Lessons learned during the HOPE-Project - which role have HBV - PowerPoint PPT Presentation

11.04.2013 AREVIR Meeting Köln Lessons learned during the HOPE-Project - which role have HBV mutations in the times of tenofovir and entecavir? Florian van Bömmel University Hospital Leipzig Hepatology Section Germany

• Current treatment of chronic HBV with nucleos(t)die analogues

Virological Response to ETV in treatment-naïve patients by HBeAg Status (undetectable HBV DNA) HBeAg(-) HBeAg(+ ) 100% 100% 98% 98% 97% 100 100 96% 90% 88% 88% 74% 80 80 63% Patients % Patients % 60 60 38% 40 40 20 20 0 0 48 6 12 24 36 48 60 6 12 24 36 60 Months Patients 11 67 66 48 42 32 338 327 296 265 227 86 on follow-up Lampertico P, et al. AASLD 2012, Boston, MA. Poster 366. Click to edit Footnote 3

Response to third line entecavir monotherapy in patients after previous consecutive failure to lamivudine and adefovir treatment Entecavir 1 mg/day Herber A, van Bömmel F et al. DGVS 2011

Suppression of HBV DNA under the detection limit during long term treatment with TDF Tenofovir Marcellin et al., AASLD 2011, Abstract 238 u. 1375 Marcellin et al., AASLD 2011, Abstract 238

HBV resistance against ADV decreases efficacy of TDF monotherapy p<0.0001 months patients under observation (n): ADV=adefovir dipivoxil ADV-resistance 21 15 3 LAM=lamivudine LAM-resistance 70 54 25 no genotypic resistance 22 18 12 van Bömmel et al., Hepatology 2010

Response to TDF monotherapy acording to baseline resistance mutations – an Australian perspective Patterson S J et al. Gut 2011;60:247-254

Response to TDF monotherapy acording to baseline resistance mutations – an Australian perspective Patterson S J et al. Gut 2011;60:247-254

TDF monotherapy in a patient with ADV resistance a) TDF TDF + LAM 8 8 10 copies/mL 7 7 6 6 5 5 HBV DNA log 4 4 3 3 2 2 lower limit of detection lower limit of detection 1 1 0 0 3 3 6 6 9 9 12 12 15 15 18 18 months 12 9 5 14 12 6 100 % HBV variants WT 50 N236T A181T+N236T 0 van Bömmel et al, Antiviral Therapy 2012

Background: Currently available HBV polymerase inhibitors and HBV resistance mutations HBV variant Resistant against Lamivudin Telbivudin Entecavir Adefovir Tenofovir Wildtyp S S S S S M204I R R I S S L180M + M204V R R I S S A181T/V I S S R S N236T S S S R I L180M + M204V/I ± I169T ± R R R S S V173L ± M250V L180M + M204V/I ± T184G ± R R R S S S202I/G EASL Clinical Practice Guideline CHB. J Hepatol. 2009;50:227-242 EASL Clinical Practice Guideline CHB. J Hepatol. 2009;50:227-242

• Beyond the „own“ reading frame mutations in the HBV s-gene

HBV Genome The HBV genome is compact (3.2kb) and contains four overlapping reading frames, encoding seven proteins Surface proteins L M S Polymerase Core Precore X

Pre-S Mutations Naturally occurring (B cell responses) Antiviral drug selected (POL/envelope overlap)

Pre-S function Important regulatory function of surface protein (transcription) Summers et al 1990 Attachment of HBV to the hepatocytes surface for initiating infection Neurath 1989, Ishikawa & Ganem 1995 T and B cell recognition sites Chisari and Ferrari 1995

Pre-S1/Pre-S2/S ORF Pre-S1 RNA (2.4kb) Pre-S2/S RNA (2.1kb) LHBs PreS1 PreS2 S MHBs S PreS2 S S SHBs

Pre-S2 Deletion Mutant Pre-S1 RNA (2.4kb) Pre-S2/S RNA (2.1kb) P39 (GP42) LHBs PreS1 PreS2 S CHO GP33 (GP36) MHBs PreS2 S S CHO CHO P24 (GP27) SHBs S CHO

Pre-S2 Deletion Mutant Pre-S1 RNA (2.4kb) Pre-S2/S RNA (2.1kb) Truncated LHBs S PreS1 Pre-S1(L) CHO P24 (GP27) SHBs S CHO

Pre-S Mutations Yoo BC et al, J Viral Hepatitis 2007

Tenofovir, Lam ivudine, Adefovir, Telbivudine, Clevudine A1 8 1 T Reverse transcriptase Polymerase Terminal Protein Spacer RNAse H gene G F A B C D E Surface gene Pre PreS1 S S2 W 1 7 2 * L Surface M proteins S Surface proteins ER lumen/virion surface X membrane Cytosol/virion interior Transactivation and HCC

Truncated s-antigens may accumulate in the hepatocytes HBV172* HBVwt 1:1 mixture of both. Surface proteins are shown as brown staining. Cell nuclei are stained in blue. Warner N, et al. Hepatology 2008

Examples for persistance of stop codons within the s-gene during TDF treatment Monat Probe M204I M204V L80V V173L L180M A181V A181T N236T A194T I169T Varianten E164D I195M W196S/* W172* W182* W199*/L V84M/WT, N122T/WT, Q130H/WT, V208I/WT, BL M204I M204V WT V173/WT L180M/WT WT WT WT WT WT R217L/WT,M335L/WT E164D/WT I195M/WT W196*/WT WT WT W199*/WT V84M/WT, N122T, S143F/WT, Q130H/WT, V208I/WT, 5 M204I/WT WT WT WT L180M/WT WT WT WT WT WT R217L,M335L/WT WT WT W196*/WT WT WT W199*/WT V84M, N122T, Q130H, V208I, 11 M204I/WT WT WT WT WT WT WT WT WT WT R217L/WT,M335L/WT WT WT W196*/WT WT WT WT WT, N122T/WT, N123T/WT, Q130H/WT, V208I/WT, 21 M204I M204V WT WT L180M/WT WT WT WT WT WT R217L/WT,M335L/WT WT I195M/WT W196*/WT WT WT W199*/WT WT, N118T/WT, N122T/WT, Q130H/WT, V208I/WT, 29 M204I M204V WT V173/WT L180M/WT WT WT WT WT WT R217L/WT,M335L/WT E164D/WT I195M/WT W196*/WT WT WT W199*/WT WT, N122T/WT, Q130H/WT, V208I/WT, 50 M204I M204V WT WT L180M/WT WT WT WT WT WT R217L/WT,M335L/WT WT I195M/WT W196*/WT WT WT W199*/WT Monat Probe M204I M204V L80V V173L L180M A181V A181T N236T A194T I169T Varianten E164D I195M W196S/* W172* W182* W199* Y124H, R266I, E271D, V282I, BL WT WT WT WT WT WT WT WT WT WT M309K WT WT WT WT WT WT Y124H, R266I, E271D, V282I, WT/sagW1 5 WT WT WT WT WT WT WT/A181T WT WT WT M309K, V191I/WT WT WT WT WT/W172* 82* 12 WT WT WT WT WT WT WT WT WT WT Y124H, V282I WT WT WT WT WT WT Y124H, R266I, E271D, V282I, 25 WT WT WT WT WT WT WT WT WT WT M309K WT WT WT WT WT WT Y124H, R266I, E271D, V282I, 33 WT WT WT WT WT WT WT WT WT WT M309K WT WT WT WT WT WT S74A, Y124H, E271D, I278V, 46 WT WT WT WT WT WT WT WT WT WT V282I, M309K WT WT WT WT WT WT Schmalbrock, van Bömmel, submitted 2013

• HBsAg mutations caused by HBV polymerase gene mutants – any clinical impact?

HBV leading to HCC Development? Multi-factorial process 1. Inflammation, damage & regeneration 2. Increase in chromosomal instability a. Integration b. Oxidative stress 3. Direct effect of the virus or viral proteins a. HBx b. PreS2 deletion mutants c. PreS2 C-terminal truncation (integrants) c. HBSP (splice protein) e. Basal Core Promoter/pre-C stop codon mutations Hino 2002, Warner & Locarnini 2009

Pre-S mutation and HCC Reference HCC (n, %) Control (n, %) Odd 95% CI P value ratio Lin et al 1 19/64 (29.7%) 25/202 (12.4%) 3.72 1.44-9.65 0.007 Yeung et al 2 23/69 (33.3%) 11/69 (15.9) 2.64 1.17-5.96 0.018 Qu et al 3 32/134 (23.9%) 14/114 (12.3%) 2.22 1.03-4.76 0.041 Chen et al 4 28/80 (35.0%) 27/160 (16.9%) 2.17 1.13-4.19 0.021 1 Lin et al, J Gastroenterology 2007; 22:1098 2 Yeung et al, J Infectious Dis 2011; 203:646 3 Qu et al, Hepatol Research 2011; 41:54 4 Chen et al, J Infectious Dis 2008; 198:1634

Pre-S Mutation & Long Term Outcome 141 HBeAg negative patients Progression to Cirrhosis Followed up for at least 36 months Incidence of Pre-S mutation at baseline 27/141 (19.1%) Chen et al, Gastroenterology 2007

Increased HCC risk in patients with prior LAM resistance Papatheodoridis GV et al, J Hepatol 2010

Hepatocarcinogenic effects PreS1 and PreS2 mutations cause over production and accumulation of LHBs in the endoplasmic reticulum Resulting in significant ER stress Induce DNA damage & genomic instability Bock et al, Hepatology 2007

• the remains of the day

Development of liver histology in 348 patients during 5 years tenofovir treatment Marcellin et al. The Lancet Volume 381, Issue 9865 2013 468 - 475

Does NA Therapy Prevent HCC? YES! 2010 Journal of Hepatology vol. 53

Long-term treatment with ETV reduces HCC incidence Figure 3. Comparison of hepatocellular carcinoma cumulative incidence rates between the ETV-treated group and the non-treated control group after propensity score matching Click to edit Footnote Hosaka T, et al. AASLD 2012, Boston, MA. Poster 357. 32

Summary • Long term treatment with NUCs is safe and effective in preventing HCC and reversing fibrosis • HBsAg mutations are beeing selected and persist during NUC treatment • liver damage or HCC by defective HBsAg secretion must be assumed for individual patients