Εξελίξεις του 2009 στην έρευνα της Ηπατίτιδας Β και Δέλτα από την Ευρωπαϊκή (EASL) και την Αμερικανική Εταιρεία Μελέτης του Ηπατος (AASLD)

17η Διεθνής Διημερίδα Ιογενούς Ηπατίτιδας Β και C 2010 Εξελίξεις του 2009 στην έρευνα της Ηπατίτιδας Β και Δέλτα από την Ευρωπαϊκή (EASL) και την Αμερικανική Εταιρεία Μελέτης του Ηπατος (AASLD) πύρος Π. Nτουράκης Iπποκράτειο Γ.Π.N. Aθηνών

ΠΡΨΣΟΘΕΡΑΠΕΤΟΜΕΝΟΙ ΑΘΕΝΕΙ Θεραπεία 1ης επιλογής: PegIFN alfa-2a Σενοφοβίρη Εντεκαβίρη

ΘΕΡΑΠΕΙΑ ΦΡΟΝΙΑ ΗΠΑΣΙΣΙΔΑ B: 2009 Απόφαση IFN (PegIFN alfa-2a) ΝΟΤΚΛΕΟ(Σ)ΙΔΙΚΑ ΑΝΑΛΟΓΑ

Οροαναστροφή HBeAg (%) Οροαναστροφή του HBeAg Όχι απ ευθείας σύγκριση, διαφορετικοί πληθυσμοί ασθενών και σχεδιασμός των μελετών 100 80 60 Επέκταση της θεραπείας με νουκλεοσ(τ)ιδικά, θεραπεία 1 χρ. με PegIFN Entecavir Tenofovir Peginterferon 40 20 21 22 22-27 31 26 29-32 39 26 35 0 1.0 ετη 1.5-2.0 έτη 3.0-4.0 έτη * Μακροχρόνια μη ανιχνεύσιμο HBV DNA. Chang TT, et al. J Viral Hepat. 2009;16:784-789. Chang TT, et al. AASLD 2006. Abstract 109. Lau GK, et al. N Engl J Med. 2005;352:2682-2695. Marcellin P, et al. N Engl J Med. 2008;359:2442-2455. Buster EH, et al. Gastroenterology. 2008;135;459-467. Heathcote J, et al. AASLD 2008. Abstract 158. Heathcote J, et al. AASLD 2009. Abstract 483. Janssen HL, et al. Lancet. 2005;365;123-129. 4

Οροαναστροφή του HBeAg Η απώλεια του HBeAg δε συνοδεύεται πάντοτε από μακρά ύφεση και οι υποτροπές είναι συχνές Hepatology 2009; 50 suppl: 407-408A

Κάθαρση HBsAg (%) Απώλεια του HBsAg σε HBeAg (+) ασθενείς Όχι απ ευθείας σύγκριση, διαφορετικοί πληθυσμοί ασθενών και σχεδιασμός των μελετών 100 Επέκταση της θεραπείας με νουκλεοσ(τ)ιδικά, θεραπεία 1 χρ. με PegIFN 80 60 Entecavir Tenofovir Peginterferon 40 20 2 3 5 5 6 6 8 8 NA 0 1.0 έτη 1.5-2.0 έτη 3.0-4.0 έτη *Μακροχρόνια μη ανιχνεύσιμο HBV DNA. Chang TT, et al. N Engl J Med. 2006;354:1001-1010. Marcellin P, et al. N Engl J Med. 2008;359:2442-2455. Buster EH, et al. Gastroenterology. 2008;135;459-467. Gish R, et al. Gastroenterology. 2007;133:1437-1444. Heathcote J. AASLD 2008. Abstract 158. Heathcote J, et al. AASLD 2009. Abstract 483. Janssen HL, et al. Lancet. 2005;365:123-129. 6

Προγνωστικοί παράγοντες απώλειας του HBsAg σε HBeAg (+) με PegIFN alfa-2a Υυλή: Λευκή > μη-λευκή [1] Γονότυπος [1-3] A>Δ HBeAg (-) < 32 εβδ της θεραπείας με PegIFN alfa-2a [3] 1. Heathcote EJ, et al. EASL 2009. Abstract 909. 2. Gish RG, et al. J Viral Hepat. 20093. Buster EH, et al. Am J Gastroenterol. 2009;104:2449-2457.

Μη ανιχνεύσιμο HBV DNA (%) Μη ανιχνευσιμότητα του HBV DNA σε HBeAg (-) ασθενείς Όχι απ ευθείας σύγκριση, διαφορετικοί πληθυσμοί ασθενών και σχεδιασμός των μελετών Επέκταση της θεραπείας με νουκλεοσ(τ)ιδικά, θεραπεία 1 χρ. με PegIFN 100 90 93 100* 87 91 87 80 60 Entecavir Tenofovir Peginterferon 40 20 15 16 0 NA 1 Yr 2 Yrs 3 Yrs *Η μελέτη προέρχεται από ένα κέντρο Lok AS, McMahon BJ. Hepatology. 2009;50:661-662. Marcellin P, et al. AASLD 2008. Abstract 146. Marcellin P, et al. AASLD 2009. Abstract 481. Marcellin P, et al. Gastroenterology. 2009;136:2169-2179. Baqai S, et al. AASLD 2009. Abstract 476.

Ασθενείς (%) Απώλεια του HBsAg σε HBeAg (-) ασθενείς μόνο με PegIFN alfa Όχι απ ευθείας σύγκριση, διαφορετικοί πληθυσμοί ασθενών και σχεδιασμός των μελετών 100 80 60 40 Επέκταση της θεραπείας με νουκλεοσ(τ)ιδικά, θεραπεία 1 χρ. με PegIFN Entecavir Tenofovir Peginterferon 20 12 4 6 < 1 0 < 1 0 NA 0 0 1.0 έτη 1.5-2.0 έτη 3.0-4.0 έτη * Μακροχρόνια μη ανιχνεύσιμο HBV DNA. Lai CL, et al. N Engl J Med. 2006;354:1011-1020. Marcellin P, et al. N Engl J Med. 2008;359:2442-2455. Marcellin P, et al. AASLD 2008. Abstract 146. Marcellin P, et al. APASL 2009. Abstract PE086. Shouval D, et al. J Hepatol. 2009;50:289-295. Marcellin P, et al. AASLD 2009. Abstract 481.

Patients (%) ΜΑΚΡΟΦΡΟΝΙΑ ΑΠΟΣΕΛΕΜΑΣΑ (5 ΦΡΟΝΙΑ) ΜΕ pegifn alfa-2a Ε HBeAg (-) 5 yrs posttreatment follow-up in patients treated with pegifn ± LAM vs LAM alone for 48 wks 100 Outcomes With PegIFN ± LAM (n = 230 [65%] of original 356) 80 60 40 20 0 13.5 15.7 16.5 HBV DNA < 400 copies/ml *vs 3.5% for LAM alone at Yr 5 (P =.022). 47.4 ALT Normalization Marcellin P, et al. ILC 2009. Abstract 924. 30.9 22.2 4.8 HBsAg Loss Yr 1 Yr 3 Yr 5 8.7 12.2*

Επίπεδα του HBsAg στη 12η εβδομάδα προβλέπουν την SVR σε HBeAg (-) 48 ασθενμείς pegifn alfa-2a για 48 εβδομ HBV DNA (< 70 copies/ml-svr σε 24 εβδομ μετά τη διακοπή Εβδ 12: HBsAg 0.5 log 10 IU/mL n = 9 SVR n = 8 PPV = 89% N = 48 No SVR SVR n = 1 n = 4 Εβδ 12: HBsAg < 0.5 log 10 IU/mL n = 39 No SVR Moucari R, et al. Hepatology. 2009;49:1151-1157. n = 35 NPV = 90%

ΕΝΔΟΗΠΑΣΙΚΑ ΕΠΙΠΕΔΑ cccdna ΣΟ ΣΕΛΟ ΣΗ ΘΕΡΑΠΕΙΑ ΠΡΟΒΛΕΠΟΤΝ ΣΗΝ SVR EOT liver biopsies available in 20 HBeAg-positive, 25 HBeAgnegative pts receiving pegifn alfa-2a + adefovir for 48 wks Baseline intrahepatic cccdna not predictive of HBeAg seroconversion in HBeAg-positive pts EOT response, SVR, or relapse in HBeAg-negative EOT intrahepatic cccdna predicted SVR Positive predictive value for HBeAg-positive pts: 73% for cccdna < 0.02 log 10 copies/cell Positive predictive value for HBeAg-negative pts: 72% for cccdna < -1.77 log 10 copies/cell Takkenberg B, et al. AASLD 2009. Abstract 486.

ΜΑΚΡΟΦΡΟΝΙΑ ΑΓΨΓΗ NUCs ΑΝΣΙΣΑΗ Ε ΥΑΡΜΑΚΑ ΑΝΕΠΙΘΤΜΗΣΕ ΕΝΕΡΓΕΙΕ

Απροσδιόριστο HBV DNA (%) ΘΕΡΑΠΕΙΑ ΜΕ ΕΝΣΕΚΑΒΙΡΗ Ε HBeAg +/- ΓΙΑ 3 ΦΡΟΝΙΑ Αναδρομική μελέτη 153 ασθενών 82% βιοχημική ALT ανταπόκριση 100 80 60 ΘΕΡΑΠΕΙΑ 100 100 93 40 20 0 Πρωτοθεραπευόμενοι Lamivudine αντίσταση Adefovir αδεφοβίρη 0 6 12 18 24 30 36 Μήνες Baqai SF, et al. AASLD 2009. Abstract 476.

GS-US-174-0102 (Study 102, HBeAg CHB) and GS-US-174-0103 (Study 103, HBeAg+ CHB) Study Design * Patients had the option to add FTC at the discretion of the investigator if confirmed HBV DNA 400 copies/ml at week 72 or beyond Marcellin P, et al., AASLD 2009; Poster #481; Heathcote E-J, et al., AASLD 2009; Poster #483.

ΠΑΡΑΜΕΝΟΤΑ ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΜΕΦΡΙ ΣΟΝ 3 ΦΡΟΝΟ (Study 102 HBeAg ) (%) Patients with HBV DNA Percentage < 400 copies/ml (%) Randomized Double-Blind Open-Label TDF LTE-TDF analysis 100 90 80 70 60 50 40 30 20 10 0 0 24 48 72 96 120 144 0 24 48 72 96 120 144 Weeks on Study Weeks on Study On-treatment LTE-TDF = 99% Long-Term TDF-TDF Evaluation, ITT evaluation from week 0 TDF-TDF observed N= 250 randomization 243100% ADV-TDF 247 244 240 242 238 ADV-TDF N= 125 OLE-TDF 124 = Open-Label 123 Extension, 123 ITT evaluation 122 from week 121 48 open 121 label Marcellin P, et al., AASLD 2009; These Poster ITT analyses #481. consider patients across both treatment groups who had 88% ADV-TDF 87% TDF-TDF 90% in LAM-Exp

ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΜΕΦΡΙ ΣΟΝ 3 ΦΡΟΝΟ (Study 102) (%) Patients with HBV DNA Percentage(%) < 400 copies/ml Marcellin P, et al., AASLD 2009; Poster #481. Randomized Double-Blind 10 0 9 0 8 0 7 0 6 0 5 0 4 0 3 0 2 0 1 0 0 Open-Label TDF 0 2 4 4 8 7 2 9 6 12 0 14 4 0 24 48 72 96 120 144 W e eks o n S tudy Weeks on Study On-treatment observed 99% TDF-TDF 100% ADV-TDF 100% in LAM-Exp Includes 3 patients who had HBV DNA <400 copies/ml at week 144 on FTC + TDF TD F - TD F N= 25 0 23 9 24 1 22 6 21 9 21 7 21 2 A D V - TD F N = 12 5 12 1 11 7 11 0 10 9 10 7 10 7

ΠΑΡΑΜΕΝΟΤΑ ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΜΕΦΡΙ ΣΟΝ 3 ΦΡΟΝΟ (Study 103, HBeAg+) (%) Patients with HBV Percentage DNA < 400 copies/ml (%) 100 90 80 70 60 50 40 30 20 10 0 Randomized Double-Blind Open-Label TDF 0 24 48 72 96 120 144 Weeks on Study Weeks on Study LTE-TDF = Long-Term Evaluation, ITT evaluation from week 0 randomization On-treatment 99% TDF-TDF OLE-TDF = Open-Label Extension, ITT evaluation from week 48 open TDF-TDF observed N= 176 170100% ADV-TDF 171 163 168 167 165 ADV-TDF N= 90 label 88 90 87 87 90 89 Heathcote E-J, et al., AASLD These 2009; ITT Poster analyses #483. consider patients across both treatment groups who had LTE-TDF analysis 72% TDF-TDF 71% ADV-TDF

ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΜΕΦΡΙ ΣΟΝ 3 ΦΡΟΝΟ (Study 103) (%) Patients with Percentage (%) HBV DNA < 400 copies/ml 100 90 80 70 60 50 40 30 20 10 0 Randomized Double-Blind Open-Label TDF Open Label TDF W eeks o n S tudy Includes 17 patients who had HBV DNA <400 copies/ml at week 144 on FTC + TDF TD F-TD F N= 176 165 160 143 145 140 130 AD V-TD F N= 90 85 85 81 80 78 76 Heathcote E-J, et al., AASLD 2009; Poster #483. 0 24 48 72 96 120 144 Weeks on Study On-treatment observed 95% TDF-TDF 91% ADV-TDF

ΑΠΨΛΕΙΑ ΣΟΤ HBeAg ΚΑΙ ΟΡΟΑΝΑΣΡΟΥΗ ΜΕΦΡΙ ΣΟΝ 3 ΦΡΟΝΟ (Study 103) % Patients % Patients 100 - = 35 30 25 20 HBeAg απώλεια HBeAg οροανστροφή 34% 30% 23% 100 - = 35 30 25 20 26% 26% 22% 15 10 5 15 10 5 0 0 Year 1 On Treatment 2 3 Year 1 On Treatment 2 3 Heathcote E-J, et al., AASLD 2009; Poster #483.

ΑΘΡΟΙΣΙΚΗ ΑΠΨΛΕΙΑ ΣΟΤ HBsAg (Study 103) 8% * 14/20 HBeAg+ patients with HBsAg loss discontinued treatment and entered treatment-free follow-up; mean 171 days off treatment 2 patients who seroconverted to anti-hbs have discontinued from the study Heathcote E-J, et al., AASLD 2009; Poster #483. * At Week 48 all patients initiate open-label TDF

Number of patients Number of patients ΓΟΝΟΣΤΠΙΚΗ ΑΝΣΙΣΑΗ ΣΟΝ 3 ΦΡΟΝΟ Total Patients on Study Patients with Resistance Patients > 400 copies/ml 450 450 400 350 300 250 200 150 100 50 0 426 389 (91%) 364 (85%) 39 (9%) 24 (6%) 13* (4%) 0 0 0 Year 3 Year 1 Year 2 Year 3 Year 1 Year 2 400 350 300 250 200 150 100 50 0 Snow-Lampart A, et al., AASLD 2009; Poster #480. * includes 7 patients on FTC+TDF combination therapy

ΘΕΡΑΠΕΙΑ ΜΕ ΣΕΝΟΥΟΒΙΡΗ Επιτυχημένη και ασφαλής σε κιρρωτικούς ασθενείς με ή χωρίς αντίσταση στη Λαμιβουδίνη J Hepatol 2009; 50Suppl1: S10-S11. Λόγω μεγαλύτερης αντιικής δράσης, συνιστάται η αντικατάσταση της αδεφοβίρης σε μη-πλήρως ανταποκριθέντες ασθενείς Hepatology 2009; 50 Suppl: 501A 537A

ΑΝΕΠΙΘΤΜΗΣΕ ΕΝΕΡΓΕΙΕ ΣΕΝΟΥΟΒΙΡΗ τα 5 χρόνια θεραπείας σε HBV/HIV συλλοιμώξεις, δραστική, αλλά συνοδεύεται από επιδείνωση της νεφρικής λειτουργίας και απώλεια οστικής μάζης Hepatology 2009; 50 Suppl: 506A

Αντιμετώπιση των παροξύνσεων της ηπατίτιδας Β Σενοφοβίρη και εντεκαβίρη δραστικές. Hepatology 2009; 50 Suppl: 307A, 422A.

EFFICACY AND SAFETY OUTCOMES AFTER 4 YEARS OF TELBIVUDINE TREATMENT IN PATIENTS WITH CHRONIC HEPATITIS B (CHB) Abstract No 482 Wang Y., et al. Patient population: 426 telbivudine-treated patients, without genotypic resistance to telbivudine at the end of the GLOBE trial enrolled into study 2303. Per protocol population 398 patients (213 HBeAg-positive, 185 HBeAgnegative). Key Results: eag+: 79% undetectable HBV DNA 86% normal serum ALT. 55% of patients had HBeAg loss 42% HBeAg seroconversion. eag-: 84% undetectable HBV DNA 91% normal serum ALT. Conclusion: 4 years of telbivudine treatment provides effective viral suppression and ALT normalization with a favorable safety profile

Response (%) ΓΡΑΣΙΚΟΣΗΣΑ ΣΔΛΠΙΒΟΤΓΙΝΗ Δ PCR (-) ΣΙ 24 ΔΒΓΟΜΑΓΔ ΣΟΝ 3 & 4 ΥΡΟΝΟ Δ HBeAg (+) GLOBE Patients Who Were PCR Negative at Week 24 (n = 111) Year 3 100 89% 92% 83% 88% Year 4 80 60 40 20 0 PCR negative* Efficacy Outcomes ALT normalization *Quantification limit 300 copies/ml by COBAS Amplicor. Denominator represents number of patients and laboratory results available for analysis at this time point. Data on file, Novartis Pharma AG. Wang Y et al. Hepatology. 2009;50(Suppl):Abstract 482.

Proportion of patients (%) ΟΡΟΑΝΑΣΡΟΥΗ ΣΟΤ HBeAg ΣΑ 4 ΦΡΟΝΙΑ Ε PCR (-) ΣΙ 24 ΕΒΔΟΜΑΔΕ GLOBE Patients Who Were PCR Negative at Week 24 (n = 111) 70 60 50 40 37% 50% 58% 64% 30 20 10 0 41/111 55/111 64/111 71/111 Year 1 Year 2 Year 3 Year 4 Cumulative seroconversion: All patients from GLOBE per protocol population in 2303 who ever had HBeAg seroconversion during 4 years. Missing data was counted as a failure. Data on file, Novartis Pharma AG. Wang Y et al. Hepatology. 2009;50(Suppl):Abstract 482.

Proportion of patients (%) 100 ΔΡΑΣΙΚΟΣΗΣΑ ΣΕΛΠΙΒΟΤΔΙΝΗ ΣΟΝ 3 & 4 ΦΡΟΝΟ Ε HBeAg ( ) 85% GLOBE Per Protocol Population 84% 83% 91% 80 60 40 Year 3 (n = 186) Year 4 (n = 185) 20 0 161/190 141/164 PCR negative* Efficacy Outcomes 129/144 ALT normalization *Quantification limit 300 copies/ml by COBAS Amplicor. 1 patient in per protocol population excluded due to noncompliance. Denominator represents number of patients and laboratory results available for analysis at this time point. Data on file, Novartis Pharma AG. Wang Y et al. Hepatology. 2009;50(Suppl):Abstract 482.

Proportion of patients (%) ΑΝΣΑΠΟΚΡΙΗ ΣΟΝ 3 & 4 ΦΡΟΝΟ Ε HBeAg ( ) ΜΕ PCR (-) ΣΙ 24 ΕΒΔΟΜΑΔΕ GLOBE Patients Who Were PCR Negative at Week 24 100 87% 86% 84% 90% 80 60 40 Year 3 (n = 161) Year 4 (n = 160) 20 0 144/166 17/24 126/149 17/22 PCR Negative * ALT Normalization Efficacy Outcomes at 3 and 4 Years *Quantification limit 300 copies/ml by COBAS Amplicor. 1 patient in per protocol population excluded due to noncompliance. Denominator represents number of patients and laboratory results available for analysis at this time point. Data on file, Novartis Pharma AG. Wang Y et al. Hepatology. 2009;50(Suppl):Abstract 482.

ΓΟΝΟΣΤΠΙΚΗ ΑΝΣΙΣΑΗ ΣΟΝ 3 & 4 ΦΡΟΝΟ ΜΕ PCR (-) ΣΙ 24 ΕΒΔΟΜΑΔΕ HBeAg positive HBeAg negative 100 PCR Negative at Week 24 75 50 25 0 3.6 6.2 5.4 2.5 (4/111) (10/161) (6/111) (4/160 ) Year 3 Year 4 * Resistance = viral breakthrough with treatment emergent resistance mutations confirmed by genetic sequencing at week 156. Quantification limit 300 copies/ml by COBAS Amplicor. 1 patient in per protocol population excluded due to noncompliance. Data on file, Novartis Pharma AG. Wang Y et al. Hepatology. 2009;50(Suppl):Abstract 482.

ΑΝΔΠΙΘΤΜΗΣΔ ΔΝΔΡΓΔΙΔ ΣΔΛΠΙΒΟΤΓΙΝΗ Πεξηθεξηθή λεπξνπάζεηα εθδειώζεθε ζε ζπλδπαζκό ηεικπηβνπδίλεο κε PEG-IFΝ. ε κνλνζεξαπεία, ζην 4,1% κπαιγία, 0,6% κπηθή αδπλακία, 0,3% κπνζίηηδα, 0,9% πεξηθεξηθή λεπξνπάζεηα. Αύμεζε ηωλ κπηθώλ ελδύκωλ 8,5% ηνλ 2ν ρξόλν 13% ζηνλ 3ν ρξόλν. J Hepatol 2009; 50Suppl1: S329-S330. 32

ΔΝΓΔΙΞΔΙ ΘΔΡΑΠΔΙΑ ΜΔ ΣΔΛΠΙΒΟΤΓΙΝΗ ύκθωλα κε ηηο νδεγίεο ηνπ EASL HBV DNA < 6.3 log10 IU/mL [< 10 7 copies/ ml]) θαη εθόζνλ δελ δηαπηζηώλεηαη ηαηκία ζηηο 24 εβδνκάδεο 33

Η ΚΛΕΒΟΤΔΙΝΗ Παρουσιάζει σημαντική αντιική δράση Αποσύρθηκε στη φάση ΙΙΙ της κλινικής μελέτης της, αφού διαπιστώθηκε μυοπάθεια και μυοσίτιδα που αποδίδεται σε μιτοχονδριακές βλάβες και νευροπάθεια J Hepatol 2009; 50Suppl1: S337. Hepatology. 2009;49:2080-2086

HBsAg Loss (n) HBsAg Loss (%) Απώλεια του HBsAg 4-5 χρόνια μετά την διακοπή θεραπείας με Adefovir 18 16 14 12 10 8 6 4 2 0 10 7 5 2 3 EOT Yr 1 Yr 2 Yr 3 Yr 4 100 80 60 40 20 0 11.11 16.66 27.77 6.06 9.09 Μακροχρόνια βιοχημικ % (n = 18) ύνολο, % (n = 33) 15.15 38.88 21.21 55.55 30.30 EOT Yr 1 Yr 2 Yr 3 Yr 4 Time Off Treatment Time Off Treatment Hadziyannis SJ, et al. EASL 2009. Abstract 18. Used with permission.

Αλλαγή του HBV DNA (log 10 IU/mL) ΑΝΣΙΙΚΗ ΔΡΑΗ ΥΑΡΜΑΚΨΝ 1.0 ΑΝΣΙΙΚΗ ΑΓΨΓΗ 0 Πρωτοπαθής μη ανταπόκριση Ιολογική διαφυγή -1.0-2.0 Ατελής ανταπόκριση -3.0-4.0 Nadir 1 log 0 6 12 18 Lok AS, et al. Hepatology. 2007;45:507-539. Mo

ΑΝΣΙΜΕΣΨΠΙΗ ΑΣΕΛΟΤ ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ Η εντεκαβίρη στα 6 χρόνια αντίσταση 1.2% [1] Η τενοφοβίρη στα 3 χρόνια χωρίς αντίσταση [2,3] Αρκετοί ανταποκρίνονται πλήρως αργότερα Παρακολούθηση στενά 1. Tenny D, et al. EASL 2009. Abstract 20. 2. Heathcote E, et al. AASLD 2009. Abstract 483. 3. Marcellin P, et al. AASLD 2009. Abstract 481.

ΤΝΔΤΑΜΕΝΗ ΑΓΨΓΗ ε πολυανθεκτικές λοιμώξεις η τενοφοβίρη χορηγείται σε συνδυασμό με εντεκαβίρη Hepatology 2009; 50 Suppl: 496A.

ΚΤΛΙΟΜΕΝΗ ΘΕΡΑΠΕΙΑ Προτάθηκε να θεραπεύονται με εντεκαβίρη μέχρι να εξαφανισθεί η ιαιμία και μετά να συνεχίζουν με λαμιβουδίνη (για λόγους εξοικονόμησης χρημάτων) Hepatology 2009; 50 Suppl: 510A,

ΑΝΣΙΜΕΣΨΠΙΗ ΜΗ- ΑΝΣΙΡΡΟΠΟΤΜΕΝΗ ΚΙΡΡΨΗ

TDF vs FTC + TDF vs ETV Randomized 2:2:1 Interim analysis at Wk 48 Wk 168 Pts with chronic hepatitis B and decompensated liver disease (N = 112) Tenofovir DF (n = 45) Emtricitabine + Tenofovir DF (n = 45) Entecavir (n = 22) Baseline Characteristic Liaw Y, et al. AASLD 2009. Abstract 222. TDF (n = 45) TDF/FTC (n = 45) ETV (n = 22) ALT > upper limit of normal, % 60 60 77 Median Child s-pugh-turcotte score 7 7 7 Median MELD score 11.0 13.0 10.5 Resistance to lamivudine, n 8 10 3

HBV DNA < 400 copies/ml (%) ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΣΙ 48 ΕΒΔΟΜΑΔΕ 100 80 71 88 73 89 TDF (n = 45) TDF/FTC (n = 45) ETV (n = 22) 60 50 40 33 20 0 Ολοι Αντίσταση LAM Ανεπιθύμητες πιο συχνά στο TDF/FTC Liaw Y, et al. AASLD 2009. Abstract 222.

ΑΝΕΠΙΘΤΜΗΣΕ ΕΝΕΡΓΕΙΕ ΣΙ 48 ΕΒΔΟΜΑΔΕ TDF (45) TVD (45) ETV (22) Επιβεβαιωμένη αύξηση 0.5 mg/dl κρεατινίνης ή Ρ < 2.0 mg/dl 9% 7% 5% - 0.5 mg/dl αύξηση κρεατινίνης - Ρ <2.0 mg/dl 9% 2% 2% 4% 5% 0 Liaw Y-F, et al., AASLD 2009; Oral #322.

ΚΛΙΝΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΣΙ 48 ΕΒΔΟΜΑΔΕ MELD score Median change Absolute MELD Week 48 (median) CTP score Mean change Absolute CTP Week 48 (median) TDF (N = 45) -2.0 8-1 6 TVD (N = 45) -2.0 8-1 6 ETV (N = 22) -2.0 8 Median ALT (U/L) 29 33 31-1 5 Liaw Y-F, et al., AASLD 2009; Oral #322.

ΟΡΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΣΙ 48 ΕΒΔΟΜΑΔΕ TDF (n = 14) FTC/TD F (n = 15) ETV (n = 7) Απώλεια HBeAg 21% 27% 0 Οροαναστροφή HBeAg 21% 13% 0 Φωρίς απώλεια HBsAg Liaw Y-F, et al., AASLD 2009; Oral #322.

RANDOMIZATIO N 1:1 ETV Versus ADV Ε ΜΗ- ΑΝΣΙΡΡΟΠΟΤΜΕΝΗ Open-label ETV 1.0 mg, once daily ADV 10 mg, once daily Long-term Observation Baseline Week 24 Week 48 Week 96 Randomized (1:1), open-label, Phase IIIb study in CHB patients with evidence of hepatic decompensation Year 5 ETV (1.0 mg/day) versus ADV (10 mg/day) treatment until the last randomized patient reaches Week 96 Liaw Y-F, et al., AASLD 2009; Poster # 422.

Mean HBV DNA (log 10 copies/ml) ΙΟΛΟΓΙΚΗ ΑΝΣΑΠΟΚΡΙΗ ΣΙ 48 ΕΒΔΟΜΑΔΕ 9 8 7 ETV 1.0 mg (n = 100) ADV 10 mg (n = 91) 6 5 ETV 4.48 ADV 3.40 p<0.0001 ETV 4.66 ADV 3.90 4 3 2 Limit of detection 300 copies/ml 1 B/L 4 8 12 16 20 24 28 32 36 40 44 48 Treatment (weeks) Number with measurements ETV: 100 98 92 87 76 71 69 ADV: 91 88 80 80 73 66 61 The difference in HBV DNA responses favoring ETV persisted when analyzed by subgroup (LVDr or HBeAg status), although the magnitude of the differences varied across subgroups Liaw Y-F, et al., AASLD 2009; Poster # 422.

ΚΛΙΝΙΚΗ ΑΝΣΑΠΟΚΡΙΗ( MELD/CTP) Week 24 Week 48 ETV ADV ETV ADV MELD score change from baseline (SE) -2.0 (0.45) -0.9 (0.46) -2.6 (0.62) -1.7 (0.50) CTP score improvement or no worsening, n (%) * 66/100 (66) 65/91 (71) 61/100 (61) 61/91 (67) CTP score 2-point reduction, n (%) * 32/100 (32) 22/91 (24) 35/100 (35) 25/91 (27) CTP class improvement, n(%) 25/93 (27) 22/81 (27) 35/93 (38) 29/81 (36) * non-completer = failure CTP class C/B to class A only Liaw Y-F, et al., AASLD 2009; Poster # 422.

Hepatology December 2009

ΓΑΛΑΚΣΙΚΗ ΟΞΕΨΗ 5 από 16 ασθενείς Βαρειά πορεία σε 3 ασθενείς MELD score >20 Τποχώρηση με διακοπή (4 ασθενείς, ο 5ος κατέληξε) Αποκλείσθηκαν άλλες αιτίες: σήψη, αιμορραγία πεπτικού, νεφρική ανεπάρκεια, ισχαιμία εντέρου, καρδιοαναπνευστική ανεπάρκεια Ηπατομεγαλία και οξεία στεάτωση σε 1 ασθενή Lange C, et al., AASLD 2009; Oral # 220.

ΓΑΛΑΚΣΙΚΗ ΟΞΕΨΗ Patient A ph 7.2, lactate 50 mg/dl OLT Patient B ph 7.1, lactate 200 mg/dl Patient C ph 7.4, lactate 35 mg/dl, BE -5 mmol/l Lamivudine Patient D ph 7.3, lactate 65 mg/dl Tenofovir Patient E ph 7.4, lactate 26 mg/dl, BE -5mmol/L Tenofovir 0 Day of entecavir-therapy 240 Lange C, et al., AASLD 2009; Oral # 220. Lactic Acidosis Lactic acidosis reversible after entecavir discontinuation: n=4 Lethal outcome: n = 1 (fulminant liver failure is a differential diagnosis)

Lactate (mg/dl) / Creatinine-Clearance ph ΠΟΡΕΙΑ ΓΑΛΑΚΣΙΚΗ ΟΞΕΨΗ 80 60 40 20 0 ETV TDF 7.45 7.40 7.35 7.30 7.25 7.20 7.15 4 5 6 7 8 9 10 11 12 13 14 15 Day of ETV treatment Lactate Creatinine-Clearance ph Lange C, et al., AASLD 2009; Oral # 220. ETV, entecavir TDF, tenofovir disoproxil fumarate

ΕΓΚΑΙΡΗ ΑΝΣΙΜΕΣΨΠΙΗ ΜΗ- ΑΝΣΙΡΡΟΠΟΤΜΕΝΗ ΚΙΡΡΨΗ Η καθυστερημένη θεραπεία δεν προλαμβάνει την ανάγκη για μεταμόσχευση της οποίας τα αποτελέσματα είναι 2 φορές χειρότερα από άλλης αιτιολογίας ένδειξη. Hepatology 2009; 50 suppl: 303A

ΕΝΕΡΓΟΠΟΙΗΗ ΦΡΟΝΙΑ HBV Φημειοθεραπεία ΛΟΙΜΨΞΗ Αιματολογικές κακοήθειες (συνηθέστερα) υμπαγείς όγκοι Ανοσοκατασταλτική αγωγή/ βιολογικές θεραπείες Μεταμοσχευμένοι (μυελός των οστών, συμπαγή όργανα-ήπαρ, νεφρός, καρδιά, πνεύμονας) Αυτοάνοσα νοσήματα (ρευματικά, νόσος του Crohn, πολλαπλή σκλήρυνση) υλλοίμωξη με HIV Τπογαμμασφαιριναιμία

ΠΑΘΟΓΕΝΕΙΑ ΣΗ ΕΝΕΡΓΟΠΟΙΗΗ ΣΗ ΦΡΟΝΙΑ HBV ΛΟΙΜΨΞΗ Ε ΑΝΟΟΚΑΣΑΣΟΛΗ Φρονία ηπατοτοξική δράση του έντονα πολλαπλασιαζόμενου ιού Mε την διακοπή της ανοσοκαταστολής ανοσιακή απάντηση έναντι του πολλαπλασιασθέντος ιού (σύνδρομο αποκατάστασης του ανοσιακού συστήματοςimmune reconstitution)

ΕΝΕΡΓΟΠΟΙΗΗ ΣΗ ΦΡΟΝΙΑ HBV ΛΟΙΜΨΞΗ ε χρονία HBV λοίμωξη HBsAg (+)-Με προφύλαξη : 37% σε 3,8%, οξεία ηπατική ανεπάρκεια 13% σε 0% θάνατος 5,5% σε 1,9% Ann Intern Med. 2008;148:519-528. το 4% σε ασθενείς με HBsAg (-), αντι-hbc (+), αντι-hbs (+/-). το 25%με αντι-cd20 (rituximab-mabthera ), (Ann Oncology 2009)

ΘΕΡΑΠΕΙΑ ΟΞΕΙΑ ΠΑΡΟΞΤΝΗ ΜΕ ENTEKABIΡH J Hepatol Δεκέμβριος 2009

NIH Guidelines: Eνδείξεις άμεσης HBV Θεραπείας Οξεία Ηπατική Ανεπάρκεια Κίρρωση με κλινικές επιπλοκές Κίρρωση ή προχωρημένη ίνωση και HBV DNA στον ορό Ασθενείς που πρόκειται να λάβουν χημειοθεραπεία για καρκίνο ή ανοσοκατασταλτική/ανοσοτροποποιητική θεραπεία Ann Intern Med. 2009;150:104-110.

ΤΣΑΕΙ ΠΡΟΛΗΧΗ ΣΨΝ HBV ΕΝΕΡΓΟΠΟΙΗΕΨΝ Lok A et al. Hepatology 2009; www. AASLD.org. Έλεγχος του HBsAg πριν να λάβει ανοσοκατασταλτική αγωγή (ΙΙ-3) ε HBV DNA <10 4 ή 2.000 IU/ml, προ της έναρξης, θεραπεία μέχρι και για 6 μήνες μετά τη διακοπή (ΙΙΙ). ε HBV DNA >10 4 ή 2.000 IU/ml = ανοσοεπαρκείς (ΙΙΙ)

ΔΕΝ ΕΓΙΝΕ ΕΛΕΓΦΟ!!! Hepatitis B prevalence and flare in Asian patients with Rheumatoid Arthritis treated with Disease Modifying Anti - Rheumatic Drug ( DMARD ) therapy - should all high risk patients be tested for HBV prior to DMARD therapy? O.Bebb; V.J.Appleby; P.Southern; P.Helliwell; S.Moreea Bradford Royal Infirmary, Bradford, United Kingdom Hepatology 2009; 50 suppl: 928A

ΔΕΝ ΕΓΙΝΕ ΕΛΕΓΦΟ!!! Trends Amongst Rheumatologists' Knowledge of Hepatitis B reactivation with immunosuppression - does it matter where and how long you're worked? J.Stine, et al. Hepatology 2009; 50 suppl: 512A R.Mendelsohn, et al. Chronic Hepatitis B Reactivation in Cancer Patients Receiving Chemotherapeutic Agents: The Case for Screening. Hepatology 2009; 50 suppl: 512A Σουλάχιστον το 50% δεν ελέγχεται

ΘΕΡΑΠΕΙΑ Ε ΚΤΗΗ Η τελμπιβουδίνη και η τενοφοβίρη κατατάσσονται στην κατηγορία B (δεν υπάρχουν ενδείξεις για βλάβη του εμβρύου σε ζώα) Η χρήση της 3TC με βάση τη χρησιμοποίησή της σε > 2000 HBV/HIV συλλοιμώξεις και της τενοφοβίρης σε χιλιάδες HIV λοιμώξεις J Hepatol 2009; 50Suppl1: S4. Hepatology 2009; 50: 497A

ΒΑΙΚΕ ΒΙΒΛΙΟΓΡΑΥΙΚΕ ΠΑΡΑΠΟΜΠΕ 2009 EUROPEAN ASSOCIATION FOR THE STUDY OF THE LIVER. EASL CLINICAL PRACTICE GUIDELINES: MANAGEMENT OF CHRONIC HEPATITIS B. J HEPATOL 2009;50:227-242 Lok AS, McMahon BJ. Chronic hepatitis B: Update 2009. Hepatology 2009;50:661-662. Sorrell MF, Belongia EA, Costa J, et al. National Institutes of Health Consensus Development Conference Statement: management of hepatitis B. Ann Intern Med 2009;150:104-110.

ΕΞΕΛΙΞΕΙ ΣΗ ΘΕΡΑΠΕΙΑ ΣΗ ΦΡΟΝΙΑ ΗΠΑΣΙΣΙΔΑ Δ H νόσος υποτροπιάζει μετά τη διακοπή της θεραπείας Μακροχρόνια αγωγή με PEG-IFΝ μπορεί να βοηθήσει ασθενείς που δεν παρουσιάζουν σημαντικές ανεπιθύμητες ενέργειες Hepatology 2009; 50(Suppl): 734A, 735A, 736A 737A Ίσως, η εντεκαβίρη μπορεί να βοηθήσει κάποιους ασθενείς Hepatology 2009; 50 suppl: 735A

ΘΕΡΑΠΕΙΑ ΦΡΟΝΙΑ ΗΠΑΣΙΣΙΔΑ B: 2009 Σο σύγχρονο δίλημμα χορήγησης θεραπείας δεν είναι σε ποιό ασθενή με χρονία HBV λοίμωξη θα δοθεί αγωγή αλλά σε ποιά χρονική περίοδο της λοίμωξης, λαμβανομένων υπ όψιν της πιθανότητας εξέλιξης σε κίρρωση και ΗΚΚ και των προβλημάτων της θεραπείας (κόστος, ανεπιθύμητες ενέργειες, αντίσταση στα αντιικά φάρμακα). Lok AS, McMahon BJ. Hepatology. 2009;50:661-662

NIH Guidelines: Eνδείξεις HBV Θεραπείας ε όσους έχουν Οξεία Ηπατική Ανεπάρκεια Κίρρωση με κλινικές επιπλοκές Κίρρωση ή προχωρημένη ίνωση και HBV DNA στον ορό Ασθενείς που πρόκειται να λάβουν χημειοθεραπεία για καρκίνο ή ανοσοκατασταλτική θεραπεία Ann Intern Med. 2009;150:104-110.

NIH Guidelines: Eνδείξεις πιθανής HBV Θεραπείας Ασθενείς με HBeAg (+) ή HBeAg (-) ΦΗΒ και ενεργό ηπατική νόσο αλλά χωρίς σημαντική ίνωση ή κίρρωση. Ann Intern Med. 2009;150:104-110.

NIH Guidelines: Eνδείξεις μη HBV Θεραπείας IU/mL, Ασθενείς στη φάση ανοσοανοχής HBeAg(+), υψηλά επίπεδα HBV DNA ALT φυσιολογικά επίπεδα ηπατική βιοψία: ελάχιστη δραστηριότητα Ανενεργείς φορείς HBeAg(-), anti HBe(+), HBV DNA <2000 ALT: σταθερά φυσιολογικά επίπεδα Ασθενείς με λανθάνουσα HBV λοίμωξη (HBV DNA (+), HBsAg (-), αντι-hbc (+), αντι-hbs (-) Ann Intern Med. 2009;150:104-110

ΘΕΡΑΠΕΙΑ ΟΞΕΙΑ ΠΑΡΟΞΤΝΗ ΜΕ ENTEKABIΡH J Hepatol Δεκέμβριος 2009

ΤΣΑΕΙ ΑΝΣΙΜΕΣΨΠΙΗ ΑΝΑΛΟΓΨ ΣΨΝ ΟΡΟΛΟΓΙΚΨΝ ΕΞΕΣΑΕΨΝ ΓΙΑ HBV Ελεγχος HBV (HBsAg, αντι-hbs, anti-hbc) HBsAg (+) HBsAg (-) Anti-HBs (-) Anti-HBc (-) HBsAg (-) Anti-HBs (+) or (-) Anti-HBc (+) ΑΝΣΙΙΚΑ Εμβολιασμός Παρακολούθηση

HBsAg+ HBV-DNA Διάρκεια της θεραπείας >2000 IU/mL <2000 IU/mL 12 μήνες >12 μήνες Μέχρι την επίτευξη των στόχων Για 6 μήνες μετά την ολοκλήρωση της θεραπείας Λαμιβουδίνη Σελιμαιβουδίνη Σενοφοβίρη Εντεκαβίρη Θεραπεία με αντιικά με υψηλό γενετικό φραγμό για ανάπτυξη αντοχής Hepatology 2009; 509:1-35, J Hepatol 2009; 50:227-242

ΘΕΡΑΠΕΙΑ ΦΡΟΝΙΑ ΗΠΑΣΙΣΙΔΑ B: 2009 Αν και τυχαιοποιημένες διπλές τυφλές μελέτες με ομάδα μαρτύρων δεν έχουν γίνει σε όλες τις κατηγορίες ασθενών, η απόφαση για χορήγηση θεραπείας βασίζεται συχνά σε κλινικές μελέτες παρατήρησης σε σύγκριση με ιστορικούς μάρτυρες. Η αγωγή με αντιικά φάρμακα φαίνεται να είναι ασφαλής. Η θεραπεία χορηγείται με βάση το πιθανό όφελος και την απουσία κινδύνου Shamliyan TA, et al Ann Intern Med 2009; 150: 111-1245

Θεραπεία σε χρονια ηπατίτιδα Β Liver Society Guidelines* HBV DNA, IU/mL HBeAg Positive ALT HBV DNA, IU/mL HBeAg Negative EASL 2009 [1] > 2000 > ULN > 2000 > ULN APASL 2008 [2] 20,000 > 2 x ULN 2000 > 2 x ULN AASLD 2009 [3] > 20,000 > 2 x ULN or (+) biopsy 20,000** ALT 2 x ULN or (+) biopsy *Although ALT and HBV DNA are primary tests used to determine treatment candidacy, the levels of elevation that warrant consideration of treatment are not universally agreed upon. Laboratory normal. 30 U/L for men and 19 U/L for women. **In patients older than 40 yrs of age, 2000 IU/mL should be considered as a cutoff for treatment. 1. EASL. J Hepatol. 2009;50:227-242. 2. Liaw YF, et al. Hepatol Int. 2008;3:263-283. 3. Lok ASF, McMahon BJ. Hepatology. 2009;50:661-662.

Nucleos(t)ide Analogues vs PegIFN Use of pegifn in younger patients Very small proportion will benefit Most will require longer treatment with nucleos(t)ide analogues PegIFN better in genotype A > B > C > D Favorable genotypes growing vanishingly rare This relationship between genotype and response seen for pegifn alfa-2b but not with pegifn alfa-2a HBeAg seroconversion with pegifn alfa-2a according to genotype A: 52%; B: 30%; C: 31%; D: 22% (not significant) Predictors of HBeAg response same for pegifn and nucleos(t)ide analogues (eg, high ALT, low HBV DNA) Flink HJ, et al. Am J Gastro. 2006;101:297-303. Lau GK, et al. N Engl J Med. 2005;352:2682-2695.

HBV DNA During Follow-up After Stopping Adefovir Patients receiving 4-5 years continuous adefovir followed longterm off treatment 33 patients who had sustained undetectable HBV DNA on treatment followed HBV DNA levels followed in 18 off-treatment sustained biochemical responders All patients initially rebounded to detectable HBV DNA Proportion of patients with HBV DNA < 1000 copies/ml 1 month after adefovir discontinuation: 5.6% 12 months after adefovir discontinuation: 55.6% 48 months after adefovir discontinuation: 66.7% Hadziyannis SJ, et al. EASL 2009. Abstract 18.

RANDOMIZATIO N 2:2:1 Study 108 Design Double Blind (DMC Evaluation ~ ~ every 24 24 weeks) TDF (N=45) TDF End of Study (3.5 years) TVD (N=45) TVD ETV (N=22) ETV Week 48 Analysis Week 168 Patients meeting the criteria for insufficient decrease in plasma HBV DNA from baseline at Week 8, or had confirmed plasma HBV DNA 400 copies/ml (69 IU/mL) from Week 24 onward could begin open-label TVD; these patients were considered failures in the efficacy analysis Liaw Y-F, et al., AASLD 2009; Oral #322.

Median Creatinine (mg/dl) Median Creatinine (mg/dl) Liaw Y-F, et al., AASLD 2009; Oral #322. Median Serum Creatinine (mg/dl) by Study Visit 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 4 8 12 16 20 24 28 32 36 40 44 48 Weeks W eekson onstudy T D F N= 45 45 42 40 39 39 40 38 37 37 38 37 37 TDF N= 45 45 42 40 39 39 40 38 37 37 38 37 37 FTC FTC/TDF /TDF N= N= 45 45 44 44 43 43 42 42 42 42 42 42 42 42 42 42 42 42 42 42 41 41 42 42 42 42 E T V N= 22 21 19 20 19 18 19 19 19 18 17 16 16 ETV N= 22 21 19 20 19 18 19 19 19 18 17 16 16 0.90 TDF 0.90 TVD 0.80 ETV

Response at Week 48 by LAM Resistance Parameter TDF (n = 45) TVD (n = 45) ETV (n = 22) Proportion HBV DNA < 400 copies/ml by confirmed LAM-R 4/8 (50%) 8/9 (89%) 1/3 (33%) ITT noncompleter/switch = failure analysis Patients who had orthotopic liver transplant are censored Hence only 9 patients are included in the denominator of TVD arm despite 10 patients with LAM-R at baseline 12/17 (71%) on TDF-containing treatment had HBV DNA < 400 c/ml None of the patients on TDF-containing treatment developed amino acid substitutions associated with resistance to tenofovir Liaw Y-F, et al., AASLD 2009; Oral #322.

Conclusions Up To 48 Weeks (Interim Analysis) All treatments were well-tolerated and had comparable safety and tolerability The overall incidence of renal events was low and no significant renal safety difference was observed between groups in this vulnerable population HBeAg loss or seroconversion was only observed in the TDF containing regimens The combination arm TVD had numerically better viral suppression than the two monotherapy arms and interim results support the use of combination therapy in patients with decompensated liver disease Liaw Y-F, et al., AASLD 2009; Oral #322.

Endpoints Primary efficacy endpoint Mean change from baseline in HBV DNA at Week 24 Secondary efficacy (Week 24 and 48) endpoints Proportion of patients with HBV DNA <300 copies/ml Proportion of patients with ALT normalization Improvement in Model for End-Stage Liver Disease (MELD)/CTP score Time-to-death, time-to-hcc (cumulative analysis, treated patients, analyzed as treated) Safety (cumulative analysis) Adverse events (AE, serious AE, discontinuations due to AE, HCC, ALT flares, death) Renal impairment, as defined by confirmed creatinine increase 0.5 mg/dl Liaw Y-F, et al., AASLD 2009; Poster # 422.

Safety Cumulative Analysis ETV (n = 102) ADV (n = 89) Mean time on therapy, weeks (SE) 108.8 (9.0) 96.6 (8.4) Any AE, n (%) 91 (89) 86 (97) Grade 3 4 AEs, n (%) 55 (54) 42 (47) Serious AEs, n (%) 70 (69) 59 (66) Death, n (%) 23 (23) 29 (33) Serum creatinine 0.5 mg/dl increase from baseline, n (%) 17 (17) 21 (24) ALT flare, n (%)* 2 (2) 1 (1) HCC, n (%) 12 (12) 18 (20) Discontinuation due to AEs, n (%) 7 (7) 5 (6) Death and HCC include events which occurred on and off treatment, all other parameters measure on-treatment events only *One additional event occurred off treatment in the ADV group Liaw Y-F, Other et al., remaining AASLD 2009; malignancies Poster # 422. (both in ETV group) were: recurrent non-hodgkin lymphoma (n = 1), basal cell

Safety in Patients With High MELD Scores A case series using ETV in decompensated cirrhotic patients documented a risk for lactic acidosis in patients with high MELD scores ( 22) ƒ In the case series, a total of 22 patients had a baseline MELD score 22 (15 ETV and 7 ADV) Clinical evaluation did not include prospective measurements of serum lactate level Clinical safety observation within these patients with high MELD score 22 were as follows: Deaths: 7/15 ETV; 5/7 ADV One AE of lactic acidosis in an ETV-treated patient required no treatment and resolved on continued ETV treatment, it occurred on study day 1293 with bicarbonate 16 mmol/l and creatinine 1.4 mg/dl (no lactate level reported). Lactate levels reported on days 1340 and 1417 were 2.5 and 2.8 mmol/l, respectively Among all treated patients (ETV 102; ADV 89), the following AEs related to lactate or low bicarbonate were identified: 1 event of lactic acidosis described above and 5 events of low bicarbonate * Liaw Y-F, et al., AASLD 2009; Poster # 422. ƒ Sarrazin et al. Hepatology 2009; HEP-09-0827; * (3 ETV a

Conclusions Both therapies were well tolerated, and the safety experience in each group was comparable and consistent with what would be expected in a CHB population with decompensated liver disease Entecavir demonstrated superior antiviral activity to adefovir in this patient population Entecavir provided clinical benefit in patients with CHB infection and decompensated cirrhosis Liaw Y-F, et al., AASLD 2009; Poster # 422.

Patients at Year 3 In Both HBeAg and HBeAg+ Studies Study 102, HBeAg Patients Study 103, HBeAg+ Patients 144 Week 0 48 72 144 Week 0 48 72 Patient retention at Year 3 remained high both studies: 87% HBeAg patients in Study 102 80% HBeAg+ patients in Study 103 17 of 51 patients eligible for FTC remained on TDF monotherapy Marcellin P, et al., AASLD 2009; Poster #481; Heathcote E-J, et al., AASLD 2009; Poster #483.

Patients Eligible to Add FTC at Week 72 and Beyond With Efficacy Outcomes Up To Year 3 Patients with Confirmed HBV DNA 400 copies/ml at Week 72 or Beyond N = 51 Added FTC FTC/TDF Did Not Add FTC TDF Number of patients (Study 102 & Study 103) 34 (67%) 17 (33%) Discontinued before Week 144 5 (15%) 3 (18%) At Week 144: HBV DNA 400 copies/ml HBV DNA < 400 copies/ml 9 (26%) 20 (59%) 2 (12%) 12 (70%) Time (weeks) to addition of FTC or eligibility to add FTC Mean (range) 80 (72-122) 79 (72-133) Gilead data on file

Baseline Characteristics of Patients Entering Year 3 TDF-TDF (N=223) ADV-TDF (N=110) TDF-TDF (N=141) ADV-TDF (N=82) Mean Age (years) 45 44 35 35 Race Caucasian Asian 66% 24% 67% 23% 55% 34% Male 80% 77% 72% 72% Prior lamivudine experience 18% 20% - - Mean HBV DNA (log 10 copies/ml) 6.83 6.99 8.66 8.84 Mean ALT (U/L) 130 171 142 159 Mean Knodell necroinflammatory score 7.8 7.9 8.2 8.5 54% 34% Knodell fibrosis score = 4 (cirrhosis) 20% 18% 22% 20% Viral Genotype A B C D HBeAg ( ),Study 102 HBeAg (+), Study 103 13% 9% 11% 65% 12% 14% 9% 63% 25% 13% 24% 33% 21% 8% 31% 36% Marcellin P, et al., AASLD 2009; Poster #481; Heathcote E-J, et al., AASLD 2009; Poster #483.

Summary of Safety Data During Open Label TDF in Studies 102 and 103 Through Week 144 HBeAg,Study 102 HBeAg+, Study 103 TDF-TDF (N=235)* ADV-TDF (N=112)* TDF-TDF (N=154)* ADV-TDF (N=84)* Study Drug-Related SAE 1 (<1%) 0 2 (1.3%) 2 (2.4%) Deaths metastatic liver carcinoma cervical cancer metastases nasopharyngeal carcinoma 2 (1.3%) 1 (<1%) 0 1 (<1%) 1 (<1%) 0 1(<1%) 0 G3 or G4 Laboratory 32 (14%) 17 (15%) 19 (12.3%) 13 (15.5%) 0 - - - 0 - - - Discontinue due to an AE hepatic neoplasm dizziness, fatigue, lack of concentration septic shock creatinine increase 3 (1.3%) 1 1 1 0 0 0 0 0 0 1 (<1%) - - - 1 (<1%) 0 - - - - Confirmed phosphorus < 2mg/dL 2 (<1%) 1 (<1%) 0 1 (1%) Confirmed 0.5 mg/dl in creatinine 0 0 0 2 (2%) Confirmed creatinine clearance <50 ml/min 0 0 0 0 * N s reflect the number of patients who entered the open-label extension Marcellin P, et al., AASLD 2009; Poster #481; Heathcote E-J, et al., AASLD 2009; Poster #483.

Marcellin P, et al., AASLD 2009; Poster #481; Heathcote E-J, et al., AASLD 2009; Poster #483. Mean Creatinine Serum Creatinine Over Time Study 103, HBeAg+ Weeks on Study

Lee S, et al., AASLD 2009; Poster #490. Asian Patients Participating in Pivotal Studies 189 Asians and 452 non-asians were enrolled across the 2 studies Asians comprised ~30% of all patients 127/426 (30%) on TDF 62/215 (29%) on ADV Combined study results from Studies 102 and 103 are presented to maximize sample size Of 178 Asian patients eligible to continue in the Open-Label Extension 163 entered and 93% completed 144 weeks

HBV DNA Remains Suppressed In Asian Patients With Up To 3 Years Of TDF Treatment (ITT) (%) Patients with HBV DNA < 400 copies/ml Percentage (%) 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 0 Randomized Double-Blind Open-Label TDF 0 4 8 12 16 20 24 28 32 36 40 44 48 56 64 72 80 88 96 108 120 132 144 0 24 48 Weeks on 72 Study 96 120 144 Weeks on Study Non-Asian N=452 447 440 443 446 437 439 442 440 441 435 Asian N=189 186 185 185 185 180 178 178 180 181 178 Lee S, et al., AASLD 2009; Poster #490. LTE-TDF analysis 81% Non-Asian 79% Asian On-treatment 97% Asian 97% Non-Asian Both studies 102 and 103 combined

Percentage (%) Percentage (%) Percentage of Patients with Normal ALT 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 10 10 0 Randomized Double-Blind 0 Open-Label TDF 0 4 8 12 16 20 24 28 32 36 40 44 48 56 64 72 80 88 96 108 120 132 144 0 24 48 Weeks 72 on Study 96 120 144 Weeks on Study Non-Asian N=452 444 433 430 428 403 396 396 389 387 375 Asian N=189 184 177 178 173 158 153 152 152 152 On-treatment observed 152 149 86% Asian 76% Non-Asian ALT ULN = 34 U/L for women 43 U/L for men Lee S, et al., AASLD 2009; Poster #490. Both studies 102 and 103 combined

Percentage (%) Serologic Response Among Asian Patients 100 90 80 70 60 50 40 30 20 10 0 17 HBeAg loss Anti-HBe 28 22 17 18 19 % % % % % Week 48 Week 96 Week 144 On-treatment observed % No Asian patient lost HBsAg Lee S, et al., AASLD 2009; Poster #490. Both studies 102 and 103 combined

Mean (95% CI) Serum Creatinine Mean (95% CI) Serum Creatinine (mg/dl) (mg/dl) Serum Creatinine Over Time 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 Randomized Double-Blind Open-Label TDF 4 8 12 16 20 28 32 36 40 44 56 64 80 88 108 132 0 24 48 72 96 120 144 Weeks Weeks on Study Non-Asian N= 452 444 434 431 430 405 403 391 383 383 367 Asian N= 189 184 177 178 173 158 155 153 152 153 149 Non-Asian Asian Lee S, et al., AASLD 2009; Poster #490. Both studies 102 and 103 combined

Snow-Lampart A, et al., AASLD 2009; Poster #480. TDF Resistance Surveillance Ongoing Up to Year 8 in Studies 102 and 103 Genotyping (HBV pol / RT) All patients: at baseline Yearly if HBV DNA 400 copies/ml ( 69 IU/mL) at discontinuation of TDF monotherapy if HBV DNA 400 copies/ml Phenotyping (HBV pol / RT) Any patient post-baseline with: conserved site changes in pol/rt virologic breakthrough (VB) ƒ polymorphic site changes (> 1 patient) ƒ Defined as a confirmed 1 log 10 increase in HBV DNA from nadir and/or confirmed HBV DNA >400 copies/ml after having <400 copies/ml

HBeAg and HBeAg+ Patients Evaluated During Year 3 Patients: TDF-TDF ADV-TDF entering Year 3 with HBV DNA >400 copies/ml on TDF monotherapy 364/426 (85%) 13/364 (4%) 6 (4 HBeAg, 2 HBeAg+) 192/215 (89%) 9/192 (5%) 5 (all HBeAg+) with VB 1 2 on FTC+TDF combination therapy 7 (all HBeAg+) 4 (all HBeAg+) with VB 3 1 VB = Virologic Breakthrough defined as a confirmed 1 log 10 increase in HBV DNA Snow-Lampart A, et al., AASLD 2009; Poster #480. from nadir or

Genotypic Resistance Surveillance Results Conserved site changes observed in 3 of 13 patients originally randomized to TDF: Patient A (TDF): rtr51k Patient B (FTC+TDF): rtl180m ± rtm204v ± rta181t Patient C (FTC+TDF): rtr192h Conserved site changes observed in 2 of 9 patients originally randomized to ADV: Patient D (ADV-TDF): rtg152e Patient E (ADV-TDF): rtn236t ± rtr274q The rtg152e change was observed during a transient VB None of the changes was associated with confirmed virologic breakthrough Conserved site changes in HBV pol/rt observed in 5 of 556 patients across both arms of Studies 102 and 103 during year 3 Not associated with persistent virologic breakthrough Not associated with altered susceptibility to tenofovir in vitro

Development of Conserved Site Changes in HBV pol/rt Did Not Impact Phenotypic Sensitivity to Tenofovir in vitro Treatment Group TDF TDF-FTC/TDF TDF-FTC/TDF ADV-TDF Treatment Group TDF-FTC/TDF ADV-TDF Viral Isolate Change from BL in HBV pol/rt Fold Change from BL a Patient A Week 144_pool rtr51k 1.4 Patient B Week144_pool b rta181t* 0.7 Patient C Week 144_pool/clones c rtr192h Replication Defective Patient E Week 144_pool Week 144_clone 1 Week 144_clone 2 Laboratory Isolate rtn236n/t rtr274r/q rtn236t rtr274q Change from control in HBV pol/rt 1.9 8.2 1.9 Fold Change from control pcmvhbv rtr192h rtr192h Replication Defective PHY92 rtg152e rtg152e d 1.6 a Values 2-fold are not statistically significant; b Constructs containing the rtl180m+rtm204v were not obtained in clonal analysis for phenotypic evaluation; C Seven clones containing the rtr192h were also tested, all were replication defective (i.e. did not grow in cell culture; d. Site-directed recombinant expressing rtg152e created for patient D as patient serum Snow-Lampart failed to generate A, et a al., phenotyping AASLD 2009; vector Poster #480.

Snow-Lampart A, et al., AASLD 2009; Poster #480. Week HBV DNA Profile For the TDF-TDF Treated Patients With Conserved Site Changes Patient A Patient B Week Patient C Week

Snow-Lampart A, et al., AASLD 2009; Poster #480. HBV DNA Profile For the ADV-TDF Treated Patients With Conserved Site Changes Patient D Patient E Week Week *Patient E off drug at week 144

Evolution of Low Levels of rtn236t on ADV-TDF Therapy: Case Study of Patient E by Allele-Specific PCR Patient E Patient showed low-levels of rtn236t at termination of ADV monotherapy Switch to TDF monotherapy resulted in a 3.8 log 10 decrease in the rtn236n/t viral population to below detection limits of HBV DNA PCR assay at most visits Snow-Lampart A, et al., AASLD 2009; Poster #480. Week

Conclusions At year 3, 87% of HBeAg patients and 80% of HBeAg+ patients remained on treatment demonstrating: Durable and potent antiviral activity, i.e. 99 % and 93% of HBeAg- and HBeAg+ patients had HBV DNA <400 copies/ml (69 IU/mL), respectively An 8% cumulative probability of HBsAg loss No resistance to TDF Up to 3 years of TDF monotherapy in 364 patients and 192 ADV treated patients following up to 2 years of TDF monotherapy Similar data observed among patients who added FTC A favorable tolerability profile Marcellin P, et al., AASLD 2009; Poster #481; Heathcote E-J, et al., AASLD 2009; Poster #483; Snow-Lampart A, et al., AASLD 2009; Poster #480.

In Vitro Tenofovir Sensitivity of HBV Populations from Clinical Specimens Containing rta181t/v and/or rtn236t Kitrinos K, et al., AASLD 2009; Poster #434. 26 clinical isolates obtained from 24 ADV-treated patients enrolled in Study 0103 (n=5) and Study 0106 (n=19) were analyzed All ADV-r patients (detected by population sequencing) with replication competent virus that were treated with TDF in GS-US-174-0106 were included Population di-deoxy sequencing of serum HBV pol/rt (LOD 400 copies/ml) was performed on all 26 isolates covers amino acids (AA) 1-344 of HBV RT Detects mutations 25% of the population 20 isolates were further analyzed using the INNO-LiPA HBV DR V3 assay Detects mutations at rtl80, rtv173, rtl180, rta181, rtt184, rta194, rts202, rtm204, rti233, rtn236, and rtl250 of HBV RT Detects mutations 5% of the population

TFV EC 50 Values For Isolates With ADV-R Mutations Isolate ADV-R Mutations a TFV EC 50 (µm) ± Mean SD b Fold Change from phy92 3003 rta181a/t 12.6 ± 2.9 0.8 1039 rta181a/t 8.8 ± 4.0 0.5 4011-1 rtn236n/t 9.3 ± 3.8 0.6 1017 rta181a/t 20.6 ± 4.3 1.3 7852-2 rtn236n/t 15.3 ± 1.8 0.9 1003 rtn236n/t 14.4 ± 4.0 0.9 1022 rta181a/t, rtn236n/t 21.4 ± 4.1 1.3 2003 rta181v/a, rtn236n/t 44.6 ± 22.6 2.7 4011-2 rtn236t 12.2 ± 8.1 0.7 4010 rta181a/t/v, rtn236n/t 24.6 ± 2.9 1.5 phy92 c WT 16.3 ± 3.8 1.0 ADV-R c rta181v, rtn236t 47.9 ± 12.4 2.9 Kitrinos K, et al., AASLD 2009; Poster #434. a Mutations detected in either INNO-LiPA or population sequencing b Values represent average of 3-4 independent assays for subject isolat c phy92 and ADV-R are genotype A laboratory strains used as controls.

HBV DNA (log 10 copies /ml) Change From Baseline HBV DNA Median Change From Baseline for TDF-Treated Patients With and Without ADV- R Through 24 Weeks 0 No ADV-R (N=16) ADV-R (N=8) -1-2 -3 Week 24 p value = 0.723-4 0 4 8 12 16 20 24 Weeks Kitrinos K, et al., AASLD 2009; Poster #434.

HBV DNA (log 10 copies /ml) HBV DNA Levels for TDF-Treated Patients 1003, 2003, and 1022 Through 24 Weeks 8 7 6 1003 (rtn236n/t) 2003 (rta181a/v + rtn236n/t) 1022 (rta181a/t) 5 4 3 2 400 copies/ Copies/mL 1 0 4 8 12 16 20 24 Kitrinos K, et al., AASLD 2009; Poster #434. Week

Kitrinos K, et al., AASLD 2009; Poster #434. Conclusions The presence of HBV mutant subpopulations ( 50%) of rta181t/v and/or rtn236t did not have an impact on TDF susceptibility in in vitro phenotyping assays Wild-type virus in these samples likely contributes to this result The presence of subpopulations of ADV-R HBV, including one patient with >90% mutant (N236T) virus, did not have an impact on clinical response to TDF through 24 weeks of treatment

Fung SK, et al., AASLD 2009; Poster #399. Tenofovir (TDF) is Effective in Lamivudine (LAM)-Resistant CHB Patients Who Harbor rta194t at Baseline Aim To determine the effect of rta194t on treatment response to TDF 300 mg daily alone or in combination with other antiviral agents in patients with lamivudineresistant HBV Patients and Methods Adult HBV patients receiving oral antiviral therapy at University Health Network Liver Clinics (Toronto, Canada) monitored for genotypic antiviral resistance Routine blood work, HBV serology and HBV DNA levels were measured every 3 months on treatment Resistance testing performed on all patients with virologic breakthrough confirmed rise in HBV DNA by > 1 log IU/ml compared to nadir in those who failed to achieve undetectable HBV DNA 6 months after starting antiviral therapy Genotyping and detection of resistance mutations were performed using a line probe assay - InnoLiPA HBV DR v3 HBV DNA was measured using real-time PCR - TaqMan 48, LLQ 12 IU/ml

Baseline Demographics 12/950 (1.2%) of the 950 consecutive treatment-experienced adult patients with chronic hepatitis B tested for antiviral resistance were found to harbor rta194t in 10/12 (83%) patients, rta194t was found in association with rtl180m+rtm204v/i After detection of LAM-resistant mutation(s), salvage therapy was started in 9/12 (75%) patients N=12 Mean Age ± SD (years) 49 ± 20 Male: Female 8: 4 % HBeAg-positive 42 Mean ALT ± SD (U/L) 52 ± 34 Mean HBV DNA ± SD (IU/ml) 5.5 ± 2.3 Mean Platelet Count ± SD (bil/l) 214 ± 68 % Cirrhosis (on US or Liver biopsy) 42 % HBV genotype (A/B/C/D) 17/33/33/17 Mean duration of lamivudine ± SD (months) prior to salvage therapy 36 ± 26 Fung SK, et al., AASLD 2009; Poster #399.

Fung SK, et al., AASLD 2009; Poster #399. Results of Genotyping Patient Genotype L80V V173L L180M M204V/I A194T 1 C + - + + Present 2 B + - + + Mixed 3 D - + + + Present 4 D + - + + Present 5 A + - + + Mixed 6 B - - + + Present 7 B - - + + Present 8 C - - + + Present 9 C - - + + Mixed 10 A - - + + Present 11 B - - - - Mixed 12 C + - - - Present

Patient Characteristics After Salvage Therapy Patient Treatment Duration (months) HBV DNA (log IU/ml) Baseline Last Last ALT (U/L) 3 LAM + ADV 30 3.6 < 12 30 4 LAM + TDF 26 6.1 Undetectable 13 5 LAM + TDF 21 6.4 Undetectable 35 6 TDF alone 13 4.3 < 12 55 8 FTC + TDF 27 5.9 Undetectable 24 9* TDF alone 18 4.5 3.4 log 10 277 10 LAM + TDF 24 4.3 Undetectable 27 11 TDF alone 8 4.5 < 12 24 12 LAM + TDF 9 7.3 < 12 21 Fung SK, et al., AASLD 2009; Poster * #399. Patient 9 underwent treatment for hepatocellular carcinoma and was admittedly non-comp

Salvage Therapy TDF 300 mg QD + LAM 100 mg QD

Fung SK, et al., AASLD 2009; Poster #399. Conclusions rta194t was detected in 12 TDF-naïve patients with lamivudine-resistant chronic hepatitis B Almost always in association with rtl180m and rtm204v/i Usually as pure viral species or mixed population TDF alone or in combination was used as salvage therapy in 9 patients Mean treatment duration of 19.5 months HBV DNA <12 IU/ml or undetectable in 7 (88%) patients 1 patient underwent treatment for hepatocellular carcinoma and was admittedly non-compliant with TDF ALT normalized in 6 (75%) patients Contrary to in vitro studies, rta194t was not associated with reduced viral suppression among LAM-resistant HBV patients salvaged with TDF alone or in combination with LAM, ADV or FTC with > 1.5 year follow-up These findings suggest rta194t may represent a viral polymorphism or a LAM compensatory mutation rather than a signature TDF mutation

Summary and Conclusions: Advances in HBV Therapy ETV associated with high response rates over 36 mos in pts with HBeAg-positive and HBeAgnegative chronic hepatitis B Fixed-dose TDF/FTC safe and effective option for treatment of pts with chronic hepatitis B and decompensated liver disease Intrahepatic cccdna levels at EOT with pegifn alfa- 2a + adefovir predictive of SVR in pts with chronic hepatitis B SVR defined as sustained undetectable HBV DNA after treatment discontinuation

Patient Characteristics Patien t Age (years ) Liver Condition HBeA g Lange C, et al., AASLD 2009; Oral # 220. HBV DNA (IU/mL) Child- Pugh MELD Score Lactic Acidosi s GPT (U/L) Bilirubin (mg/dl) A 36 OLT, ITBL Neg <300 C 38 Yes 40 50.0 2.2 B 79 C 60 Acute liver failure OLT, recirrhosis INR Outcome Resolved, re-olt,virologic response Neg 8,000,000 29 Yes 1800 32.0 2.4 Death Pos 10,300 C 28 Yes 19 7.3 2.2 Resolved D 60 Cirrhosis, HCC Neg 1,200,000 B 25 Yes 80 6.0 1.8 E 61 Cirrhosis, HCC Neg <300 B 22 Yes 40 4.1 1.9 Resolved, virologic response Resolved, virologic response F 74 Cirrhosis Neg 270,000 B 17 No 61 3.9 1.4 Virologic response G 25 Cirrhosis Pos 700 B 14 No 36 1.4 1.7 Virologic response H 43 Cirrhosis Neg <300 B 12 No 58 0.9 1.7 Virologic response I 64 Cirrhosis, HCC Pos 5,267,000 B 11 No 130 1.3 1.3 Virologic response J 47 Cirrhosis Neg 151,000 A 11 No 144 0.8 1.9 Virologic response K 43 Cirrhosis Pos 160,000 A 7 No 44 1.1 1.1 Partial Virologic response 99,000,00

Ευνοϊκοί Παράγοντες Επιλογής αρχικώς της IFN Παράγοντες σχετιζόμενοι με τον ιό και τον ξενιστή Γονότυπος A ή B > C ή D HBV DNA < 2 x10 6 IU/mL ALT (εκκίνησης) ALT (> 3 x ULN) Ειδικά δημογραφικά χαρακτηριστικά Νέοι σε ηλικία ασθενείς Νέες γυναίκες που προγραμματίζουν μελλοντικά εγκυμοσύνη Προτίμηση του ασθενή Φωρίς συλλοίμωξη με HIV HCV / ΗDV συλλοίμωξη

Eυνοϊκοί Παράγοντες αρχικής Επιλογής NUCs χετιζόμενοι με τον ιό και τον ξενιστή HBV DNA επίπεδα( εκκίνησης και υπό θεραπεία) ALT επίπεδα Ειδικά δημογραφικά χαρακτηριστικά ασθενείς μεγαλύτερης ηλικίας Προτίμηση του ασθενή HIV συλλοίμωξη Όχι HCV συλλοίμωξη

ΠΡΨΣΟΘΕΡΑΠΕΤΟΜΕΝΟΙ ΑΘΕΝΕΙ HBeAg οροαναστροφή στα 3 ίδια με 1 χρόνο PegIFN Aπώλεια HBsAg 10% at 3-4 yrs ε HBeAg (+) στα 3-4 χρόνια λίγο καλύτερα η PegIFN ε HBeAg ( ) μόνο με PegIFN