Bristol-Myers Squibb Company announced that Daklinza (daclatasvir, 60 mg), an NS5A replication complex inhibitor, has been approved by the US Food and Drug Administration (FDA) in combination with sofosbuvir (with or without ribavirin) in genotypes 1 and 3. The expanded label includes data in three additional challenging-to-treat patient populations: chronic hepatitis C virus (HCV) patients with HIV-1 coinfection, advanced cirrhosis, or post-liver transplant recurrence of HCV.

The Daklinza plus sofosbuvir regimen is already available for the treatment of chronic HCV genotype 3, and is currently the only 12-week, once-daily all-oral treatment option for these patients. Sustained virologic response (SVR) rates are reduced in genotype 3 patients with cirrhosis receiving Daklinza and sofosbuvir for 12 weeks without ribavirin. The recommended dosage of Daklinza is 60 mg in combination with sofosbuvir with or without (+/-) ribavirin for 12 weeks.

“The expanded indication for Daklinza offers an additional treatment option for multiple subsets of patients who have genotype 1 or 3 chronic HCV,” said Chris Boerner, head of US commercial, Bristol-Myers Squibb. “HCV/HIV-coinfected patients and patients with advanced cirrhosis or post-transplant recurrence of HCV still pose a treatment challenge to physicians. As part of our commitment to the HCV community, we have sought to make new treatment options available for these and other targeted populations that have not yet been able to fully benefit from currently available next-generation medicines.”

Daklinza is contraindicated in combination with drugs that strongly induce CYP3A and, thus, may lead to lower exposure and loss of efficacy of Daklinza. Daklinza also may be associated with the risk of adverse reactions or loss of virologic response due to drug interactions. In addition, there is a risk of serious symptomatic bradycardia when co-administered with sofosbuvir and amiodarone. Please see full Important Safety Information below for more details.

The efficacy and safety of the Daklinza regimens were evaluated in the phase 3 ALLY-1 and ALLY-2 clinical trials.

The ALLY-2 trial enrolled 153 treatment-naïve (n=101) and treatment-experienced (n=52) HCV/HIV-coinfected patients treated with Daklinza plus sofosbuvir for 12 weeks. Sustained virologic response was the primary endpoint and was defined as HCV RNA below the LLOQ at post-treatment week 12 (SVR12) in genotype 1 treatment-naïve patients.

In ALLY-2, SVR12 rates were high regardless of baseline subgroup, including Black/African-American (98 per cent, n=50 in all genotypes studied), and high baseline viral load (=6,000,000 IU/mL) (97 per cent, n=62 in all genotypes studied). Rates of SVR12 were also similar among the concomitant HAART (highly active antiretroviral therapy) regimens used, which included protease inhibitors (97 per cent, n=70 in all genotypes), non-nucleoside reverse transcriptase inhibitors (100 per cent, n=40 in all genotypes), and integrase inhibitors (95 per cent, n=39 in all genotypes).

Among the 153 patients in ALLY-2, there were no treatment-related serious adverse events (SAEs) and no discontinuations due to adverse events (AEs). The most common treatment-related AEs at a frequency of =5 per cent in ALLY-2 were fatigue (15 per cent), nausea (9 per cent), headache (8 per cent) and diarrhea (7 per cent).

“The high SVR rates achieved with the daclatasvir-based (Daklinza) regimen in HCV/HIV-coinfected patients are extremely encouraging for potentially helping to address a serious health concern for individuals with HIV,” said Kenneth Sherman, M.D., Ph.D., Gould Professor of Medicine and Director, Division of Digestive Diseases, University of Cincinnati College of Medicine.

“Approximately a quarter of all HIV patients in the US are coinfected with HCV, and have historically been particularly challenging to treat due to the complexities of the overlapping therapeutic regimens used to treat each infection. New options that allow for the treatment of HCV without altering HIV medicines are still a significant need for these patients.” The dose of Daklinza may need to be adjusted when used with some antiretroviral regimens.

The ALLY-1 trial enrolled 113 patients with chronic HCV infection and Child-Pugh A, B, or C advanced cirrhosis (n=60) or HCV recurrence after liver transplant (n=53) treated with Daklinza plus sofosbuvir with ribavirin for 12 weeks. The primary endpoint was SVR12 in each treatment cohort.

SVR12 rates were comparable between genotype 3 (5/6 with Child-Pugh B or C cirrhosis and 10/11 post-liver transplant) and genotype 1 subjects with or without decompensated cirrhosis.

Among all patients in ALLY-1, there were no treatment-related SAEs. Of the 15 (13 per cent) patients who discontinued study drug for adverse events, 13 (12 per cent) patients discontinued ribavirin only and 2 (2 per cent) patients discontinued all study drugs. The most common treatment-related AEs at a frequency of =5 per cent in either cohort of ALLY-1 were headache (12 per cent, 30 per cent), anemia (20 per cent, 19 per cent), fatigue (15 per cent, 17 per cent), nausea (15 per cent, 6 per cent), rash (8 per cent, 2 per cent), diarrhea (3 per cent, 6 per cent), insomnia (3 per cent, 6 per cent), dizziness (0, 6 per cent), and somnolence (5 per cent, 0) in the advanced cirrhotic and post-transplant treatment groups, respectively.

The ALLY-1 and -2 trials demonstrated that Daklinza is able to be administered with the most commonly used medications for the treatment of HIV and post-transplant immunosuppression. Based on the drug-drug interaction profile, there is no need to change or adjust HAART regimens, including darunavir-ritonavir, atazanavir-ritonavir, lopinavir-ritonavir, efavirenz, raltegravir, dolutegravir, nevirapine and rilpivirine. The dose of Daklinza was adjusted for some HAART regimens. Daklinza is also compatible with many immunosuppressive regimens, with no treatment-limiting drug-drug interactions. The ALLY-1 trial studied most immunosuppressants: cyclosporine, tacrolimus, sirolimus, everolimus, corticosteroids, or mycophenolate mofetil.

“Post-liver transplant patients with HCV recurrence and patients with advanced cirrhosis can be difficult to manage because of the potential for drug-drug interactions associated with immunosuppressive treatments and the complex conditions of liver disease,” said Fred Poordad, M.D., ALLY-1 lead investigator and clinical professor of medicine, chief, hepatology, University of Texas Health Science Center and VP, academic and clinical affairs, Texas Liver Institute.

“Transplant patients need to take a variety of immunosuppressive medications to prevent organ rejection, and treatment with Daklinza plus sofosbuvir and ribavirin allows patients to preserve their new liver by treating HCV before its progression to more severe disease, while still maintaining the critical regimens required to manage immunosuppression.”

For genotype 1a patients with cirrhosis, prior to the initiation of treatment with Daklinza-based regimens, consider screening for the presence of NS5A polymorphisms at amino acid positions M28, Q30, L31, and Y93.

ALLY-2 was an open-label trial that included 153 patients (genotypes 1-4i) with chronic HCV and HIV coinfection. Patients received Daklinza 60 mg (dose-adjusted for concomitant antiretroviral use) plus sofosbuvir 400 mg once daily for 12 weeks and were monitored for 24 weeks post-treatment.

The 153 patients had a median age of 53 years (range, 24-71); 88 per cent of the patients were male; 63 per cent were white, 33 per cent were black, and 1 per cent were Asian. Most patients (80 per cent) had baseline HCV RNA levels greater than or equal to 800,000 IU/ml. Sixty-eight per cent of patients had HCV genotype 1a, 15 per cent had HCV genotype 1b, 8 per cent had genotype 2, 7 per cent had genotype 3, and 2 per cent had genotype 4. Daklinza is indicated in genotype 1 and genotype 3 only. Sixteen percent of all patients had compensated cirrhosis. Concomitant HIV therapy included PI-based regimens (darunavir + ritonavir, atazanavir + ritonavir, or lopinavir/ritonavir) for 46 per cent of patients, NNRTI-based regimens (efavirenz, nevirapine, or rilpivirine) for 26 per cent, integrase-based regimens (raltegravir or dolutegravir) for 26 per cent, and nucleoside-only regimens (abacavir + emtricitabine + zidovudine) for 1 per cent. Two patients were not receiving treatment for HIV.

ALLY-1 was an open-label trial that included 113 patients (genotypes 1-4, 6i) with chronic HCV infection and Child-Pugh A, B, or C cirrhosis or HCV recurrence after liver transplant. Patients received Daklinza 60 mg plus sofosbuvir 400 mg once daily with ribavirin for 12 weeks and were monitored for 24 weeks post-treatment. The recommended initial dose of ribavirin was 600 mg or less daily with food and could be adjusted up to 1000 mg per day if tolerated.

The 113 treated patients in ALLY-1 had a median age of 59 years (range, 19-82); 67 per cent of the patients were male; 96 per cent were white, 4 per cent were black, and 1 per cent were Asian. Most patients (59 per cent) were treatment-experienced, and most (71 per cent) had baseline HCV RNA levels greater than or equal to 800,000 IU/mL. Fifty-eight percent of patients had HCV genotype 1a, 19 per cent had HCV genotype 1b, 4 per cent had genotype 2, 15 per cent had genotype 3, 4 per cent had genotype 4, and 1 per cent had genotype 6. Daklinza is indicated in genotype 1 and genotype 3 only. Among the 60 patients in the cirrhosis cohort, 20 per cent were Child-Pugh class A, 53 per cent were Child-Pugh class B, 27 per cent were Child-Pugh class C, and 35 per cent had a Baseline Model for End-Stage Liver Disease (MELD) score of 15 or greater. Most (55 per cent) of the 53 patients in the post-transplant cohort had F3 or F4 fibrosis (based on FibroSURE® results).