integrative study of hcv and treatment

1. Prepared by pharmacist/ Mohamed Adel
Graduate of zagazig university 2016

2. HCV was discovered in 1989 and was found to be
the major cause of non-A, non-B post-transfusion
hepatitis.
It is single RNA stranded virus of the flaviviridae
family which contain classical flaviviruses such as
yellow fever and dengue.
HCV contribute to a significant health burden all
over the world due to an estimated 130 – 170
million people chronically infected
The most common blood prone pathogen.

3. The hcv is an enveloped RNA virus.
1-structure of the virion
2-the RNA Genome.
1-structure of the virion
Spherical shape with 50–80 nm in diameter.
It has outer surface and spikes like E1 and E2
glycoprotein heterodimers embedded in the lipid
bilayer surrounding a nucleocapsid composed of core
protein and the single-stranded RNA genome

4. Envelope
glycoprotein 1
E1
Envelope
glycoprotein 2
E2
RNA genome
Envelope
lipid
Protein
capsid
Core
HCV Structure
Enveloped HCV virions are 50–80 nm in diameter, with E1 and E2 glycoprotein
heterodimers embedded in the lipid bilayer surrounding a nucleocapsid composed
of core protein and the single-stranded RNA genome

5. Non-structural
protein
Structural
Protein
NS5BNS3 NS5ANS4BNS4ANS2NS1C E1 E2
Structural Protein 3’NTR5’NTR
RNA
HCV
RNApolymerase
RNAdependent
INF-ResistanceFactor
Regulatorofviral
replication&
assembly
Organizerofreplication
complex&membranousweb
NS3proteaseCofactor
RNAHelicase
Metalloprotease
Serineprotease
Assemblyfactor
Transmembraneprotein
Autoprotease,assemblyfactor
Viroporin&assemblyfactor
Envelopeglycoprotein
Nucleocapsid
Protease
inhibitor
Replicase
inhibitor
Polymeras
e inhibitor

7. 1-viral adsorption and entry;
Hcv begin with attachment by E1 &E2 Spikes with the host cell
receptors including ; tetraspanin (CD81), scavenger receptor B type-I
(SR-BI),tight junction protein claudin-1 (CLDN1), occluding
(OCLN), epidermal growth factor receptor (EGFR) and ephrin
receptor type A2.
The process is mediated by LDL &VLDL due that HCV virions,
existing as lipoviroparticles (LVPs) whose composition ressemble
LDL &VLDL associated with apoE or apoB.
After receptor binding, the virus is internalized by endocytosis.
The acidic endosomes cause the fusion of the envelop with
membrane then release of viral RNA to the host cytoplasm.

9. 1-HCV is characterized by rapid and permanent
changes in its antigenic structure; makes T and B
lymphocytes unable to identify and respond to these
permanently changed antigens. Like the E2
glycoprotein spikes contains hyper variable regions
(could reach 10¹¹ per day) containing
immunodominant neutralization epitopes thought to
function as immunological decoys to shield more
conserved neutralization epitopes the former
process called (quasi-species).
2-HCV virions, existing as lipoviroparticles (LVPs)
whose composition ressemble LDL &VLDL associated
with apoE or apoB.

10. HCV RNA bind with 60s & 40s ribosomal unit
forming the translating complex at the endoplasmic
reticulum.
The translation of HCV RNA ORF result 3000 amino
acid polyprotein precursor.
The polyprotein is processed by protease.
The cellular signal peptidase(SP) cleaves the
protein core, E1,E2,P7( NS1).
In an auto cleavage mechanism requiring two
identical molecules to make up the composite active
site e.g.; the NS2-NS3 cysteine protease cleaves itself
exactly the junction between NS2 &NS3.
While the NS3 –NS4A serine protease (assisted by its
bound cofactor, NS4A )cleave the remain
protein(NS3, NS4A, NS4B, NS5A and NS5B).

12. NS5B is the HCV RNA dependent RNA polymerase which is the enz
key for viral RNA
replication.
NS5B uses the +ve HCV RNA strand as a template for the synthesis
of –ve HCV RNA strand that used for synthesis of more +ve HCV
RNA as the progeny of HCV.
NS4B & NS5A forms an ER-derived membranous web containing the
non structural HCV protein in which RNA replication takes place.
NS5A phosphoprotein consists of three loosely defined in RNA
binding & essential for RNA replication & participates in virus
Assembly.
NS3 has helicase activity that facilitate the HCV RNA replication (help
in the separation of template &RNA capable of nucleic-acid binding
and 3′ to 5′ translocation coupled to hydrolysis of ATP.
Although its exact role is unknown, this activity could be important
for separation of nascent and template RNA strands, unwinding of
local RNA secondary structures or displacement of RNA-binding
proteins).

13. After viral protein and RNA are synthesized, they
arranged in order to produce a new virus.
it appear to linked with lipid metabolism.
HCV infection cause intracellular distribution of lipid
droplet from cytoplasm to accumulate around
perinuclear region in HCV infected cells.
HCV virions, existing as lipoviroparticles (LVPs)
whose composition resemble LDL &VLDL associated
with apoE or apoB.

14. Older Treatments of Hepatitis C:
Interferon & Ribavirin
Interferon alpha is an inhibitor of HCV replication that induces specific
host genes with antiviral functions
Process of how (endogenous) interferon works:
Virus enters cell and use host machinery to reproduce, Interferon genes are
turned on, Produced and released by dying cell, Binds to the receptor on
the cell membrane which turns on genes for antiviral proteins, Antiviral
proteins block viral production.
Interferon alpha (exogenous) ;This drug induces host-genes that have anti
viral function.
Ribavirin acts in synergy with interferon alpha; boosts efficacy from 10% to
50%
Ribavirin competes with guanosine in the formation of viral mRNA cap
structure1
Interferes with enzymes responsible for functional methylation which is
crucial for the virus.

15. Older treatment options are interferon-ribavirin drug regimens that
have a 50-70% cure rate depending on the HCV genotype three times
weekly. then therapy become consisted of pegylated interferon-α
(peg-IFN-α) and ribavirin once weekly for up to 48 weeks, which
leads to a virologic cure for about 50% of adherent patients.
Many patients can’t tolerate interferon due to side effects and
comorbidities, while ribavirin is teratogenic, Used to treat Hepatitis
C for 20 years
Severe side effects are one of the most frequent causes of treatment
discontinuation; Cytopenia, depression, autoimmunity, and they
include flu-like and neuropsychiatric symptoms, autoimmune
diseases and hemolytic anemia and rashes

16. moaDrugsgroup
Covalently and reversibly binds to
NS3/4A protease active site through
alpha-ketoamide functional group
Boceprevir/Asunaprevir
Telaprevir/Grazoprevir
Semiprevir/Glecaprevir
Paritaprevir/Voxilaprevir
HCV NS3/4A
Serine
protease
inhibitors
( previr )
Uprifosbuvir(nucleotide analogue)/Sofosbuvir(nucleotide analogue)
undergoes triphosphorylation to its active form. nucleotide analogue
triphosphate then competes with uridine(differs from uridine
triphosphate because of the fluoro and methyl group on the 2’ carbon)
to be in by the HCV RNA polymerase into the elongating RNA primer
strand, resulting in chain Termination.
HCV NS5B
polymerase
inhibitors
(buvir )
Dasabuvir(non-nucleotide analogue) which binds to the palm
domain of NS5B and induces a conformational change which renders
the polymerase unable to elongate viral RNA.
preventing RNA replication and
virion assembly via binding to NS5A,
a nonstructural phosphoprotein
encoded by HCV. Binding to the N-
terminus of the D1 domain of NS5A
prevents its interaction with host cell
proteins and membrane.
Dalctasvir/velpatasvir
Ledipasvir/Pibrentasvir
Ombitasvir/Ruzasvir/Elbasvir
HCV NS5A
replication
complex(Repli
case)
inhibitors
( asvir)

17. HCV NS3/4A
Serine protease inhibitors
( previr )
Covalently and reversibly binds to NS3/4A
protease active site through alpha-
ketoamide functional group
Sofosbuvir is efficiently taken up by
hepatocytes and then undergoes
triphosphorylation to its active
form. Sofosbuvir triphosphate then
competes with uridine to be incorporated
by the HCV RNA polymerase into the
elongating RNA primer strand, resulting
in chain termination.

18. Sofosbuvir …..All genotypes
Simeprevir …..G 1 , 4
Daclatasvir…..All genotypes
Sofosbuvir/Ledipasvir Ombitasvir/Paritaprevir/r..G
1,4,5,6
Ribavirin
N.P; the are 6 genotypes of hcv, HCV BURDEN IN
EGYPT
The highest prevalence of HCV infection is present in
Egypt, with 92.5% of patients infected with genotype
4, 3.6% patients with genotype 1, 3.2% patients with
multiple genotypes, and < 1% patients with other
genotypes[2,3,5,6]

19. Interferon Containing Regimens
PEG/RBV+SOF
PEG/RBV+SMV
That was canceled later due to S/E.

20. Interferon Free Regimens
Sofosbuvir (Sovaldi) SOF +ribavirin RBV
Sofosbuvir/ledipasvir SOF/LDP (Harvoni)
SOF/LDP (Harvoni)+ ribavirin RBV
Ombotasvir/Paritaprevir/Ritonavir (qurevo)
Sofosbuvir (Sovaldi) SOF +Simeprevir (Olysio) SMV
Sofosbuvir (Sovaldi) SOF +Simeprevir (Olysio) SMV+ribavirin RBV
Sofosbuvir (Sovaldi) SOF +Daclatasvir (Daklinza) DCV
Sofosbuvir (Sovaldi) SOF +Daclatasvir (Daklinza) DCV+ ribavirin RBV

22. 1-Easy to treat group:
Treatment naïve.
-T.Bil ≤ 1.2 mg/dl.– Serum Albumin ≥ 3.5g/dl– INR ≤ 1.2.– Platelet
count ≥ 150000 /mm3.
eligible to be treated by any of the following regimens for 12 weeks:
– Paritaprevir-r/Ombitasvir + RBV
– Sofosbuvir + Daclatasvir
2- Difficult to treat group:–
Peg-Interferon treatment experienced.
– Total serum bilirubin > 1.2 mg/dl.– Serum albumin < 3.5 g/dl.
– INR > 1.2– Platelet count < 150000/mm3
eligible to be treated by any of the following regimens for 12 weeks:
– Sofosbuvir + Daclatasvir + RBV
– The starting dose of RBV is 600 mg/day.
A trial should be done
to reach a dose of 1000 mg/day based on the patient
tolerability.

23. 1. Non-responders to previous DAAs regimens
I. Retreatment of patients with previous SOF/DAC regimen failure
A. Non-cirrhotic patients and patients with compensated cirrhosis
B. Child’s B cirrhotic patients
C. delaying of therapy
II. Retreatment patients previous SOF/SIM Regimen Failure
2. Advanced liver disease (Child ≥ 9)
3. Post-organ transplantation
4. Chronic kidney disease (CKD)
5. HCV co-infection with HBV and HIV

24. Special Population Group:
1- Non-responders to previous DAAs regimens
I. Retreatment of patients with previous SOF/DAC regimen failure
A. Non-cirrhotic patients and patients with compensated cirrhosis
- Option 1: SOF/QUREVO/RBV for 12 weeks ( RBV ineligible:
extend therapy for 24 weeks).
- Option 2: SOF/SIM/DAC/RBV for 12 weeks ( RBV ineligible: extend
therapy for 24 weeks).
SOF/DAC/RBV for 24 weeks
B. Child’s B cirrhotic patients: (Refer to specialized centers)
C. delaying of therapy:
Child’C cirrhotic patients /
Previous failure to 24 weeks SOF/DAC ± RBV regimen /
Previous deterioration on same treatment
2. Retreatment patients previous SOF/SIM Regimen Failure:
SOF/DAC/RBV for 12 weeks ( RBV ineligible: extend therapy for 24
weeks).
NB: RBV dose: 1000 mg/day for patients < 75 kg
1200 mg/day for patients ≥ 75 kg

25. 2-Advanced liver disease (Child ≥ 9)
Treatment is allowed only in one of several
assigned specialized centers.
The following regimen is used for 12 weeks
SOF/DCV/RBV
The dose of RBV is 600 mg/day. A trial should be
done to reach a dose of 1000 mg/day based on
the patient tolerability.
3-Post-organ transplantation
SOF/DCV ± RBV for 24 weeks

27. 4-Chronic kidney disease (CKD)
In patients with serum creatinine exceeding the upper limit of
normal, eGFR is calculated and accordingly:
1. eGFR > 30 ml/min treat by the usual regimens.
2. eGFR ≤ 30 ml/min treat by:
Paritaprevir/retonavir/ombitasvir + RBV
Provided the following are fulfilled:
1. Patients have compensated liver (cirrhosis Child A or no cirrhosis)
2. Hb level at least 10 gm./dl
3. The patient has no associated uncontrolled co-morbidity (cardiac,
neuropsych;..)
4. A nephrologist consultation is done. A report determining the
treatment eligibility and necessity and the exact RBV
Remaining Blood Volume Pulse recommended dosage (and time of
administration in relation to dialysis).
5. In case of dialysis, the patient should be aware of the high risk of Re-
infection by signing a consent form.

28. 5-HCV co-infection with HBV and HIV
Patients should be treated with the same
regimens, following the same rules as HCV mono /-
infected patients.
If HBV replicates at significant levels before,
during or after HCV clearance, concurrent
HBV nucleoside/neocleotide analogue
therapy is indicated.
Co-management by the hepatologist and the treating
infectious disease physician is needed.
SOF should not be received in combination with
Tipranavir antiretroviral protease inhibitor used in the
therapy and prevention of human immunodeficiency
virus (HIV) infection and the acquired
immunodeficiency syndrome (AIDS).

29. 1-Hepatitis C Viruses: Genomes and Molecular
Biology.https://www.ncbi.nlm.nih.gov/books/NBK1621
2-Viral Hepatitis C,Lali Sharvadze Associated Professor
3-Understanding the hepatitis C virus life cycle paves the way for highly
effective therapies
Troels K H Scheel1–3 & Charles M Rice.
4-introdction to medicinal chemistry, garham,patrick.
5-Challenges in Modern Drug Discovery: A Case
Study of Boceprevir, an HCV Protease Inhibitor
for the Treatment of Hepatitis C Virus Infection
F. GEORGE NJOROGE,* KEVIN X. CHEN, NENG-YAN
6-Hepatitis C Treatment 2017- 2018 By DR MONKEZ M YOUSIF
Professor of Internal Medicine Member of AGA, EASL, ISC-Hepatitis
WG
6-Antiviral Nucleoside and Nucleotide Analogs: A Review
Sawsan Mahmoud1, Sherifa Hasabelnaby1, Sherif F. Hammad1, Tamer
M. Sak