ALLY-1 Trial Results Show Investigational Daclatasvir-Based Regimen Cures 94% of Post-Liver Transplant Patients with Hepatitis C and Up to 94% of Hepatitis C Patients with Cirrhosis (Child-Pugh Class A or B)

97% of post-transplant patients with HCV genotype 1a achieved cure

91% of post-transplant patients with HCV genotype 3 achieved cure 

No need seen to alter existing transplantation medication regimens

Saturday, April 25, 2015 10:00 am EDT

Dateline:

PRINCETON, N.J., APRIL 25, 2015

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(PRINCETON, N.J., APRIL 25, 2015) – Bristol-Myers Squibb Company (NYSE:BMY) today announced that primary endpoints were successfully met in ALLY-1, a Phase III clinical trial evaluating a 12-week regimen of daclatasvir and sofosbuvir once-daily with ribavirin for the treatment of patients with chronic hepatitis C virus (HCV) with either advanced cirrhosis or post-liver transplant recurrence of HCV. The data was presented as a late-breaker at The International Liver Congress™ 2015, the 50^th annual meeting of the European Association for the Study of the Liver (EASL) in Vienna, Austria from April 22-26.

“The results of the ALLY-1 trial point to the potential of this investigational daclatasvir-based regimen in a patient population with high unmet needs despite recent advances in hepatitis C treatment,” said Fred Poordad, M.D., ALLY-1 Lead Investigator and Clinical Professor of Medicine at The University of Texas Health Science Center at San Antonio. “Transplant patients take a variety of immunosuppressive medications to prevent organ rejection; that complicates the treatment of hepatitis C. In ALLY-1, we saw no drug-drug interactions between transplant and hepatitis C therapies and no need to make dose adjustments to patients’ transplant-related drugs while they received the daclatasvir-based regimen that resulted in high SVR12 rates.”

The study’s primary endpoints were reached, with 95% of post-transplant genotype 1 patients and 82% of genotype 1 patients with advanced cirrhosis achieving SVR12. Among all ALLY-1 patients, 94% of those with post-transplant HCV recurrence and 83% of all participants with advanced cirrhosis achieved cure (sustained virologic response 12 weeks after treatment; SVR12).

The Child-Pugh scoring system is commonly used to assess the severity and prognosis of chronic liver disease and cirrhosis, and uses an A through C classification (C being the most advanced) to categorize disease progression. Patients with class C cirrhosis are decompensated, often with later-stage conditions such as ascites (the build-up of fluid in the abdomen), hepatic encephalopathy (confusion or altered level of consciousness due to the liver’s inability to remove toxins from the blood), and abnormal liver function, which can complicate treatment. The ALLY-1 trial included 16 patients with decompensated cirrhosis Child-Pugh class C; nine (56%) achieved SVR12.

Over the course of the study, four advanced cirrhotic patients received a liver transplant during treatment; 3 of 4 extended treatment post-transplant (see study design below), and all 4 achieved SVR12.

In the study, there were no serious adverse events related to study medications throughout the treatment phase. The most common adverse events (≥10%) were headache (15%, 36%), fatigue (18%, 28%), anemia (20%, 19%), diarrhea (8%, 19%), nausea (17%, 6%), and arthralgia (2%, 13%) in the advanced cirrhotic and post-transplant cohorts, respectively. One patient discontinued therapy after 31 days due to headache, but still achieved SVR12. Nine patients in the cirrhosis cohort relapsed post-treatment, and one had detectable HCV RNA at the end of treatment; there were no on-treatment virologic breakthroughs. Three patients (genotypes 1a, 1b, 3) in the post-transplantation cohort relapsed. All 12 patients with relapse are being retreated with daclatasvir and sofosbuvir with ribavirin for 24 weeks.

HCV is the leading indication for liver transplantation worldwide. Without treatment, HCV infection of the new liver after transplant is inevitable, and is associated with rapid progression to cirrhosis and death in up to 30% of patients within 5 years. The ALLY-1 study is the third study to report out of the Phase III ALLY program, which evaluates daclatasvir in combination with sofosbuvir in multiple high-unmet need patient populations and is at the center of Bristol-Myers Squibb’s HCV research focus. The ALLY-2 and ALLY-3 studies have previously been presented at the 2015 Conference for Retroviral and Opportunistic Infections and the 2014 American Association for the Study of the Liver’s The Liver Meeting, respectively, and subanalyses from each study with the ribavirin-free regimen of daclatasvir and sofosbuvir were presented as posters during EASL 2015.

Additionally, EASL issued 2015 Hepatitis C treatment guidelines that include a regimen of daclatasvir+sofosbuvir as the first 12-week treatment for patients with genotype-3 virus. The EASL guidelines now list daclatasvir+sofosbuvir regimens as options for treating all HCV genotypes and for use with patients coinfected with HCV/HIV. (Guidelines available here.)

Other Bristol-Myers Squibb presentations at The International Liver Congress included data from compassionate use programs in the EU that add to the real-world clinical evidence informing the use of daclatasvir-based regimens to treat patients with HCV conditions posing high unmet medical needs.

“The ALLY-1 trial results build off the ALLY-2 and ALLY-3 studies by demonstrating the versatility of the daclatasvir-based regimen to provide HCV cure in multiple patient populations that have been historically hard to manage, such as HCV genotype 3 patients, HIV/HCV coinfected patients, and patients with decompensated cirrhosis,” said Douglas Manion, M.D., Head of Specialty Development, Bristol-Myers Squibb. “Post-liver transplant and cirrhotic patients represent a still-unmet need and continue to present challenges to currently available regimens.” 

About ALLY-1: Study Design

This Phase III open-label clinical trial enrolled treatment-naïve and treatment-experienced patients with HCV infection of any genotype in 2 cohorts: advanced cirrhosis (n=60) and post-liver transplant with HCV recurrence (n=53). All patients received daclatasvir 60 mg plus sofosbuvir 400 mg once-daily with ribavirin initially dosed at 600 mg/d (with potential for adjustment based on hemoglobin levels and creatinine clearance) for 12 weeks. Patients receiving a variety of immunosuppressive agents were permitted. In the cirrhosis cohort, patients transplanted during treatment could receive 12 weeks of extended treatment immediately post-transplant, regardless of treatment duration before transplant. The primary endpoint was the SVR12 rate (defined as HCV RNA <LLOQ (25 IU/mL) at post-treatment week 12) among genotype 1 patients in each cohort.

About Hepatitis C

Hepatitis C is a virus that infects the liver and is transmitted through direct contact with infected blood and blood products. Approximately 170 million people worldwide are infected with hepatitis C. Up to 90 percent of those infected with hepatitis C will not spontaneously clear the virus and will become chronically infected. According to the World Health Organization, up to 20 percent of people with chronic hepatitis C will develop cirrhosis; of those, up to 20 percent may progress to liver cancer.

About Bristol-Myers Squibb’s HCV Portfolio

Bristol-Myers Squibb’s research efforts are focused on advancing late-stage compounds to deliver the most value to patients with hepatitis C. At the core of our pipeline is daclatasvir, a NS5A complex inhibitor which continues to be investigated in multiple treatment regimens and in patients with co-morbidities.

Daclatasvir was approved in Europe in August 2014 for use in combination with other medicinal products across genotypes 1, 2, 3 and 4 for the treatment of chronic hepatitis C virus (HCV) infection in adults. Beyond Europe, it is approved in Japan, as well as multiple countries in Latin and South America, the Middle East and Asia Pacific. Additionally, the U.S. FDA currently is reviewing a New Drug Application (NDA) for the use of daclatasvir and sofosbuvir to treat patients with HCV genotype 3.

About Bristol-Myers Squibb

Bristol-Myers Squibb is a global biopharmaceutical company whose mission is to discover, develop and deliver innovative medicines that help patients prevail over serious diseases. For more information, please visit http://www.bms.com or follow us on Twitter at http://twitter.com/bmsnews.

Bristol-Myers Squibb Forward Looking Statement

This press release contains "forward-looking statements" as that term is defined in the Private Securities Litigation Reform Act of 1995 regarding the research, development and commercialization of pharmaceutical products. Such forward-looking statements are based on current expectations and involve inherent risks and uncertainties, including factors that could delay, divert or change any of them, and could cause actual outcomes and results to differ materially from current expectations. No forward-looking statement can be guaranteed. Among other risks, there can be no guarantee that daclatasvir will receive regulatory approval in the United States, or if approved, that it will become a commercially successful product. Forward-looking statements in this press release should be evaluated together with the many uncertainties that affect Bristol-Myers Squibb's business, particularly those identified in the cautionary factors discussion in Bristol-Myers Squibb's Annual Report on Form 10-K for the year ended December 31, 2014, in our Quarterly Reports on Form 10-Q and our Current Reports on Form 8-K. Bristol-Myers Squibb undertakes no obligation to publicly update any forward-looking statement, whether as a result of new information, future events or otherwise.

Contact:

Media:
Robert Perry, Office: 609-419-5378, Cell: 407-492-4616, rob.perry@bms.com

Investors:
Ranya Dajani, 609-252-5330, ranya.dajani@bms.com

Source

Hepatitis C: Phase III data show Boehringer Ingelheim’s faldaprevir* is effective even in patients with common drug-resistant viral variant

16 December 2013

Summary: Naturally occurring mutations in the hepatitis C virus (HCV) are common and many lead to reduced efficacy of antiviral treatments. Faldaprevir* has now been shown to be effective even in patients with the common HCV Q80K variant,¹ which affects an estimated 700,000^2,3,4 patients in the USA alone. Faldaprevir* is being studied in combinations both with and without interferon. The EMA recently granted accelerated assessment for faldaprevir* as part of an interferon-based regimen and a decision on marketing authorisation is anticipated next year.^5,6

For media outside of the US, the UK & Canada only

INGELHEIM, 16 December, 2013 – Data show that Boehringer Ingelheim’s second-generation protease inhibitor faldaprevir*, when used in combination with pegylated interferon and ribavirin, was effective even with the presence of naturally-occurring mutant variants of the hepatitis C virus (HCV), such as the NS3 Q80K polymorphism. The Q80K mutant was detected in 23% (49/127, STARTVerso™1) and 40% (159/398, STARTVerso™2) of genotype-1a infected patients. Its presence was found to have no effect on the chances of viral cure (SVR12) in genotype-1 infected hepatitis C patients treated with faldaprevir* plus pegylated interferon and ribavirin.¹ These data were presented last week at HEP DART 2013, taking place in Big Island, Hawaii.

"These data are encouraging as they demonstrate that HCV genotype-1 infected patients irrespective of the presence of the common HCV Q80K variant may benefit from faldaprevir," said Christoph Sarrazin, M.D., Professor of Medicine at the Johann Wolfgang Goethe University Hospital in Frankfurt, Germany. "In some parts of the world, the Q80K mutation is present in almost 50% of genotype-1a infected patients, who will potentially require additional screening prior to using some HCV protease inhibitors. With faldaprevir’s* efficacy against HCV Q80K, physicians should be able to avoid screening for this mutation prior to treatment of genotype-1a infected patients."

The HCV NS3/4A protease is essential for viral replication and is a key target for direct acting antiviral (DAA) treatments such as faldaprevir*. The NS3 Q80K variant is the most commonly observed NS3 polymorphism in genotype-1a HCV and has been reported in up to 47% of genotype-1a infected patients. The variation in frequency is influenced by the geography, with the prevalence of Q80K being particularly high in the USA.⁴

Faldaprevir* is the core component of Boehringer Ingelheim’s investigational hepatitis C pipeline and is being studied in combinations both with and without interferon. Faldaprevir* was recently granted accelerated assessment by the European Medicines Agency. If approved by the European Commission, faldaprevir* could be available for marketing in the EU in the second half of 2014 as part of an interferon-based regimen. In addition, Boehringer Ingelheim aims to deliver one of the first interferon-free regimens for the treatment of hepatitis C infection. Pivotal Phase III HCVerso® data for the interferon-free regimen of faldaprevir*, deleobuvir* and ribavirin will be available in 2014.

Additional data from Boehringer Ingelheim at HEP DART
Data presented last week as part of the ‘oral abstract session II’ show a high rate of virologic response in patients treated with a 12 week all-oral combination of Boehringer Ingelheim’s faldaprevir* and deleobuvir* and Presidio’s PPI-668* with and without ribavirin.⁷ Results from the ongoing Phase II trial were recently presented at the 64^th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD).

NOTES TO EDITORS

The Boehringer Ingelheim NewsHome: An innovative resource for journalists
The Boehringer Ingelheim hepatitis C www.newshome.com is the one-stop-shop for clear, concise and easy to understand information about hepatitis C for media.

About Boehringer Ingelheim
The Boehringer Ingelheim group is one of the world’s 20 leading pharmaceutical companies. Headquartered in Ingelheim, Germany, it operates globally with 140 affiliates and more than 46,000 employees. Since it was founded in 1885, the family-owned company has been committed to researching, developing, manufacturing and marketing novel medications of high therapeutic value for human and veterinary medicine.

Social responsibility is a central element of Boehringer Ingelheim's culture. Involvement in social projects, caring for employees and their families, and providing equal opportunities for all employees form the foundation of the global operations. Mutual cooperation and respect, as well as environmental protection and sustainability are intrinsic factors in all of Boehringer Ingelheim’s endeavors.

In 2012, Boehringer Ingelheim achieved net sales of about 14.7 billion euro. R&D expenditure in the business area Prescription Medicines corresponds to 22.5% of its net sales.

*Faldaprevir, deleobuvir and PPI-668 are investigational compounds and not yet approved.Their safety and efficacy have not yet been fully established.

References
1. Sarrazin et al. NS3/4A baseline polymorphisms and treatment-emergent variants in HCV genotype-1 infected, treatment-naïve patients from the Phase III STARTVerso1 and 2 clinical studies of faldaprevir plus pegylated interferon a-2A and ribavirin. Presented at HEP DART 2013.
2. Centers for Disease Control and Prevention. Hepatitis C FAQs for health professionals. http://www.cdc.gov/hepatitis/hcv/hcvfaq.htm [last accessed 03/12/13]
3. Theodore Sy, M. Mazen Jamal. Epidemiology of Hepatitis C Virus (HCV) Infection. Int J Med Sci 2006; 3(2):41-46.
4. Berger et al. Baseline HCV NS3 Polymorphisms and their Impact on Treatment Response in Clinical Studies of the HCV NS3 Protease Inhibitor Faldaprevir. Antimicrob Agents Chemother. 2013 Nov 11.
5. Boehringer Ingelheim Data on file. European Medicines Agency, Human Medicines Evaluation Division. (Faldaprevir Boehringer Ingelheim, Boehringer Ingelheim International GmbH). Submission validation, 21 November, 2013
6. Boehringer Ingelheim Data on file. European Medicines Agency, Human Medicines Evaluation Division. (Faldaprevir Boehringer Ingelheim, Boehringer Ingelheim International GmbH). Accelerated assessment acceptance, 12 November, 2013
7. Lalezari, et al. Rapid and Consistent Virologic Responses in a Phase 2 Trial of a New All-Oral Combination of Faldaprevir, Deleobuvir and PPI-668, with and without Ribavirin, in Patients with HCV Genotype-1a Infection. Presented at HEP DART 2013

Source

Boehringer Ingelheim broadens efforts for interferon-free hepatitis C treatments through clinical collaboration with Presidio Pharmaceuticals

10 September 2013

• First Phase IIa study includes Presidio’s PPI-668 in genotype-1a infected patients¹; collaboration offers the potential to explore additional HCV genotypes in future trials
• Boehringer Ingelheim’s Phase III interferon-free HCVerso® trials in genotype-1b infected patients are fully enrolled; results are expected in Q2 2014^2,3

For media outside USA, UK and Canada only

INGELHEIM, 10 September 2013 – Boehringer Ingelheim today announced the completion of patient enrolment for a Phase IIa clinical trial investigating a new interferon-free, all-oral, direct-acting antiviral (DAA) combination treatment for patients with genotype-1a chronic hepatitis C virus (HCV) infection. The trial is conducted in collaboration with Presidio Pharmaceuticals, Inc. and evaluates Boehringer Ingelheim’s investigational compounds, the protease inhibitor faldaprevir⁺ and non-nucleoside NS5B polymerase inhibitor, deleobuvir⁺, in combination with Presidio’s pan-genotypic NS5A inhibitor, PPI-668, with and without ribavirin.¹

The trial includes 36 treatment-naïve genotype-1a infected patients treated for 12 weeks with this all-oral DAA regimen, with 24 weeks of post-treatment follow-up. The primary endpoint of the trial is sustained virologic response 12 weeks after treatment is completed (SVR12).¹ This Phase IIa trial of a novel combination therapy is part of Boehringer Ingelheim’s commitment to develop new, tailored interferon and potentially ribavirin-free HCV regimens for a broad range of HCV patients.

In March 2013, the two companies entered a non-exclusive collaboration to evaluate the three DAAs in combination regimens. Both companies will retain all rights to their respective compounds. Presidio has operational responsibility for this collaborative trial, with oversight by an intercompany project team. Final results are expected in Q2 2014.¹

"We are pleased to announce that enrolment is complete in this collaborative Phase IIa trial evaluating a new 12-week interferon-free treatment regimen. This regimen complements and expands our HCV portfolio with the goal of providing interferon-free treatments to patients with HCV," said Professor Klaus Dugi, Senior Vice President Medicine at Boehringer Ingelheim. "This study is the next step in our continued commitment to deliver effective and well-tolerated treatment options that are optimised for patients with different hepatitis C genotypes. The pan-genotypic properties of PPI-668 bear the potential to explore the efficacy of this regimen in a wider range of HCV genotypes in the future."

Eliminating injectable interferon from treatment is a critical goal in hepatitis C management.⁴ Clinical studies have shown that up to 50 percent of patients may not be eligible for treatment with interferon due to contraindications.⁵ Patients may also find interferon challenging due to the long treatment duration and side-effects. These side-effects commonly include fatigue, anxiety, depression, gastrointestinal and flu-like symptoms as well as more serious side-effects such as heart failure, sepsis, leukopenia, depression and vision loss.^6,7

"Clinical trials evaluating multiple DAAs are exciting because they can help bring us closer to our goal of developing more effective and tolerable interferon-free and potentially ribavirin-free therapies," said Jacob Lalezari M.D., Director of Quest Clinical Research in San Francisco, CA. "By treating patients with multiple compounds that attack the hepatitis C virus in different ways, we hope to be able to cure more patients in less time with fewer of the side-effects associated with existing treatment options."

Boehringer Ingelheim has a comprehensive interferon-free clinical trial programme which includes three pivotal Phase III studies (HCVerso®). The HCVerso® studies include approximately 1,100 treatment-naïve HCV genotype-1b patients, including those who are interferon eligible or ineligible and patients with compensated liver cirrhosis.^2,3

For more information regarding the trial, please visit www.clinicaltrials.gov.

NOTES TO EDITORS

The Boehringer Ingelheim NewsHome: An innovative resource for journalists
The Boehringer Ingelheim hepatitis C www.NewsHome.com is available and is the one-stop-shop for clear, concise and easy to understand information about hepatitis C for media.

About Boehringer Ingelheim in hepatitis C
Through pioneering science, Boehringer Ingelheim is striving to find answers to the pressing challenges still faced by the diverse population of hepatitis C patients. The company’s comprehensively designed hepatitis C clinical trial programme includes a broad range of patients, including the challenging to cure, that clinicians see every day in clinical practice.

Boehringer Ingelheim is developing faldaprevir⁺, an optimised second generation protease inhibitor, as the core component for both interferon-based and interferon-free treatment regimens.

Interferon-based therapy with faldaprevir⁺ has the potential to improve cure rates with the added convenience of once-daily dosing and no dietary requirements for intake. Faldaprevir⁺ has proven efficacy in a broad range of genotype-1a and 1b hepatitis C patients. The Phase III STARTVerso® trial programme, which includes treatment-naïve, treatment-experienced and HIV co-infected patients with hepatitis C virus, is nearly complete.^13,14,15,16

Deleobuvir⁺ (BI 207127) is a potent investigational non-nucleoside NS5B polymerase inhibitor to treat patients with genotype-1b hepatitis C virus. Phase III HCVerso® trials, investigating the interferon-free regimen of twice-daily deleobuvir in combination with once-daily faldaprevir⁺ and ribavirin, are well underway.^2,3

As part of Boehringer Ingelheim’s long-term commitment to hepatitis C, the company is also evaluating other combinations of investigational hepatitis C compounds that work in different ways. Boehringer Ingelheim’s recent collaboration with Presidio Pharmaceuticals, Inc. for a Phase II clinical study investigating an interferon-free, all-oral, potentially ribavirin-free combination is part of the company’s continued exploration to discover and develop innovative options for the treatment of HCV.

About Hepatitis C
Hepatitis C is a blood-borne infectious disease caused by the hepatitis C virus which lives and replicates in the liver. Hepatitis C is a leading cause of chronic liver disease, liver cancer and transplantation.⁸ Chronic hepatitis C is a major public health issue and one of the most prevalent infectious diseases worldwide, affecting around 170 million people,⁹ with 3-4 million new cases occurring each year.¹⁰

It is common for hepatitis C patients to remain undiagnosed due to the initial unspecific symptoms of the disease. Consequently, a large number of patients first present to their physician when they experience symptoms or already have liver disease.¹¹ Patients with advanced liver disease are challenging to cure, yet have the greatest need for more effective and better tolerated treatments.

Of patients with chronic hepatitis C, 20 percent will develop liver cirrhosis, of which 2-5 percent will die every year.¹² Advanced liver disease due to hepatitis C currently represents the main cause for liver transplantation in the western world.¹²

About Boehringer Ingelheim
The Boehringer Ingelheim group is one of the world’s 20 leading pharmaceutical companies. Headquartered in Ingelheim, Germany, it operates globally with 140 affiliates and more than 46,000 employees. Since it was founded in 1885, the family-owned company has been committed to researching, developing, manufacturing and marketing novel medications of high therapeutic value for human and veterinary medicine.

Social responsibility is a central element of Boehringer Ingelheim's culture. Involvement in social projects, caring for employees and their families, and providing equal opportunities for all employees form the foundation of the global operations. Mutual cooperation and respect, as well as environmental protection and sustainability are intrinsic factors in all of Boehringer Ingelheim’s endeavors.

In 2012, Boehringer Ingelheim achieved net sales of about 14.7 billion euro. R&D expenditure in the business area Prescription Medicines corresponds to 22.5% of its net sales.

About Presidio in HCV
Presidio Pharmaceuticals, Inc. is a San Francisco-based clinical stage specialty pharmaceutical company focused on the discovery and development of oral pan-genotypic therapeutics for HCV patients. Efforts are currently focused on novel inhibitors of both the HCV NS5A and NS5B genes. PPI-668 is an investigational, pan-genotypic, once daily, NS5A inhibitor. In earlier clinical studies in healthy volunteers and HCV-infected patients, PPI-668 has been well-tolerated to date with no serious or severe adverse events and no apparent pattern of treatment-related clinical side effects or laboratory abnormalities. PPI-668 achieves plasma concentrations high enough to inhibit most pre-existing resistant variants and achieves steady-state levels after a single dose. In a clinical study of PPI-668 monotherapy in GT1 HCV-infected patients, viral load reductions of 3.5 to 3.7 log10 HCV were achieved in 1-2 days. Activity was also noted in GT3 HCV-infected patients.¹⁷

Presidio’s NS5B inhibitor, PPI-383, is a novel pan-genotypic non-nucleosidic inhibitor with potential to inhibit all of the major HCV genotypes. This compound is currently in Phase 1 studies in healthy subjects. For more information, please visit our website at: www.presidiopharma.com.

⁺ Faldaprevir and BI 207127 are investigational compounds and not yet approved. Their safety and efficacy have not yet been fully established

Media contact

Boehringer Ingelheim

Media & PR
Dr Reinhard Malin
Binger Strasse 173
55216 Ingelheim am Rhein

GERMANY

Phone + 49 - 6132 – 77 90815

Fax + 49 - 6132 – 77 6601

References

1. ClinicalTrials.gov. Study of PPI-668, BI 207127 and Faldaprevir, With and Without Ribavirin, in the Treatment of Chronic Hepatitis C

2. ClinicalTrials.gov. IFN-free Combination Therapy in HCV-infected Patients Treatment-naive:HCVerso1. http://clinicaltrial.gov/ct2/show/NCT01732796?term=faldaprevir+bi+207127&rank=3  [Last accessed 17/04/13]

3. ClinicalTrials.gov. Phase 3 Study of BI 207127 in Combination With Faldaprevir and Ribavirin for Treatment of Patients With Hepatitis C Infection, Including Patients Who Are Not Eligible to Receive Peginterferon: HCVerso2. http://clinicaltrial.gov/ct2/show/NCT01728324?term=faldaprevir+bi+207127&rank=2  [Last accessed 17/04/13 ]

4. Jazwinski and Muir. Direct-Acting Antiviral Medications for Chronic Hepatitis C Virus Infection. October 2012.

5. Kramer JR. et al. Gaps In The Achievement Of Effectiveness Of HCV Treatment In National VA Practice. J Hepatology 2012; 56:320-5

6. National Institutes of Health; US Department of Health and Human Services. Chronic Hepatitis C: Current Disease Management. Bethesda, MD: National Institutes of Health; 2010. NIH Publication 10-4230 4

7. World Health Organization. Global Alert and Response: Hepatitis C Prevention and Treatment. http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/en/index5.html

8. World Health Organisation. Hepatitis C. 2002 http://www.who.int/csr/disease/hepatitis/Hepc.pdf  [Last accessed on 23/07/13]

9. Centers for Disease Control and Prevention (2012) Hepatitis C available at: HYPERLINK "http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/hepatitis-c.htm  [Last accessed on 23/07/13]

10. World Health Organisation. Hepatitis C Fact Sheet. Updated July 2012 http://www.who.int/mediacentre/factsheets/fs164/en/index.html  [Last accessed on 16/07/13]

11. Chen S.L., Morgan T.R. The Natural History of Hepatitis C Virus (HCV) Infection. Int J Med Sci 2006; 3:47-52. Available from http://www.medsci.org/v03p0047.htm  [Last accessed on 16/07/13]

12. Soriano, Vincent et al. New Therapies for Hepatitis C Virus Infection. Clinical Infectious Disease, February 2009

13. ClinicalTrials.gov. Efficacy and Safety of BI 201335 in Combination With Pegylated Interferon-alpha and Ribavirin in Treatment-naïve Genotype 1 Hepatitis C Infected Patients. http://clinicaltrials.gov/ct2/show/NCT01343888?term=bi+201335&rank=4  [Last accessed 17/04/13]

14. ClinicalTrials.gov. BI 201335 Used in Treatment Naive Patients Infected With Genotype 1 Chronic Hepatitis C Infection. http://clinicaltrials.gov/ct2/show/NCT01297270?term=bi+201335&rank=5  [Last accessed 17/04/13]

15. ClinicalTrials.gov. Pivotal Trial Treatment Experienced Patient Infected With Hepatitis C Virus (HCV) Genotype 1 (GT1). http://clinicaltrials.gov/ct2/show/NCT01358864?term=bi+201335&rank=14  [Last accessed 17/04/13]

16. ClinicalTrials.gov. Phase III Trial of BI 201335 in Treatment Naive (TN) and Relapser Hepatitis C Virus (HCV)- Human Immunodeficiency Virus (HIV) Coinfected Patients. http://clinicaltrials.gov/ct2/show/NCT01399619?term=bi+201335+HIV&rank=1  [Last accessed 17/04/13]

17. Lalezari, J. Et al. PPI-668, A Potent New Pan-Genotypic HCV NS5A Inhibitor: Phase 1 Efficacy and Safety. Poster Presented at 63rd Annual Mtg. of the American Association for the Study of Liver Diseases. November 2012

Source

Interferon-free treatment for genotype-1b hepatitis C patients: an interview with Professor Wulf Boecher, Boehringer Ingelheim

Published on July 30, 2013 at 6:32 AM

Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)

Please can you give a brief introduction to genotype-1b hepatitis C and how it differs from subtype 1a?

Genotype 1 is, worldwide, the most prevalent genotype of the hepatitis C virus. It accounts for around seventy percent of all hepatitis C infections.

With the introduction of protease inhibitors, it became known that the subtypes 1a and 1b make a difference in terms of treatment response.

Subtypes 1a and 1b are genetically closely related. They share seventy to eighty percent of their genome. However, 1a turned out to be more difficult to treat than 1b, which is easier to treat.

That was also the case with the already approved protease inhibitors, and still is the case with the second generation of protease inhibitors (PIs) like faldaprevir or other second generation PIs that are in late stage development. And it applies for interferon based as well as interferon-free treatments.

Faldaprevir's target in viral polyprotein processing.

*Please note faldaprevir (BI 201335) is an investigational compound and not yet approved. Its safety and efficacy has not yet been fully established.

Source: Boehringer Ingelheim

Do genotypes 1a and 1b affect equal numbers of people, or is one more common than the other?

It is regionally very different. In the US, genotype 1a is more prevalent where it accounts for roughly seventy percent of genotype 1 infections.

In Europe, there is slightly more genotype 1b. So there’s roughly a sixty-forty split, with sixty percent being genotype 1b, forty percent 1a.

If you go further East the prevalence of 1b becomes nearly the only genotype 1. So in Japan, in China, and in large parts of Asia, genotype 1b is basically the vastly prevailing or the only genotype 1 subtype.

Hepatitis C virus travelling in the bloodstream.

Source: Boehringer Ingelheim

Why is eliminating injectable interferon from HCV treatment regimens highly desirable?

I have been working on hepatitis C treatment for many years and it is not only subcutaneous injections that make patients uncomfortable. Interferon really makes patients sick for the whole course of treatment and with current treatments this can be as long as twenty four or forty eight weeks, so nearly one year.

Patients feel like they have the flu, with fever, myalgia, chills, and many other symptoms. Also their neuro-cognitive function is reduced. They have low blood cell count that can lead to infections and to severe bleedings. They suffer from psychiatric side effects like severe depression. There are suicides associated with treatment with interferon.

So interferon is really a trouble-maker for patients; it makes patients sick for the duration of their treatment and it is less effective than the oral treatments that are to come. Treatment lasts longer and there is a high chance patients won’t be cured at the end. In contrast, current triple therapies the next generation triple therapies, as well as the future interferon-free treatments, offer shorter treatment duration and higher cure rates.

Faldaprevir* Protease Inhibitior Mode of Action.

*Please note faldaprevir (BI 201335) is an investigational compound and not yet approved. Its safety and efficacy has not yet been fully established.

Source: Boehringer Ingelheim

How did your interferon-free combination treatment originate and what stage of development is it currently at?

It’s actually based on the knowledge of HIV and tuberculosis treatment; where by combining different oral drugs with a different mode of action it is possible to control or eliminate the virus or mycobacteria.

In HCV, we had two different mode-of-action drugs in late stage development that we combined. We had actually thought we may possibly have a forty-five percent cure rate, which would still have been a very attractive cure rate for patients without any treatment options.

Up to fifty percent of hepatitis c patients right now do not tolerate interferon or have contra-indications against interferon.

But then in our phase two studies we found out that by focusing on the easier-to-treat genotype 1b patients, eighty five to ninety five percent of patients can be cured. This makes this combination very attractive as an alternative to replace interferon-based treatments.

And with this interferon-free treatment, we are currently in phase III development.

Please can you tell us about the recent Phase IIb study into the efficacy and safety of this combination treatment?

This is our second phase IIb trial. Initially (in the SOUND-C2 trial) we tested our interferon-free treatment regimen of faldaprevir, deleobuvir and ribavirin in a large study. We had 362 patients, including patients with liver cirrhosis and all stages of liver disease.

We found that genotype 1a patients are indeed difficult to treat, achieving lower cure rates. That would have been attractive maybe three, four years ago, but not nowadays.

But in this study genotype 1b patients had a cure rate of eighty-five percent.

Then we modified the regimen. We shortened treatment from twenty eight to sixteen weeks in SOUND-C3, which is the study we just published at the Asian Pacific Liver Conference (APASL) in June.

We also dropped a so-called induction dose. So in the old regimen, we had a high dose of our polymerase inhibitor and this was not so well tolerated, as we found out.

So we dropped this, we shortened treatment and we found in genotype 1b patients ninety five percent achieved viral cure. But it turned out that in the more difficult to treat population of genotype 1a patients, only two of seventeen patients were cured. And that confirmed our decision to focus on genotype 1b patients with this regimen.

Progression of liver damage caused by infection with hepatitis C.

Source: Boehringer Ingelheim

What were the results of this study and what do they indicate?

The very high cure rates of ninety five percent confirm our decision to focus on genotype 1b patients with this regimen.

We dropped genotype 1a patients from this regimen. However we are currently investigating a third compound in combination with our interferon free combination with which we strive to address genotype 1a patients.

The tolerability was very good. This was as expected from interferon-free treatment. We saw only minor effects on the red blood cells, which was due to the ribavirin component of the regimen, but we didn’t see any effects on white blood cells or platelets.

We did see mostly mild adverse events like mild rashes or nausea, which were the most common side effects.

Did any patients experience serious adverse events during the trial?

Only two patients had to discontinue treatment for adverse events and only one patient reported a serious adverse event (SAE). So overall, I think we can say that this is very good tolerability.

What serious adverse event did the patient experience?

The SAE patient was a patient who had severe dehydration. He was hospitalized to get some infusions and discontinued HCV treatment early after 6 weeks of treatment. However the condition was managed and resolved and the patient recovered completely from the event but also from his hepatitis C.

What are your plans for the future?

For genotype 1b patients we are in the middle of our phase III evaluations. We are expecting results early next year.

We have three on-going phase III trials:-

• One in treatment-naive genotype 1b patients.
• One in a treatment-naive population that includes interferon ineligible patients, which are patients who have contra indications to interferon based treatments. So these patients have currently no treatment option at all.
• We have a third trial that goes to the highest unmet medical need population, which are patients with decompensated liver cirrhosis.

The first two trials also include patients with compensated liver cirrhosis, but the third trial really addresses the late stage liver cirrhosis, or decompensated liver cirrhosis. These are patients that will die if they do not receive a liver transplant. All studies are on-going as we speak.

Our trials are comprehensively designed and address the real-world patients that physicians see every day in clinical practice. Through robust science, our goal is to provide a safe and highly effective interferon-free treatment for genotype-1b patients.

How do you think the future of genotype-1b hepatitis C treatments will progress?

From a patient and a prescriber or physician’s perspective, the future is very bright.

There are several companies and there will be several regimens available to physicians to pick the best treatment option for a given patient.

There are many factors that need to be considered when prescribing HCV treatments, so there will be no one-size-fits-all approach. In the future individualized treatment will become a reality. Physicians will be able to pick the best treatment option for a given patient depending on:-

• the virus genotype and patient genetics
• on individual patient conditions
• age
• gender
• co-morbidities
• co-medications

Everything will play into this and there will be several interferon-free treatment options that can be really tailored individually to a given patient.

It is exactly our strategy to provide tailored therapy which is optimal for specific patient populations. I think this is where we believe we will excel in.

The treatment landscape will become more complex. In the past, we had only to pick between prescribing pegylated interferon for twenty four, or forty eight weeks, and ribavirin in eight hundred, one thousand or twelve hundred milligrams. This was very easy, no drug-drug interactions.

The future looks like it will be more individualized, with physicians choosing which regimen to provide based on the individual patient’s profile. But this is in fact a luxury situation and a great opportunity.

Where can readers find more information?

Readers can find more information on Boehringer Ingelheim at: http://www.boehringer-ingelheim.com/

Readers can also find more information on HCV at: http://www.newshome.com/

About Professor Wulf Boecher

Wulf trained and worked more than 15 years at Mainz University Hospital in Germany as a Gastroenterologist/ Hepatologist and Infectious Diseases Specialist, where he lectures as an Associate Professor for Internal Medicine.

His main scientific focus has been immune pathogenesis and new treatments of HBV, HCV and HIV infection.

Wulf joined Boehringer Ingelheim for the clinical development of new HCV treatments in 2007 and currently holds the position of Associate Therapeutic Area Head Virology.

Source

Achillion Announces Positive Proof-of-Concept Data With ACH-3102

September 27, 2012

-Second-Generation Pan-Genotypic NS5A Inhibitor Achieves Potent Antiviral Activity
of Mean Maximum 3.74 Log₁₀ Reduction Following a Single Dose -

- Initiated Enrollment in a Phase 2 Clinical Trial Evaluating ACH-3102 Plus Ribavirin for the Treatment of HCV Genotype 1b-

- Hosting Analyst Day Today With Live Webcast Beginning at 1:00 p.m. ET -

NEW HAVEN, Conn., Sept. 27, 2012 (GLOBE NEWSWIRE) -- Achillion Pharmaceuticals, Inc. (Nasdaq:ACHN) today announced positive proof-of-concept results with ACH-3102, a second-generation pan-genotypic NS5A inhibitor being developed for the treatment of chronic hepatitis C viral infections (HCV). Administration of a single-dose of ACH-3102 to genotype (GT) 1a HCV-infected subjects resulted in a mean maximum 3.74 log₁₀ reduction in HCV RNA (range 2.9 — 4.6 log₁₀). Significant reductions in HCV RNA were achieved in subjects with resistant variants at baseline, including L31M and Y93C variants.

Based on these data, combined with safety and tolerability results from the Phase 1a trial in healthy subjects evaluating up to 14 days of ACH-3102, Achillion has initiated a pilot Phase 2 clinical trial evaluating ACH-3102 in combination with ribavirin for the treatment of patients with chronic GT 1b HCV.

"We believe these proof-of-concept results demonstrate the differentiation of ACH-3102 from first-generation NS5A inhibitors. The potency of ACH-3102 was successfully shown against genotype 1a, historically the hardest to treat HCV subtype," commented Michael Kishbauch, President and Chief Executive Officer of Achillion. "Furthermore, we believe the enhanced resistance profile of ACH-3102 observed in vitro has been validated in the clinic with robust antiviral activity against baseline mutations such as L31M. These results support our belief that this second-generation pan-genotypic NS5A inhibitor has the potential to become a cornerstone compound."

ACH-3102: Phase 1 Program

In May 2012, Achillion initiated a Phase 1a clinical trial evaluating the safety and tolerability of single and multiple ascending doses of ACH-3102 in healthy volunteers. To date, 42 healthy volunteers have received a single dose of ACH-3102, ranging from 25 mg to 1,000 mg. An additional 32 healthy volunteers have received 14 days of ACH-3102 once-daily evaluating various dosing regimens. Preliminary data from the single and multiple ascending dose groups demonstrated that ACH-3102 was well tolerated at all doses evaluated. There were no serious adverse events and no clinically significant changes in vital signs, electrocardiograms (ECGs), or laboratory evaluations. All reported adverse events were classified as mild or moderate and were transient in nature.

In August 2012, Achillion initiated a Phase 1b clinical trial enrolling a total of 14 patients infected with GT 1a chronic HCV, of which 2 received placebo and 12 received a single dose of 50 mg, 150 mg or 300 mg ACH-3102. No serious adverse events were reported and there were no patient discontinuations.

The mean maximum HCV RNA decline for each dose group is provided below:

An assessment of clinical virology was conducted on baseline samples from all 12 patients receiving a single-dose of ACH-3102. Sequencing revealed one patient had a baseline L31M mutation (300 mg dose group, maximum HCV RNA decline of 3.4 log₁₀) and another patient had a baseline Y93C mutation (300 dose group, maximum HCV RNA decline of 4.6 log₁₀). These mutations have been previously reported to convey a high level of resistance to first-generation NS5A inhibitors which was not observed following exposure to ACH-3102.

ACH-3102: All-oral, interferon-free pilot Phase 2 12-week trial of ACH-3102 and ribavirin for the treatment of HCV GT 1b

Achillion has initiated patient enrollment in an open-label Phase 2 pilot trial evaluating 12-weeks of once-daily ACH-3102 in combination with ribavirin for the treatment of HCV GT 1b. This study will initially enroll up to 16 treatment-naïve patients with GT 1b IL28B CC HCV. Patients will receive 225 mg of ACH-3102 on day 1 followed by 75 mg of ACH-3102 once daily on subsequent days in combination with twice daily ribavirin. The primary objective of the trial is to determine the safety and sustained virologic response 12 weeks after the completion of treatment (SVR12) with secondary endpoints assessing safety, pharmacokinetics, pharmacodynamics, and virologic endpoints including rapid virologic response (RVR) and extended RVR (eRVR). Achillion expects to report initial RVR results from this study during the fourth quarter of 2012.

Mr. Kishbauch further commented, "With the initiation of this all-oral 12-week study evaluating ACH-3102 and ribavirin for the treatment of HCV genotype 1b, we have rapidly advanced our portfolio and believe the attributes of ACH-3102, as well as sovaprevir, our Phase 2 protease inhibitor, have the potential to provide optimized compounds for the broad treatment of HCV."

Analyst Day Webcast

Achillion is hosting its inaugural Analyst Day and simultaneous webcast on Thursday, September 27, 2012 at 1:00 p.m. Eastern Time. To access a copy of the presentation and the live audio webcast of the event, please visit www.achillion.com. Please connect to Achillion's website several minutes prior to the start of the broadcast to ensure adequate time for any software download that may be necessary. A replay of the webcast will be available on www.achillion.com beginning approximately 2 hours after the conclusion of the event.

About HCV

The hepatitis C virus is the most common cause of viral hepatitis, which is an inflammation of the liver. It is currently estimated that more than 170 million people are infected with HCV worldwide including more than 5 million people in the United States, more than twice as widespread as HIV. Three-fourths of the HCV patient population is undiagnosed; it is a silent epidemic and a major global health threat. Chronic hepatitis, if left untreated, can lead to permanent liver damage that can result in the development of liver cancer, liver failure or death. Few therapeutic options currently exist for the treatment of HCV infection. The current standard of care is limited by its specificity for certain types of HCV, significant side-effect profile, and injectable route of administration.

About Achillion Pharmaceuticals

Achillion is an innovative pharmaceutical company dedicated to bringing important new treatments to patients with infectious disease. Achillion's proven discovery and development teams have advanced multiple product candidates with novel mechanisms of action. Achillion is focused on solutions for the most challenging problems in infectious disease including HCV and resistant bacterial infections. For more information on Achillion Pharmaceuticals, please visit www.achillion.com or call 1-203-624-7000 begin_of_the_skype_highlighting 1-203-624-7000 end_of_the_skype_highlighting.

Forward-Looking Statements

This press release includes forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 that are subject to risks, uncertainties and other important factors that could cause actual results to differ materially from those indicated by such forward-looking statements, including statements with respect to the favorable activity and potential benefits of ACH-3102 and sovaprevir, and expectations about milestone achievement including the potential to report RVR results during the fourth quarter of 2012. Among the factors that could cause actual results to differ materially from those indicated by such forward-looking statements are risks relating to, among other things, Achillion's ability to: replicate in later clinical trials the positive results found in nonclinical studies and earlier stage clinical studies of sovaprevir, ACH-2684, and ACH-3102; advance the development of its drug candidates under the timelines it anticipates in current and future clinical trials; obtain necessary regulatory approvals; obtain patent protection for its drug candidates and the freedom to operate under third party intellectual property; establish commercial manufacturing arrangements; identify, enter into and maintain collaboration agreements with appropriate third-parties; compete successfully with other companies that are seeking to develop improved therapies for the treatment of HCV; manage expenses; and raise the substantial additional capital needed to achieve its business objectives. These and other risks are described in the reports filed by Achillion with the U.S. Securities and Exchange Commission, including its Annual Report on Form 10-K for the fiscal year ended December 31, 2011 and its subsequent SEC filings.

In addition, any forward-looking statement in this press release represents Achillion's views only as of the date of this press release and should not be relied upon as representing its views as of any subsequent date. Achillion disclaims any obligation to update any forward-looking statement, except as required by applicable law.

Source

Hepatitis C genotype 1a replicon improved through introduction of fitness mutations

Christian Voitenleitner¹, Jill Bechtel¹, Ann Arfsten², and Robert Hamatake¹

¹GlaxoSmithKline, Research Triangle Park, NC, USA
²InterMune, Brisbane, CA, USA

BioTechniques, Vol. 52, No. 4, April 2012, pp. 273–275

 Full Text (PDF)

Hepatitis C virus (HCV) is a plus-strand RNA virus in the Flaviviridae family with replication restricted to hepatocytes of humans and chimpanzees. HCV infects more than 3% of the world population, leading to increased risk of liver cirrhosis and hepatocellular carcinoma. The search for HCV model systems has been hampered by the fact that HCV isolates taken from patients replicate poorly, if at all, in in vitro cell culture systems. The first selectable subgenomic replicon capable of replicating autonomously—generated in the laboratory of Ralf Bartenschlager (1)—revealed a series of so called adaptive mutations that allow this construct to replicate in tissue culture (2-4). These subgenomic HCV replicons have proven to be powerful tools for studying viral replication or performing drug screening, and additional mutations have been reported that enhance the fitness of stable genotype 1a systems (5). Given the error prone nature of the RNA-dependent RNA polymerase NS5B, resistance to direct acting antivirals develops rapidly necessitating the ability to screen a compound against a panel of resistant replicons during drug development. Since keeping stable replicon cell lines of all these mutant replicon systems is prohibitive, mutant replicons are often used in transient assays rather than in stable cell lines. In transient assays, the hepatoma cell line Huh7-Lunet (6) is electroporated with in vitro transcribed HCV RNA that contains a luciferase reporter. The transfected cells are transferred onto 96-well plates containing compounds of interest in a dilution series. Luciferase activity is measured after 72 h to establish EC₅₀ values of compounds against certain replicons (Figure 1A). The genotype 1a-H77 subgenomic replicon (7), which contains a luciferase/neomycin (neo) reporter cassette as well as the structural proteins NS3 through NS5B and two adaptive mutations in NS3/4A and NS5A, P1496L and S2204I, respectively, has very low luciferase levels after 72 h resulting in a low signal to noise ratio (Figure 2A).

Figure 1. Schematic of transient transfections. (Click to enlarge)

Figure 2. The 1a-fit replicon shows enhanced fitness in transient assays. (Click to enlarge)

This low signal makes it difficult to obtain robust data on the potency of compounds against the 1a-H77 replicons, especially those resistance mutant replicons exhibiting even further diminished replication capacity.

In order to quickly evaluate lead compounds against our large panel of resistance mutations, we needed to create a system with a quick luciferase reporter readout that had a robust signal to noise ratio at the assay readout time of 72 h. An additional advantage of a transient system is that there is no additional accumulation of mutations as can happen in a stable cell line propagated for several cell division cycles. In order to achieve this goal, we started with a replicon system that originated from a resistance screen with an HCV inhibitor targeting NS4B and revealed a mutation in NS4B, E1726G, which conferred fitness to the 1a-H77 replicon. Replicons carrying this mutation manifested higher luciferase units at the 72 h time point of a transient transfection (Figure 2A), yet did not impact the activity of HCV inhibitors to various targets (Figure 2C). Furthermore, a publication from Stan Lemon's laboratory reported several mutations that enhanced replication of the 1a-H77 replicon (8). We chose the mutation in the NS4A gene, K1691R, for minimal interference with our compound targets, while still displaying increased fitness in the 1a replicon. In an effort to further improve the luciferase signal resulting from transient transfection of the 1a-H77 replicon, we introduced both mutations into the 1a-H77 subgenomic replicon. Site-directed mutagenesis using the Quikchange Kit from Stratagene resulted in the 1a-fit (1a-H77-K1691R/ E1726G) replicon (Figure 1B).

In order to assess and compare the robustness of these replicons, we performed a transient transfection, followed by a time course up to the assay readout time of 72 h (Figure 2A). After the initial burst of luminescence at 4 h, which stems from translation of the luciferase gene from the transfected RNA rather than replicated RNA, we saw an initial decline in all samples, which indicated the lag until proteins from the replicated RNA begin to be made. At 48 h, 1a-E1726G showed higher signal than 1a-H77; this difference continued through the 72 h time point. The 1a-fit vector consistently showed the highest luminescence, with a 10-fold higher readout than the 1a-E1726G and a hundred-fold higher readout than 1a-wt at 72 h. Some mutations obtained from resistance screens and introduced into the replicon system are known to reduce replicon fitness significantly. One example is the NS5B site IV mutation in 1a, C316Y, which has only 7% replication capacity compared with 1a-wildtype (9). We tested this mutant replicon and showed that, although replication fitness is still impaired relative to wildtype, the luciferase units of 1a-fit-C316Y after 72 h are high enough (>300,000 RLU) to give a robust signal to noise ratio (Figure 2B). This signal represents a vast improvement when compared with the signal of C316Y in the original 1a-H77, which ranged from about 1500 to 3000 RLU.

To verify that the two newly introduced mutations had no effect on compound potency of HCV inhibitors hitting various targets, we tested and compared a series of inhibitors against the 1a-H77, the 1a-E1726G and the 1a-fit replicons (Figure 2C). When tested against a variety of compounds targeting protease, NS4B, NS5A, and various sites of NS5B, the 1a-fit replicon resulted in the same compound potency as the 1a-H77 or the 1a-E1726G replicon, suggesting that neither of these two newly introduced mutations altered compound potencies, but were merely conferring fitness to the replicon.

In summary, we have shown that introducing two mutations in NS4A and NS5B, respectively, could enhance replication fitness and increased the signal to noise ratio about 100-fold compared with the 1a-H77 replicon, resulting in more robust data for HCV inhibitors. This newly described replicon construct provides a quick reporter gene response through its Luciferase readout, as well as a robust signal for reliable determination of compound potencies. Because of the relative ease of introduction of mutations into the replicon, this system can be used to quickly profile a large number of compounds on a panel of resistance mutations against various HCV targets.

Acknowledgments

The authors would like to thank Ermias Woldu at GlaxoSmithKline for his technical assistance.

Competing interests

The authors declare no competing interests.

Correspondence
Address correspondence to Christian Voitenleitner, GlaxoSmithKline, 5 Moore Drive HCV DPU, N3.3235C, Research Triangle Park, NC, USA. Email: christian.a.voitenleitner@gsk.com

References

1.) Lohmann, V., F. Korner, J. Koch, U. Herian, L. Theilmann, and R. Bartenschlager. 1999. Replication of subgenomic hepatitis C virus RNAs in a hepatoma cell line. Science 285:110-113.

2.) Krieger, N., V. Lohmann, and R. Bartenschlager. 2001. Enhancement of hepatitis C virus RNA replication by cell culture-adaptive mutations. J. Virol. 75:4614-4624.

3.) Lohmann, V., F. Korner, A. Dobierzewska, and R. Bartenschlager. 2001. Mutations in hepatitis C virus RNAs conferring cell culture adaptation. J. Virol. 75:1437-1449.

4.) Lohmann, V., S. Hoffmann, U. Herian, F. Penin, and R. Bartenschlager. 2003. Viral and cellular determinants of hepatitis C virus RNA replication in cell culture. J. Virol. 77:3007-3019.

5.) Robinson, M., H. Yang, S.C. Sun, B. Peng, Y. Tian, N. Pagratis, A.E. Greenstein, and W.E. Delaney. 2010. Novel hepatitis C virus reporter replicon cell lines enable efficient antiviral screening against genotype 1a. Antimicrob. Agents Chemother. 54:3099-3106.

6.) Blight, K.J., J.A. McKeating, and C.M. Rice. 2002. Highly permissive cell lines for subgenomic and genomic hepatitis C virus RNA replication. J. Virol. 76:13001-13014.

7.) Blight, K.J., J.A. McKeating, J. Marcotrigiano, and C.M. Rice. 2003. Efficient replication of hepatitis C virus genotype 1a RNAs in cell culture. J. Virol. 77:3181-3190.

8.) Yi, M., and S.M. Lemon. 2004. Adaptive mutations producing efficient replication of genotype 1a hepatitis C virus RNA in normal Huh7 cells. J. Virol. 78:7904-7915.

9.) McCown, M.F., S. Rajyaguru, S. Kular, N. Cammack, and I. Najera. 2009. GT-1a or GT-1b subtype-specific resistance profiles for hepatitis C virus inhibitors telaprevir and HCV-796. Antimicrob. Agents Chemother. 53:2129-2132.

10.) van den Hoff, M.J., A.F. Moorman, and W.H. Lamers. 1992. Electroporation in ‘intracellular’ buffer increases cell survival. Nucleic Acids Res. 20:2902.

Source

Differences in virological response to peginterferon-[alpha] plus ribavirin in HIV-positive patients coinfected with HCV subtypes 1a or 1b

JAIDS Journal of Acquired Immune Deficiency Syndromes:

POST ACCEPTANCE, 22 February 2012

doi: 10.1097/QAI.0b013e31824f5506

Original Article: PDF Only

Rallón, Norma I.; Pineda, Juan A.; Soriano, Vincent; Neukam, Karin; Vispo, Eugenia; Rivero, Antonio; Labarga, Pablo; Caruz, Antonio; Restrepo, Clara; Camacho, Angela; Barreiro, Pablo; Benito, Jose M.

Abstract

Background: Both viral and host factors influence response to peginterferon-[alpha] plus ribavirin (pegIFN[alpha]/RBV) in patients with chronic hepatitis C. The impact of these variables is more pronounced in HIV/HCV-coinfected individuals, in whom treatment response rates are lower.

Methods: Virological responses at multiple time points were assessed in all HIV/HCV-coinfected patients that completed a first course of pegIFN[alpha]/RBV. Viral responses were stratified by HCV geno/subtypes and IL28B rs12979860 variants.

Results: A total of 331 HIV/HCV-coinfected patients were analyzed. HCV geno/subtype distribution was as follows: HCV-1a in 97, HCV-1b in 62, HCV-3 in 122 and HCV-4 in 50. Age, gender, CD4 counts, plasma HIV-RNA and liver fibrosis stage did not differ significantly across HCV geno/subtypes. In contrast, mean serum HCV-RNA was greater in HCV-1a compared to the rest (p<0.0001). The proportion of IL28B CC variants was higher in HCV-3 compared to the rest (p=0.001).

Virological responses were better in HCV-1b than HCV-1a at any given time point during therapy. IL28B variants significantly influenced virological responses across all HCV-1 subtypes, with the strongest effect seen in HCV-1a. In a multivariate linear regression analysis, both HCV-1b and IL28B CC variants were significantly associated with greater HCV-RNA drops at weeks 4 (R=0.52, p<0.0001) and 12 (R=0.49, p<0.0001) of therapy.

Conclusion: The response to pegIFN[alpha]/RBV therapy is lower in HCV-1a than HCV-1b in HIV/HCV-coinfected patients. The strongest influence of IL28B variants is seen in HCV-1a. This information may be relevant when using most directly acting antivirals in coinfected patients along with pegIFN[alpha]/RBV, given that selection of drug resistance occurs more frequently in HCV-1a than HCV-1b.

Source

AASLD: Genotype 1b vs 1a and Peg/Rbv Lead-In

by Jules Levin, NATAP

The phase 3 presentations at the recent AASLD did not address the genotype 1a vs 1b question, difference in SVR rates but here is data from phase 2. In studies at AASLD and other previous studies examining oral HCV drug regimens that did not contain peg/rbv genotype 1a often is associated with the development of more drug resistance and higher viral failure rates. A more potent regimen and the use of a nucleoside or nucleotide in the regimen would be expected to help, but what's the affect of adding peg/rbv to 1 oral, either boceprevir or telaprevir. Phase 3 presentations of both drugs at AASLD did not address this but here is what I found from phase 2 data.

from Lancet Aug 2010 SPRINT1 publication:

Efficacy of boceprevir, an NS3 protease inhibitor, in combination ...
Aug 9, 2010 ... The aim of the hepatitis C virus SPRINT-1 (Serine Protease Inhibitor Therapy-1) study was to establish the safety and efficacy of boceprevir ...
www.natap.org/2010/HCV/080910_01.htm

In the boceprevir groups, the lead-in groups were associated with a modestly lower rate of breakthrough than were the groups with no lead in. Combining across treatment groups, the rate of breakthrough in the boceprevir lead-in groups was 4% (nine of 206) compared with 9% (19/210) in the boceprevir groups with no lead in (p=0·057).

The lead-in (PR4) allowed us to examine the relation of peginterferon and ribavirin responsiveness at week 4 to SVR with boceprevir-containing regimens. In the PR4 28-week or 48-week groups, SVR was similar in participants with greater than 1·5 log10 reduction in hepatitis C virus RNA from baseline before the addition of boceprevir. Higher SVR was noted in participants who received PRB for 44 weeks with less than 1·5 log10 reduction from baseline at PR4 (figure 5). In patients with less than 1 log10 reduction with PR4, 55% (95% CI 32-76) SVR was noted in the PR4/PRB44 group.

The viral response during the lead-in could help to predict best possible treatment duration. Patients achieving less than 1·5 log10 reduction in viral level after PR4 benefit most from a treatment duration of 48 weeks, whereas those with greater than 1·5 log10 reduction show similar SVR irrespective of treatment duration of 28 weeks or 48 weeks.

The lead-in can identify null responders to peginterferon alfa-2b and ribavirin, who seem to be at greatest risk for treatment failure with specifically targeted therapies and for development of resistance. However, in our cohort, a substantial proportion of null responders during the lead-in period went on to achieve SVR with the addition of boceprevir.16, 27

This study assessed the use of a PR4 lead-in before the addition of boceprevir, as well as the effect of starting all three drugs concomitantly, and compared these groups with PR48 control. In the novel lead-in approach, we recorded increased SVR and a reduction in relapse and breakthrough, and allowed for potential determination of treatment duration on the basis of responsiveness to the PR4 lead-in. However, in the direct comparison between lead-in and non-lead-in groups, relapse reduction did not differ significantly, although the absence of a statistically conclusive result is not surprising since the sample size did not allow detection of modest diff erences between lead-in and non-lead-in groups.

Table 4: Factors aff ecting sustained virological relapse (genotype 1b predicts better respons ethan 1a, but clearly 1a responds.)

PR4 (lead-in)=peginterferon alfa-2b 1·5 µg/kg plus ribavirin 800-1400 mg per day for 4 weeks. PR48 (control)=peginterferon alfa-2b 1·5 µg/kg plus ribavirin 800-1400 mg per day for 48 weeks. PRB24/28/44/48=peginterferon alfa-2b, ribavirin, and boceprevir 800 mg three times a day for 24, 28, 44, or 48 weeks. OR=odds ratio. SVR=sustained virological response. HCV=hepatitis C virus. *For each baseline subgroup, the odds ratio and 95% CI for treatment eff ect (PR4/PRB44 vs PR48) are based on logistic regression model with adjustment for stratification factors (race and cirrhosis status). Significant predictor of SVR based on multivariable logistic regression analysis (all boceprevir-containing groups combined): race (non-black vs black; OR 2·7, 95% CI 1·49-5·04); genotype (1b vs 1a/other; 2·0, 1·22-3·32); baseline viral load (low vs high; 2·3, 1·04-5·12); and standardised baseline platelet count (continuous; 0·8, 0·61-0·94). Viral genotype was measured with the TruGene assay (Bayer HealthCare, Berkeley, CA, USA). §Analyses of the relations between SVR and hepatitis C virus genotype, fasting glucose, and baseline platelet count were not preplanned. Baseline platelet count included in multivariable logistic regression analysis as a continuous variable, standardised by transforming each patient's count as: (count-overall mean)/(overall SD). SVR rates are provided as descriptive statistics for platelet count intervals based on mean and SD: 169·5=1 SD below mean; 237·4=mean; 305·4=1 SD above mean. Data are number (%) for pooled boceprevir groups.

Telaprevir PROVE 2 publication NEJM April 30 2009:
Independent Predictors of Sustained Virologic Response
The association between a sustained virologic re- sponse and independent variables was explored with the use of a logistic-regression model. Treat- ment group and baseline HCV RNA level were the only two variables significantly associated with a sustained virologic response (P<0.001) (Table 1 in the Supplementary Appendix, available with the full text of this article at NEJM.org).

PROVE1
The viral population at the time of breakthrough consisted predominantly of variants containing mutations V36M and R155K (in 10 patients infected with HCV genotype 1a) or A156T (in 1 patient with HCV genotype 1b). The remaining patient had missed several days of dosing and had a breakthrough at day 8; this patient was infected with predominantly wild-type virus.

In PROVE2 (genotype 1b was not a significant predictor but a nonsignificant predictor):
Supplementary Table 1. Independent predictors of an SVR in multivariate analysis of baseline parameters. The following baseline variables were included in the analysis: gender, age (less or more than 45 years), BMI, baseline HCV RNA level (less or more than 800,000 IU/mL), genotype 1 subtype (1a vs 1b), ALT level, glucose level and treatment arm. Variables with a weak association (P>0.20) with the SVR in the initial logistic regression model were excluded from the final model. 95% CI: 95% confidence interval.

Source

Evidence for separation of HCV subtype 1a into two distinct clades

Journal of Viral Hepatitis

Early View (Articles online in advance of print)
Published Online: 21 Jun 2010
© 2010 Blackwell Publishing Ltd

B. E. Pickett 1 , R. Striker 2,3 and E. J. Lefkowitz 1
1 Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA ; 2 W. S. Middleton Memorial Veterans Administration Hospital, Madison, WI, USA; and 3 Departments of Medicine and Medical Microbiology & Immunology, University of Wisconsin, Madison, WI, USA

Correspondence to Elliot Lefkowitz, BBRB 276/11, 1530 3rd Ave S, Birmingham, AL 35294-2170, USA. E-mail: elliotl@uab.edu

KEYWORDS
bioinformatics • drug resistance • hepatitis C virus • phylogeny • selection pressure

ABSTRACT
Summary. The nucleotide sequence diversity present among hepatitis C virus (HCV) isolates allows rapid adjustment to exterior forces including host immunity and drug therapy. This viral response reflects a combination of a high rate of replication together with an error-prone RNA-dependent RNA polymerase, providing for the selection and proliferation of the viruses with the highest fitness. We examined HCV subtype 1a whole-genome sequences to identify positions contributing to genotypic and phenotypic diversity. Phylogenetic tree reconstructions showed two distinct clades existing within the 1a subtype with each clade having a star-like tree topology and lacking definite correlation between time or place of isolation and phylogeny. Identification of significant phylogenetically informative sites at the nucleotide level revealed positions not only contributing to clade differentiation, but which are located at or proximal to codons associated with resistance to protease inhibitors (NS3 Q41) or polymerase inhibitors (NS5B S368). Synonymous/nonsynonymous substitution mutation analyses revealed that the majority of nucleotide mutations yielded synonymous amino acids, indicating the presence of purifying selection pressure across the polyprotein with pockets of positive selection also being detected. Despite evidence for divergence at several loci, certain 1a characteristics were preserved including the length of the alternative reading frame/F protein (ARF/F) gene, and a subtype 1a-specific phosphorylation site in NS5A (S349). Our analysis suggests that there may be strain-specific differences in the development of antiviral resistance to viruses infecting patients who are dependent on the genetic variation separating these two clades.

Received January 2010; accepted for publication April 2010

DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1365-2893.2010.01342.x About DOI
 
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