Wednesday, February 22, 2017

Ontario Becomes First Province To List EPCLUSA™ On Public Drug Plan To Treat All Six Genotypes Of Chronic Hepatitis C Infection

Feb. 22, 2017
Ontario Becomes First Province To List EPCLUSA™ On Public Drug Plan To Treat All Six Genotypes Of Chronic Hepatitis C Infection

-- Ontario Also Broadens Access for Patients
with Less Advanced Disease with Co-Factors --

MISSISSAUGA, ON, Feb. 22, 2017 /CNW/ - Gilead Sciences Canada, Inc. (Gilead Canada) today announced, effective February 28th, 2017, Ontario will provide public access to EPCLUSA™ (sofosbuvir/velpatasvir) tablets, the first once-daily, pan-genotypic single tablet regimen for the treatment of adults with genotype 1-6 chronic hepatitis C virus (HCV) infection. This listing will support patients to access curative therapy, and will advance Canada's efforts to achieving its World Health Organization commitment to eliminate hepatitis C by 2030.

EPCLUSA, one tablet taken daily for 12 weeks, is for use in adult patients without cirrhosis or with compensated cirrhosis, and in combination with ribavirin (RBV) for those with decompensated cirrhosis. It is also the first single tablet regimen approved for the treatment of patients with genotypes 2 and 3, without the need for RBV.

The approval of EPCLUSA was supported by data from four international Phase 3 studies, ASTRAL-1, ASTRAL-2, ASTRAL-3 and ASTRAL-4. Of the 1,035 patients with compensated disease treated with EPCLUSA for 12 weeks in the ASTRAL-1, ASTRAL-2 and ASTRAL-3 studies, 1,015 (98 per cent) achieved SVR12 (sustained virologic response 12 weeks after the end of treatment). In ASTRAL-4, patients with decompensated cirrhosis receiving EPCLUSA with RBV for 12 weeks achieved a high SVR12 rate (94 per cent) compared to those who received EPCLUSA for 12 weeks or 24 weeks without RBV (83 per cent and 86 per cent, respectively). The most common adverse events in the four ASTRAL studies were headache, fatigue and nausea, and were comparable in incidence to the placebo group included in ASTRAL-1.

The Ontario listing follows the completion of a recent agreement between the pan-Canadian Pharmaceutical Alliance (pCPA) with member provincial, territorial and federal drug plans to fund this innovative therapy for patients. In addition, aligned with the pCPA agreement, Ontario will expand access to include patients with less advanced disease (fibrosis scores of F0 or F1) if they have been diagnosed with certain co-existing factors. All HCV patients with fibrosis scores of F2 or higher also remain eligible for reimbursement.

For more information on the expanded access criteria: http://www.health.gov.on.ca/en/pro/programs/drugs/formulary42/summary_edition42_20170228.pdf

"We now have the ability to cure the majority of patients with chronic HCV with a simple, safe and effective 12-week treatment, regardless of genotype or patient history," said Dr. Curtis Cooper, Associate Professor of Medicine, University of Ottawa, and Director, The Ottawa Hospital and Regional Hepatitis Program. "Broader access to EPCLUSA, particularly at the earlier stage of the disease, means that we can move more quickly to help patients achieve a cure and improve their quality of life, while saving valuable funds associated with the significant long-term burden of illness and costs to the healthcare system."

In Ontario, the Public Health Agency of Canada estimates that more than 102,000 people are living with chronic HCV. In Canada, it is estimated that 250,000 Canadians are living with chronic HCV, with thousands of new cases diagnosed each year. There are six genotypes of hepatitis C. Genotype 1 infection is the most prevalent genotype in Canada representing 64.1 per cent of infected individuals. Genotypes 2 and 3 account for approximately 14.1 per cent and 20.2 per cent of infections in Canada, whereas genotypes 4, 5, and 6 are less prevalent in Canada (0.3 per cent).

"Canada, and other countries, have committed to eliminating hepatitis C by 2030, and to accomplish this goal we need to significantly increase treatment rates," said Dr. Morris Sherman, Chairperson, Canadian Liver Foundation and hepatologist at Toronto General Hospital. "Treatment regimens are getting shorter, simpler and more widely effective across genotypes meaning that treatment is now easier for both patients and physicians to manage.

"Currently, an estimated 44 per cent still remain undiagnosed, so increasing treatment rates also means improving screening and diagnosis, which is why the Canadian Liver Foundation recommends that all Canadians born between 1945-1975 receive a one-time test for hepatitis C," added Dr. Sherman. "Treatment should be an option for everyone, but the cost of treatment has been an obstacle. We're glad to see that the pCPA and the provinces are taking steps to make these treatments accessible regardless of where someone lives or their ability to pay."

"Gilead Canada is pleased that the pCPA and the Ontario Ministry of Health and Long-Term Care are recognizing the innovation and clinical value of EPCLUSA for the treatment of all genotypes of hepatitis C in a single tablet regimen," said Kennet Brysting, General Manager, Gilead Canada. "Broader treatment access for patients will potentially have a profound impact on disease elimination efforts in Canada, and supporting such efforts is a key priority for our company. We will continue to work closely with all jurisdictions to bring this simple and cost-effective curative treatment to all eligible patients, regardless of their genotype or stage of fibrosis."

Related
ZEPATIER®
Feb. 22, 2017
Ontario and British Columbia expand treatment access to chronic hepatitis C (CHC) patients
Effective February 28, Ontario will become the first province to reimburse ZEPATIER®  (elbasvir/grazoprevir), a simple one pill, once daily, 12 week no ribavirin regimen for most patients, and will be followed by British Columbia on March 21

  • In addition to patients with liver fibrosis stage F2+, patients with liver fibrosis stage F0 and F1 with poor prognostic factors, who had no public access to a potential cure under existing public plans, are now eligible for treatment
  • Patients with CHC genotypes 1 and 4, with chronic kidney disease (CKD) and intraveinous drug users - representing the highest number of new cases1 - will have access to treatment

  • KIRKLAND, QC, Feb. 22, 2017 /CNW Telbec/ - An estimated 185,000 people in Ontario and
    British Columbia have hepatitis C, a chronic liver disease that, if left untreated, can lead to cirrhosis, liver cancer and liver transplants.2 Merck Canada Inc. today announced that the Government of Ontario and of British Columbia are strengthening their commitment in the global fight against hepatitis C by becoming the first provinces to reimburse ZEPATIER® (elbasvir/grazoprevir). Zepatier is indicated in the treatment of chronic hepatitis C genotypes 1, 3 or 4 infections in adults patients.3 The product monograph with detailed product indication is available online by clicking here.
    "We're pleased to have worked with the pan-Canadian Pharmaceutical Alliance (pCPA) and participating jurisdictions to provide access to Zepatier to patients who need it, including those at higher risk," says Chirfi Guindo, President and Managing Director, Merck Canada Inc. "Hepatitis C is a curable disease, and today's announcement brings us one step closer to eradicating the virus in Canada."

    For the first time special populations, including hepatitis C patients with fibrosis stage F0 and F1 who are co-infected with human immunodeficiency virus (HIV) or hepatitis B virus or who have chronic kidney disease (CKD), will be eligible for treatment as of February 28th under the Ontario Drug Benefit Program (ODB), and as of March 21st under B.C.'s PharmaCare program.

    "The publicly funded availability of Zepatier in Canada for hepatitis C treatment represents a major milestone in the access to care for patients; not only those patients with advanced liver damage or cirrhosis have access to treatment but now those who may progress to more serious liver damage in the future can be cured. The dedication of Merck to addressing clinical studies in targeted and specific populations in need such as those with cirrhosis, advanced kidney disease and those who inject drugs, allow all treaters to use this treatment regimen to cure their patients safely," said Dr. Sergio Borgia, Medical Director and Corporate Division Head of the Infectious Disease Program at William Osler Health System.

    These provincial public funding announcements follow the World Health Organization's (WHO) adoption of  the first global health strategy on viral hepatitis, which includes a goal of 30% reduction in new cases of hepatitis B and C by 2020 and a 10% reduction in mortality, as well as increased access to treatment for hepatitis B and C.4 In June 2016, the Government of Canada announced its commitment in the global fight against viral hepatitis with the adoption of the Global Strategy on Viral Hepatitis. It has for objective to eliminate hepatitis B and C by 2030.5

    Feb. 22, 2017
    More patients to benefit from hepatitis C treatments
    Thousands of British Columbians living with hepatitis C will have better access to treatment as a result of successful negotiations brokered by the pan-Canadian Pharmaceutical Alliance (pCPA).
    “This agreement changes the landscape for hepatitis C patients living in B.C.,” said Health Minister Terry Lake. “Not only are there four new treatment options for what is now a curable virus, but the savings that were negotiated will allow us to cover treatment options for all hepatitis C patients – rather than just those in more advanced stages of the disease.”
    British Columbia and Ontario co-led the negotiations with the drug manufacturers on behalf of the pCPA. The alliance helps provinces and territories leverage their collective buying power and negotiate better prices for new drugs.....

    Daklinza (daclatasvir) – new
    Epclusa (sofosbuvir/velpatasvir) – new
    Harvoni (ledipasvir/sofosbuvir)
    Sovaldi (sofosbuvir)
    Sunvepra (asunaprevir) – new
    Zepatier (elbasvir/grazoprevir) – new

    Continue Reading...

    Deal reduces price of life-saving hepatitis C drugs for Canadians

    More patients to benefit from hepatitis C treatments
    Thousands of British Columbians living with hepatitis C will have better access to treatment as a result of successful negotiations brokered by the pan-Canadian Pharmaceutical Alliance (pCPA).

    “This agreement changes the landscape for hepatitis C patients living in B.C.,” said Health Minister Terry Lake. “Not only are there four new treatment options for what is now a curable virus, but the savings that were negotiated will allow us to cover treatment options for all hepatitis C patients – rather than just those in more advanced stages of the disease.”

    British Columbia and Ontario co-led the negotiations with the drug manufacturers on behalf of the pCPA. The alliance helps provinces and territories leverage their collective buying power and negotiate better prices for new drugs.

    The collaborative effort resulted in a significant cost savings to drug plans for participating provinces and territories. The agreement also allows access to treatment for all eligible patients in a fiscally sustainable manner. Prices and terms for this negotiation are confidential.
    The list cost to the health system for hepatitis C treatment has ranged from $45,000 to over $100,000 per patient, depending on the drug and disease progression.
    Agreements with the pCPA were reached with Gilead Sciences Canada, Merck Canada, and Bristol-Myers Squibb Canada to provide several hepatitis C drugs at an improved cost:
    • Daklinza (daclatasvir) – new
    • Epclusa (sofosbuvir/velpatasvir) – new
    • Harvoni (ledipasvir/sofosbuvir)
    • Sovaldi (sofosbuvir)
    • Sunvepra (asunaprevir) – new
    • Zepatier (elbasvir/grazoprevir) – new
    PharmaCare is expanding the criteria in March 2017 to provide coverage to more patients living with hepatitis C. Physicians can apply for coverage of the new drugs on behalf of their patients on or around March 21, 2017. Starting in 2018-19, PharmaCare will provide coverage for any British Columbian living with chronic hepatitis C, regardless of the type or severity of their disease.

    Up to 75,000 British Columbians are estimated to be living with hepatitis C. Approximately 24% of those exposed to the virus are able to clear it on their own. However, when left untreated, it can cause serious complications such as liver failure and liver cancer. The new modern hepatitis C therapies are highly effective, with the ability to clear the virus at rates over 95%.

    If untreated, hepatitis C virus infection can be a life-threatening communicable disease. Risk and harm reduction practices are strongly encouraged for those who may be at higher risk for re-acquiring the virus after successful treatment, including people who inject drugs, men who have sex with men, and commercial sex workers.

    Hepatitis C is the most-frequent cause of premature death among reportable infectious diseases in North America, and has become the most-frequent cause of premature death among people living with both hepatitis C and HIV.

    Quick Facts:
    • Hepatitis C is a serious, communicable disease that is spread through direct contact with the blood of a person living with the virus. Symptoms may include fatigue, jaundice, abdominal pain and joint pain. In some people, it can cause liver damage (cirrhosis) or liver cancer.
    • Up to 75,000 people are estimated to be living with hepatitis C in British Columbia. However, many people with the virus have no symptoms. About one-quarter of people living with hepatitis C do not know they have it.
    • About one-quarter of people with hepatitis C do not need treatment, as their body fights off the infection.
    • Once someone is successfully treated and cured of hepatitis C infection, they are no longer able to pass the disease on to others.
    • Currently, there is no vaccine to prevent hepatitis C infection.
    • From March 2015 to December 2016, PharmaCare coverage was provided to about 3,800 people in B.C. for medication used to treat chronic hepatitis C.
    Learn More:
    For more information on the pan-Canadian Pharmaceutical Alliance:
    http://www.pmprovincesterritoires.ca/en/initiatives/358-pan-canadian-pharmaceutical-alliance
    For more information about B.C.’s PharmaCare program:
    http://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents

    Source https://news.gov.bc.ca/releases/2017HLTH0037-000374

    Deal reduces price of life-saving hepatitis C drugs for Canadians
    Kelly Grant - HEALTH REPORTER
    Tens of thousands of Canadian patients with mild versions of chronic hepatitis C could soon receive public funding for medications that cure the infection now that the provinces have sealed a deal with three pharmaceutical companies to reduce the cost of the ultra-expensive drugs.

    The pan-Canadian Pharmaceutical Alliance (pCPA), which negotiates prices on behalf of the provincial and territorial public drug programs, announced on Tuesday that it had reached an agreement with the makers of six breakthrough hepatitis C medications, including the best-known drugs in the class, Harvoni and Sovaldi.

    HCV Genotype 1 No Longer a Treatment Bugbear

    AGA Reading Room

    HCV Genotype 1 No Longer a Treatment Bugbear
    by Pippa Wysong
    Contributing Writer, MedPage Today

    Hepatitis C (HCV) genotype 1 is now the HCV subtype most easily treated with direct-acting agents (DAAs), and cure rates approach 100%. Since genotype 1 infection is the most common subtype, affecting approximately 75% of HCV-infected patients worldwide, and was traditionally harder to treat, scientists directed efforts to develop DAAs effective against genotype 1. There are now multiple DAA regimens available for patients with genotype 1 HCV infection. Clinicians need to consider subtype (genotype 1a versus 1b), insurance factors, and patient factors such as the presence or absence of cirrhosis and the presence of resistant variants when deciding on which regimen to pick. In some situations, specific resistance testing should be done prior to initiating treatment in order to determine the efficacy of the chosen regimen.

    Treating patients with genotype 1 hepatitis C (HCV) can be rewarding because of a simple fact: modern direct-acting agents (DAAs) have a nearly 100 percent cure rate. Yet only four years ago, genotype 1 was considered the most difficult-to-treat type of HCV.
    Back then, interferon regimens were used, and cure rates for genotype 1 hovered around 50 percent, while genotypes 2 and 3 were considered better treatment successes stories.

    Continue reading..

    Genetic variant linked to risk of liver cancer after hep C eradication

    Related - Genome-wide Association Study Identifies TLL1 Variant Associated With Development of Hepatocellular Carcinoma After Eradication of Hepatitis C Virus Infection
    Download PDF.

    Genetic variant linked to risk of liver cancer after hep C eradication
    By Will Boggs MD
    NEW YORK (Reuters Health) – A single nucleotide polymorphism (SNP) in the tolloid-like 1 (TLL1) gene is associated with the development of hepatocellular carcinoma (HCC) after eradication of hepatitis C virus (HCV) infection, researchers from Japan report.

    “When we constructed different models for predicting HCC in patients with mild as opposed to advanced hepatic fibrosis by combining this TLL1 variant with other distinct risk factors, these proposed models including TLL1 variant could be useful for predicting the occurrence of HCC after achieving sustained virological response (SVR) in the clinical practice,” Dr. Yasuhito Tanaka from Nagoya City University Graduate School of Medical Sciences told Reuters Health by email.

    Even after SVR, as many as 2% of patients develop HCC within three years and as many as 8.8% develop HCC within five years, Dr. Tanaka and colleagues write in Gastroenterology, online February 3.

    Continue reading...

    Of Interest
    Liver Cancer After Treatment For Hepatitis C
    ​Research demonstrates that while SVR markedly reduced liver-related complications and liver cancer, some long-term risk for liver cancer remained in those who were cured of Hepatitis C. But after direct-acting antiviral therapy does the risk of developing liver cancer increase?

    Tuesday, February 21, 2017

    Novel emerging treatments for hepatitis C infection: a fast-moving pipeline

    Of Interest
    Abbvie dual combination Glecaprevir /Pibrentasvir
    Gilead fixed dose combination SOF/VEL/VOX
    Merck fixed-dose combination tablet MK3 (MK-3682/grazoprevir/ruzasvir)

    . 2017 Feb; 10(2): 277–282.
    Published online 2017 Jan 25. doi:  10.1177/1756283X16683875

    This update reviews some upcoming therapies for the treatment of chronic hepatitis C
    See table 1 below for; Direct-acting combination antiviral therapies expected to be approved in 2017

    Novel emerging treatments for hepatitis C infection: a fast-moving pipeline
    Ara A. Kardashian and Paul J. Pockros

    Abstract
    Advances in the treatment of chronic hepatitis C has been one of the pinnacles of medical science in the last 25 years. The age of direct-acting antivirals (DAAs) has led to cure rates >95% with shorter duration and low toxicity regimens, thus changing the landscape of the era of pegylated interferon and ribavirin (RBV). However, there remain some challenges with these therapies as there are multiple regimens available with a fair amount of sophistication required to administer them. Treatment continues to require knowledge of prior treatment status, viral genotype and fibrosis assessment, thus affording an opportunity for improvement in future regimens. This update reviews some upcoming therapies for the treatment of chronic hepatitis C.
    Keywords: direct-acting antivirals, emerging treatments, hepatitis C

    Introduction
    Direct-acting antivirals (DAAs) target viral proteins of the hepatitis C virus (HCV) which are critical for viral replication, resulting in the four classes of antivirals currently approved: nonstructural protein 3 (NS3) protease inhibitors (PI), NS5A inhibitors, NS5b nucleot(s)ide polymerase inhibitors and NS5b non-nucleot(s)ide polymerase inhibitors. It is unlikely that drugs will be developed outside of these classes, other than recent efforts with microRNA-122. Instead, we will see improvements upon the current drugs with second generation compounds. There remain unmet needs for treatment in some patients such as those who have failed NS5A regimens, those who have developed resistance-associated substitutions (RASs) and those who have pre-existing RASs that confer resistance. Other opportunities for improvement include pangenotypic regimens, eliminating the need for ribavirin (RBV), reducing duration of therapy, and reducing the cost of therapy. This review will address novel therapies currently in late phase studies.

    Current treatment options
    Currently, treatment options are organized by genotype, presence or absence of cirrhosis, and treatment experience. The following is a brief overview of available regimens and their indications, not an indepth review.

    Treatment-naïve patients
    For genotype 1, treatment options include daily fixed-dose combinations of elbasvir/grazoprevir, ledipasvir/sofosbuvir, paritaprevir/ritonavir/ombitasvir with dasabuvir and RBV, sofosbuvir/velpatasvir, as well as simeprevir plus sofosbuvir, and daclatasvir plus sofosbuvir. Variations in the regimen are based on genotype (1a versus 1b), presence or absence of compensated cirrhosis, and presence of pretreatment RASs. Currently, only one regimen requires pretreatment determination of the presence of NS5A RASs (elbasvir/grazoprevir). If an RAS is present at positions M28, Q30, L31 or Y93, then the patient requires 16 rather than 12 weeks of treatment with the addition of RBV.1 The details of all these regimens are available in the current American Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America (IDSA) Guideline document.2

    For genotypes 2 and 3, sofosbuvir/velpatasvir and daclatasvir plus sofosbuvir are available. Again, duration can vary based on presence of cirrhosis and RBV is required in some patients with genotype 3 HCV infection. Genotype 4 regimens include 12 weeks of daily fixed-dose combinations of paritaprevir/ritonavir/ombitasvir with RBV, sofosbuvir/velpatasvir, elbasvir/grazoprevir, and ledipasvir/sofosbuvir.2 Additionally, in the European Association for the Study of the Liver (EASL) guidelines, sofosbuvir/simeprevir and sofosbuvir/daclatasvir are indicated.3 Treatment-naïve genotype 5 and 6 HCV options are daily fixed-dose combinations of sofosbuvir/velpatasvir or ledipasvir/sofosbuvir, both for 12 weeks for those without cirrhosis or with compensated cirrhosis2,3 and sofosbuvir/daclatasvir for 12 weeks.3

    Treatment-experienced patients
    Options for those having failed prior therapy depends on what was previously used and presence of RASs in addition to the same factors stated previously (genotype, presence or absence of cirrhosis). In general, the same options are available if the prior treatment was with pegylated interferon (PEG-IFN) and RBV. This is congruent with the guidelines published by EASL.3

    If sofosbuvir plus RBV with or without PEG-IFN was used previously, ledipasvir/sofosbuvir with RBV for 12 weeks is recommended in those without cirrhosis while the duration is extended to 24 weeks in the presence of compensated cirrhosis. If an NS3 protease inhibitor (simeprevir, telaprevir, boceprevir) was used previously with PEG-IFN and RBV, then daily fixed-dose combinations of ledipasvir/sofosbuvir, sofosbuvir/velpatasvir, daclatasvir plus sofosbuvir or elbasvir/grazoprevir with RBV (at 12 or 16 weeks if baseline NS5A RASs present) are recommended for those with or without compensated cirrhosis.2 Patients who have proved to be particularly difficult to treat are those with genotype 3 who are treatment-experienced and have cirrhosis. Current recommendations for these patients are for sofosbuvir/velpatasvir with weight-based RBV for 12 weeks or daclatasvir plus sofosbuvir with weight-based RBV for 24 weeks. For those with genotype 3 treatment experience who have failed prior sofosbuvir and RBV, whether they have cirrhosis or not, there are less data to support guidance.2

    Those failing newer treatments including simeprevir plus sofosbuvir and NS5A inhibitors (daclatasvir, elbasvir, ledipasvir, ombitasvir, velpatasvir) have less formal recommendations. Essentially the AASLD/IDSA guideline recommends testing for NS3 and NS5A RASs, tailoring treatment to the results, and extending dual DAA therapy to 24 weeks with the addition of RBV (if not contraindicated). Triple or quadruple DAA therapy may also be considered.2 In contrast, the EASL guidelines recommend retreatment with a non-IFN regimen with weight-based RBV for 12 weeks with METAVIR fibrosis scores of F0–F2 but for 24 weeks if with F3 fibrosis or cirrhosis.3

    For genotype 2 or 3 patients who have previously treated with sofosbuvir plus RBV, daclatasvir plus sofosbuvir with or without RBV for 24 weeks or daily fixed-dose combination sofosbuvir/velpatasvir with RBV for 12 weeks are options. Currently, no formal recommendations exist for the retreatment of DAA failures in those with genotypes 5 or 6.2

    EASL guidelines for sofosbuvir failures include retreatment with sofosbuvir/ledipasvir for genotypes 1 and 4–6, sofosbuvir/velpatasvir or sofosbuvir/daclatasvir for all genotypes, ritonavir-boosted paritaprevir with ombitasvir for genotype 4 and the addition of dasabuvir for genotype 1, and sofosbuvir plus simeprevir for genotype 4. If those genotype 1 or 4 patients already failed sofosbuvir plus simeprevir, they can be retreated with a combination of sofosbuvir with ledipasvir, velpatasvir, or daclatasvir. Genotype 1 or 4 patients who have failed NS5A-containing DAA regimens may be retreated with sofosbuvir plus ritonavir-boosted paritaprevir with ombitasvir for genotype 4 or grazoprevir/elbasvir with sofosbuvir for genotypes 1 and 4 or sofosbuvir, simeprevir and daclatasvir for genotypes 1 and 4 for 12 weeks. For those with genotypes 5 or 6 failing an NS5A-containing regimen, the combination of sofosbuvir and velpatasvir with RBV for 24 weeks is recommended.3

    Novel regimens expected to be approved in 2017
    There are a number of combination regimens currently in phase III development that are expected to be available in 2017. All of these will be pangenotypic, RBV-free and be effective in genotype 1a patients who have failed a DAA regimen containing an NS5A inhibitor. The regimens may be double combinations of very potent pangenotypic protease inhibitors and NS5A inhibitors or triple combinations of protease inhibitors, NS5A inhibitors and NS5b nucleos(t)ide polymerase inhibitors (see Table 1). There are other future regimens beyond these regimens that are anticipated in 2018 or beyond but they are not yet in phase III development so will not be discussed herein.

    Table 1.
    Direct-acting combination antiviral therapies expected to be approved in 2017.

    GZR + RZV + MK-3682RZV + MK-3682SOF + VEL + GS-9857ABT-493+ABT530
    ManufacturerMerck (Kenilworth, NJ, USA)Merck (Kenilworth, NJ, USA)Gilead (Foster City, CA, USA)AbbVie (Lake Bluff, IL, USA)
    Number of drugsTripletDoubletTripletDoublet
    Drug classesPI + NS5A + NS5bNS5A + NS5bNS5b + NS5A + PIPI + NS5A
    Requires RBV?NoNoNoNo
    Duration of therapy4–12 weeks4–12 weeks12 weeks8–12 weeks
    Genotype efficacyPangenotypicPangenotypicPangenotypicPangenotypic
    DAA-failure with NS5A RASsEffective, but may require addition of RBVEffective, but may require addition of RBVEffectiveEffective
    ABT-493, gleaprevir; ABT-530, pibrentasvir; DAA, direct-acting antivirals; GS-9857, voxilaprevir; GZR, grazoprevir; NS5A, NS5A inhibitor; NS5b, NS5b nucleos(t)ide polymerase inhibitor; PI, NS3/4A protease inhibitor; RAS, resistance-associated substitutions; RBV, ribavirin; RZV, ruzasvir; SOF, sofosbuvir; VEL, velpatasvir

    External link. Please review our privacy policy.
                    
    Addressing treatment failures is becoming increasingly important in the era of DAA therapy. For genotype 1 infection, the single-pill combination of ledipasvir (NS5A inhibitor) with sofosbuvir (NS5b nucleotide polymerase inhibitor; Harvoni™ Gilead Sciences, Foster City, CA) has shown cure rates >95%.4 According to the Center for Disease Control and Prevention, there are 2.7–3.9 million people in the United States (US) with HCV infection.5 Of these, approximately 75% have genotype 1, highlighting the importance of this patient population sustained virologic response at follow-up week 12.6

    Glecaprevir (ABT-493) + pibrentasvir (ABT-530)
    Glecaprevir (ABT-493) is a pangenotypic NS3/4A protease inhibitor while pibrentasvir (ABT-530) is a pangenotypic NS5A inhibitor active against common single-position NS5A variants. The two compounds are being developed together in a fixed-dose doublet regimen by AbbVie Pharmaceuticals (Lake Bluff, IL). Different durations of therapy are being evaluated between 6–12 weeks and none of the regimens require RBV. The population being studied does not include decompensated cirrhosis due to the previous experience seen in this group with paritaprevir, telaprevir, simeprevir and other first-generation NS3/4 PIs.7

    In the replicon model, the second-generation protease inhibitor glecaprevir showed potent activity against all genotypes with half-maximal effective concentration (EC50) ranging from 0.85–2.8 nm. These numbers are on par or superior to those seen with grazoprevir and paritaprevir. The other drug in the second-generation doublet regimen, pibrentasvir, showed an EC50 range of 1–4 pm across all genotypes, better than other currently available pangenotypic NS5A inhibitors. The SURVEYOR-I study demonstrated 98–100% SVR4 in HCV genotype 1 noncirrhotic treatment-naïve or PEG-IFN/RBV null-responders with the combination of the two drugs.8

    The MAGELLAN-I study used a combination of glecaprevir and pibrentasvir to treat those with treatment failures to earlier generation DAAs. The patient population included those with NS3 (30%), NS5A (20%), and both NS3 and NS5A (32%) RASs. Using intention-to-treat (ITT) analysis, for glecaprevir/pibrentasvir at doses of 200 mg/120 mg, the sustained virologic response (SVR) at follow-up week 12 was 100% (n=6). For doses of 300 mg/120 mg, SVR12 was 86% (19/22) and with the addition of RBV 800 mg it was 91% (20/22). Using modified ITT analysis (mITT), those same SVR12s were 100%, 95% and 95%, respectively. Failure was due to both viral breakthrough (n=1) and relapse (n=1).9

    The same glecaprevir/pibrentasvir combination was used in a partially randomized, phase II trial for genotype 3 patients with cirrhosis.10 Doses were 200 mg or 300 mg for glecaprevir (30 patients in each group) and 40 mg or 120 mg for pibrentasvir with or without RBV (31 and 30 patients respectively). Again, the study group included those patients with NS3 and NS5A variants either alone or together. By ITT analysis, SVR12 was 93–94% for combination therapy both with and without the addition of RBV.11 The 40 mg arm of pibrentasvir performed less well and will thus not be pursued further.

    Sofosbuvir/velpatasvir + voxilaprevir (GS-9857)
    The single-pill fixed-dose regimen of sofosbuvir 400 mg and velpatasvir 90 mg is currently approved for all genotypes in the US (Epclusa™; Gilead Sciences, Foster City, CA).12 This regimen must be given for 12 weeks and has not been shown to be effective in patients who have failed NS5A-containing DAA regimens with NS5A RASs. As well, although the compound is approved for decompensated cirrhosis, it must be administered with RBV in this population.12 Gilead Sciences, Foster City, CA, is developing a triplet-combination regimen that would include the addition of a protease inhibitor to sofosbuvir/velpatasvir and offer the possibility of a pangenotypic regimen that would be effective against DAA failures.

    This fixed-dose combination of sofosbuvir/velpatasvir was studied in conjunction with voxilaprevir (GS-9857), a pangenotypic NS3/4A protease inhibitor, for DAA-experienced patients with genotype 1. SVR12 for triple therapy was 100% while triple therapy with the addition of RBV had an SVR12 of 96% with overall SVR12 of 98%. Overall, 75% of patients had baseline RASs (NS5A, NS3 or both). Within this group, SVR12 was 97% but 100% for those without any baseline RASs.13

    The same drug combination was studied for genotypes 1, 2, 3, 4 and 6. SVR12 was 99% overall and 100% for genotype 1 in treatment-naïve patients with (n = 15) or without cirrhosis (n = 30) and treatment-experienced patients with cirrhosis (n = 17) or polymerase inhibitor-experienced patients with or without cirrhosis (n = 28), 100% for genotype 2, 97% for genotype 3 patients with cirrhosis who were treatment-naïve (n = 18) or treatment-experienced (n = 19), and 100% for genotypes 4 and 6. Those without RASs had an SVR12 of 100% while those with NS3, NS5A or both variants had overall SVR12 of 99%.13-15

    MK-3682 + grazoprevir + elbasvir or MK-3682 + grazoprevir + MK-8408
    There are two triplet therapies and at least one doublet regimen in development by Merck (Kenilworth, NJ) that include MK-3682 (a novel NS5b nucleotide polymerase inhibitor) with or without grazoprevir and with either elbasvir or MK-8408 (a novel NS5A inhibitor). MK-3682 was tested in 300 mg and 450 mg doses in the CREST 1 (for genotypes 1 and 2) and CREST 2 (for genotype 3) studies. The CREST 1 study showed mITT SVR24 of 91–100% for genotypes 1 (n = 93 with 46 GT1a and 47 GT1b) with either elbasvir or MK-8408 at both doses for MK-3682. However, only the MK-3682 (450 mg)/grazoprevir/MK-8408 regimen showed efficacy >90% in genotype 2 patients (n = 61). For genotype 3 patients, both the 300 mg and 450 mg doses of MK-3682 showed SVR24 rates >90% (n = 86).16,17

    Importantly, the presence of genotype 1 NS5A RASs had no effect on SVR12 rates, including those at the 28, 30, 31 and 93 positions. However, none of these patients had failed prior NS5A-containing regimens. Patients were also tested for the presence of pre-existing genotype 1 NS3 and NS5b RASs and these had no effect on SVR12 rates. The same was true in genotype 2 patients however the SVR rates in genotype 3 patients with NS5A RASs were slightly lower than in those without RASs. The tolerability and side-effect profile of these regimens proved to be excellent with essentially no late alanine aminotransferase (ALT) or aspartate aminotransferase (AST) elevations, and very few serious adverse events. The most common side effects seen in the MK-3682 groups were minimal with headache and fatigue.16

    A regimen earlier in development, two of whose three components are currently unapproved, consists of simeprevir, odalasvir (NS5A inhibitor), and ALS-335 (nucleotide polymerase inhibitor). In a recent press release of 20 patients with treatment-naïve genotype 1 treated with the triplet regimen for 8 weeks, 100% achieved SVR24. Additional promising preliminary results were presented for 6 or 8-week regimens as well as an 8-week regimen of the doublet combination of odalasvir (50 mg every other day) and AL-335 (800 mg daily) for 8 weeks. Adverse effects were mild except for a single serious adverse event (Mobitz type 1 second-degree atrioventricular block), which was attributed to treatment.18

    MicroRNA-122 inhibition
    MicroRNAs regulate messenger RNA levels and translation. Liver-expressed microRNA-122 (miR-122), plays a role in HCV infection of all genotypes by interacting with the HCV RNA genome. Jopling and colleagues19 showed that by sequestering miR-122 in liver cells, the replication of HCV RNA could be diminished. Miravirsen (Santaris Pharma; Copenhagen, Denmark), a locked nucleic acid-modified DNA phosphorothioate antisense oligonucleotide, designed to sequester miR-122 was studied in a phase IIa trial. Although thought to be pangenotypically effective, this trial enrolled only HCV genotype 1 patients (n=36) who received different subcutaneous doses of miravirsen on a weekly basis. Results showed dose-dependent reduction in HCV RNA levels with some durable response. Of note, no viral resistance was noted.20 Another modified oligonucleotide, RG-101, has also been studied in a small trial. A single subcutaneous dose of either 2 or 4 mg/kg was given to 28 total patients. A total of 6 patients in the 2 mg/kg group and 9 patients in the 4 mg/kg group had undetectable levels at 8 weeks while 7 of the 15 responders maintained this at week 20.21 Overall, microRNA-122 targets have shown some promise in small trials however this compound is currently on clinical hold in the US due to Food and Drug Administration concerns about safety. It is unclear what, if any, role these compounds would play in future HCV therapy.

    Link Of Interest On This Blog
    RG-101
    January 31, 2017 Regulus Announces Continuation of RG-101 Clinical Hold - FDA requests longer-term follow-up data from ongoing studies

    Conclusion
    The value of a single-pill, fixed-dose, RBV-free regimen for all genotypes is obvious as it would obviate the need for genotype and RAS testing prior to treatment and would likely be simple and well tolerated. In addition, the advantage of a shorter duration has been already demonstrated with the use of sofosbuvir/ledipasvir (Harvoni™) in genotype 1 treatment-naïve noncirrhotic patients. The ultimate goal of new regimens will be to remove the complexity of treatment and thus place therapy in the hands of primary care physicians as well as specialists. We think we are well on the road towards this goal and we will likely have multiple drug regimens that afford this simplicity by 2017.

    Unresolved issues remain, however, including the cost and access to these drugs and the continued need to evaluate chronic HCV patients for advanced fibrosis or cirrhosis prior to treatment. These patients may be cured with the same regimen however they require assessment for esophageal varices before and after therapy and screening for hepatocellular carcinoma before and at 6 month intervals after successful treatment. Additionally, the safety and efficacy of these fixed-dose regimens will vary in certain populations such as those with end-stage renal disease and decompensated cirrhosis. There will also continue to be drug–drug interactions which preclude their use with other drugs and thus require attention to these details. As such, we think that therapy will remain in the hands of specialists in the near-term but this may change in later years.

    Footnotes
    Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

    Conflict of interest statement: Research grants paid to Scripps Health: Gilead, Merck, AbbVie, BMS, HCV Target. Honoraria paid to PJP for Advisory Boards and Speaking/Teaching: Gilead, Merck, AbbVie, Intercept.

    Contributor Information
    Ara A. Kardashian, Fellow, Division of Gastroenterology/Hepatology, Scripps Clinic, La Jolla, CA, USA.

    Paul J. Pockros, Director of Clinical Research, Scripps Translational Science Institute, Scripps Clinic, 10666 N Torrey Pines Rd, La Jolla, CA 92037, USA.

    References - Full Text

    Neuropsychiatric Symptoms in Patients With HCV Cured of Infection

    Neuropsychiatric Symptoms in Patients With HCV Cured of Infection


    Disabling chronic fatigue is reported in approximately 60% of patients with confirmed hepatitis C virus (HCV) infection,1,2 as well as decreased quality of life (QoL)3,4 and cognitive dysfunction (eg, deficits in attention and verbal learning).5,6 While these neuropsychiatric symptoms may be expected in patients with ongoing HCV infection, it is questionable whether these effects are also present in HCV-exposed patients who currently are cured of the infection (polymerase chain reaction-negative [PCR-]).

    A study7 recently published in the Journal of Viral Hepatitis found no evidence linking the presence of HCV infection with these neuropsychiatric symptoms. Instead, researchers suggest that the fatigue and impairment in health-related quality of life (HRQoL) and cognitive and mental function commonly found in HCV-exposed patients may be explained by either an HCV infection-triggered autoimmune response persisting beyond virus clearance or the development of a virus variant in the brain.7

    Really Rapid Review — CROI 2017, Seattle

    NEJM Journal Watch

    The Conference on Retroviruses and Opportunistic Infections (CROI) returned to Seattle this past week for its 24th meeting. It’s the 4th time CROI has been held in Seattle, an excellent city for a meeting of this size, which includes “only” 4200 people. The convention center is pleasant and user-friendly — big but not cavernous, actually encourages interactions with colleagues — and there are numerous hotels and restaurants within walking distance, plus more Starbucks per square foot than any place on the planet.

    From a content perspective, the big change for CROI 2017 was the return of numerous studies on antiretroviral therapy, studies involving both approved and investigational agents. The last several years, by contrast, had relative dominance of pre-exposure prophylaxis and hepatitis C studies. With PrEP, one had the sense at the meeting that we’re now waiting for the next strategies (long-acting injectables, for example).

    As for hepatitis C, well that’s been all but solved (except for the implementation part). How do you improve on 97%-plus cured. Hooray!

    Links
    Conference Coverage
    Conference on Retroviruses and Opportunistic Infections (CROI)
    February 13-16, 2017, Seattle WA
    NATAP
    hivandhepatitis.com
    http://www.aidsmap.com/croi-2017
    http://www.medpagetoday.com/meetingcoverage/croi

    What are the Most Accurate Non-invasive Techniques for Measuring Liver Fibrosis and Steatosis?

    What are the Most Accurate Non-invasive Techniques for Measuring Liver Fibrosis and Steatosis?

    Magnetic resonance elastography (MRE) is more accurate than transient elastography (TE) in identifying liver fibrosis of stage 1 or more, researchers report in the February issue of Gastroenterology, using biopsy analysis as the standard. They also show that MRI-based proton density fat fraction (MRI-PDFF) analysis is more accurate than TE-based controlled attenuation parameter (CAP) assessment in detecting all grades of steatosis in patients with non-alcoholic fatty liver disease (NAFLD).

    It is important to accurately measure the level of fibrosis in livers of patients with NAFLD, as it associates with long-term outcomes. Steatosis quantification is also important. Nonalcoholic steatohepatitis (NASH) is a strong indicator of disease progression, but until recently, only liver biopsies have been sufficient to identify inflammation.
    Continue reading....

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    Does FibroScan Accurately Assess Liver Fibrosis?