1. Optimal therapy in genotype 2 and 3 patients Antonio Craxì Liver & GI Unit, Di.Bi.M.I.S., University of Palermo, Italy craxanto@unipa.it

2. Treatment for patients infected with HCV genotype 2 or 3: the current SOC End-of-treatment virological response Sustained virological response End-of-treatment virological response Sustained virological response HCV RNA detection at end of treatment and 24 weeks later HCV RNA detection at end of treatment and 24 weeks later Pegylated interferon + ribavirin 0.8 g per day x 24 weeks Pegylated interferon + ribavirin 0.8 g per day x 24 weeks No liver biopsy or serological markers of disease severity No liver biopsy or serological markers of disease severity

3. Optimising treatment based on genotype: 48 weeks for G1, 24 weeks for G2/3 84% 79% 0 20 40 60 SVR (%) Genotype 1 80 81% 80% 100 Genotype 2/3 24-LD 24-SD 48-LD 48-SD 96 144 99 153 LD = RBV 800 mg/day SD = RBV 1000/1200 mg/day Hadziyannis S, et al. Ann Intern Med 2004; 140: 346 PEG IFN alfa2a 180  g plus Ribavirin 29% 41% 42% 52% n= 101 118 250 271

4. 0 2 4 68 10 12 14 –5 –4 –3 –2 –1 0 Mean decline in HCV RNA (log 10 copies/mL) Days Genotype 2 Genotype 1 Neumann A et al. J Infect Dis 2000; 182: 28 HCV RNA kinetics during antiviral treatment: importance of HCV genotype

5. Pooled analysis of genotype 2 and 3 patients treated with antivirals for 24 weeks Andriulli, APT 2008, 28:397 AuthorYear Genotype 3 Genotype 2 Working group 2005110/17194/147 Brown2006151/251213/298 Mangia200513/1740/53 Meyer-Wyss200647/6721/24 Rizzetto2005118/14880/92 Shiffman2007244/369268/356 Zeuzem2004143/18239/42 Zeuzem200415/2027/38 Pooled (fixed effect) 841/1225782/1050 1/641/161/4141664 Better Genotype 3 Better Genotype 2 1.489 (1.233/1.798) HCV G2: SVR 74% (782/1050) irrespective of viral load HCV G3: LVL: SVR 75% (405/737) HVL: SVR 58% (298/500)

6. Response rates in genotype 2/3 patients (pooled analysis of Fried, Hadzyiannis, Shiffman) G2 (n=395) G3 (426) RVR (<50 IU/mL)71%60% cEVR (<50 IU/mL)24%29% pEVR (≥ 2log drop)1%3% SVR77%68% SVR in pts with RVR86% SVR in pts with cEVR *61%54% SVR in pts with pEVR **-- * Not including RVR; ** not including RVR or cEVR Fried MW, et al. J Hepatol 2008; 48 (Suppl 2); Abstract 7

7. The Good, the Bad and the Ugly  March 2006: Female, 38 yrs, HCV known since 1999 (surgery 1977) Female, 38 yrs, HCV known since 1999 (surgery 1977) No alcohol, BW 61 kg, BMI 22 No alcohol, BW 61 kg, BMI 22 ALT 3  8 unl ALT 3  8 unl HCV G2, HCV RNA 6.5 x 10 6 IU/ml HCV G2, HCV RNA 6.5 x 10 6 IU/ml Fibroscan  4.3 KPa, no liver biopsy Fibroscan  4.3 KPa, no liver biopsy  April to October 2006: PEG IFN  -2a 180  g/wk + RBV 800 mg, ITT 24 weeks PEG IFN  -2a 180  g/wk + RBV 800 mg, ITT 24 weeks Excellent tolerance and adherence Excellent tolerance and adherence RVR at 4 weeks, EVR at 12, ETR at 24 RVR at 4 weeks, EVR at 12, ETR at 24  March 2007: SVR confirmed SVR confirmed The Good Overtreatment? YES NO

8. The Good, the Bad and the Ugly  May 2007: Male, 46 yrs, HCV known since 2004 (no risk factors) Male, 46 yrs, HCV known since 2004 (no risk factors) Alcohol 50 gm/day up to 2004, BW 86 kg, BMI 29 Alcohol 50 gm/day up to 2004, BW 86 kg, BMI 29 ALT 2  4 unl ALT 2  4 unl HCV G2, HCV RNA 4.3 x 10 6 IU/ml HCV G2, HCV RNA 4.3 x 10 6 IU/ml Fibroscan  8.1 KPa, biopsy: stage 3 grade 2 Metavir Fibroscan  8.1 KPa, biopsy: stage 3 grade 2 Metavir  July 2007: Starts PEG IFN  -2b 1.5  g/Kg/wk + RBV 1200 mg, ITT 24 weeks Starts PEG IFN  -2b 1.5  g/Kg/wk + RBV 1200 mg, ITT 24 weeks Modest tolerability, adherence >80/80/80 Modest tolerability, adherence >80/80/80 No RVR at 4 weeks, EVR at 12 No RVR at 4 weeks, EVR at 12  October 2007: Patient decides to stop at 15 weeks, while HCV RNA negative (work problems, tolerability, has heard about short treatments) Patient decides to stop at 15 weeks, while HCV RNA negative (work problems, tolerability, has heard about short treatments)  December 2007: HCV RNA positive, ALT flare HCV RNA positive, ALT flare The Bad Undertreatment (too short)? YES NO

9. The Good, the Bad and the Ugly  October 2003: Male, 39 yrs, HCV known since early ’90s (IVDU in the ’80s) Male, 39 yrs, HCV known since early ’90s (IVDU in the ’80s) Alcohol 80 gm/day up to 2003, “stopped?”; BW 102 kg, BMI 34 Alcohol 80 gm/day up to 2003, “stopped?”; BW 102 kg, BMI 34 ALT 2  5 unl, PLT 104.000/mm 3 ALT 2  5 unl, PLT 104.000/mm 3 HCV G3, HCV RNA 1.8 x 10 6 IU/ml; HBV and HOV negative HCV G3, HCV RNA 1.8 x 10 6 IU/ml; HBV and HOV negative Fibroscan  16.5 KPa, biopsy: stage 4 grade 2 Metavir Fibroscan  16.5 KPa, biopsy: stage 4 grade 2 Metavir F1 esophageal varices F1 esophageal varices  December 2003  May 2004: Starts PEG IFN  -2a 180  g + RBV 800 mg, ITT 24 weeks Starts PEG IFN  -2a 180  g + RBV 800 mg, ITT 24 weeks Good tolerability, PEG IFN 135  g since week 8 due to cytopenia Good tolerability, PEG IFN 135  g since week 8 due to cytopenia No RVR at 4 weeks, EVR at 12, ETR at 24 weeks No RVR at 4 weeks, EVR at 12, ETR at 24 weeks  October 2004: HCV RNA positive, ALT flare HCV RNA positive, ALT flare The Ugly Undertreatment (not enough)? YES NO

10. Optimization of treatment for HCV genotype 2 or 3: 2009 Extended treatment (48 weeks)? Standard treatment (24 weeks)? Short treatment (12-16 weeks)? HCV genotype 2 or 3 patients - Who needs: HCV genotype 2 or 3 patients - Who needs:

11. Shortening Therapy: Study Designs Week 0 Shiffman Gt 2/3 PEG-IFNα-2a 180 µg qwk, RBV 800 mg Mangia Gt 2/3 PEG-IFNα-2b 1.0 µg/kg qwk, RBV 1000/1200 mg 2 16 weeks 24 weeks 1.Shiffman ML, et al. N Engl J Med. 2007;357:124-134. 2.Mangia A, et al. N Engl J Med. 2005;352:2609-2017. 24 weeks Week 4 12 weeks 24 weeks 24-wk Follow-up + – n = 732 n = 731 n = 133 n = 80 n = 70

12. Shorter Treatment Duration? Shiffman ML, et al. N Engl J Med. 2007;357:124-134; Mangia A, et al. N Engl J Med. 2005;352:2609-2017. Standard duration regimen (24 wk) Variable duration (12 or 24 wk) 0 20 40 60 80 100 Any HCV Gt HCV Gt 2 HCV Gt 3 76 77 82 62 SVR, % Shiffman et al: Lower SVR rates at 16 vs 24 wk (Gt 2/3)* Mangia et al: SVR rates comparable at 12 vs 24 wk (Gt 2/3)* 0 20 40 60 80 100 Any HCV Gt HCV Gt 2 HCV Gt 3 SVR, % HCV Gt 3 62 70 62 75 62 66 P <.001 P =.23 Standard duration (24 wk) Shorter duration (16 wk) * LOD <50 IU/mL (70) (213) (53) (160)(17)(53) (732)(731)(356)(372)(369)(358)

13. Relapse rates in Genotype 2 and 3 12 – 16 wks 24 wks 0 5 10 15 20 25 30 35 Shiffman 2007 % All patients % 0 5 10 15 20 25 30 35 Mangia 2005Dalgard 2008 RVR patients

14. Shiffman ML, et al. N Engl J Med. 2007;357:124-134. Patients infected with HCV genotype 2/3 (N = 1291) RVR: 67% (871 / 1291) SVR 378/461370/410 55/205105/215 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% SVR ACCELERATE Trial: SVR in Patients With and Without an RVR 82% 27%49% 90% 16 wks 24 wks 16 wks 24 wks No RVR: 33% (420 / 1291)

15. SVR rate with 16 vs.24 weeks of treatment in G2/3 patients with an RVR and LVL 16 weeks PEG IFN alfa 2a plus RBV 800 mg/day n=123n=101 n=295n=260 n=49n=43 ≤400 000 IU/mL400–800 000 IU/mL>800 000 IU/mL 90% 84% 78% 95% 92% 88% SVR (%) 0 20 40 60 80 100 Standard analysis 24 weeks PEG IFN alfa 2a plus RBV 800 mg/day Shiffman ML, et al. N Engl J Med. 2007;357:124-134.

16. Dalgard, Hepatology 2008, 47:35 PEG IFN alfa-2b and RBV for 14 vs 24 weeks in patients with HCV G2 or 3 and rapid virological response PEG IFN alfa 2b 1.5 ug/kg, RBV 800-1400 mg 14 wks 24 wks n.SVRRelapsen.SVRRelapse Overall139 120 (86) 146136(93.2) Geno 3 110 93 (84) 17 (16) 115 106 (92) 9 (8) 229 27 (93) 2 ( 7) 2 ( 7)31 30 (97) 30 (97) 1 (3) Viral load Geno 3 ≥ 400,000 IU ≥ 400,000 IU66 57 (86) 9 (14) 66 57 ( 86) 57 ( 86) 9 (14) < 400,000 IU < 400,000 IU36 29 (80) 7 (20) 44 44 (100) 0 (0) Geno 2 ≥ 400,000 IU ≥ 400,000 IU22 20 (90) 2 (10) 19 18 (95) 1 (5) < 400,000 IU < 400,000 IU66(100) 0 (0) 11 11 (100) 0 (0)

17. 56% 38% Genotype 2 (n=55) (%) 0 10 20 30 40 50 60 70 80 90 100 12 weeks of treatment Genotype 3 (n=137) Genotype 3 (n=139) Genotype 2 (n=49) 24 weeks of treatment 5% 58% 31% 9% 82% 12% 6% 78% 12% 10% Lagging, Hepatology 2008, 47:1837 SVR Relapse NR Randomized comparison of 12 or 24 weeks of PEG IFN alfa-2a and RBV in chronic HCV G2/3 infection RBV 800 mg

18. Meta-analysis of short vs standard therapy in genotypes 2 and 3 patients with RVR AuthorYearShortStandardDalgard2008120/139136/146 Shiffman2007385/487397/466 Mangia2005113/15341/45 Bonardi200629/3227/31 Yu200743/4385/87 Pooled (fixed effect) 690/854686/775 1/641/161/4141664 Better Short Better Standard 1.629 (1.234/2.152) Andriulli, APT 2008, 28:397

19. SVR-Rate (%) Relapse Rate (%) 100 80 60 40 20 0 65 67 76 n= 22/34 n= 20/30 n= 28/37 67 PegIFN alfa 2a Riba 1000-1200 24 weeks Peg IFN alfa 2a Riba 800 48 weeks PegIFN alfa2a Riba 1000-1200 48 weeks 26 n= 14/21 n= 15/27 PegIFN alfa 2a Riba 800 24 weeks 24 n= 7/209 13 3/23 n= 1/27 Should Treatment be Intensified in Genotypes 2/3 without RVR ? Retrospective analysis 1 Fried M et al, N Engl J Med al. 2002 2 Hadziyannis el at. Ann Intern Med 2004 4 Willems B et al. EASL 2007

20. Optimization of treatment for HCV genotype 2 or 3: 2009 Extended treatment (48 weeks)? Standard treatement (24 weeks)? Short treatment (12-16 weeks)? HCV genotype 2 or 3 patients - Who needs: HCV genotype 2 or 3 patients - Who needs: Cofactors?

21. Bruno et al, EASL 2008, poster SVR rates in genotype 2/3 patients (pooled analysis of ACCELERATE, Fried, Hadzyiannis)

22. Lagging, Hepatology 2008, 47:1837 Randomized comparison of 12 or 24 weeks of PEG IFN alfa-2a and RBV in chronic HCV G2/3 infection 80% 14% < 40 years of age (n=76) (%) 0 10 20 30 40 50 60 70 80 90 100 12 weeks of treatment ≥ 40 years of age (n=118) ≥ 40 years of age (n=112) < 40 years of age (n=76) 24 weeks of treatment 5% 45% 10% 83% 8% 9% 75% 15% 9% SVR Relapse NR RBV 800 mg

23. RVR and SVR in patients receiving Peg-IFN  2a 135  g + RBV 11 mg/Kg for 24 Weeks Weiland O et al J Viral Hep 2008;15:641-645

24. Ribavirin dosage and SVR in G2/3 patients Hadziyannis:Ann Intern Med. 2004;140:346-355. Willems et al: J Hepatol, 2006 Volume 46, S1, p S6

25. SVR in G2/3 patients according to schedule and to RBV concentration at 4 weeks p = 0.02 p = 0.12 12 weeks24 weeks Christensen et al, EASL 2008

26. WIN-R: impact of weight-based RBV dosing on SVR in G2/3 patients SVR % 65-85 kg 86-105 kg > 105 kg P value Weight-based RBV dosing, RBV 800-1400 mg (n = 325) Genotype 2/3 64.159.261.2.356 Flat dosing, RBV 800 mg (n = 333) Genotype 2/3 63.655.455.2.034 Jacobson IM, et al. Hepatology. 2007;46:971-981.

27. A RCT of RBV 400 mg vs 800 mg/day in combination with PEG IFN  -2a ITT analysis at 24 week Ribavirin 800 mgRibavirin 400 mg HCV G 2 No. of patients =18 SVR = 77.8% No. of patients = 19 SVR = 63.2% HCV G 3 No. of patients = 123 SVR = 67.5% No. of patients = 122 SVR = 63.9% Ferenci P et al Hepatology 2008;47:1816-1823

28. Response-guided treatment for HCV GT 2/3 RVR: a meta-analysis Di Martino V, et al. AASLD 2008. Abstract 213. Pooled RCTs of GT 2/3 RVR (7 studies, n=2054) SVR increase with 24 Weeks vs shorter treatment, % (95% CI) 16 weeks treatment* (n=1782) 2 (-5 to 8) 12 or 14 weeks treatment (n=272) 11 (5 to 18) Fixed-dose RBV † 13 (0 to 25) Weight-based RBV 3 (-2 to 9) *Irrespective of RBV regimen. † Irrespective of duration of shorter treatment.

29. Mangia, Hepatology 2009, in press Determinants of relapse after 12 weeks of therapy in 496 patients with HCV G2 or G3 with RVR PEG IFN alfa 2b 1.5 ug/kg, RBV 800-1200 mg Predictors of relapse p OR; 95% CI Age >45 years 0.004- BMI >30 kg / m 2 0.0001 2.5; 1.49 – 4.20* Platelets <140.000/mm 3 0.0001 1.7; 1.03 – 2.70* *independently associated with SVR EOT: 96%: SVR: 82%, Relapse: 14%

30. EOT 33 (76.7%) SVR 30 (70%) Re-treatment of 43 relapsers after short therapy with standard (24 wks) treatment duration Mangia et al, J Hepatol 2008; 48 (Suppl 2): S6

31. Albinterferon - IFN Naïve, Gt 2/3 (Achieve 2/3): SVR Rates alb-IFN 1200 µg q2wk N=311 100 80 60 40 20 0 All Pts (933) 79. 8 80 alb-IFN 900 µg q2wk N=310 SVR Rate, % ITT analysis; q2wk, every 2 weeks; ribavirin 800 mg flat dose; G2/3 n=420/513 HGS press release, December 8, 2008 PEG IFN  2a 180 µg wk N=312 84.8 P= ns

32. R7128 in HCV G 2/3 nonresponders Gane E, et al. AASLD 2008. Abstract LB10.  No virologic breakthrough reported  Adverse events similar to previous reports GT 2 R7128 + PegIFN/RBV GT 3 R7128 + PegIFN/RBV GT 2 placebo + PegIFN/RBV GT 3 placebo + PegIFN/RBV Weeks HCV RNA (log 10 IU/mL) R7128 treatment period 018765432 8 7 6 5 4 3 2 1 0 Individual Patient HCV RNA Values Over Time R7128: nucleoside analogue HCV polymerase inhibitor HCV GT 2/3 patients with previous treatment failure (N = 25)

33. The G2/G3 RGT algorithm: 2009 on… G2/3 HVL 24 weeks LVL 16 weeks 24 weeks 48 weeks? STOP Week 4 Week 12 Week 24 ------ + + ≥2log - + + <2 log - ++++++ STAT-C ? Short therapy not to be chosen if F3/F4 fibrosis is present Age >40 associated to reduced SVR