58th Annual Meeting of the American Association for the Study of Liver Diseases Boston, MA November 2-6, 2007.

58th Annual Meeting of the American Association for the

Study of Liver Diseases

Boston, MA

November 2-6, 2007

Epidemiology and Natural History of HBV Infection

Douglas Dieterich MD

Mount Sinai School of Medicine

New York, NY

How Old is HBV?

▬ HBV associated with humans for >1,000 years but no definitive evidence

▬ Recent evidence establishes ≥500 years

▬ Naturally mummified body of a Korean child found virtually intact

▬ Laparoscopy: Large organ in RUQ and biopsies sent for pathology and HBV DNA testing- HBV DNA genotype C isolated

from the liver- Pathology: Appeared to be normal liver

Klein A, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 925.

7 Taiwanese townships aged 30–65 years

(n=89,293)

Baseline HBsAg+(n=9800)

Baseline HBV DNA(n=3851)

Follow-up analysisfor cirrhosis/HCC

(n=3774)

Viral Load Predicts Disease Progression:The REVEAL Study

Risk Evaluation of Viremia Elevation & Associated Liver Disease

Prospective, multicenter, observational cohort study

Chen CJ. JAMA. 2006;295:65-73.

1991-19921991-1992RecruitmentRecruitment

June 2004: June 2004: 43,993 PYs follow-up43,993 PYs follow-up

• 24% PCR neg

• 85% HBeAg(-)

• 94% ALT<45 IU/L

• 98% non-cirrhotic

(on Ultrasound)

Effect of Chronic Elevations of HBV DNA Level on HCC Risk

▬ Impact of increasing HBV DNA levels was assessed - Subset with HBV DNA ≥104 c/mL, no cirrhosis, anti-HCV negative

▬ 71 new cases of HCC (n=1,289; 15,508 PY)- 69% males

▬ Risk of HCC was strongly associated with increasingHBV DNA level in a dose dependent fashion:

Chen C, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 920.

REVEAL Study

HBV DNA (Copies/mL) Hazards Ratio (95% CI)

<300 Referrant*

300-9,999 6.1 (0.8 – 48.2)*

10,000 – 99,999 6.2 (0.8 – 48.4)*

100,000 – 999,999 7.7 (1 – 60.8)*

>1 million 13.1 (1.7 – 99.6)**P value for trend <0.001

Changes in HBV DNA Using a Trajectory Model Increased HCC Risk

Chen C, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 906; Iloeje U, et al. Ibid. Poster 907.

Cumulative Incidence of HCC by HBV DNA Trajectory Classes

Cumulative Incidence of HCC by HBV DNA Trajectory Classes

Year of Follow-upYear of Follow-up

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0 1 2 3 4 5 6 7 8 9 10 11 12

0.09

13

Reference Group: HBV DNA < 104 at enrollment

Class I: Medium to Low

Class II: Medium to Medium

Class III: High to High

Class IV: Persistently Very High

Reference Group: HBV DNA < 104 at enrollment

Class I: Medium to Low

Class II: Medium to Medium

Class III: High to High

Class IV: Persistently Very High

Cu

mu

lativ

e I

nci

de

nce

of

HC

CC

um

ula

tive

In

cid

en

ce o

f H

CC

▬ Compared to HBsAg (-) patients:

▬ Increasing HBV from one level to another was also a risk for HCC

HBV DNA (c/mL)

HRHR

Trajectory

<300 3.0 --

300-9,999 3.3 0.7

10,000-99,999

14 2.6

100,000-999,999

32 8.5

>1 million 30.2 10

HBV DNA Levels Predict HCC Recurrence After RFA

▬ 66 pts with HBV and HCC were treated with RFA*▬ Recurrence rates on follow up (mean 3.2 year):

- One year 30%- Two year 60%- Three year 74.3%

▬ Multivariate Analysis for risk of recurrence

Risk Factor Risk ratio (95% CI, p value) Platelet count (<150,000/mm3) 3.74 (1.56-8.97, 0.003)

HBV DNA level (≥10,000 c/mL) 2.87 (1.16-7.09, 0.023)

Goto T, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 917.

*Radio-Frequency Ablation

Serial HBV Measurements Predict Disease Progression

▬ Study from Thrace, Greece evaluated risk factors for CHB disease progression▬ 257 CHB pts enrolled: 14 HBeAg(+), 243 HBeAg(-)

- F/U 12.5 years (mean)- Viral markers, liver biochemistry and PE every 6 mos.- Liver Bx and abdominal U/S every 2-4 years

▬ 27% of HBeAg(-) pts intermittently had HBV DNA <104

- Serial measurements are necessary to find real HBV DNA levels▬ Multivariate Odds Ratio (OR) of fibrosis risk:

Zacharakis G, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 898.

HR 95% CI P value

HBV DNA(>104 vs <104 c/mL

604.865 67.233-999.999 <0.0001

ALT(<40 vs >40 IU)

0.002 <0.001-0.015 <0.0001

Age(<40 vs >40 yrs)

0.057 0.006-0.519 0.011

Significant Liver Disease in Asymptomatic Patients

▬ 105 treatment-naïve patients with CHB- HBV DNA > 105 c/ml, ALT ≤ 2x ULN x 12 mos, mean age 37 years

▬ Significant fibrosis in 60% and histology in 66%▬ Compared to patients < 20 years of age:

▬ Conclusion: A large portion of patients with ALT< 2x ULN have significant fibrosis on liver biopsy

Park JY, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 942.

Age (years) Odds Ratio (95% CI)

20-29 7.1 (1.4-36.9)

30-39 14.2 (2.1-94.2)

40-49 24.4 (4.2-141.3)

>50 38.8 (4.0-309.8)

R is k o f F ib ro s is b y A L T L evel

19.8

43.5

0

10

20

30

40

50

P ercent

0 - 0.75 x ULN 0.75 - 1 x ULN

Significant Histological Findings in Patients with Normal ALT

▬ Study comparing liver histology in CHB pts with persistently normal (n=139) and abnormal (n=135) ALT

▬ Normal ALT group: 24% significant fibrosis, 9.4% cirrhosis

▬ Within normal ALT range, fibrosis rate higher in pts with higher ALT

▬ Age >40 years significant risk for fibrosis

▬ No correlation with HBeAg status or HBV DNA level

Gui H, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 936.

Pat

ient

Per

cent

P=0.029

HBeAg Seroconversion is a Poor Clinical Endpoint

▬ 298 patients with documented HBeAg seroconversion- 116 treatment-induced, 182 spontaneous

▬ Reactivation in 71 patients (39%)- Older age, male gender and higher ALT at seroconversion were risks

for reactivation (all p<0.006)- No difference between IFN, ADV, LAM treatment

▬ Treatment induced seroconversion less durable than spontaneous- Remission of ALT shorter (14 vs 22 mos., p=0.037)- More likely to have HBeAg reactivation at 48 mos. (38% vs 25%,

p=0.048)

Lim, GL et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 937.

Longitudinal Study of HBsAg Seroclearance

▬ 298 patients with HBsAg clearance- 71% male, med. age 43.1

- Med. F/U 36 mos after HBsAg clearance

▬ 29 liver biopsies: 44% anti-HBs(+) - 100% detectable HBV DNA

- 79% cccDNA

▬ 7 pts with HCC and 9 with liver decompensation- ↑risk with age ≥50 at HBeAg

seroconversion for HCC and significant fibrosis (p=0.001)

Wong, D et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 900.

Cum

ulat

ive

Ris

k of

HC

C (

%)

Cum

ulat

ive

Ris

k of

HC

C (

%)

20

15

10

5

0

0 12 24 26 48 60 72 84 96 108 120

* p = 0.004

HBsAg seroclearance at age ≥ 50*

HBsAg seroclearance at age < 50*

Follow-up (month)Follow-up (month)Age of HBsAgseroclearanceAge of HBsAgseroclearance

No. ofpatients

at risk

No. ofpatients

at risk 147 120 86 63 51 46 38 31 24 18 12≥50

151 124 102 87 71 56 47 37 21 15 10<50

HBV and Gender

▬ Longitudinal study to assess gender and natural course of HBeAg(+) CHB (1977-1998)- 454 males, 110 females- Mean F/U 12 yrs

▬ No differences in:- Hepatitis B flares - Spontaneous HBeAg seroconversion

▬ ↑Risk persistent ALT elevation in males (47% vs. 15%, p<0.0001)- May be cause of faster progression to cirrhosis

Lin E, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 928.

Liver Transplants for HBV Declining

▬ All LTx candidates newly registered to the Organ Procurement and Transplantation Network (UNOS) (1985-2006)

▬ Unique individual patient for primary LTx ▬ All diagnostic information used to identify patients

with HBV or HCV:- Diagnostic codes and written-in diagnosis - Laboratory data

- HBsAg, HBV-DNA, anti-HCV, HCV-RNA

Kim WR, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 12.

Therapeutic Strategies for HBV Treatment

Emmet Keeffe MD

Stanford University School of Medicine

Palo Alto, CA

Effect of Lamivudine and Adefovir on Development of HCC

▬ Evaluation of LAM and ADV effect on HCC in pts with HBV-related cirrhosis

▬ Retrospective study: 111 pts on oral antiviral and 111 untreated pts randomly selected and matched according to age, gender, Child-Pugh class A, and HBeAg(+)

Eun J, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 961.

LAM LAM

LAMContinued(n=590)

LAMswitched(n=284)

Treat(n=111)

Untreated

(n=1592)

Control (n=111)

Baseline Characteristics

Treated Group (n=111)

Control Group(n=111) p-values

Clinical Data

Age (years) 42.8 ± 8.4 43.1 ± 9.8 NS

Sex (M/F), n (%) 78/33 (70.3/29.7) 78/33 (66.1/33.9) NS*

Family history, yes (%) 63 (56.8) 64 (57.7) NS*

Interferon history, n (%) 20 (18.0) 20 (18.0) NS*

Laboratory data

AST (IU/L) 137 ± 145 103 ± 120 0.061

ALT (IU/L) 159 ± 176 127 ± 182 NS

Total bilirubin (mg/dL) 1.1 ± 0.6 1.1 ± 0.6 NS

Albumin (g/dL) 4.0 ± 0.4 3.8 ± 0.5 0.007

Platelet (x10³/mm³) 113 ± 28 104 ± 35 0.045

HBV DNA (pg/mL) 1183.1 ± 2473.3 346.3 ± 833.0 0.005

Follow-up period (years) 4.4 ± 2.2 5.4 ± 4.1 <0.001

HCC, n 5 36

Age at diagnosis 54.2 ± 6.4 53.8 ± 10.0 NS


Cumulative Incidence of HCC

Control (32.4%) (n=104)

40

0 5 10 15 20

Cum

ulat

ive

Inci

denc

e of

H

CC

(%

)

Years Elapsed

Log-rank, p<0.003

20

0

Treated (4.5%) (n=111)

Conclusion: Oral antiviral agents, such as LAM and ADV, may reduce the incidence of HCC in patients with HBV-related liver cirrhosis


Entecavir Therapy in HBeAg(+) CHB

ETVN=354

Responders [R]HBV DNA <0.7 MEq/mL by bDNA and HBeAg loss

Virologic Responders [VR]HBV DNA <0.7 MEq/mL by bDNA and HBeAg(+)

Non-responders [NR]HBV DNA ≥0.7 MEq/mL by bDNA

NR=19

VR=247

R=74

Week 48

21 Non-respondersAt Week 48 or who became non-responders during Year 2

151 Virologic RespondersAt Week 96

11 RespondersAt Week 48 or who became responders during Year 2 who relapsed during off-treatment follow-up

Week 144

ETV-022 ETV-901

Week 96 Week 192

NR=8

VR=198

R=37

243

Study DesignStudy Design

Han S, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 938.


HBeAg(+) ETV 4-Yr Cohort

(N=146)

Age, mean (years) 36

Male (%) 80

Race:

Asian (%) 64

Non-Asian (%) 36

HBV DNA by PCR, mean (log10 copies/mL) 9.91

ALT, mean (U/L) 122

413

26

2730

Nucleoside-naïve HBeAg(+) ETV 4 year Treatment Cohort


ABCDOther

HBV Genotype (%)

ETV-022 and ETV-901

Outcomes and Conclusions

▬ 91% nucleoside-naïve HBeAg(+) on ETV for 4 years had undetectable HBV DNA

▬ 86% maintenance of normal ALT levels

▬ Additional patients in year 3 and 4 had HBeAg loss and HBeAg seroconversion

▬ Only one patient developed resistance

Endpoint Week 192*

HBV DNA <300 copies/mL 98/108 (91%)

ALT ≤ 1 x ULN 96/112 (86%)

HBeAg Loss** 39/96 (41%)

HBeAg seroconversion** 15/96 (16%)


* Denominator represent patients with available samples** Numbers/proportions represent additional patients achievingHBeAg loss or HBeAg seroconversion during treatment in ETV-901

ETV-022 and ETV-901

Long-term Follow-up on ETV Nonresponders

ETV

NR

VR

R

Week 48

Non-responders 30

Virologic Responders 225

Responders

397

ETV-022 [HBeAg(+)] and ETV-027 [HBeAg(-)] ETV-901

Week 96

NR

VR

R

Cumulative response outcomes

Patients who enrolled in ETV-901

Non-responders 21

Virologic Responders 166

Responders

105

Study DesignStudy Design

Sherman M, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 997.

All Treated (N=354)

Nonresponders(N=146)

Age, mean (years) 35 35

Male (%) 77 81

Race:

Asian (%) 58 38

Non-Asian (%) 42 62

HBV DNA by PCR, mean

(log10 copies/mL)9.62 10.39

ALT, mean (U/L) 140 106

HBV Genotype (%)



Baseline Characteristics of All Treated Patients in ETV-022 vs. Protocol-Defined Nonresponders Who Subsequently Entered ETV-901

27

1931

1013A

B

C

D

Other

48

195

1414

ETV-901: ETV Nonresponders

Long-term Outcomes

EndpointAchieved endpoint in

ETV-901Maintained endpoint at

Last observation

HBV DNA <300 copies/mL 15/21 (71%) 12/21 (57%)

ALT Normalization 20/21 (95%) 13/21 (62%)

HBeAg seroconversion 7/21 (33%) 7/21 (33%)

▬ Four patients experienced a virologic breakthrough; none developed ETV resistance

▬ No patients discontinued due to adverse events



Conclusions

▬ Fewer than 5% of nucleoside-naïve patients treated with ETV in studies ETV-022 and ETV-027 met protocol-defined criteria of “Non-Response”

▬ Most “non-responders” who continued to receive ETV treatment in rollover study ETV-901 achieved HBV DNA <300 copies/mL and ALT normalization

▬ 4 patients experienced virologic breakthrough during treatment in ETV-901; however, genotypic and phenotypic analysis failed to show evidence of ETV resistance

▬ Treatment compliance should be evaluated in patientswith non-response



Telbivudine Therapy:Baseline Variables Predict Outcomes

Entry criteria: • Nucleos(t)ide-naïve patients, aged 16-70, with HBeAg(+) (n=921)

or HBeAg(-) (n=446) CHB and compensated liver disease

• Serum HBV DNA >6 log10 copies/mL

• Serum ALT ≥1.3-10 x ULN• Pretreatment liver biopsy consistent with CHB

Randomization 1:1

Lamivudine (n=687)

Telbivudine (n=680)

0 52 weeks(Primary Endpoint)

104 Weeks(Final Analysis)

Zeuzem S, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 994.

Methods

▬ Baseline variables included in the model- age, body mass index (BMI), serum ALT, Ishak fibrosis

score, serum HBV DNA level, Knodell histologic activity index (HAI) score, gender, and HBV genotype

▬ For analysis of on-treatment predictive factors, patients were categorized according to- serum HBV DNA level at Weeks 12 and 24: PCR-negative; <3 log10

copies/mL; 3-4 log10 copies/mL, and ≥4 log10 copies/mL

- baseline ALT level: <2 x ULN, 2-5 x ULN, and >5 x ULN

▬ For stepwise multiple regression analyses, patients were categorized as HBV DNA PCR-negative or not PCR-negative at Weeks 12 and 24


GLOBE Substudy

GLOBE Substudy

Odds ratio ± 95% CI

ALT normalization BMI (P<0.001)

Week 24 PCR-negative (P<0.001)

Age (P=0.013)

2.69

2.49

1.93

HBeAgseroconversion


Baseline ALT (P=0.001)

2.61

2.80

Serum HBV DNAPCR-negative


5.66

Baseline HBV DNA (P=0.015)

Baseline ALT (P=0.005)

BMI (P=0.021)

2.00

2.00

1.73

Resistance


Age (P<0.001)

Gender (P=0.028)

0.16

0.40

0.49

0 1 2 3 4 5 6 7 8 9 10 11

ALT normalization

Week 24 PCR-negative (P=0.002)

Age (P=0.004)

3.98

3.74

BMI (P=0.010)

Serum HBV DNAPCR-negative

Week 24 PCR-negative (P<0.001)9.76

3.79

24.4

Resistance

0.06

0.10

0.23

0.23


Baseline Ishak fibrosis score (P=0.002)

BMI (P=0.039)

Age (P=0.047)

Odds ratio ± 95% CI

0 1 2 3 4 5 6 7 8 9 10 11


HBeAg(+) HBeAg(-)

Baseline Variables and On-Treatment (Week 24) Predictors of Week 104 Outcomes

71% of telbivudine treated patients achieved

PCR negativity at Week 24(n=57/80)

Baseline ALT ≥2 x ULN, HBV DNA <9 log10

(n=80)

89% PCR-negative

at Week 104(n=51/57)

52% Seroconversion

at Week 104(n=25/48)

1.8% Resistance at Week 104

(n=1/57)

81%ALT normalat Week 104

(n=46/57)


Globe SubstudyWeek 104 Outcomes With Telbivudine: HBeAg(+)

95% of telbivudine treated patients achieved

PCR negativity at Week 24(n=86/91)

Baseline HBV DNA <7 log10

(n=91)

91% PCR-negative

at Week 104(n=78/86)

2% Resistance at Week 104

(n=2/86)

83% ALT normalat Week 104

(n=57/69)

Week 104 Outcomes With Telbivudine: HBeAg(-)


Globe Substudy

Conclusions

▬ High rates of efficacy and low resistance occurred after 2 years telbivudine treatment in patients with:- HBeAg(+) and elevated ALT and HBV DNA <9 log10 c/mL

- HBeAg(-) and <7 log10 c/mL at baseline

- Optimal viral load reduction at week 24

▬ These parameters may contribute to on-treatment patient management strategies


GLOBE Substudy

Brown C, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 940.

1.00

0.75

0.50

0.25

0

0 100 200 300 400 500 600 700 800

Su

rviv

al D

istr

ibu

tion

Fu

nct

ion

* Grade 1–2 CK elevations are only counted for subjects who did not have Grade 3–4 CK elevation

LdT

LAM

Chronic Telbivudine Therapy: Creatine Kinase Elevations and Muscle Toxicity

▬ FDA review of the telbivudine approval database for CK elevations and adverse event patterns consistent with muscle toxicity- Data reviewed from trials that prospectively measured CK levels and recorded clinical adverse events, and

in which LdT was used in at least one arm- Time to onset and frequency of CK elevations from the pivotal phase 3 trial (52 week data) were assessed

Time-to-Onset (days) of New-Onset CK Elevations (Grade 1-4) in NV-02B-007*

Conclusions

▬ Emerging pattern of a myopathy with chronic telbudine therapy- Unknown if associated with mitochondrial toxicity

▬ Imperfect relationship between the timing and severity of CK elevations and myopathy and variable demography and symptom presentation- Further characterization of toxicity, including mechanism

and predisposing factors, warranted

▬ Myopathy may occur more frequently in the population treated longer-term with telbivudine

Brown C, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 940.

LdT Myopathy

Model for Predicting Sustained HBeAg Loss with Peginterferon Alfa-2b

▬ 233 pts randomized to PEG-IFN α-2b 100 μg ± LAM100 mg for 52 weeks

▬ Univariate logistic regression analysis, followed by backward stepwise selection used to identify predictors of HBeAg loss at 26 weeks- Model based on HBV genotype, serum HBV DNA, ALT, GGT and previous IFN therapy provided an

adequate prediction of PEG-IFN induced HBeAg loss

▬ Nomogram was generated from the logistic regression formula

Buster E, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 1002.

Probability of sustained HBeAg loss:Calculated by drawing a vertical line to the top points axis through each variable. Sum points for each variable and locate on Total score axis. A vertical line is projected from Total score axis to the bottom scale to get predicted probability

Probability of sustained HBeAg loss:Calculated by drawing a vertical line to the top points axis through each variable. Sum points for each variable and locate on Total score axis. A vertical line is projected from Total score axis to the bottom scale to get predicted probability

log it (p) – 3.3861 -42854 *(geno-B) -26463 *(geno-C) -0.4907 * (geno-D) +1.4497 *log ALT -0.8043 * previous IFN -0.3849 *log HBV DNA +1.2644 * log GGT +6.8256 *log ALT *(geno-B) +2.3102 *log ALT *(geno-C) -0.3586 –log ALT *(geno-D).

Chance HBeAg Loss (%)Chance HBeAg Loss (%)

Total ScoreTotal Score

Previous IFNPrevious IFN

HBV DNA (log)HBV DNA (log)

GGT (x ULN)GGT (x ULN)

PointsPoints

ALT

(x

ULN

)by

Gen

otyp

eA

LT (

x U

LN)

by G

enot

ype A

B

C

D

A

B

C

D

55 1010 2020 3030 4040 50506060 7070 8080 9090 9595

00 44 66 222222 88 1212 14141010 1616 20201818

YesYes NoNo

1111 99 881010 77 5566

11 3322 55

n14n14

11 3322 44

11 33 44

11 44

00 22 33 101011 44 66 7755 9988

Cases Demonstrating Use of Nomogram

Point Per Variable:

Total Score

ChanceHBeAg Loss

ALT – Genotype

HBV DNA

GGTPrevious

IFN

Case ITurkish male with genotype D infection, ALT 1.2 x ULN, GVB DNA 8 log10 copies/mL, GGT 0.8 X ULN and previously treated with IFN.

8.3 2.6 0 0 10.9 27%

Case IIChinese female with genotype C infection, ALT 0.9 x ULN, HBV DNA 9.65 Log10 copies/mL, GGT 0.3 x ULN and no previous IFN.

3.6 1.25 0 1.8 6.65 <5%

Case IIIDutch male with genotype A infection, ALT 3.8 x ULN, HBV DNA 9.4 Log10 copies/mL, GGT 2.1 x ULN and no previous IFN.

9.9 1.4 0.9 1.8 14.0 61%

Buster E, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 1002.

Effect of Lamivudine ± Adefovir on Esophageal Varices (EV)

▬ Open-label, prospective cohort study- 123 HBeAg(-), cirrhotic pts on LAM (100 mg/d) ADV

(10 mg/d)

▬ Intensive F/U- LFTs and HBV DNA every 2 mos.- Drug-resistance test, AFP and US scan every 6 mos.- Upper GI endoscopy at baseline and every other year

for pts without EV and every year for pts with EV

▬ Multiple Endpoints Assessed

Iavarone M, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 775.

*median (range)


Age, mean (years) 54 (34-72)

Male, No. 106 (86%)

ALT, IU/L* 56 (19-840)

HBV DNA, log10 cps/mL* 6.0 (3.5-9.3)

Child-Pugh’s Score A 100 (81%)

Esophageal Varics

F0 84 (68%)

F1 32 (26%)

F2 6 (5%)

F3 1 (1%)

CRS 2 ( 2%)

PHG 34 (28%)


Follow-up*


F0N=84

Unchanged75 (89%)

Worsened9 (11%)

Development Rate2.0% X year

Due to decompensation, HCC

F0N=32

Improved16 (50%)

Worsened3 (9%)

Progression Rate2.0% X year

Due to thrombosis, HCC

Unchanged13 (41%)

*Median of 76 mos. (range 11-126 mos.)

EV During 76 Months of LAM±ADV

Changes in Size of EV with LAM±ADV

▬ EV worsened in 3% with long-term HBV suppression with LAM±ADV vs. 25% with LAM+ADV after clinical resistance (p=0.0003)

▬ Overall, yearly rates of development and progression of EV were 2.0 and 2.0, respectively, both lower than expected in cohort of untreated virologic cirrhosis

*HBV-DNA persistently < 3.3 log10 copies/ml on therapy with LAM or LAM+ADV for virological resistance**HBV DNA10 > 6 log and ALT > ULN, confirmed by molecular analysis.


0

20

40

60

80

100RegressionStableProgression (p=0.0003)

Response*N=81

Resistance**N=42

10

30

50

70

90

New Therapies for HBV Treatment

Mark Sulkowski MD

Johns Hopkins School of Medicine

Baltimore, MD

Novel HBV Therapy

▬ HBV replication is closely linked to the life-time risk of disease outcomes (HCC, ESLD)

▬ New treatment paradigm = long-term suppression of HBV replication:- ↓ hepatic inflammation and fibrosis - ↓ risk of hepatic decompensation and/or HCC

▬ Increasing recognition of resistant HBV variants in previously treated persons

▬ Role of new anti-HBV therapies - Tenofovir- Clevudine- α-glalactosylceramide - Combination antiviral therapy

Tenofovir DF is a Nucleotide Analogue Inhibitor of HBV DNA Polymerase

▬ TDF is a nucleotide analogue- Inhibits HIV-1 RNA transcriptase and HBV DNA

polymerase- Obligate chain terminator

▬ TDF shown to have activity in patients mono-infected with HBV and co-infected with HIV/HBV

▬ TDF is approved for the treatment of HIV-1 infection - 1.3 million patient years safety exposure in HIV and 6

years clinical safety data

▬ Two pivotal HBV trials

Study GS-US-174-0103:TDF vs. ADV in HBeAg(+) Pts

Randomized, Double-Blind, Comparison of Tenofovir vs. Adefovir for HBeAg(+) Chronic Hepatitis B▬ Treatment naïve, HBeAg(+),18-69 years of age with compensated liver disease▬ HBV DNA >106 c/mL and ALT ≥ 2x and < 10xULN▬ Knodell Necroinflammatory score ≥ 3▬ HIV, HDV, HCV negative

RA

ND

OM

IZA

TIO

N 2

:1

Tenofovir 300 mg (n =176)

Adefovir 10 mg (n = 90)

Open-label5 Years

Week 240Liver Biopsy

Week 48Liver Biopsy

Pre-treatment Liver Biopsy

Double Blind

Tenofovir 300 mg

Heathcote J, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster LB6.

Primary Endpoint of Complete Response:HBV DNA <400 copies/mL AND Histologic improvement (at least a 2-point reduction in the Knodell necroinflammatory score without worsening in fibrosis)



TDF(N=176)

ADV(N=90)

Mean Age 34 34

Race White Asian

52%36%

51%36%

Male 68% 71%

Mean HBV (log10 c/mL) 8.64 8.88

Mean ALT (U/mL) 142 155

Mean Knodell Necroinflammatory Score 8.3 8.5

Mean Knodell Fibrosis Score 2.1 2.3

Knodell Fibrosis (Score = 4) 20% 21%

Genotype A B C D

24%15%25%32%

21%11%30%35%


GS-US-174-0103

Primary and Secondary Endpoints (ITT)

P<0.001P>0.05 P<0.001

% P

atie

nts

Complete Response Histological Improvement

HBV DNA<400 copies/mL

6774 76

12

68

13

0

10

20

30

40

50

60

70

80

90

100

TDF

ADV


GS-US-174-0103

Mean HBV DNA Change


GS-US-174-0103

P<0.001

Treatment

TDFADV

Me

an

(9

5%

CI)

HB

V D

NA

(L

og

10 C

op

ies/

mL

)

1

2

3

4

5

6

7

8

9

10

Weeks on Study0 4 8 12 16 20 24 28 32 36 40 44 48

176TDF N=176176 173173173 165165165 166166166 160160160 90ADV N= 90 90 88 88 88 85 85 85 84 84 84 84 84 84

LLOQ

Study GS-US-174-0102:TDF vs. ADV in HBeAg(-) Pts

Randomized, Double-Blind, Comparison of Tenofovir vs. Adefovir for HBeAg(-) Chronic Hepatitis B▬ HBeAg(+),18-69 years of age with compensated liver disease▬ HBV DNA >105 c/mL and ALT ≥ 2x and < 10xULN▬ Knodell Necroinflammatory score ≥ 3▬ HIV, HDV, HCV negative▬ LAM Experienced or Naïve

RA

ND

OM

IZA

TIO

N 2

:1

Tenofovir 300 mg (n =250)

Adefovir 10 mg (n = 125)

Open-label5 Years

Week 240Liver Biopsy

Week 48Liver Biopsy

Pre-treatment Liver Biopsy

Double Blind

Tenofovir 300 mg

Marcellin P, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster LB2.




TDF(N=250)

ADV(N=125)

Mean Age (years) 44 43

Race White Asian

64%25%

65%24%

Male 77% 78%

Mean HBV DNA (log10 c/mL) 6.86 6.98

Mean ALT (U/L) 128 164

Mean Knodell Necroinflammatory Score Mean Knodell Fibrosis Score

7.82.3

7.82.4

Knodell Fibrosis Score = 4 (Cirrhosis) 19% 20%

Genotype A B C D

12%9%12%64%

11%14%10%63%


GS-US-174-0102

Primary and Secondary Endpoints

P<0.001P>0.05

P<0.001

% P

atie

nts

(IT

T)

Complete Response

Histological Improvement

HBV DNA<400 copies/mL

71 72

93

49

6963

0

10

20

30

40

50

60

70

80

90

100TDF

ADV


GS-US-174-0102

Mean HBV DNA Change


GS-US-174-0102

P<0.001

LLOQ

Treatment

TDFADV

Me

an

(9

5%

CI)

HB

V D

NA

(L

og

10

Co

pie

s/m

L)

1

2

3

4

5

6

7

8

Weeks on Study

0 4 8 12 16 20 24 28 32 36 40 44 48

250TDF N= 250250 242242242 239239239 242242242 241241241125ADV N= 125125 123123123 121121121 117117117 117117117

Safety and Resistance

▬ Grade 2-4 AEs: No significant differences▬ AEs leading to discontinuation: None drug-related▬ No TDF or ADV subject had a confirmed 0.5 mg

increase in serum creatinine or creatinine clearance < 50 ml/min

▬ Incidence of ALT flare (>10 x ULN and 2 x baseline) was low and similar in the two treatment groups (1.2% vs. 0.8%)

▬ No subject developed mutations associated with TDF resistance


GS-US-174-0102

Tenofovir in Treatment-Experienced Patients

▬ Retrospective Cohort (n=108)- TDF 300 mg/d

▬ Inclusion criteria- Chronic HBV infection,

HBeAg(+) or (-)- Rx naive or experienced

(nucleos(t)ide analogs or interferon-α)

▬ Pts with genotypic resistance to ADV excluded


Age (mean years) 42

Male sex 78%

Cirrhosis 19%

HBeAg(+) 69%

HBV DNA (mean log10 copies/mL) 6.6 (4 - 9.7)

ALT (mean U/L) 154 (10 – 1597)

LAM Experienced 86%

YMDD Mutations 59%

ADV Experienced 77%

Treatment Naive 5.5%

Van Bömmel F, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 83.

TDF in ADV-resistant HBV

▬ In vitro, ADV resistance mutations confer partial resistance to TDF- rtN236T ~ 5-fold decrease and

rtA181T/V ~ 1-fold decrease

▬ 10 HBV monoinfected pts with ADV resistance treated with TDF 300 mg/day

▬ Significant HBV DNA responses:- End of follow-up (17.4 months,

12 – 24), 6 pts < 1000 c/mL and 5 pts < 400 c/mL

- 2 pts added LAM: Both < 400 c/mL

▬ Persistence of ADV resistance variants but no new mutations identified

Van Bömmel F, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 960.

-3.3

-4.4

6 Months 12 months

Median HBV DNA Decline on TDF (log10c/mL)

Clevudine Decreases HBsAg titer

▬ Oral, once daily pyrimidine nucleoside analog (marketed in Korea)- Published reports indicate significant activity against

HBeAg(+) and (-)

▬ 50 Rx naïve patients- Clevudine 30mg/day x 24 weeks followed by 10 mg/day

for 24 weeks- HBsAg and HBV DNA (LOD = 300 copies/mL) followed

Byun KS, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 985.

Clevudine Outcomes

▬ HBV suppression was associated with a significant decrease in HBsAg titer

▬ Clinical significance of reductions in HBsAg is not known- Potential for increased

HBsAg clearance - Limited clinical utility

Byun KS, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 985.

HBV DNA and HBsAg change in pts with HBsAg > 40,000 IU/mL

HBV DNA and HBsAg change in pts with HBsAg > 40,000 IU/mL

-

20,000

40,000

60,000

80,000

100,000

D1 W12 W24 W36 W48

HB

sAg(

IU/m

L)

0

2

4

6

8

HB

V D

NA

(lo

g 10)

HBsAg HBV DNA

α-Galactosylceramide:Ineffective in HBV infection

▬ α-Galactosylceramide (α–GalCer)- Actives NK cells - Immunomodulatory activity via proinflammatory cytokines

(e.g., IL-6)- Inhibits HBV replication in transgenic mice

▬ Randomized controlled trial, 27 patients with CHB- α–GalCer 0.1, 1, 10 µg/kg or placebo via SC injection at

0, 4, 8 weeks

▬ No effect on HBV DNA or serum ALT level▬ Poorly tolerated

ter Borg M, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 1004.

▬ In vitro anti-HBV activity alone or in combination in human hepatoma cell line▬ Additive antiviral effect observed with LdT + TDF and weak synergistic effect with

LdT + ETV

▬ Mutation at position M204 confers resistance to both LdT and ETV ▬ Conclusion: “The use of LdT in combination with ETV is not recommended in the clinic”

In vitro Activity of Telbivudine Plus Tenofovir or Entecavir

Patty A, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 958.

Anti-HEV in vitro activity of (a) LdT and ETV alone and in combination and (b) LdT and TDF alone and in combination

Anti-HEV in vitro activity of (a) LdT and ETV alone and in combination and (b) LdT and TDF alone and in combination

HB

V D

NA

, %

HB

V D

NA

, %

a)a)

Increasing Drug Concentration Increasing Drug Concentration

8080

6060

4040

2020

00

LdT aloneLdT aloneETV aloneETV aloneLdT + ETV 1.25 nMLdT + ETV 1.25 nM100100

b)b)

Increasing Drug Concentration Increasing Drug Concentration

8080

6060

4040

2020

00

LdT aloneLdT aloneTDF aloneTDF aloneLdT + TDF 0.16 µMLdT + TDF 0.16 µM100100

Resistance Issues with HBV Treatment

Yves Benhamou MD

Groupe Hospitalier Pitie-Salpetriere

Paris, France

HBV Resistance Mutations

845 a.a.

Terminalprotein

Spacer Pol/RT RNaseH

A B C ED

YMDDGVGLSPFLLA

I(G) II(F)

LAM Resistance rtL80V/I rtV173L rtM204V/I/SrtL180M

ADV Resistance rtA181T/V rtN236T

rtI233V ??

ETV Resistance rtL180M rtM204V/I

rtT184S/A/I/L rtS202G/C rtM250I/V

LdT Resistance rtL80V/I rtL180M rtM204I L229W/V

Locarnini S, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 1003.

HBV Polymerase Mutations by Treatment

V1

73L

A1

81V

L1

80M

A1

84G

I16

9T

LAM

ETV

LdT

ADV

Resistance Mutations Associated with Viral Breakthrough in Patients on Treatment L

80I

/V

Primary Mutation Compensatory Mutation

A1

81T

S2

02I

M2

04

I

M2

04

V

L2

29W

/V

N2

36T

M2

05

V

Cross resistance

Locarnini S, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 1003.

Cross-resistance To Multiple Antiviral Agents

▬ NRTI have revolutionized the treatment of CHB

▬ Sequential NRTIs can promote the emergence of multi-drug resistant mutants

▬ Case report of HBeAg(-) patient - Poor response to sequential ADV, LAM and ETV- Polymerase substitutions: rtA181T, rtI233V, rtN236T and rtM250L- Cloning established that these encoded on single genome- Multi-drug resistance on phenotype were determined

▬ Mutant HBV clones encoding rtI233V, rtM250L, rtA181T/N236T/M250L and rtA181T/I233V/N236T/M250L were generated by site directed mutagenesis

▬ Virus replication and its inhibition were monitored

Shaw T, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 986.

In Vitro Assessment of Effect of Resistance Mutations

▬ rtA181T/I233V/N236T/M250L- High level resistance to all L-nucleosides: LAM, LdT, Clevudine

and Emtricitabine

- Lower level resistance to ADV and TDF

▬ rtI233V and M250L no significant drug resistance▬ Conclusions:

- Sequential treatment with NRTI promotes multi-drug resistance.

- Combination therapy optimized to individual viral phenotypes could reduce multi-drug resistance.

Relative Sensitivity to L-nucleosides

Relative Sensitivity to Deoxyguanosine Analogs

Relative Sensitivity to Acyclic PurineNucleotide Analogs

Shaw T, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 986.

Ra

tio (

ML

/Wt)

WT

-0.10

1.00

10.00

rtQ33V

LdTLFMAULMVFTC

rtM250L Triple Quad

Ra

tio (

ML

/Wt)

WT

-0.10

1.00

10.00

rtQ33V

ETVFLGDAPDABV

rtM250L Triple Quad

Ra

tio (

ML

/Wt)

WT

-0.10

1.00

10.00

rtQ33V

ADV

TDFANA

rtM250L Triple Quad

HBV Quasispecies From Naïve to Viral Breakthrough

▬ HBV polymerase gene (rt1-rt280) was cloned before and at breakthrough during LAM therapy in 5 CHB patients with LAM failure

▬ Before treatment mutations at the LAM and ADV resistance sites were found▬ At the time of viral breakthrough, LAM resistant mutations were identified in 94%▬ No mutations at rt169, rt181, rt184, rt202, or rt236 were identified▬ Mutations in the polymerase gene of HBV preexist▬ Early detection of drug-resistant mutants before antiviral therapy may prevent treatment failure

Ahn SH, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 912.

L80 V/I T125N W153Q I169T V173L L180M A151V/T M204V/I Q215S

P1 7% 8% 2% 1% 1%

P2 1% 1% 2% 1% 1%

P3 1% 1% 1%

P4 2%

P5 1% 1% ?? / 1% 0% / 2%

P6 2% / 1%

P7 1% 1%

Pre-existing LMV Resistance Mutations at PretreatmentPre-existing LMV Resistance Mutations at Pretreatment

Restores replication in presence of LMV (J Viral Hepat 2006, 13 427)

Increased Resistance to ADV and ETV Over Time

▬ Number of available anti-HBV drugs is increasing ▬ Increasing use of antivirals can affect the frequency of

resistance mutations in the treated population.▬ Emergence of resistance may compromise efficacy of

drugs in the future▬ Large clinical database of HBV polymerase gene sequences

(n=10,800 clinical samples) to assess changes in the prevalence of resistance-associated mutations for LAM, ADV and ETV over a 5-year period (2002-2007)

Kagan RM, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 954.

ADV and ETV Resistance Tracks Prescription Utilization


An

nu

al P

resc

riptio

ns

x 1

00

1,000

800

600

400

200

0

0.8%

0.7%

0.6%

0.5%

0.4%

0.3%

0.2%

0.1%

0.0%Y2005 Y2006 Y2007*

Year

ETV prescriptions Predicted ETV resistance

Pre

dicte

d R

esista

nce

1,600

1,200

800

400

0

4%

3%

2%

1%

0%Y2003 Y2005 Y2007*

Year

ADV prescriptions Predicted ADV resistance

Y2004 Y2006

Frequencies of LAM and ADV Associated Mutations Vary by HBV Genotype

Genotype A

(N=1726)

Genotype B

(n=2898)

Genotype C

(n=3191)

Genotype D

(n=791)P*

LAM

M204V 11% 2.6% 3.7% 3.9% <0.001

M204I 2.5% 2.7% 4.8% 3.4% <0.001

L181M 12% 2.8% 5.8% 5.8% <0.001

ADVA181T 0.8% 0.4% 2.5% 1.1% <0.001

A181V 0.5% 0.4% 1.8% 1.5% <0.001

N236T 0.5% 1.6% 1.2% 1.3% NS

* Chi-square test with 3 d.f. and a Bonferroni correction for 6 comparisons* Chi-square test with 3 d.f. and a Bonferroni correction for 6 comparisons


Conclusions

▬ Prevalence of LAM resistance has declined▬ Prevalence of ADV and ETV resistance has

increased with their utilization▬ Resistance to:

- LAM higher in HBV genotype A- ADV higher in HBV genotype C


Double-Blind Study

Nucleoside Therapy

ETV-047

Naïve

ETV-053

Naïve

ETV-052

LAM refractory

HBV DNA (copies/mL) ≥107,8 ≥105 ≥105

ObjectiveDose-response,

bridgingSafety and efficacy Safety and efficacy

Treatment Group0.01, 0.1, 0.5mg ETV

100mg LAM0.1, 0.5mg ETV 0.5, 1mg ETV

Duration (Weeks) 24 52 52

No. of Patients 137 66 84

Rollover Study (ETV-060)

Open Study ETV-080

Treatment Group 0.5mg 0.5mg 1mg

No. of Patients 134 66 82

Long-Term Emergence of Entecavir Resistance in HBeAg(+) Patients

▬ Study Design: Cumulative resistance assessed in patients from three phase 2 dose ranging studies (n=284) prior to entering an open-label rollover study of ETV (ETV-060)

Kobashi H, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 963.

Genotypic Resistance of ETV in Nucleoside Naïve Patients

▬ 5/167 patients had evidence of genotypic ETVr over 3 year period of treatment

▬ 1/66 patients who received continuous treatment for 3 years of ETV 0.5 mg daily had evidence of ETVr


ETV-047Naïve 103 pts

1 Year(ETV-060)

-2 Year(100w)

-3 Year(148w)

0.01mg: 35pts 0 pts 0 pts 2 pts35 pts

24 weeks



ETV-053Naïve 86 pts


52 weeks


At Approved

Dose0.5mg: 66pts 66 pts 1/66 pts (1.5%)

▬ 29/82 LAM resistant pts had evidence of genotypic ETV resistance over 3 year period of treatment and 21 of them experienced breakthrough

Genotypic Resistance of ETV in LAM Refractory Patients


1 Year(ETV-060)

-2 Year(100w)

-3 Year(148w)

ETV-052LAMr 84 pts

0.5mg* 0 pts 11 pts 6 pts32 pts

52 weeks

1.0mg 0 pts 8 pts 4 pts42 pts

At Approved

DoseCumulative ETVr substitutions

12/42 pts (29%)

0 pts 8 pts 12 pts

1 Year(ETV-060)

~2 Year(100w)

~3 Year(148w)

Total 82 pts

* Approved dose to LAMr patients is 1.0mg daily

LAMr before ETV Emerged ETVr

L180M+M204I/V

(n=15)

T184A (n=9)

S202G (n=3)

T184A+S202G (n=3)M204V

(n=6)

L180M+T184A (n=4)

L180M+S202G (n=2)

ADV in LAM-resistant CHB

▬ Evaluation of ADV in LAM-resistant CHB- 146 HBeAg(+) CHB with

LAM-resistance- Treated with ADV mean

of 25 mos. (12-42)

▬ Response rates and role of primary non-response in prediction of virologic response and resistance evaluated

Park NH, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 983.

Primary non-response: Decrease in HBV DNA < 2 log copies/mL from baseline at week 24 of ADV

100

80

60

40

20

0

0

(%)

P < 0.05

Primary Responder

Primary Non-responder

12 24 36 48Months

Cu

mu

lati

ve R

ate

of

Vir

olo

gic

Res

po

nse

Month %

12 9.9

24 26.6

36 48.3

Primary Responder

Month %

12 2.9

24 7.5

36 12.2


Cumulative rates of virologic response

ADV in LAM-resistant CHB

*Breakthrough: > 1 log10 c/mL increase in HBV DNA from nadir †Primary non-response: Decrease in HBV DNA < 2 log copies/mL from baseline at week 24 of ADV

Park NH, et al. 58th AASLD; Boston, MA; November 2-6, 2007. Poster 983.

Month %

12 2.7

24 11.2

36 24.9

Month %

12 13.2

24 25.1

36 62.4

100

80

60

40

20

0

0

(%)

P < 0.05

Primary Responder


12 24 36 48Months

Cum

ulat

ive

Rat

e of

Viro

logi

c B

reak

thro

ugh Primary Responder Primary Non-responder

Breakthrough* in Primary Non-responders and Responders† During ADV Therapy

58th Annual Meeting of the American Association for the

Study of Liver Diseases

Boston, MA

November 2-6, 2007

58th Annual Meeting of the American Association for the Study of Liver Diseases Boston, MA November 2-6, 2007.

Documents

baseline hbv dnan

chbhbv dna

hbeag pts

vs significant liver

liver histology

liver disease prospective

years significant risk

liver biochemistry