Pawlotzky hcv resistances.pptx du16

HCV Resistance and DAA Treatment Failures

Prof. Jean-Michel Pawlotsky, MD, PhD

National Reference Center for Viral Hepatitis B, C and delta

Department of Virology & INSERM U955

Henri Mondor HospitalUniversity of Paris-Est

Créteil, France

I

HCV Genetic Variability and Mechanisms of Resistance

HCV RNA-DependentRNA Polymerase

• Errors during replication:• frequent• spontaneous• at random positions

• Lack of “proofreading” activity

=> Accumulation of genomic mutations

=> Selection

Properties of HCV RdRp

Mutant Selection

• At the level of populations of infected individuals:

• Genotypes and subtypes

• At the level of an infected individual:• Viral quasispecies

Quasispecies Distributionof Viruses

sensitive

resistant

Mechanisms of Resistance

sensitive

resistant

Drug


sensitive

resistant

Drug

resistant


sensitive

sensitive

resistant

Drug Stop drug

resistant


sensitive

sensitive

resistant

sensitive

resistant

Drug Stop drug

resistant


sensitive

sensitive

resistant

Drug Stop drug

resistant


sensitive

resistant + very fit

sensitive

II

HCV DAAs and Resistance

HCV Lifecycle

(Pawlotsky JM, Antivir Ther 2012;17:1109-17)

Available HCV DAA Classes


NS3/4A protease inhibitors




Nucleotide analogues





Non-nucleoside inhibitors





Non-nucleoside inhibitors

NS5A inhibitors

NS5A inhibitors

SummaryLow-barrier drug High-barrier drug

NS3 protease inhibitorsNS5A inhibitors

Non-nucleoside RdRp inhibitors


Nucleotide analogue inhibitors of HCV RdRp

CatalyticSite

Nucleotide Analogue Inhibitors of HCV RdRp


Sofosbuvir (Gilead)MK-3682 (Merck)AL-335 (Janssen)

PangenotypicHigh barrier to resistance

Nucleotide Analogue Inhibitors of HCV RdRp

Nucleotide Analogue Resistance

(Lontok et al., Hepatology 2015;62:1623-32)

NS5A inhibitors

NS5A Protein

Domain III

Domain II

Domain I

Required for HCV RNA replication

Required for HCV viral particle assembly

May be involved in the release of HCV particles

NS5A Dimer

ER membrane

Cytosol

ER lumen

1st-wave

Daclatasvir (BMS) Ledipasvir (Gilead)Ombitasvir (Abbvie)

2nd-wave

Elbasvir (Merck)Velpatasvir (Gilead)Odalasvir (Janssen)Ravidasvir (Presidio)

Pangenotypic(except ledipasvir)

Low barrier to resistancePangenotypic

Slightly higher barrier to resistance?

NS5A Inhibitors2nd-generation?

ABT-530 (Abbvie)MK-8408 (Merck)

PangenotypicHigher barrier to resistance?

1st-generation

NS5A Inhibitor Resistance

(Adapted from Tellinghuisen et al., Nature 2005;435:374-9)

H1Conservedsurface

H1

58Chain B

Amino Acids at RAV positions

2430

2858

923132 38

9293 30

3124

28

3832

93 Chain A

NB: Residues 32 and 38 behind molecule

NS5A Inhibitor Resistance



NS3 Protease Inhibitors

(Raney et al., J Biol Chem 2010:285:22725-31)

1st-wave

Telaprevir (Janssen)Boceprevir (Merck)

2nd-wave

Simeprevir (Janssen)Paritaprevir/r (Abbvie)

Asunaprevir (BMS, Asia)Vaniprevir (Merck, Asia)

2nd-generation

Grazoprevir (Merck)ABT-493 (Abbvie)GS-9857 (Gilead)

Only genotype 1Low barrier to resistance

All genotypes except 3Low barrier to resistance

Pangenotypic (~)Higher barrier to

resistance

NS3/4A Protease Inhibitors

*Not approved yet in US and EU

1st-generation

Protease Inhibitor Resistance


Non-nucleoside inhibitors of HCV RdRp

Non-Nucleoside Inhibitors (NNI)

Thumb I

Thumb II

Palm I

Palm II

A

BC

D

Palm-1 inhibitors

Dasabuvir (Abbvie)

Non-Nucleoside Inhibitors (NNI)

Genotype 1 onlyLow barrier to resistance

NNI Resistance


III

HCV Resistance in IFN-Free Regimens

BaselinePrevalence of RAVs

S282T RAV in RdRp (NS5B)• No S282T (0/8598) was detected in any pretreatment patient

samples (deep sequencing, cutoff = 1%)

Europe n=1,767

Asian=954

Oceanian=1,094

African=17

North America n=4,766

(Gane et al., AASLD 2015)

Prevalence of NS5A RAVs (G1a)Deep sequencing, 1% cutoff

(Zeuzem et al., AASLD 2015)

Europe25% (130/517)

Asia Pacific15% (4/27)

Oceania27% (89/328)

North America26% (686/2638)USACanadaPuerto Rico

BelgiumSwitzerlandCzech RepublicGermanySpainFranceUnited KingdomItalyNetherlandsPoland

ChinaIndiaJapanKoreaRussiaTaiwan

AustraliaNew Zealand

Prevalence of NS5A RAVs (G1a)Akin to population sequencing, 15% cutoff


Europe14%

Asia Pacific7%

Oceania16%

North America13% USACanadaPuerto Rico




Prevalence of NS5A RAVs by Region (G1a)

Prev

alen

ce (%

)

Q30H/R L31M Y93H Multiple RAVs0

5

10

15

20

4.9%3.7%

2.1%

4.8%4.1% 4.4%

1.2%

4.4%

7.6%

5.8%

2.4%

7.6%

North America Europe Oceania

N=2638 N=2638 N=2638 N=2638N=517 N=517 N=517 N=517N=328 N=328 N=328 N=328

Asia Pacific not included due to low number of patients with GT1a (n=27)

NB: Q30H/R, L31M and Y93H RAVs confer >100 fold shift to LDV.


Prevalence of NS5A RAVs (G1b)Deep sequencing, 1% cutoff


Europe25% (105/416)

Asia Pacific26% (150/570)

Oceania26% (26/99)

North America23% (184/802)USACanadaPuerto Rico




Prevalence of NS5A RAVs (G1b)Akin to population sequencing, 15% cutoff


Europe17%

Asia Pacific20%

Oceania19%

North America16% USACanadaPuerto Rico




Prevalence of NS5A RAVs by Region (G1b)


L31M/I/V Y93H Multiple RAVs0

2

4

6

8

10

12

14

16

18

20

8.5%

14.6%

1.1%

9.4%

16.1%

1.2%

13.1%14.1%

1.0%

3.9%

18.2%

2.1%

North America Europe Oceania Asia Pacific

NB: L31M/I/V confer 3-43 fold shift to LDV; Y93H confers >100 fold shift to LDV

N=802 N=416 N=99 N=570 N=802 N=416 N=99 N=570 N=802 N=416 N=/99 N=570

Prev

alen

ce (%

)

Influence of Baseline RAVs on IFN-Free Treatment Outcomes

Sofosbuvir + Simeprevir ± RBVCOSMOS Cohort 2- Gen 1, Naive and NR, F3-F4

(Lawitz et al., Lancet 2014;384:1756-65)

93%

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

SOF+SIM+RBVAll patients SOF+SIM+RBVSOF+SIM

N=80 N=27 N=14 N=24

12 weeks 24 weeks

93%93%

SOF+SIM

N=15

100%94%

Sofosbuvir + Simeprevir ± RBVCOSMOS Pooled cohorts 1 & 2- Subtype 1a, Q80K

88%

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

SOF+SIM+RBVAll patients SOF+SIM+RBVSOF+SIM

N=80 N=27 N=14 N=24

12 weeks 24 weeks

83%89%

SOF+SIM

N=15

100%

88%

(Lawitz et al., Lancet 2014;384:1756-65)

92%

AnyRAV

N=318

97%

No RAVs

N=1629

SVR According to Baseline NS5A RAVs ION-1, -2, -3: Sofosbuvir + Ledipasvir ± RBV

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

(Sarrazin et al., manuscript submitted)

92%

AnyRAV

N=318

97%

No RAVs

N=1629

SVR According to Baseline NS5A RAVs ION-1, -2, -3: Sofosbuvir + Ledipasvir ± RBV

97%

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

K24R

86%

M28T

94%

Q30H

82%

Q30R

91%

L31M

92%

Y93H

N=68 N=28 N=80 N=89N=29 N=48

(Sarrazin et al., manuscript submitted)

SVR to Sofosbuvir/Ledipasvir According to NS5A RAVs (513 cirrhotic patients)

(Sarrazin et al., EASL 2015)

SVR According to Baseline NS5A RAVs


SVR

12 (%

)

Without cirrhosis With cirrhosis

Rx-Naive Rx-Exp’dRx-Naive Rx-Exp’d

*HCV RNA < 6 million IU/mL.

8 Wks* 12 Wks 12 Wks 12 Wks 12 Wks + RBV

12 Wks + RBV

24 Wks24 Wks

No RAVsWith RAVs

100

80

60

40

20

0

98 99 99 9990

99 96 96 100 10088

10089

9687

100

N=32 N=108 N=189 N=509 N=88 N=300 N=27 N=68 N=10 N=27 N=9 N=19 N=66 N=214 N=15 N=84

Grazoprevir + ElbasvirC-EDGE TN– Phase III, Rx-naïve, Gt 1, w/o cirrhosis, 12 weeks

89%

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

Bs NS3 RAVs

97%

N=86 N=65 N=25 N=104

100%96%

N=19 N=135

99%

58%

N=18 N=112

100%94%

No BsNS3 RAVs

Bs NS3

RAVs

No BsNS3

RAVs

BsNS5ARAVs

No BsNS5ARAVs

BsNS5A RAVs

No BsNS5A RAVs

GT 1a GT 1b GT 1a GT 1b(Zeuzem et al., Ann Intern Med 2015;163:1-13)

Grazoprevir + Elbasvir + RBVIntegrated analysis of patients with G1a from Phase II and III trials,

TN or TE, w/o cirrhosis, 12 or 16-18 weeks

(Thompson et al., AASLD 2015)

No NS5A RAVs (73%)

N=38

100%

NS5A RAVs (27%)

N=14

100%

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

No NS5A RAVs (66%)

N=289

98%

NS5A RAVs (34%)

N=150

91%

Rx-naïve and PR relapsers12 weeks, no RBV

PR nonresponders16-18 weeks, + RBV

Influence of Baseline NS5A RAVsGrazoprevir-Elbasvir, 12 (no RBV) or 16-18 weeks (+RBV), prior NR

(Jacobson et al., AASLD 2015)

Pts with RAVs by population sequencingPts without RAVs

GT1a, Previous nonresponse GT1b, Previous nonresponse

100% 100%

N=51

EBR/GZR 12 wks EBR/GZR + RBV 16/18 wks

EBR/GZR 12 wks EBR/GZR + RBV 16/18 wks

SVR

12 (%

)

100

80

60

40

20

0EBR RAVs

NS5A class RAVs

EBR RAVs

NS5A class RAVs

EBR RAVs

NS5A class RAVs

EBR RAVs

NS5A class RAVs

97%

29%

N=61 N=7

96%

64%

N=54 N=14

100% 100%

N=44 N=8

100%

67%

N=28 N=6

100%

83%

N=22 N=12

100% 100%

N=26 N=12

100% 100%

N=22 N=16N=1

Summary

• The detection, by means of population sequencing, of HCV RAVs at baseline has an impact on the rate of SVR with IFN-free regimens

• Parameters that matter include:• The genotype/subtype• The treatment regimen received (drugs, duration, RBV)• The proportion of RAVs in the viral quasispecies at baseline• The level of resistance conferred by the substitutions

Selection of RAVs in Patients who Fail to Achieve an SVR

The Henri Mondor Experience161 patients treated in IFN-free regimens

in clinical trials

Protease inhibitors received

Paritaprevir/rSimeprevirFaldaprevirAsunaprevirDanoprevir/r

NS5A inhibitors received

DaclatasvirOmbitasvirLedipasvir

Nucleotide analoguereceived

Sofosbuvir

(Data on file; unpublished)

The Henri Mondor Experience161 patients treated in IFN-free regimens

in clinical trials

13 did not achieve an SVR

8 relapses 3 breakthroughs 2 intolerant


The Henri Mondor ExperienceRegion Observed substitutions

NS3 protease

V36M, D103N, R155KI71VR155KQ80K, R155KA147V, D168VA4M, V36M, R155KP146S, Q80L

NS5A Y93CL31V, Y93H

NS5B RNA polymeraseL433FQ65R, S189N/SS47E


Selection of RAVs in Patients who Failed after LDV (no SOF)

16%(12/76)

84%(64/76)

BeforeLDV Treatment

99%(72/73)

1%

At Virologic Failure With LDV Treatment

Patients without NS5A RAVsPatients with NS5A RAVs

Patients who failed after a ledipasvir-containing treatment

(without sofosbuvir)

(Dvory-Sobol et al., EASL 2015)

Treatment Failures in SAPPHIRE-2Genotype 1, Rx-experienced, 3D ± Ribavirin

Virologic failure in 7/297 patients (2.4%)

(Zeuzem et al., N Engl J Med 2014;370:1604-1614)

Summary

• In most (if not all) patients who fail to achieve an SVR on an IFN-free regimen, viruses that are resistant to one or more of the DAAs administered are present as the dominant species at the time of relapse

Post-treatment RAV Persistence in Patients who Fail to Achieve an SVR

Replacement of PI-Resistant Viruses by Wild-Type Viruses

(Lenz et al., J Hepatol 2015;62:1008-14)

Persistence of RAVs in Patients who Failed after LDV (no SOF)

0

20

40

60

80

100 98% 100% 98% 100%95%

82%Pa

tient

s W

ith N

S5A

RA

Vs (%

)

Registry Study

N=63 N=58 N=43 N=45 N=55 N=58

(Dvory-Sobol et al., EASL 2015)

Persistence of RAVs in Patients who Relapsed after 3D

67/2510 patients with genotype 1a and virologic failure after 3D

(Krishnan et al., EASL 2015)

NS5A RAVs

(ombitasvir)

NS5B RAVs

(dasabuvir)

NS3 RAVs

(paritaprevir)

24 wks post-treatment

48 wks post-treatment

Prev

alen

ce o

f RAV

s (%

)

0

10

20

30

40

50

60

70

80

90

100

N=70 N=44 N=35N=51N=67 N=57

46%

9%

97% 96%

75%

57%

Summary

• After IFN-free treatment failure, HCV variants resistant to protease inhibitors progressively disappear by population sequencing, replaced by wild-type virus

• In contrast, viruses resistant to NS5A inhibitors and to NNIs persist for years, maybe for ever, as dominant species

IV

Retreatment Options

Retreatment of Patients who Failed an IFN-Free Regimen

• Recommendations are based on indirect evidence and subject to change when more data become available

• The retreatment regimen should contain• Sofosbuvir because of the high barrier to resistance• 1 or 2 other DAA(s), if possible with no cross-resistance

with the DAA(s) already administered• Ribavirin

• Treatment duration should be 12 or 24 weeks (24 weeks recommended in F3-F4)

(European Association for the Study of the Liver. J Hepatol 2015;63:199-236)

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

87%

Total

80%

Genotype 1a

100%

Genotype 1b

Retreatment of NS5A Inhibitor Failures with Sofosbuvir + Simeprevir 12 wks

100%

Genotype 4

(Hézode et al., AASLD 2015)

N=15 N=10 N=3 N=2

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100 92%

1a, no cirrhosis12 wks + RBV

100%

1a, cirrhosis24 wks + RBV

100%

1b12 wks, no RBV

Retreatment of DAA Failures with Sofosbuvir + 3D 12 wk (QUARTZ-I)

(Poordad et al., AASLD 2015)

N=15 N=6 N=2

100%

Overall

N=23

Retreatment with Sofosbuvir + Grazoprevir/Elbasvir + RBVC-SWIFT Retreatment- G1, short (4-6-8 wk) SOF-GZR-EBR treatment failures

(Lawitz et al., AASLD 2015)

100%

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100

No

100%

Yes

100%

4 wk

100%

6-8 wk

100%

No

100%

Yes

N=18 N=8 N=5 N=18N=5 N=15

Cirrhosis Prior Rx duration

BaselineNS5A RAVs

V

Utility of HCV Resistance Testing

Utility of HCV Resistance Testing

• Lack of standardization of the assays

• Best timing for testing• Prior to therapy• At the time of relapse• At the time of retreatment

• Guidelines for interpretation and retreatment decisions

VI

Avoiding Treatment Failures

European Association for the Study of the Liver. J Hepatol 2015;63:199-236

Characteristics that Inform Treatment Option Selection

Treatment selection

Prior treatment

experience

HCV genotype/subtype

Severity of liver

disease

Patient co-morbidities

PK profile of

treatment

Drug-drug interactions

(European Association for the Study of the Liver. J Hepatol 2015;63:199-236)

SVR

12 ra

te (%

)

0

10

20

30

40

50

60

70

80

90

100 90%

12 wkNo RBV

96%

12 wk+RBV

98%

24 wkNo RBV

Sofosbuvir/Ledipasvir ± RBVRx-experienced patients with compensated cirrhosis

100%

24 wk+RBV

(Reddy et al., Hepatology 2015;62:79-86)

SVR to Sofosbuvir/Ledipasvir According to NS5A RAVs (513 cirrhotic patients)

LDV/SOF LDV/SOF+RBV LDV/SOF LDV/SOF+RBV0

20

40

60

80

100 88% 94% 85% 100%95% 97% 100% 100%

SVR1

2 (%

)

N=26 N=91 N=34 N=169 N=20 N=113 N=14 N=44

12 Weeks 12 Weeks 24 Weeks 24 Weeks

Pre-existing NS5A RAVs No pre-existing NS5A RAVs

(Sarrazin et al., EASL 2015)

Ombitasvir/Paritaprevir/r + Dasabuvir ± RBV TURQUOISE II-Phase III, Genotype 1, Rx-naïve and -experienced,

Compensated cirrhosis (CPA), 12-24 weeks

(Poordad et al., N Engl J Med 2014;370:1973-82)

0

20

40

60

80

100 92%93% 100%

80%93% 100% 100% 93%

N=64 N=15N=56 N=13 N=11 N=50N=10 N=42

SVR

12 (%

)

12 weeks24 weeks

Genotype 1a

Conclusions

• Optimizing first-line treatment is required to avoid DAA-based treatment failures associated with HCV resistance

• Retreatment options exist, based on the combination of sofosbuvir plus 2 or 3 other DAAs, eventually with ribavirin

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Pawlotzky hcv resistances.pptx du16

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