New hepatitis B drug development disillusions: time to reset?

Sequential Peg-IFN after bepirovirsen may reduce post-treatment relapse in chronic hepatitis B

BACKGROUND & AIMS

Bepirovirsen, an antisense oligonucleotide, induces sustained reductions in hepatitis B surface antigen (HBsAg) and HBV DNA to below the lower limit of quantification (

METHODS

In this phase IIb, multicentre, open-label trial, participants on stable nucleos(t)ide analogue (NA) therapy were randomised 1:1 to bepirovirsen 300 mg once weekly (plus loading dose on Days 4 and 11) for 24 (Arm 1) or 12 (Arm 2) weeks followed by Peg-IFN 180 μg once weekly for up to 24 weeks, with up to 36 weeks follow-up. Participants continued NA therapy throughout. The primary outcome was the proportion of participants with HBsAg <0.05 IU/ml and HBV DNA

RESULTS

The intent-to-treat population included 108 participants (Arm 1, n = 55; Arm 2, n = 53). The primary outcome was achieved by 5 (9%) participants in Arm 1 and 8 (15%) in Arm 2. All responders had baseline HBsAg ≤3,000 IU/ml. Indirect comparison with the phase IIb study B-Clear indicates that sequential addition of Peg-IFN may reduce the relapse rates previously observed with bepirovirsen alone. The proportions of participants with adverse events and treatment-related adverse events in both treatment windows were similar between treatment arms.

CONCLUSIONS

Sequential therapy with bepirovirsen followed by Peg-IFN is tolerable and effective in participants with chronic HBV infection on stable NA therapy. This proof-of-concept trial demonstrates a potential strategy to extend responses to bepirovirsen by reducing relapse.

IMPACT AND IMPLICATIONS

This phase IIb study investigated whether sequential therapy with bepirovirsen followed by Peg-IFN could improve off-treatment response rates to bepirovirsen alone by converting partial bepirovirsen responders to full responders and/or reducing relapse rates in participants with chronic HBV. These data show that sequential therapy with bepirovirsen followed by Peg-IFN is tolerable and effective; in patients with a bepirovirsen response, sequential treatment with Peg-IFN may help to reduce off-treatment relapses in participants on stable NA. Participants had a similar response during bepirovirsen treatment as seen in B-Clear, with increased response rates in participants with lower baseline HBsAg; all responders to the sequential regimen had baseline HBsAg <3000 IU/mL. As the first study of antisense oligonucleotide-mediated RNA silencing followed by interferon immunomodulation in patients with chronic HBV infection, this study is an important proof-of-concept for sequential therapy, shedding light on the therapeutic potential of utilising immunomodulators following suppression of HBV antigens.

CLINICAL TRIAL NUMBER

NCT04676724.

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Key Words

• Hepatitis B
• antisense oligonucleotide
• bepirovirsen
• pegylated interferon-α-2a
• sequential therapy

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Affiliation(s)

Maria Buti Liver Unit, Hospital Vall d'Hebrón, Barcelona and CIBER-EHD del Instituto Carlos III, Barcelona, Spain.
Jeong Heo Department of Internal Medicine, College of Medicine, Pusan National University, Busan, Republic of Korea; Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.
Yasuhito Tanaka Department of Gastroenterology and Hepatology, Kumamoto University Hospital, Kumamoto, Japan
Pietro Andreone Medicina Interna a indirizzo Metabolico-Nutrizionale, Ospedale Clinicizzato di Baggiovara, AOU di Modena, Modena, Italy; Dipartimento SMECHIMAI, Università di Modena e Reggio Emilia, Modena, Italy
Masanori Atsukawa Nippon Medical School Hospital, Tokyo, Japan
Joaquín Cabezas Gastroenterology and Hepatology Department, University Hospital Marques de Valdecilla, Santander, Spain; Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Santander, Spain
Eric Chak UC Davis, Sacramento, California, USA
Carla S Coffin Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Calgary, Canada
Kei Fujiwara Nagoya City University Hospital, Aichi, Japan
Natalya Gankina Krasnojarsk Regional Center of AIDS prevention, Krasnojarsk, Russian Federation
Stuart C Gordon Henry Ford Health and Wayne State University School of Medicine, Detroit, MI, USA
Ewa Janczewska Department of Basic Medical Sciences, Faculty of Public Health in Bytom, Medical University of Silesia, Myslowice, Poland
Atsumasa Komori National Hospital Organization, NHO Nagasaki Medical Center, Nagasaki, Japan
Pietro Lampertico Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; CRC "A. M. and A. Migliavacca" Center for Liver Disease, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
Stuart McPherson Hepatology and Newcastle NIHR Biomedical Research Centre, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle-upon-Tyne, UK
Vyacheslav Morozov Hepatologist Medical Company, Samara, Russian Federation
Robert Plesniak University of Rzeszow Centrum Medyczne w Lancucie Sp. z o.o., Lancut, Poland
Sébastien Poulin Clinique Médecine Urbaine du Quartier Latin, Montréal, Québec, Canada
Pablo Ryan Hospital Infanta Leonor and CIBERINFEC, del Instituto Carlos III., Madrid, Spain
Olga Sagalova South Ural State Medical University, Chelyabinsk, Russian Federation
Guoping Sheng Department of Infectious Disease, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University, Shulan International Medical College, Hangzhou, Zhejiang, China
Natalya Voloshina Medical Centre Healthy Family, Novosibirsk, Russian Federation
Qing Xie Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
Hyung Joon Yim Korea University Ansan Hospital, Ansan, Republic of Korea
Susan Dixon GSK, London, UK
Melanie Paff GSK, Collegeville, PA, USA
Leigh Felton GSK, London, UK
Maximilian Lee GSK, Collegeville, PA, USA
Thomas Greene GSK, Collegeville, PA, USA
Jessica Lim GSK, Collegeville, PA, USA
Divya Lakshminarayanan GSK, Collegeville, PA, USA
Grant McGonagle GSK, London, UK
Helene Plein GSK, London, UK
Amir S Youssef GSK, Collegeville, PA, USA
Rob Elston GSK, Stevenage, UK
Stuart Kendrick GSK, Stevenage, UK
Dickens Theodore GSK, Durham, NC, USA

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Expanding indications for chronic hepatitis B treatment: Is it really desirable to treat everyone?

Chronic viral hepatitis causes an increased risk of progressive liver disease and hepatocellular carcinoma. On the wave of the World Health Organization's goal to reduce new cases and deaths from hepatitis B and C by 2030, there is an increasing call to expand the indications for treatment of chronic hepatitis B. Currently, the main goal of treatment is to achieve a functional cure due to the inability of current drugs to completely eradicate the virus. There are still many discrepancies between available guidelines in terms of eligibility for treatment as well as an uncertainty about the appropriate treatment duration. This editorial addresses key questions about the topic and whether indications for treatment should be expanded.

A new approach to prevent, diagnose, and treat hepatitis B in Africa

There are 82 million people living with hepatitis B (PLWHB) in the World Health Organization Africa region, where it is the main cause of liver disease. Effective vaccines have been available for over 40 years, yet there are 990,000 new infections annually, due to limited implementation of hepatitis B birth dose vaccination and antenatal tenofovir prophylaxis for highly viraemic women, which could eliminate mother-to-child transmission. Despite effective and cheap antiviral treatment which can suppress hepatitis B virus replication and reduce the risk of hepatocellular carcinoma (HCC), < 2% of PLWHB are diagnosed, and only 0.1% are treated. As a result, PLWHB are frequently diagnosed only when they have already developed decompensated cirrhosis and late-stage HCC, and consequently 80,000 hepatitis B-associated deaths occur each year. Major barriers include complex treatment guidelines which were derived from high-income settings, lack of affordable diagnostics, lack or insufficient domestic funding for hepatitis care, and limited healthcare infrastructure. Current treatment criteria may overlook patients at risk of cirrhosis and HCC. Therefore, expanded and simplified treatment criteria are needed. We advocate for decentralized community treatment programmes, adapted for low-resource and rural settings with limited laboratory infrastructure. We propose a strategy of treat-all except patients fulfilling criteria that suggest low risk of disease progression. Expanded treatment represents a financial challenge requiring concerted action from policy makers, industry, and international donor agencies. It is crucial to accelerate hepatitis B elimination plans, integrate hepatitis B care into existing healthcare programmes, and prioritize longitudinal and implementation research to improve care for PLWHB.

Therapies against chronic hepatitis B infections: The times they are a-changin', but the changing is slow!

PREAMBULAR NOTA BENE

As a tribute to Dr Mike Bray, the following review of literature willbe mainly based on published data andconcepts, but will also contain my personal views, and in this respect could be more considered as a bioassay. Even though a cost-effective and excellent prophylactic vaccine exists since many years to protect against hepatitis B virus (HBV) infection, academic-researcher/drug-developers/stakeholders are still busy with the R&D of novel therapies that could eventually have an impact on its worldwide incidence. The Taiwanese experience have univocally demonstrated the effectiveness of constrained national HBV prophylactic vaccination programs to prevent the most dramatic HBV-induced end-stage liver disease, which is hepatocellular carcinoma; but yet the number of individuals chronically infected with the virus, for whom the existing prophylactic vaccine is no longer useful, remains high, with around 300 million individuals around the globe. In this review/bioassay, recent findings and novel concepts on prospective therapies against HBV infections will be discussed; yet it does not have the pretention to be exhaustive, as "pure immunotherapeutic concepts" will be mainly let aside (or referred to other reviews) due to a lack of expertise of this writer, but also due to the lack of, or incremental, positive results in clinical trials as-off today with these approaches.