stefan zeuzem. what is the optimal treatment of naive patients with chronic hepatitis c ? 2 nd paris...
TRANSCRIPT
Stefan ZEUZEM
What is the optimal treatment of naive patients
with chronic hepatitis C ?
2nd Paris Hepatitis Conference Palais des Congrès, Paris, 22-23 January 2007
Stefan ZeuzemJ.W. Goethe University Hospital
Frankfurt, Germany
Peginterferon alfa-2a/2b + Ribavirin for treatment of chronic hepatitis C
37
61
46
76
0
20
40
60
80
100
IFN + RBV PEG-IFNalfa-2a +
RBV
33
79
42
82
0
20
40
60
80
100
IFN + RBV PEG-IFNalfa-2b +
RBV
HCV-1
HCV-2,3
Su
sta
ine
d vi
rolo
gic
S
ust
ain
ed
viro
log
ic
resp
ons
e (
%)
resp
ons
e (
%)
Manns et al., Lancet 2001;358:958-965
Fried et al., N Engl J Med 2002; 347:975-982
PEG-IFN alfa-2a + RBV (LD vs SD) for treatment of chronic hepatitis C
29
42 41
52
0
20
40
60
80
100
24 wks 48 wks
84 81 79 80
0
20
40
60
80
100
24 wks 48 wks
Su
sta
ine
d vi
rolo
gic
S
ust
ain
ed
viro
log
ic
resp
ons
e (
%)
resp
ons
e (
%)
Hadziyannis et al., Ann Intern Med 2004;40:346-355
HCV-1 HCV-2,3
RBV 800 mg/d RBV 1000-1200 mg/d
HCV genotyping
HCV-1 (4,5,6)HCV RNA quant.
HCV-2,3
Combination treatment800 mg Ribavirin
for 24 weeks
Combination treatment1000-1200 mg Ribavirin
HCV RNA quant. at week 12
< 2log decline 2log declineHCV RNA +
stop treatmentor
continue withPEG-IFN alone
for inhibition of fibrosis
progression
continue txuntil week 24
if HCV RNA -continue tx
until week 48
2log declineHCV RNA -
continue txuntil week 48
Individualisation according to HCV genotype:
Shorter treatment in HCV-1?
Virologic response in patients with HCV-1 and HCV RNA < 600,000 IU/mL
0
10
20
30
40
50
60
70
80
90
All patients Week 4 Week 12 Week 24/EOT
SVR
Relapse
Time to first negative HCV RNAPEG-IFN -2b + RBVZeuzem et al., J Hepatol 2006
Pat
ient
s (%
)
(47%) (26%) (10%)
50%
37%
89%
25%17%
8%
75%80%
Patients with HCV-1 and HCV RNA < 600,000 IU/mL
Investigator HCV-1patients
HCV-1 & LVL
Quantification assay
Data source
Manns et al. 1034 290 (28.1%)
qPCR (NGI) Lancet 2001
Jacobson et al.
2710 989(36.5%)
SP TaqMan SPRI data base
Fried et al. 725 253(34.9%)
Cobas Amplicor HCV Monitor 2.0
NEJM 2002
Hadziyannis et al.
740 267(36.1%)
Cobas Amplicor HCV Monitor 2.0
Ann Intern Med 2004
Total 5209 1799(34.5%)
Zeuzem, Zeuzem, J HepatolJ Hepatol 2006 2006
Early identification of HCV 1 patients responding to 24 wks PEG-IFN alfa-2a/RBV
89 88
73
91
1623
3544
0
20
40
60
80
100
HCV RNA < 50IU/mL at week 4
HCV RNA > 50IU/mL at week 4
24-LD
24-SD
48-LD
48-SD
Jensen et al., Jensen et al., HepatologyHepatology 2006;43:954-60
Sus
tain
ed v
irolo
gic
Sus
tain
ed v
irolo
gic
resp
onse
(%
)re
spon
se (
%)
18 33 40 55 81 84 208 210
*Logit scale5.6 log10 IU/mL ~400 x103 IU/mL
GAM analysisEffect of pre-treatment HCV RNA on SVR
Pro
bab
ility
of
SV
R*
Baseline HCV RNA (log10 IU/ml)
3 4 6 75
0.5
0.88
0.98
0.9985.6 log10 IU/mL
Individualisation according to HCV genotype:
Longer treatment in HCV-1 ?
Extended treatment duration for HCV 1: 48 vs 72 weeks of PEG-IFN alfa-2a + RBV
80 76
17
29
0
10
20
30
40
50
60
70
80
HCV RNA < 50 IU/mL at week 12
HCV RNA ≥ 50 IU/mL at week 12
48 wks
72 wks
Sus
tain
ed v
irolo
gic
resp
onse
rat
e (%
)
Berg, et al. Gastroenterology 2006;130:1086-1097
104/130 90/119 17/100 31/106
P=0.040
Virologic relapse rates in patients with rapid virologic response
7
16 1512
0
5
10
15
20
25
30
< 50 IU/mL < 50 IU/mL
48 wks
72 wks
Berg, et al. Gastroenterology 2006;130:1086-1097
Viro
logi
c re
laps
e ra
te (
%)
Week 4 Week 12
19/123 12/1013/46 5/32
Virologic relapse rates in patients with slow virologic response
37
23
64
40
0
10
20
30
40
50
60
70
> 50 IU/mL > 50 IU/mL
48 wks
72 wks
Berg, et al. Gastroenterology 2006;130:1086-1097
Viro
logi
c re
laps
e ra
te (
%)
Week 4 Week 12
30/47 21/5246/124 28/122
P=0.016 P=0.021
Peginterferon alfa-2a plus ribavirin for 48 vs. 72 weeks in patients with detectable
HCV RNA at week 4 of treatment
0
10
20
30
40
50
60
HCV-1 HCV-1 / <800,000 IU/mL
HCV-1 / >800,000 IU/mL
48 wks
72 wks
Sanchez-Tapias et al., Gastroenterology 2006;131:451-460
Sus
tain
ed v
irolo
gic
resp
onse
rat
e (%
)
28%
44%
27% 28%
51%
37%
P=0.003 P=0.002 P=0.35
Peginterferon alfa-2a plus ribavirin for 48 vs. 72 weeks in patients with detectable
HCV RNA at week 4 of treatment
0
10
20
30
40
50
60
HCV-1 HCV-1 / <800,000 IU/mL
HCV-1 / >800,000 IU/mL
48 wks
72 wks
Sanchez-Tapias et al., Gastroenterology 2006;131:451-460
Viro
logi
c re
laps
e ra
te (
%)
17%
53%
27%23%
55%50%
P=0.002 P=0.007 P=0.15
Individualisation according to HCV genotype:
Shorter treatment in HCV-2 and HCV-3 ?
PEG-IFN-2b + RBV for treatment of chronic HCV-2 and -3 infection (ITT)
0%
20%
40%
60%
80%
100%
all patients 14 wks tx 24 wks tx
SVR
Relapse
NR
Pat
ient
s (%
)
82%
10%14%
90%
56%
26%
Dalgard et al., Hepatology 2004;40:1260-65
4% 0%
19%
End-of-treatment (ETR) and sustained virologic response (SVR)
- HCV genotypes 2 and 3 combined -
0%
20%
40%
60%
80%
100%
Group A Group B Group C
ETR
SVR
Viro
logi
c re
spon
se (
%) 94%
81%
67/71
SVR B vs C: SVR B vs C: PP = 0.003 = 0.003
(16 weeks)(16 weeks) (24 weeks)(24 weeks)
82% 86%
69%
39%
(24 weeks)(24 weeks)
58/71 59/69 56/69 9/13 5/13
v. Wagner et al, Gastroenterology 2005
Sustained virologic response (SVR) according to HCV genotype
0%
20%
40%
60%
80%
100%
Group A Group B Group C
HCV-2
HCV-3
SV
R (
%)
76% 77%
40/53
(24 weeks)(24 weeks) (12 weeks)(12 weeks)
76%87%
72%
41%
(24 weeks)(24 weeks)
13/17 89/102 24/31 42/58 9/22
Mangia et al, N Engl J Med 2005
Tx: PEG-IFN alfa-2b 1.0 µg/kg + RBV 1000-1200 mg
Treatment of chronic HCV-2 infection with PEG-IFN alfa-2a + RBV for 16 vs. 24 weeks
0%
20%
40%
60%
80%
100%
RVR SVR
16 weeks 24 weeks
Viro
logi
c re
spon
se (
%)
86%94%
43/50
87%95%
87/100 47/50 95/100
M-L Yu et al, GUT 2006
PEG-IFN alfa-2a + RBV for 16 or 24 weeks in HCV-2 and -3 (ACCELERATE Study)
65% 62%
76%70%
0%
20%
40%
60%
80%
100%
Standard Analysis Intent-to-treat
16 weeks PEG-IFN alfa-2a 180 ug + RBV 800 mg24 weeks PEG-IFN alfa-2a 180 ug + RBV 800 mg
P <.0001P <.0001 P =.0004P =.0004
N=679 N=732 N=731N=630
Shiffman et al., Late-Breaker Abstract EASL 2006Shiffman et al., Late-Breaker Abstract EASL 2006
84%
61%
83%
59%
89%80% 85%
66%
0%
20%
40%
60%
80%
100%
≤400,000 IU/mL >400,000 IU/mL ≤400,000 IU/mL >400,000 IU/mL
16 weeks PEG-IFN alfa-2a 180 ug + Ribavirin 800 mg24 weeks PEG-IFN alfa-2a 180 ug + Ribavirin 800 mg
SV
R (
%)
SV
R (
%)
Standard population; VR = HCV RNA < 50 IU/mLStandard population; VR = HCV RNA < 50 IU/mL
Genotype 2Genotype 2 Genotype 3Genotype 3
N=61 N=46 N=285 N=92 N=84 N=241 N=243N=257
74%74%
94%94%
80%80%
98%98%
56%56%
67%67%75%75%
85%85%90%90%
70%70%
92%92%
77%77%
52%52%
65%65%
72%72%
60%60%
Shiffman et al., Late-Breaker Abstract EASL 2006Shiffman et al., Late-Breaker Abstract EASL 2006
PEG-IFN alfa-2a + RBV for 16 or 24 weeks in HCV-2 and -3 (ACCELERATE Study)
PEG-IFN alfa-2a 180 µg qw Ribavirin 800 mg qd
PEG-IFN α-2a 180 µg qwRibavirin
800-1200 mg qd
PEG-IFN α-2b 1.0 µg/kg qw
Ribavirin 1000-1200 mg qd
PEG-IFN α-2b 1.5 µg/kg qw
Ribavirin 800-1400 mg qd
No Yes Yes Yes
1221531469
(993 US)273
Global Italy Germany Norway
~0.6 x 106 50%<0.6 x 106~1 x 1065.6 x 106
46 46.6-49.7 38-42 37 (median)
81.5 69.5 74-80 76 (median)
50% 78% 25% 19%
RegimenRegimen
% GT 2% GT 2
NumberNumber
RegionRegion
Mean baseline Mean baseline viral load viral load IU/mlIU/ml
Mean Age (yrs)Mean Age (yrs)
Treatment Treatment duration based duration based on RVR?on RVR?
Mean body Mean body weight (kg)weight (kg)
ACCELERATEACCELERATE VON WAGNERVON WAGNERMANGIAMANGIA DALGARDDALGARD
Individualisation according to HCV genotype:
Longer treatment in HCV-3 (HVL) ?
Relapse rate by HCV genotype and baseline viral load in patients treated for
24 weeks (Peg-IFN alfa-2b + RBV)
0
5
10
15
20
25
< 600,000IU/mL
> 600,000IU/mL
< 600,000IU/mL
> 600,000IU/mL
Rel
apse
(%
)
HCV-2 HCV-3
5%9% 8%
23%
Zeuzem et al., J Hepatol 2004
Individualisation according to HCV genotype:
Treatment duration for HCV-4 ?
PEG-IFN-2a + ribavirin for treatment of patients with chronic HCV-4 infection
0
10
20
30
40
50
60
70
80
24 weeks 48 weeks
800 mg RBV
1000/1200 mg RBV
sust
aine
d vi
rolo
gic
resp
onse
(%
)
0%
67%63%
79%
M Diago et al., Ann Intern Med 2004;140:72-73
Sustained virologic response (SVR) in patients infected with HCV-4
0%
20%
40%
60%
80%
100%
24 weeks 36 weeks 48 weeks
SV
R (
%)
66%
29%
69%
Kamal et al, GUT 2005
Tx: PEG-IFN alfa-2b 1.5 µg/kg + RBV 1000-1200 mg
Sustained virologic response (SVR) in patients infected with HCV-4 (HVL)
0%
20%
40%
60%
80%
100%
24 weeks 36 weeks 48 weeks
SV
R (
%)
35%
0%
65%
Kamal et al, GUT 2005
Tx: PEG-IFN alfa-2b 1.5 µg/kg + RBV 1000-1200 mg
Future individualization of therapy
0 1 2 31
2
3
4
5
6
7
7 14 21 28
Limit of detection
days
Se
rum
HC
V R
NA
(lo
g)
FPR (0.0 < 0,05)
RVR( 0.35)
NR (c < 0,2)
HCV-2, HCV-3 (LVL) 12-16 WochenDelgaard et al. 2005; v. Wagner et al. 2005Mangia et al. 2005, Shiffman et al. 2006
HCV-2 (HVL) 24 WeeksShiffman et al. 2006
HCV-3 (HVL), HCV-4 (LVL)36-48 (?) Wochenv. Wagner et al. 2005, Kamal et al. 2006
HCV-1 (LVL, RVR) 24 WochenZeuzem et al. 2004, Zeuzem et al. 2005
HCV-1, HCV-4 48 WochenManns et al. 2002, Hadziyannis et al. 2004Kamal et al., 2005
HCV-1 (SPR) 72 WochenButi et al. 2003, Berg et al. 2006
(0.05 < 0.35)SPR
Conclusions (1)
• Virologic response rates are better in HCV-2 than HCV-3 infected patients
• Certain patients with HCV-2 or HCV-3 infection may be successfully treated with 12-16 weeks of combination therapy
• Patients infected with HCV-3 and high viral load may require longer than 24 weeks of combination therapy
Conclusions (2)
• Patients infected with HCV-1 and low baseline viral load who respond early (at week 4) may only require 24 weeks of combination therapy
• Slow viral responders infected with HCV-1 benefit from longer than 48 weeks of combination therapy
• Compliance and adherence important
• Future options: small molecules (HCV protease and polymerase inhibitors)