‡ Long-term Follow-up Evaluation of the Efficacy and Safety of Tenofovir Disoproxil Fumarate (TDF) in a European Multicenter (Nucleos(t)ide Experienced) Hepatitis B Virus HBV-infected Cohort F. van Bömmel 1, R. de Man 2, P. Ferenci 3, J.P. Bronowiki 4, B. Fülöp 1, H. Wedemeyer 5, A. Erhardt 6, D. Hüppe 7, M. Bourlière 8, C. Sarrazin 9, J. Trojan 9, P. Buggisch 10, J. Petersen 10, U. Spengler 11, S. Brost 12, M. Schuchmann 14, H. Wasmuth 15, J. Reijnders 2, K. Deterding 5, K. Rutter 3, H-H. Feucht 16, B. Wiedenmann 1, T. Berg 1 1 Medizinisch Klinik m. S. Hepatologie und Gastroenterologie, Charité-Universitätsmedizin Berlin, Berlin,Germany. 2 Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam,Netherlands. 3 Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria. 4 Service d'Hépato-Gastroentérologie, CHU de Nancy, Nancy, France. 5 Abteilung für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Germany. 6 Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum der Heinrich-Heine-Universität, Düsseldorf, Germany. 7 Gastroenterologische Gemeinschaftspraxis, Gastroenterologische Gemeinschaftspraxis, Herne, Germany. 8 Service d'Hépatogastroentérologie, Hôpital St Joseph, Marseille, France. 9 Department of Internal Medicine, Johann Wolfgang Goethe University Medical Centre, Frankfurt a.M., Germany. 10 IFI-Institut, Asklepios Klinik St. Georg, Hamburg, Germany. 11 Zentrum für Innere Medizin, Universitätsklinikum Bonn, Bonn, Germany. 12 Innere Medizin IV, Universitätsklinikum Heidelberg, Heidelberg, Germany. 13 Unité d' hépatogastroentérologie, Centre Hospitalier Général, Pau, France. 14 I. Department of Internal Medicin, Universitätsklinikum Mainz, Mainz, Germany. 15 Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Germany. 16 Laborgemeinschaft Hamburg, Laborgemeinschaft Hamburg, Hamburg, Germany. 60 th Annual Meeting of the American Association for the Study of Liver Diseases © in Boston, MA Oral # 221

Florian van Bömmel, MD Charité University Hospital Berlin, Germany I have received scientific funding by Gilead Sciences Inc. AND My presentation does not include discussion of off-label or investigational use.

‡ Aims of the Study Evaluation of 1.Long-term efficacy and safety of tenofovir disoproxil fumarate (TDF) monotherapy in treatment-experienced patients with HBV monoinfection 2.Kinetics of HBs-antigen levels 3.Long-term renal safety van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Study Design Retrospective Cohort Analysis of the follow up of treatment with TDF 300 mg QD monotherapy in HBV-monoinfected patients with history of failure to treatment with nucleos(t)ide analogues 19 centers participated in Germany, France, Austria and The Netherlands Collection of data from all patients with HBV monoinfection and TDF monotherapy in participating centers to avoid bias van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Endpoints Primary Endpoint: –Virologic response, defined as HBV DNA below LLOQ (<400 copies/mL, Cobas Amplicor assay, Roche)] Secondary Endpoints: –HBsAg response, defined by changes in HBsAg levels –Renal safety; changes in glomerular filtration rate –Frequency of resistance development van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Results: Patients 290 patients with chronic HBV monoinfection were treated with TDF at the 19 participating centers between 2002 and patients were excluded due to: –HBV DNA < 104 copies/mL at TDF baseline (n=37) –treatment with TDF < 6 months (n=45) –non-compliance to TDF as reported by treating physician (n=14) 194 patients remained in analysis population; median time on TDF treatment 30±17 [6-86] months van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Characteristics of the Eligible Patients (n=194) Overall Cohort (n = 194) Mean age ±SD [ra] (years)46 ± 13 [18-77] Mean weight ±SD [range] (kg)75 ± 17 [39-128] Mean height ±SD [range] (cm)171± 10 [ ] Sex (m/f)142/52 HBeAg positive (n) [%]135 [70] Mean HBV DNA at baseline ± SD [range] (log 10 copies/mL) 8.6 ± 0.4 [4 - 10] Mean ALT at baseline ± SD [range] (IU/mL)137 ± 274 [ ] Liver cirrhosis (n) [%]28 [14] Mean creatinine in serum ±SD [range] (mg/dl)0.89± 0.4 [ ] pre-treatment with different nucleos(t)ide analogues Pre-treatment with adefovir (n) [%] mean duration of lamivudine treatment ± SD (months) [range] 110 [57] 25 ± 21 [8-126] Pre-treatment with lamivudine (n) [%] mean duration of adefovir treatment ± SD (months) [range] 159 [82] 12 ±13 [6-56] van Bömmel, et al., AASLD 2009; Oral # 221.

‡ 1) Virologic response 2) HBsAg kinetics 3) Renal Safety van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Probability of Achieving HBV DNA Levels <400 copies/mL During 12 Months Treatment with Tenofovir (n=194) Patients under observation (n): Patients with HBV DNA > 400 copies/mL (n): % Patients with HBV DNA < 400 copies/mL Kaplan-Meier analysis Months of TDF Treatment van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Individual Kinetics of HBV DNA Levels in Patients with Detectable HBV DNA (> 400 copies/mL) after 12 Months Treatment with Tenofovir (n=32) van Bömmel, et al., AASLD 2009; Oral # 221. HBV DNA log 10 copies/mL Patients who achieved HBV DNA < 400 cp/mL months of treatment Patients with HBV DNA > 400 cp/mL months of treatment lower limit of detection

‡ HBV DNA log 10 copies/mL Individual Kinetics of HBV DNA Levels in Patients with Detectable HBV DNA (> 400 copies/mL) after 12 Months Treatment with Tenofovir (n=32) Patients with HBV DNA > 400 cp/mL months of treatment TDF 300 mg + lamivudine 100 mg TDF 300 mg monotherapy van Bömmel, et al., AASLD 2009; Oral # 221. Patients who achieved HBV DNA < 400 cp/mL lower limit of detection

‡ 1) Virologic response 2) HBsAg kinetics 3) Renal Safety van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Kinetic of mean HBsAg Levels During Treatment with Tenofovir (n=71) Patients under observation (n): log IU/mL -p=n.s. Error Bars 95% Cl Mean HBsAg (U/mL) BL36912 van Bömmel, et al., AASLD 2009; Oral # 221.

‡ 1) Virologic response 2) HBsAg kinetics 3) Renal Safety van Bömmel, et al., AASLD 2009; Oral # 221.

‡ 181 patients were included Subjects were excluded if they met the following criteria: –HBV DNA < 104 copies/mL at TDF baseline (n=37) –treatment with TDF < 6 months (n=45) –availability of results for serum creatinine, age and weight from baseline TDF treatment and during treatment van Bömmel, et al., AASLD 2009; Oral # 221. Sub-group Analysis: Renal Toxicity

‡ Glomerular filtration rate (GFR) was estimated –by MDRD (Modification of Diet in Renal Disease formula): GFR (ml/min/1.73 m²) = 186 x (creatinine /0.95) x (age) – x (0.742 for females) x (1.21 for patients with African origin) –by Cockcroft-Gault formula: Ccr (mL/min) = ((140 – age) x body weight) /72 x creatinine in serum)) x 0.85 for females van Bömmel, et al., AASLD 2009; Oral # 221. Sub-group Analysis: Renal Toxicity

‡ Overall Cohort (n = 181) Mean age ±SD [ra] (years)46 ± 14 [18-77] Mean weight ±SD [range] (kg)75 ± 16 [39-128] Mean height ±SD [range] (cm)171± 10 [ ] Sex (m/f)135/46 HBeAg positive (n) [%]129 [71] Mean HBV DNA at baseline ± SD [range] (log 10 copies/mL)8.6 ± 9.2 [4 - 10] Mean ALT at baseline ± SD [range] (IU/mL)136 ± 286 [ ] Liver cirrhosis (n) [%]26 [14] Mean creatinine in serum ±SD [range] (mg/dl)0.91± 0.4 [0,3-4,2] Mean glomerular filtration rate (by MDRD) ±SD [range] (mL/min/1,73m)93 ± 25 [15-174] Mean creatinine clearance (by Cockroft-Gault) ±SD [range] (mL/min)112 ± 36 [22-237] Pre-existing risk factors for renal insufficiency (n = 26) Liver transplantation (n) [%]2 [1] Kidney transplantation (n) [%]5 [3] Arterial hypertension (n) [%]15 [8] Diabetes mellitus (n) [%]2 [1] Glomerular nephritis (n) [%]2 [1] van Bömmel, et al., AASLD 2009; Oral # 221. Characteristics of Patients in Safety Analysis

‡ GFR during TDF treatment estimated by MDRD and Cockcroft-Gault estimation (n=181) Patients under observation (n): mL/min = -13% p=0.002 Mean GFR (ml/min) Duration of TDF Treatment month 0month 12month 24month 36month 48month 60 Patients under observation (n): mL/min/1.73m 2 = -11% p=0.01 Error Bars: 95% Cl Mean GFR (mL/min/1.73 m 2 ) Duration of TDF Treatment GFR estimated by MDRD formulaGFR estimated by Cockroft-Gault formula van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Changes in GFR during TDF treatment by MDRD and Cockcroft-Gault estimation (n=181) 58% n=105 22% n=40 6% n=11 1% n=2 13% n=23 GFR estimated by MDRD formula Percent Changes in GFR (%) % ±10%10-20%20-30%<30% 59% n=107 26% n=48 1% n=2 1% n=2 12% n=22 GFR estimated by Cockcroft-Gault formula % ±10%10-20%20-30%<30% van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Characteristics of Patients with Moderate (n=11) or Severe (n=2) Changes in GFR during TDF Treatment by MDRD estimation van Bömmel, et al., AASLD 2009; Oral # 221. GFR estimated by MDRD formula Mean GFR (mL/min/1.73 m 2 ) Duration of TDF Treatment

‡ Characteristics of Patients with Moderate (n=11) or Severe (n=2) Changes in GFR during TDF Treatment by MDRD estimation (cont’d) moderate decrease % (n=11) severe decrease. > 30 % (n=2) m m m m m m w m m m m m m AH no m m m m w m m m m sex Secondary diseases TDF LAM ADV weight age start of TDF EOBS LT none AH AH. DM KT Treatment duration (months): Creatinine (mg/dL) at: MDMR (mL/min/1.73m 2 ) at: start of TDF EOBS Cockcroft-Gault (mL/min) at: start of TDF EOBS GFR AH=arterial hypertension, DM=diabetes mellitus, KT=kidney transplant LT=liver transplant, EBOS=end of observation van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Changes in GFR during TDF treatment in Patients with elevated Creatinine Levels at baseline by MDRD and Cockcroft-Gault formula (n=10) van Bömmel, et al., AASLD 2009; Oral # 221. Mean GFR (mL/min) Duration of Treatment (months) GFR by Cockroft-Gault formula Mean GFR (mL/min/1,73 m 2 ) Duration of Treatment (months) GFR by MDRD

‡ Summary Treatment with TDF in this cohort of treatment-experienced patients resulted in potent suppression of HBV DNA No virologic breakthrough was observed during the follow- up period, also in patients with incomplete response at months 12 There was no significant decrease in mean HBsAg-levels A mild (10%) reduction in glomerular filtration rate was observed in many patients, however TDF treatment did not need to be adjusted or interrupted due to renal toxicity van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Conclusion TDF monotherapy is an effective and well tolerated option for long term treatment in HBV monoinfected patients with prior treatment experience, including those with pre-existing renal dysfunction van Bömmel, et al., AASLD 2009; Oral # 221.

‡ Acknowledgments This work was supported by the German Network of Excellence (HEPNET) and the European network VIRGIL Funded in part by Gilead Sciences, Inc. van Bömmel, et al., AASLD 2009; Oral # 221.