1. Hepatitis web study H EPATITIS W EB S TUDY H EPATITIS C O NLINE Treatment of Chronic HCV Genotype 2 Robert G. Gish MD Staff Physician, Stanford University Medical Center Senior Medical Director, St Josephs Hospital and Medical Center, Liver Program, Phoenix, Arizona Clinical Professor of Medicine, University of Nevada, Las Vegas Medical Director, Hepatitis B Foundation Vice Chair, Executive Committee, National Viral Hepatitis Roundtable (NVHR) Last Updated: May 14, 2014

2. Hepatitis web study Hepatitis web study Background and Definitions Initial Treatment and Retreatment of Prior Relapsers Retreatment of Prior Nonresponders Issues and Controversies Future Therapies Summary Background and Definitions Initial Treatment and Retreatment of Prior Relapsers Retreatment of Prior Nonresponders Issues and Controversies Future Therapies Summary Treatment of Chronic HCV Genotype 2

3. Hepatitis web study Hepatitis web study Background and Definitions T REATMENT OF C HRONIC H EPATITIS C: G ENOTYPE 2

4. Hepatitis web study Treatment of Chronic HCV Genotype 2 Background HCV infects ~ 5 million people in the US today Genotype 2 is second most common HCV genotype in US Up to 85% of patients have contraindications for interferon therapy Small proportion of untreated patients are genotype 2 today due to historically high treatment and cure rates

5. Hepatitis web study Virologic Responses with HCV Therapy Sustained Virologic Response at 12 Weeks Post Therapy (SVR12) Sustained Virologic Response (SVR12) = Undetectable HCV RNA 12 Weeks Post Treatment Undetectable Treatment Post Treatment 12 Weeks End of Treatment SVR12

6. Hepatitis web study Virologic Failure with HCV Therapy Relapser and Nonresponder (Null and Partial) Different Types of Virologic Failure with HCV Therapy Treatment Relapser Partial Responder Null Responder Undetectable Nonresponder

7. Hepatitis web study Source: AASLD/IDSA/IAS-USA (www.hcvguidelines.org). Accessed May 12, 2014www.hcvguidelines.org AASLD/IDSA/IAS-USA 2014 HCV Treatment Recommendations Criteria for Interferon Ineligible Interferon Ineligible is defined as one or more of the following: Intolerance to interferon Autoimmune hepatitis and other autoimmune disorders Hypersensitivity to peginterferon or any of its components Decompensated hepatic disease Major uncontrolled depressive illness A baseline neutrophil count below 1500/μL, a baseline platelet count below 90,000/μL or baseline hemoglobin below 10 g/dL A history of preexisting cardiac disease

8. Hepatitis web study Hepatitis web study Treatment-Naïve and Prior Relapsers T REATMENT OF C HRONIC H EPATITIS C: G ENOTYPE 2

9. Hepatitis web study Source: AASLD/IDSA/IAS-USA (www.hcvguidelines.org). Viewed April 22, 2014www.hcvguidelines.org AASLD/IDSA/IAS-USA 2014 HCV Treatment Recommendations Initial Therapy for Patients with Genotype 2 Chronic HCV Patients with GT 2 HCV: Initial Treatment & Retreatment of Relapsers* Recommended Therapy, Regardless of Eligibility for Interferon Therapy Sofosbuvir + Ribavirin x 12 weeks Alternative Therapy, Regardless of Eligibility for Interferon Therapy None Not Recommended Peginterferon + Ribavirin x 24 weeks Monotherapy with Peginterferon, Ribavirin, or a Direct Acting Antiviral Agent Any Regimen with Telaprevir, Boceprevir, or Simeprevir *Patients who experienced relapse after Peginterferon plus Ribavirin therapy

10. Hepatitis web study Treatment-Naïve & Prior Relapsers with GT2 Chronic HCV Key Studies that Support Treatment Recommendations Sofosbuvir + Ribavirin - FISSION - POSITRON - VALENCE

11. Hepatitis web study Source: Lawitz E, et al. N Engl J Med. 2013;368:1878-87. 2436 Week 012 N =243 N =256 SVR12 Sofosbuvir + Ribavirin for Treatment-Naïve HCV GT 2 or 3 FISSION Trial: Design Peginterferon + RBV (fixed-dose) Sofosbuvir + RBV (weight-based) Drug Dosing Sofosbuvir: 400 mg once daily Peginterferon alfa-2a: 180 µg once weekly Weight-based Ribavirin (in 2 divided doses): 1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg Fixed-dose Ribavirin (in 2 divided doses): 800 mg/day

12. Hepatitis web study Sofosbuvir + Ribavirin for Treatment-Naïve HCV GT 2 or 3 FISSION Trial: Results SVR12 by Genotype Source: Lawitz E, et al. N Engl J Med. 2013;368:1878-87. RBV = Ribavirin; PEG = Peginterferon 68/7052/67102/183110/176170/253162/243

13. Hepatitis web study Source: Jacobson I, et al. N Engl J Med. 2013;368:1867-77. N =71 Placebo 12 weeks Sofosbuvir + RBV 12 weeks Sofosbuvir + RBV 12 weeks N =207 SVR12 Sofosbuvir + Ribavirin for HCV GT 2 or 3 (PEG not an option) POSITRON Trial: Design 24 Week 012 SVR12 Drug Dosing Sofosbuvir: 400 mg once daily Weight-Based Ribavirin (in 2 divided doses): 1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg

14. Hepatitis web study Sofosbuvir + Ribavirin for HCV GT 2,3 (PEG not an option) POSITRON: Results with Sofosbuvir + Ribavirin SVR12 by HCV Genotype Source: Jacobson I, et al. N Engl J Med. 2013;368:1867-77. Placebo arm = 0% SVR12 101/10960/98

15. Hepatitis web study Source: Zeuzem S, et al. N Engl J Med. 2014 May 4. [Epub ahead of print] 2436 Week 012 Sofosbuvir + Ribavirin for Treatment Naïve & Experienced HCV GT 2 or 3 VALENCE: Treatment Arms SVR12 Sofosbuvir + RBV (n = 73) SVR12 Sofosbuvir + RBV (n = 250) GT 2 GT 3 Drug Dosing Sofosbuvir 400 mg once daily Ribavirin (weight-based and divided bid): 1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg Original Study Protocol: Placebo versus 12 weeks treatment for GT 2 and 3. Amended Protocol: GT3 treatment extended from 12 to 24 weeks; Placebo arm offered alternative treatment Note: 85 patients enrolled in placebo arm

16. Hepatitis web study Sofosbuvir + Ribavirin for Treatment Naïve & Experienced HCV GT 2 or 3 VALENCE: Results for Treatment-Naïve GT 2 SVR12 for Treatment-Naïve GT 2 Source: Zeuzem S, et al. N Engl J Med. 2014 May 4. [Epub ahead of print]

17. Hepatitis web study Hepatitis web study Retreatment of Prior Nonresponders T REATMENT OF C HRONIC H EPATITIS C: G ENOTYPE 2

18. Hepatitis web study Source: AASLD/IDSA/IAS-USA (www.hcvguidelines.org). Viewed April 22, 2014www.hcvguidelines.org AASLD/IDSA/IAS-USA 2014 HCV Treatment Recommendations Retreatment of Patients with Genotype 2 Chronic HCV Patients with GT 2 HCV: Retreatment of Prior Nonresponders* Recommended Therapy Sofosbuvir + Ribavirin x 12 weeks^ Alternative Therapy Sofosbuvir + Peginterferon + Ribavirin x 12 weeks Not Recommended Peginterferon + Ribavirin +/- [Telaprevir, Boceprevir, or Simeprevir] Monotherapy with Peginterferon, Ribavirin, or a Direct Acting Antiviral Agent Treatment of Decompensated Cirrhosis with Peginterferon *Patients who experienced nonresponse (partial or null) with Peginterferon plus Ribavirin therapy ^Patients with cirrhosis may benefit by extension of therapy to 16 weeks

19. Hepatitis web study Treatment Experienced Nonresponders with GT2 Chronic HCV Key Studies that Support Treatment Recommendations Sofosbuvir + Ribavirin - FUSION - VALENCE Sofosbuvir + Ribavirin + Peginterferon - LONESTAR-2

20. Hepatitis web study Source: Jacobson I, et al. N Engl J Med. 2013;368:1867-77. N =98 Sofosbuvir + RBV 16 weeks Sofosbuvir + RBV 16 weeks Sofosbuvir + RBV 12 weeks Sofosbuvir + RBV 12 weeks N =103 SVR12 Sofosbuvir + RBV in Treatment-Experienced HCV GT 2 or 3 FUSION Trial: Design 24Week0122816 SVR12 Placebo Drug Dosing Sofosbuvir: 400 mg once daily Weight-Based Ribavirin (in 2 divided doses): 1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg

21. Hepatitis web study Sofosbuvir + RBV in Treatment-Experienced HCV GT 2 or 3 FUSION Trial: Results for GT2 SVR12 for Treatment-Experienced GT2 Source: Jacobson I, et al. N Engl J Med. 2013;368:1867-77. SOF = Sofosbuvir; RBV = Ribavirin 31/3630/3225/266/1023/237/9

22. Hepatitis web study Source: Zeuzem S, et al. N Engl J Med. 2014 May 4. [Epub ahead of print] 2436 Week 012 Sofosbuvir + Ribavirin for Treatment Naïve & Experienced HCV GT 2 or 3 VALENCE: Treatment Arms SVR12 Sofosbuvir + RBV (n = 73) SVR12 Sofosbuvir + RBV (n = 250) GT 2 GT 3 Drug Dosing Sofosbuvir 400 mg once daily Ribavirin (weight-based and divided bid): 1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg Original Study Protocol: Placebo versus 12 weeks treatment for GT 2 and 3. Amended Protocol: GT3 treatment extended from 12 to 24 weeks; Placebo arm offered alternative treatment Note: 85 patients enrolled in placebo arm

23. Hepatitis web study Sofosbuvir + Ribavirin for Treatment Naïve & Experienced HCV GT 2 or 3 VALENCE: Results for Treatment Experienced GT 2 SVR12 for Treatment-Experienced GT 2 Source: Zeuzem S, et al. N Engl J Med. 2014 May 4. [Epub ahead of print]

24. Hepatitis web study Source: Lawitz E, et al. 64th AASLD; Washington, DC. 2013. Abstract LB-4. Sofosbuvir + PEG + RBV in Treatment-Experienced HCV GT 2 or 3 LONESTAR-2 Trial: Design 24 Week 012 Sofosbuvir + Peginterferon + Ribavirin N = 47 SVR12 Drug Dosing Sofosbuvir: 400 mg once daily Peginterferon alfa-2a: 180 µg once weekly Ribavirin (weight-based and in 2 divided doses): 1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg GT 2 or 3

25. Hepatitis web study Sofosbuvir + PEG + RBV in Treatment-Experienced HCV GT 2 or 3 LONESTAR-2 Trial: Results SVR12 in Treatment-Experienced by HCV Genotype Source: Lawitz E, et al. 64th AASLD; Washington, DC. 2013. Abstract LB-4. 42/4722/2320/24

26. Hepatitis web study Hepatitis web study Issues and Controversies T REATMENT OF C HRONIC H EPATITIS C: G ENOTYPE 2

27. Hepatitis web study Treatment of Genotype 2 Chronic HCV Issues and Controversies Cost of Therapy: wait for price competition? With cure rates as high as 96%, are we over-treating most patients? - Can we shorten therapy to 4 or 6 weeks to save treatment costs? When to Defer Therapy: - Decisions on when to warehouse? - Based on mild histology or lack of evidence of systemic disease (Non) Role of IL-28b Testing, now obviated Degree of Liver Fibrosis - How to stage? - MRE, Fibroscan, Supersonic, Spleen Size, APRI score, platelet count

28. Hepatitis web study Hepatitis web study How is cost of therapy impacting treatment decisions?

29. Hepatitis web study Hepatitis C Genotype 2 Estimated Medication Costs for Treatment-Naïve & Prior Relapsers Patients with GT 2 HCV: Initial Treatment & Retreatment of Relapsers Regimen and Duration Regimen Cost Recommended Therapy Sofosbuvir + Ribavirin x 12 weeks$85,000 Alternative Therapy NoneNA

30. Hepatitis web study Hepatitis C Genotype 2 Estimated Medication Costs for Retreatment of Nonresponders Patients with GT 2 HCV: Retreatment of Nonresponders Regimen and Duration Regimen Cost Recommended Therapy Sofosbuvir + Ribavirin x 12 weeks$85,000 Sofosbuvir + Ribavirin x 16 weeks*$113,000 Alternative Therapy Sofosbuvir + Peginterferon + Ribavirin x 12 weeks$97,000 *Note: some experts extend therapy to 16 weeks in nonresponder GT2 patients with cirrhosis

31. Hepatitis web study Source for Figure: Camilla Graham, MD, MPH. Beth Israel Deaconess Medical Center Data Sources: (1) Lawitz E, et al. NEJM 2013; 368:1878-87. (2) Jacobson I, et al. NEJM 2013; 368:1867-77. (3) Antiviral Drugs Advisory Committee Meeting, FDA and Gilead reviews, 10/25/2013. (4) Package Insert, Gilead.com 12/7/2013. HCV Therapy for Genotype 2 Chronic HCV Cost Analysis Based on Cost per SVR Patient CharacteristicsRegimen OptionsSVRCost per SVR Naïve, no cirrhosis SOF + RBV x 12 wks92-98%$95,263 PEG + RBV x 24 wks80%$53,350 Naïve, cirrhosisSOF + RBV x 12 wks91-94%$97,312 Treatment experienced, no cirrhosis SOF + RBV x 12 wks91-96%$96,276 Treatment experienced, cirrhosis SOF + RBV x 16 wks78%$154,658 SOF + PEG + RBV x 12 wks93%$113,269

32. Hepatitis web study Hepatitis web study Treat now or defer therapy?

33. Hepatitis web study Factors Favoring Treat GT2 Now Advanced Fibrosis (F3-F4) - Platelet count < 150,000/uL - Large spleen and/or portal vein - Esophageal varices Synthetic dysfunction Systemic disease - Cryoglobulinemia ([+] Rheumatoid Factor) Highly motivated patients/symptomatic patients Patients with Increased Mortality Risk - All cause - HCC risk

34. Hepatitis web study Hepatitis web study Future Treatment Options H EPATITIS C: G ENOTYPE 2

35. Hepatitis web study Future Regimens for GT-2 Daclatasvir + Sofosbuvir - Daclatasvir: NS5A replication inhibitor - Sofosbuvir: NS5B polymerase inhibitor ABT-450/r-Ombitasvir +/- Ribavirin - ABT-450/r: NS3 protease inhibitor with ritonavir boosting - Ombitasvir (formerly ABT-267): NS5A replication inhibitor

36. Hepatitis web study Source: Sulkowski MS, et al. N Engl J Med. 2014;370:211-21. Daclatasvir + Sofosbuvir +/- Ribavirin for HCV GT 1-3 A1444-040 Design: Treatment-Naïve 24 Week Rx SOF × 7 days, then DCV + SOF SVR12 Week 024 N =14 Drug Dosing Daclatasvir (DCV): 60 mg once daily Sofosbuvir (SOF): 400 mg once daily Ribavirin (RBV): GT1, given weight-based and divided bid (1000 mg/day if < 75 kg or 1200 mg/day if ≥ 75 kg) Ribavirin (RBV): GT 2 or 3 (800 mg/day) 36 Rx Naïve GT 2 or 3 n = 44 n = 14 n = 16 12 DCV + SOF n = 14 DCV + SOF + RBV SVR12 SOF × 7 days, then DCV + SOF SVR12 Rx Naïve GT 1a/1b n = 44 n = 14 n = 15 DCV + SOF n = 15 DCV + SOF + RBV SVR12

37. Hepatitis web study Daclatasvir + Sofosbuvir +/- Ribavirin for HCV GT 1-3 A1444-040: Results for Treatment-Naïve GT 2 SVR12 for Patient with GT 2, by Treatment Regimen Source: Sulkowski MS, et al. N Engl J Med. 2014;370:211-21. DCV = daclatasvir; SOF = sofosbuvir; RBV = ribavirin 9/98/85/7

38. Hepatitis web study Summary Points for Treatment of Chronic HCV GT-2 Genotype 2 highly responsive to 12 weeks of all-oral therapy Relatively little retreatment data since high SVR rates with therapy in naïve patients Few GT2 studies moving forward with new therapies Will be difficult to enroll large studies required for licensing trials New pangenotypic drugs will be used for genotype 2 off-label (prediction)

39. Hepatitis web study Hepatitis web study This slide deck is from the University of Washington’s Hepatitis C Online and Hepatitis Web Study projects. Hepatitis C Online www.hepatitisc.uw.edu www.hepatitisc.uw.edu Hepatitis Web Study http://depts.washington.edu/hepstudy/ http://depts.washington.edu/hepstudy/ Funded by a grant from the Centers for Disease Control and Prevention. This slide deck is from the University of Washington’s Hepatitis C Online and Hepatitis Web Study projects. Hepatitis C Online www.hepatitisc.uw.edu www.hepatitisc.uw.edu Hepatitis Web Study http://depts.washington.edu/hepstudy/ http://depts.washington.edu/hepstudy/ Funded by a grant from the Centers for Disease Control and Prevention.