The latest advances in hepatitis C are related in several recent publications:
- Hepatology 2013; 57: 2143-54.
- Hepatology 2013; 57: 2155-63.
- Clin Gastroenterol Hepatol 2013; 11: 612-619.
The first two studies provide specific information about the effectiveness of Faldaprevir combined with peginterferon alfa-2a/ribavirin (PEG/RBV) in treatment-naive patients and patients with prior nonresponse respectively. The third reference provides the big picture regarding all of the emerging treatments.
In the first study, the “SILEN-C1” phase 2 trial, 429 patients without cirrhosis were randomized to several treatment arms. 423 of the 429 patients were genotype 1. This large study involved 89 centers in 15 countries. All of the treatment groups received PEG/RBV along with either placebo, faldaprevir 120 mg with lead-in (LI), faldaprevir 240 mg LI and faldaprevir 240 mg without LI. Faldaprevir is a NS3/4A protease inhibitor which can be administered orally once a day. Results: SVR achieved in 56% (placebo), 72% (faldaprevir 120mg LI), 72% (faldaprevir 240 mg LI), and 84% (faldaprevir 240 mg without LI). Discontinuation rates were 1%, 4%, 11%, and 5% for the aforementioned treatment groups.
In the second study, the “SILEN-C2” trial, 290 non cirrhotic genotype 1 patients with either no response or partial response to previous treatment underwent a 48 week treatment trial with a similar design as the SILEN-C1. Results: SVR rates among partial responders were 32% (faldaprevir 240 mg LI), 50% (faldaprevir 240 mg without LI), and 42%(faldaprevir 240 mg BID/LI). Among null responders, SVR rates were 21% (faldaprevir 240 mg LI), 35% (faldaprevir 240 mg without LI), and 29% (faldaprevir 240 mg BID/LI). Adverse reactions were higher in those on higher doses and included anemia, rash, indirect hyperbilirubinemia, and nausea. Discontinuation rates were 6%, 4%, and 23% for the aforementioned treatment groups.
The third study provides a landscape of current treatment and emerging treatments. Given the improvement in SVR among genotype 1 patients, the use of either telaprevir or boceprevir in combination with PEG/RBV is the “new standard of care” among adult patients with HCV. Studies supporting telaprevir include the ADVANCE study, the REALIZE trial, and the OPTIMIZE study. For boceprevir, its effectiveness was demonstrated with SPRINT-2, and RESPOND-2.
Both boceprevir and telaprevir, are NS3/4A serine protease inhibitors and are considered direct acting antivirals (DAAs). On the horizon:
- Simeprevir -NS3/4A protease inhibitor. Studies: PILLAR, ASPIRE. SVR: 75-86% in treatment-naive patients. Once daily, no rash or increased anemia. Hyperbilirubinemia can occur.
- Faldaprevir -see above studies.
- Danoprevir -NS3/4A protease inhibitor. Study: DAUPHINE. For genotypes 1 and 4. 100% SVR in genotype 4. Rates of withdrawal with danoprevir were similar to placebo.
- Daclatasvir -NS5A replication inhibitor. Study: COMMAND-1. For genotypes 1 and 4.
- Sofosbuvir -NS5B polymerase inhibitor. Studies: PROTON, ATOMIC. For genotypes 1, 4, and 6.
- Multiple DAAs in combination. Studies: MATTERHORN, INFORM-SVR, AVIATOR, ELECTRON, SOUND-2
Related blog posts:
- Pediatric HCV Guidelines | gutsandgrowth
- The cost of progress in treating Hepatitis C | gutsandgrowth
- HCV now more deadly than HIV | gutsandgrowth
- Vaniprevir for HCV | gutsandgrowth
- Missing “C” | gutsandgrowth
- More HCV options -phase 3 for Sofosbuvir | gutsandgrowth
- Curing Hepatitis C without interferon | gutsandgrowth