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Jean-Michel PAWLOTSKY. How to Use Virological Tools for the Optimal Management of Chronic Hepatitis C ? Prof. Jean-Michel Pawlotsky, MD, PhD French National.

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Presentation on theme: "Jean-Michel PAWLOTSKY. How to Use Virological Tools for the Optimal Management of Chronic Hepatitis C ? Prof. Jean-Michel Pawlotsky, MD, PhD French National."— Presentation transcript:

1 Jean-Michel PAWLOTSKY

2 How to Use Virological Tools for the Optimal Management of Chronic Hepatitis C ? Prof. Jean-Michel Pawlotsky, MD, PhD French National Reference Center for Hepatitis B, C and delta, Department of Virology & INSERM U841, Henri Mondor Hospital University of Paris 12 Créteil, France

3 Virological Markers in HCV Treatment Monitoring HCV genotypeHCV genotype Tailor ribavirin dose and treatment durationTailor ribavirin dose and treatment duration HCV RNA presence and levelHCV RNA presence and level Decide to treatDecide to treat Assess virological responsesAssess virological responses Tailor treatment duration to the actual virological responseTailor treatment duration to the actual virological response

4 I HCV Virological Tools

5 HCV Genotype Determination

6 HCV Genotypes (Simmonds P., et al. Hepatology 2005;42:962-73)

7 HCV Genotype Determination Molecular methods (genotyping):Molecular methods (genotyping): Direct sequence analysisDirect sequence analysis Reverse hybridization: “line probe assay“ (Inno-LiPA)Reverse hybridization: “line probe assay“ (Inno-LiPA) Serological methods (“serotyping“)Serological methods (“serotyping“) Competitive ELISACompetitive ELISA

8 HCV Genotype Determination HCV genome

9 HCV Genotype Determination HCV genome NS5B

10 HCV Genotype Determination HCV genome NS5B 5’ noncoding region

11 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) 491 patients, HCV genotype 1 (local method)

12 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) 491 patients, HCV genotype 1 (local method) NS5B sequence analysis

13 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) 491 patients, HCV genotype 1 (local method) 1a (n=226, 46%) 1b (n=245, 50%) other 1 (n=11, 2%) 1d (n=4) 1e (n=2) 1i (n=1) 1l (n=1) 1nd (n=3) NS5B sequence analysis non-1 (n=9, 2%) 2l (n=1) 3a (n=2) 6 (n=6)

14 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 1a (n=226) 5’NC region 1a (n=180) 1b (n=39) 1nd (n=7)

15 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 1a (n=226) NS5B 1b (n=245) 5’NC region 1a (n=180) 1b (n=39) 1nd (n=7) 5’NC region 1b (n=229) 1a (n=8) 1nd (n=8)

16 7% Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 1a (n=226) NS5B 1b (n=245) 5’NC region 1a (n=180) 1b (n=39) 1nd (n=7) 5’NC region 1b (n=229) 1a (n=8) 1nd (n=8) 20%

17 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 1d (n=4) 1e (n=2) 1i (n=1) 1l (n=1) 1nd (n=3) 5’NC region 1b (n=3) 1nd (n=1) 1a (n=2) 1nd (n=1) 1a (n=1) 1a (n=2) 1b (n=1)

18 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 1d (n=4) 1e (n=2) 1i (n=1) 1l (n=1) 1nd (n=3) 5’NC region 1b (n=3) 1nd (n=1) 1a (n=2) 1nd (n=1) 1a (n=1) 1a (n=2) 1b (n=1) 100%

19 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 2l (n=1) 3a (n=2) 6 (n=6) 5’NC region 1 (n=1) 3a (n=2) 1a (n=1) 1b (n=5)

20 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 2l (n=1) 3a (n=2) 6 (n=6) 5’NC region 1 (n=1) 3a (n=2) 1a (n=1) 1b (n=5) ?

21 Subtyping in the 5’NC Region (Chevaliez S., et al., AASLD 2006) NS5B 2l (n=1) 3a (n=2) 6 (n=6) 5’NC region 1 (n=1) 3a (n=2) 1a (n=1) 1b (n=5) ? ?

22 Current LiPA Assay 2a/b 3a 4a 1b 1a 5a 6a Marker CC CC AC AC 3456789101112131415161718192021 Band positions 5’NC region probes

23 New LiPA Assay 3 18 17 15 19 20 21 23. AC Marker CC CC AC AC 4 8 7 5 6 9 10 11 12 13 14 25. 1 a 26. 1 b 24. 6 c-l 16 2a/b 3a 4a 6a 1b 61a 5’NC region probes core region probes

24 GenotypeSubtype 1 a, b 2 a, b, c 3 a, b, c, k 4 a, b, c, d, e, f, h 5a 6 a, c-l New LiPA Assay

25 Detection and Quantification of HCV RNA

26 Ranges of Linear Quantification of HCV RNA Assays (IU/ml) 10 10 2 10 3 10 4 10 5 10 6 10 7 10 8 Cobas Amplicor HCV Monitor v2.0 Versant HCV RNA 3.0 (bDNA) Untreated hepatitis C

27 Advantages of Real-Time PCR Quantification Improved sensitivityImproved sensitivity No carryover contaminationNo carryover contamination Extended dynamic range of quantificationExtended dynamic range of quantification Precision and reproducibilityPrecision and reproducibility

28 Real-Time PCR Platforms for HCV RNA Roche Molecular Systems:Roche Molecular Systems: Cobas Taqman ® HCV TestCobas Taqman ® HCV Test Amplification: Cobas Taqman ®Amplification: Cobas Taqman ® Extraction: Cobas Ampliprep ® (CAP/CTM)Extraction: Cobas Ampliprep ® (CAP/CTM) Abbott DiagnosticAbbott Diagnostic Abbott Real-Time HCV AssayAbbott Real-Time HCV Assay Amplification: m2000 RT SystemAmplification: m2000 RT System Extraction: m2000 SP (m2000 Real-Time PCR System)Extraction: m2000 SP (m2000 Real-Time PCR System)

29 Ranges of Linear Quantification of HCV RNA Assays (IU/ml) 10 10 2 10 3 10 4 10 5 10 6 10 7 10 8 Cobas Amplicor HCV Monitor v2.0 Versant HCV RNA 3.0 (bDNA) Untreated hepatitis C

30 Ranges of Linear Quantification of HCV RNA Assays (IU/ml) 10 10 2 10 3 10 4 10 5 10 6 10 7 10 8 Cobas Amplicor HCV Monitor v2.0 Versant HCV RNA 3.0 (bDNA) Untreated hepatitis C Cobas TaqMan HCV Test (Roche) Abbott Real-Time HCV Assay (Abbott)

31 Roche Real-Time PCR Cobas Ampliprep ® Cobas Taqman ® Cobas Ampliprep ® /Cobas Taqman ® (CAP/CTM) platform

32 Calibration of CAP/CTM HCV AcroMetrix HCV RNA Panel r = 0.9981; p < 0.0001 HCV RNA level in CAP/CTM (Log 10 IU/ml) 6 5 4 3 2 1 0 7 8 Expected HCV RNA level (Log 10 IU/ml) 012345678 (Chevaliez et al., Hepatology 2007; in press)

33 Overestimation of HCV RNA Levels in CAP/CTM vs bDNA -1.5 -0.5 0 0.5 1.0 1.5 Genotype 1 Genotype 2 Genotype 3 Genotype 4 Genotype 5 Difference between HCV RNA levels measured in CAP/CTM and in bDNA (in Log 10 UI/ml) (Chevaliez et al., Hepatology 2007; in press)

34 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 HCV RNA (Log 10 IU/ml) Dilutions undiluted 1/5 1/25 1/1251/625 1/3125 1/156251/78125 HCV genotype 1 1.0 2.0 3.0 4.0 5.0 6.0 7.08.0 HCV RNA (Log 10 IU/ml) Dilutions undiluted 1/5 1/25 1/1251/625 1/3125 1/15625 1/78125 HCV genotype 2 Overestimation of HCV RNA Levels in CAP/CTM vs bDNA (Chevaliez et al., Hepatology 2007; in press)

35 Genotype 1 (n=29) Genotype 2 (n=27) Genotype 3 (n=29) Genotype 4 (n=30) Genotype 5 (n=9) Genotype 6 (n=2) -1.5 1.0 - 1. 0 1.50.0 0.5 -0.5 Underestimation of HCV RNA Levels by CAP/CTM in Genotypes 2 and 4 (Chevaliez et al., Hepatology 2007; in press)

36 Genotype 1 (n=29) Genotype 2 (n=27) Genotype 3 (n=29) Genotype 4 (n=30) Genotype 5 (n=9) Genotype 6 (n=2) -1.5 1.0 - 1. 0 1.50.0 0.5 -0.5 Underestimation of HCV RNA Levels by CAP/CTM in Genotypes 2 and 4 (Chevaliez et al., Hepatology 2007; in press) 15% 30%

37 Abbott Real-Time PCR m2000 RT

38 (Chevaliez et al., in progress) Abbott Real-Time PCR

39 II Treatment Algorithms

40 HCV Genotype Determination Type1Types 2, 3 Types 4, 5, 6

41 HCV GENOTYPE 1

42 Assessment of liver disease severity

43 HCV GENOTYPE 1 Assessment of liver disease severity Good prognosis Follow-up without treatment

44 HCV GENOTYPE 1 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks

45 HCV GENOTYPE 1 HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks

46 HCV GENOTYPE 1 < 2 log HCV RNA decrease HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks Stop treatment OR continue to slow liver disease progression

47 HCV GENOTYPE 1 ≥ 2 log HCV RNA decrease or HCV RNA (-) Continue treatment < 2 log HCV RNA decrease HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks Stop treatment OR continue to slow liver disease progression

48 HCV GENOTYPE 1 ≥ 2 log HCV RNA decrease or HCV RNA (-) Continue treatment < 2 log HCV RNA decrease HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV RNA quantification at week 24 Stop treatment OR continue to slow liver disease progression

49 HCV GENOTYPE 1 ≥ 2 log HCV RNA decrease or HCV RNA (-) Continue treatment < 2 log HCV RNA decrease HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV RNA quantification at week 24 HCV RNA ≥ 50 IU/ml Stop treatment OR continue to slow liver disease progression Stop treatment OR continue to slow liver disease progression

50 HCV GENOTYPE 1 ≥ 2 log HCV RNA decrease or HCV RNA (-) Continue treatment < 2 log HCV RNA decrease HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV RNA quantification at week 24 HCV RNA <50 IU/ml Continue treatment HCV RNA ≥ 50 IU/ml Stop treatment OR continue to slow liver disease progression Stop treatment OR continue to slow liver disease progression

51 HCV GENOTYPE 1 ≥ 2 log HCV RNA decrease or HCV RNA (-) Continue treatment < 2 log HCV RNA decrease HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment HCV RNA detection at the end of treatment and 24 weeks later Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV RNA quantification at week 24 HCV RNA <50 IU/ml Continue treatment HCV RNA ≥ 50 IU/ml Stop treatment OR continue to slow liver disease progression Stop treatment OR continue to slow liver disease progression

52 HCV GENOTYPE 1 ≥ 2 log HCV RNA decrease or HCV RNA (-) Continue treatment < 2 log HCV RNA decrease End-of-treatment virological response Sustained virological response HCV RNA quantification at baseline and at week 12 Assessment of liver disease severity Bad prognosis Good prognosis Follow-up without treatment HCV RNA detection at the end of treatment and 24 weeks later Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV RNA quantification at week 24 HCV RNA <50 IU/ml Continue treatment HCV RNA ≥ 50 IU/ml Stop treatment OR continue to slow liver disease progression Stop treatment OR continue to slow liver disease progression

53 HCV GENOTYPES 2 or 3

54 Peginterferon + ribavirin 0.8 g qd 24 weeks HCV GENOTYPES 2 or 3

55 Peginterferon + ribavirin 0.8 g qd 24 weeks HCV RNA detection at the end of treatment and 24 weeks later HCV GENOTYPES 2 or 3

56 Peginterferon + ribavirin 0.8 g qd 24 weeks End-of-treatment virological response Sustained virological response HCV RNA detection at the end of treatment and 24 weeks later HCV GENOTYPES 2 or 3

57 HCV GENOTYPES 4, 5 or 6

58 Liver biopsy or serological markers of disease severity HCV GENOTYPES 4, 5 or 6

59 Liver biopsy or serological markers of disease severity Good prognosis Follow-up without treatment HCV GENOTYPES 4, 5 or 6

60 Liver biopsy or serological markers of disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV GENOTYPES 4, 5 or 6

61 Liver biopsy or serological markers of disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks HCV RNA detection at the end of treatment and 24 weeks later HCV GENOTYPES 4, 5 or 6

62 Liver biopsy or serological markers of disease severity Bad prognosis Good prognosis Follow-up without treatment Peginterferon + ribavirin 1.0-1.2 g qd 48 weeks End-of-treatment virological response Sustained virological response HCV RNA detection at the end of treatment and 24 weeks later HCV GENOTYPES 4, 5 or 6

63 III Future Challenges

64 Future Challenges Better tailor treatment duration:Better tailor treatment duration: Treat shorter when no more is neededTreat shorter when no more is needed Treat longer when more is neededTreat longer when more is needed

65 Shorter Treatment

66 16 weeks 24 weeks 0 20 40 60 80 100 65% 82% 65% 71% % SVR 60% 70% 86% 77% n=346n=303n=333n=327 Genotype 2 Genotype 3 p=<0.0001 p=0.1565 60% 70% 66% 76% ACCELERATE Trial (Genotypes 2 & 3) (Shiffman et al., EASL 2006)

67 Tailored Duration in Genotypes 2/3 Standard duration group (n = 70)Standard duration group (n = 70) 24 weeks of peginterferon-ribavirin therapy24 weeks of peginterferon-ribavirin therapy SVR: 76%SVR: 76% Variable duration group (n = 213)Variable duration group (n = 213) 12 weeks of treatment if HCV RNA negative* at week 412 weeks of treatment if HCV RNA negative* at week 4 24 weeks of treatment if HCV RNA positive* at week 424 weeks of treatment if HCV RNA positive* at week 4 SVR: 82%SVR: 82% * < 50 IU/ml (Mangia et al., N Engl J Med 2005;352:2609-17)

68 Patients infected with HCV genotype 1Patients infected with HCV genotype 1 Baseline HCV RNA level < 600,000 IU/mlBaseline HCV RNA level < 600,000 IU/ml PegIFN-  2b + ribavirinPegIFN-  2b + ribavirin Treatment duration: 24 weeksTreatment duration: 24 weeks Comparison with historical data from the Manns’ trial (Lancet 2001)Comparison with historical data from the Manns’ trial (Lancet 2001) Shorter Duration in Genotype 1 (Zeuzem et al., J Hepatol 2006;44:97-103)

69 Shorter Duration in Genotype 1 0 10 20 30 40 50 60 70 80 90 100 Week 4Week 12Week 24 24 weeks 48 weeks (historical data from the Mann’s trial) Time to first negative HCV RNA (< 50 IU/ml) % Sustained virological response (Zeuzem et al., J Hepatol 2006;44:97-103)

70 PegIFN-  2a + ribavirin:PegIFN-  2a + ribavirin: 24-LD: 0.8 g/d of ribavirin, 24 weeks24-LD: 0.8 g/d of ribavirin, 24 weeks 24-SD: 1.0-1.2 g/d of ribavirin, 24 weeks24-SD: 1.0-1.2 g/d of ribavirin, 24 weeks 48-LD: 0.8 g/d of ribavirin, 48 weeks48-LD: 0.8 g/d of ribavirin, 48 weeks 48-SD: 1.0-1.2 g/d of ribavirin, 48 weeks48-SD: 1.0-1.2 g/d of ribavirin, 48 weeks Tailored Duration in Genotype 1 (Jensen et al., Hepatology 2006;43:954-960)

71 0 10 20 30 40 50 60 70 80 90 100 HCV RNA < 50 IU/ml at week 4HCV RNA ≥ 50 IU/ml at week 4 24-LD 24-SD % Sustained virological response (Jensen et al., Hepatology 2006;43:954-960) Tailored Duration in Genotype 1 48-LD 48-SD

72 Longer Treatment

73 Patients with HCV Genotypes 2/3 Older ageOlder age Male genderMale gender High BMIHigh BMI Fibrosis ≥ F3Fibrosis ≥ F3

74 Longer Treatment in Genotype 1 0 10 20 30 40 50 60 70 80 90 100 48 weeks (n=230) 72 weeks (n=225) 53% 54% % SVR (Berg et al., Gastroenterology 2006;130:1086-97)

75 Longer Treatment in Genotype 1 (Berg et al., Gastroenterology 2006;130:1086-97) 0 10 20 30 40 50 60 70 80 90 Week 4Week 12Week 4Week 12 48 weeks 72 weeks HCV RNA < 50 IU/ml % Sustained virological response HCV RNA ≥ 50 IU/ml) NS NS NS p=0.04

76 Summary The rapid virologic responders may receive shorter therapy, whatever the HCV genotypeThe rapid virologic responders may receive shorter therapy, whatever the HCV genotype The slow virologic responders may benefit from longer therapy, whatever the HCV genotypeThe slow virologic responders may benefit from longer therapy, whatever the HCV genotype

77 New Algorithms Genotypes 1, 4 (5 and 6 ?)Genotypes 1, 4 (5 and 6 ?) 24 weeks24 weeks 48 weeks48 weeks 72 weeks72 weeks Genotypes 2 and 3Genotypes 2 and 3 12-16 weeks12-16 weeks 24 weeks24 weeks 48 weeks48 weeks

78 Ranges of Linear Quantification of HCV RNA Assays (IU/ml) 10 10 2 10 3 10 4 10 5 10 6 10 7 10 8 Cobas Amplicor HCV Monitor v2.0 Versant HCV RNA 3.0 (bDNA) Untreated hepatitis C Cobas TaqMan HCV Test (Roche) Abbott Real-Time HCV Assay (Abbott)

79 Urgent Needs Retrospective analyses of major trials (including HCV RNA retesting with more sensitive, real-time PCR-based assays)Retrospective analyses of major trials (including HCV RNA retesting with more sensitive, real-time PCR-based assays) Identification of the decision thresholds with the best predictive value:Identification of the decision thresholds with the best predictive value: Definition of the early virologic responseDefinition of the early virologic response Definition of the slow virologic responseDefinition of the slow virologic response Prospective validation in randomized clinical trials +++Prospective validation in randomized clinical trials +++

80 Conclusions (1) New virological assays are availableNew virological assays are available The new LiPA assay will improve accuracy of genotype and subtype determinationThe new LiPA assay will improve accuracy of genotype and subtype determination Real-time PCR assays are currently replacing classical methods for HCV RNA quantification:Real-time PCR assays are currently replacing classical methods for HCV RNA quantification: They bring: - nearly full automation - improved sensitivity - broader dynamic ranges of quantificationThey bring: - nearly full automation - improved sensitivity - broader dynamic ranges of quantification The current commercial assays still need to be improved in order to ensure accuracyThe current commercial assays still need to be improved in order to ensure accuracy

81 The current algorithms use the HCV genotype and HCV RNA level monitoring:The current algorithms use the HCV genotype and HCV RNA level monitoring: To tailor initial therapyTo tailor initial therapy To stop therapy in those patients unlikely to achieve a sustained virological response, in order to avoid useless costs and side-effectsTo stop therapy in those patients unlikely to achieve a sustained virological response, in order to avoid useless costs and side-effects Future algorithms should now be established to tailor treatment duration to the genotype and the early virologic response, in order to increase cure ratesFuture algorithms should now be established to tailor treatment duration to the genotype and the early virologic response, in order to increase cure rates Conclusions (2)


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