN a-2a IFN a-2b + RBV Peg-IFNa-2b Peg-IFNa-2a HCV replicons In vitro HCV replication Peg-IFNa-2a in HCV/HIV IFN a-2b BILN-2061 Phase 1b 0 20 40 60 80 100 SVR(%) Relativemisery Boceprevir Telaprevir IFN-free DAA regimens New DAAs (w/ Peg/RBV) You are here
  • 38. COSMOS: Sofosbuvir + Simeprevir • Gt 1 null responders to PEG/RBV • Stage F0-F2 liver fibrosis • SOF 400mg QD, SMV 150mg QD, RBV 1000/1200 Lawitz E. CROI 2013.
  • 39. 12 Week Arms Results 96 93 0 20 40 60 80 100 EOT SVR4 SVR8 SMV+SOF+RBV SMV+SOF Lawitz E. CROI 2013. 26/27 13/14 UndetectableHCVRNA(%) Likely the first IFN-free therapy you could write for “off-label” • Limited to genotype 1 • Limited preliminary data • No data in cirrhotics • Drug interaction eliminate many HAART options
  • 40. Sofosbuvir plus Daclatasvir 0 20 40 60 80 100 EOT SVR12 SVR24 GT1 + GT1 - GT2/3 + GT2/3 - GT1 PI + GT1 PI - 205556 20 21 Sulkowski M. EASL 2013. 1414 GT1: 12 and 24 weeks. GT2/3: 24 weeks. GT1 PI failures: 24 weeks The second IFN-free therapy available off-label? • Pan-genotypic • Robust preliminary data • Data in TVR/BOC failures • Cirrhosis data lacking • Supporting drug interaction data • Few, if any, HAART limitations • FDC of SOF/LDV not far behind
  • 41. Upcoming Studies Co-Infection Studies • AbbVie M14-004 trial: GT1 naïve or experienced – ABT-450/r/ABT-267 + ABT-333 + RBV – ATV or RAL based HAART – August 2013 • ACTG 5329: GT 1 naïve – ABT-450/r/ABT-267 + ABT-333 + RBV – DRV or RAL based HAART – Fall/Winter 2013 • ACTG 5327 – SOF/RBV for acute HCV infection • Any genotype – HIV + or -; any HAART regimen – Summer/Fall 2013
  • 42. Acknowledgements Owen Clinic Lalo Cachay Francesca Torriani Jen Lin Brad Collwell Craig Ballard Lucas Hill Joe Montanez All the Owen providers/staff AVRC Jill Kunkel Joanne Santangelo Kathy Nuffer Julie Hoffman Alex Kuo Chip Bob Gish Connie Benson Richard Haubrich UCSD GI/Hepatology AVRC Regulatory and Business