Efficacy and Safety of Glecaprevir/Pibrentasvir in Patients Coinfected With Hepatitis C Virus and Human Immunodeficiency Virus Type 1: The EXPEDITION-2 Study

Public Health Considerations among People who Inject Drugs with HIV/HCV Co-Infection: A Review

Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) co-infection among persons who inject drugs (PWID) is a major public health concern. There are limited data in clinical trials on the use of direct-acting antiviral (DAA) therapy for treatment of HCV in co-infected PWID. It is critical for these patients to gain access to treatment in order to decrease progression of liver disease and decrease transmission of both HIV and HCV. Additional harm reduction interventions, including needle and syringe programs and opioid substitution treatment, should be made available to this vulnerable population. Despite the importance of DAA treatment, the cost of DAA therapy and access to medical care is still a barrier to appropriate therapy. The purpose of this review is to present available data on the use of DAAs in co-infected PWID, review guideline recommendations for treatment and retreatment of HCV in co-infected PWID, provide cost considerations for DAA therapy, and provide recommendations about caring for patients who continue to inject drugs.

Treating HCV Infection: It Doesn't Get Much Better Than This

Direct-acting antiviral (DAA) regimens now allow treatment of previously untreated or treated (including prior DAA failures) patients with chronic hepatitis C virus (HCV) infection with 8 or 12 week regimens, largely without the use of ribavirin. Newer next-generation pan-genotypic regimens with activity against resistance-associated substitutions include glecaprevir/pibrentasvir (GLE/PIB), a combination of a nonstructural protein (NS)3 protease inhibitor and an NS5A inhibitor, and sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX), a combination of an NS5B polymerase inhibitor, NS5A inhibitor, and NS3 protease inhibitor. Both regimens have indications in DAA-experienced patients. GLE/PIB is approved for treatment of patients with genotype 1, 2, 3, 4, 5, or 6 infection without cirrhosis or with compensated cirrhosis and for the treatment of patients with genotype 1 infection previously treated with a regimen containing an NS5A inhibitor or an NS3/4A protease inhibitor, but not the combination. SOF/VEL/VOX is approved for retreatment of patients without cirrhosis or with compensated cirrhosis with genotype 1, 2, 3, 4, 5, or 6 infection previously treated with an NS5A inhibitor-containing regimen, or with genotype 1a or 3 previously treated with a SOF-containing regimen without an NS5A inhibitor. This article summarizes an IAS-USA webinar given by Susanna Naggie, MD, MHS, on August 30, 2018.

Real-World Efficacy and Safety of Pangenotypic Direct-Acting Antivirals Against Hepatitis C Virus Infection

BACKGROUND

Advances in the development of Direct-Acting Antivirals (DAAs), particularly pangenotypic drugs, have led to a high rate of hepatitis C virus (HCV) eradication. Notably, real- world studies have confirmed the efficacy and safety of pangenotypic DAA combinations reported in registration trials. The aim of this study was to review the treatment recommendations, and the efficacy and safety data of anti-HCV pangenotypic drugs reported in registration clinical trials and in recent real-life cohort studies.

METHODS

We reviewed the efficacy and safety data of pangenotypic anti-HCV drug combinations reported in original articles and in online conference abstracts.

RESULTS

Current pangenotypic drug combinations resulted in very high rates of sustained virologic response and few adverse reactions in real-life settings. SVR12 rates in real-life studies ranged from 90-100% depending on the pangenotypic combination, the HCV genotype and the stage of liver disease. Most adverse reactions reported in real-life settings were mild in intensity and rarely led to treatment discontinuation. These results are in accordance with those of clinical trials.

CONCLUSION

Pangenotypic DAAs result in very high rates of sustained virologic responses and are well tolerated. However, they are contraindicated in patients with decompensated cirrhosis or advanced chronic kidney disease who failed previous DDA-based treatment. Further research is required to customize treatment to "unpackage" current DAA combinations and to develop generic drugs against HCV.

Looking at the positives: proactive management of STIs in people with HIV

Patients who are HIV-positive and co-infected with other sexually transmitted infections (STIs) are at risk of increased morbidity and mortality. This is of clinical significance. There has been a dramatic increase in the incidence of STIs, particularly syphilis, gonorrhoea, Mycoplasma genitalium and hepatitis C virus (HCV) in HIV-positive patients. The reasons for this are multifactorial, but contributing factors may include effective treatment for HIV, increased STI testing, use of HIV pre-exposure prophylaxis and use of social media to meet sexual partners. The rate of syphilis-HIV co-infection is increasing, with a corresponding increase in its incidence in the wider community. HIV-positive patients infected with syphilis are more likely to have neurological invasion, causing syndromes of neurosyphilis and ocular syphilis. HIV infection accelerates HCV disease progression in co-infected patients, and liver disease is a leading cause of non-AIDS-related mortality among patients who are HIV-positive. Since several direct-acting antivirals have become subsidised in Australia, there has been an increase in treatment uptake and a decrease in HCV viraemia in HIV-positive patients. The incidence of other sexually transmitted bacterial infections such as Neisseria gonorrhoeae and M. genitalium is increasing in HIV patients, causing urethritis, proctitis and other syndromes. Increasing antimicrobial resistance has also become a major concern, making treatment of these infections challenging. Increased appropriate testing and vigilant management of these STIs with data acquisition on antimicrobial sensitivities and antimicrobial stewardship are essential to prevent ongoing epidemics and emergence of resistance. Although efforts to prevent, treat and reduce epidemics of STIs in patients living with HIV are underway, further advances are needed to reduce the significant morbidity associated with co-infection in this patient setting.

Sofosbuvir, velpatasvir and voxilaprevir: a new triple combination for hepatitis C virus treatment. One pill fits all? Is it the end of the road?

The advent of oral direct-acting antiviral agents (DAAs) has dramatically improved the hepatitis C virus (HCV) treatment landscape in the last 4 years, providing cure rates over 95% with a shorter duration of treatment and a very good safety profile. This has enabled access to treatment in nearly all HCV infected patients. The launch of two pangenotypic fixed dose combinations (FDCs) in 2017 made a new step forward in HCV treatment by slightly increasing efficacy and more importantly allowing the treatment of patients without HCV genotyping, and in some cases without fibrosis assessment. However, retreatment of the few DAA failure patients was still an issue for some HCV genotypes. The launch of the triple regimen FDC, sofosbuvir/velpatasvir/voxilaprevir, solves this issue by providing a cure rate over 96% regardless of HCV genotype. In this review, we describe the current HCV treatment landscape and focus on the development of this triple FDC either in treatment-naïve or treatment-experienced patients with previous failure on a DAA regimen.

ESRD patients coinfected with human immunodeficiency virus and Hepatitis C: Outcomes and management challenges

HIV infection is a major public health problem worldwide. Due to shared modes of acquisition, many HIV+ patients are coinfected with Hepatitis C. HIV/HCV coinfected patients have an increased burden of chronic kidney disease and are more likely to progress to end-stage renal disease. Dialysis survival is diminished in the coinfected population, even in the contemporary era. Kidney transplantation offers a survival benefit over remaining on dialysis; however, posttransplant outcomes are inferior compared to patients with HIV infection alone. Direct acting antiviral agents may offer an opportunity to improve patient survival, but there are significant drug-drug interactions involving the direct acting antiviral agents, antiretroviral therapy, and immunosuppression that the clinician should be aware of.

Efficacy and safety of glecaprevir/pibrentasvir in patients with chronic hepatitis C virus genotype 5 or 6 infection (ENDURANCE-5,6): an open-label, multicentre, phase 3b trial

BACKGROUND

The pangenotypic direct-acting antiviral regimen of glecaprevir coformulated with pibrentasvir is approved to treat chronic hepatitis C virus (HCV) genotype 1-6 infection in adults. In registrational studies, 84 (99%) of 85 patients with HCV genotype 5 or 6 infection achieved a sustained virological response (SVR) with glecaprevir/pibrentasvir, with no virological failures. To increase the body of data for these less prevalent genotypes, ENDURANCE-5,6 evaluated the efficacy and safety of glecaprevir/pibrentasvir exclusively in patients infected with HCV genotype 5 or 6.

METHODS

ENDURANCE-5,6 was a phase 3b, single-arm, open-label, multicentre trial done in 24 hospitals or clinics in Europe, Oceania, North America, South Africa, and southeast Asia. Adults with chronic HCV genotype 5 or 6 infection who were previously untreated or treatment-experienced were eligible to be enrolled. Glecaprevir/pibrentasvir (300 mg/120 mg) was given orally once daily for 8 weeks (for patients without cirrhosis) or 12 weeks (for patients with compensated cirrhosis). The primary efficacy endpoint was SVR12 (ie, HCV RNA <15 IU/mL at 12 weeks post-treatment), assessed within each HCV genotype, and analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02966795.

FINDINGS

Between Feb 9, 2017, and Aug 28, 2018, 84 patients were enrolled: 23 with genotype 5 infection and 61 with genotype 6 infection. Overall, 82 (97·6%, 95% CI 94·4-100·0) of the 84 patients achieved SVR12. 22 (95·7%, 95% CI 87·3-100·0) of 23 patients with genotype 5 infection achieved SVR12, as did 60 (98·4%, CI 95·2-100·0) of 61 with genotype 6 infection. One patient with an HCV genotype 6f infection and cirrhosis had on-treatment virological failure at treatment week 12, and one patient with HCV genotype 5a without cirrhosis who had achieved SVR at post-treatment week 4 relapsed at post-treatment week 12. Five (6%) patients had serious adverse events, none of which were deemed related to glecaprevir/pibrentsavir or led to discontinuation. Fatigue (11 [13%] patients) and headache (11 [13%]) were the only adverse events that occurred in 10% or more of patients. No post-baseline grade 3 or higher increases in aminotransferase concentrations were reported.

INTERPRETATION

Glecaprevir/pibrentasvir achieved high SVR12 rates, comparable with data reported in registrational studies, and was well tolerated in patients with HCV genotype 5 or 6 infection with compensated liver disease.

FUNDING

AbbVie.

A changing paradigm: management and treatment of the HCV/HIV-co-infected patient

Hepatitis C virus (HCV) treatment in HIV/HCV co-infected individuals has renewed relevance given the ongoing opioid crisis and rise of new HIV and HCV infections associated with injection drug use. Patients co-infected with HIV and HCV demonstrate increased rates of hepatic fibrosis, progression to liver failure, and liver-related mortality. HIV co-infection does not impact outcomes of current HCV treatments, and patients should be treated the same as HCV mono-infected persons, though attention to drug:drug interactions is required. In this review, we discuss the mechanisms mediating injury to the liver in HIV mono-infection and HIV/HCV co-infection, and present the landmark trials of HCV treatment in HIV-infected individuals.

Hepatitis C Guidance 2018 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection

Recognizing the importance of timely guidance regarding the rapidly evolving field of hepatitis C management, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) developed a web-based process for the expeditious formulation and dissemination of evidence-based recommendations. Launched in 2014, the hepatitis C virus (HCV) guidance website undergoes periodic updates as necessitated by availability of new therapeutic agents and/or research data. A major update was released electronically in September 2017, prompted primarily by approval of new direct-acting antiviral agents and expansion of the guidance's scope. This update summarizes the latest release of the HCV guidance and focuses on new or amended recommendations since the previous September 2015 print publication. The recommendations herein were developed by volunteer hepatology and infectious disease experts representing AASLD and IDSA and have been peer reviewed and approved by each society's governing board.

Glecaprevir/pibrentasvir expands reach while reducing cost and duration of hepatitis C virus therapy

Hepatitis C virus (HCV) treatments have dramatically progressed from poorly tolerated, moderately successful interferon-based therapies to highly effective all-oral interferon-free regimens. While sustained virologic responses have significantly improved with fixed-dose combinations (FDC) of these direct-acting antivirals (DAA), cost remains high and certain populations of patients remain difficult to treat. Glecaprevir (GLE, an NS3/4A protease inhibitor) and pibrentasvir (PIB, NS5A inhibitor) were recently approved as a FDC therapy for HCV, and have expanded reach, reduced cost, and in certain populations, reduced HCV treatment duration. GLE/PIB is effective across all genotypes, and has been shown to be effective in HIV-infected patients, patients with chronic kidney disease, and Child-Pugh A-compensated cirrhosis. GLE/PIB is also effective for a shortened duration of 8 weeks in treatment-naive non-cirrhotic patients.

Formulary Drug Reviews: Glecaprevir/Pibrentasvir

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