Long-term efficacy and safety of switching from lamivudine + adefovir to tenofovir disoproxil fumarate in virologically suppressed patients

Accepted Manuscript Title: Long-term efficacy and safety of switching from Lamivudine+Adefovir to Tenofovir disoproxil fumarate in virologically suppressed patients Authors: Massimo Fasano, Paolo Maggi, Armando Leone, Anna Volpe, Jose Ramon Fiore, Gioacchino Angarano, Teresa Antonia Santantonio PII: DOI: Reference:

S1590-8658(17)30144-5 http://dx.doi.org/doi:10.1016/j.dld.2017.01.140 YDLD 3343

To appear in:

Digestive and Liver Disease

Received date: Accepted date:

17-6-2016 6-1-2017

Please cite this article as: Fasano Massimo, Maggi Paolo, Leone Armando, Volpe Anna, Fiore Jose Ramon, Angarano Gioacchino, Santantonio Teresa Antonia.Longterm efficacy and safety of switching from Lamivudine+Adefovir to Tenofovir disoproxil fumarate in virologically suppressed patients.Digestive and Liver Disease http://dx.doi.org/10.1016/j.dld.2017.01.140 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.

Title: Long-term efficacy and safety of switching from Lamivudine+Adefovir to Tenofovir disoproxil fumarate in virologically suppressed patients

Running head: Switching from LAM+ADV to TDF monotherapy

Authors and affiliations: Massimo Fasano1, Paolo Maggi2, Armando Leone2, Anna Volpe2, Jose Ramon Fiore1, Gioacchino Angarano2, Teresa Antonia Santantonio1 1Clinic

of Infectious Diseases, University of Foggia, Italy; 2Clinic of Infectious Diseases,

University of Bari, Italy.

Grant Support: none

Corresponding author: Teresa Antonia Santantonio Clinic of Infectious Diseases University of Foggia, Ospedali Riuniti Viale Pinto 1 71100 Foggia, Italy TEL: +39-0881-732216 FAX: +39-0881-732215 e-mail: [email protected]

WORD COUNT MAIN TEXT: 2664 WORD COUNT ABSTRACT: 209 Figures: 0 Tables: 6

Abstract

Background and Aim: Tenofovir disoproxil fumarate (TDF) is recommended as first-line monotherapy for nucleos(t)ide (NA)-naïve chronic hepatitis B (CHB) patients and as a second-line rescue therapy for NA-experienced patients with a previous treatment failure. However, data regarding the efficacy of TDF monotherapy in patients with lamivudine resistance (LAM-R) successfully treated with LAM+adefovir (ADV) are limited. Herein, the efficacy and safety of switching from LAM+ADV to TDF monotherapy in clinical practice have been evaluated. Methods: Sixty LAM-R HBeAg-negative CHB patients treated with ADV add-on therapy and stable viral suppression, were switched to TDF monotherapy and prospectively evaluated for virological response, liver and renal function, and bone mineral density. Results: During a median period of 57 months of TDF monotherapy, all patients maintained a virological response, four of whom cleared HBsAg (6.6%) and discontinued treatment. Monitoring of renal function showed no case of the Fanconi syndrome, no significant alterations of median serum creatinine, eGFR and phosphate levels, although a reduction of TDF dosage was required in five patients (8.3%). Despite the stable virological suppression, five cirrhotic patients and one CHB patient developed hepatocellular carcinoma. Conclusions: Our results demonstrate the efficacy of switching to TDF monotherapy in virologically suppressed CHB patients receiving long-term LAM+ADV therapy, with a low rate of adverse events.

Abbreviations: HBV, hepatitis B virus; LAM, Lamivudine; TDF, Tenofovir; ADV, Adefovir; NA, nucleos(t)ide analogue; CHB, chronic hepatitis B; ULN, upper limit of normal; HCC, hepatocellular carcinoma; eGFR, extimated Glomerular Filtration Rate.

Keywords: chronic hepatitis B; antiviral therapy; tenofovir, nucleos(t)ide analogues;

INTRODUCTION

Lamivudine (LAM), the first oral nucleoside analogue (NA) approved for treatment of chronic hepatitis B (CHB), has been the only oral antiviral available for many years; consequently, patients have been treated with this drug and a significant number developed resistance (LAM-R) [1]. Moreover, because of its low cost, this drug continues to be used in many countries, and the pool of patients who have developed resistance to LAM continues to increase. Optimal management of patients with resistance to LAM alone, or to both LAM and adefovir dipivoxil (ADV), and even more those with multidrug resistance, still presents a problem for the clinician [2,3]. The therapeutic options for patients with LAM-R have changed significantly in recent years. ADV add-on strategy was the initial rescue therapy for LAM-R patients [4]; however, ADV is no longer recommended due to its low potency, the high rate of resistance and the risk of nephrotoxicity. After its approval, tenofovir disoproxil fumarate (TDF) has been increasingly used as rescue therapy for patients with LAM-R or ADV-R, either as mono- or combination therapy [5-8]. A recent randomized study has demonstrated that TDF monotherapy is as effective as the TDF+emtricitabine combination for maintaining viral suppression in LAM-R patients [9]. Moreover, TDF monotherapy has also proved to be superior to continuous add-on therapy in CHB patients with suboptimal response to LAM+ADV [10] and equally efficacious as the TDF+LAM combination in LAM-R patients who failed LAM+ADV combination therapy [11]. However, all these studies have a short follow up and data on the long-term efficacy of TDF treatment in patients with LAM-R CHB successfully treated with LAM+ADV are limited. In this study, the long-term efficacy and safety of switching from LAM+ADV to TDF monotherapy in LAM-R HBeAg-negative CHB patients with stable viral suppression have been evaluated in clinical practice.

METHODS

Study population From November 2010 to April 2011, 60 Italian consecutive HBeAg-negative CHB patients with LAM-R, successfully treated with ADV add-on strategy (10 mg/day orally) in two

Apulian referral centers (Bari, Foggia), were included in this observational cohort study. All patients had at least 24 months of stable virological suppression with LAM+ADV treatment and were directly switched to TDF monotherapy. One patient assumed ADV at a reduced dosage due to a Stage-III chronic kidney disease and therefore was switched to TDF on alternate days. Patients with decompensated liver cirrhosis and HIV co-infection were excluded. All 60 LAM-R patients showed a virological breakthrough during LAM monotherapy and the presence of LAM-mutations was confirmed by genotypic test for 35/60 patients (Table 1). Our study cohort has also been object of a previous publication which focused on bone and kidney toxicity induced by nucleos(t)ide analogue therapy [12].

Study Objectives and Endpoints. The primary endpoint of this study was to evaluate the maintenance of undetectable HBV DNA during TDF monotherapy in LAM-R patients virologically suppressed with ADV+LAM therapy and thus, the primary endpoint was an undetectable HBV DNA level with real-time quantitative polymerase chain reaction during TDF treatment. The secondary endpoints were: the loss of hepatitis B surface antigen (HBsAg) or seroconversion, the safety of TDF and its tolerability.

Follow up of participants After switching to TDF, patients were followed for a median period of 57 months (range 5-63) and evaluated at each visit for efficacy of treatment, compliance with study medication and adverse events. During the first year, serum ALT levels, creatinine, serum phosphate, urinalysis and HBV DNA levels were monitored every three months, and every six months thereafter. Serum ALT (upper limit of normal: 40 U/L), creatinine, and phosphorus levels were tested by routine automated techniques. HBV DNA was assessed by real-time PCR assay (linear dynamic detection range: 13 IU/mL to 1×10 9 IU/mL; Abbott Laboratories, Chicago, Illinois, USA). HBsAg serum levels were measured by protocol at baseline and yearly thereafter,

using

a

commercial

chemiluminescent

immunoassay

(Architect

HBsAg

quantitative, Abbott Diagnostics, Wiesbaden Germany). Cirrhotic patients underwent surveillance for hepatocellular carcinoma (HCC) development by monitoring serum α-fetoprotein levels and abdominal ultrasound every six months.

Renal function was assessed by calculating the eGFR using the chronic kidney disease epidemiology collaboration (CKD-EPI) formula. Bone mineral density (BMD) measurements of the lumbar spine and femoral neck were determined via dual-energy Xray absorptiometry (DXA) at the start of TDF and every 2 years thereafter. Loss of BMD was as a 5% reduction of BMD in spine and neck after 2 year of TDF treatment. Serum 25 hydroxyvitamin D [25(OH)D] levels were measured at TDF switching and a supplementation was offered in case of deficiency. Written informed consent to participate was provided by all patients.

Statistical analysis Data were expressed as median and range for discrete variables and as counts and percentages for qualitative variables. The cumulative incidence of virological breakthrough was assessed by the Kaplan–Meier method. All data were analyzed using the SPSS statistical software package (version 12; SPSS, Inc., Chicago, IL, USA).

RESULTS

Sixty HBeAg-negative LAM-R chronic hepatitis B patients treated with ADV+LAM combination therapy virologically suppressed for at least 24 months were switched to TDF monotherapy. The baseline clinical and demographic characteristics are shown in Table 2. Median age was 58 years (range 33–81), 48 were males, all patients were HBeAg-negative, anti-HBe positive; a genotypic resistance test was performed in 35/60 patients and a genotype D was documented in all 35 patients. An histological diagnosis of cirrhosis was present in 20/60 patients; six additional patients had biochemical and ultrasonographic signs of cirrhosis. Esophageal varices were present in 8/26 patients with cirrhosis. At switching to TDF monotherapy, diagnosis of previous HCC was present in five cirrhotic patients. A coinfection with HDV or HCV was present in two patients; all patients were negative for HIV co-infection. In 22/60 patients (36.6%) the presence of comorbidities (arterial hypertension, diabetes, depression, hypothyroidism, renal impairment) was reported, requiring concomitant medications. After switching to TDF monotherapy, all patients were followed for a median period of 57 months (range 5–63).

Virologic, biochemical and serologic response During TDF monotherapy, HBV DNA remained persistently undetectable and no patient presented transient HBV DNA blips. ALT levels were normal (<40 U/L) in 49/60 patients (81.6%) at baseline and in 56/60 (93.3%) at the end of FU. According to Prati et al [13], when using lower ULN for ALT (30 U/L for males and 19 U/L for females), only 17/48 males had normal ALT at baseline, while at the end of FU, ALT levels were normal in 37/48. Among females, only 2/12 had normal ALT at baseline, whereas at the end of FU, the ALT levels were normal in 4/12. A decline ≥1 log of quantitative HBsAg (qHBsAg) was observed in 20% of patients. At last visit, 24 patients had qHBsAg >1000 IU/ml, 17 patients qHBsAg 100-1000 IU/ml, 19 patients qHBsAg<100 IU/ml, and four patients cleared HBsAg (6.6%). In these patients (three with chronic hepatitis and one with cirrhosis), HBsAg loss was observed after a median time of 16.5 months (range 8-48) of TDF treatment and all had at TDF switching low levels of qHBsAg ranging from 0.59 IU/ml to 230 IU/ml. These low qHBsAg levels were most likely due to a previous long-term virological suppression under ADV+LAM therapy. After HBsAg loss, all four patients continued TDF for an additional 12 months (consolidation therapy) and then discontinued treatment. No relapse was observed up to 43 months of follow up. Patients with HBsAg loss discontinued TDF in absence of seroconversion to anti-HBs, as we demonstrated in our previous study, that long-term NA therapy can be safely discontinued in clinical practice regardless of anti-HBs seroconversion and duration of consolidation therapy, even in patients with advanced liver disease [14]. During the study period, no chronic hepatitis B patient showed progression to cirrhosis and no patient with cirrhosis experienced clinical decompensation or esophageal variceal bleeding. No patient underwent a liver biopsy in order to demonstrate an histological improvement at the end of FU. During TDF monotherapy, despite the stable virologic suppression, five patients with cirrhosis and one CHB patient, developed HCC after a median of 26.5 months (range 7-47). When also considering the previous viral suppression during LAM+ADV, these six patients developed HCC after a median of 77.5 months (range 43-117) of total viral suppression (Table 3). In addition, four of five cirrhotic patients who had a previous diagnosis of HCC at the moment of TDF switching, demonstrated recurrence of HCC during TDF therapy leading to death in all of them.

Safety and Tolerability TDF treatment was well tolerated and no significant side effects were reported in all patients except for one in whom TDF was discontinued after 37 months due to severe arthromyalgia. This patient was switched to entecavir at 1 mg/day, with complete resolution of symptoms. The monitoring of renal function did not demonstrate significant changes in the median levels of serum creatinine and phosphorus, while median eGFR values slightly decreased at the end of follow-up (Table 4 and Table 5). Overall, five patients (8.3%) had to reduce the TDF dose after a median of 53 months (range 6-59), four patients because of a significant eGFR decline (<60 ml/min) and one due to <2 mg/dL serum phosphate levels (Table 6). However, no case of the Fanconi syndrome was reported during the study. At baseline, a total of 26.9% of patients had a urinary protein excretion above the normal range; in the majority of these patients, the proteinuria was mild (1000 mg/24 h), and only one patient had moderate proteinuria at baseline (1000 to 3000 mg/24 h). During the study, the mean value for proteinuria did not vary significantly and the average was close to the cut-off for normal proteinuria. At the beginning of TDF therapy, DXA was performed in all patients; osteoporosis (T-score <2.5), osteopenia (T-score between -1 and -2.5) and normal BMD were observed at femoral neck in 1.6% (1 patient), 27.4% and 70.6% and at lumbar spine in 3.3% (2 patients), 42.6% and 53.7% of patients, respectively. After 2 years of TDF therapy, 57/60 patients repeated DXA; overall, 47 patients remained unchanged (including the 3 patients with baseline osteoporosis, even though they underwent osteoporosis treatment), while 10 showed a loss of BMD (9 male, 1 female, 3 patients had cirrhosis, 2 patients with renal impairment and reduced TDF dosage). In particular, eight patients with normal BMD progressed to osteopenia and two patients with osteopenia worsened to osteoporosis. In 56/60 patients (93.3%) a 25(OH)-vitamin D insufficiency was observed at switching to TDF montherapy and all received supplementation with cholecalciferol.

DISCUSSION

This long-term (up to 5 years) observational cohort study demonstrates for the first time in clinical practice the antiviral efficacy of switching to TDF monotherapy in a homogeneous cohort of HBeAg-negative LAM-R CHB patients virologically suppressed during long-term LAM plus ADV combination therapy. TDF is the most recent NA approved as first-line therapy for naive patients with CHB due to its potent antiviral activity and high genetic barrier to the development of resistance [15-17]. In clinical studies, TDF has demonstrated a superior antiviral efficacy compared to ADV with a more favorable safety and tolerability profile [18]. Long-term results from two phase-III trials in previously untreated patients, demonstrated that TDF was safe and well-tolerated and associated with durable virological response with no evidence of resistance throughout 8 years [19, 20]. Moreover, TDF has been increasingly used in the last decade as rescue therapy in experienced patients with LAM-R or ADV-R, either as mono- or combination therapy [5-8]. A recent randomized study has demonstrated that TDF monotherapy is as effective as the TDF+emtricitabine combination for maintaining viral suppression in LAM-R patients [9]. Moreover, TDF monotherapy has also proved to be superior to continuous add-on therapy in CHB patients with suboptimal response to LAM+ADV [10] and equally efficacious as the TDF+LAM combination in LAM-R patients who failed LAM+ADV combination therapy [11]. Recently, in order to verify whether TDF can replace LAM+ADV when viral suppression has been achieved by LAM/ADV combination treatment, Huang and colleagues randomized 107 LAM-R CHB patients virologically suppressed by LAM+ADV therapy either to continue LAM/ADV treatment or to switch to TDF monotherapy. Interim analysis results showed that after a mean follow up period of 72 weeks, 5 subjects (9.4%) in the TDF group and 7 (13%) in the LAM/ADV group experienced viral rebound (HBV DNA>100 IU/ml). HBV DNA rebound was transient and all TDF subjects became HBV DNA undetectable at the next visit. No patient with viral rebound had rtN181A/T or rtN236T mutations. According to these preliminary results, the authors concluded that switching to TDF monotherapy after LAM/ADV treatment for LAM-R CHB is effective in maintaining suppression of HBV DNA [21]. Compared to this study in which the high rate of relapse was most likely due to problems of adherence, in our long-term study the TDF monotherapy maintained HBV DNA suppression to below 13 IU/ml in all patients and no transient HBV DNA blips were observed throughout a median follow-up of 57 months.

The advantages of simplifying therapy by substituting ADV+LAM with TDF are remarkable in that the costs are reduced and adherence is improved, important issues when administering life-long therapies. Another advantage of the TDF shift is the avoidance of long-term exposure to ADV which is known to be more nephrotoxic than TDF. Under TDF treatment, all patients maintained a good renal function; however, despite no significant changes in eGFR, during the study period, there was a drop from 92 to 82.9

mL/min after only 1 year of TDF.

Moreover, after 60 months of TDF, the number of patients having eGFR <60 mL/min increased from 1 to 5 patients for whom it was necessary to adapt the TDF dose. These findings emphasize the importance of continued close monitoring of renal function in patients treated with TDF, especially if previously exposed to ADV. In addition, a potential benefit of early switching ADV to TDF is to avoid the selection of ADVR mutants which might compromise the efficacy of the subsequent TDF rescue therapy. In fact, although in vivo TDF monotherapy was shown to be as effective as TDF/emtricitabine combination therapy, regardless of the presence of baseline ADV mutations, in vitro studies have demonstrated that HBV strains expressing rtA181T/V and/or rtN236T substitutions have a reduced susceptibility to TDF [22,23]. A recent European cohort study indicated that the probability of achieving HBV DNA levels <400 copies/mL with TDF monotherapy was significantly lower in patients with ADV resistance and a high baseline viral load (>107 copies/mL) when compared to those without ADV resistant mutants [5]. Although it was not the object of the study, it is interesting to note that in our cohort of long-term suppressed patients, the risk of developing HCC was not eliminated. In fact, five cirrhotic patients and one with CH, virologically suppressed for more than five years, developed HCC with multifocal presentation in three, and rapid progression to death in four. Overall, TDF treatment was well tolerated, with no serious adverse events. However, in this real-life study one patient was forced to discontinue TDF and change therapy due to intense myalgia. After excluding other causes of muscle damage and suspecting a possible correlation with TDF, we replaced TDF with ETV with a subsequent complete remission of symptoms. Data from the present cohort revealed a loss of BMD in 10 patients (16%) after 2 years of TDF therapy, suggesting the possibility that use of TDF for treatment of chronic hepatitis B patients previously exposed to long-term ADV therapy, may be associated with BMD loss, in

agreement with previous reports on BMD changes in HIV-infected cohorts [24]. Further studies will be required to confirm whether there is a direct meaningful effect of TDF on BMD loss. Our observational study has the strength of a long follow up, however there are some limitations regarding the small sample size and the absence of a control group of patients who remained in ADV+LAM therapy, although data in the literature have clearly demonstrated the advantage of switching from ADV to TDF. In conclusion, our results demonstrate in clinical practice the efficacy of TDF monotherapy in the maintenance of undetectable HBV DNA

virologically suppressed patients receiving

LAM+ADV combination therapy.

Author contributions: All authors contributed to conception and design, acquisition of data, analysis and interpretation of data, and final approval of the version to be published

Conflict-of-interest statement: All authors of the manuscript declare that they have no commercial, personal, political, intellectual or religious interests in connection with this paper.

Acknowledgments The authors are grateful to Ms. Paulene Butts for her assistance in the preparation of the manuscript.

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Table 1. Resistance patterns of mutations in the reverse transcriptase region in 35 of 60 LAM-R patients. Mutation patterns

No. of patients

rtL180M, rtM204I rtL180M, rtM204V rtL80I, rtM204I rtL80V, rtM204I rtM204I

11 15 5 2 2

rt= reverse transcriptase region

Table 2. Baseline demographic, clinical and virologic characteristics of 60 patients treated with TDF Male, n (%) Age, median yr (range) BMI, median Kg/m2 (range) Overweight, BMI >25 <30, n (%) BMI >30, n (%) HCV coinfection, n (%) HDV coinfection, n (%) HBeAg negative, n (%) Undetectable HBV DNA, n (%)

48 (80) 58 (33-81) 25.87 (19-40) 30 (50) 5 (8.3) 1 (1.6) 1 (1.6) 60 (100) 60 (100)

(<13 IU/ml)

Prior ADV+LAM duration, median, mo (range) 63 (24-96) Liver cirrhosis, n (%) 26 (43.3) Child A, n (%) 26 (100) Esophageal varices, n (%) 8 (30.7) HCC, n (%) 5 (8.3) Concomitant diseases, n (%) 22 (36.6) Hypertension, n (%) 12 (54.5) Hypothyroidism, n (%) 4 (18.2) Glomerulonephritis, n (%) 1 (4.5) Diabetes, n (%) 3 (13.6) Depression, n (%) 3 (13.6) Chronic renal impairment*, n (%) 1 (4.5) Reduced TDF dose, n (%) 1 (1.6) n=number of patients, BMI=Body Mass Index, mo=months, ADV=Adefovir dipivoxil, LAM=Lamivudine, HCC= Hepatocellular carcinoma * Stage-III chronic kidney disease (CKD)

Table 3. Development of HCC in six patients with long-term viral suppression Liver disease

TDF duration

(years)

1

60

C

26

2

67

C

7

Pts

Age

(months)

Total duration of HBV DNA suppression

HCC

Treatment

Outcome

117

Multifocal

None

Dead

69

Multifocal

Chemotherapy

Live

(months)

3

63

C

43

72

Single

4

70

C

24

43

Multifocal

5

56

C

27

83

Single

6

63

CH

47

96

Single

C= Cirrhosis; CH= Chronic Hepatitis; HCC= Hepatocellular carcinoma

Hepatic Resection Hepatic Resection Hepatic Resection Hepatic Resection

Dead Live Dead Dead

Table 4. Trends of serum creatinine, eGFR and phosphate levels during TDF monotherapy Baseline (N=60) Serum creatinine, mg/dl 0.87 median (range) (0.55-1.71) eGFR, ml/min by CKD-EPI 92.2 median (range) (42.5-146) Serum phosphorus, mg/dl 2.9 median (range) (1.6-3.8) N=number of patients still at risk during FU Variables

Months 12 (N=59) 0.95 (0.32-1.69) 82.9 (43.147.1) 3.0 (2.10-4.0)

Months 24 (N=58) 0.94 (0.62-1.70) 82.3 (60.1-140.1) 3.0 (1.6-5.2)

Months 36 (N=56) 0.96 (0.60-1.72) 82.9 (60-142.1) 2.9 (2.0-4.0)

Months 48 (N=35) 0.93 (0.66-1.77) 83.1 (65-138.8) 3.0 (2.1-4.1)

Months 60 (N=13) 0.90 (0.55-1.85) 81.9 (56-140) 2.9 (2.0-3.9)

Table 5. Monitoring of renal function in 60 patients treated with TDF Baseline (N= 60)

Months 12 (N=59)

Months 24 (N=58)

Months 36 (N=56)

Months 48 (N=35)

Months 60 (N=13)

eGFR >90 ml/min by CKD-EPI n (%)

39 (65)

39 (66.1)

36 (62)

35 (62.5)

21 (60)

7 (54)

eGFR 60-89 ml/min by CKD-EPI n (%)

20 (33.4)

19 (32.2)

22 (37.9)

21 (37.5)

14 (40)

3 (23)

eGFR <60 ml/min by CKD-EPI n (%)

1 (1.6)

1 (1.7)

0

0

0

3 (23)

Serum phosphorus >2.5 mg/dl n (%)

50 (83.4)

48 (81.6)

46 (79.3)

41 (73.2)

23 (65.7)

9 (69.2)

Serum phosphorus 2.0-2.5 mg/dl n (%)

9 (15)

11 (18.4)

10 (17.3)

15 (26.8)

12 (34.3)

4 (30.8)

Serum phosphorus <2.0 mg/dl n (%)

1 (1.6)

0

2 (3.4)

0

0

0

Variables

n=number of patients

Table 6. Patients with renal toxicity requiring TDF dose reduction eGFR Pts

Liver disease

Age*

LAM+ADV duration

(years)

(months)

Comorbidities

Time to DR (months)

1 C 68 36 Hypertension 6 2 C 59 93 None 55 3 CH 53 69 Nephrectomy 59 4 CH 48 48 None 53 5 CH 53 62 None 22 C= Cirrhosis; CH= Chronic Hepatitis; DR= Dose reduction; * age at TDF switching

Phosphatemia

(ml/min)

(mg/dl)

Baseline

At TDF switching

Baseline

At TDF switching

75 72 109 71 130

58 56 58 53 85

2.9 3.1 3.6 2.9 2.1

3.1 4 3.5 3.2 1.8