Resistenstesting ved HCV. Tore Jarl Gutteberg, UNN & UIT Disclosures Lectures & consultations for Gilead, ABBVIE, MSD, ROCHE

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1 Resistenstesting ved HCV Tore Jarl Gutteberg, UNN & UIT Disclosures Lectures & consultations for Gilead, ABBVIE, MSD, ROCHE

2 Medarbeidere Norge Kileng H, Florholmen J Goll R Paulssen EJ Kristiansen MG Moen OS Berg LK Sverige Kjellin M, Lennerstrand J Lannergård A Duberg A.S Aleman S Akaberi D, Wesslén L Danielsson A Bernfort L Verden Howe A Sarrazin C Pawlotsky JM Applegate T Grebely J Boucher C Feld J

3 1. Pearlman BL et al. EASL Tsai, N et al. EASL Belperio PS et al. J. Hepatology Calleja JL Et al., J. Hepatology 2017;66: DIRECT-ACTING ANTIVIRALS (DAA) PROVIDE >95% SVR SHARED

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5 Hepatitis C virus resistance to direct-acting antiviral drugs (DAAs) Drug class Efficacy Genotypic coverage Barrier to resistance Drug Protease inhibitors (PI) -previr +++ 1, 4, 1, 4, 1, 4, Moderate (++) (1a < 1b) Simeprevir Paritaprevir Grazoprevir* Glecaprevir*** Voxilaprevir**** NS5A inhibitors -asvir +++ 1,3,4,6 1,4 1,4 1, Low (+) Daclatasvir Ledipasvir Elbasvir* Ombitasvir Velpatasvir** Pibrentasvir*** Nucleosid inhibitors of NS5B polymerase -buvir Non-nucleosid inhibitors of NS5B polymerase -buvir High (+++) Sofosbuvir**/**** ++ 1 Low (+) Dasabuvir *Zepatier (grazoprevir/elbasvir) **Epclusa (velpatasvir/sofosbuvir) ***Maviret (glecaprevir/pibrentasvir) ****Vosevi (voxitaprevir/sofosbuvir) Adapted from Asselah T 1, Marcellin P. Liver Int Feb;33 Suppl 1: doi: /liv Lennerstrand J. ttps://

6 The Central Dogma of Molecular Biology: DNA makes RNA makes proteins

7 Pre-existing polymorphisms and acquired resistence Small single-stranded RNA virus Very high replication rate virus particles/day RNA polymerase lacks proof reading many variants/polymorphisms. Quasispecies. Baseline/pre-existing naturally resistant variants Treatment-acquired resistance Half life of NS5A resistance: >5 years Virco UK 1999

8 Referensgruppen för AntiViral terapi (RAV) Resistance-Associated Substitutions in HCV (RAS) * Lennerstrand J. usage-of-antivirals-and-the-occurrence-of-antiviral-resistance-in-norway ravn.pdf

9 * * * * Lennerstrand J. 6e3c92/usage-of-antivirals-and-the-occurrence-of-antiviralresistance-in-norway ravn.pdf

10 CONCLUSIONS SHARED Through international collaborations, SHARED provides an opportunity to conduct in-depth analyses for HCV drug resistance % of the DAA-failures have selected resistant viruses. RAS patterns are unique among genotypes; many RAS are prevalent in natural isolates. New RAS were observed in real-world clinics. Rare genotypes tend to select multiple RAS 20% of the genotype 4 patients selected NS5B S282T after failing sofosbuvir-containing regimens Resistance data from GT4-6 and re-treatment are much needed!

11 EASL gudelines 2018 on resistance testing No standardized tests for resistance of HCV to approved drugs are available as purchasable kits. Resistance testing in Europe mostly relies on in-house techniques based on population sequencing. In USA it is performed since 2016 by large diagnostic companies: LabCorp (Monogram) and Quest. Sanger sequencing or deep sequencing are recommended, using 15% cut off. Systematic testing for HCV resistance prior to treatment (i.e. at baseline) in direct-acting antiviral (DAA) drug-naive individuals is not recommended. The current EASL recommendations suggest treatment regimens that do not necessitate any resistance testing prior to first-line therapy (e.g. Maviret (glecaprevir/pibrentasvir) and Vosevi (voxitaprevir/sofosbuvir)). In areas where these regimens are not available or not reimbursed, physicians who have easy access to reliable resistance tests can use these results to guide their decisions, according to the EASL Recommendations for Treatment of Hepatitis C Sept 2016 (Table 2): baseline testing is recommended when Zepatier (grazoprevir/elbasvir) or Harvoni (ledipasvir/sofosbuvir) is to be used for GT 1a patients. In patients with cirrhosis and genotype 3 baseline resistance testing for NS5A RAS (Y93H) ought to be done prior to Epclusa (velpatasvir/sofosbuvir) treatment. Vosevi is mainly recommended for retreatment of NS5A treatment failures of GT1a and GT3

12 Anbefalinger HCV resistenstesting 1) GT 1a: Zepatier (elbasvir/grazoprevir) Harvoni (ledipasvir/sofosbuvir) baseline resistens NS5A analyser 1) GT 3a: Epclusa (sofosbuvir/velpatasvir) baseline resistens NS5A analyser 2) Testing før behandling Leger som har lett tilgang på sikre resistens tester, kan bruke disse til å veilede behandlingen ifølge «EASL Recommendations for Treatment of Hepatitis C 2016.» 3) Mindre feilbehandling 4) Alle med behandlingssvikt 5) Resistensovervåkning

13 APPENDIX Resistance-Associated Substitutions in HCV (RAS) Nucleotide analogue (NS5B) NS5A inhibitors (NS5A) Protease inhibitors (NS3) Non-nucleoside palm-1 inhibitor (NS5B)

14 Nucleotide analogue (NS5B) NS5A inhibitors (NS5A) Protease inhibitors (NS3) Non-nucleoside palm-1 inhibitor (NS5B)

15 HCV RAS analyser i Skandinavia Sted Aalborg, Danmark Uppsala, Sverige Gøteborg, Sverige Metode Sanger/Population Sanger/Population Next Generation Sequencing Sensitivitet 15-20% 15-20% 10% Personkontakt Anja Ernst Clinical Labotatory Geneticist (ErCLG) Ms. Sc. Ph.D. AALBORG UNIVERSITY HOSPITAL Johan Lennerstrand Forsker Ph.D. Midori Kjellin Mikrobiolog/Ph.D. student Kåre Bondesson Överläkare Akademiske sjukhuset Magnus Lindh Sektionschef, Professor Sahlgrenska Universitetssjukhuset Telefon / / E-post ae@rn.dk johan.lennerstrand@medsci.uu.se midori.kjellin@akademiska.se kare.bondeson@akademiska.se / virologen.su@vgregion.se

16 Vår metod är sedan 2017 ackrediterat enlig SWEDAC. Här kommer ett kort utkast hur vi går till väga vid resistensbedömningarna: NS3 och NS5A resistensbestämning Indikation/Medicinsk betydelse/användningsområde Enligt EASL Recommendations on treatment of hepatitis C RASar och genotyp (gt) används som kliniskt beslutskriterium för att bedöma trolig risk för resistens med behandlingar med aktuella DAAs. Resistensbestämning NS3- och/eller NS5A-genen sekvenseras och NS3 respektive NS5A proteinets partiella sekvens kan härledas ur denna sekvens. Nukleotidsekvensen granskas manuellt för kontroll av kvalitet och integritet. Kända varianter av den translaterade aminosyra(aa)sekvensen är associerad till ökad resistens mot NS3 respektive NS5A-läkemedel (Resistance Associated Substitutions, RAS) och detekteras med online-verktyget Geno2Pheno. Tolkning och bedömning För varje fynd (RAS) görs en samlad bedömning med hjälp av följande algoritmer och referenser: Geno2Pheno EASL guidelines 2018 AASLD, HCV Guidance 2018 HCVDrag/HCV Forum Publicerade in vitro och in vivo-data, inklusive fold resistance-data: Wyles et al, HCV Drug Resistance July/August 2017 Sorbo M. C. et al, Drug Resistance Updates, 2018 Palanisamy N. et al 2018, Antiviral Therapy Vänliga hälsningar, Midori Kjellin Mikrobiolog Klinisk Mikrobiologi Molekylär Virologi Akademiska sjukhuset Besöksadress: Hubben, Uppsala Science Park Dag Hammarskjölds Väg 38 Postadress: Uppsala Telefon: