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Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09.

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Presentation on theme: "Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09."— Presentation transcript:

1 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 1 PegIntron Maintenance Therapy in Cirrhotic (METAVIR F4) HCV Patients Who Failed to Respond to Interferon/Ribavirin (IR) Therapy: Final Results of the EPIC 3 Cirrhosis Maintenance Trial J Bruix, T Poynard, M Colombo, E Schiff, J Reichen, K Burak, EJL Heathcote, T Berg, J-L Poo, C Brandao Mello, R Guenther, C Niederau, R Terg, N Boparai, J Harvey, LH Griffel, M Burroughs, CA Brass, JK Albrecht for the EPIC 3 Study Group 44th Annual Meeting of the European Association for the Study of the Liver Friday, April 24, 2009 Copenhagen, Denmark

2 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 2 Background and Aims   A large proportion of HCV patients are nonresponders to previous treatment   HCV-related cirrhosis is associated with hepatocellular carcinoma (HCC) and end-stage liver disease (ESLD)   Interferon therapy has been associated with reduction in rates of HCC a and ESLD-related events b   The aim of this study was to compare long-term, low- dose PEG-IFN alfa-2b with observed controls regarding the occurrence of HCC and ESLD-related events in cirrhotic patients (F4)   Similar trials   COPILOT: 548 cirrhotics; primary end-point negative b   HALT- C: included 428 cirrhotics; all endpoints negative c a Yohsida et al., Gut 2000;47: b Afdhal et al., J. Hepatol, 2008; 48, S2, A3 c DiBiesgelie et al., NEJM, 2008;359:

3 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 3 HCV RNA negative at week 12 Continue P/R for 48 wk EPIC 3 Program Design Nonresponder Trial* : N = 2333 CHC with fibrosis (F2, F3, or F4 METAVIR) Evaluation of virological response at week 12 Chronic Suppression for Noncirrhotics, n = 575 METAVIR F2 or F3 subjects PEG-Intron 0.5  g/kg/wk vs control Duration: 3 years Chronic Suppression for Cirrhotics, n = 626 (Child-Pugh A, Compensated) METAVIR F4 subjects PEG-Intron 0.5  g/kg/wk vs control Max. duration: up to 5 years METAVIR F4 CHC subjects DIRECT ENROLLERS n = 172 n = 454 HCV-RNA Negative HCV-RNA Positive F2/3 F4 * Poynard et al., Gastro 2009:136:

4 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 4 Methods   Study duration   Up to 5 years from time first subject was randomized or occurrence of 98 clinical events   Statistical plan: 90% power for 98 events and hazard ratio of 2   Study completed based upon 5-year rule   Primary objective – time to first clinical event   Liver decompensation (variceal bleed, >grade 2 enceph, ascites requiring Rx, CPT C); HCC; death; liver transplantation.   Clinical evaluation/3 months, US every 6 months   Clinical events, with the exception of death and liver transplantation, were adjudicated by an external adjudication committee

5 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 5 Methods (cont)   Secondary objective – time to disease progression   Includes all clinical events and   Development of Child-Pugh B   Emergence of varices   Enlargement of pre-existing varices requiring additional therapy   Additional prospective analyses in subjects with baseline portal hypertension   Prospectively planned based upon results of COPILOT study   Defined as the existence of esophageal varices   Sensitivity analysis performed using definition of splenomegaly and platelet count <100K

6 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 6 Baseline Demographics Roll-over Subjects From Treatment PhaseDirect EnrollersAll Randomized PEG (n = 224) Control (n = 230) PEG (n = 87) Control (n = 85) PEG (n = 311) Control (n = 315) Male, n (%)155 (69)156 (68)51 (59)59 (69)206 (66)216 (68) Caucasian, n (%)189 (84)197 (86)69 (79)68 (80)258 (83)265 (84) Age, years (SD)52.2 (7.6)51.7 (8.0)52.3 (7.3)53.0 (6.4)52.3 (7.5)52.0 (7.6) Weight, kg (SD)78.08 (14.35)77.48 (14.36) (17.62) (16.26)79.48 (15.47) (15.08) BMI, kg/m 2 (SD)26.72 (4.07)26.78 (4.25)28.55 (5.09) (4.38)27.24 (4.45)27.13 (4.32) Genotype 1, n (%)207 (92)217 (94)71 (82)68 (80)278 (89)285 (90) Viral Load >600,000 IU/mL, n (%) Baseline ALT U/L (SD) 155 (69) (70.2) 161 (70) (80.4) 58 (67) 102 (66.5) 59 (69) (65.9) 213 (68) (69.4) 220 (70) 114.7(77.0)

7 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 7 Time to First Clinical Event* Liver decompensation (variceal bleed, >grade 2 enceph, ascites requiring Rx, CPT C); HCC; death; liver transplantation * All Randomized Subjects from sites not closed for noncompliance. *P = 0.144, HR = vs observed controls Probability of Failure Time At Risk PEG: CONTROL: CONTROL PEG CONTROL Censored mean treatment duration = 32 months mean treatment duration = 31 months

8 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 8 Clinical Events by Treatment Arm Event, n (%) Observed Controls n = 315 PEG-IFN alfa-2b n = 311 Subjects With Clinical Event a 36 (11)27 (9)* Ascites b 13 (4)10 (3) Childs Pugh Class C b 1 (<1)4 (1) Variceal bleeding b 10 (3)1 (<1) HCC b 13 (4)12 (4) ≥Grade 2 hepatic encephalopathy b 3 (1)4 (1) Liver transplantation 4 (1)2 (<1) Death6 (2)7 (2) a Earliest event counted in case of multiple events. b Events were adjudicated. c Based on Cox proportional Hazards model with age (≤50, >50 years) and participation in retreatment phase (yes, no) as stratification factors.

9 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 9 Time to Disease Progression* Primary events plus: Development of Child-Pugh B, Emergence of varices, Enlargement of pre-existing varices requiring additional therapy * All Randomized Subjects from sites not closed for noncompliance. Probability of Failure Time At Risk PEG: CONTROL: PEG PEG CONTROL Censored HR: (95% CI 1.130, 2.166) P = CONTROL

10 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 10 Subgroup Analyses All Randomized Subjects AFP, alfa fetoprotein; PTL HTN, portal hypertension; VL viral load Observation better PEG-IFN alfa-2b better Baseline/Disease Characteristic Category AFP ≤40ng/mL No PTL HTN PTL HTN Albumin >4g/dL Albumin ≤4g/dL Child Pugh class >5 Child Pugh class ≤5 Platelet >100,000/mm 3 Platelet ≤100,000/mm 3 Nonresponder Relapser All subjects Body weight >105 kg Body weight kg Body weight kg Body weight <65 kg VL >600,000 IU/mL VL ≤600,000 IU/mL Genotype 2/3 Genotype 1 Noncaucasian Caucasian Direct enroller From Retreatment phase Female Male Age >50 years Age ≤50 years

11 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 11 Time to First Clinical Event Baseline Varices  Portal hypertension defined as esophageal varices at baseline  EGD performed at baseline, EOT and when clinically indicated  Findings confirmed by exploratory analysis when portal hypertension defined as platelet <100 and presence of splenomegaly Probability of Failure Time At Risk PEG: CONTROL: CONTROL PEG PEG CONTROL Censored Probability of Failure Time At Risk PEG: CONTROL: CONTROL PEG PEG CONTROL Censored Varices at Baseline No Varices at Baseline p=0.963 HR=1.014 p=0.016 HR=4.028

12 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 12 Clinical Events by Treatment Arm Subjects with Portal Hypertension at Baseline Subjects may have multiple events.

13 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 13 Summary of Adverse Events Leading to Discontinuation Event, n (%) PEG-IFN alfa-2b n = 311 Observed Controls n = 315 Subjects Reporting any AE53 (17)12 (4) Psychiatric disorders8 (3)1 (<1) Investigations8 (3)0 Infections (all)7 (2)0 Blood and lymphatic disorders5 (2)0 Neoplasms5 (2)4 (1) Nervous system disorders4 (1)1 (<1) Gastrointestinal disorders4 (1) Respiratory disorders3 (1)0 Hepatobiliary disorders2 (1)0 General disorders2 (1)0 Cardiac disorders1 (<1)0 Endocrine disorders1 (<1)0 Eye disorders1 (<1)0 Musculoskeletal disorders1 (<1) Renal and urinary disorders1 (<1)0 Vascular disorders1 (<1)0 Metabolism and nutrition disorders01 (<1)

14 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 14 Adverse Events: More Serious Infections in PEG-IFN alfa-2b Group Expert Review   Conclusions from review by 2 infectious disease specialists   Predominance of events in PEG-IFN alfa-2b-treated patients   No pattern that suggests relationship to Rx in timing, type of infection, WBC count   Events seem random ControlExperimental EPIC 3 All patients1% (3/315)8% (25/311) Baseline portal hypertension0% (0/52)7% (3/46) HALT-C8.5% (44/517)8% (44/533) COPILOT6.3% (17/269)2.8 % (8/286)

15 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 15 Serious Adverse Events Infection/Infestation in Cirrhotic Subjects NDescription Treated Subjects (n = 25) Bacterial Pneumonia, bronchitis, bronchiectasis Pyelonephritis/UTI Abscess: lung, subQ, rectal, psoas, abdominal wall Sepsis/bacteremia/endocarditis Cellulitis/soft tissue infection Discitis Tuberculosis1 Fungal1Esophageal candidiasis Viral3Viral meningitis, gastroenteritis, febrile infection Procedure2Appendicitis Observed Subjects (n = 3) Bacterial3Pneumonia, bronchitis, E. coli UTI Treated subjects: 3 deaths (pneumonia, septic shock, sepsis).

16 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 16 Results Summary   Mean treatment duration   PEG-IFN alfa-2b: 32 months, 14 subjects for 5 yrs   Observed controls: 31 months, 10 subjects for 5 yrs   Primary end point failed: Time to clinical event (adjudicated events + death/liver transplant)   Treatment has no effect on occurrence of HCC   Significant treatment effect in Disease Progression   Portal hypertension   Treatment benefit suggested in subjects with baseline portal hypertension

17 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 17 Conclusions   Long-term therapy with low-dose PEG-IFN alfa-2b has no effect on incidence of HCC in HCV-infected cirrhotics   Long-term therapy with low-dose PEG-IFN alfa-2b may be beneficial for cirrhotic patients with chronic HCV and portal hypertension

18 Bruix J, et al. Presented at the 44 th Annual Meeting of the European Association for the Study of the Liver (EASL), April 24, 2009, Copenhagen, Denmark.04/28/09 18 Switzerland Switzerland EPIC 3 Investigators Michael Manns Claus Niederau Wolfgang Schmidt Ulrich Spengler Reinhart Zachoval Stefan Zeuzem Emanuel K. Manesis Alfredo Alberti Antonino Picciotto Mauro Podda Mario Rizzetto Maria Grazia Rumi Erica Villa Anna Linda Zignego Antonio Craxi Jorge-Luis Poo Armando Carvalho Ana Maria Vale Alvaro Reymunde Jose Sanchez-Tapias Doris Toro Esther Torres Ramon Perez Alvarez Jose Luis Calleja Miguel Angel Serra Desfilis Moises Diago Rafael Esteban-Mur Ricardo Moreno-Otero Mayra Ramos-Gomez G. Castellanos Tortajada Ramon Planas Vila Luis Colombato Jose Curciarello Hugo Fainboim Adrian Gadano Leonardo Pinchuk Marcelo Silva Hugo Tanno Ruben Terg Wendy Cheng Darrell Crawford Jacob George Gary Jeffrey Barbara Leggett Lindsay Mollison Meng Ngu Stuart Roberts Douglas Routley William Sievert Harald Brunner Andreas Maieron Jean Delwaide Yves Horsmans H. Van Vlierberghe Flair Carrilho Henrique S. M. Coelho Maria Lucia Gomes Ferraz Raymundo P.F. Filho Roberto Focaccia Fernando Lopes Goncales Luiz Lyra Angelo Mattos Marcos Mauad Carlos Brandao Mello Dominique Araujo Muzzillo Heitor Rosa Rosangela Teixeira Frank Anderson Kelly Warren Burak Robert Enns Victor Feinman Klaus Siegfried Gutfreund E. Jenny Heathcote Nir Hilzenrat Kelly Kaita Paul Marotta Kevork Peltekian Florence Wong Adriana Varon Karl Barange Marc Bourliere Jean-Pierre Bronowicki Xavier Causse Patrick Marcellin Raoul Poupon Thierry Poynard Albert Tran Christian Trepo Thomas Berg Peter Buggisch Wolfgang Caselmann Dieter Haussinger Holger Hinrichsen Rolf Hultcrantz Beat Muellhaupt Jurg Reichen Ming-Yang Lai Geoffrey Dusheiko William Rosenberg Luis Balart Henry Bodenheimer Steven Flamm Stuart Gordon Ira Jacobson Paul King Paul Kwo Luis Marsano Arthur J. McCullough Thomas McGarrity John McHutchison Mary Pat Pauly Robert Perrillo Fred Poordad Robert Reindollar Vinod Rustgi Eugene Schiff Warren Schmidt Obaid S. Shaikh Kenneth Sherman Coleman Smith Mark Sulkowski Naoky Tsai Argentina Argentina Australia Australia Austria Austria Belgium Belgium Brazil Brazil Canada Canada Columbia Columbia France France Germany Germany Greece Greece Italy Italy Mexico Mexico Portugal Portugal Puerto Rico Puerto Rico Spain Sweden Sweden Taiwan Taiwan UK UK USA USA


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