Home Hepatitis Response guided therapy for reducing duration of direct acting antivirals in chronic hepatitis C infected patients: a Pilot study

# Response guided therapy for reducing duration of direct acting antivirals in chronic hepatitis C infected patients: a Pilot study

### Patient population and clinical data

This was an open label, single arm, prospective, pilot study recruiting up to 30 consecutive CHC patients eligible for DAA treatment. Enrollment was conducted at 2 tertiary care hospitals in Israel, Soroka Medical Center in Beer-Sheva and Rabin Medical Center, Beilinson campus, in Petah-Tikva. Both centers are part of Clalit Health Services, the largest health fund in Israel. Male and female patients with compensated liver disease were enrolled in the study if they were ≥ 18 years of age, had HCV genotype 1–4, with RNA viral load > 105 IU/mL at screening and on at least one other occasion 6 months or more prior to enrollment and had an ALT < 10 times the upper limit of normal. Patients were excluded from the study if they were pregnant, had evidence of another cause of chronic liver disease, had decompensated liver disease, eGFR < 60 mL/min as calculated by the Cockroft-Gault equation, imaging findings suspicious for hepatocellular carcinoma or evidence of extra-hepatic malignancy (excluding basal cell or squamous cell carcinoma) in the 5 years preceding enrollment. Full eligibility criteria for this study are provided in the Supplementary File.

Liver fibrosis staging was performed by either transient elastography or FibroTest. Cirrhosis was defined by liver stiffness measurement of ≥ 12 kPa or by a Fibrotest score of ≥ 0.75.

The following clinical and virological variables were recorded: demographics (age, gender), body mass index, treatment regimen and duration, HCV genotype, baseline viral load, complete blood count, alanine aminotransferase, albumin, creatinine, bilirubin and International Normalized Ratio, HCV RNA levels at specific time points prior to, during, and post-treatment and stiffness measurement or FibroTest score measurements. All authors had access to the study data and reviewed and approved the final manuscript.

### Ethical statement

The study was approved by the institutional review boards of Soroka and Rabin Medical Centers and was conducted in compliance with the Declaration of Helsinki, Good Clinical Practice guidelines, and local regulatory requirements. All patients provided written informed consent.

### Treatment regimens

Patients enrolled in the study received one of four DAA regimes currently provided by the health system in Israel:

1. 1.

Daily fixed dose combination of Elbasvir 50 mg + Grazoprevir 100 mg (ELB/GRZ)

2. 2.

Daily fixed dose combination of Ledipasvir 90 mg + Sofosbuvir 400 mg (SOF/LED)

3. 3.

Daily fixed dose combination of Sofosbuvir 400 mg + Velpatasvir 100 mg (SOF/VEL).

4. 4.

Daily fixed dose combination of Glecaprevir 100 mg + Pibrentasvir 40 mg (GLE/PIB).

Treatment regimens were selected based on the treating physicians’ preference, in alignment with the EASL 2018 guidelines for the treatment of CHC.

### Mathematical modeling

HCV viral kinetics under DAA therapy was assumed to follow the standard biphasic model18:

$$frac{dI}{dt}=beta {T}_{0}V-delta I$$

(1)

$$frac{dV}{dt}=left(1-varepsilon right)pI-cV$$

where T0 represents the number of target cells (i.e., hepatocytes), I, the number of infected cells and V, is the viral load in blood. Virus, V, infects target cells with rate constant β, generating productively-infected cells, I, which produce new virions at rate p per infected cell. Infected cells are lost at a rate δ per infected cell and virions are assumed to be cleared from blood at rate c per virion. DAA effect ε is defined as the therapy efficacy 0 ≤ ε ≤ 1 in blocking viral production/secretion.

### Parameter estimations

Similar to our previous modeling studies, we assumed the target cell (i.e., hepatocytes) level remained constant during therapy at pre-treatment (or baseline) level T0 = 1 × 107. The initial infected cell level is represented by the steady state pre-treatment level of I0 = βV0T0/δ, where V0 = pre-treatment viral load of each patient. Viral production rate constant was set to p = cV0/I0. Because of lack of frequent sampling during the first 2 days after initiation of therapy the pharmacological delay of DAA was fixed to 0 h. Parameter β was set to 2 × 10–7 ml/virion/day. The remaining parameters (c, ε and δ) were estimated by fitting the model with the observed data using Berkeley Madonna (V.8.3).

### Time to cure

As previously done12,14,16,17, the TTC was defined as the time to reach less than one HCV particle in the entire extracellular body fluid, which was estimated based on body weight. For example, a value of 1 virus copy in 15L of extracellular body fluid volume, i.e. V = 7 × 10–5 IU/ml, was used as the threshold for cure. The model (Eq. 1) was fit to the measured HCV RNA kinetic data of each patient during the first 4 weeks of DAA therapy in real time in order to predict TTC for each participant.

### Patient monitoring and intervention

At baseline, blood was drawn for complete blood count, liver enzymes, bilirubin, albumin and HCV RNA. Following initiation of DAA therapy, repeated HCV RNA measurements were obtained on day 2, weeks 1, 2 and 4, at end-of-treatment (EOT) and then at weeks 4, 12 and/or 24 post-treatment. At week 4 of treatment, HCV RNA values from baseline through week 4 were modeled for each patient to project TTC. Based on individual model prediction of TTC, study participants were assigned the following lengths of DAA treatment:

1. 1.

Patients with estimated TTC  < 6 weeks of therapy – received a total of 6 weeks of DAA treatment.

2. 2.

Patients with estimated 6 ≤ TTC < 8 weeks of therapy- received a total of 8 weeks of DAA treatment.

3. 3.

Patients with estimated 8 ≤ TTC < 10 weeks of therapy- received a total of 10 weeks of DAA treatment.

4. 4.

Patients with estimated 10 ≤ TTC ≤ 12 weeks of therapy- received a total of 12 weeks of DAA treatment.

5. 5.

Patients with HCV RNA below lower limit of quantification (LLoQ) at day 2 – received a total of 6 weeks of DAA treatment.

Patients with estimated TTC of more than 12 weeks of therapy, with either ELB/GRZ, SOF/LED, or SOF/VEL, or of more than 8 weeks with PIB/GLE, received 12 or 8 weeks of DAA treatment, respectively, according to standard of care (SOC).

### Molecular assays

HCV RNA was measured by reverse transcription followed by real-time PCR using the GeneXpert assay (Cepheid, Sunnyvale CA, U.S) with a LLoQ of 10 IU/mL and lower limit of detection of 4 IU/mL. SVR was defined as undetectable serum HCV RNA 12 or 24 weeks after stopping antiviral treatment.

HCV genotyping was performed by the Abbott RealTime HCV Genotype II assay. This assay uses four sets of PCR primers. One set of primers targets a region within the 5′ untranslated region of the HCV genome that is recognized by GT-specific fluorescent-labeled probes. To subtype GT1, a second primer set is designed to amplify the nonstructural 5b region of genotype 1a and a third primer set is designed to amplify the nonstructural 5b region of genotype 1b (Abbott, Chicago, Illinois, USA).

In the single patient who relapsed, serum drug-resistant viral variants carrying resistant-associated substitutions (RAS) in the NS3 and NS5A regions, were explored by population (Sanger) sequencing19 (ABI PRISM 3100 genetic analyzer DNA Sequencer, Applied Biosystems, Foster City, CA, USA) and BigDye Terminator v1.1 Cycle Sequencing kit (Applied Biosystems, Foster City, CA, USA).

### Endpoints

The primary efficacy endpoints were: 1. The proportion of SVR at 12 or 24 weeks after EOT in all patients who received at least 4 weeks of therapy with any of the four DAA regimens. 2. The percentage of patients in whom duration of treatment with DAA could be shortened to less than SOC. Secondary endpoints included the development of treatment-associated RAS in patients who did not reach SVR, the rate of serious adverse events and treatment discontinuations due to adverse events.

### Statistical analyses

The primary efficacy analysis was designed to numerically compare the proportion of SVR among patients receiving RGT with one of the four DAA regimens, with a prespecified performance goal of 85%. This is a benchmark based on the general trend toward increasing proportions of SVR in recent years and was therefore chosen as a fixed, clinically relevant threshold representing a true measure of treatment benefit and a one to which the primary efficacy endpoint of this study was compared. This was a pilot study and therefore a formal power calculation of sample size was not applicable. We chose to enroll up to 30 patients to allow exploration of RGT efficacy.

The modified intention-to-treat population consisted of all patients who received at least 80% of their total HCV treatment drug doses throughout the entire treatment period and for whom HCV viral load data were available for baseline, day 2, week 1 and/or 2, week 4 and 12/24-week post-treatment. Patients who received less than 80% of the doses were to be excluded. This modified intention-to-treat population was used for analysis of the primary efficacy endpoints. This population was used for analysis of all safety endpoints.

Baseline medical histories and preexisting conditions were summarized by treatment duration groups. Viral load data was presented by treatment duration group and time point in summary tabulations and by-patient listings. These data were also presented graphically. Mean and median levels and change from baseline of the viral load was calculated at each time point. P-value < 0.05 was considered significant. Statistical analyses were performed using SPSS version 25 (IBM SPSS, Chicago, IL).