Daclatasvir Plus Peginterferon and Ribavirin Is Noninferior to Peginterferon and Ribavirin Alone, and Reduces the Duration of Treatment for HCV Genotype 2 or 3 Infection

Accepted Manuscript Daclatasvir plus Peginterferon and Ribavirin is Non-inferior to Peginterferon and Ribavirin Alone, and Reduces Duration of Treatment for HCV Genotype 2 or 3 Infection Gregory J. Dore, Eric Lawitz, Christophe Hézode, Stephen D. Shafran, Alnoor Ramji, Harvey A. Tatum, Gloria Taliani, Albert Tran, Maurizia R. Brunetto, Serena Zaltron, Simone I. Strasser, Nina Weis, Wayne Ghesquiere, Samuel S. Lee, Dominique Larrey, Stanislas Pol, Hugh Harley, Jacob George, Scott Fung, Victor de Lédinghen, Peggy Hagens, Fiona McPhee, Dennis Hernandez, David Cohen, Elizabeth Cooney, Stephanie Noviello, Eric A. Hughes PII: DOI: Reference:

S0016-5085(14)01206-2 10.1053/j.gastro.2014.10.007 YGAST 59381

To appear in: Gastroenterology Accepted Date: 6 October 2014 Please cite this article as: Dore GJ, Lawitz E, Hézode C, Shafran SD, Ramji A, Tatum HA, Taliani G, Tran A, Brunetto MR, Zaltron S, Strasser SI, Weis N, Ghesquiere W, Lee SS, Larrey D, Pol S, Harley H, George J, Fung S, de Lédinghen V, Hagens P, McPhee F, Hernandez D, Cohen D, Cooney E, Noviello S, Hughes EA, Daclatasvir plus Peginterferon and Ribavirin is Non-inferior to Peginterferon and Ribavirin Alone, and Reduces Duration of Treatment for HCV Genotype 2 or 3 Infection, Gastroenterology (2014), doi: 10.1053/j.gastro.2014.10.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. All studies published in Gastroenterology are embargoed until 3PM ET of the day they are published as corrected proofs on-line. Studies cannot be publicized as accepted manuscripts or uncorrected proofs.

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TITLE PAGE Title:

Reduces Duration of Treatment for HCV Genotype 2 or 3 Infection

Short Title:

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Daclatasvir Regimen for HCV Genotype 2 or 3

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Daclatasvir plus Peginterferon and Ribavirin is Non-inferior to Peginterferon and Ribavirin Alone, and

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Authors:

Gregory J Dore,1 Eric Lawitz,2 Christophe Hézode,3 Stephen D Shafran,4 Alnoor Ramji,5 Harvey A Tatum,6 Gloria Taliani,7 Albert Tran,8 Maurizia R Brunetto,9 Serena Zaltron,10 Simone I Strasser,11 Nina Weis,12 Wayne Ghesquiere,13 Samuel S Lee,14 Dominique Larrey,15 Stanislas Pol,16 Hugh Harley,17 Jacob George,18 Scott Fung,19 Victor de Lédinghen,20 Peggy Hagens,21 Fiona McPhee,22 Dennis Hernandez,22 David

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Institutions:

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Cohen,22 Elizabeth Cooney,22 Stephanie Noviello,23 Eric A Hughes,23

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Kirby Institute, UNSW Australia and St Vincent’s Hospital, Sydney, Australia; 2The Texas Liver Institute,

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University of Texas Health Science Center, San Antonio, TX; 3Hôpital Henri Mondor, Créteil, France; 4

University of Alberta, Edmonton, AB, Canada; 5Gastrointestinal Research Institute, Vancouver, BC,

Canada; 6Options Health Research, Tulsa, OK; 7Sapienza Università di Roma, Rome, Italy; 8Hôpital De L'Archet 2, Nice, France; 9University Hospital, Pisa, Italy; 10Azienda Ospedaliera Spedali Civili, Brescia, Italy; 11Royal Prince Alfred Hospital, Sydney, Australia; 12Copenhagen University Hospital, Hvidovre, Denmark; 13Vancouver Island Health Authority, University of British Columbia, Victoria, BC, Canada; 14

Heritage Medical Research Clinic, University of Calgary, Calgary, AB, Canada; 15Hôpital Saint Eloi,

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Montpellier, France; 16Université Paris Descartes, Hôpital Cochin, Paris, France; 17Royal Adelaide Hospital and University of Adelaide, Adelaide, Australia; 18Storr Liver Unit, Westmead Millennium Institute, University of Sydney and Westmead Hospital, Sydney, Australia; 19Toronto General Hospital, Toronto,

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ON, Canada; 20Hôpital Haut-Lévêque, Pessac, France; 21Bristol-Myers Squibb Research and Development,

Myers Squibb Research and Development, Princeton, NJ

Grant support:

Abbreviations: HCV, hepatitis C virus

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LLOQ, lower limit of quantitation

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This study was funded by Bristol-Myers Squibb

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Braine-l’Alleud, Belgium; 22Bristol-Myers Squibb Research and Development, Wallingford, CT; 23Bristol-

Peg-alfa, pegylated interferon alfa PDR, protocol-defined response

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RBV, ribavirin

SVR, sustained virologic response: undetectable HCV RNA post-treatment

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SVR12, sustained virologic response 12 weeks post-treatment SVR24, sustained virologic response 24 weeks post-treatment

Corresponding author: Gregory J Dore

Viral Hepatitis Clinical Research Program The Kirby Institute

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UNSW Australia Sydney, NSW 2052, Australia Tel: +61 2 9385 0900

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Fax: +61 2 9385 0876 E-mail: [email protected]

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Acknowledgments

The authors thank the patients and their families, research staff at all participating sites, and Bristol-

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Myers Squibb Research and Development colleagues. JG is supported by the Robert W. Storr Bequest to the Sydney Medical Foundation, University of Sydney; a National Health and Medical Research Council of Australia (NHMRC) Program Grant No. 1053206 and Project grant 1047417.

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Disclosures:

GJ Dore has been a clinical investigator, consultant, speaker, and/or has received travel sponsorship from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Janssen, Merck, Roche, and Vertex. E

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Lawitz has been a consultant, research grant recipient, and/or speaker for AbbVie, Achillion, BioCryst, Biotica, Boehringer Ingelheim, Bristol-Myers Squibb, Enanta, Gilead, GlaxoSmithKline, Idenix, Intercept,

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Janssen, Kadmon, Medtronic, Merck, Novartis, Presidio, Roche, Santaris, Theravance, and Vertex. C Hézode has been a clinical investigator, speaker and/or consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Janssen, Merck, and Roche. SD Shafran has been a clinical investigator, speaker and/or consultant for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Janssen, Merck, Pfizer, Roche and Vertex. A Ramji has been a clinical investigator, consultant, speaker, and/or received research grants from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Merck, Roche, Vertex, Janssen, and Novartis. HA Tatum has been a clinical investigator and/or speaker for

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Gilead, Merck, AbbVie, Boehringer Ingelheim, and Genentech. G Taliani has received personal fees from AbbVie, Bristol-Myers Squibb, Gilead, Janssen, Merck, and Roche. A Tran has been a clinical investigator for AbbVie, Bristol-Myers Squibb, Gilead, and Janssen. MR Brunetto has received personal fees from

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AbbVie, Bristol-Myers Squibb, Gilead, Janssen, Merck, Novartis, and Roche. S Strasser has been a

consultant, speaker and has received travel support from Bristol-Myers Squibb. N Weis has been a clinical investigators, consultant and/or speaker for Bristol-Myers Squibb, Gilead, GlaxoSmithKline,

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Janssen, Merck, and Roche. SS Lee has received research grants and personal fees from AbbVie,

Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Janssen, Merck, Roche, and Vertex. D Larrey has

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been a consultant and or clinical investigator for AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Janssen, Merck, Roche, and Sanofi. H Harley has been a consultant for Bristol-Myers Squibb. J George has been a consultant and received lecture fees from AbbVie, Boehringer Ingelheim, BristolMyers Squibb, Gilead, Janssen, Merck, and Roche. S Fung has been a speaker/consultant for Gilead,

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Merck, Roche and Vertex. V DeLedinghen has received personal fees from AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Echosens, Gilead, Janssen, Merck, and Roche. P Hagens, F McPhee, D Hernandez, D Cohen, E Cooney, S Noviello, and EA Hughes are employees of Bristol-Myers Squibb. S

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Writing assistance:

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Zaltron, W Ghesquiere, and S Pol have no conflicts to disclose.

Editorial assistance for preparation of this manuscript was provided by Richard Boehme, PhD, of Articulate Science and was funded by Bristol-Myers Squibb.

Author contributions: GJ Dore, E Lawitz, C Hézode, SD Shafran, A Ramji, HA Tatum, G Taliani, A Tran, MR Brunetto, S Zaltron, SI Strasser, N Weis, W Ghesquiere, SS Lee, D Larrey, S Pol, H Harley, J George, S Fung, and V de Lédinghen

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participated in study design, data acquisition, analysis and interpretation, and manuscript preparation and critical review. P Hagens, E Cooney, S Noviello, and EA Hughes participated in study concept and design, administration, technical support, and manuscript preparation and critical review. D Cohen

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participated in study design, conducted statistical analyses, and reviewed the manuscript. F McPhee and

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D Hernandez participated in study data acquisition and manuscript critical review.

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Abstract Background and Aims: Twenty-four weeks of treatment with peginterferon and ribavirin for chronic

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hepatitis C virus (HCV) genotype 2 or 3 infection produces a sustained virologic response (SVR) in 70%– 80% of patients. We performed a randomized, double-blind, phase 2b study to assess whether adding daclatasvir, an NS5A inhibitor active against these genotypes, improves efficacy and shortens therapy. Methods: Patients with HCV genotype 2 or 3 infection (n=151), enrolled at research centers in North

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America, Europe, or Australia, were randomly assigned to groups given 12 or 16 weeks of daclatasvir (60 mg once daily), or 24 weeks of placebo, each combined with peginterferon alfa-2a and ribavirin.

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Treatment was extended to 24 weeks for recipients of daclatasvir who did not meet the criteria for early virologic response. The primary endpoint was sustained virological response 24 weeks after treatment (SVR24).

Results: Baseline characteristics were similar among patients within each HCV genotype group.

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However, the 80 patients with HCV genotype 3, compared to the 71 patients with HCV genotype 2, were younger (mean, 45 vs 53 years old) and a larger proportion had cirrhosis (23% vs 1%). Among patients with HCV genotype 2 infection, an SVR24 was achieved by 83%, 83%, and 63% of those in the

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daclatasvir 12 week, daclatasvir 16 week, or placebo groups, respectively; among patients with HCV genotype 3 infection, an SVR24 was achieved by 69%, 67%, and 59% of patients in these groups.

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Differences between genotypes were largely attributable to the higher frequency of post-treatment relapse among patients infected with HCV genotype 3. In both daclatasvir arms for both HCV genotypes, the lower bound of the 80% confidence interval of the difference in SVR24 rates between the daclatasvir and placebo arms was above –20%, establishing non-inferiority. Safety findings were similar among groups, and typical of those expected from peginterferon alfa and ribavirin therapy. Conclusions: Twelve or 16 weeks of treatment with daclatasvir, in combination with peginterferon alfa2a and ribavirin, is well tolerated and effective therapy for patients with HCV genotype 2 or 3 infections.

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Daclatasvir-containing regimens could reduce the duration of therapy for these patients. Clinicaltrials.gov number: NCT01257204.

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Keywords: Antiviral; combination therapy; NS5A replication complex inhibitor, DAA

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Background The burden of disease associated with chronic hepatitis C virus (HCV) infection remains high; the estimated 500,000 HCV-related deaths in 2010 ranks 25th among all causes of death globally.1

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HCV genotype can influence disease characteristics, treatment options and therapeutic response

rates.2,3 Although global distributions vary, genotypes 2 and 3 are both common worldwide. Compared with other genotypes, genotype 3 infection has been associated with increased risk of hepatic fibrosis

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progression, hepatic steatosis, and development of hepatocellular carcinoma in cirrhotic patients, while genotype 2 infection has been associated with increased frequency of acute exacerbations of hepatitis

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but is generally more responsive to treatment.4-7

The standard of care for patients with chronic HCV infection has evolved. The ongoing development of direct-acting antivirals has delivered improvements in both efficacy outcomes and tolerability. Following

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the recent approval of sofosbuvir, the recommended treatment in the US for infection with genotypes 2 and 3 has been updated to 12 weeks or 24 weeks, respectively, of sofosbuvir in combination with ribavirin (RBV).8 This regimen, which is also approved in Europe, provides sustained virologic response

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(SVR) rates of 94% for genotype 2 infection and 84% for genotype 3.8 Where sofosbuvir is not available, the standard of care remains 24 weeks of peg-alfa/RBV for these genotypes, which provides SVR rates of

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74% and 68% for genotypes 2 and 3, respectively, according to a meta-analysis.9 Thus, although improved therapies for genotypes 2 and 3 are now available in the US and other Western countries, further exploration of alternative regimens is warranted to address required duration of therapy, and to provide additional options for situations where all-oral therapies are not available or appropriate.

Daclatasvir (DCV; BMS-790052) is a selective, first-in-class NS5A replication complex inhibitor with pangenotypic HCV activity and additive to synergistic activity in vitro when combined with peg-alfa and

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other direct-acting antivirals.10-12 Daclatasvir inhibits HCV RNA replication through interactions with the NS5A protein, an essential component of the HCV replication complex.13 Daclatasvir has a human pharmacokinetic profile consistent with once-daily dosing, and has a generally low potential to cause

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drug-drug interactions with other medications.14,15 Daclatasvir in combination with peg-alfa/RBV has demonstrated high SVR rates in patients with genotype 1 or 4 infection, with the potential to reduce the required duration of therapy from 48 to 24 weeks in most patients. In a phase 2b response-guided study

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of daclatasvir 60 mg + peg-alfa-2a/RBV in patients with HCV genotype 1 or 4 infection, 87% of

daclatasvir + peg-alfa/RBV recipients qualified for 24 weeks of treatment and 60% (genotype 1) or 100%

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(genotype 4) achieved SVR12, compared with corresponding SVR rates of 36% or 50%, respectively, following 48 weeks of treatment with placebo + peg-alfa-2a/RBV.16 Daclatasvir in combination with pegalfa/RBV has been generally well tolerated in clinical studies, with an adverse event profile similar to that of peg-alfa/RBV alone.16,17 In this study, the efficacy and safety of daclatasvir combined with peg-

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alfa/RBV administered for 12 or 16 weeks were compared with standard of care (peg-alfa/RBV for 24

Methods Study design

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weeks) in adult treatment-naive patients with HCV genotype 2 or 3 infection.

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The objective of this randomized, double-blind, three-arm phase 2b study was to compare the antiviral activity and safety of 12 or 16 weeks of treatment with daclatasvir plus peg-alfa/RBV with 24 weeks of treatment with placebo plus peg-alfa-2a/RBV (Figure 1) (Study AI444-031; clinicaltrials.gov identifier NCT01257204). Patients on daclatasvir-containing regimens who achieved a protocol-defined response (PDR; HCV RNA < lower limit of quantitation [LLOQ] at Week 4 and < LLOQTND (target not detected) at Week 10) ended treatment at Week 12 or 16, according to treatment group. Patients on daclatasvircontaining regimens who failed to achieve a PDR discontinued daclatasvir at Week 12 and received an

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additional 12 weeks of placebo + peg-alfa/RBV. In addition, in all study arms treatment with daclatasvir or placebo was discontinued for patients who met on-treatment virologic failure criteria; these patients could continue peg-alfa/RBV to Week 24 at the investigator’s discretion. On-treatment virologic failure

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included those with <1 log10 IU/mL decrease of HCV RNA from baseline at Week 4, and those with ontreatment virologic breakthrough defined as confirmed (within 2 weeks) > 1 log10 increase in HCV RNA over nadir, or confirmed HCV RNA ≥ LLOQ after confirmed HCV RNA
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discontinued for patients who failed to achieve an HCV RNA decrease from baseline of ≥ 2 log10 IU/mL and ≥ LLOQ at Week 12. Patients received posttreatment follow-up for 24 weeks (12- or 16-week

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regimens) or 36 weeks (24-week regimens).

The study protocol and informed consent procedures were approved by an independent ethics committee and institutional review boards at each participating site prior to study initiation. The study

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was designed and conducted by the sponsor (Bristol-Myers Squibb) in collaboration with the principal investigators, and was conducted in compliance with the Declaration of Helsinki, local regulatory requirements, and Good Clinical Practice, as defined by the International Conference on Harmonisation.

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The sponsor collected the data, monitored study conduct, and performed the statistical analyses. The manuscript was prepared by the principal academic and sponsor authors, with assistance from a medical

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writer paid by Bristol-Myers Squibb and with input from all the other authors. All authors had access to the study data and reviewed and approved the final manuscript.

Patients

Patients were enrolled at 31 centers in North America, Australia, and Europe between January and May, 2011. Enrolled patients were adult males and females aged 18-70 years, with chronic HCV genotype 2 or 3 infection and no prior exposure to HCV therapeutic agents including direct-acting antivirals, interferon

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preparations, or ribavirin. Patients were stratified by HCV genotype (2 or 3) prior to randomization; each HCV genotype group was capped at approximately 50% of the study population. Patients within each

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genotype group were randomly assigned (1:1:1) among the three treatment groups.

Plasma HCV RNA levels at screening were required to be ≥ 100,000 IU/mL. Liver disease staging was conducted by liver biopsy within two years of screening (or at any time for biopsies confirming cirrhosis)

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or by Fibroscan® within one year of screening (≥ 14.6 kPa was considered consistent with cirrhosis); patients with compensated cirrhosis were capped at approximately 10% of the study population.

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Women of childbearing potential and males who were sexually active partners of women of childbearing potential were required to use two forms of contraception, including at least one barrier method.

Exclusion criteria included history or evidence of hepatocellular carcinoma, decompensated cirrhosis, or

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chronic liver disease other than hepatitis C; history of cancer within 5 years of enrollment; chronic HBV or HIV infection; presence of any other medical, psychiatric and/or social reason that would render the patient inappropriate for study participation; gastrointestinal disease or surgical procedure that may

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impact absorption of study drug; medical conditions prohibiting use of peg-alfa-2a or RBV, based on their respective product labels; or a history of hypersensitivity to compounds related to NS5A inhibitors.

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Exclusionary laboratory parameters included alanine aminotransferase (ALT) ≥ 5 x upper limit of normal; total bilirubin ≥ 2 mg/dL; international normalized ratio ≥ 1.7; albumin ≤ 3.5 g/dL; hemoglobin ≤ 12 g/dL (females) or ≤ 13 g/dL (males); absolute neutrophil count ≤ 1.5 x 109 cells/L (≤ 1.2 x 109 cells/L for patients of black race); platelets ≤ 90 x 109 cells/L; creatinine clearance ≤ 50 mL/min; alpha fetoprotein > 100 ng/mL; QTcF > 450 msec (males) or > 470 msec (females).

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Prohibited concomitant medications included inducers or strong or moderate inhibitors of CYP3A4; P-gp substrates with a narrow therapeutic index; strong P-gp inhibitors; non-study medications with known or potential anti-HCV activity; or any prescription or herbal product not prescribed for treatment of a

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specific clinical condition. Doses of concomitant medications were required to be stable for ≥ 4 weeks prior to the first dose of study drug.

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Study drug dosing

All patients received antiviral combination therapy with peg-alfa-2a (Pegasys®) 180 μg weekly, RBV 400

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mg twice daily (800 mg/day), and daclatasvir 60 mg once daily or matching placebo from the beginning of the study. Daclatasvir or matching placebo was dosed as two 30 mg tablets once daily, taken with a light meal. Ribavirin was dosed as two 200 mg tablets twice daily with food; peg-alfa was self-

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administered once weekly.

Randomization procedures and statistical considerations The target sample size of 24 patients per treatment group for each HCV genotype provided >85%

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probability to infer that at least one daclatasvir-containing regimen has antiviral activity that is comparable to peg-alfa/RBV alone, as assessed by the proportion of subjects with SVR24 assuming an

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SVR24 rate of 80% for each regimen and genotype and based on 80% confidence intervals and the protocol-defined non-inferiority margin of -20%. This non-inferiority margin was considered the best approach for balancing the need to minimize sample size while providing adequate data to assess risk/benefit parameters for this regimen. For the same reason, there were no adjustments for multiplicity. Analyses were completed according to the predefined statistical analysis plan. With the target sample size of 48 patients per treatment group (genotypes 2 and 3 combined), a safety event occurring at an incident rate of 4% could be detected with 86% probability.

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Patients selected for screening were registered through an interactive voice response system (IVRS) designated by the sponsor. Patients meeting eligibility criteria were randomly assigned (1:1:1) by the

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IVRS to one of the three treatment arms: daclatasvir 12 weeks, daclatasvir 16 weeks, or placebo 24 weeks (each combined with peg-alfa-2a/RBV), with stratification according to HCV genotype.

Randomized treatment assignment was placebo-controlled and site/patient-blinded until completion of

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the post-treatment Week 24 analyses. The sponsor remained blind through the Week 16 analysis.

However, partial unblinding occurred for patients who achieved PDR and stopped treatment at Week 12

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or 16 since substitution of an injectable placebo for peginterferon was not feasible.

Categorical variables were summarized with counts and percents. Continuous variables were summarized with univariate statistics (e.g., mean, median, standard error). Longitudinal summaries of

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safety and efficacy endpoints used pre-defined visit week windows. Response rates and 80% exact binomial confidence intervals were determined by treatment regimen using modified intention to treat

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and observed values separately for each HCV genotype.

Safety and efficacy assessments

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Assessments, including physical examination, vital signs, adverse events, laboratory tests, and concomitant medications were conducted at screening, study day 1 (baseline), Weeks 1, 2, 4, 8, 10, 12, 16, and 20, at the end of treatment, and at posttreatment Week 4. Twelve-lead electrocardiograms were recorded at screening and at the end of treatment. HCV RNA levels were determined at these same time points as well as at posttreatment Weeks 12, 24, and (for patients who completed 12 or 16 weeks of treatment) Week 36. For subjects with virologic failure, 48 weeks of follow-up was required. Serum HCV RNA levels were determined at a central laboratory using the Roche COBAS® TaqMan® HCV

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assay, v. 2.0, LLOQ=25 IU/mL, limit of detection 10 IU/mL. Additional screening or baseline assessments included HCV genotype and subtype (VERSANT HCV genotype 2.0 assay) and host IL28B genotype,

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determined by PCR amplification and sequencing of the rs12979860 single nucleotide polymorphism.

Endpoints

The predefined primary efficacy endpoint was the proportion of patients with HCV RNA
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posttreatment Week 24 (SVR24) for each genotype in the modified intention-to-treat population, defined as all patients who received at least one dose of study medication. SVR24 was also assessed in an as-

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observed analysis which excluded patients with missing data at posttreatment Week 24. Secondary predefined endpoints included safety assessments and the proportions of patients, by genotype, with HCV RNA < LLOQTND at Week 4 (rapid virologic response; RVR) and posttreatment Week 12 (SVR12). In a prespecified analysis, HCV resistance-associated polymorphisms were characterized in all patients at

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baseline and in all patients with HCV RNA levels ≥1000 IU/mL following virologic failure. Virologic failure was defined as virologic breakthrough, < 1 log10 HCV RNA decrease from baseline at Week 4, < 2 log10 HCV RNA decrease from baseline at Week 12, detectable HCV RNA at the end of treatment, or relapse,

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defined as detectable HCV RNA at any posttreatment assessment in patients with HCV RNA
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population and clonal sequencing of the patient-derived HCV NS5A region. Post-hoc descriptive exploration of factors that may have contributed to relapse in patients with genotype 3 infection was also undertaken.

Results Patients

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A total of 196 patients were screened; 152 were randomly assigned to treatment groups and 151 were treated (Figure 2). Forty-four patients were not randomized; the predominant reason was no longer meeting study protocol entry criteria. One patient (daclatasvir 16-week group) was randomized but

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withdrew consent before initiating study treatment and was excluded from the modified intention-totreat population for subsequent analyses. Study treatment was completed by 131 of 151 patients.

Treatment was discontinued for lack of efficacy in one daclatasvir recipient and three placebo recipients,

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and for adverse events in four daclatasvir recipients and two placebo recipients. Ten patients across

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study arms discontinued due to withdrawal of consent, patient request, or non-compliance.

Demographic parameters were generally similar across treatment groups (Table 1). Patients with genotype 2 were older (median 52.5–55 years across treatment groups) than those with genotype 3 (44–46 years). Baseline HCV RNA levels and IL28B genotype distributions were similar across HCV

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genotype and treatment groups. Although the frequency of cirrhosis was higher in patients with HCV genotype 3 (14.8–26.9% across treatment groups) than genotype 2 (0–4.2%), there was a similar

Virologic response

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frequency of cirrhosis across treatment groups within each HCV genotype.

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HCV RNA levels declined more rapidly in the daclatasvir + peg-alfa/RBV groups compared with placebo + peg-alfa/RBV (Figure 3). Among daclatasvir recipients, initial HCV RNA responses were similar in patients with HCV genotypes 2 and 3, and approached peak reductions by Week 4. Responses converged in the daclatasvir and placebo groups as treatment continued (Table 2). At the end of treatment, HCV RNA was
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In the primary modified intention-to-treat analysis, SVR24 was achieved by 20/24 (83%; 80% CI: 73.6– 93.1) and 19/23 (83%, 72.5–92.7) daclatasvir recipients with genotype 2 infection in the 12-week and

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16-week arms, respectively, compared with 15/24 (63%, 49.8–75.2) in the placebo group (Table 2). The differences between both daclatasvir arms and placebo met statistical criteria for non-inferiority based on a 2-sided 80% CI (12-week arm: 20.8%, 80% CI: 4.9–36.8; 16-week arm: 20.1%, 80% CI: 3.9–36.3). In

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patients with genotype 3, 18/26 (69%, 57.6–80.8) and 18/27 (67%, 55.0–78.3) daclatasvir recipients achieved SVR24 in the 12-week and 16-week arms, respectively, compared with 16/27 (59%, 47.1–71.4)

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in the placebo group. The differences between both daclatasvir arms and placebo met statistical criteria for non-inferiority (12-week arm: 10.0%, 80% CI: –6.8–26.7; 16-week arm: 7.4%, 80% CI: –9.4–24.2). SVR24 was achieved by higher proportions of both daclatasvir and placebo recipients with genotype 2 compared with genotype 3, primarily due to more frequent posttreatment relapse in patients with

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genotype 3. Among daclatasvir recipients, SVR24 rates were similar in the 12- and 16-week treatment groups for both HCV genotypes. SVR24 rates for both daclatasvir and placebo recipients were somewhat lower in genotype 3 patients with cirrhosis, compared with non-cirrhotics, although the population with

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cirrhosis was small. SVR24 was achieved by 3/7 (43%) and 2/4 (50%) cirrhotic patients receiving daclatasvir + peg-alfa/RBV for 12 or 16 weeks, respectively, compared with 15/19 (79%) or 14/20 (70%)

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non-cirrhotic patients. In the placebo arm, SVR24 was achieved by 3/7 (43%) cirrhotic genotype 3 patients and 13/20 (65%) non-cirrhotic patients.

In the as-observed analysis that excluded patients with missing HCV RNA data at posttreatment Week 24, SVR24 was achieved by 20/21 (95%) or 19/19 (100%) patients with genotype 2 infection in the daclatasvir 12-week and 16-week groups, respectively, compared with 15/18 (83.3%) in the placebo group. In a similar analysis in patients with genotype 3, SVR24 was achieved by 18/25 (72%) or 18/26

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(69%) of patients in the daclatasvir 12-week or 16-week groups, respectively, compared with 16/23 (70%) in the placebo group.

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Overall, 83% of daclatasvir + peg-alfa/RBV recipients achieved PDR and received the assigned treatment duration of 12 or 16 weeks (Table 2). PDR rates were similar for patients with HCV genotypes 2 and 3. Of patients who achieved PDR, 34/39 (87%) with genotype 2 and 32/44 (73%) with genotype 3

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subsequently achieved SVR24. Patients without PDR stopped daclatasvir at Week 12 and received an additional 12 weeks of peg-alfa/RBV. Overall, 9/17 (53%) patients without PDR achieved SVR24, including

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5/8 with genotype 2 infection and 4/9 with genotype 3.

SVR24 was achieved by 15/17 (88%) daclatasvir recipients and 5/6 (83%) placebo recipients with HCV genotype 2 infection and IL28B genotype CC, compared with 23/29 (79%) daclatasvir recipients and

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10/18 (56%) placebo recipients with genotypes CT or TT. In patients with HCV genotype 3, SVR24 was achieved by 14/22 (64%) daclatasvir recipients and 7/11 (64%) placebo recipients with IL28B genotype

CT or TT.

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Virologic failure

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CC, compared with 22/30 (73%) daclatasvir recipients and 9/16 (56%) placebo recipients with genotype

On-treatment virologic breakthrough was infrequent, occurring only in two placebo recipients (one from each HCV genotype subgroup) (Table 3). Posttreatment relapse was experienced by six patients in each of the two daclatasvir treatment groups with genotype 3 infection, and by one daclatasvir recipient from the 12-week treatment group with genotype 2. In the placebo group, relapse occurred in two patients with genotype 2 infection and in three with genotype 3. In all 12 daclatasvir recipients with genotype 3 who relapsed, the daclatasvir resistance-associated polymorphisms NS5A-Y93H or -A30K were present

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at failure. Comparison of baseline polymorphisms with treatment outcomes in patients with genotype 3 suggests that pre-existence of Y93H or A30K may increase the risk of subsequent relapse but is not a definitive predictor: four of the eight (50%) daclatasvir recipients with Y93H or A30K at baseline

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subsequently relapsed, compared with eight of the 43 patients (16%) without these polymorphisms.

Potential associations between baseline characteristics and posttreatment relapse were investigated in

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daclatasvir recipients with genotype 3 infection. Relapse occurred in 4/11 (36%) cirrhotic patients

compared with 8/39 (21%) non-cirrhotics, in 5/9 (56%) patients with BMI ≥ 30 kg/m2 compared with

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7/44 (16%) with BMI < 30 kg/m2, and in 12/40 (30%) patients with baseline HCV RNA ≥ 800,000 IU/mL compared with 0/13 with HCV RNA < 800,000 IU/mL. Relapse occurred in 6/23 (26%) patients with IL28B genotype CC, compared with 6/29 (21%) patients with non-CC genotypes. There was no apparent

Safety and tolerability

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association between early (Week 4) virologic response and subsequent relapse.

There were no unexpected safety signals and no deaths. The most commonly reported adverse events

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and laboratory abnormalities were those typically associated with use of peg-alfa/RBV, and these events occurred at generally comparable rates across treatment groups (Table 4). Treatment-related adverse

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events that occurred in ≥ 5% of patients in any treatment group, in order of overall frequency, were fatigue, neutropenia, asthenia, anemia, depression, insomnia, pruritus, myalgia, rash, influenza-like illness, and thrombocytopenia. Events of rash, pruritus and anemia that have been reported at higher frequencies with telaprevir and/or boceprevir regimens, compared with peg-alfa/RBV alone, occurred at similar frequency in the daclatasvir and placebo groups.18,19

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The frequencies of on-treatment serious adverse events and adverse events leading to discontinuation of study therapy were comparable for daclatasvir and placebo recipients (Table 4). Four (4%) daclatasvir recipients experienced five on-treatment serious adverse events that included gastroenteritis (with

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fever, nausea, vomiting and diarrhea of unknown origin that resolved subsequently), rectal ulcer with hemorrhage and hyperbilirubinemia in a patient with underlying cirrhosis, hepatocellular carcinoma in a cirrhotic patient after four weeks of therapy, and biliary colic. Three (6%) placebo recipients experienced

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serious adverse events that included upper abdominal pain, epicondylitis, and conversion disorder. Seven (7%) daclatasvir recipients discontinued study therapy due to adverse events that included

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depression, neutropenia, gastrointestinal inflammation, hyperbilirubinemia, grade 2 exfoliative dermatitis, grade 3 exfoliative rash, and grade 3 rash. Two (4%) placebo recipients discontinued study therapy due to adverse events that included anemia and thrombocytopenia, and retinopathy, respectively. The most common laboratory abnormalities were cytopenias typical of peg-alfa/RBV

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therapy; these events occurred at comparable rates across treatment arms. Two daclatasvir recipients experienced grade 3 and grade 4 bilirubin elevations, respectively; these were considered unrelated to

Discussion

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study treatment by the investigators.

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Therapeutic regimens that include direct-acting antivirals can increase efficacy and reduce the required duration of therapy for patients with chronic HCV infection, providing advantages for both patients and healthcare providers. Results of this study confirm that the pan-genotypic in vitro activity of daclatasvir is reflected by clinical activity in patients infected with genotypes 2 and 3, consistent with previous data in patients infected with genotypes 1 and 4.12,16,17 Addition of daclatasvir to peg-alfa/RBV provided more rapid suppression of serum HCV RNA levels than peg-alfa/RBV alone, followed by similar or greater rates of SVR with shorter (12 or 16 weeks) duration of therapy. At the end of treatment, response rates were

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>91% with or without daclatasvir in patients with genotype 2; subsequent SVR24 rates were 83% in the daclatasvir groups compared with 63% with peg-alfa/RBV alone. In patients with genotype 3 infection, end-of-treatment responses were 89-96% in the daclatasvir groups compared with 78% with peg-

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alfa/RBV alone; subsequent SVR24 rates were 67-69% in the daclatasvir groups, compared with 59% with peg-alfa/RBV alone. Thus, in both genotype 2 and 3 infection, the data suggest that daclatasvir

combined with peg-alfa/RBV achieved the goal of reducing duration of therapy while maintaining or

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improving SVR rates.

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The majority (83%) of daclatasvir recipients achieved PDR; most of these subsequently achieved SVR24 following the protocol-defined treatment durations of 12 or 16 weeks. PDR was achieved by similar proportions of daclatasvir recipients in the 12- and 16-week treatment groups regardless of HCV genotype. SVR24 was less frequent in genotype 3 cirrhotics (45%) than in non-cirrhotics (74%) in the

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combined daclatasvir arms. Although the number of genotype 3 cirrhotic patients was small (18 patients), a similar difference in SVR rates between cirrhotic and non-cirrhotic patients was observed in the placebo arm (43% vs 65%, respectively) and is consistent with previous results with regimens

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containing the nucleotide NS5B inhibitor sofosbuvir, suggesting that alternate strategies may be needed

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to optimize response rates in cirrhotic patients.20-22

In the primary modified intention-to-treat analysis, SVR24 rates in the placebo arms were approximately 10% lower than the 74% and 68% SVR rates reported in a meta-analysis of studies with peg-alfa/RBV in genotype 2 or 3 infection, respectively.9 However, results in the as-observed analysis that excluded patients with missing posttreatment data were more consistent with previous experience; SVR24 rates of 83% and 70% were achieved in the placebo groups with genotypes 2 and 3, respectively. Of note, in the as-observed analysis, a numerical difference between the daclatasvir and placebo arms remained for

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genotype 2 (95% or 100% vs 83%), but SVR24 rates were similar for genotype 3 (72% or 69% vs 70%) with a shortened treatment duration in daclatasvir-containing regimens.

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Most of the differences between end of treatment responses and SVR24 rates in patients with genotype 3 infection were due to posttreatment relapse, which was more frequent in patients with genotype 3 than genotype 2. Among daclatasvir recipients, one patient with genotype 2 and 12 with genotype 3

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relapsed. Several factors, including those previously associated with a lower response rate to pegalfa/RBV, were explored in an attempt to understand the cause for relapse in these subjects.3

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Although the small sample size precludes formal statistical analysis of predictive factors, relapse rates were found to be higher in patients with cirrhosis, high HCV RNA levels at baseline, or high BMI. IL28B genotype had no evident effect on relapse rate. Pre-existing daclatasvir-resistant NS5A polymorphisms may have contributed to relapse, since these were present at baseline in a higher proportion of patients

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who subsequently relapsed compared with those who achieved SVR, but the association was incomplete, suggesting that other contributing factors are involved. Hepatic steatosis was not evaluated in this study, but previous studies suggest that HCV infection, particularly genotype 3, increases risk of

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steatosis and, although results vary, steatosis may increase the risk of relapse following peg-alfa/RBV therapy.23-25 Further study is needed to determine if steatosis influences relapse rates with daclatasvir

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regimens in this population.

Pre-existing daclatasvir-resistant polymorphisms did not appear to facilitate on-treatment virologic breakthrough. Only one daclatasvir recipient experienced breakthrough; this patient had no NS5A resistance-associated polymorphisms detected at baseline by either population or clonal sequencing, but daclatasvir-resistant variants emerged rapidly after the start of therapy. In contrast, 23 of 44 patients with genotype 2 infection and eight of 51 with genotype 3 had detectable NS5A polymorphisms

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resistant to daclatasvir at baseline by population sequencing, but none of these patients experienced breakthrough.26 The presence of these polymorphisms may have contributed to a slower initial response in some patients. However, the generally good response to peg-alfa/RBV of patients with genotype 2 or

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3 infection complicates analysis of factors contributing to daclatasvir-related virologic failure.

The difference in SVR rates for patients with HCV genotypes 2 and 3 in our study is consistent with

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studies of sofosbuvir combined with RBV.20,21 In both our study and the sofosbuvir studies, on-treatment virologic responses were robust and similar for genotypes 2 and 3, but were followed by genotype-

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specific differences in posttreatment relapse. However, treatment duration had a marked effect on relapse rates in genotype 3 patients following sofosbuvir/RBV therapy: 56% and 85% of patients achieved SVR12 after 12 and 24 weeks of therapy, respectively.21,22 These results suggest that a more extended period of viral suppression may reduce posttreatment relapse in patients with genotype 3

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infection. Regimen potency may also be important; combinations of two or more direct-acting antivirals may provide further efficacy improvements in patients with genotype 3 infection. In this regard, 24 weeks of therapy with the dual combination of daclatasvir and sofosbuvir achieved 100% SVR12 (N=14) in

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a mixed population of genotype 2- and 3-infected patients, and a 12-week regimen of sofosbuvir combined with the NS5A inhibitor GS-5816 achieved SVR12 in 93% of patients with genotype 3

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infection.27,28

Safety profiles of the study regimens were generally similar and comparable to that typically reported with peg-alfa/RBV.29,30 Consistent with the results of previous studies in genotype 1 infection, there were no marked differences in the patterns of adverse events or laboratory abnormalities between treatment groups, and no evidence suggesting that daclatasvir contributed to overall regimen

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tolerability or safety.16,17 Rash occurred with similar frequency in the daclatasvir and placebo arms, consistent with previous studies of daclatasvir combined with peg-alfa/RBV.16,17

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Limitations of this study include the relatively small sample size that limits quantitative comparisons of efficacy outcomes and definitive conclusions regarding the possible contribution of daclatasvir to lowfrequency safety signals. The predominance of white race among study participants precludes

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assessment of possible effects of ethnicity, and the small number of cirrhotic patients limits conclusions

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regarding the possible effects of disease stage on efficacy and safety outcomes.

In summary, the results of this study confirm that daclatasvir has activity in patients with chronic HCV genotype 2 or 3 infection, consistent with previous findings in patients with genotypes 1 and 4. The combination of daclatasvir with peg-alfa/RBV achieved more rapid viral suppression, similar or higher

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SVR24 rates after a shorter 12 or 16 weeks of therapy, coupled with similar tolerability compared with peginterferon/ribavirin. For the primary endpoint of SVR24, the differences between both daclatasvir arms and placebo met statistical criteria for non-inferiority in patients with genotype 2 and genotype 3

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infection. Coupled with findings from studies of all-oral daclatasvir regimens, these results suggest that combinations of daclatasvir with other potent antiviral agents may offer alternatives to the current

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standard of care for genotype 2 and 3 infection, and support ongoing phase 3 studies of multiple daclatasvir-based all-oral regimens.

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References 1. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet

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2012;380:2095-2128.

2. Negro F, Alberti A. The global health burden of hepatitis C virus infection. Liver Int 2011;31 Suppl 2:13.

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3. Ghany MG, Strader DB, Thomas DL, Seeff LB, American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology 2009;49:1335-1374.

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4. Nkontchou G, Ziol M, Aout M, et al. HCV genotype 3 is associated with a higher hepatocellular carcinoma incidence in patients with ongoing viral C cirrhosis. J Viral Hepat 2011;18:e516-22. 5. Larsen C, Bousquet V, Delarocque-Astagneau E, et al. Hepatitis C virus genotype 3 and the risk of severe liver disease in a large population of drug users in France. J Med Virol 2010;82:1647-1654.

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6. Bochud PY, Cai T, Overbeck K, et al. Genotype 3 is associated with accelerated fibrosis progression in chronic hepatitis C. J Hepatol 2009;51:655-666.

7. Coppola N, Vatiero LM, Sagnelli E. HCV genotype 2 as a risk factor for reactivation of chronic HCV

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infection. Gut 2005;54:1207.

8. American Association for the Study of Liver Diseases, Infectious Diseases Society of America.

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Recommendations for testing, managing, and treating hepatitis C; 2014. Available at: http://www.hcvguidelines.org/. Accessed March 18, 2014. 9. Andriulli A, Mangia A, Iacobellis A, Ippolito A, Leandro G, Zeuzem S. Meta-analysis: the outcome of anti-viral therapy in HCV genotype 2 and genotype 3 infected patients with chronic hepatitis. Aliment Pharmacol Ther 2008;28:397-404. 10. Wang C, Huang H, Valera L, et al. Hepatitis C virus RNA elimination and development of resistance in replicon cells treated with BMS-790052. Antimicrob Agents Chemother 2012;56:1350-1358.

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11. Pelosi LA, Voss S, Liu M, Gao M, Lemm JA. Effect on hepatitis C virus replication of combinations of direct-acting antivirals, including NS5A inhibitor daclatasvir. Antimicrob Agents Chemother 2012;56:5230-5239.

2013;3:514-520.

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12. Gao M. Antiviral activity and resistance of HCV NS5A replication complex inhibitors. Curr Opin Virol

13. Qiu D, Lemm JA, O'Boyle DR,2nd, et al. The effects of NS5A inhibitors on NS5A phosphorylation,

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polyprotein processing and localization. J Gen Virol 2011;92:2502-2511.

14. Nettles RE, Gao M, Bifano M, et al. Multiple ascending dose study of BMS-790052, an NS5A

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replication complex inhibitor, in patients infected with hepatitis C virus genotype 1. Hepatology 2011;54:1956-1965.

15. Pol S. Daclatasvir, an efficient inhibitor of the hepatitis C virus replication complex protein NS5A: review of virological data, treatment rationale and clinical trials. Clin Invest 2013;3:191-207.

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16. Hezode C, Hirschfield GM, Ghesquiere W, et al. Daclatasvir plus peginterferon alfa and ribavirin for treatment-naive chronic hepatitis C genotype 1 or 4 infection: a randomised study. Gut 2014; doi:10.1136/gutjnl-2014-307498.

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17. Pol S, Ghalib RH, Rustgi VK, et al. Daclatasvir for previously untreated chronic hepatitis C genotype 1 infection: a randomised, parallel-group, double-blind, placebo-controlled, dose-finding, phase 2a trial.

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Lancet Infect Dis 2012;12:671-677.

18. Jacobson IM, McHutchison JG, Dusheiko G, et al. Telaprevir for previously untreated chronic hepatitis C virus infection. N Engl J Med 2011;364:2405-2416. 19. Poordad F, McCone Jr J, Bacon BR, et al. Boceprevir for untreated chronic HCV genotype 1 infection. N Engl J Med 2011;364:1195-1206. 20. Jacobson IM, Gordon SC, Kowdley KV, et al. Sofosbuvir for hepatitis C genotype 2 or 3 in patients without treatment options. N Engl J Med 2013;368:1867-1877.

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21. Lawitz E, Mangia A, Wyles D, et al. Sofosbuvir for previously untreated chronic hepatitis C infection. N Engl J Med 2013;368:1878-1887. 22. Zeuzem S, Dusheiko GM, Salupere R, et al. Sofosbuvir + ribavirin for 12 or 24 weeks for patients with

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HCV genotype 2 or 3: the VALENCE trial. Hepatology 2013;58 (4 Suppl):733A-734A.

23. Restivo L, Zampino R, Guerrera B, Ruggiero L, Adinolfi LE. Steatosis is the predictor of relapse in HCV genotype 3- but not 2-infected patients treated with 12 weeks of pegylated interferon-alpha-2a plus

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ribavirin and RVR. J Viral Hepat 2012;19:346-352.

24. Reddy KR, Govindarajan S, Marcellin P, et al. Hepatic steatosis in chronic hepatitis C: baseline host

J Viral Hepat 2008;15:129-136.

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and viral characteristics and influence on response to therapy with peginterferon alpha-2a plus ribavirin.

25. Rodriguez-Torres M, Govindarajan S, Diago M, et al. Hepatic steatosis in patients with chronic hepatitis C virus genotype 2 or 3 does not affect viral response in patients treated with peginterferon

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alpha-2a (40KD) (PEGASYS) plus ribavirin (COPEGUS) for 16 or 24 weeks. Liver Int 2009;29:237-241. 26. McPhee F, Hernandez D, Zhou N, et al. Characterization of HCV NS5A resistance variants in naive patients infected with genotypes 2 and 3 receiving short-term treatment of daclatasvir in combination

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with pegylated interferon-alfa and ribavirin [abstract]. Hepatology 2012;56:579A-580A. 27. Sulkowski MS, Gardiner DF, Rodriguez-Torres M, et al. Daclatasvir plus sofosbuvir for previously

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treated or untreated chronic HCV infection. N Engl J Med 2014;370:211-221. 28. Everson GT, Tran TT, Towner WJ, et al. Safety and efficacy of treatment with interferon-free, ribavirin-free combination of sofosbuvir + GS-5816 for 12 weeks in treatment-naive patients with genotypes 1-6 HCV infection. 49th EASL conference, April 9-13, 2014, London, UK. 29. McHutchison JG, Lawitz EJ, Shiffman ML, et al. Peginterferon alfa-2b or alfa-2a with ribavirin for treatment of hepatitis C infection. N Engl J Med 2009;361:580-593.

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30. Hadziyannis SJ, Sette H,Jr, Morgan TR, et al. Peginterferon-alpha2a and ribavirin combination therapy in chronic hepatitis C: a randomized study of treatment duration and ribavirin dose. Ann Intern

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Med 2004;140:346-355.

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Figure legends Figure 1. Study Design Patients were randomly assigned (1:1:1) to one of three treatment groups: daclatasvir + peg-alfa/RBV

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for 12 weeks; daclatasvir + peg-alfa/RBV for 16 weeks, or placebo + peg-alfa/RBV for 24 weeks. Patients in the daclatasvir groups who achieved a protocol-defined response (PDR) discontinued all treatment at the protocol-defined end point (Week 12 or Week 16). Daclatasvir recipients without PDR discontinued

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daclatasvir at Week 12 and received an additional 12 weeks of placebo + peg-alfa/RBV. PDR was defined as HCV RNA < lower limit of quantitation (LLOQ), target not detected or target detected at Week 4 and

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Figure 2. Patient Disposition

The disposition of patients through the study is shown. The final modified intention-to-treat analysis

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included all patients who initiated treatment regardless of withdrawals or other events prior to the end of follow-up. One patient in the 12-week cohort, three patients in the 16-week cohort and two patients in the placebo cohort did not enter follow-up due to withdrawal of consent, loss to follow-up, or subject

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request to discontinue. Four of the five patients in the placebo arm who discontinued follow-up for reason “other” did so in order to transition into a retreatment study; one patient left the country. DCV,

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daclatasvir; peg-alfa/RBV, peginterferon alfa/ribavirin.

Figure 3. Virologic Responses

Mean HCV RNA levels ± 80% confidence intervals through treatment Week 12 are shown for (A) genotype 2 and (B) genotype 3. Initial responses in the daclatasvir arms were similar across genotypes, and greater than those in the placebo arms. LLOQ, assay lower limit of quantitation; DCV, daclatasvir; peg-alfa/RBV, peginterferon alfa/ribavirin.

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Table 1. Demographic and Baseline Disease Characteristics Genotype 2

Genotype 3

Daclatasvir +

Placebo +

Daclatasvir +

Daclatasvir +

Placebo +

Peg-alfa/RBV

Peg-alfa/RBV

Peg-alfa/RBV

Peg-alfa/RBV

Peg-alfa/RBV

Peg-alfa/RBV

12 weeks

16 weeks

24 weeks

12 weeks

16 weeks

24 weeks

N = 24

N = 23

N = 24

N = 26

N = 27

N = 27

51.5 (30-64)

52.0 (25-64)

55.0 (37-63)

46.0 (28-61)

44.0 (31-67)

46.0 (20-62)

13 (54.2)

15 (65.2)

11 (45.8)

19 (73.1)

22 (81.5)

16 (59.3)

22 (91.7)

18 (78.3)

21 (87.5)

23 (88.5)

25 (92.6)

20 (74.1)

0

2 (8.7)

2 (8.3)

0

0

0

Asian

1 (4.2)

3 (13.0)

1 (4.2)

2 (7.7)

2 (7.4)

5 (18.5)

Other

1 (4.2)

0

0

1 (3.8)

0

2 (7.4)

6.6 (0.73)

6.8 (0.49)

6.6 (0.59)

6.2 (0.85)

6.4 (0.67)

6.5 (0.59)

20 (83.3)

21 (91.3)

21 (87.5)

18 (69.2)

22 (81.5)

24 (88.9)

Parameter Age, median (range) Male, n (%)

Black/African Amer.

HCV RNA, mean log

10

IU/mL (SD) HCV RNA ≥ 800,000

IU/mL, n (%) IL28B genotype

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(rs12979860)

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White

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Race, n (%)

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Daclatasvir +

10 (41.7)

7 (30.4)

6 (25.0)

10 (38.5)

12 (44.4)

11 (40.7)

CT

9 (37.5)

13 (56.5)

15 (62.5)

11 (42.3)

13 (48.1)

15 (55.6)

TT

4 (16.7)

3 (13.0)

3 (12.5)

5 (19.2)

1 (3.7)

1 (3.7)

Not determined

1 (4.2)

0

0

0

1 (3.7)

0

24 (100.0)

23 (100.0)

21 (87.5)

19 (73.1)

20 (74.1)

20 (74.1)

0

0

1 (4.2)

7 (26.9)

4 (14.8)

7 (25.9)

0

0

2 (8.3)

0

3 (11.1)

0

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Baseline cirrhosis, n (%) Absent

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Present

Not reported

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Table 2. Virologic Outcomes Genotype 2 Daclatasvir +

Daclatasvir +

Genotype 3 Placebo +

Daclatasvir +

Daclatasvir +

Placebo +

Peg-alfa/RBV Peg-alfa/RBV Peg-alfa/RBV Peg-alfa/RBV Peg-alfa/RBV Peg-alfa/RBV 16 weeks

24 weeks

12 weeks

16 weeks

24 weeks

N = 24

N = 23

N = 24

N = 26

N = 27

N = 27

HCV RNA undetectable

21/24 (87.5)

17/23 (73.9)

10/24 (41.7)

22/26 (84.6)

18/27 (66.7)

10/27 (37.0)

Week 4

[78.8, 96.2]

[62.2, 85.6]

[28.8, 54.6]

[75.5, 93.7]

[55.0, 78.3]

[47.1, 71.4]

HCV RNA undetectable

22/24 (91.7)

19/23 (82.6)

18/24 (75.0)

21/26 (80.8)

24/27 (88.9)

16/27 (59.3)

Week 12

[84.4, 98.9]

[72.5, 92.7]

[63.7, 86.3]

[70.9, 90.7]

[81.1, 96.6]

[47.1, 71.4]

HCV RNA undetectable

23/24 (95.8)

21/23 (91.3)

22/24 (91.7)

25/26 (96.2)

24/27 (88.9)

21/27 (77.8)

End of treatment

[90.6, 100.0]

[83.8, 98.8]

[84.4, 98.9]

[91.3, 100.0]

[81.1, 96.6]

[67.5, 88.0]

SVR12

21/24 (87.5)

19/23 (82.6)

17/24 (70.8)

18/26 (69.2)

21/27 (77.8)

14/27 (51.9)

[78.8, 96.2]

[72.5, 92.7]

[58.9, 82.7]

[57.6, 80.8]

[67.5, 88.0]

[39.5, 64.2]

20/24 (83.3)

19/23 (82.6)

15/24 (62.5)

18/26 (69.2)

18/27 (66.7)

16/27 (59.3)

[73.6, 93.1]

[72.5, 92.7]

[49.8, 75.2]

[57.6, 80.8]

[55.0, 78.3]

[47.1, 71.4]

0

0

1/24 (4.2)

0

0

1/27 (3.7)

0

2/24 (8.3)

7/26 (26.9)

7/27 (25.9)

3/27 (11.1)

21/24 (87.5)

18/23 (78.3)

NA

22/26 (84.6)

22/27 (81.5)

NA

[78.8, 96.2]

[67.2, 89.3]

[75.5, 93.7]

[71.9, 91.1]

HCV RNA undetectable

20/21 (95.2)

17/18 (94.4)

21/22 (95.5)

21/22 (95.5)

End of treatment

[82.7, 99.5]

[80.1, 99.4]

[83.4, 99.5]

[83.4, 99.5]

SVR12

18/21 (85.7) 18/18 (100.0)

16/22 (72.7)

19/22 (86.4)

[57.0, 85.0]

[72.1, 94.9]

16/22 (72.7)

16/22 (72.7)

[57.0, 85.0]

[57.0, 85.0]

SVR24

a

Viral breakthrough

[70.9, 94.6]

[88.0, 100.0]

17/21 (81.0)

17/18 (94.4)

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SVR24

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Patients with PDR

PDR

1/24 (4.2)

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Posttreatment relapse

[65.5, 91.4]

a

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All patients

Endpoint, n/N (%) [80% CI]

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12 weeks

NA

NA

NA

[80.1, 99.4]

NA

NA

NA

In an as-observed analysis that excluded patients with missing posttreatment data, SVR24 rates in patients

with genotype 2 were 95% and 100% for the daclatasvir 12-week and 16-week groups, respectively, compared with 83% in the placebo group. Corresponding SVR24 rates in patients with genotype 3 were 72% and 69% in the 12- and 16-week daclatasvir groups and 70% in the placebo group.

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Table 3. Virologic Failure Daclatasvir +

Placebo +

Peg-alfa/RBV

Peg-alfa/RBV

Peg-alfa/RBV

12 weeks

16 weeks

24 weeks

N = 24

N = 23

Virologic breakthrough

0

0

Week 4 futility rulec

0

0

0

Partial responsea

0

0

1 (4.2)

Posttreatment relapseb

1/23 (4.3)

Genotype 3

1 (4.2)

2/22 (9.1)

N = 27

N = 27

0

1 (3.7)

1 (3.7)

2 (7.4)

1 (3.8)

1 (3.7)

2 (7.4)

6/25 (24.0)

6/24 (25.0)

3/21 (14.3)

0

Week 4 futility rulec

0

TE D

Virologic breakthrough

Posttreatment relapseb

N = 24

0/21

N = 26

Partial responsea

SC

Genotype 2

M AN U

n (%)

RI PT

Daclatasvir +

≥ 2 log10 decrease from baseline at Week 12 and >LLOQTD at end of treatment.

b

Denominator indicates number of patients with HCV RNA < LLOQTND at end of treatment.

c

< 1 log10 decrease of HCV RNA from baseline at Week 4.

AC C

EP

a

3

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Table 4. On-Treatment Safety and Adverse Events Placebo +

Peg-alfa/RBV

Peg-alfa/RBV

Peg-alfa/RBV

12 weeks

16 weeks

24 weeks

(N = 50)

(N = 50)

(N = 51)

Key safety outcomes 4 (8)

AEs leading to discontinuation

4 (8)

Grade 3/4 AEs

0

3 (6)

3 (6)

2 (4)

M AN U

On-treatment serious AEs

RI PT

Daclatasvir +

SC

Number of patients (%)

Daclatasvir +

7 (14)

4 (8)

6 (12)

27 (54)

22 (44)

30 (59)

13 (26)

12 (24)

12 (24)

14 (28)

13 (26)

14 (28)

4 (8)

3 (6)

5 (10)

10 (20)

12 (24)

16 (31)

Lymphocytopenia

5 (10)

7 (14)

4 (8)

Anemia

3 (6)

0

3 (6)

Thrombocytopenia

1 (2)

2 (4)

4 (8)

ALT increase

1 (2)

1 (2)

0

Bilirubin increase

2 (4)

0

0

Treatment-related grade 2-4 AEs

TE D

AE of interest (grade 1-4) Rash Pruritus

EP

Anemia

Grade 3/4 laboratory abnormalities

AC C

Neutropenia

4

AC C

EP

TE D

M AN U

SC

RI PT

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AC C

EP

TE D

M AN U

SC

RI PT

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AC C

EP

TE D

M AN U

SC

RI PT

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