Journal of Clinical Virology 61 (2014) 149–151
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Short communication
Patients eligible for treatment with simeprevir in a French center Virginie Morel a,b , Gilles Duverlie a,b , Etienne Brochot a,b, * a b
Department of Virology, Amiens University Medical Center, Amiens, France Virology Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 March 2014 Received in revised form 24 June 2014 Accepted 24 June 2014
Background: Simeprevir (Olysio1), a second-wave protease inhibitor recently approved for the treatment of chronic hepatitis C, is not indicated in patients with genotype 1a strain harboring the Q80K protease mutation. Phase 2 and 3 studies on this molecule mainly focused on North American patients and the prevalence of Q80K is particularly high in the USA (around 50%). The prevalence of this mutation in other parts of the world is currently unknown. Objectives: The purpose of our study was to perform a detection of this mutation in a single PCR technique and to study the prevalence of this Q80K mutation in a non U.S. population. We can thus estimate the proportion of HCV positive patients who can be treated with simeprevir. Study design: We conducted a meta-analysis of response rates in the presence or absence of this mutation in randomized trials and then describe a simple and reliable method to detect this mutation. We also examined bilirubin levels in our cohort of 95 HCV genotype 1a patients. Results: Ten patients (10.5%) had a Q80K mutation and 12 patients exhibited bilirubin levels above the upper limit of normal at baseline. In our cohort, 21 patients (22%) were therefore ineligible for treatment with simeprevir. The prevalence of this mutation seems to be much lower in European patients. Conclusion: In conclusion, before considering treatment with simeprevir, physicians must be able to screen for the Q80K mutation. ã 2014 Elsevier B.V. All rights reserved.
Keywords: HCV treatment Simeprevir Q80 K mutation
1. Background Simeprevir (Olysio) is a single pill, once-daily oral HCV NS3/4a protease inhibitor recently approved for the treatment of chronic HCV infection. This drug is part of the second wave of protease inhibitors with substantially similar virologic efficacy but with fewer side effects. While telaprevir and boceprevir belong to the class of a-ketoamide electrophilic trap-containing inhibitors, simeprevir belongs to the class of macrocyclic protease inhibitors. The package insert includes a recommendation concerning patients infected with genotype 1a NS3 Q80K mutation, a strain of the virus for which the product was less effective. The effect of the naturally occurring NS3 Q80K polymorphism confers low-level resistance to SMV (with a fold change in EC50 value of 7.7 as a single amino acid substitution in a genotype 1b replicon) [5] and an impact on SVR. Healthcare professionals are advised to screen for this mutation and, when positive, should consider another therapy.
In Phase 2b and 3 randomized control trials [1,2,4,9], there was no clear benefit for treatment with simeprevir/PEG-IFN/RBV compared to PEG-IFN/RBV regimen alone in genotype 1a HCVinfected patients with a baseline Q80K mutation, thereby suggesting that the mutation inactivated simeprevir in this study (Fig. 1). This may be clinically relevant. The observed prevalence of Q80K polymorphic variants at baseline in the U.S. population of the Phase 2b and Phase 3 trials was 50% overall (369/734). No prevalence data are available for this mutation in other parts of the world. Another problem identified related to the use of simeprevir in some patients was elevation of serum bilirubin during treatment. In vitro studies have demonstrated that simeprevir is an inhibitor of bilirubin transporters OATP1B1 and MRP2, suggesting a likely mechanism for the observed elevations of serum bilirubin [3]. Bilirubin clearance from the blood is principally a three-step process involving bilirubin uptake (anion transporter OATP1B1), bilirubin conjugation (enzyme UGT1A1) and subsequent transportation into the bile (transporter MRP2). 2. Objectives
* Corresponding author at: Laboratoire de Virologie, Centre de Biologie Humaine, CHU Amiens, Avenue René Laënnec, Salouel, F-80054 Amiens cedex 1, France.
http://dx.doi.org/10.1016/j.jcv.2014.06.023 1386-6532/ ã 2014 Elsevier B.V. All rights reserved.
In some patients waiting for treatment, bilirubin levels are already above normal and these patients are infected with a virus
150
V. Morel et al. / Journal of Clinical Virology 61 (2014) 149–151
Table 1 Characteristics of HCV genotype 1a patients with or without Q80K mutation.
Men/women, n/n (% men) Age (years) Viral load, IU/ml x 106
All (n = 95)
Without Q80K (n = 85)
With Q80K (n = 10)
p value
74/21 (78)
65/20 (76)
9/1 (90)
NS
52.31 12.17 53.01 11.27 45.7 18.23 6.04 0.74 6.07 0.74 5.77 0.72
Previous treatment status, n (%) Naive 66 18 Relapse Non-responder 11
60 15 10
6 3 1
NS
Bilirubin toxicity grade 0 83 1 7 2 1 3 4
74 7 1 3
9 0 0 1
NS
Values are expressed as mean standard deviation. NS: not significant.
Fig. 1. SVR rates in genotype 1a patients treated with simeprevir in Phase 2 and 3 trials (*p < 0.05; **p < 0.01; ***p < 0.001 compared to patients without the Q80K mutation).
having the Q80K mutation. Treatment with simeprevir is therefore not appropriate in these patients, as other options are or will be available. Thus, in order to estimate the percentage of patients with genotype 1a eligible for treatment with simeprevir in European patients, we described a simple method of detecting the Q80K mutation that allowed us to analyze the prevalence of Q80K mutation at baseline in a French population of 95 patients. We also analyzed baseline bilirubin levels in this population. 3. Study design Plasma samples from 95 HCV-positive patients infected with genotype 1a HCV were selected for this study. HCV genotypes were determined by analysis of genome sequences of the NS5B region. RNA was extracted from 200 ml plasma using the NucliSens easyMAG1 v2.0 (Biomérieux). RNA was reverse-transcribed and amplified with the one-step RT-PCR kit (Qiagen), using primers NS31a-Q80F (50 -ATCAATGGGGTATGCTGGACTGTC-30 ) and NS31aQ80R (50 -ACATCGGCGTGCCTCGTGACCAG-30 ). A fragment of the NS3 gene from nucleotide 3561 to 3759 was obtained (nucleotide positions according to the reference strain AF009606). Cycle sequencing of the purified amplicons was performed using the Applied Biosystems BigDye Terminators v1.1 kit, according to the manufacturer’s instructions. Sequences obtained were purified and read by the ABI PRISM. PCR primers were used as sequencing primers. The clade of those HCV 1a strains was then determined by submitting the sequences in the freely available internet tool geno2pheno. Patients bilirubin levels were categorized according to the following protocol-defined toxicity grades: grade 0 (within normal limits), grade 1 (1–1.5 upper limit of normal [ULN]), grade 2 (1.6–2.5 ULN), grade 3 (2.6–5.0 ULN).
the United States by the manufacturer. The Q80L mutation was detected in 2 patients, but, according to the literature, it is not known to cause resistance to simeprevir. Furthermore, in our cohort, 12 patients had bilirubin levels above the upper limit of normal (1 patient with the Q80K mutation and 11 patients without the mutation). Thus, 21 out of 95 patients (22.1%) of our cohort were not candidates for treatment with simeprevir. 5. Discussion In the United States, HCV 1a is even more prevalent than HCV 1b, as about 57% of patients with hepatitis C have genotype 1a [8]. The prevalence of Q80K is therefore particularly high in the USA. Likewise, genotypes 1a and 1b differ in terms of their susceptibility to DAA with a lower barrier to resistance for genotype 1a [6]. A Swedish study involving 53 patients with genotype 1a found a prevalence of 5.3% for Q80K mutation [7]. In view of our data and those of the literature, the prevalence of this Q80K mutation is not evenly distributed between the various regions of the world. We used direct sequencing for detection of this mutation as was done in clinical trials [2,9]. Ultra deep sequencing would probably have indicated a higher percentage of patients with this mutation. However, the clinical relevance of this technique is unclear, in view of its very low sensitivity cut-offs. In addition, we describe a simple method available in many laboratories in the future to discriminate patients eligible for treatment with simeprevir. In conclusion, based on data from clinical trials on the rate of sustained virologic response in the presence of the Q80K mutation and according to our data, it is important to screen for this mutation, which has a heterogeneous distribution throughout the world. Funding: Own resource laboratory.
4. Results Competing interests: In our cohort of 95 patients with genotype 1a (41 HCV 1a/clade I and 54 HCV 1a/clade II), 10 patients (10.5%) presented the Q80K mutation at baseline. Interestingly, all of these 10 HCV variants belong to clade I. Patient characteristics in the 2 groups are summarized in Table 1. The proportion of patients with this mutation in our cohort was much lower than the data reported in
No conflict of interest. Ethical approval: Biological collection approved by the local ethics committee.
V. Morel et al. / Journal of Clinical Virology 61 (2014) 149–151
Contributors Virginie Morel: analysis and interpretation of data; drafting of the manuscript; administrative support. Gilles Duverlie: drafting of the manuscript; critical revision of the manuscript for important intellectual content; administrative support. Etienne Brochot: analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis; administrative support Acknowledgement We are grateful to Anthony Saul for English corrections. References [1] Forns S, Lawitz E, Zeuzem S, Gane E, Bronowicki J, Andreone P, et al. Simeprevir (TMC435) with peg-interferon a-2a/ribavirin for treatment of chronic HCV genotype 1 infection in patients who relapsed after previous interferon-based therapy: efficacy and safety in patient sub-populations in the PROMISE phase III trial. Hepatology 2013;58:737A.
151
[2] Fried MW, Buti M, Dore GJ, Flisiak R, Ferenci P, Jacobson I, et al. Once-daily simeprevir (TMC435) with pegylated interferon and ribavirin in treatmentnaive genotype 1 hepatitis C: the randomized PILLAR study. Hepatology 2013;58:1918–29. [3] Huisman MT, Snoeys J, Monbaliu J, Martens M,. Sekar VJ, Raoof A, In vitro studies investigating the mechanism of interaction between TMC435 and hepatic transporters. Poster 278 presented at the 61st Annual Meeting of the American Association for the Study of Liver Diseases (AASLD). [4] Jacobson I, Dore GJ, Foster GR, Fried MW, Manns M, Marcellin P, et al. Simeprevir (TMC435) with peginterferon/ribavirin for treatment of chronic HCV genotype 1 infection in treatment- naïve patients: efficacy in difficult-to-treat patient subpopulations in the QUEST 1 and 2 phase III trials. Hepatology 2013;58:756A–7A. [5] Lenz O, Verbinnen T, Lin TI, Vijgen L, Cummings MD, Lindberg J, et al. In vitro resistance profile of the hepatitis C virus NS3/4A protease inhibitor TMC435. Antimicrob Agents Chemother 2010;54:1878–87. [6] Manns MP, von Hahn T. Novel therapies for hepatitis C – one pill fits all? Nat Rev Drug Discov 2013;12:595–610. [7] Palanisamy N, Danielsson A, Kokkula C, Yin H, Bondeson K, Wesslen L, et al. Implications of baseline polymorphisms for potential resistance to NS3 protease inhibitors in Hepatitis C virus genotypes 1a, 2b and 3a. Antiviral Res 2013;99:12–7. [8] Simmonds P. Variability of hepatitis C virus. Hepatology 1995;21:570–83. [9] Zeuzem S, Berg T, Gane E, Ferenci P, Foster GR, Fried MW, et al. Simeprevir increases rate of sustained virologic response among treatment-experienced patients with HCV genotype-1 infection: a phase IIb trial. Gastroenterology 2014;441:e436.
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Short communication
Patients eligible for treatment with simeprevir in a French center Virginie Morel a,b , Gilles Duverlie a,b , Etienne Brochot a,b, * a b
Department of Virology, Amiens University Medical Center, Amiens, France Virology Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 March 2014 Received in revised form 24 June 2014 Accepted 24 June 2014
Background: Simeprevir (Olysio1), a second-wave protease inhibitor recently approved for the treatment of chronic hepatitis C, is not indicated in patients with genotype 1a strain harboring the Q80K protease mutation. Phase 2 and 3 studies on this molecule mainly focused on North American patients and the prevalence of Q80K is particularly high in the USA (around 50%). The prevalence of this mutation in other parts of the world is currently unknown. Objectives: The purpose of our study was to perform a detection of this mutation in a single PCR technique and to study the prevalence of this Q80K mutation in a non U.S. population. We can thus estimate the proportion of HCV positive patients who can be treated with simeprevir. Study design: We conducted a meta-analysis of response rates in the presence or absence of this mutation in randomized trials and then describe a simple and reliable method to detect this mutation. We also examined bilirubin levels in our cohort of 95 HCV genotype 1a patients. Results: Ten patients (10.5%) had a Q80K mutation and 12 patients exhibited bilirubin levels above the upper limit of normal at baseline. In our cohort, 21 patients (22%) were therefore ineligible for treatment with simeprevir. The prevalence of this mutation seems to be much lower in European patients. Conclusion: In conclusion, before considering treatment with simeprevir, physicians must be able to screen for the Q80K mutation. ã 2014 Elsevier B.V. All rights reserved.
Keywords: HCV treatment Simeprevir Q80 K mutation
1. Background Simeprevir (Olysio) is a single pill, once-daily oral HCV NS3/4a protease inhibitor recently approved for the treatment of chronic HCV infection. This drug is part of the second wave of protease inhibitors with substantially similar virologic efficacy but with fewer side effects. While telaprevir and boceprevir belong to the class of a-ketoamide electrophilic trap-containing inhibitors, simeprevir belongs to the class of macrocyclic protease inhibitors. The package insert includes a recommendation concerning patients infected with genotype 1a NS3 Q80K mutation, a strain of the virus for which the product was less effective. The effect of the naturally occurring NS3 Q80K polymorphism confers low-level resistance to SMV (with a fold change in EC50 value of 7.7 as a single amino acid substitution in a genotype 1b replicon) [5] and an impact on SVR. Healthcare professionals are advised to screen for this mutation and, when positive, should consider another therapy.
In Phase 2b and 3 randomized control trials [1,2,4,9], there was no clear benefit for treatment with simeprevir/PEG-IFN/RBV compared to PEG-IFN/RBV regimen alone in genotype 1a HCVinfected patients with a baseline Q80K mutation, thereby suggesting that the mutation inactivated simeprevir in this study (Fig. 1). This may be clinically relevant. The observed prevalence of Q80K polymorphic variants at baseline in the U.S. population of the Phase 2b and Phase 3 trials was 50% overall (369/734). No prevalence data are available for this mutation in other parts of the world. Another problem identified related to the use of simeprevir in some patients was elevation of serum bilirubin during treatment. In vitro studies have demonstrated that simeprevir is an inhibitor of bilirubin transporters OATP1B1 and MRP2, suggesting a likely mechanism for the observed elevations of serum bilirubin [3]. Bilirubin clearance from the blood is principally a three-step process involving bilirubin uptake (anion transporter OATP1B1), bilirubin conjugation (enzyme UGT1A1) and subsequent transportation into the bile (transporter MRP2). 2. Objectives
* Corresponding author at: Laboratoire de Virologie, Centre de Biologie Humaine, CHU Amiens, Avenue René Laënnec, Salouel, F-80054 Amiens cedex 1, France.
http://dx.doi.org/10.1016/j.jcv.2014.06.023 1386-6532/ ã 2014 Elsevier B.V. All rights reserved.
In some patients waiting for treatment, bilirubin levels are already above normal and these patients are infected with a virus
150
V. Morel et al. / Journal of Clinical Virology 61 (2014) 149–151
Table 1 Characteristics of HCV genotype 1a patients with or without Q80K mutation.
Men/women, n/n (% men) Age (years) Viral load, IU/ml x 106
All (n = 95)
Without Q80K (n = 85)
With Q80K (n = 10)
p value
74/21 (78)
65/20 (76)
9/1 (90)
NS
52.31 12.17 53.01 11.27 45.7 18.23 6.04 0.74 6.07 0.74 5.77 0.72
Previous treatment status, n (%) Naive 66 18 Relapse Non-responder 11
60 15 10
6 3 1
NS
Bilirubin toxicity grade 0 83 1 7 2 1 3 4
74 7 1 3
9 0 0 1
NS
Values are expressed as mean standard deviation. NS: not significant.
Fig. 1. SVR rates in genotype 1a patients treated with simeprevir in Phase 2 and 3 trials (*p < 0.05; **p < 0.01; ***p < 0.001 compared to patients without the Q80K mutation).
having the Q80K mutation. Treatment with simeprevir is therefore not appropriate in these patients, as other options are or will be available. Thus, in order to estimate the percentage of patients with genotype 1a eligible for treatment with simeprevir in European patients, we described a simple method of detecting the Q80K mutation that allowed us to analyze the prevalence of Q80K mutation at baseline in a French population of 95 patients. We also analyzed baseline bilirubin levels in this population. 3. Study design Plasma samples from 95 HCV-positive patients infected with genotype 1a HCV were selected for this study. HCV genotypes were determined by analysis of genome sequences of the NS5B region. RNA was extracted from 200 ml plasma using the NucliSens easyMAG1 v2.0 (Biomérieux). RNA was reverse-transcribed and amplified with the one-step RT-PCR kit (Qiagen), using primers NS31a-Q80F (50 -ATCAATGGGGTATGCTGGACTGTC-30 ) and NS31aQ80R (50 -ACATCGGCGTGCCTCGTGACCAG-30 ). A fragment of the NS3 gene from nucleotide 3561 to 3759 was obtained (nucleotide positions according to the reference strain AF009606). Cycle sequencing of the purified amplicons was performed using the Applied Biosystems BigDye Terminators v1.1 kit, according to the manufacturer’s instructions. Sequences obtained were purified and read by the ABI PRISM. PCR primers were used as sequencing primers. The clade of those HCV 1a strains was then determined by submitting the sequences in the freely available internet tool geno2pheno. Patients bilirubin levels were categorized according to the following protocol-defined toxicity grades: grade 0 (within normal limits), grade 1 (1–1.5 upper limit of normal [ULN]), grade 2 (1.6–2.5 ULN), grade 3 (2.6–5.0 ULN).
the United States by the manufacturer. The Q80L mutation was detected in 2 patients, but, according to the literature, it is not known to cause resistance to simeprevir. Furthermore, in our cohort, 12 patients had bilirubin levels above the upper limit of normal (1 patient with the Q80K mutation and 11 patients without the mutation). Thus, 21 out of 95 patients (22.1%) of our cohort were not candidates for treatment with simeprevir. 5. Discussion In the United States, HCV 1a is even more prevalent than HCV 1b, as about 57% of patients with hepatitis C have genotype 1a [8]. The prevalence of Q80K is therefore particularly high in the USA. Likewise, genotypes 1a and 1b differ in terms of their susceptibility to DAA with a lower barrier to resistance for genotype 1a [6]. A Swedish study involving 53 patients with genotype 1a found a prevalence of 5.3% for Q80K mutation [7]. In view of our data and those of the literature, the prevalence of this Q80K mutation is not evenly distributed between the various regions of the world. We used direct sequencing for detection of this mutation as was done in clinical trials [2,9]. Ultra deep sequencing would probably have indicated a higher percentage of patients with this mutation. However, the clinical relevance of this technique is unclear, in view of its very low sensitivity cut-offs. In addition, we describe a simple method available in many laboratories in the future to discriminate patients eligible for treatment with simeprevir. In conclusion, based on data from clinical trials on the rate of sustained virologic response in the presence of the Q80K mutation and according to our data, it is important to screen for this mutation, which has a heterogeneous distribution throughout the world. Funding: Own resource laboratory.
4. Results Competing interests: In our cohort of 95 patients with genotype 1a (41 HCV 1a/clade I and 54 HCV 1a/clade II), 10 patients (10.5%) presented the Q80K mutation at baseline. Interestingly, all of these 10 HCV variants belong to clade I. Patient characteristics in the 2 groups are summarized in Table 1. The proportion of patients with this mutation in our cohort was much lower than the data reported in
No conflict of interest. Ethical approval: Biological collection approved by the local ethics committee.
V. Morel et al. / Journal of Clinical Virology 61 (2014) 149–151
Contributors Virginie Morel: analysis and interpretation of data; drafting of the manuscript; administrative support. Gilles Duverlie: drafting of the manuscript; critical revision of the manuscript for important intellectual content; administrative support. Etienne Brochot: analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical analysis; administrative support Acknowledgement We are grateful to Anthony Saul for English corrections. References [1] Forns S, Lawitz E, Zeuzem S, Gane E, Bronowicki J, Andreone P, et al. Simeprevir (TMC435) with peg-interferon a-2a/ribavirin for treatment of chronic HCV genotype 1 infection in patients who relapsed after previous interferon-based therapy: efficacy and safety in patient sub-populations in the PROMISE phase III trial. Hepatology 2013;58:737A.
151
[2] Fried MW, Buti M, Dore GJ, Flisiak R, Ferenci P, Jacobson I, et al. Once-daily simeprevir (TMC435) with pegylated interferon and ribavirin in treatmentnaive genotype 1 hepatitis C: the randomized PILLAR study. Hepatology 2013;58:1918–29. [3] Huisman MT, Snoeys J, Monbaliu J, Martens M,. Sekar VJ, Raoof A, In vitro studies investigating the mechanism of interaction between TMC435 and hepatic transporters. Poster 278 presented at the 61st Annual Meeting of the American Association for the Study of Liver Diseases (AASLD). [4] Jacobson I, Dore GJ, Foster GR, Fried MW, Manns M, Marcellin P, et al. Simeprevir (TMC435) with peginterferon/ribavirin for treatment of chronic HCV genotype 1 infection in treatment- naïve patients: efficacy in difficult-to-treat patient subpopulations in the QUEST 1 and 2 phase III trials. Hepatology 2013;58:756A–7A. [5] Lenz O, Verbinnen T, Lin TI, Vijgen L, Cummings MD, Lindberg J, et al. In vitro resistance profile of the hepatitis C virus NS3/4A protease inhibitor TMC435. Antimicrob Agents Chemother 2010;54:1878–87. [6] Manns MP, von Hahn T. Novel therapies for hepatitis C – one pill fits all? Nat Rev Drug Discov 2013;12:595–610. [7] Palanisamy N, Danielsson A, Kokkula C, Yin H, Bondeson K, Wesslen L, et al. Implications of baseline polymorphisms for potential resistance to NS3 protease inhibitors in Hepatitis C virus genotypes 1a, 2b and 3a. Antiviral Res 2013;99:12–7. [8] Simmonds P. Variability of hepatitis C virus. Hepatology 1995;21:570–83. [9] Zeuzem S, Berg T, Gane E, Ferenci P, Foster GR, Fried MW, et al. Simeprevir increases rate of sustained virologic response among treatment-experienced patients with HCV genotype-1 infection: a phase IIb trial. Gastroenterology 2014;441:e436.
