TERAPIA DELL’EPATITE CRONICA DA HCV: ATTUALITA’ E PROSPETTIVE FUTURE U.O.MALATTIE INFETTIVE OSMA ASL 10 FIRENZE Direttore: F.Mazzotta Pierluigi Blanc

GLOBAL EPIDEMIOLOGY OF HCV -170 million cases (3%)

Virology- Geographic variation

HCV: genotipi

Modified from Lauer et al. (Slow) Female sex, young age at infection, IL28B CC?  30 years Normal liver Acute infection Chronic (50-80%) hepatitis Cirrhosis (20 %) Risk of HCC (1-4%/yr) Rate of progression  20 years (Fast) Alcohol, steatosis, iron, BMI, old age, coinfections, male sex, immune deficiency, IL28B TT? Modified from Lauer et al.

HOST FACTORS in chronic hepatitic C progression and response to therapy Gender Age Duration of infection Genetic factors: IL28B polymorphisms Psychological factors Metabolic Steatosis BMI-Visceral obesity Insulinresistance Type 2diabetes Iron HCV

Gli obiettivi ed endpoint della terapia Eradicare l’infezione da HCV: Prevenire le complicanze: necroinfiammazione, fibrosi, cirrosi, epatocarcinoma, morte; Endpoint finale  Sustained Virological Response; Endpoint intermedi  determinazione HCV-RNA in corso di terapia: Settimane 4, 12 e 24 L’eradicazione dell’HCV porta alla fine del processo necroinfiammatorio e nei pazienti non cirrotici all’interruzione della fibrosi

Evolution of hepatitis C treatment Discovery of HCV genome Treatment with IFN alfa for 24 or 48 weeks – 3x weekly dosing – Poor outcomes SVR <20% Addition of RBV to IFN alfa improved outcomes SVR ~40% Peg-IFN mono – once-weekly dosing SVR ~40% Peg-IFN alfa plus RBV becomes gold standard SVR >55% 1989 1998 2001 2002 8

Pegylated Interferons Combination Sustained Virological Response (week 72) Overall Response P = 0.01 P = 0.001 La successiva analisi dei risultati in termini di risposta virologica sostenuta a fine follow-up (settimana 72) con i due interferoni pegilati + ribavirina è possibile evidenziare come il peginterferone alfa-2b (12 KD) abbia conseguito, rispetto all’interferone-ribavirina una differenza in termini di risposta virologica sostenuta del 7% (54% vs 47%) e priva di significatività statistica (P = 0.01) mentre per il peginterferone alfa-2a (40 KD) è possibile evidenziare, rispetto all’interferone-ribavirina una differenza in termini di risposta virologica sostenuta del 12% (56% vs 44%) e statisticamente significativa (P = 0.001). Occorre inoltre considerare come una differenza di almeno il 10% tra il braccio sperimentale e quello di controllo venga unanimamente riconosciuta dalla comunità scientifica internazionale come significativa da un punto di vista clinico.  = 7%  = 12% n = 505 n = 511 n = 444 n = 453 IFN -2b/RBV 3 MIU PEG-IFN -2b/RBV 1.5 µg/kg IFN -2b/RBV 3 MIU PEG-IFN -2a/RBV 180 µg Results presented are from 2 separate and independent trials Manns MP et al. Lancet 2001;358:958-965. Fried MW et al. Digestive Disease Week, Atlanta, May, 2001.

Pegylated Interferons Combination Sustained Virological Response (week 72) Genotype 2/3 P = 0.46 P = 0.005 Risposta Virologica Sostenuta stratificata per Genotipo L’analisi dei risultati in termini di risposta virologica sostenuta conseguita nei genotipi 2 e 3 con i due interferoni pegilati + ribavirina evidenzia per il peginterferone alfa-2b (12 KD), rispetto all’interferone-ribavirina una differenza in termini di risposta virologica sostenuta del 3% soltanto (82% vs 79%) e priva di significatività statistica (P = 0.46), mentre per il peginterferone alfa-2a (40 KD) è possibile evidenziare, rispetto all’interferone-ribavirina una differenza in termini di risposta virologica sostenuta del 15% (76% vs 61%) e statisticamente significativa (P = 0.005). I genotipi 2 e 3 rappresentano, come noto, i sottotipi di HCV i più facili da trattare e per i quali è generalmente attesa una percentuale di risposta alta.  = 3%  = 15% n = 146 n = 147 n = 145 n = 140 IFN -2b/RBV 3 MIU PEG-IFN -2b/RBV 1.5 µg/kg IFN -2b/RBV 3 MIU PEG-IFN -2a/RBV 180 µg Results presented are from 2 separate and independent trials Manns MP et al. Lancet 2001;358:958-965. Fried MW et al. Digestive Disease Week, Atlanta, May, 2001.

Pegylated Interferons Combination Sustained Virological Response (week 72) Genotype 1 P = 0.013 P = 0.02 Risposta Virologica Sostenuta stratificata per Genotipo L’analisi dei risultati in termini di risposta virologica sostenuta conseguita, nel genotipo 1, con i due interferoni pegilati + ribavirina evidenzia per il peginterferone alfa-2b (12 KD), rispetto all’interferone-ribavirina una differenza in termini di risposta virologica sostenuta del 9% (42% vs 33%) e per il peginterferone alfa-2a (40 KD) è possibile evidenziare, rispetto all’interferone-ribavirina una differenza del 10% (46% vs 36%) raggiungendo sempre la significatività statistica (P = 0.013).  = 10%  = 9% n = 343 n = 348 n = 285 n = 298 IFN -2b/RBV 3 MIU PEG-IFN -2b/RBV 1.5 µg/kg IFN -2b/RBV 3 MIU PEG-IFN -2a/RBV 180 µg Results presented are from 2 separate and independent trials Manns MP et al. Lancet 2001;358:958-965. Fried MW et al. Digestive Disease Week, Atlanta, May, 2001.

Standard of Care: Pegylated Interferon and Ribavirin

Pharmacokinetics of Pegylated Interferons Alfa-2a and Alfa-2b 20,000 T1/2 77 hours PEG-IFN alfa-2a SC once weekly 15,000 pg/mL 1000 PEG-IFN -2b SC once weekly T1/2 40 hours Pharmacokinetics of peginterferons alfa-2a and alfa-2b compared to standard interferon therapy Once weekly administration of either peginterferon alfa-2a or alfa-2b achieves significantly higher and more sustained blood levels than three times weekly administration of a standard interferon. Blood levels of peginterferon alfa-2a are significantly higher than those of peginterferon alfa-2b and the half-life is approximately twice as long as peginterferon alfa-2b. However, peginterferon alfa-2b appears to be a more potent inhibitor of HCV replication in vitro. Both agents have been shown to have approximately twice the efficacy of standard interferon preparations in clinical trials and, when combined with ribavirin, to have similar efficacy in the treatment of chronic hepatitis C. Glue,P.; Fang,J.W.; Rouzier-Panis,R.; Raffanel,C.; Sabo,R.; Gupta,S.K.; Salfi,M.; Jacobs,S. Pegylated interferon-alpha2b: pharmacokinetics, pharmacodynamics, safety, and preliminary efficacy data. Hepatitis C Intervention Therapy Group. Clin Pharmacol Ther 2000;68:556-7. 100 IFN tiw T1/2 77 hours 10 1 10 20 40 60 80 100 120 140 160 180 Hours

IDEAL Study: Schema and Regimens

IDEAL Study: SVR in US Genotype 1 Patients

Safety, Psychiatric Disorders and Hematologic Parameters

PAZIENTI CON EPATOPATIA CRONICA SEGUITI PRESSO U. O PAZIENTI CON EPATOPATIA CRONICA SEGUITI PRESSO U.O. MALATTIE INFETTIVE OSMA ASL 10 420 1040 487

SVR % PER TIPO DI PEGIFN E GENOTIPO PAZIENTI NAIVES (133 su 200) 133 naives SVR 78 (58.6%) 67 ritrattati SVR 6 ( 8.9%) 133 naives G1 G2 G3 G4 SVR(%) 43.7 87.5 71.4 50

RISULTATI PEGIFNa2a + Ribavirina 800-1200mg 108 PEGIFNa2b + Ribavirina 800-1200mg 92 SVR 84 (42%) NR 72 (36%) RELAPSE 20 (10%) SOSPENSIONE 16 ( 8%) ER 8 ( 4%)

SVR % PER TIPO DI PEGIFN E GENOTIPO TIPO DI PEGIFN overall G1 G2 G3 G4 PEGIFNa2a 39.8 30.3 62.5 50 50 PEGIFNa2b 43.4 27.9 66.6 56.6 50

CASISTICHE A CONFRONTO 1 SVR overall 2 SVR su NAIVE

SOC Le linee –guida riconoscono come SOC l’associazione di interferone peghilato e ribavirina (duplice); A tal riguardo, relativamente ai due interferoni peghilati si affermano i seguenti aspetti: I due farmaci hanno profilo pk diverso; Lo studio IDEAL non ha mostrato differenze; Due studi italiani (MIST, Ascione), hanno mostrato vantaggio dell’alfa 2a, soprattutto nel G1; L’argomento è dibattuto  non esistono evidenze conclusive per indicare uno rispetto ad un altro.

Predictive Factors of Therapy Response Baseline Factors Positive Negative IL28B TT Genotype 2 & 3 IL28B CC High Viral Load Genotype 1 Low Viral Load Caucasian, Asian African Americans Fibrosis F3-F4 Fibrosis F1-F2 Da Esteban e coll 2011 24 24

RIASSUMENDO…. Pazienti naive: Pazienti relapser: Sintesi delle evidenze con le attuali terapie: G1, terapia 48 settimane : SVR 45 – 54%; G2/3, terapia 24 settimane : SVR 65 – 82% (più alta nel G2); Principali predittori di risposta: Polimorfismo IL28B; Genotipo HCV; Stadio della fibrosi Pazienti relapser: Rate di relapse con attuali terapie : 15 -25%; Risposta al ritrattamento con PegIFN e RBV 32 – 53%; Pazienti non-responder: Risposta al ritrattamento con PegIFN e RBV : 4 – 14%;

The likelihood of SVR is directly proportional to the time of HCV RNA disappearance EASL Clinical Practice Guidelines Management of HCV infection 2011 SoC (PegIFN+RBV) therapy duration can be taylored to the on-treatment virological response: Upon treatment, HCVRNA should be assessed at three time points, regardless of the HCV genotype: baseline, week 4 and 12 Week 24 testing may also be useful in selected patients 12 w 24 w 4 w T.0 26

SVR rates in genotype 1 patients RVR 16% (90/569) No EVR 20% (111/569) pEVR 22% (128/569) SVR: 27% (34/128) cEVR 42% (240/569) SVR: 68% (162/240) EASL 2011: Stop treatment at w. 12 if HCVRNA decrease is less than 2 log10 IU/ml: SVR rate with SoC <2% 27

The Importance of RVR EASL 2011 RVR: Rapid virologic response: undetecteble HCVRNA at week 12 in a sensitive assay -lower limit of detection ≤ 50 IU/ml- (24-27 G1 and 64-76% G2-3) -G1 pts with RVR + basal LVL (below400.000-800.000 IU/ml)= should be treated for 24 w. (Hadziyannis et al 2004, Jensen et al, 2006; Ferenci et al2008; Zeuzem et al 2006; Mangia et al 2008; Moreno et al, 2010) -G2-G3 pts with RVR + basal LVL ( “ ) should be treated for 16 w. (slightly higher chance of relapse) (Diago et al, 2010; Dalgard et al, 2008, Mangia et al, 2005; von Wagner et al, 2005, Yu et al, 2007) -No duration shortening is recommanded in G2-G3 pts with RVR + basal LVL but advanced fibrosis, cirrhosis, # cofactors affecting response . (Shiffman et al, 2007; Kau et al, 2008; Romero-Gomez et al, 2008;Zeuzem et al, 2004) 28

Effectiveness of extended treatment duration in HCV G1 Slow Responders 58% 44% 38% 28% 26% 18% No.455 No.510 No.455 Sanchez-Tapias et al* Berg et al* Pearlman et al** *RBV 800mg **RBV 800-1400mg Sànchez-Tapias et al. Gastroenterology 2006;131:451-460 Berg et al, Gastroenterology 2006; 130:1086-97 Perlman et al 2007; 46:1688-94 29

Consistent improvement with 72 weeks therapy in HCV G1 pEVR patients 100 90 80 69% 48 weeks 70 72 weeks 60 52% SVR (%) 50 44% 40 30 20 16% 10 n= 31 25 25 16 TeraVic-4 Ferenci et al.* RBV 1000/1 200 mg/day RBV 800 mg/day From Alberti A, 2008, modified * Includes small number (<10%) of G4 patients 30

The Importance of Delayed Viral Response (DVR) EASL 2011: The Importance of Delayed Viral Response (DVR) G1 pts. with DVR can be treated for 72 w in the hope to minimizing the risk of relapse G non-1: insufficient data exist Mangia et al, 2008; Berg et al, 2006; Pearlman et al, 2007; Sanchez-Tapias et al, 2006; Ferenci et al, 2010; Buti et al, 2010; Farnik et al, 2010 31

Il problema dei non responder Il numero dei non-responders incrementa annualmente Si estende una popolazione di pazienti cirrotici con evoluzione di malattia Per tali pazienti l’ultima possibilità è rappresentata dall’OLT Morbidity and mortality associated with chronic hepatitis C is projected to increase dramatically as shown on the first few slides of this presentation. The number of nonresponders is increasing yearly and will present an increasing burden on the healthcare system, at least until the year 2020. Nonresponse is influenced by a multitude of factors—host, genetic, and viral related. Suboptimal adherence should always be considered as a potential reason for any treatment failure, and it is advisable to obtain office medical records if the patient was treated in an outside clinic.

I Tentativi Tre grandi studi randomizzati, HALT-C, COPILOT, e EPIC3, hanno esaminato il ruolo della monoterapia di mantenimento con basse dosi di peginterferone nei pazienti che non avevano raggiunto SVR alle terapie standard. I trials sono molto simili e sono stati inclusi pazienti con stadi relativamente avanzati della malattia. In effetti, il 40% dei pazienti nello studio HALT-C e 83% nel COPILOT avevano cirrosi. L'HALT-C e gli studi EPIC3 incluso un lead-in fase con peginterferone a dosi standard e ribavirina prima del periodo di mantenimento , mentre lo studio COPILOT non ha incluso un lead-in fase. In generale, i pazienti in ogni prova sono stati trattati con terapia di mantenimento a basse dosi di 3,5-4,0 anni.

Design and Baseline Characteristics of HCV Maintenance Therapy Trials HALT-C COPILOT EPIC3 Fibrosis score Ishak 3-6 Metavir 2-4 Nonresponders, n 1050 (IFN/RBV failures) 600 (PegIFN/RBV + IFN/RBV failures) 978 (PegIFN/RBV + IFN/RBV failures) Endpoint Fibrosis/clinical Clinical Arm 1 PegIFN alfa-2a 90 µg/wk PegIFN alfa-2b 0.5 µg/kg/wk Arm 2 Observation Colchicine 6 mg BID Lead-in phase PegIFN alfa-2a 180 µg/wk + RBV 1000-1200 mg/day None PegIFN alfa-2b 1.5 µg/kg/wk + RBV 800-1400 mg/day Treatment duration, yrs 3.5 4.0 Cirrhosis, % 40 83 N/A BID, twice daily; HCV, hepatitis C virus; IFN, interferon; pegIFN, peginterferon; RBV, ribavirin.   Three large randomized trials, HALT-C, COPILOT, and EPIC3, examined the role of maintenance monotherapy with lower doses of peginterferon in patients who did not achieve SVR to standard therapies. The trials were very similar and included patients with relatively advanced stages of disease. In fact, 40% of patients in the HALT-C study and 83% in the COPILOT trial had cirrhosis. The HALT-C and EPIC3 studies included a lead-in phase with standard-dose peginterferon/ribavirin before the maintenance dosing period, whereas the COPILOT study did not include a lead-in phase. In general, patients in each trial were treated with low-dose maintenance therapy for 3.5-4.0 years.

Summary of Maintenance PegIFN Trials in HCV Patients I 3 ampi studi randomizzati non hanno dimostrato miglioramento complessivo endpoint significativi, come la progressione della fibrosi, HCC, o morte COPILOT [1]: il 49% dei pazienti hanno avuto manifestazioni cliniche nei 4 anni della durata del trattamento. HALT-C [2]: Nessuna differenza significativa tra la terapia di mantenimento versus osservazione in qualsiasi endpoint primario 34,1% vs 33,8%, HR: 1.01 (95% CI: 0,81-1,26) EPIC3 [3]: gli eventi clinici non ha ridotto significativamente da terapia di mantenimento versus osservazione generale (p = 0,144), ma una terapia di mantenimento può ritardare la progressione dell'ipertensione portale e sanguinamento da varici esofagee nel sottogruppo di pazienti I pazienti con fibrosi avanzata, anche se non cirrotici, in grado di sviluppare HCC e dovrebbero essere sottoposti a sorveglianza 1. Afdhal N, et al. EASL 2008. Abstract 3. 2. Di Bisceglie AM, et al. N Engl J Med. 2008;359:2429-2441. 3. Bruix J, et al. EASL 2009. Abstract 49.

Chi deve essere trattato? Tutti i pazienti naive con malattia epatica compensata da HCV che sono disposti a farsi trattare e non hanno controindicazioni alla terapia con PEG-IFN alfa e RBV devono essere considerati per il trattamento, indipendentemente dal valore delle ALT al BL; La terapia deve essere iniziata nei pazienti con fibrosi avanzata e presa fortemente in considerazione nei pazienti con fibrosi moderata; I pazienti con HCV G1 che non rispondono ad un ciclo di terapia con PegIFN e ribavina non devono essere trattati con lo stesso schema  devono aspettare le nuove molecole; I pazienti con HCV di genotipo diverso dall’1 che non rispondono ad un ciclo di terapia con PegIFN e ribavina possono essere ritrattati con PegIFN e ribavina, poiché le nuove terapie non offrono loro una possibilità di terapia.

Selected HCV Drugs in Clinical Development Type of Drug Drug Interferons Albinterferon alfa-2b Controlled-release interferon alfa-2b Interferon alfa-2bXL ITCA638 Peginterferon-lambda (PEG-rIL-29) Ribavirin prodrug Taribavirin Other drugs Nitazoxanide Silibinin Immuno-modulators Therapeutic vaccines

Selected HCV Drugs in Clinical Development HCV Inhibitors Drug Entry inhibitors PRO206 (development recently halted) Cyanovirin-N Polyclonal immunoglobulins Monoclonal antibodies NS3/4A protease inhibitors Telaprevir (VX-950) Boceprevir (SCH 503034) TMC435 R7227 (ITMN-191) MK-7009 BI201335 SCH 900518 Nucleos(t)ide analogues R7128 IDX184 Nonnucleoside RdRp inhibitor GS-9190 ANA598 BI207127 VCH-916 Filibuvir (PF-00868554) NS5A inhibitors BMS-790052 Cyclophilin inhibitors DEBIO-025 SCY-635 NIM811 HCV assembly/release inhibitors Celgosivir .

Schematic Representation of the HCV Lifecycle Transport and release Receptor binding and endocytosis Fusion and uncoating (+) RNA ER lumen LD LD Virion assembly LD Membranous web ER lumen Translation and polyprotein processing RNA replication Reprinted by permission from Macmillan Publishers Ltd: NATURE Lindenbach BD, Rice CM. Unravelling hepatitis C virus replication from genome to function. 36:933-938, copyright 2005. www.nature.com 39

Schematic Representation of the HCV Lifecycle Inhibitors of HCV Entry and Fusion Inhibitors of HCV Entry and Fusion Every step of the HCV life cycle constitutes a potential target for 1 or several classes of inhibitor molecules with multiple target sites (DAA) Schematic Representation of the HCV Lifecycle Inhibitors of HCV entry and fusion (i.e., PRO 206) Transport and release Receptor binding and endocytosis Inhibitors of HCV Assembly and Release (i.e., Celgosivir) Fusion and uncoating Inhibitors of HCV Polyprotein Translation (i.e., VGX-410C ) (+) RNA ER lumen Inhibitors of HCV Polyprotein Processing (i.e., telaprevir (VX-950), boceprevir (SCH 503034), TMC 435, ITMN-191/R7227, MK-7009, BI 201335, and SCH 900518. ) LD LD Virion assembly LD Membranous web Inhibitors of HCV Replication Direct inhibitors of the HCV RdRp: nucleoside/nucleotide analogues and nonnucleoside inhibitors. NS5A inhibitors and cyclophilin inhibitors. ER lumen Translation and polyprotein processing RNA replication NATURE Lindenbach BD, Rice CM. Unravelling hepatitis C virus replication from genome to function. 2005. 40

DAA Targets Under Investigation NS3/4A Protease Function I Inhibition of NS3/4A protease leads to blocking of HCV polyprotein processing HCV polyprotein C E1 E2 p7 2 3 3 4A 4B 5A 5B NS3-protease cofactor Cysteine protease Core RNA-dependent RNA polymerase Envelope Serine Protease NTPase/ helicase Inhibition of NS3/4A protease leads to restoration of innate immune system From Sarrazin, modified 41

DAA (Direct-Acting Antivirals): prospettive Soppressione virale rapida e potente Aumento della SVR nei genotipi difficili, in particolare nel genotipo 1 Riduzione della durata della terapia per alcuni pazienti naive (?) Recupero della risposta nei non responders 42

Caratteristiche di base degli inibitori della proteasi Interagiscono con la triade catalitica della NS3 serina proteasi Solco di legame piatto Farmaci potenti Dipendenti dal genotipo HCV Rapida selezione di ceppi resistenti Il solco di legame piatto li rende instabili (singole mutazioni possono spostarle dal sito di attacco). Potenti 4 logaritmi. Anche se non del tutto genotipo dipendenti. 43

Caratteristiche di base degli inibitori nucleosidici della polimerasi Analoghi del substrato naturale Devono essere trifosforilati Funzionano come terminatori di catena nelle molecole di RNA in allungamento Agiscono su tutti i genotipi Alta barriera genetica allo sviluppo di resistenze Singolarmente poco potenti Interessanti le ultime due 44

Inibitori allosterici della sintesi della catena di RNA Caratteristiche di base degli inibitori non nucleosidici della polimerasi Inibitori allosterici della sintesi della catena di RNA Diversi siti di attacco sulla polimerasi Dipendenti dal genotipo HCV L’efficacia può essere influenzata da polimorfismi naturali Rapida selezione di ceppi resistenti Meno lontani dall’immissione in commercio. La mutazione per uno non dà resistenza di classe 45

Boceprevir and Telaprevir Boceprevir, a potent inhibitor of HCV NS3/4A protease Telaprevir, a potent inhibitor of HCV NS3/4A protease Both being tested in combination with standard-of-care pegIFN alfa-2/RBV in phase III studies in chronic HCV infection Boceprevir SPRINT 1-2: naive GT1 patients RESPOND-2: nonresponder GT1 patients (partial responders and relapsers) Telaprevir PROVE 1, PROVE 2, ADVANCE: naive GT1 patients ILLUMINATE: response-guided therapy in naive GT1 paitents PROVE 3, REALIZE: nonresponder GT1 patients (null responders, partial responders, relapsers) GT1, genotype 1; HCV, hepatitis C virus.   This slide is a summary of the clinical development of the protease inhibitors boceprevir and telaprevir. Both boceprevir and telaprevir are potent inhibitors of the NS3/4A serine protease; both have been tested in combination with the standard of care (peginterferon plus ribavirin) in large phase III trials. The phase III trials for boceprevir were SPRINT-2 and RESPOND-2. In SPRINT-2, only treatment-naive genotype 1–infected patients were enrolled. The nonresponder trial for boceprevir in phase III is called RESPOND-2. Nonresponders were HCV genotype 1–infected patients who had had a partial response to the previous treatment or a relapse. Partial responders were defined as those patients who had ≥ 2 log10 IU/mL decline at Week 12 of previous therapy. The pivotal phase III trials that included telaprevir are ADVANCE, ILLUMINATE, and REALIZE. ADVANCE investigated the treatment of treatment-naive, HCV genotype 1–infected patients with the addition of either 8 or 12 weeks of telaprevir to the standard of care. ILLUMINATE investigated the question of whether treatment can be shortened in rapid responders. REALIZE is the nonresponder study for telaprevir, but this trial included not only partial responders and relapsers but also those who have experienced a null response to previous treatment, that is, patients who have had < 2 log10 IU/mL decline in HCV RNA with previous standard of care treatment. 46

Similarities and Differences in Phase III Studies of TVR and BOC in GT1 Naive Pts Parameter TVR[1] BOC[2] PR lead-in? No Yes: 4 wks PegIFN alfa formulation 2a 2b PI dosing requirements TID; administer with fatty meal TID Duration of PI triple therapy 8-12 wks followed by 12-40 wks PR 24-44 wks after 4 wks PR lead-in Qualification for shortened therapy (response guided) Undetectable HCV RNA until Wk 12 of triple therapy Undetectable HCV RNA until Wk 24 of triple therapy Qualified for shortened therapy, % 58 (24 wks) 44 (28 wks) SVR, % 69-75 63-66 Relapse, % 9 Adverse events more frequent in PI arms Rash, anemia, pruritus, nausea Anemia, dysgeusia BOC, boceprevir; eRVR, early rapid virologic response; GT1, genotype 1; pegIFN, peginterferon; PI, protease inhibitor; PR, peginterferon/ribavirin; SVR, sustained virologic response; TID, 3 times daily; TPV, telaprevir.   This slide summarizes the similarities and differences in the phase III trials using boceprevir or telaprevir. The first difference is that the studies using boceprevir incorporated a lead-in phase of peginterferon/ribavirin before boceprevir was added. During this lead-in phase, patients received peginterferon/ribavirin for the first 4 weeks without the protease inhibitor. In the telaprevir trials, all patients were started immediately with all 3 compounds—peginterferon, ribavirin, and telaprevir—together. The peginterferon alfa formulation is different between the trials. All telaprevir phase III trials included peginterferon alfa-2a, and all boceprevir trials used peginterferon alfa-2b. The dosing intervals are similar: 3 times daily dosing is required for both protease inhibitors. Some trials are investigating whether telaprevir could also be given twice daily, but at this time we have only limited data that this may be possible. Therefore, at approval, the dosing schedule will most likely be 3 times daily for both compounds. The duration of the protease triple therapy also differs. With telaprevir, the addition of the protease inhibitor is generally for 12 weeks followed by another 12-40 weeks of peginterferon/ribavirin; the addition of boceprevir is typically longer, for 24 weeks at least. The qualification for shortened therapy is defined with eRVR for both compounds. However, in the telaprevir trials, eRVR was defined from Week 4 to 12, and for the boceprevir trials it was defined from Week 8 (ie, 4 weeks after the addition of boceprevir) until Week 24 of triple therapy. The proportion of patients who qualified for shortened therapy was slightly larger for telaprevir compared with boceprevir; however, SVR rates were quite similar, as indicated on this slide. There were clearly differences in the adverse event profiles. There are some characteristic side effects for telaprevir, typically rash, anemia, pruritus, and nausea in some patients. The typical side effects for boceprevir are anemia and dysgeusia (bad taste). 1. Jacobson IM, et al. AASLD 2010. Abstract 211. 2. Poordad F, et al. AASLD 2010. Abstract LB-4. 47

Somiglianze e differenze La prima differenza è che gli studi con Boceprevir vi è un lead-in dopo la fase di peginterferone e ribavirina. I pazienti hanno ricevuto peginterferone e ribavirina per le prime 4 settimane senza inibitore della proteasi. Negli studi di Telaprevir, tutti i pazienti hanno iniziato subito con tutti e 3 i farmaci: peginterferone, ribavirina e Telaprevir. La formulazione del peginterferone alfa è diversa nei vari studi registrativi di fase III Telaprevir alfa-2a, mentre Boceprevir alfa-2b. Gli intervalli di dosaggio sono invece simili: 3 somministrazioni giornaliere. Alcuni studi stanno indagando se Telaprevir possa essere somministrato due volte al giorno, ma in questo momento abbiamo solo dati limitati .

SVR Rates in the SPRINT-1 (Phase II) Trial in Naive Patients Infected With Genotype 1 HCV Treatment Arm N SVR, n (%) P Value vs Control Control* 104 39 (38) -- P/R/B 28 wks† 107 58 (54) .013 P/R 4 wks -> P/R/B 24 wks‡ 103 58 (56) .0005 P/R/B 48 wks§ 69 (67) < .0001 P/R 4 wks -> P/R/B 44 wks|| 77 (75) P/low-dose R/B 48 wks¶ 59 21 (36) NR *Control: peginterferon alfa-2b 1.5 g/kg/wk + weight-based ribavirin (800-1400 mg/day) for 48 wks. †P/R/B 28 wks = boceprevir 800 mg 3 times daily + peginterferon alfa-2b + weight-based ribavirin for 28 wks (no lead-in phase). ‡P/R 4 wks -> P/R/B 24 wks: peginterferon alfa-2b + weight-based ribavirin for 4 wks (lead-in phase), then boceprevir + peginterferon alfa-2b + weight-based ribavirin for 24 wks. §P/R/B 48 wks: boceprevir + peginterferon alfa-2b + weight-based ribavirin for 48 weeks (no lead-in phase). ||P/R 4 wks -> P/R/B 44 wks: peginterferon alfa-2b + weight-based ribavirin for 4 wks (lead-in phase), then boceprevir + peginterferon alfa-2b + weight-based ribavirin for 44 wks. ¶P/low-dose R/B 48 wks: boceprevir + peginterferon alfa-2b + low weight-based dose ribavirin (400-1000 mg/day) for 48wks. Kwo P, et al. EASL 2009. Abstract 4.

Treatment-experienced patients with GT1 HCV Phase III RESPOND-2: Boceprevir in GT1 Prior Nonresponders to PegIFN/RBV Wk 8 Wk 36 Wk 48 If detectable at Wk 8 BOC + PR* PR* Follow-up† PR* (n = 162) BOC + PR* Follow-up† Treatment-experienced patients with GT1 HCV (N = 403) PR* (n = 161) BOC + PR* Follow-up† Nei non responders: lead in poi 36 settimane se non rvr, PR* (n = 80) Follow-up† *BOC 800 mg TID; pegIFN alfa-2b 1.5 µg/kg/wk; weight-based RBV 600-1400 mg/day. †Follow-up for 24 wks after completion of therapy. Bacon BR, AASLD 2010 50

RESPOND-2: SVR Rates According to Treatment Arm and Prior Response 4-wk PR + response-guided BOC + PR (n = 162) P < .0001 vs control (both arms) 100 4-wk PR + 44-wk BOC + PR (n = 161) 80 75 48-wk PR (n = 80) 66 69 59* 60 52 SVR (%) 40 40 La RGT raggiunge quasi gli stessi risultati consentendo di abbreviare il trattamento a 36 settimane anzichè 48. Ancora migliori I relapsers dei non responders. Maggiore è il calo durante la leading phase e meglio rispondono alla fine. 29 21 20 95/ 162 107/161 17/80 23/57 30/58 7 72/105 77/103 15/51 2/29 Overall Previous Nonresponders Previous Relapsers Bacon BR, AASLD 2010 51

SVR Rates in PROVE 1, PROVE 2, and PROVE 3 Trials Study Patient Population Treatment Arm* N SVR,† n (%) P Value vs PR48 PROVE 1[1] Treatment naive, genotype 1* PR48‡ 75 31 (41) T12PR24§ 79 48 (61) .02 T12PR48|| 53 (67) .002 T12PR12¶ 17 6 (35) ND PROVE 2[2] Treatment naive, genotype 1 82 38 (46) 81 56 (69) .004 49 (60) .12 T12P12# 78 28 (36) .20 PROVE 3[3] Peginterferon and ribavirin treatment failure, genotype 1 114 16 (14) 115 59 (51) < .001 T24PR48** 113 59 (52) T24P24‡‡ 111 26 (23) .035 *Peginterferon alfa-2a administered at 180 μg/week. Ribavirin administered at 1000 or 1200 mg/day according to body weight. Telaprevir administered at 1250 mg on Day 1 then 750 mg every 8 hours thereafter. †Intent-to-treat analysis. ‡PR48: peginterferon alfa-2a + ribavirin for 48 weeks. §T12PR24: telaprevir + peginterferon alfa-2a + ribavirin for 12 weeks followed by peginterferon alfa-2a + ribavirin for 12 weeks. ||T12PR48: telaprevir + peginterferon alfa-2a + ribavirin for 12 weeks followed by peginterferon alfa-2a + ribavirin for 36 weeks. ¶T12PR12: telaprevir + peginterferon alfa-2a + ribavirin for 12 weeks. #T12P12: telaprevir + peginterferon alfa-2a without ribavirin for 12 weeks. **T24PR48: telaprevir + peginterferon alfa-2a + ribavirin for 24 weeks followed by peginterferon alfa-2a + ribavirin for 24 weeks. ‡‡T24P24: telaprevir + peginterferon alfa-2a without ribavirin for 24 weeks. ND, not determined; SVR, sustained virologic response. 1. McHutchison JG, et al. N Engl J Med. 2009;360:1827-1838. 2. Hézode C, et al. N Engl J Med. 2009;360:1839-1850. 3. Manns M, et al. EASL 2009. Abstract 1044.

REALIZE: SVR in base alla precedente risposta Conferma di quanto detto prima REALIZE S.Zeuzem et al. J.Hepatology 2011 Suppl 1,vol 54,A5, EASL 30-3/3-4-2011.BERLIN 53

Boceprevir: Adverse Events and Discontinuations Outcome RGT arm 48 wks tx (exp. Arm) Control arm Adverse event, % Anemia 49 29 EPO use 41 46 21 Dysgeusia 37 43 18 stop due to AEs 12 16 2 1 Telaprevir: Adverse Events AE % 12-Wk TPV+ P/R 12-Wk TPV + 24-Wk P/R 12-Wk TPV + 48-Wk P/R Control Arm Pruritus 24 48 40 23 Rash 53 60 61 41 Anemia 35 37 29 27

Caratteristiche HCV Drive replicativo importante (1012 particelle al giorno) Non ha capacità di riparare gli errori commessi durante la replicazione con circa 1020 varianti al giorno (ogni particella ha circa 108 mutazioni) Facile sviluppo di resistenza

Le mutazioni esistono in pazienti naive % Importanza delle terapie di combinazione Genotipo HCV Gaudieri S, Hepatology 2009 56

Cross-resistenza inibitori della proteasi V36 T54 V65 Q80 R155 A156s A156v D168 V170 Telaprevir Boceprevir Narlaprevir ITMN-191 MK-7009 TMC435 BI201335 Alcune mutazioni conferiscono resistenza di classe, vedremo con i prossimi Susser S, Hepatology 2009 57

CRITICITA’ La terapia con DAD per essere efficace necessita dell’associazione con PEGIFN e ribavirina I farmaci di nuova generazione sono gravati da un alto tasso di induzione di resistenze La necessità di ricorrere a terapie di associazione comporta il determinarsi di due altri problemi: a) l’aderenza al trattamento b) i costi

Nuovi agenti antivirali: quale futuro? potenziamento o sostituzione? Attuale SOC Triplice terapia Quadruplice terapia Regime interferon free Peg-IFN RBV Inibitore proteasi Inibitore polimerasi Futuro verso regimi IFN free 2010-2011 2011 2012-2013 2016 59

Grazie per l’attenzione