ITPA activity and Ribavirin Ctrough are both predictive of ribavirin-induced anemia in HIV-HCV patients receiving boceprevir-based triple therapy

BOCEPREVIH ANRS HC-27 trial

C Solas, I Poizot-Martin, A Tavenard, F Kheloufi, A Renault, T Lavrut, S Quaranta, M Bourlière, P Halfon, L Piroth, E Bellissant, B Lacarelle, JM Molina,

R Garraffo and the ANRS HC27 BOCEPREVIH Study Group

Pharmacokinetics – INSERM U911-CRO2 Timone Hospital- University of Méditerranée

Laboratoire de Pharmacocinétique et Toxicologie

CHU Timone, Marseille CRO2, INSERM U911

Faculté de Pharmacie, Marseille 15th IWCPHHT, Washington 19-21 May 2014

• Ribavirin (RBV)-induced hemolytic anemia is a major cause of toxicity

→ RBV dose reduction → EPO use → Treatment discontinuation → Lower SVR rate

• Polymorphisms (SNPs) on the inosine triphosphatase (ITPA) gene have been associated with a protective effect against RBV-induced anemia, in particular variants rs1127354 (ITPA c.94 C>A) and rs7270101 (ITPA c. 124+21A>C)

INTRODUCTION

• ITPA deficiency had been associated with a protective effect against RBV-induced anemia in:

- HCV mono-infected pts on P/R therapy (Sakamoto & al , 2010; Fellay & al , 2010; Kurozaki & al, 2011; Azakami & al, 2011;

Thompson & al, 2010; Lötsch & al, 2011; Tsubota & al, 2012; Rau & al, 2013; Krishnan & al, 2012; D‘Avolio & al, 2012; Hai & al, 2014, …)

- HCV mono-infected pts on P/R/Telaprevir (Chayama & al, 2011; Ishida & al, 2013; Ogawa & al, 2013; Suzuki & al, 2011)

- HIV-HCV co-infected pts on P/R therapy (Naggie & al, 2012; Domingo & al, 2012; Osinusi & al, 2012; Rallon & al, 2011)

• But ITPA deficiency was also associated with : • less RBV dose reduction • lower Hb decline ≥ 2 g/dl • less EPO use

INTRODUCTION

INTRODUCTION

Sulkowski M, 62rd AASLD 2011, Abstr 353

Study Objectives

• ITPA SNPs have been clearly shown to strongly influence the risk of ribavirin-induced anemia • Pts with an ITPA deficiency are less likely to develop anemia during P/R therapy in HIV-HCV co-infected pts • RBV Ctrough was also demonstrated to be a good predictive factor of RBV-induced anemia • Boceprevir (BOC) is a NS3/4A protease inhibitor which may also cause an important hematotoxicity

Is ITPA deficiency still predictive of RBV-induced anemia in HIV-HCV co-infected pts treated with P/R/BOC ?

Is RBV Ctrough always a good predictive factor of anemia in HIV-HCV co-infected pts treated with P/R/BOC ?

In the ANRS-HC27 BocepreVIH trial, we conducted a sub-study to evaluate

the relationships between ITPA deficiency, RBV Ctrough, and anemia

PATIENTS AND METHODS

• BocepreVIH ANRS HC-27

• multi-center, single arm, open label Phase 2 trial in HIV-HCV genotype 1 co-infected patients who previously failed Peg-IFN/RBV

• 64 patients enrolled, treated with Peg-IFNα2b (1.5 μg/kg/wk) + RBV (800 to 1400 mg/day) + BOC 800 mg tid for 44 weeks with a lead-in phase of P/R for 4 weeks

• Pharmacokinetics

• RBV and BOC plasma Ctrough determined at W4 (RBV only) and W8 • HPLC-DAD method for RBV with a LOQ = 0.2 µg/ml • LC-MS/MS method for BOC with a LOQ = 25 ng/ml

PATIENTS AND METHODS

• Genotyping of ITPA polymorphisms • 2 variants : rs1127354 and rs7270101 • Taqman real-time PCR method

• ITPA deficiency was defined as follow1,2

rs1127354 rs7270101 Predicted ITPAse activity

Predicted ITPA deficiency

wild-type (C/C) wild-type (A/A) 100% absence

wild-type (C/C) heterozygosity (A/C) 60% mild

heterozygosity (C/A) wild-type (A/A) 30% moderate

wild-type (C/C) homozygosity (C/C) 30% moderate

heterozygosity (C/A) heterozygosity (A/C) 10% severe

homozygosity (A/A) wild-type (A/A) < 5% severe

1Thompson & al, Gastroenterology 2011 ; 2Fellay & al. Nature 2010

PATIENTS AND METHODS

• Statistical analysis • performed using SAS 9.3 • non-parametric tests (Wilcoxon-Mann-Whitney test and Signed rank

test for paired data) were used for comparison of quantitative variables • Fisher exact test and Chi2 test were used for comparison of qualitative

variables • Pearson correlations were used to evaluate correlation between RBV

Ctrough , BOC Ctrough and hemoglobin • ROC analysis was used to determine the RBV cut-off associated with Hb

decline > 2 g/dl • Multivariate logistic regression analyses were used to determine the

predictive factors associated with hematotoxicity at W4 and W8

RESULTS :

ITPAse deficiency n Population

frequency Literature data

frequency1,2

absence 42 66.7 % 69,7 % - 67 %

mild 13 20.6 % 16,5 % - 20 %

moderate 7 11.1 % 13,5 % - 11 %

severe 1 1.6 % 0,30 % - 0% 33%

1Thompson & al, Gastroenterology 2011 ; 2Fellay & al. Nature 2010

RBV Ctrough statistically higher at W8, after BOC initiation

W4 and W8 RBV Ctrough significantly correlated

median (IQR), n W4 (PR) W8 (PR/BOC) p

RBV Ctrough, µg/ml All patients

1.7 (1.4 - 2.1), n=59

2.7 (2.2 – 3.1), n=48

-

RBV Ctrough* , µg/ml

Pts with RBV dose modification excluded

1.7 (1.4 – 2.1), n=42

2.7 (2.1 – 3.2), n=42

< 0.0001

BOC Ctrough , ng/ml All patients

- 131

(108 - 310), n=41** -

p<0.0001

RESULTS :

* pts with data available at W4+W8 ** 2 pts with BOC Ctrough below LOQ (n=39)

<

• No difference on RBV Ctrough between patients with a lower or a functional ITPA activity at W4 and W8

W4 RBV Ctrough (µg/ml)

1.6 (1.4 - 1.9), n=17

1.7 (1.4 - 2.1), n=33 p = 0.644

W8 RBV Ctrough (µg/ml)

2.5 (1.9 - 3.0 ), n=16

2.8 (2.3 - 3.6), n=27 p = 0.155

Median (IQR), n Lower ITPA activity

Functional ITPA activity

P-value

RESULTS :

• RBV Ctrough was significantly correlated with anemia at W4 and W8

• ROC analysis determined a RBV Ctrough cut-off at 2 µg/ml (AUC=0.524) associated with a Hb decline > 2 g/dl at W4 with a sensitivity of 41% and a specificity of 83%

• BOC Ctrough at W8 was not correlated with anemia for any parameters

Variables Correlation coefficient between variable and W4 RBV Ctrough P-value

W4 Hb (g/dl) -0.38263 0.005 D0-W4 Hb decline (g/dl) -0.09522 0.497 W8 Hb (g/dl) -0.42635 0.006 D0-W8 Hb decline (g/dl) -0.32245 0.042

RESULTS :

Variable median (IQR), n or n (%) RBV Ctrough < 2 µg/ml RBV Ctrough > 2 µg/ml P-value

W4 Hb (g/dl) 13.5 12.5 p = 0. 024 (12.6 ; 14.4) ; n=38 (11.9; 13.7) ; n=14

W8 Hb (g/dl) 12.5 11.2 p = 0. 017 (11.4; 13.1) ; n=31 (10.2; 11.8) ; n=8

D0-W4 Hb decline (g/dl) -1.65 -2.25 p =0. 176 (-2.3; -0.9); n=38 (-2.8; -1.5); n=14

D0-W8 Hb decline (g/dl) -2.8 (-4.3; -2.1); n=31

-4.25 (-4.8 ; -4.08) ; n=8

p = 0. 024

RESULTS :

Pts with a RBV Ctrough > 2µg/ml have significantly lower W4 and W8 Hb and a higher Hb decline at W8 only

• Patients who had a RBV dose modification or stopped treatment or received EPO were excluded from the analysis

RESULTS :

W4 (n=10) W8 (n=15)

RBV discontinuation (severe side-effects 2, personal reason 1)

1 2

RBV dose modification - Weight loss - Vomiting - Mistake in the RBV dose taken by the patient

5 1 1 3

2 2

EPO use 2 9

Missing data 2 2

Variable median (IQR), n or n (%) ITPA Deficient pts ITPA Non-deficient pts P-value

W4 Hb (g/dl) 14.3 12.8 p = 0. 003 (13.0 ; 14.6) ; n=18 (12 ; 13.6) ; n=36

W8 Hb (g/dl) 12.7 12.0 p = 0. 271 (11.7 ; 12.8) ; n=17 (11.2 ; 12.5) ; n=24

EPO use between D0 and W8 p = 0.011 Yes 0 11 (26%) No 21 (100%) 31 (74%)

D0-W4 Hb decline (g/dl) -1.0 -2.05 p =0. 022

(-2.3; -0.6); n=18 (-2.6; -1.5); n=36

D0-W8 Hb decline (g/dl) -2.7

(-4.1; -2.1); n=17 -4.05

(-4.6 ; -2.75) ; n=24 p = 0. 05

RESULTS :

ITPA deficiency was significantly correlated with higher W4 Hb, lower Hb decline at W4 and W8 and lower EPO use

RESULTS :

n=6 n=13

n=10 n=25

RESULTS :

Variable No Toxicity Toxicity P-value

Sex p = 0.352 male 36 (78%) 12 (67%) female 10 (22%) 6 (33%) D0 Hb (g/dl) 15.5

(14.6 ; 15.9) ; n=46 15.0

(14.2; 15.3); n=18 p = 0.091

W4 Hb (g/dl) 13.6

(12.6; 14.4); n=44 12.4

(11.9; 13.2); n=18 p = 0.017

ITPA deficiency p = 0.018 Yes 19 (42%) 2 (11%) No 26 (58%) 16 (89%) W4 RBV Ctrough (µg/ml) 1.6

(1.3 ; 2.0) ; n=42 1.9

(1.7 ; 2.6) ; n=17 p = 0.012

• Toxicity = EPO use (Hb<11g/dl or Hb decline> 0.4g/dl), RBV dose reduction (Hb<10g/dl) or transfusion

Hematotoxicity was significantly associated with a lower W4 Hb, ITPA deficiency and higher W4 RBV Ctrough

RESULTS :

Variables Coefficients P-value

ITPA deficiency 0.9158 0.005 W4 RBV Ctrough -0.5198 0.017 Gender -0.9306 0.011 Age -0.0171 0.538 RBV dose (mg/d) 0.00082 0.424

Variables Coefficients P-value

ITPA deficiency 0.4859 0.179 W4 RBV Ctrough -1.0395 0.008 W8 RBV Ctrough -0.2259 0.431 W8 BOC Ctrough -0.0002 0.401 Gender 0.2662 0.551 Age 0.0407 0.316 RBV dose (mg/d) 0.0003 0.759

• Hemoglobin W4 (n=52)

• Hemoglobin W8 (n=30)

• This study firstly reports in HIV-HCV co-infected pts during P/R/BOC therapy :

– a significant protective effect of ITPA deficiency on RBV-induced anemia associated with a lower EPO use

– a significant association between RBV Ctrough and anemia with a cut-off =2 µg/ml as best predictive factor, as reported during P/R therapy

– ITPA deficiency was not correlated with RBV Ctrough

– BOC Ctrough was not correlated with anemia

• RBV Ctrough statistically higher at W8, after BOC initiation

– higher RBV Ctrough after telaprevir initiation also recently reported in the TelapreVIH ANRS trial (Cotte L, CROI 2014, Abstr. 664LB)

SUMMARY

• W4 RBV Ctrough and ITPA deficiency were both independent predictive factor of anemia

→ interest of ITPA genotyping to identify pts for whom a lower RBV dose would be required, particularly in such regimen and such “fragile” population

→ interest of maintaining RBV TDM to prevent and manage RBV-induced anemia

• Perspectives

– explore renal function to understand the interaction between RBV and BOC

– assess the relationship between ITPA deficiency, RBV Ctrough and treatment virologic response (SVR)

SUMMARY

ACKNOWLEDGEMENTS

Coordinating Investigator: Isabelle POIZOT-MARTIN

Clinical coordination: Marc BOURLIERE – Lionel PIROTH – Philippe HALFON

Pharmacological and pharmacokinetics coordination: Rodolphe GARRAFFO

Virological coordination: Philippe COLSON – Catherine TAMALET

Pharmacogenetics : Bruno LACARELLE – Caroline SOLAS – Sylvie QUARANTA – F arid KHELOUFI

Social sciences: Bruno SPIRE

Study Management : CMG Rennes - CIC Inserm0203

Methodology: Eric BELLISSANT

Project Manager: Claire FOUGEROU-LEURENT

Statistics: Alain RENAULT, Aude TAVENARD

Clinical Research Associates: Christelle TUAL –Mélanie GLOTIN – Aurélie VEISLINGER

Data Management: Hélène DANJOU

Data & Safety Monitoring Board : François BAILLY - Firouzé BANI-SADR - Fabrice CARRAT - Alain MARRAUD - Fabien ZOULIM

Drug Safety Inserm-ANRS : Alpha DIALLO

Scientific Board

Inga BERTUCCI (Sponsor Project Manager) – Eric BELLISSANT – Alain RENAULT – Claire FOUGEROU-LEURENT – Jean-Michel MOLINA – Bruno SPIRE – Catherine TAMALET – Lionel PIROTH – Philippe HALFON – Philippe COLSON – Marc BOURLIERE – Rodolphe GARRAFFO – Bruno LACARELLE – Caroline SOLAS – Alix DE JACQUELOT

Clinical Investigators

Isabelle POIZOT-MARTIN, Olivia FAUCHER, Marseille – Dominique GUYADER, Rennes – Jean-Michel MOLINA, Claire PINTADO, Memounatou RADJI, Paris – Stéphanie DOMINGUEZ, Créteil – Laurent ALRIC, Toulouse – Isabelle ROSA, Créteil – Jacques REYNES, Alain MAKINSON, René BAGLIONI, Montpellier – Michel DUPON, Bordeaux – Dominique SALMON-CERON, Hanane MEHAWEJ, Paris – Philippe PERRE, La Roche/Yon – Antoine CHERET, Tourcoing – Olivier BOUCHAUD, Bobigny – Thierry MAY, Vandoeuvre les Nancy – Pierre DELLAMONICA, Nice – David REY, Strasbourg – Philippe BONNARD,Thomas L’YAVANC, Paris – Eric ROSENTHAL, Alissa NAQVI, Nice – Anne GERVAIS, Paris – Vincent LEROY, Grenoble – Claudine DUVIVIER, Michka SHOAI-TEHRANI, Paris – Patrick MIAILHES, Lyon – Elina TEICHER, Le Kremlin Bicêtre – Stanislas POL, Laurence Bousquet, Paris – Philippe HALFON, Marseille – Isabelle RAVAUX, Marseille – Lionel PIROTH, Dijon – Marc BOURLIERE, Marseille – Vincent JEANTILS, Bondy – Jean-Charles DUCLOS-VALLEE, Villejuif – François BOUE, Clamart – Laurence GERARD, Paris – Ghassan RIACHI, Rouen – Anne FRESARD, Saint Etienne

MSD for providing ViraferonPeg®, Rebetol® and boceprevir

Health care providers

All the patients and their families

Sponsor : Inserm-ANRS