AASLD Feedback on HBV Dr Allister J Grant Consultant Hepatologist University Hospitals Leicester NHS Trust 62 th Annual Meeting November 4 – 8, 2011 San Francisco, CA

No Resistance to Tenofovir (TDF) Following up to 240 Weeks of Treatment in HBeAg+ and HBeAg- CHB Infection Marcellin, P, et al. AASLD 2011; Oral #238 Pre-treatment Liver Biopsy RANDOMIZATION 2:1 Tenofovir DF 300 mg N=250 & N=176 Adefovir Dipivoxil 10 mg N=125 & N=90 Year 1 Liver Biopsy 1 Year 1 Week 72Year 8 Tenofovir DF 300 mg Tenofovir DF 300 mg Year 3 N=235 N=154 N=112 N=84 Year 5/ Week 240 Liver Biopsy At Week 72, patients with HBV DNA ≥ 400 copies/mL had the option at the discretion of the investigator to add emtricitabine (FTC) Retention rate at Week 240: 81% for HBeAg-, 70% for HBeAg+ Study 102 (HBeAg- Patients) and 103 (HBeAg+ Patients)

Study 102 (HBeAg-): Proportion of Patients with HBV DNA <400 copies/mL Long-term evaluation [LTE-TDF] (missing/ addition of FTC = failure) Marcellin, P, et al AASLD, Poster #1375.Marcellin, P, et al. AASLD 2011; Oral #238. Week 240: TDF-TDF 83% ADV-TDF 84% Overall: 83%

The Addition of FTC to TDF Between Weeks Did Not Impact Subsequent HBV DNA Decline 57/641 (9%) eligible to add FTC to TDF at/after Week 72 19/57 (33%) remained on TDF monotherapy 14/19 (74%) HBV DNA < 400 copies/mL At Week 240/ last visit 38/57 (67%) added FTC to TDF 24/38 (63%) HBV DNA < 400 copies/mL At Week 240/ last visit All subjects analyzed with >400 copies/mL had no evidence of TDF resistance Marcellin, P, et al. AASLD 2011; Oral #238.

Virologic Breakthrough was Infrequent and Associated with Non-adherence 4/495 (0.8%) of patients were classified as having virologic breakthrough during Year 5 3 patients had documented non-adherence during the time of breakthrough (TFV plasma levels undetectable) All 4 patients had HBV DNA return to <400 copies/mL during Year 6 Phenotypic analysis revealed isolates from all virologic breakthrough patients were sensitive to tenofovir (fold change values <2 compared to baseline ) Marcellin, P, et al. AASLD 2011; Oral #238.

Efficacy Summary Year 3Year (eAg-) 103 (eAg+) 102 (eAg-) 103 (eAg+) HBV DNA <400 c/mL87%71%83%65% HBV DNA <400 c/mL99%93%99%97% ALT normalization84%74%85%73% HBeAg loss (seroconversion) na 3 34% (26%) na 50% (40%) HBsAg loss (seroconversion) 0 9% (7%) n=1 (Week 240) 11% (9%) Marcellin, P, et al. AASLD 2011; Oral #238.

Five years of Treatment with Tenofovir DF for Chronic Hepatitis B Infection is Associated with Sustained Viral Suppression and Significant Regression of Histological Fibrosis and Cirrhosis P. Marcellin 1, M. Buti 2, E.J. Gane 3, Z. Krastev 4, R. Flisiak 5, G. Germanidis 6, M.K. Washington 7, C.N. Barnes 8, J.F. Flaherty 8, J.D. Bornstein 8, J.G. McHutchison 8, E.J. Heathcote 9 1 Hôpital Beaujon, APHP, Clichy, France, 2 Hospital General Universitari Vall d’Hebron and Ciberehd, Barcelona, Spain, 3 Auckland City Hospital, Auckland, New Zealand, 4 University Hospital “St. Ivan Rilsky”, Sofia, Bulgaria, 5 Medical University ofBialystok, Bialystok, Poland, 6 University Hospital of Thessaloniki, Thessaloniki, Greece, 7 Vanderbilt University, Nashville, TN, United States, 8 Gilead Sciences Inc., Foster City, CA, United States, 9 University of Toronto, Toronto, ON, Canada Marcellin, P, et al. AASLD 2011; Poster #1375.

Change in Ishak Fibrosis Scores at Year 5 by Baseline Fibrosis Score Baseline Ishak Fibrosis Score Improvement No Change Worsening % 20% 30% 40% 50% 60% 70% 80% 90% 100 % Percentage of Subjects n=10n=126n=79n=37n=19n=77 Marcellin, P, et al. AASLD 2011; Oral # paired biopsies at Year 5 (71%) 96% (335/348) of patients with paired biopsies either improved (≥ 1 unit decrease in fibrosis score) or did not change at Year 5 Percentage of the population with cirrhosis (Ishak Score ≥5) progressively decreased from 28% at baseline to 8% at Year 5

Distribution of Ishak Fibrosis Scores at Baseline, Year 1, and Year 5 344/348 patients had liver biopsy data available at all three time points Percentage of the population with cirrhosis (Ishak Score ≥5) progressively decreased from 28% at baseline to 8% at Year 5 Marcellin, P, et al. AASLD 2011; Poster #1375.

Authors’ Conclusions Over 5 years, sustained virologic suppression is associated with histologic improvement and regression of liver fibrosis – Largest prospective dataset of chronic HBV patients with sequential biopsies – 96% of patients with paired biopsies had either improvement or no worsening of fibrosis – 74% of patients with cirrhosis at baseline were no longer cirrhotic at year 5 – 98% of patients on TDF had undetectable HBV DNA levels of < 400 copies/mL Virologic and biochemical responses are maintained – Sustained virologic suppression maintained through 5 years – ALT normalization maintained in the majority of patients – 11% of patients had confirmed HBs-Ag loss (8% with seroconversion) with 5 years of TDF – No resistance detected to TDF through 5 years Marcellin, P, et al. AASLD 2011; Poster #1375.

Effects of Tenofovir on Vitamin D Levels in Chronic Hepatitis B Mono-infected Patients: A Single Centre “Real Life” Cohort Experience Huyen-Ly Nguyen, Mohammad A B Al-Freah, Roy Sherwood, Ivana Carey, Dorothy Joe, Abid Suddle, Phillip M. Harrison, Kosh Agarwal Institute of Liver Studies, King’s College Hospital, London, UK Nguyen, HL, et al. AASLD 2011; Poster #509.

1 Mueller NJ et al. AIDS 2010; 24(8): Introduction Vitamin D deficiency has been shown to be prevalent in patients with viral diseases such as HIV. Data derived from HIV population demonstrate negative effects of Tenofovir (TDF) on vitamin D levels and bone mineral density 1 To determine the impact of Tenofovir on vitamin D levels as well as metabolic bone parameters in patients mono-infected with HBV Nguyen, HL, et al. AASLD 2011; Poster #509.

Methods Retrospective study of all patients treated with TDF or Entecavir (ETV) in our centre (n=313) from May 2006 to September 2010 Collected data included demographic, clinical variables, Vitamin D (VD), phosphate, calcium and alkaline phosphatase levels at baseline and at 12 months after initiation of TDF or ETV Data collection at baseline (initiation of TDF or ETV) and following 12 months of treatment (+/- 3 months) Patients on combination of TDF and ETV (n=22) and those that received VD supplementation within 3 months prior to initiation of antiviral therapy or at any point during the 12 months follow up (n=114) we excluded Nguyen, HL, et al. AASLD 2011; Poster #509.

Baseline Vitamin D Analysis Significant seasonal variability, with higher vitamin D levels detected during the Summer and lowest levels during the Winter The prevalence of vitamin D deficiency in this cohort of patients was 71.7%, defined as vitamin D levels < 22 µg/L There is a significant variability in vitamin D levels among the different racial groups of patients being treated at our centre in South East London Vitamin D deficiency was more prevalent in men than women 85% vs 72% Median VD according to season p = 0.015, Kruskal-Wallis, n = Vitamin D μg/L Season WinterSpring SummerAutumn Median VD according to ethnicity p = Kruskal-Wallis, n = Vitamin D μg/L Ethnic Group Afro- Caribbean SE Asian European Indian Other Nguyen, HL, et al. AASLD 2011; Poster #509.

Comparison of Baseline Characteristics According to Anti-Viral Therapy (cont.) VariablesTenofovir (142)Entecavir (77)P-value VD (µg/L)16.1 (4-49)16.1 (6-50)0.465 VD deficiency (%)84 (66.3)41 (73.2)0.343 Calcium (mmol/L)2.23 ( )2.25 ( )0.147 Phosphate (mmol/L)0.98 ( )0.93 ( )0.04 ALP (IU/L)73 (37-296)69 (42-229)0.177 Hb (g/dL)14.2 ( )14.6 ( )0.02 PLT x 10 9 /mL (63-503)208 (63-418)0.53 Bilirubin (µg/L)11 (3-148)12 (4-37)0.581 Albumin (g/dL)44 (24-50)44 (29-50)0.687 INR1.05 ( )1.05 ( )0.973 AST (IU/L)29 (12-215)40 (20-328)<0.001 The TDF cohort had a higher baseline phosphate level than those on ETV There was no significant difference in the remaining metabolic bone parameters at baseline ALP = Alkaline phosphatase

Nguyen, HL, et al. AASLD 2011; Poster # Months Interval Data Antiviral agentBone markersBaseline12 MonthsP-value TDF (N=142) VD16.10 (4-49)14.7 ( )0.43 Calcium2.24 ( )2.23 ( )0.032 Phosphate0.99 ( )1.07 ( )0.121 ALP72 (45-215)79 (42-769)<0.001 ETV (N=77) VD16.00 (4-50) Calcium2.25 ( )2.23 ( )0.056 Phosphate0.91 ( )0.96 ( )0.228 ALP70 (42-229)68 (36-168)0.202 No difference in vitamin D levels at baseline and at 12 months in either of the treatment groups The TDF cohort showed a significant rise in alkaline phosphatase and a fall in calcium which may indicate development of metabolic bone disease

Authors’ Conclusions Vitamin D deficiency is highly prevalent in this cohort of chronic hepatitis B mono-infected patients No significant decrease in vitamin D levels after 12 months of treatment with either TDF or ETV Significant rise in ALP and decline in calcium in the TDF cohort and a downward calcium trend in the ETV cohort suggesting adverse effects on bone metabolism Further long term follow-up with additional radiological assessment of bone mineral density is warranted to establish if AVT such as TDF and ETV are associated with a negative effect on bone metabolism Nguyen, HL, et al. AASLD 2011; Poster #509.

Bone Mineral Density Results (Year 4 to Year 5) No significant changes were observed in mean (SD) BMD results from year 4 to year 5 for hip and lumbar spine No consistent trends were observed in T score (see Table) or Z score (data not shown) category shifts between year 4 and year 5 a. T Score ranges: normal > -1, osteopenia -1 to -2.5, osteoporosis < -2.5; pooled data (N=266 hip; N=276 spine) Year 4 to 5 shifts in T scores a HipSpine normal → osteopenia3 patients7 patients osteopenia → normal2 patients8 patients osteopenia → osteoporosis0 patients1 patient osteoporosis → osteopenia0 patients2 patients Marcellin, et al. AASLD 2011; Poster #1385.

Entecavir (ETV) Monotherapy for 96 Weeks is Comparable to Combination Therapy with ETV Plus Tenofovir (TDF) in Nucleos(t)ide-naïve Patients with Chronic Hepatitis B (CHB): The BE-LOW Study A.S. Lok 1, H. Trinh 2, G. Carosi 3, U. Akarca 4, A. Gadano 5, F. Habersetzer 6, W. Sievert 7, D. Wong 8, M. Lovegren 9, D. Cohen 9, C. Llamoso 9 Lok, AS, et al. AASLD 2011; Oral # University of Michigan, Ann Arbor, MI, United States. 2. Pacific Health Foundation, San Jose, CA, United States. 3. Institute of Infectious and Tropical Disease, University of Brescia, Brescia, Italy. 4. Department of Gastroenterology, Ege University, Izmir, Turkey. 5. Seccion Hepatologia, Hospital Italiano de Buenos Aires – Argentina, Ciudad de Buenos Aires, Argentina. 6. Service d’Hepato-gastroenterologie, Nouvel Hopital Civil, Strasbourg, France. 7. Department of Medicine, Monash University, Melbourne, VIC, Australia. 8. Toronto Western Hospital, University Health Network, Toronto, ON, Canada. 9. Research and Development, Bristol-Meyers Squibb Company, Wallingford, CT, United States

ETV-110: Study Design Week 96 Primary endpoint Baseline Dosing x 100 weeks RANDOMIZATION 1:1 ETV 0.5 mg + TDF 300 mg, once daily (N = 197) * ETV 0.5 mg, once daily (N = 182) * Further anti-HBV therapy at discretion of investigator – up to 24 weeks follow-up Randomized, open-label, Phase IIIb trial NA-naïve CHB, HBeAg(-) patients capped at 30% *Modified intent-to-treat (ITT) population: received at least one dose of study medication Lok, AS, et al. AASLD 2011; Oral #223.

HBV DNA <50 IU/mL at Weeks 48 and 96: Overall HBV DNA <50 IU/mL (% patients) Difference 9.9% (95% CI 1.5, 18.4) Number of Patients: Non-completer = failure *Primary endpoint Lok, AS, et al. AASLD 2011; Oral #223. Difference 6.9% (95% CI -1.0, 14.9) *

HBV DNA <50 IU/mL at Weeks 48 and 96: By Baseline HBeAg Status HBeAg(+)HBeAg(-) Lok, AS, et al. AASLD 2011; Oral #223.

Authors’ Conclusions At Week 96, both treatment arms (ETV monotherapy and ETV + TDF combination therapy) showed comparable antiviral efficacy in a mixed population (70% HBeAg[+]) of NA-naïve CHB patients Both treatments were well tolerated with comparable safety profiles Combination of ETV + TDF did not provide an overall benefit compared to ETV monotherapy. However, it may – Provide incremental benefit in HBeAg(+) patients with baseline viral load ≥ 10 8 IU/mL – Have a role in clinical settings in patients with high viral load where rapid HBV DNA decline is important Lok, AS, et al. AASLD 2011; Oral #223.

Quantitative HBsAg as Predictor of Outcomes in Chronic Hepatitis B Patients with chronic hepatitis B enrolled (N = 4155) and followed until 2004 – Natural history study of previously untreated patients In multivariate analysis, baseline HBsAg level independently predicted spontaneous HBV DNA and HBsAg clearance Liu J, et al. AASLD Abstract Cumulative Incidence of HBV DNA Seroclearance 0 Yrs % 41.9% 42.2% 86.0% P <.001 Baseline HBV DNA ≥ 10 4 copies/mL (N = 1449) Baseline HBsAg (IU/mL) ≥ 10, < Cumulative Incidence of HBsAg Seroclearance 0 Yrs % 45.9% 49.1% 86.6% P <.001 HBsAg Seropositives (N = 2946) Baseline HBsAg (IU/mL) ≥ 10, < %

Initiation of LAM in 2nd vs 3rd Trimester in Pregnant Women With High HBV Viremia Retrospective analysis of lamivudine initiated in 2nd vs 3rd trimester in women with HBV DNA > 6 log 10 copies/mL – All babies received HBIG and appropriate vaccinations – Vertical transmission determined by HBsAg and HBV DNA status at 7-12 month Significant reduction of perinatal transmission with similar efficacy when LAM administered in 2nd or 3rd trimester among highly viremic women Han GR, et al. AASLD Abstract Infants With HBsAg+ in the Venous Blood (%) LAM Use in the 2T LAM Use in the 3T Untreated Infants’ HBsAg status at birth Infants’ HBsAg status at 28 wks P =.003 P =.004 P < / / 45 28/ 92 8/

HBV Reactivation Among Patients With Cancer Retrospective cohort, chart review of 10,729 patients with solid or hematologic cancers who received initial chemotherapy between % of patients at risk for HBV reactivation screened – HBsAg: 87 – HBsAg and anti-HBc: 1665 – Anti-HBc: 35 Hwang JP, et al. AASLD Abstract 172.

High HBV Reactivation Rate Among Patients With Cancer 34 patients experienced HBV reactivation – HBsAg+: 14/26 (54%) – Anti-HBc+: 20/125 (16%) – Leukemia: 14 – Lymphoma: 8 – Myeloma: 1 – Solid tumors (eg, lung, colon, HCC): 11 – Rituximab treated: 10 – 26% prophylaxis Rx and 32% rescue Rx – All cause mortality 22% prophylaxis vs. 71% Rescue vs. 72% No Rx Hwang JP, et al. AASLD Abstract 172.  Mean age: 47 yrs with reactivation vs 54 yrs for no reactivation Patients With Reactivation (%) Cancer Type Solid (9/63) Hematologic (23/82)

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