1. Nezam H. Afdhal, MD, FRCPI Professor of Medicine Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts HCV Alert: New Data on Resistance to DAAs and Implications for Therapy This activity is supported by an independent educational grant from Janssen Therapeutics.

2. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy About These Slides  Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent  These slides may not be published or posted online without permission from Clinical Care Options (email permissions@clinicaloptions.com) Disclaimer The materials published on the Clinical Care Options Web site reflect the views of the authors of the CCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providing educational grants. The materials may discuss uses and dosages for therapeutic products that have not been approved by the United States Food and Drug Administration. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or using any therapies described in these materials.

3. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Faculty Program Chair Nezam H. Afdhal, MD, FRCPI Professor of Medicine Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts

4. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Faculty Jordan J. Feld, MD, MPH Associate Professor of Medicine University of Toronto Hepatologist Toronto Centre for Liver Disease Sandra Rotman Centre for Global Health Toronto, Canada Norah Terrault, MD, MPH Professor of Medicine and Surgery Director, Viral Hepatitis Center Division of Gastroenterology University of California, San Francisco San Francisco, California Mark S. Sulkowski, MD Professor of Medicine Medical Director, Viral Hepatitis Center Divisions of Infectious Diseases and Gastroenterology/Hepatology Johns Hopkins University School of Medicine Baltimore, Maryland

5. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Faculty Disclosures Nezam Afdhal, MD, FRCPI, has disclosed that he has received funds for research support from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Merck, and Vertex; has received consulting fees from AbbVie, Achillion, Catabasis, Cocrystal, Echosens, Gilead Sciences, GlaxoSmithKline, Janssen, Ligand, Merck, Roivant, Sandhill Scientific, and Spring Bank; and has stock options with Spring Bank. Jordan J. Feld, MD, MPH, has disclosed that he has received consulting fees from AbbVie, Bristol-Myers Squibb, Gilead Sciences, Janssen, Merck, and Theravance and funds for research support from AbbVie, Boehringer Ingelheim, Gilead Sciences, Janssen, Merck, and Santaris.

6. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Faculty Disclosures Mark S. Sulkowski, MD, has disclosed that he has received consulting fees from AbbVie, Achillion, Bristol ‐ Myers Squibb, Gilead Sciences, Janssen, and Merck; and funds for research support (paid to his institution) from AbbVie, Bristol ‐ Myers Squibb, Gilead Sciences, Janssen, and Merck. Norah Terrault, MD, MPH, has disclosed that she has received funds for research support from AbbVie, Biotest, Eisai, Gilead Sciences, Novartis, and Vertex and consulting fees from Achillion, Biotest, Bristol-Myers Squibb, Gilead Sciences, Janssen, and Merck.

7. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Virologic Barriers to Resistance Genetic barrier  Number and type of nucleotide changes required for a virus to acquire resistance to an antiviral regimen [1] Viral fitness  Relative capacity of a viral variant to replicate in a given environment 1. Rong L, et al. Sci Transl Med. 2010;2:30ra32. 2. Le Pogam S et al. J Virol. 2006;80:6146-6154. 3. Le Pogam S, et al. J Infect Dis. 2010;202:1510-1519 Fitness of Polymerase Inhibitor Mutants [2,3] Wild Type L419MM423TI482L L419M/M423T S282T 1.75.5.25 0 % Fitness

8. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Resistant Variants Are Present Before and Can Be Selected During Treatment  HCV is a mixture of related but distinct populations of virions in each pt [1]  Most resistant variants are unfit and may be undetectable prior to therapy [2,3] 1. Pawlotsky JM. Clin Liver Dis. 2003;7:45-66. 2. Kuntzen T, et al. Hepatology. 2008;48:1769-1778. 3. Bartels DJ, et al. J Infect Dis. 2008;198:800-807. Image reproduced and adapted with permission from Forum for Collaborative HIV Research. www.hivforum.org Antiviral therapy eliminates sensitive variants Resistant variants expand Sensitive virus Resistant virus Antiviral therapy

9. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy HCV NS3/4A Protease Resistance Lenz O, et al. Antimicrob Agents Chemother. 2010;54:1878-1887. Reproduced with permission from American Society for Microbiology. doi:10.1128/AAC.01452-09 Copyright © 2010, American Society for Microbiology. All Rights Reserved. Q80 R155 D168 A156 F43

10. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy NaiveExp’d1a + Q80K 1a no Q80K All pts 97 Impact of Treatment Exp, Q80K Depends on Cirrhosis (12 Wks’ SMV + SOF in GT1) 1. Kwo P, et al. EASL 2015. Abstract LP14. 2. Lawitz E, et al. EASL 2015. Abstract LP04. SVR12 (%) 100 80 60 40 20 0 97 95 96 112/ 115 38/ 40 44/ 46 68/ 70 n/N = NaiveExp’d Treatment History HCV GT 1a + Q80K 1a no Q80K 97 150/ 155 All pts 88 79 74 92 44/ 50 42/ 53 25/ 34 35/ 38 Treatment History HCV GT 83 86/ 103 No Cirrhosis (OPTIMIST-1 [1] ) Cirrhosis (OPTIMIST-2 [2] ) 100 80 60 40 20 0 n/N =

11. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy OPTIMIST-2: Resistance Analysis in GT1 Cirrhotics in Whom SMV + SOF Failed  Treatment-emergent NS3 mutations detected in 79% (11/14) of evaluable pts who did not achieve SVR12 –Observed at position 168, R155K, or combinations  NS5B polymorphism S282T not detected at baseline or at time of treatment failure  No NS3 baseline polymorphisms observed aside from Q80K Lawitz E, et al. EASL 2015. Abstract LP04.

12. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy AASLD/IDSA Guidance for Resistance Testing When Considering SMV + SOF  In pts with both genotype 1a HCV infection and compensated cirrhosis, if considering SMV + SOF, test for Q80K polymorphism –If Q80K variant is present, consider a regimen other than SMV + SOF  Applies to treatment-naive and treatment-experienced pts  Q80K testing not required for: –Pts with genotype 1b HCV infection –Pts without cirrhosis –Pts in whom you are considering other DAAs AASLD/IDSA/IAS-USA. HCV Guidance.

13. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy ION-2: DAAs Effective Against NS3 RAVs After Boceprevir or Telaprevir  Virologic failure: 1 breakthrough in 24-wk LDV/SOF + RBV due to nonadherence; 11 relapses (7 in 12-wk LDV/SOF, 4 in 12-wk LDV/SOF + RBV)  14% of pts had NS5A RAVs at baseline; 89% of these achieved SVR12; 71% of pts had NS3 RAVs at baseline; 98% of these achieved SVR12 40/ 43 62/ 66 45/ 47 62/ 64 58/ 58 49/ 50 58/ 59 51/ 51 12 Wks24 Wks LDV/SOF + RBV LDV/SOF SVR12 (%) 100 80 60 40 20 0 93 94 96 97 100 98 100 Failure of pegIFN/RBV Failure of PI Treatment History Afdhal N, et al. N Engl J Med. 2014;370:1483-1493.

14. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Fold-Change in EC50Genotype 1aGenotype 1b PositionM28TQ30RL31M/VY93H/NL31VY93H/N FDA approved Daclatasvir [1,3] > 100 x> 1000 x> 100 x> 1000 x< 10 x< 100 x Ledipasvir [1] 20 x> 100 x > 1000 x> 1000 x/? Ombitasvir [2] > 1000 x> 100 x < 3 x > 10,000 x< 10 x< 100 x > 100 x 1. Cheng G, et al. EASL 2012. Abstract 1172. 2. Krishnan P, et al. Antimicrob Agents Chemother. 2015;59:979-987. 3. Yang G, et al. EASL 2013. Abstract 1199. 4. Ng T, et al. CROI 2014. Abstract 639. Resistance Analysis of Select NS5A Inhibitors in Genotype 1 HCV > 100 x3 to 100 x < 3 x

15. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy NS5A RAVS with < 100 x resistance Sarrazin C. AASLD 2014. Abstract 1926. Impact of Duration of LDV/SOF on SVR12 in Pts With Baseline NS5A Resistance 100 80 60 40 20 0 100 80 60 40 20 0 100 83 95 100 65 95 100 99 100 92 96 100 9697 12/ 12 24/ 29 184/ 193 110/ 116 11/ 17 5/ 5 27/ 27 44/ 46 362/ 373 95/ 96 6/ 6 7/ 7 8/ 8 24/ 25 174/ 183 8 Wks12 Wks24 Wks Treatment Naive Treatment Experienced 12 Wks24 Wks SVR12 (%) n/N = NS5A RAVS with > 100 x resistanceNo NS5A RAVs

16. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Durability of Treatment-Emergent NS5A RAVs After Virologic Failure  Study of pts not achieving SVR after receiving LDV without SOF  NS5A RAVs persisted in majority of pts for 96 wks 100 80 60 40 20 0 VFBaselineFU-12FU-24FU-48FU-96 98 100 98 100 95 86 Pts With NS5A RAVs (%) Registry Study 62/ 63 58/ 58 42/ 43 45/ 45 52/ 55 50/ 58 n/N = Dvory-Sobol H, et al. EASL 2015. Abstract O059.

17. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Pooled Analysis: RAV Persistence After Failure of PTV/RTV-, OMV-, DSV-Based Tx 100 80 60 40 20 0 PTV-Containing Regimens AnyD168R155K 46 9 38 77 29 4 100 80 60 40 20 0 OMV-Containing Regimens AnyM28V/TQ30E/K/R 97 96 97 100 93 89 100 80 60 40 20 0 DSV-Containing Regimens AnyS556G 75 90 57 77 Follow-up Wk 24 Follow-up Wk 48 n/N = 31/ 67 5/57 21/ 55 2/53 10/ 13 2/7 68/ 70 32/ 33 38/ 41 49/ 51 21/ 21 25/ 28 33/ 44 27/ 30 20/ 35 17/ 22 RAVs (%) NS3/4A PositionNS5A PositionNS5B Position Krishnan P. EASL 2015. Abstract O057.

18. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy 92 100 91 0/1 200/ 218 AVIATOR: No Impact of Baseline RAVs in GT1a Pts Treated With OMV/PTV/RTV + DSV  Treatment naive pts or null responders to previous pegIFN/RBV  All differences in SVR24 with vs without baseline RAVs were nonsignificant Krishnan P, et al. Antimicrob Agents Chemother. 2015;59:5445-5454. 100 80 60 40 20 0 NS3 RAVs Q80KD168 88 94 0 92 100 80 60 40 20 0 NS5A RAVs M28V/TQ30RL31V 86 92 100 91 100 80 60 40 20 0 NS5B RAVs S556GC316Y 100 50 93 With RAV n/N = 12/ 14 3/ 3 1/ 1 192/ 209 201/ 220 203/ 222 7/ 7 1/ 2 220/ 239 226/ 244 Y93C/N/H 80 92 4/ 5 200/ 218 78/ 89 122/ 130 SVR24 (%) Without RAV

19. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Wyles DL, et al. Hepatology. 2015;61:1793-1797. GT1 HCV with previous SOF failure (29% cirrhotic)* (N = 51) LDV/SOF + RBV 12 Wks *25 pts (49%) were previously treated with SOF + pegIFN/RBV, 21 (41%) with SOF ± RBV, 5 (10%) with SOF placebo plus pegIFN/RBV or GS-0938 monotherapy, 1 (2%) with SOF monotherapy. † 1 pt who relapsed found to have GT3a HCV infection and enrolled in error. SVR12, % 98 † LDV/SOF + RBV in GT 1 HCV Pts With Previous Failure on Sofosbuvir Regimens  Phase II trial

20. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy  GT1 HCV–infected pts with and without cirrhosis previously treated with 8 or 12 wks of LDV/SOF ± RBV or LDV/SOF + GS-966 24 Wks of LDV/SOF Retreatment After Failure of 8-12 Wks of LDV/SOF-Based Tx Lawitz E, et al. EASL 2015. Abstract O005. Previous Tx Duration 100 80 60 40 20 0 SVR12 (%) All NoYes 71 68 74 15/ 22 14/ 19 NoYes8 Wks12 Wks Cirrhosis BL NS5A RAVs 80 46 60 100 24/ 30 5/ 11 11/ 11 18/ 30 n/N = 29/ 41

21. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy 24 Wks of LDV/SOF After Failure of LDV/ SOF-Based Tx: Effect of Baseline RAVs  NS5B variants emerged during retreatment in 33% of pts (4/12) with virologic failure –S282T: n = 2; L159F: n = 1; S282T + L159F: n = 1 Lawitz E, et al. EASL 2015. Abstract O005. SVR12 by Baseline NS5A RAVs, n/N (%)LDV/SOF for 24 Wks Number of RAVs 0011/11 (100) 1111/16 (69)  ≥ 27/14 (50) Single NS5A RAV  Q30R or M28T5/5 (100)  L31M4/5 (80)  Y93H/N2/6 (33)

22. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy GT1 Pts With NS5A Failure: Who Needs Resistance Testing?  If previous failure of any NS5A inhibitors (including DCV + SOF, LDV/SOF, OMV/PTV/RTV + DSV) and minimal liver disease, deferral preferred pending further data –If cirrhosis or other need for urgent treatment, test for NS3 and NS5A RAVs  Applies to genotype 1a and 1b HCV infection  NS3 and NS5A testing not required for: –Previous failure of NS3/4A PIs (including simeprevir, boceprevir, telaprevir) –Previous failure of NS5B inhibitors (sofosbuvir) –Tx-naive pts (unless considering SMV + SOF in cirrhotic GT1a) AASLD/IDSA/IAS-USA. HCV Guidance.

23. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Selecting Treatment Based on Resistance Testing Results  If genotype 1a or 1b HCV infection and previous failure with any NS5A inhibitors and cirrhotic or other need for urgent treatment: AASLD/IDSA/IAS-USA. HCV Guidance. RAV Testing ResultRetreatment RegimenDuration No NS5A RAVsLedipasvir/sofosbuvir + ribavirin24 wks NS5A but no NS3 RAVsSimeprevir + sofosbuvir + ribavirin24 wks NS5A and NS3 RAVs Retreatment in a clinical trial setting

24. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Is Ribavirin Required for Pts With Cirrhosis?  Integrated analysis of > 500 pts with cirrhosis treated with LDV/SOF ± RBV  Treatment-experienced pts had previously received HCV PI  Although NS5A resistance not measured, RBV overcomes shorter treatment duration in patients with HCV cirrhosis and prior treatment failure SVR12, %Total (N = 513) Treatment Naive (n = 161) Treatment Experienced (n = 352) Overall 969895 12 wks ± RBV 959794 24 wks ± RBV 989998 Without RBV959695 With RBV979996 12 wks without RBV929690 12 wks with RBV969896 24 wks without RBV989798 24 wks with RBV100 Reddy KR, et al. Hepatology. 2015;62:79-86.

25. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Is Ribavirin Required for Pts With Cirrhosis and NS5A RAVs?  Integrated analysis of > 500 pts with cirrhosis treated with LDV/SOF ± RBV  Treatment experienced patients had previously received HCV PI SVR12, % (n/N)18With NS5A RAVsWithout NS5A RAVs Overall 91 (86/94)98 (407/417) 12 wks without RBV88 (23/26)95 (86/91) 12 wks with RBV94 (32/34)97 (164/169) 24 wks without RBV85 (17/20)100 (113/113) 24 wks with RBV100 (14/14)100 (44/44) Reddy KR, et al. Hepatology. 2015;62:79-86.

26. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Personal Recommendations for Resistance in GT3 and GT4 HCV Infection  Genotype 3 –Treatment failures on daclatasvir should be tested for NS5A RAVs –BOSON: Adding pegIFN to SOF/RBV appears to help overcome virologic failure due to resistance in GT3 [1] –Improved SVR12 vs SOF/RBV alone in both treatment-naive and treatment-experienced pts, with or without cirrhosis  Genotype 4 –Resistance testing should be performed if considering retreatment after LDV/SOF failure –Use SMV/SOF/RBV for NS5A RAVs 1. Foster GR, et al. EASL 2015. Abstract LO5.

27. clinicaloptions.com/hepatitis HCV Alert: New Data on Resistance to DAAs and Implications for Therapy Summary  Baseline RAVs (especially NS5A) are present in treatment-naive pts  Treatment-emergent RAVs (including multidrug-resistant RAVs) seen in treatment failure and in all DAA classes and rarely with SOF  NS3 RAVs have low replication efficacy and disappear over 9-18 mos –If considering SMV + SOF: In treatment-naive and treatment-experienced pts with both genotype 1a HCV infection and compensated cirrhosis, ensure no Q80K  NS5A treatment-emergent RAVs persistent and a clinical challenge –If failure with any NS5A inhibitors (including DCV + SOF, LDV/SOF, OMV/PTV/RTV + DSV), and treatment is urgent, test for NS3 and NS5A RAVs –Use SMV + SOF + RBV if NS5A but no NS3 RAVs –Use LDV/SOF + RBV if no NS5A RAVs –Treat in clinical trial if both NS5A and NS3 RAVs present  Resistance testing may be of benefit in treatment failures

28. Go Online for More CCO Coverage of HCV Resistance! Online CME-certified interactive text module with expert analysis of key data CME-certified downloadable slides with slidenotes clinicaloptions.com/hepatitis