Hep B Blog
Hepatitis B Research

Hepatitis B Research Review: February

 

Welcome to the Hepatitis B Research Review! This monthly blog shares recent scientific findings with members of Baruch S. Blumberg Institute (BSBI) labs and the hepatitis B (HBV) community. Technical articles concerning HBV, Hepatocellular Carcinoma, and STING protein will be highlighted as well as scientific breakthroughs in cancer, immunology, and virology. For each article, a brief synopsis reporting key points is provided as the BSBI does not enjoy the luxury of a library subscription. The hope is to disseminate relevant articles across our labs and the hep B community. 

 Summary: This month, researchers in Beijing, China have reported that a therapeutic vaccine composed of polylactic acid microparticles loaded with HBV surface antigen and the mouse STING agonist DMXAA showed efficacy in clearing HBV infection in a mouse model. Researchers from Wuhan, China have reported that SOX2, a transcription factor important for cell proliferation is also a host restriction factor for HBV infection. Also, researchers from the University of Boulder in conjunction with Dr. James Chen’s lab in Dallas have reported the synthesis of two potent cGAS inhibitors.

The incorporation of cationic property and immunopotentiator in poly (lactic acid) microparticles promoted the immune response against chronic hepatitis B – Journal of Controlled Release

This paper from the Chinese Academy of Sciences in Beijing, introduces a microparticle vaccine which may be used to treat chronic HBV infection (CHB). The 1μm diameter microparticle is made from polylactic acid (PLA), which is a biodegradable polymer typically synthesized from plant starch. The microparticle also contains didodecyldimethylammonium bromide (DDAB) which is a double-chain cationic surfactant. This group has previously shown that DDAB may be used as a carrier for the HBV surface protein (HBsAg). DDAB also gives the microparticle a positive charge, which accelerates its phagocytosis into antigen-presenting cells (APCs) and facilitates its escape from lysosomal degradation once in the cell. Additionally, the group loaded microparticles with the mouse STING agonist  5,6-dimethylxanthenone-4-acetic acid (DMXAA). The microparticles were refereed to as DDAB-PLA (DP) and DDAB-PLA-DMXAA (DP-D) respectively. Both types of microparticle were saturated with HBV surface antigen (HBsAg). The microparticles were first tested on mouse bone marrow dendritic cells (BMDCs). Administration of microparticles caused less than a 20% reduction of cell viability in these cultures. BMDCs treated with DP-D microparticles had at least ten-fold more expression of IRF-7 and IFN-β mRNA as measured by RT-qPCR than those treated with HBsAg or DP microparticles alone. Surprisingly, the DP-D microparticle-treated cells also had about twice the expression of these genes compared to the positive control HBsAg + DMXAA, which contained ten times more DMXAA than the microparticles. This indicates that the DP-D microparticles induced the STING pathway with high efficiency due to their bioavailability. Next, the group found that DP-D microparticles induced the highest level of chemokine expression (measured via RT-qPCR) and immune cell recruitment (measured via flow cytometry) at the site of injection in inoculated mice compared with HBsAg alone, HBsAg with aluminum salts (traditional vaccine adjuvant), and DP microparticles. This result shows that the DP-D microparticles induced both an innate immune response and an adaptive immune response in mice. Further, the group showed that BMDCs treated with DP-D microparticles had a high level of maturation, expressing CD40, CD86, and MHCII molecules on their surface as measured by flow cytometry. Finally, the group administered the HBsAg-primed microparticles to mice infected with recombinant HBV (rAAV-1.3HBV virus, serotype ayw). Mice treated with both types of microparticles showed a higher cytokine response as well as a higher titer of anti-HBsAg antibody as measured by ELISA. Mice treated with the DP-D microparticles had the most profound immune cell activation and  fastest clearance of serum HBsAg. The microparticle vaccine introduced in this publication is promising because it is highly efficient in delivering antigen to immune cells. The microparticles are unique in that they contain a small molecule STING agonist inside. This design is clever because this vaccine stimulates the innate immune system by activating STING and the adaptive immune system by displaying HBsAg to APCs. This promotes HBV clearance in a multifaceted approach: immune cells produce cytokines through the STING pathway, T cells recognize and destroy infected cells, and B cells secrete anti-HBsAg antibodies to neutralize newly formed viruses. This publication highlights the versatility of biodegradable microparticle technology in designing unique approaches to combat infection. Micro- and nanoparticle delivery systems represent a promising avenue for future drugs to combat HBV and other viruses.

SOX2 Represses Hepatitis B Virus Replication by Binding to the Viral EnhII/Cp and Inhibiting the Promoter Activation – Viruses
This paper from Wuhan University in China identifies the protein sex determining region Y box 2 (SOX2) as a host factor that restricts HBV replication. SOX2 is a transcription factor critical for cell proliferation and the tumorigenecity of solid tumors. In 2006, expression of SOX2 along with three other transcription factors was shown to convert somatic cells into induced pluripotent stem cells. Overexpression of SOX2 indicates poor prognosis in patients undergoing resection of HCC. In HCC cells, SOX2 has also been found to induce the expression of programmed death ligand-1 (PD-L1), leading to the tumor’s evasion of the host immune system. Previously, it has been demonstrated that HBV infection induces increased expression of SOX2 in hepatocytes. This study demonstrates that SOX2 inhibits HBV replication by binding to the Enhancer II (EnhII) and Core Promoter (Cp) regions of the HBV genome. By binding to the EnhII/Cp region, SOX2 disrupts the transcription of the mRNA species precore, core, polymerase, and pgRNA. This reduction of mRNA transcription results in reduced levels of core-associated DNA, HBV surface antigen (HBsAg), and HBV e antigen (HBeAg). To learn this, the group co-transfected both HepG2 and Huh7 cells with a fixed concentration of  HBV 1.3-mer plasmid DNA alongside variable concentrations of Flag-tagged SOX2 in pcDNA3.1 plasmid DNA. Cells transfected with higher concentrations of SOX2 plasmid DNA showed reduced levels of HBV mRNAs (3.5, 2.4, and 2.1 kb) via Northern blotting. SOX2-transfected cells also showed reduced levels of HBV core-associated DNA via qPCR as well as reduced levels of both HBsAg and HBeAg via ELISA. Next, in order to learn  if SOX2 interacts directly with an HBV promoter, a dual-luciferase reporter assay was implemented. Here, four vectors were used, each containing one of the HBV enhancer and/or promoter sequences (preS1, preS2, EnhⅡ/Cp, and EnhⅠ/Xp) upstream of a firefly luciferase reporter. Each of these firefly luciferase reporter vectors were co-transfected into HepG2 cells alongside variable concentrations of SOX2 plasmid DNA. A plasmid encoding Renilla luciferase was also included at a constant concentration in each transfection as a control for transfection efficiency. While firefly luciferase has an emission of 625 nm (red), Renilla luciferase has an emission of 525 nm (green). Therefore, levels of red fluorescence were used to measure the activity of the HBV enhancer/promoter sequences and levels of green fluorescence were utilized as a control for transfection efficiency. Co-transfection with SOX2 significantly diminished the luciferase activity of the EnhII/Cp reporter only and in a dose-responsive manner, indicating its interaction with that region of the HBV genome. Further, using HBV-producing HepAD38 cells, chromatin immunoprecipitation coupled with quantitative PCR (ChIP-qPCR) was used to isolate SOX2 protein and then determine what DNA sequence it was bound to. The EnhII/Cp sequence was found to be highly enriched on SOX2 protein. In order to determine which part of the SOX2 protein is required for binding to the EnhII/Cp region, truncated forms of SOX2 were generated in the pcDNA3.1 plasmid. Using the assays described above, it was found that only SOX2 mutants lacking the high mobility group (HMG) domain were unable to bind to the EnhII/Cp region and suppress HBV products. Interestingly, it was found that SOX2 mutants lacking the transcription activation (TA) domain were still able to bind to the EnhII/Cp region. Further, it was demonstrated by Western blot of subcellular fractions and immunofluorescence that SOX2 mutants lacking the HMG domain were unable to enter the nucleus. Finally, studies were performed in an in vivo BALB/c mouse model. Mice were given a hydrodynamic injection of an adeno-associated viral vector conferring HBV (pAAV-HBV1.3) alongside pcDNA3.1 plasmid DNA conferring SOX, SOX2 lacking HMG domain ( SOXΔHMG), or empty vector. Levels of HBsAG and HBeAg in the blood at days two and four were reduced only in mice given the full length SOX2 plasmid. Additionally, mice given the full length SOX2 plasmid had a reduction of 3.5kb HBV mRNA in liver tissues as measured by qPCR and a lower abundance of HBV core antigen (HBcAg) in liver tissues as measured by immunohistochemical staining. This study shows that SOX2 protein, previously shown to be upregulated by HBV, plays an anti-HBV role in the liver. SOX2 is therefore a new host restriction factor of HBV replication. SOX2 may be one protein which contributes to HBV-induced hepatocarcinogenesis, given its role in promoting the transcription of genes involved in cell proliferation. In the future, SOX2 may be utilized for its anti-HBV activity or targeted for the treatment of HCC.

 Discovery of Small Molecule Cyclic GMP-AMP Synthase Inhibitors – The Journal of Organic Chemistry

This paper from the University of Colorado Boulder introduces the development of novel small molecule inhibitors of the protein cyclic GMP-AMP synthase (cGAS). This publication is in conjunction with Dr. James Chen’s laboratory at the University of Texas Southwestern Medical Center in Dallas, Texas. Dr. Chen’s lab discovered cGAS in 2012. cGAS is a cytosolic, double-stranded DNA (dsDNA)-sensing protein. It belongs to the nucleotidyltransferase family of enzymes which transfer nucleoside monophosphates, the substituents of nucleic acids. When cGAS recognizes dsDNA, it synthesizes the cyclic dinucleotide cyclic GMP-AMP (cGAMP). cGAMP acts as a second messenger and activates the stimulator of interferon genes protein (STING). Once activated, STING triggers TBK1- and IKK-mediated activation of the transcription factors interferon regulatory factor 3 (IRF3) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB). In the nucleus, IRF3 and NF-kB induce the expression of type I interferons and other inflammatory cytokines. cGAS is essential for detecting foreign pathogens which contain dsDNA and triggering an innate immune response to clear them. However, excessive or dysfunctional cGAS activity may lead to chronic inflammation and/or autoimmunity. Pharmacologic inhibition of cGAS may provide treatments for diseases including Aicardi-Goutiés syndrome (AGS), lupus erythematosus, and cancer. Current small molecule inhibitors of cGAS are limited by poor specificity and/or cellular activity. In this study, a high throughput virtual screen (HTVS) was utilized to screen about 1.75 million drug-like compounds for activity against the dimer-forming and DNA-binding faces of mouse cGAS (mcGAS). mcGAS was utilized for the in silico screen because the human cGAS (hcGAS)-DNA complex was only recently published. From this virtual screen, ten compounds were further investigated, leading to the selection of one lead compound. This lead was further optimized for greater potency through chemical modifications resulting in the analogues CU-32 and CU-76. The IC50 of both compounds is below 1µM. To test these compounds’ selectivity for cGAS, human monocyte cells THP-1 were either transfected with  interferon-stimulatory DNA (ISD) or infected with Sendai virus (SeV). ISD is a 45-basepair DNA known to activate cGAS, while SeV is a single-stranded RNA (ssRNA) virus known to activate the RIG-I-MAVS pathway; both stimuli are known to result in IRF3 activation and dimerization. Following treatment with both compounds, Western blot of the cells was conducted probing for the formation of IRF3 dimers. In ISD-treated cells, CU-32 and CU-76 inhibited the formation of IRF3 dimers in a dose responsive manner. Neither compound had any effect on IRF3 dimer formation in SeV-infected cells. This result indicates that these inhibitors are selective to cGAS. Using in silico molecular docking studies, the group speculates that these compounds disrupt the interface of the cGAS dimer, allosterically inhibiting dimerization. The discovery of novel cGAS inhibitors is exciting and important for multiple reasons. These compounds, if made commercially available will allow for improved experimentation investigating the cGAS/STING pathway. If these compounds or their derivatives are found to be safe and effective in humans, they may be promising candidates for the treatment of autoimmune disorders or cancer.

 

Meet our guest blogger, David Schad, B.Sc., Junior Research Fellow at the Baruch S. Blumberg Institute studying programmed cell death such as apoptosis and necroptosis in the context of hepatitis B infection under the direction of PI Dr. Roshan Thapa. David also mentors high school students from local area schools as part of an after-school program in the new teaching lab at the PA Biotech Center. His passion is learning, teaching and collaborating with others to conduct research to better understand nature.

 

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention

New Resource: Guide To Hepatitis B Management for Primary Care Providers

The Hepatitis B Primary Care Workgroup has released a new resource that helps primary care providers prevent, diagnose, and manage hepatitis B! Hepatitis B experts from diverse health disciplines have contributed to making this comprehensive guide, which is available to download for free on the University of Washington’s website. 

Hepatitis B is a complex condition that typically is managed by a liver specialist (hepatologist). However, many people in the U.S. and other parts of the world do not have access to a hepatologist. Many primary care doctors do not feel comfortable or know how to properly care for someone living with hepatitis B. This leaves a large gap in managing and treating the infection. Hepatitis B Management: Guidance for the Primary Care Provider helps to close this gap by giving all providers the tools to understand the virus and how to manage it.

Dr. Amy Tang, Director of Immigrant Health at NorthEast Medical Services and one of the hepatitis B experts involved in creating the guide, answered a few questions about why this resource is so important: 

 

Why was a guide on hepatitis B management needed? What gaps will this help fill? 

 

Primary care providers are recommended to screen and vaccinate for hepatitis B in at-risk individuals.  However, when an individual tests positive for hepatitis B, they are typically referred to a specialist for care.  Because the majority of persons with chronic hepatitis B in the United States are foreign-born with limited English proficiency and often face both linguistic and access barriers to specialists, referral and retention in specialty care for chronic hepatitis B can often lead to lost follow-up.  Chronic hepatitis B management involves visits at least every 6 months for lab monitoring as well as routine ultrasounds for liver cancer surveillance for patients who fulfill high-risk criteria for liver cancer including Asian and African men over 40 years of age and Asian women over 50 years of age.  Because primary care is already performing routine blood tests and cancer screening for a variety of other chronic diseases such as diabetes, hypertension, and breast, cervical, and colon cancers respectively, we believe that empowering primary care providers with a simple to use hepatitis B algorithm would promote increased access and retention in care for persons with chronic hepatitis B.

 

How does this tool work towards the elimination of hepatitis B? 

 

The National Academies of Science, Engineering, and Medicine report for viral hepatitis elimination by 2030 recommends that primary care providers work closely with hepatitis B specialists and their organizations, e.g., the American Association for the Study of Liver Diseases (AASLD) and the Infectious Disease Society of America (IDSA), to increase primary care capacity for HBV screening, vaccination, monitoring, and treatment. Thus the National Taskforce on Hepatitis B in collaboration with ECHO Institute and San Francisco Hep B Free—Bay Area hosted a meeting at the 2018 AASLD Annual Liver Meeting in San Francisco to convene a workgroup of hepatitis B specialists in hepatology, infectious disease, public health, primary care, and pharmacy, as well as representatives from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) to discuss how we can increase primary care capacity for not only hepatitis B screening and vaccination, but also management and treatment.

Currently, the majority of hepatitis B care is managed by specialists.  AASLD puts forth guidelines and guidance for hepatitis B every couple of years, however, the guidelines can be lengthy, difficult to access, or intimidating for busy primary care providers to utilize. We polled over 100 primary care providers across the country through the National Association of Community Health Centers’ network of providers and found that primary care providers were interested in managing hepatitis B but felt like they did not have the tools and resources at their fingertips to do it manage it confidently.  They reported using web-based references like Up-to-Date for easily accessible guidance on conditions they were less familiar with. Thus, we wanted to create an easy to use document that would be easily accessible and free online. We teamed up with University of Washington’s Hepatitis B Online to host our Hepatitis B Guidance for Primary Care Providers as a means to widely disseminate our recommendations and work towards the elimination of hepatitis B in the United States and globally.

 

How and when should primary care providers use this? 

 

Primary care providers should use this hepatitis B guidance document when they decide to screen a patient for hepatitis B as the document guides them through how to properly screen for hepatitis B in asymptomatic individuals, how to interpret their lab results and provide appropriate counseling, and for patients who screen positive for hepatitis B, how to perform their initial evaluation, monitoring, treatment, and liver cancer surveillance.  We also have a dedicated section on perinatal management of women screened for hepatitis B that clearly illustrates the simple steps that can be taken by the primary care provider to prevent transmission of hepatitis B from mother to child. 

The guide includes detailed information on the following topics:

  • Chronic Hepatitis B Testing and Management Algorithm
  • Interpretation of hepatitis B test results
  • Tests to run on a hepatitis B surface antigen positive (HBsAg +) individual and how to counsel them
  • Monitoring and management of the HBsAg + individual 
  • Managing pregnant women who are HBsAg + 
  • Monitoring for liver cancer

The guide is part of Hepatitis B Online – a free suite of materials for providers that supplies information on all topics related to hepatitis B such as when a person should begin treatment and liver cancer screenings. The website also includes prescribing information for approved hepatitis B treatments, and clinical calculators to aid in interpreting predictors of liver damage such as the AST to Platelet Ratio Index (APRI) and fibrosis score. 

 To access and download the new tool, click here! 

Hepatitis B Diagnosis & Monitoring, Hepatitis B Prevention

New Resource: Guide To Hepatitis B Management for Primary Care Providers

The Hepatitis B Primary Care Workgroup has released a new resource that helps primary care providers prevent, diagnose, and manage hepatitis B! Hepatitis B experts from diverse health disciplines have contributed to making this comprehensive guide, which is available to download for free on the University of Washington’s website. 

Hepatitis B is a complex condition that typically is managed by a liver specialist (hepatologist). However, many people in the U.S. and other parts of the world do not have access to a hepatologist. Many primary care doctors do not feel comfor table or know how to properly care for someone living with hepatitis B. This leaves a large gap in managing and treating the infection. Hepatitis B Management: Guidance for the Primary Care Provider helps to close this gap by giving all providers the tools to understand the virus and how to manage it.

Dr. Amy Tang, Director of Immigrant Health at NorthEast Medical Services and one of the hepatitis B experts involved in creating the guide, answered a few questions about why this resource is so important: 

Why was a guide on hepatitis B management needed? What gaps will this help fill? 

Primary care providers are recommended to screen and vaccinate for hepatitis B in at-risk individuals.  However, when an individual tests positive for hepatitis B, they are typically referred to a specialist for care.  Because the majority of persons with chronic hepatitis B in the United States are foreign-born with limited English proficiency and often face both linguistic and access barriers to specialists, referral and retention in specialty care for chronic hepatitis B can often lead to lost follow-up.  Chronic hepatitis B management involves visits at least every 6 months for lab monitoring as well as routine ultrasounds for liver cancer surveillance for patients who fulfill high-risk criteria for liver cancer including Asian and African men over 40 years of age and Asian women over 50 years of age.  Because primary care is already performing routine blood tests and cancer screening for a variety of other chronic diseases such as diabetes, hypertension, and breast, cervical, and colon cancers respectively, we believe that empowering primary care providers with a simple to use hepatitis B algorithm would promote increased access and retention in care for persons with chronic hepatitis B.

How does this tool work towards the elimination of hepatitis B? 

The National Academies of Science, Engineering, and Medicine report for viral hepatitis elimination by 2030 recommends that primary care providers work closely with hepatitis B specialists and their organizations, e.g., the American Association for the Study of Liver Diseases (AASLD) and the Infectious Disease Society of America (IDSA), to increase primary care capacity for HBV screening, vaccination, monitoring, and treatment. Thus the National Taskforce on Hepatitis B in collaboration with ECHO Institute and San Francisco Hep B Free—Bay Area hosted a meeting at the 2018 AASLD Annual Liver Meeting in San Francisco to convene a workgroup of hepatitis B specialists in hepatology, infectious disease, public health, primary care, and pharmacy, as well as representatives from American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) to discuss how we can increase primary care capacity for not only hepatitis B screening and vaccination, but also management and treatment.

Currently, the majority of hepatitis B care is managed by specialists.  AASLD puts forth guidelines and guidance for hepatitis B every couple of years, however the guidelines can be lengthy, difficult to access, or intimidating for busy primary care providers to utilize. We polled over 100 primary care providers across the country through the National Association of Community Health Centers’ network of providers and found that primary care providers were interested in managing hepatitis B but felt like they did not have the tools and resources at their fingertips to do it manage it confidently.  They reported using web-based references like Up-to-Date for easily accessible guidance on conditions they were less familiar with. Thus, we wanted to create an easy to use document that would be easily accessible and free online. We teamed up with University of Washington’s Hepatitis B Online to host our Hepatitis B Guidance for Primary Care Providers as a means to widely disseminate our recommendations and work towards the elimination of hepatitis B in the United States and globally.

How and when should primary care providers use this? 

Primary care providers should use this hepatitis B guidance document when they decide to screen a patient for hepatitis B as the document guides them through how to properly screen for hepatitis B in asymptomatic individuals, how to interpret their lab results and provide appropriate counseling, and for patients who screen positive for hepatitis B, how to perform their initial evaluation, monitoring, treatment, and liver cancer surveillance.  We also have a dedicated section on perinatal management of women screened for hepatitis B that clearly illustrates the simple steps that can be taken by the primary care provider to prevent transmission of hepatitis B from mother to child. 

The guide includes detailed information on the following topics: 

  • Chronic Hepatitis B Testing and Management Algorithm
  • Interpretation of hepatitis B test results
  • Tests to run on a hepatitis B surface antigen positive (HBsAg +) individual and how to counsel them
  • Monitoring and management of the HBsAg + individual 
  • Managing pregnant women who are HBsAg + 
  • Monitoring for liver cancer

The guide is part of Hepatitis B Online – a free suite of materials for providers that supplies information on all topics related to hepatitis B such as when a person should begin treatment and liver cancer screenings. The website also includes prescribing information for approved hepatitis B treatments, and clinical calculators to aid in interpreting predictors of liver damage such as the AST to Platelet Ratio Index (APRI) and fibrosis score. 

 To access and download the new tool, click here! 

Hepatitis B Advocacy, Hepatitis B Treatment, Living with Hepatitis B

Copay Accumulators – What They Are and What They Mean For Your Prescriptions

In January of 2020, the Centers for Medicare and Medicaid Services (CMS)  proposed a new rule that could increase the out-of-pocket costs for people who take prescription medication for hepatitis B in the U.S. The proposed rule states that health insurance companies would be able to collect patient coinsurance through pharmaceutical manufacturer financial assistance. However, the insurance companies will be allowed to disregard any coinsurance paid with copay assistance when calculating how much the patient has paid toward their deductible and annual out-of-pocket (OOP) limit. 

This proposal – titled 2021 Notice of Benefit and Payment Parameters – reverses a recent ruling that would have required health insurance companies to count the value of manufacturer copay assistance toward an enrollee’s annual deductible and OOP limit in most circumstances1.  This rule acknowledged that manufacturer copay assistance helps lessen the financial burden of medications for patients. In the US, prescription drugs can be extremely costly, making manufacturer’s copay assistance programs necessary for many patients.  For example, brand name treatments are often expensive in order to help pharmaceutical companies earn back the costs of the research and time spent making the medication. Sometimes, the brand name treatments are the only ones that are available, like Vemlidy, or the only version that a person can take. A reversal of the rule would mean that hepatitis B patients and those living with other chronic illnesses may have to pay a larger amount of out-of-pocket costs for their medications. 

To understand the significance of this change, we first need to understand what a copay accumulator is. 

What is a Copay Accumulator Program and How Does It Work?  

A copay accumulator – or accumulator adjustment program – is a strategy used by insurance companies and Pharmacy Benefits Managers (PBMs) that stop manufacturer copay assistance coupons from counting towards two things: 1) the deductible and 2) the maximum out-of-pocket spending. What does this mean? 

Previously, a person could receive financial assistance from companies that make a drug, and that would count towards their deductible and/or out-of-pocket costs, depending upon the insurance plan. Pharmaceutical companies often provide financial assistance (such as a co-pay card) to help underinsured individuals afford expensive medications. This means that the person paying for the drug would end up saving money, often thousands of dollars. 

Why Is This an Issue? 

As the AIDS Institute explains it, “ … the trend in health insurance benefit design is to shift more of the cost of health care to patients through high deductibles and coinsurance rates …In order to afford the medicine they need, patients increasingly rely on manufacturer copay assistance.” With copay accumulators, the individuals who need assistance the most will be unable to receive it, and will end up paying more for their treatments. 

Below is an example of a copay accumulator program from the Patient Access Network (PAN)  Foundation: 

 

 

 

 

As shown in the above image, with a copay accumulator program – meaning her manufacturer’s assistance is no longer counted toward her out-of-pocket limit- the consumer ends up paying more, while the insurance company is able to reduce the amount they are paying. 

Copay accumulator programs are making life-saving treatments increasingly inaccessible. Research shows that the more out-of-pocket costs a person has to pay, the more likely they are to abandon their medication. Once on a hepatitis B medication, stopping suddenly or only taking it once in a while can cause flares and lead to an even higher risk of liver damage. 

In the United States, many of those who are living with hepatitis B come from underserved populations with limited access to healthcare. Oftentimes, cultural differences and language barriers can make it difficult to access and utilize the services they need. Now, copay accumulators are making the navigation process even more complex and placing a higher cost burden on patients. 

 1 The rule required insurance companies to count manufacturer copay assistance toward a patient’s deductible and OOP limit for all brand name drugs for which there is no generic alternative and in cases where the patient gained access to the brand name drug through an insurance plan’s appeals or exceptions process.

Hepatitis B Research, Hepatitis Delta (HDV)

Drug Update: Replicor Researchers Talk to HBF About Potential New Hep B and D Treatment

In October 2019, the Hepatitis B Foundation had the opportunity to speak with Andrew Vaillant, Ph.D., Chief Scientific Officer at Replicor at the annual International HBV Meeting in Melbourne, Australia. Dr. Vaillant gave us an inside look at REP 2139 – their drug candidate developed for the treatment of chronic hepatitis B and HBV/HDV coinfection. REP 2139 is a nucleic acid polymer that removes surface antigen (HBsAg) and as part of combination therapy, has achieved functional cure for chronic HBV (sustained HBsAg loss) and sustained clearance of HDV infection from the blood in early phase II proof of concept clinical trials it has completed to date. REP 2139 is currently in phase II of clinical trials. Below is Dr. Vaillant’s response to a series of questions we posed to him.

1. Replicor’s drug candidate REP 2139 is a nucleic acid polymer (NAP) for the treatment of chronic hepatitis B. Can you explain the mechanism for this drug and how it works?

REP 2139 is a polymer built from the building blocks the body uses to store genetic material in the body (nucleic acids). These building blocks are linked together in a unique pattern to form nucleic acid polymers (or NAPs for short) and in the case of REP 2139, use only naturally occurring nucleic acids and modifications to prevent it being recognized as a foreign molecule. As a result, REP 2139 is very well tolerated and safe in clinical trials.

In HBV infection, the most abundant viral antigen in the blood is the hepatitis B surface antigen (HBsAg) which plays an important role in preventing immune control of HBV. Circulating HBsAg is almost entirely in the form of non-infectious HBV subviral particles (SVP) which are produced independently from viral replication, making this viral antigen difficult to target with approved therapies. REP 2139 naturally enters liver cells (hepatocytes) and blocks the assembly of SVP in any hepatocyte producing SVPs. This mechanism effectively blocks the replenishment of HBsAg in the blood and also reduces HBsAg inside these hepatocytes. The overall antiviral effect of REP 2139 is to allow the body to clear HBsAg in order to reduce or remove the inhibition of immune control caused by this viral antigen.

2. REP 2165 is also mentioned as a drug candidate. Can you explain the difference between REP 2139 and REP 2165.

REP 2165 is a close cousin of REP 2139 being examined for potential use in future therapy with more frequent dosing to improve HBsAg response in selected cases and was proven to be as effective as REP 2139 in this study. More information about REP 2165 can be found under question 6.

3. Can you share the latest results from phase 2 trials? How is REP 2139 administered to patients, and for what duration of time? What kind of side effects can patients expect with REP 2139?

In our latest trials, side effects have been limited to mild effects from pegylated interferon (pegIFN). REP 2139 is currently given in a formulation (REP 2139-Mg) which results in little to no side effects during administration. REP 2139 is currently administered once every week for 48 weeks by intravenous infusion in combination with other antiviral agents. REP 2139-Mg is expected to be as effective with a once weekly injection under the skin (subcutaneous injection) which will be used in future trials.

4. Is REP 2139 equally effective in HBeAg positive and negative patients?

REP 2139 is effective in HBeAg positive and in HBeAg negative patients in multiple genotypes. As REP 2139 targets a host protein involved in SVP formation and not the virus or SVP directly, its antiviral effects are expected to be similar in all HBV genotypes and may also be effective in the presence of other co-infections with HBV such as HCV and HIV.

5. Can REP 2139 be safely used in patients with cirrhosis?

Another of the remarkable features of NAP based therapy is the high rate of flares in liver transaminases during therapy (occurring in almost all participants in the REP 401 study). Patients with these flares had no symptoms or any negative impact on their liver function.

Continually expanding evidence in the field tells us that during treatment of HBV, these flares are signs of elimination of HBV infection from the liver and are not accompanied by changes in liver function. These same features appear to hold true for transaminase flares during NAP therapy and, when occurring in the absence of HBsAg in the blood, are highly correlated with functional cure in our clinical trials. The ability of cirrhotic patients to tolerate these flares will be tested in future trials and we are encouraged by recent results (produced by a different group) with pegIFN in HBV / HDV co-infected patients showing that host mediated transaminase flares may also be well tolerated in cirrhotic patients.

6. Do you anticipate combination therapy will be needed? Will combination therapy include immune modulators like pegylated interferon and/or treatment with antivirals?

Replicor’s latest REP 401 study is the first in the field to feature triple combination therapy: Tenofovir disoproxil fumarate (TDF), pegIFN and either REP 2139-Mg or REP 2165-Mg. REP 2165 is a close cousin of REP 2139 being examined for potential use in future therapy with more frequent dosing to improve HBsAg response in selected cases and was proven to be as effective as REP 2139 in this study. In addition to the excellent control of HBV DNA with TDF exposure, this triple combination therapy for 48 weeks led to meaningful HBsAg decline (greater than a 10-fold reduction from baseline) in 90 % of participants, HBsAg clearance to very low levels similar to HBsAg “negative” in the qualitative test used in the United States (< 0.05 IU/mL) and HBsAg seroconversion (often with very high titers of anti-HBs antibodies) in 60% of participants. After removal of all treatment (including TDF), a 48-week follow-up yielded very encouraging results: 89% had normal liver function, 56% had reduced liver inflammation, 39% had stable virologic control and an additional 39% had functional cure with HBsAg seroconversion. These results illustrate the effectiveness of combining potent HBsAg reduction with immunotherapy but also suggest that direct acting antivirals such as TDF and entecavir may also contribute to establishing functional cure in a combination setting.

7. Surface antigen loss is key to people living with chronic HBV. Do you believe REP 2139 can provide a functional cure for chronic HBV?

In an early clinical study using NAPs alone, HBsAg clearance by itself resulted in virologic control (low level infection with normal liver infection no longer requiring therapy under current guidelines ) or functional cure (complete control of HBV DNA and HBsAg) persisting after removal of all therapy only in a small proportion of patients but stable throughout a 5 year follow-up. Importantly, HBsAg clearance with REP 2139 in a subsequent study led not only to a dramatic improvement in the activity of various immunotherapies (including pegIFN) but to virologic control occurring in a larger proportion of patients after removal of therapy persisting throughout more than 2 years of follow-up. As a result of these early studies, Replicor believes that the best approach to achieving functional cure of HBV infection is to simultaneously combine potent HBsAg reduction using REP 2139 with immunotherapy to restore effective and long-lasting immune control.

8. Which countries do you anticipate phase 3 trials to occur? Do you anticipate trials in the U.S?

Replicor believes that the combination of therapy with NUCs such as TDF and ETV, pegIFN and REP 2139-Mg will be the first available therapy to offer patients a real chance of eliminating the need for therapy and establishing functional control of their HBV infection and normalizing their liver function. Work is ongoing to start a phase II US trial in collaboration with the Aids Clinical Trials Group as soon as possible. We are also planning to assess other immunotherapies, the effectiveness of which we believe will be similarly improved with HBsAg clearance as we have demonstrated for pegIFN.

9. With regard to hepatitis delta, is there a difference in the mechanism for how it works?

REP 2139 is also potently active against HDV infection and is able to rapidly eliminate HDV RNA, normalize liver function and reverse the liver inflammation associated with HBV / HDV co-infection. The completed follow-up results from our long term follow-up study of co-infected participants treated with REP 2139 and pegIFN show complete control of HDV infection at 3.5 years follow-up in the absence of all therapy in a large proportion of patients. In many patients this control of HDV infection was associated with functional cure of HBV and in some patients with virologic control of HBV. This potent effect against HDV infection is assumed to be driven not only from the effect of REP 2139 on SVP (which also forms the envelope of the HDV virus) but on the ability of REP 2139 to interact with different forms of the hepatitis delta antigen protein essential for HDV replication and assembly.

Thank you to Dr. Vaillant for taking the time to talk to us about REP 2139. The results look promising! We look forward to learning more from continuing and new trials with REP 2139, used alone and in combination with antivirals and immune modulators. We know the hepatitis B virus is challenging, but those living with chronic HBV look forward to a day when there are therapies resulting in a durable loss of surface antigen and sustained viral suppression in a reasonable, finite amount of time. 

Liver, Liver Health, Living with Hepatitis B

Love Your Liver This Valentine’s Day

For most people, Valentine’s Day is a day full of love, but for those living with hepatitis B, it can be filled with dread and anticipation. Perhaps you haven’t told your significant other that you have been diagnosed with hepatitis B, or maybe you are spending this year alone because you are scared to begin a relationship. This year, instead of focusing on others, take Valentine’s Day to love yourself – and your liver! 

Taking Care of Your Liver 

Find a Knowledgeable Provider (and be sure to see them regularly!): 

Most people who are diagnosed with hepatitis B lead long, healthy lives. The key is proper care and monitoring by a trained healthcare provider. If you do not yet have a healthcare provider who is regularly monitoring your diagnosis, you can search our physician directory to find one near you. You can also search the World Hepatitis Alliance’s member list to find local resources and organizations who can help you identify a provider in your area.  

It is always a good idea to conduct your own research as well! Look into what your provider specializes in, as some may be more knowledgeable about the infection than others. Ideally, it would be best to regularly see a hepatologist – someone who specializes directly in diseases of the liver. However, due to finances and other constraints, this may not be an option for everyone. Seeing any doctor is extremely important, but if you only have access to a provider who is not as experienced in hepatitis B, make sure that they are performing the correct tests to monitor the health of your liver. At each follow-up appointment, your doctor should: check your liver enzymes (ALT, AST), perform a physical exam of the liver, and any other blood tests they might feel is needed to determine the stage of the infection and the health of the liver. Sometimes, the doctor will also perform an ultrasound of the liver to get a better picture of what is going on. You can find some questions that are important to ask your doctor here. 

Watch What You Consume: 

When people are first diagnosed with hepatitis B, they may feel fine and may not consider making small changes in their daily lives. The truth is that your diet plays a large role in the health of your liver! Everything that enters your body is filtered through your liver. This makes adopting healthy habits essential to keeping the liver in good shape. A standard rule of liver disease is to avoid alcohol – even small amounts – and maintain a steady diet of fruits and vegetables. Foods that are high in fat, salt, and sugar content can lead to weight gain, which puts a strain on your liver. Beware of what you are drinking as well! Drinks like juices and sodas might seem like healthier options, but often contain high amounts of sugar. Diet sodas may lack sugar but have other additives which may have other health implications. Opt for flavored water or seltzer to satisfy a sweet craving instead! If healthier beverage options are not readily available, see if any coffee is available. Studies have shown that drinking coffee can lower one’s risk of developing liver damage and liver cancer – just be sure to watch how much sugar and creamer you put in it! Other diseases of the liver, such as fatty liver, can also increase your risk of liver damage and liver cancer, so it is extremely important to be aware of the risks and what you are consuming. 

Those living with hepatitis B should also be aware of aflatoxins. Aflatoxins – which can cause liver cancer – are natural toxins that are produced by a mold that grows on crops like corn, peanuts, and tree nuts. Aflatoxins are more common in warm, humid parts of the world, such as African countries and areas with tropical climates. Before eating any grains and nuts, check for any signs of mold. If the food appears to be moldy, do not consume it. The World Health Organization also recommends buying grains and nuts as fresh as possible to minimize the risk of aflatoxin exposure. The fresher the food is, the less time it has been in storage, which is where aflatoxins commonly grow. 

Be Mindful of Your Stress Levels: 

Living with hepatitis B can be a big stressor, especially for those who may face stigma and discrimination. Research shows that stress can negatively impact liver health. Take some time to find ways that might relieve your stress, such as meditation, listening to music. Being social can also be a stress reliever for some, so try spending more time with your trusted friends and family members. Exercise is also a great stress reliever and it has the benefit of helping you maintain a healthy weight! 

If you are celebrating Valentine’s Day with your partner or if you are in a new relationship, remember that hepatitis B is preventable and cannot be transmitted casually! Holding hands, kissing, or sharing utensils or food made by someone who is living with hepatitis B will not spread the infection. Hepatitis B is a vaccine-preventable disease so make sure that they have completed their hep B vaccine series. If they are not protected from hepatitis B, be sure to practice safe sex (use a condom) to prevent transmission.

Hepatitis B Research

Hepatitis B Research Review – February

Welcome to the Hepatitis B Research Review! This monthly blog shares recent scientific findings with members of Baruch S. Blumberg Institute (BSBI) labs and the hepatitis B (HBV) community. Technical articles concerning HBV, Hepatocellular Carcinoma, and STING protein will be highlighted as well as scientific breakthroughs in cancer, immunology, and virology. For each article, a brief synopsis reporting key points is provided as the BSBI does not enjoy the luxury of a library subscription. The hope is to disseminate relevant articles across our labs and the hep B community. 

This paper from the University of Duisburg-Essen in Germany shows that hepatocytes infected with HBV exhibit innate immune signaling via the pattern precognition receptor (PRR) Toll-Like Receptor 2 (TLR2). The adaptive immune response to HBV infection is well characterized and is broken into phases based on serological testing of antibodies produced against the virus. However, whether HBV infection triggers an innate immune response has remained controversial, with the long-held belief being that HBV evades the innate immune system as a “stealth virus”. Contrary to this view, studies of acute HBV infection in patients have indicated an early, innate immune response to HBV characterized by a natural killer (NK) cell response. Toll-like receptors (TLRs) are a class of membrane-bound receptor proteins which play a key role in innate immunity by recognizing foreign pathogens and activating inflammatory signaling cascades. A previous publication from this group has demonstrated that primary human hepatocytes (PHHs) can be stimulated through the TLR proteins TLR1-9. In this paper, PHHs from human donors were infected with HBV ex vivo. Then, expression of the innate immune cytokines Interleukin 1 Beta (IL1B), Interleukin 6 (IL6), and Tumor Necrosis Factor Alpha (TNFα) were measured by quantitative, reverse-transcription polymerase chain reaction (qRT-PCR). HBV-infected PHHs showed greatly increased expression of these genes at three hours after infection compared to mock-infected and not treated PHHs. Additionally, immunocytochemical staining revealed translocation of the transcription factor nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) to the nuclei of HBV-infected PHHs, indicating a cytokine response. Next, to characterize the innate immune response caused by HBV infection, a DNA microarray was used. Here, PHHs were either infected with HBV or treated with a known TLR ligand such as Pam3Cys (TLR2 agonist) or poly(I:C) (TLR3 agonist). Then, RNA was extracted from the cells and converted through a complementary DNA (cDNA) intermediate into biotin-labeled anti-sense RNA (aRNA) which was then hybridized to a Human Genome U219 Array Plate. This plate, coated with over 530,000 DNA probes representing over 20,000 human genes served as a scaffold for complementary base-pair binding of the aRNAs derived from the cells. Once bound to the microarray, the biotin-labeled aRNAs were detected by staining with streptavidin phycoerythrin, resulting in a fluorescent signal wherever complementary base-paring occurred. This microarray analysis revealed which specific inflammatory genes were up-regulated in the PHHs by each stimuli. Gene expression signals which were induced by HBV infection were compared with those induced by the TLR agonists. The gene expression profile of HBV-infected PHHs was most similar to that of PHHs treated with the TLR2 agonist Pam3Cys. This data indicates that HBV infection induces a TLR2-like innate immune response. Importantly, no expression of interferon-stimulated genes (ISGs) was detected in the microarray analysis. Finally, PHHs were pre-treated with neutralizing antibodies against TLR2 (nABTLR2) prior to infection with HBV. HBV-mediated induction of IL1B, IL6 and TNF was significantly reduced by nABTLR2 pre-treatment and conversely, HBV replication was increased. In summary, this paper shows that PHHs exhibited an innate immune response to HBV infection via the TLR2 pathway. The group suggests that this response is one of the body’s first steps leading to HBV clearance. Furthermore, in the discussion section the group indicates that the HBV surface antigen (HBsAg) is likely the protein component of HBV which activates TLR2 upon infection. This finding may help in the development of strategies to cure chronic HBV infection.

​This paper from Wuhan University in China reports that HBV infection can increase the expression of Programmed Death Ligand 1 (PD-L1) on the surface of infected hepatocytes, allowing them to escape destruction by the adaptive immune system. PD-L1 is the binding partner of Programmed Death 1 (PD-1), an immune checkpoint protein on the surface of T cells. The expression of PD-L1 on cell surfaces allows for their recognition by circulating T cells as part of the body and not an outside threat. This interaction is important for the prevention of autoimmune disorders in which the immune system attacks healthy cells of the body. However, PD-L1 is commonly over-expressed in a number of cancers and is a hallmark of especially aggressive cancers. PD-L1 expression on cancer cells allows them to neutralize T cells which specifically target them. This is one example of an “immune-escape” strategy exhibited by cancers. Accordingly, PD-L1 and PD-1 are the target of a number of FDA approved immunotherapies for cancer including the PD-L1 inhibitors Tecentriq, Bavencio, and Imfinzi and the PD-1 inhibitors Keytruda, Opdivo, and Libtayo. These drugs are some of the first in their class in that they are not small molecules, but are recombinant, monoclonal antibodies. Phosphatase and tensin homologue deleted on chromosome 10 (PTEN) is a tumor suppressor which is mutated or deleted in many human cancers. PTEN is a phosphatase, a protein which dephosphorylates other molecules. This group has previously shown that PTEN plays a role in antiviral innate immunity. Therefore, they wanted to see if PTEN also regulates the adaptive immune response in the context of HBV infection. First, they used immunohistochemical staining of patient liver tissues to compare the levels of PTEN and PDL-1 in patients chronically infected with HBV vs healthy controls. There was a reduced staining of PTEN and a heightened staining of PD-L1 in chronic HBV tissues compared to controls. The group then found a similar correlation using immunofluorescence, qPCR and Western blotting of HepG2 cells vs HepG2.2.15 (HBV-producing) cells. They also transfected HepG2 cells and infected mice via hydrodynamic injection with an HBV-containing vector (pHBV1.3) or an empty vector control (pUC18) and then performed qPCR and/or Western blotting.  In all systems, HBV infection/production induced a reduction of PTEN and an increase in PD-L1 expression. Then, in order to elucidate this phenomenon further, a PTEN-expressing plasmid was transfected into HepG2.2.15 cells, which resulted in a reduction in PD-L1 mRNA and protein. Conversely, PTEN knockdown in HepG2.2.15 cells resulted in a two-fold increase in PD-L1 mRNA and protein expression. These results show that HBV inhibits PTEN expression which in turn causes up-regulation of PD-L1. Next, the group transfected HepG2 and Huh7 cells with a number of constructs conferring individual HBV proteins. They found that HBV X protein (HBx) and HBV polymerase (HBp) reduced PTEN expression more than any other HBV protein components. Next, the group analyzed how HBV production in hepatocytes affected human T cells grown in co-culture. Jurkat T cells were co-cultured with either HepG2 or HepG2.2.15 cells and then analyzed by flow cytometry. Jurkat T cells grown alongside the HBV-producing HepG2.2.15 cells had a higher incidence of apoptosis, a higher expression of PD-1, and less Interleukin-2 (IL-2) secretion than those grown alongside HepG2 cells. This result indicates that HBV-infected hepatocytes suppress local T cell responses by PD-L1/PD-1 signaling. Finally, the group used a mouse model of HBV infection to show that PTEN over-expression promotes HBV clearance in vivo. This paper shows that PD-L1, a highly studied drug target implicated in the immune-escape of cancers is also up-regulated by HBV infection. Furthermore, the HBV proteins responsible for this up-regulation are HBx and HBp. This finding may help in the development of  immunotherapies to treat chronic HBV infection. Perhaps FDA approved PD-L1 or PD-1 inhibitors may be used in conjunction with interferon alpha treatment or HBV antivirals to boost the immune response against HBV-infected hepatocytes.

This paper from National Tsing Hua University in Hsinchu, Taiwan reports the design and testing of nanoparticles which selectively confer immunogene therapy to hepatocellular carcenoma (HCC) cells. Nanoparticles are very small (1-1000nm) particles which have become an attractive novel drug candidate in recent years. The use of nanoparticles as medicine would enable the customizable delivery of DNA, RNA, or protein payloads to cells. The novel nanoparticles presented here deliver both a small interfering RNA (siRNA) against the Programmed Death Ligand 1 (PD-L1) gene as well as a plasmid DNA (pDNA) encoding the cytokine Interleukin 2 (IL-2). The strategy behind the nanoparticles’ design is to both inhibit an immunosuppressive gene (PD-L1) and up-regulate an immunostimmulatory gene (IL-2) in tumor cells. Delivery of such genes to tumor cells would make them more vulnerable to destruction by circulating cytotoxic T cells (CD8+ T cells). This type of approach is needed, because many advanced tumors create an immunosuppressive tumor micro-environment (TME) rendering many cancer treatments ineffective. The nanoparticles presented here are referred to as tumor-targeted lipid dendrimer-calcium phosphate (TT-LDCP) nanoparticles. The nanoparticles consist of a core of calcium phosphate, thymine-capped polyamidomine (PAMAM) dendrimers, siRNA, and pDNA. This core is coated with an inner lipid called DOPA and outer leaflet lipids DOPC, DOTAP, and DSPE-PEG. The nanoparticle is then tagged with SP94 (SFSIIHTPILPL), a polypeptide which selectively binds to HCC cells but not healthy hepatocytes. Dendrimers are repeatedly-branching molecules which exhibit a sphere-like shape. PAMAMs are the most well-characterized class of dendrimers, consisting of branching amide and amine groups. The calcium phosphate and PAMAM dendrimers in the core of the TT-LDCP nanoparticle promote endosomal escape of the nucleic acid payload. Additionally, this group shows that the PAMAM dendrimers in TT-LDCP nanoparticles also activate the STING pathway. The group showed that STING was activated by treating mouse HCC cells HCA-1 with complete nanoparticles or those lacking the dendrimers. Cells treated with complete nanoparticles showed, by Western blot a higher level of both TBK1 and IRF3 phosphorylation than those treated with incomplete nanoparticles. Those cells treated with complete nanoparticles also displayed heightened transcription of the STING-triggered proinflammatory genes Ifnb,Ccl5, and Cxcl10 as measured by qPCR. Furthermore, the group showed that treatment using their nanoparticles of mice bearing orthotopic HCC implants resulted in dendritic cell maturation in those animals, regardless of the identity of the genes delivered. These results indicate that the dendrimers used in the TT-LDCP nanoparticles not only serve for efficient delivery of nucleic acids, but also as adjuvants that stimulate the STING pathway and activate tumor-infiltrating dendritic cells. This publication gives a glimpse into what future therapies for cancer may look like. The nanoparticle designed by this group is unique in that it has multiple functionalities: selectively targeting HCC cells, inhibiting PD-L1 expression, inducing IL-2 expression, and activating the STING pathway. Such a complex design is bound to require fine tuning before it can become a medicine. But a multi-target immunotherapeutic such as this may be exactly what is needed to help the body fight against aggressive, immunosupressive tumors.

Lay Summary: 
This month, the innate immune system was the focus of HBV research. Scientists hope to find how the innate immune system interacts with HBV during viral infection and proliferation. Doing so will shed light on host factors which lead to chronic infection and inform antiviral strategies. Notably, this month a human protein, MX2 was found to have potent anti-HBV activity by preventing cccDNA formation. Also, a microRNA encoded by HBV called HBV-miR-3 was found to activate the human innate immune system to limit HBV replication. This month, a paper studying woodchuck hepatitis virus (WHV) traked activation of the innate immune system as well as he adaptive immune system in an acute infection model. Also this month, concerning hepatocellular carcenoma (HCC), the alternative splicing of mRNA in tumors was found to vary in HCC patients based upon their risk factor (HBV, HCV, or alcohol). Finally, a review was published this month concerning STING, an innate immune protein which is not activated by HBV infection but which may prove a valuable tool for cancer treatment.  

Meet our guest blogger, David Schad, B.Sc., Junior Research Fellow at the Baruch S. Blumberg Institute studying programmed cell death such as apoptosis and necroptosis in the context of hepatitis B infection under the direction of PI Dr. Roshan Thapa. David also mentors high school students from local area schools as part of an after-school program in the new teaching lab at the PA Biotech Center. His passion is learning, teaching and collaborating with others to conduct research to better understand nature.

Hepatitis B Research, Living with Hepatitis B, News

Hep B Patient Engagement Survey: Help Guide The Future of Hepatitis B Therapies

If you’ve ever wanted to help guide the future of hepatitis B treatments, now is your chance! The Hepatitis B Foundation has created a short survey that is designed to capture a comprehensive view of the patient experience. The survey, which takes approximately 20-25 minutes to complete, will be made available for use by the US Food and Drug Administration (FDA) and drug development researchers to help clinical trial development for future hepatitis B therapies. All survey responses are anonymous.  

All individuals living with chronic hepatitis B are welcome to take this survey! After answering a few standard questions, participants will be asked whether or not they are currently on treatment for hepatitis B. If they are on treatment, the survey will prompt the participant to answer a few questions about their experience with the medication, such as how it makes you feel to take it, 

and what challenges you may face while taking your medication. All participants, regardless of their current treatment status, will have an opportunity to provide feedback on what they hope future medications will look like! 

The patient perspective is essential to creating a treatment that is not only effective but something that those living with hepatitis B would be willing to take. Oftentimes, researchers do not have the opportunity to gather insight into what patients are looking for or how a therapy would impact their lives. This can result in missed dosages of a medication, or avoiding a therapy altogether, rendering the treatment ineffective. This survey is also unique because it seeks to capture the diverse experiences of global patients living with hepatitis B. As we want to ensure that new treatments are as universal as possible, gathering the thoughts of both international and national individuals will ensure that different voices and opinions are captured! 

The survey is the first part of a multistep process to collect information on the patient experience. In the upcoming months, we will carry out focus groups and interviews to have a better understanding of what it is like to live with hepatitis B, its impact on a person’s daily life, and more. The information collected will help to direct our patient-focused drug development meeting – a chance for stakeholders and those living with hepatitis B to meet and discuss the patient perspective –  in June 2020.

The work being done will result in a broader understanding of how individuals are affected by the disease and more informed decisions regarding future hepatitis B therapies. Help guide the future of hepatitis B clinical trials and drug development by taking the survey today! 

Hepatitis B Research, Hepatitis Delta (HDV)

Eiger BioPharmaceuticals: Developing Two New Hepatitis Delta Treatments

Eiger is currently working on two new drugs for hepatitis delta; Lonafarnib and Pegylated Interferon Lambda, which are both currently inphase 3 clinical trials. Lonafarnib is a new type of treatment that attempts to control hepatitis delta through a new method: through blocking a key enzyme that is needed for the hepatitis delta virus to replicate. Blocking this enzyme prevents a new virus from being created, which may control and even cure hepatitis delta.

Lambda is being developed as a better tolerated interferon compared to interferon alfa (IFN alfa). Interferons work by stimulating the body’s own immune system to fight the virus. Pegylated interferon alpha, which is the only current treatment for hepatitis delta, is a difficult treatment to tolerate, with many patients experiencing unpleasant side-effects. Lambda utilizes the same method of treatment as IFN alfa, in combination with a new strategy, which stimulates an immune response and targets receptors in the liver, which may reduce side effects and result in improved tolerability.

Below is Eiger Biopharmaceuticals’ response to a series of questions we posed to them. 

Image courtesy of Praisaeng, at FreeDigitalPhotos.net.

1. Lambda is an immunomodulator and Lonafarnib is a prenylation inhibitor. Can you explain in laymen’s terms the mechanism for these drugs and how they work?

Eiger’s wording: Lonafarnib is a well-characterized, first-in-class, orally active inhibitor of an enzyme that is key to a vital process in the life cycle of HDV. Inhibiting this enzyme blocks the ability of HDV to assemble and package viral particles. Currently approved nucleos(t)ide treatments for HBV only suppress HBV DNA, do not affect HBsAg, and have no impact on HDV infection.

Lambda is being developed as a better tolerated interferon compared to interferon alfa (IFN alfa). Lambda is a well-characterized, first-in-class, type III interferon (IFN) that stimulates immune responses that are critical for the development of host protection during viral infections. By targeting receptors that are localized in the liver, Lambda treatment may reduce side effects and result in improved tolerability .

Can you share, in simple terms, the basic results of Eiger phase 3 studies for hepatitis delta trials? Are these drugs equally effective in HBeAg positive and negative HBV patients?

The Eiger Phase 2 LOWR program with Lonafarnib has been completed. Over 120 patients were dosed in Phase 2 dose-finding studies to identify combination regimens of lonafarnib (LNF) and ritonavir (RTV) with and without pegylated interferon-alfa (PEG IFN α), with efficacy and tolerability to enable viral load suppression of HDV RNA and ALT normalization at Week 24.

  • Dosing regimens of LNF 50 mg twice daily + RTV 100 mg twice daily with and without PEG IFN-a-2a 180 mcg once weekly were identified with the following reported results:
    • All-oral: Lonafarnib boosted with ritonavir
    •  29% of patients achieved ≥ 2 log decline and ALT normalization
  •  Combination: Lonafarnib boosted with ritonavir + PEG IFN-a-2a
    •  63% of patients achieved ≥ 2 log decline and ALT normalization

These dosing arms are being further studied in the global Phase 3 D-LIVR study. Phase 2 studies have not been stratified by HBeAg status.

The D-LIVR Study, a Phase 3 pivotal trial, is on-going and evaluating the safety and efficacy of lonafarnib treatments in patients chronically infected with Hepatitis Delta Virus (HDV). Topline Week 48 data will be available in 2021.

2. How will Lambda and Lonafarnib be administered to patients?

Lonafarnib capsules are administered orally twice daily by mouth. Lonafarnib is taken in combination with ritonavir, a therapeutic booster that increases the bioavailability of lonafarnib. Ritonavir tablets are administered orally twice daily by mouth.

Pegylated interferon-lambda is administered as a self-administered subcutaneous injection once weekly.

3. Do you anticipate combination therapy will be needed and if so, which combinations do you anticipate?

No form of viral hepatitis has been cured with a single drug. Combinations of treatments with different mechanism of actions have always been required.

Lonafarnib and interferons have different mechanisms of action and have been studied as monotherapies and in combination together as treatments for HDV. While each treatment alone reduces the HDV viral load, combination studies have shown that using these treatments together leads to a synergistic effect and further reduces the HDV viral load.

Recently, the interim end of treatment results of peginterferon lambda (Lambda) and lonafarnib combination study in HDV-infected patients were presented at AASLD 2019. The LIFT study is being conducted within the National Institutes of Health (NIH) at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). LIFT is a Phase 2a open-label study of 26 adult patients with chronic HDV treated with Lambda 180 mcg once weekly in combination with Lonafarnib 50 mg twice daily boosted with ritonavir 100 mg twice daily for 24 weeks. Primary efficacy endpoint is > 2 log HDV RNA decline at end of treatment. At the time of analysis, 19 of 26 patients had reached Week 24. Median HDV RNA decline was 3.4 log IU/mL (IQR: 2.9-4.5, p<0.0001) with 53% (10 of 19) patients achieving below the limit of quantification and 37% (7 of 19) patients achieving undetectable HDV RNA at Week 24. 18 of 19 patients (95%) achieved primary endpoint of > 2 log decline during 24 weeks of therapy. We believe these data are the most encouraging yet in pursuit of HDV cure.

4. What kind of side effects can patients expect with Lambda and Lonafarnib, with or without combination therapy?

The most common side effects of lonafarnib include diarrhea, nausea, fatigue, decreased appetite, vomiting, abdominal pain, and decreased weight. Antacid, antiemetic, and antidiarrheal medications may be used prophylactically to treat these gastrointestinal side effects.

The most common side effects of pegylated interferon-lambda (Lambda) are the expected side effects of interferons. However, these side effects have been demonstrated to be much milder and less severe than what has been previously been shown with pegylated interferon-alfa (alfa). These include musculoskeletal (myalgia, arthralgia, and back pain), flu-like symptoms (chills, pyrexia, and pain) and elevated alanine aminotransferase (ALT) levels.

A combination of these side effects is expected with combination therapy.

5. Are Lambda and Lonafarnib safe for use in people with cirrhosis?

Currently, the safety and efficacy of lonafarnib and pegylated interferon-lambda are being investigated in persons chronically infected with HDV. The clinical trials require study participants meet certain eligibility criteria to be included in these studies. These eligibility criteria may or may not reflect the type of patient who will use these therapies after they receive FDA approval.

Phase 2 and Phase 3 studies both include patients with well-compensated cirrhosis.

6. With a clearance of HDV, would you also anticipate a loss of surface antigen – functional cure for chronic HBV as well? If so, in what percentage of HBeAg and HBeAb patients?

HDV is always found as a co-infection with HBV because HDV requires just a small amount of HBV surface antigen (HBsAg) to complete HDV viron replication. However, an HDV / HBV coinfection leads to much more severe chronic viral hepatitis compared to HBV monoinfection alone. Therefore, it is important to treat HDV, even if HBV is not cured. It is possible to clear HDV RNA without loss of HBsAg.

7. Lambda and Lonafarnib are currently in phase 3 trials for delta. Are you able to provide an approximate timeline for when it will be approved for use in U.S. and Europe?

Eiger BioPharmaceuticals is committed to developing safe and effective therapies for HDV and providing patients with a pathway to gain access to approved therapies as quickly as possible.

The D-LIVR Study is a global study that is evaluating the safety and efficacy of lonafarnib treatment in patients chronically infected with HDV. The D-LIVR Study is recruiting subjects in up to 20 countries in over 100 study sites. The D-LIVR study includes 48 weeks of treatment with two different lonafarnib-based treatment regimens, followed by 24 weeks of follow-up. Primary endpoint is ≥ 2 log decline and ALT normalization at Week 48. Topline data from the Phase 3 D-LIVR study will be available in 2021. For more information about study locations and eligibility, please visit www.clinicaltrials.gov  (NCT03719313).

End of Phase 2 meeting with FDA to discuss Phase 3 development with Lambda monotherapy is planned for Q1 2020.

Baruch S. Blumberg Institute