Supplementary Appendix · 2014. 8. 18. · Supplementary Appendix This appendix has been provided...
Transcript of Supplementary Appendix · 2014. 8. 18. · Supplementary Appendix This appendix has been provided...
Supplementary Appendix
This appendix has been provided by the authors to give readers additional information about their work.
Supplement to: Afdhal N, Reddy KR, Nelson DR, et al. Ledipasvir and sofosbuvir for previously treated HCV genotype 1 infection. N Engl J Med DOI: 10.1056/NEJMoa1316366
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Contents
Page
ION-2 Principal Investigators............................................................................................................................ 3
Statistical Hypothesis for the Primary Efficacy Endpoint................................................................................. 4
Figure S1. Algorithm for Prior Treatment Response Categorization................................................................. 5
Table S1. Reasons for Screen Failure................................................................................................................ 6
Figure S2. Patient Disposition.................................................................................. ........................................ 7
Study Assessments........................................................................................................................................... 8
Criteria for Determining Treatment Duration for Group 1............................................................................... 9
Table S2. Bonferroni-Adjusted Confidence Intervals for the Pairwise Differences in SVR12 Rates.................. 10
Table S3. Sustained Virologic Response by Subgroups..................................................................................... 11
Table S4. Proportion of Patients with ALT >ULN at Baseline Who Had ALT Normalization During Treatment 13
Table S5. Baseline Characteristics of Patients with Virologic Relapse after Treatment.................................... 14
Exact Logistic Regression Analysis for Evaluating Associations between Baseline Characteristics and SVR12. 15
Table S6: Univariate Exact Logistic Regression in Assessing Factors Associated with SVR12........................... 15
Table S7: Final Exact Logistic Regression Model Identifying Factor(s) Associated with SVR12........................ 16
Table S8. Contingency Table of Cirrhosis Status and Treatment Duration with SVR12.................................... 16
Figure S3. Mean HCV RNA in the 1st Weeks of Treatment by Baseline NS5A Resistance-Associated Variants. 17
Figure S4. Proportion of Patients with HCV RNA <LLOQ by Baseline NS5A Resistance-Associated Variants.... 18
Table S9. Proportion of Patients with HCV RNA <25 IU/mL during Treatment by Cirrhosis Status.................. 19
Table S10. SVR12 by Early Viral Response and Cirrhosis Status........................................................................ 21
Table S11. Platelets and Change from Baseline by Visit.................................................................................... 22
Table S12. Albumin and Change from Baseline by Visit..................................................................................... 23
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ION-2 Principal Investigators
Nezam Afdhal, Avanish Aggarwal, Sanjeev Arora, Leslie Bank, Kimberly Beavers, Nicholaos
Bellos, Michael Bennett, David Bernstein, Thomas Boyer, Robert Brown Jr, Mario Chojkier,
Christopher Christensen, James Cooper, Adrian Di Bisceglie, Richard Elion, Robert Emslie,
Kyle Etzkorn, Gregory Everson, Steven Flamm, Todd Frederick, Bradley Freilich, Michael
Galambos, Joseph Galati, Reem Ghalib, Norman Gitlin, Stuart Gordon, David Hassman, Trevor
Hawkins, Robert Herring, Federico Hinestrosa, Charles Howell, Ira Jacobson, Marcelo
Kugelmas, Paul Kwo, Jacob Lalezari, Eric Lawitz, Claudia Martorell, Anthony Mills, Ronald
Nahass, David Nelson, Mindie Nguyen, Keyur Patel, Paul Pockros, Gary Poleynard, John
Poterucha, John Poulos, David Pound, Ronald Pruitt, Bruce Rashbaum, Natarajan Ravendhran,
K. Rajender Reddy, Robert Reindollar, Peter Ruane, Vinod Rustgi, Michael Ryan, Eugene
Schiff, Thomas Sepe, Aasim Sheikh, Mitchell Shiffman, Coleman Smith, Mark Sulkowski, Hugo
Vargas, Kimberly Workowski, David Wyles, Ziad Younes
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Statistical Hypothesis for the Primary Efficacy Endpoint
The 4 primary statistical hypotheses of the study were that the SVR12 rates in each of the 4
treatment groups of the study would be higher than the adjusted historical SVR null rate of 25%.
The 25% null SVR rate was derived from the historical data as follows:
1) For treatment experienced subjects (eg, PEG+RBV) receiving a PI-based triple therapy
regimen, a historical retreatment SVR rate of approximately 65% was calculated from the
telaprevir (REALIZE study) and boceprevir (RESPOND-2 study) data after adjusting for the
expected proportion of subjects with cirrhosis (approximately 20%) in this study. The
weighted average of the telaprevir and boceprevir data provided an estimate of SVR rate to
be approximately 69% in noncirrhotic subjects and 50% in cirrhotic subjects. The
retreatment SVR rate for the historical control in this study (ie, a patient population of 80%
noncirrhotics and 20% cirrhotics) was then calculated to be approximately 65% (ie, 0.8 ×
69% + 0.2 ×50%);
2) For subjects who have had failed treatment with a PI + PEG+ RBV retreatment options
are currently lacking. A conservative retreatment SVR rate of 5% was therefore used.
In this study, the expected proportion of subjects having had prior treatment with a
PI+PEG+RBV was approximately 50%. A 35% null SVR rate was obtained after averaging a
65% retreatment SVR control rate for treatment experienced subjects (eg, PEG+RBV) being
retreated with PI+PEG+RBV (current SOC)and a 5% SVR control rate for subjects who failed
prior treatment of a PI+PEG+RBV, if retreated with a PI+PEG+RBV. In addition, we allowed a
discount of 10 percentage points in efficacy due to the expected improved safety profile and
significantly shorter duration associated with the treatment, which resulted in a null SVR rate for
this study of 25%.
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Figure S1. Algorithm for Prior Treatment Response Categorization
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Table S1. Reasons for Screen Failure
Of the 551 patients screened, 110 were screen failures (four patients failed for more than one
reason)
Screen failure
patients who did
not meet criteria Inclusion criteria
31 Lab parameters at screening: ALT ≤10xULN, AST ≤10xULN, Hgb ≥12 g/dL (M) & 11 g/dL
(F), Platelets ≥50,000/uL, INR ≤1.5, Albumin ≥3 g/dL, Direct bilirubin ≤1.5xULN, HbA1c
≤8.5%, Creatinine clearance ≥60 mL /min, INR ≤1.5 × ULN
10 Cirrhosis determination:
a) Cirrhosis is defined as any one of the following: i) Liver biopsy showing cirrhosis (e.g.,
Metavir score = 4 or Ishak score ≥ 5), ii) FibroTest® score of > 0.75 AND an AST: platelet
ratio index (APRI) of > 2 during Screening
b) Absence of cirrhosis is defined as any one of the following: i) Liver biopsy within 2 years of
Screening showing absence of cirrhosis, ii) FibroTest® score of ≤ 0.48 AND APRI of ≤ 1
during Screening
c) In the absence of a definitive diagnosis of presence or absence of cirrhosis by the above
criteria, a liver biopsy is required; liver biopsy results will supersede blood test results and be
considered definitive.
5 Liver imaging within 6 months of Baseline/Day 1 to exclude hepatocellular carcinoma is
required in patients with cirrhosis
3 Prior virologic failure after treatment with a pegylated interferon (PEG) and ribavirin (RBV)
regimen, including those who have failed treatment with a NS3/4A protease inhibitor (PI) plus
PEG/RBV regimen. Subjects must not have discontinued prior therapy due to an adverse event.
2 Willing and able to provide written informed consent
2 HCV RNA 104 IU/mL at Screening
1 HCV genotype 1a, 1b, or mixed 1a/1b at Screening as determined by the Central Laboratory.
1 Not pregnant or nursing
1 Subject must be of generally good health, with the exception of chronic HCV infection
Exclusion criteria
8 Clinically-relevant drug abuse within 12 months of screening.
2 History of clinically-significant illness or any other major medical disorder that may interfere
with treatment, assessment, or compliance with the protocol
1 Chronic liver disease of a non-HCV etiology
1 Prohibited concomitant medication
Screen failure
patients who did
meet criteria Reason for non-enrollment
3 Subject withdrew consent
16 Study enrollment closed
27 Other
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Figure S2. Patient Disposition
109 were assigned to receive SOF + LDV for 12 weeks
N = 109
111 were assigned to receive SOF + LDV + RBV for 24
weeks N = 111
111 were assigned to receive SOF + LDV +
RBV for 12 weeks N = 111
109 were assigned to receive SOF + LDV for 24 weeks
N = 109
109 included in the efficacy and safety analyses
111 included in the efficacy and safety analyses
111 included in the efficacy and safety analyses
109 included in the efficacy and safety analyses
109 completed treatment
110 completed treatment
111 completed treatment
107 completed treatment
551 screened
441 randomized
1 randomized patient was never dosed
110 screen failures 64 did not meet eligibility criteria 16 due to close of enrollment period 3 withdrew consent 27 due to other reasons
440 randomized and treated
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Study Assessments
HCV genotype and subtype were determined using the Siemens VERSANT HCV Genotype
INNO-LiPA 2.0 assay. IL28B genotype was determined by PCR amplification and sequencing of
the rs12979860 single-nucleotide polymorphism.
On-treatment assessments included laboratory testing, serum HCV RNA, vital signs,
electrocardiography, and symptom-directed physical examinations. All adverse events were
recorded and graded according to a standardized scale (see Appendix 3 of study protocol,
available at NEJM.org).
Plasma samples for viral sequence analysis were collected at Baseline/Day 1 and every
subsequent visit (as appropriate).
Patients with virologic failure underwent resistance testing. Analyses of samples for HCV NS5A
and NS5B substitutions at baseline and virologic failure time points were conducted. DDL
Diagnostics Laboratory (Rijswijk, The Netherlands, EU) performed amplification and population
sequencing, and WuXi Apptec (Shanghai, China) performed deep sequencing assays to identify
treatment-emergent virologic resistance.
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Criteria for Determining Treatment Duration for Group 1
The duration of treatment for the first group depended on emerging results from the LONESTAR
trial (clinicaltrials.gov number NCT01726517). One treatment group in LONESTAR was made
up of patients who had previously received unsuccessful treatment with a protease-inhibitor
regimen (50% of whom could have cirrhosis). This group received 12 weeks of treatment with
the sofosbuvir-ledipasvir fixed-dose combination. If at least 75% of those patients had HCV
RNA <LLOQ 4 weeks after the end of treatment, patients randomized in the present study to
receive sofosbuvir-ledipasvir for the pending treatment duration (ie12 or 24 weeks) in the current
study would stop treatment with sofosbuvir-ledipasvir after 12 weeks; if not, they would
continue to 24 weeks.
The rate of sustained virologic response in the group of 19 patients receiving sofosbuvir-
ledipasvir in the LONESTAR trial was 95% (18 of 19 patients).1 Therefore, patients in group 1
of ION-2 stopped treatment after 12 weeks.
1. Lawitz E, Poordad FF, Pang PS, et al. Sofosbuvir and ledipasvir fixed-dose combination with and without
ribavirin in treatment-naïve and previously treated patients with genotype 1 hepatitis C virus infection
(LONESTAR): an open-label, randomised, phase 2 trial. Lancet 2014;383:515-23.
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Table S2. Bonferroni-Adjusted Confidence Intervals for the Pairwise Differences in SVR12 Rates
SOF/LDV
12 Weeks
(N = 109)
SOF/LDV + RBV
12 Weeks
(N = 111)
SOF/LDV
24 Weeks
(N = 109)
SOF/LDV + RBV
24 Weeks
(N = 111)
SVR12
95% CI
102/109 (93.6%)
87.2% to 97.4%
107/111 (96.4%)
91.0% to 99.0%
108/109 (99.1%)
95.0% to 100.0%
110/111 (99.1%)
95.1% to 100.0%
SOF/LDV 12 weeks vs SOF/LDV + RBV 12 weeks
Prop Diff
(99.17% CI)
-2.7%
(-12.4%, 7.0%)
SOF/LDV 24 weeks vs SOF/LDV + RBV 24 weeks
Prop Diff
(99.17% CI)
-0.04%
(-7.6%, 7.5%)
SOF/LDV 12 weeks vs SOF/LDV 24 weeks
Prop Diff
(99.17% CI)
-5.5%
(-14.6%, 3.6%)
SOF/LDV + RBV 12 weeks vs SOF/LDV + RBV 24 weeks
Prop Diff
(99.17% CI)
-2.7%
(-11.0%, 5.5%)
SOF/LDV 12 weeks vs SOF/LDV + RBV 24 weeks
Prop Diff
(99.17% CI)
-5.5%
(-14.6%, 3.6%)
SOF/LDV + RBV 12 weeks vs SOF/LDV 24 weeks
Prop Diff
(99.17% CI)
-2.8%
(-11.1%, 5.5%)
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Table S3. Sustained Virologic Response by Subgroups
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Table S3. Sustained Virologic Response by Subgroups (continued)
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Table S4. Proportion of Patients with ALT >ULN at Baseline Who Had ALT
Normalization During Treatment
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Table S5. Baseline Characteristics of Patients with Virologic Relapse after Treatment
12-Week Treatment
Group Age
(years) Race Sex HCV
Genotype
HCV RNA (log10 IU/mL)
Platelets (×10
3/µL) IL28B
Cirrhosis (yes/no)
Baseline NS5A RAV
(yes/no) Prior Treatment Prior Treatment Response
SOF-LDV 64 White M 1b 6.6 75 CT Yes No PI+Peg-IFN+RBV Relapse/ Breakthrough
SOF-LDV 62 White M 1b 6.7 101 CT Yes No Peg-IFN+RBV Null Responder
SOF-LDV 64 White M 1a 5.9 53 CT Yes No PI+Peg-IFN+RBV Relapse/ Breakthrough
SOF-LDV 61 White M 1b 6.7 237 CT No Yes Peg-IFN+RBV Null Responder
SOF-LDV 58 White F 1a 7.2 253 CT No Yes PI+Peg-IFN+RBV Non-Responder
SOF-LDV 57 White F 1a 5.9 126 CT No Yes PI+Peg-IFN+RBV Relapse/ Breakthrough
SOF-LDV 54 White M 1a 7.2 262 CT No Yes Peg-IFN+RBV Non-Responder: Partial Responder
SOF-LDV+RBV 60 White M 1a 6.7 174 TT Yes Yes PI+Peg-IFN+RBV Non-Responder
SOF-LDV+RBV 65 White M 1a 7.1 249 CT Yes No Peg-IFN+RBV Relapse/ Breakthrough
SOF-LDV+RBV 63 Black M 1a 7.2 122 CT Yes No PI+Peg-IFN+RBV Non-Responder
SOF-LDV+RBV 60 White M 1a 7.1 105 CT Yes Yes Peg-IFN+RBV Relapse/ Breakthrough
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Exact logistic regression analysis for evaluating associations between baseline
characteristics and SVR12
Univariate exact logistic regression analysis was performed to assess the relationship between sustained
virologic response and 15 baseline demographic and clinical factors: treatment with or without RBV, 12
or 24 weeks of treatment, age (<65 or ≥65 years old), sex, race (black or non-black), ethnicity
(Hispanic/Latino or not Hispanic/Latino), HCV genotype (1a or 1b), cirrhosis (yes or no), response to
prior HCV therapy (relapse/breakthrough or non-responder), prior HCV therapy (PEG+RBV or
PI+PEG+RBV), baseline HCV RNA viral load (<800,000 IU/mL or ≥800,000 IU/mL), BMI (<30 or ≥30
kg/m2), IL28B alleles (CC or non-CC), GGT, and platelets (<125 or ≥125 ×10
3/µL ). Factors found to be
significant according to in the univariate analysis (p value <0.05) were then evaluated in a multivariate
exact logistic regression model using a forward selection procedure to identify the factors most predictive
of sustained virologic response. Factors found to be significant (p value <0.05) using this forward
selection procedure were included in the final exact logistic regression analysis.
Table S6. Univariate Exact Logistic Regression in Assessing Factors Associated with SVR12
Variable Odds Ratio
95%
Confidence Limit
2-Sided
P Value
Treatment: with ribavivin 1.651 (0.468, 6.524) 0.5524
Treatment: 24 weeks 5.718 (1.226, 53.702) 0.0206
Age group (years): <65 1.103 (0.025, 7.939) 1.0000
Sex: female 3.003 (0.643, 28.233) 0.2257
Race: black 1.171 (0.248, 11.093) 1.0000
Ethnicity: Hispanic or Latino 1.933 (0.313, Infinity) 0.5453
HCV genotype: 1a 1.123 (0.195, 4.484) 1.0000
Cirrhosis: no 4.958 (1.386, 18.378) 0.0124
Response to prior HCV therapy: relapse/breakthrough 1.482 (0.419, 5.433) 0.6709
Prior HCV therapy: PEG+RBV 1.047 (0.296, 3.837) 1.0000
Baseline HCV RNA (IU/mL): <800,000 1.554 (0.221, 67.836) 1.0000
Baseline BMI (kg/m2): ≥30 1.624 (0.410. 9.329) 0.6857
IL28B: CC 1.735 (0.247, 75.621) 1.0000
Baseline GGT (U/L) (continuous) 0.998 (0.994, 1.003) 0.3928
Baseline platelets (×103/µL): ≥125 5.144 (1.269, 18.724) 0.0216
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Table S7. Final Exact Logistic Regression Model Identifying Factor(s) Associated with
SVR12
Variable Odds Ratio
95%
Confidence Limit
2-Sided
P Value
Cirrhosis: no 5.103 (1.406, 19.194) 0.0117
Treatment: 24 weeks 5.864 (1.243, 55.526) 0.0195
Table S8. Contingency Table of Cirrhosis Status and Treatment Duration with SVR12
SVR12 SVR12 Rate
(95% CI) Yes No
Cirrhosis
yes 81 7 92.1%
(84.3%, 96.7%)
no 346 6 98.3%
(96.3%, 99.4%)
Treatment
Duration
12 weeks 209 11 95.0%
(91.2%, 97.5%)
24 weeks 218 2 99.1%
(96.8%, 99.9%) Note: The exact 95% CI of SVR12 rate is based on the Clopper-Pearson method.
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Figure S3. Mean HCV RNA in the 1st Weeks of Treatment by Baseline NS5A Resistance-Associated Variants
All randomized subjects who received at least 1 dose of any study drug and had determined baseline NS5A are
included. One subject who had failed baseline NS5A is excluded.
Each error bar is constructed using 1 standard deviation from the mean.
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Figure S4. Proportion of Patients with HCV RNA <LLOQ by Baseline NS5A Resistance-Associated Variants
All randomized subjects who received at least 1 dose of any study drug and had determined baseline NS5A are
included. One subject who had failed baseline NS5A is excluded.
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Table S9. Proportion of Patients with HCV RNA <25 IU/mL during Treatment by
Cirrhosis Status
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Table S9. Proportion of Patients with HCV RNA <25 IU/mL during Treatment by
Cirrhosis Status (continued)
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Table S10. SVR12 by Early Viral Response and Cirrhosis Status
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Table S11. Platelets and Change from Baseline by Visit
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Table S12. Albumin and Change from Baseline by Visit