Final results of the telaprevir access program: Fibroscan values predict safety and efficacy in hepatitis c patients with advanced fibrosis or cirrhosis

RESEARCH ARTICLE Final Results of the Telaprevir Access Program: FibroScan Values Predict Safety and Efficacy in Hepatitis C Patients with Advanced Fibrosis or Cirrhosis Antonia Lepida 1 , Massimo Colombo 2 , Inmaculada Fernandez 3 , Djamal Abdurakhmanov 4 , Paulo Abrao Ferreira 5 , Simone I. Strasser 6 , Petr Urbanek 7 , Alessandra Mangia 8 , José L. Calleja 9 , Wafae Iraqi 10 , Ralph DeMasi 11 , Isabelle Lonjon-Domanec 10 , Christophe Moreno 1☯ *, Heiner Wedemeyer 12☯ 1Liver Unit, Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium, 2Department of Medicine, Division of Gastroenterology, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Universita’degli Studi di Milano, Milan, Italy, 3Hospital Universitario 12 de Octubre, Sección de Aparato Digestivo, Madrid, Spain, 4I.M. Sechenov First Moscow State Medical University, E.M. Tareev Clinic for Nephrology, Internal and Occupational Medicine, Moscow, Russia, 5Outpatient Clinic to HIV and Viral Hepatitis Division of Infectious Disease, Federal University of São Paulo, São Paulo, Brazil, 6AW Morrow Gastroenterology and Liver Center, Royal Prince Alfred hospital and University of Sydney, Sydney, Australia, 7Department of Internal Medicine, First Medical Faculty, Charles University, and Central Military Hospital Prague, Prague, Czech Republic, 8Liver Unit, IRCCS Hospital 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, Italy, 9Gastroenterology, Hospital Universitario Puerta de Hierro, Universidad Autonoma de Madrid, CIBERehd, Madrid, Spain, 10 Janssen Pharmaceuticals, Paris, France, 11 Janssen Research and development, Titusville, New Jersey, United States of America, 12 Medizinische Hochschule Hannover, Hannover, Germany ☯These authors contributed equally to this work. *[email protected] Abstract Background Liver stiffness determined by transient elastography is correlated with hepatic fibrosis stage and has high accuracy for detecting severe fibrosis and cirrhosis in chronic hepatitis C patients. We evaluated the clinical value of baseline FibroScan values for the prediction of safety and efficacy of telaprevir-based therapy in patients with advanced fibrosis and cirrhosis in the telaprevir Early Access Program HEP3002. Methods 1,772 patients with HCV-1 and bridging fibrosis or cirrhosis were treated with telaprevir plus pegylated interferon-αand ribavirin (PR) for 12 weeks followed by PR alone, the total treatment duration depending on virological response and previous response type. Liver fibrosis stage was determined either by liver biopsy or by non-invasive markers. 1,282 patients (72%) had disease stage assessed by FibroScan; among those 46% were classified as Metavir F3 at baseline and 54% as F4. PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 1/15 OPEN ACCESS Citation: Lepida A, Colombo M, Fernandez I, Abdurakhmanov D, Abrao Ferreira P, Strasser SI, et al. (2015) Final Results of the Telaprevir Access Program: FibroScan Values Predict Safety and Efficacy in Hepatitis C Patients with Advanced Fibrosis or Cirrhosis. PLoS ONE 10(9): e0138503. doi:10.1371/journal.pone.0138503 Editor: Vincent Wong, The Chinese University of Hong Kong, HONG KONG Received: May 28, 2015 Accepted: August 29, 2015 Published: September 23, 2015 Copyright: © 2015 Lepida et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: This study was funded by Janssen Pharmaceuticals. WI, RD and IL-D are employed by Janssen Pharmaceuticals. Janssen Pharmaceuticals provided support in the form of salaries for authors WI, RD and IL-D, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’section. Results Overall, 1,139 patients (64%) achieved a sustained virological response (SVR) by intention- to-treat analysis. Baseline FibroScan values were tested for association with SVR and the occurrence of adverse events. By univariate analysis, higher baseline FibroScan values were predictive of lower sustained virological response rates and treatment-related anemia. By multivariate analysis, FibroScan was no longer statistically significant as an independent predictor, but higher FibroScan values were correlated with the occurrence of infections and serious adverse events. Conclusions FibroScan has a limited utility as a predictor of safety and efficacy in patients treated with telaprevir-based triple therapy. Nevertheless it can be used in association with other clinical and biological parameters to help determine patients who will benefit from the triple regiments. Trial Registration ClinicalTrials.gov NCT01508286 Introduction Chronic hepatitis C virus (HCV) infection is a major public health issue as it affects approximately 180 million people worldwide [1] and is a leading cause of cirrhosis, end stage liver disease and hepatocellular carcinoma (HCC) and one of the most common indications of liver transplantation in the Western countries [1,2]. Virus eradication arrests the progression of liver disease and diminishes the rates of liver specific and all causes of mortality [3–5]. Chronic HCV infection management has evolved over recent years from pegylated interferon-αand ribavirin (PR) to combination of direct-acting antiviral agents (DAA) with PR after approval of HCV NS3/4A serine protease inhibitors (PI), telaprevir and boceprevir [1]. Limited data are available on the safety and efficacy of these PIs in patients with advanced liver fibrosis or cirrhosis, as these patients were under-represented in Phase III clinical trials [6–9]. Results from post-hoc analysis of these trials showed an increased rate of serious adverse events (SAEs), poor tolerability and suboptimal rates of sustained virologic response (SVR) in patients with advanced hepatic fibrosis [6–12]. Few real-life studies evaluating safety and efficacy of triple therapy have been conducted on patients with advanced HCV-related liver disease [13–18]. Among them, the French multicenter early access program in treatment experienced patients with HCV-cirrhosis (ANRS CO20-CUPIC) [14] showed a high rate of severe complications and even mortality, while similar observations were made in other studies [15,19–22]. The Early Access Program (EAP) HEP3002 was launched in 2011 in 16 nations, giving access to treatment with telaprevir to treatment-naive and experienced patients with bridging hepatic fibrosis and compensated cirrhosis due to HCV genotype 1 infection [13]. Transient elastography (TE), also known as FibroScan), is a validated non-invasive method to evaluate hepatic fibrosis in patients with chronic hepatitis C viral infection [23,24] and has a high level of accuracy for detecting severe fibrosis and cirrhosis [25–27]. Furthermore, TE has a prognostic value in predicting severe portal hypertension, presence of oesophageal varices and occurrence of liver-related complications in patients with cirrhosis [25,26,28–30]. Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 2/15 Competing Interests: The authors of this manuscript have read the journal's policy and have the following competing interests: This study was funded by Janssen Pharmaceuticals. IL-D, WI and RD are employees of Janssen. The authors also acknowledge Stephanie Gibson (Zoetic Science, an Ashfield Company, part of UDG Healthcare plc, Macclesfield, UK) for editing and co-ordination support, which was funded by Janssen Pharmaceuticals. AL: No conflicts of interest. MC: Grant and research support: BMS, Gilead Science; Advisory committees: Merck, Roche, Novartis, Bayer, BMS, Gilead Science, Tibotec, Vertex, Janssen Cilag, Achillion, Lundbeck, GSK, GenSpera, AbbVie, AlfaWasserman, Jennerex; Speaking and teaching: Tibotec, Roche, Novartis, Bayer, BMS, Gilead Science, Vertex, Merck, Janssen, Sanofi. IF: Janssen: Speakers bureau; Gilead, MSD, Roche: Speakers bureau. DA: Speaker and had grants for lectures and clinical trials from Merck, Janssen, Roche, Novartis, BMS. PAF: Speaker and Clinical Investigator to Roche, Abbvie, Janssen, BMS, Boheringer, Merck, Gilead. SIS: Speaker and advisor: Janssen, MSD, Roche, BMS, Gilead Sciences, Abbvie, Bayer, Norgine. PU: No conflicts of interest regarding the topic of manuscript. CM: Speaker or adviser for Abbvie, MSD, Janssen, Bristol-Myers Squibb and Gilead Sciences pharmaceutical companies. Research Grant from MSD, Janssen, Astellas, Gilead Sciences, Novartis and Roche pharmaceutical companies. AM: Consultant for Gilead Sciences, Abbvie, Speaker bureau for Janssen, Gilead, ROCHE, MSD, Research grant for Gilead, ROCHE, MSD. JLC: Speaker or adviser for Abbvie, MSD, Roche, Janssen, Bristol-Myers Squibb and Gilead Sciences pharmaceutical companies. A Hill: Consultant for Janssen. HW: Honoraria for consulting and/or lectures: Abbvie, Abbott, Achillion, BMS, Gilead, Janssen, MSD, Novartis, Roche, Roche Diagnostics, Siemens, Transgene. Grant support: Roche, BMS, MSD. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials. Studies of fibrosis evolution using non-invasive markers, during and after PR therapy in small cohorts of HCV-infected patients have been reported [31–41], but few studies investigated the utility of FibroScan as an SVR predictor. Among them, only two [32,36] demonstrated that TE could provide information for the prediction of virological response prior to therapy. To our knowledge, no studies have evaluated the possible association between baseline FibroScan values and the occurrence of SAEs or liver-related complications during anti-HCV treatment, and no information regarding the use of TE in therapy guidance is available. Here, we present the final results of EAP HEP3002 trial, in which about two thirds of the patients were initially evaluated for fibrosis stage using the FibroScan technology, representing a unique opportunity to explore FibroScan potential in the everyday clinical practice. Data from the HEP3002 trial were retrospectively analyzed to determine the clinical value of baseline FibroScan values for predicting safety and efficacy of telaprevir-based triple therapy in patients with advanced fibrosis or cirrhosis. Patients and Methods Study design HEP3002 is an open-label EAP of HCV genotype 1 patients with advanced hepatic fibrosis or cirrhosis treated with telaprevir-based therapy (ClinicalTrials.gov NCT01508286)(S1 Protocol, S1 TREND Checklist). The program included patients from 16 centers across 181 sites in Europe, South America and Australasia and the enrolment criteria were similar to those of the REALIZE Phase III trial [9]. Patient recruitment and follow-up occurred between May 2011 and May 2014; the outline of the study has been described previously [13]. Informed written consent was obtained from each patient included in the study. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the following institutions and human research committees: Therapeutic Goods Administration, Australia; Bundesamt für Sicherheit im Gesundheitswesen, Austra; Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten, Belgium; Agência Nacional de Vigilância Sanitária, Brazil; State Institute for Drug Control, Czech Republic; Bundesinstitut für Arzneimittel und Medizinprodukte, Germany, National Organization for Medicines, Greece, L’Agenzia Italiana del Farmaco, Italy; Ministry of Health, Luxembourg; Centrale Commissie voor Mensgebonden Onderzoek, The Netherlands; Medsafe, New Zealand; National Medicines Agency, Romania; Ministry of Health and Social Development of the Russian Federation, Russia; Ministry of Health, Serbia; State Institute for Drug Control, Slovakia; Agencia Española de Medicamentos y Productos Sanitarios, Spain and Swissmedic, Switzerland. Patients were between 18 and 70 years and had documented severe liver fibrosis [Metavir F3 or Ishak 3–4 (S 3, 4)] or cirrhosis [Metavir F4 or Ishak 5, 6 (S5, 6)] due to HCV genotype 1 infection. In order to be included, patients had to have an absolute neutrophil count >1,500/ mm³, platelets >90,000/mm³ and hemoglobin >12 g/dL for women and >13 g/dL for men. Key exclusion criteria included history or other evidence of decompensated liver disease, HCC, history of alcohol abuse, infection with HCV other than genotype 1 or co-infection with hepatitis B virus or human immunodeficiency virus. Both untreated patients and patients who failed to respond to a previous treatment were included, as long as they had not previously received an HCV protease or polymerase inhibitor. During the first 12 weeks of the program, all patients received 750 mg of TVR orally every 8 hours, in combination with PR. The type (α2a versus α 2b pegylated interferon; Copegus versus Rebetol) and doses of PR were selected according to local guidelines. After 12 weeks of combination treatment, PR alone was administered for another 12 or 36 weeks depending on the virologic response to treatment and/or previous response type; detailed description of the treatment regimens has been reported [13]. Patients Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 3/15 were assessed at weeks 4 and 12 to determine whether they met the predefined stopping rules based on virologic response. If at either time point HCV RNA levels were greater than 1,000 IU/mL, all treatment was permanently discontinued. Measures of disease severity and treatment efficacy Hepatic fibrosis was assessed histologically or by non-invasive means. Liver specimens were obtained by percutaneous liver biopsy and fibrosis was staged using either the Metavir or the Ishak score. Patients who did not undergo a biopsy were evaluated by Fibrotest or FibroScan. The FibroScan cut-offs proposed by Castéra et al [42] were used to diagnose bridging fibrosis and cirrhosis. In this study the authors prospectively assessed the performance of FibroScan in HCV patients, compared to histology. The proposed cut-off values were determined from the distribution of stiffness values according to fibrosis stage for the maximum sum of sensitivity and specificity. The cut-offs for advanced fibrosis (F3 = numerous septa without cirrhosis) and cirrhosis (F4) were 9.5 kPa and 12.5 kPa respectively. The Child Pugh score system was used to define clinical status, with Child Pugh A stage indicating compensated liver disease. The type of previous response to PR treatment was defined by standard criteria [9]. HCV RNA levels were measured using a range of assays at local investigational sites. The majority of sites used Roche COBAS TaqMan versions 1 or 2 with a lower limit of quantification (LLOQ) of 15–25 IU/mL and a lower limit of detection (LLOD) of 10 IU/mL, or Abbott RealTime assay with a LLOQ of 12 IU/mL and a LLOD of 10–12 IU/mL. Safety assessments Data on safety issues were collected during the treatment period and follow-up, including laboratory assessments, physical examinations, evaluation of vital signs and the reporting of adverse events (AEs). AEs were graded by investigators using the DAIDS criteria [43] except for rash, for which protocol-specific guidance for grading and management was provided. Anemia was defined as an AE according to the following guidelines: grade 1 hemoglobin values between 10.0 and 10.9 g/dL or any decrease from baseline between 2.5 and 3.4 g/dL; grade 2 hemoglobin values between 9.0 and 9.9 g/dL or any decrease of hemoglobin between 3.5 and 4.4 g/dL; grade 3 hemoglobin values between 7.0 and 8.9 g/dL or any decrease of hemoglobin 4.5 g/dL; and grade 4 an hemoglobin value less than 7.0 g/dL. Anemia developed during treatment was managed by reduction of ribavirin doses according to label recommendations. Use of blood transfusions, erythropoetin (EPO) or iron-based products was allowed during the trial. Telaprevir dose reduction was prohibited, and if ribavirin dose modifications or discontinuation did not result in an improvement of hemoglobin levels, telaprevir was then discontinued. The detailed methodology of the safety assessments has been formerly described [13]. Statistical methods Since this program was designed to provide patients with early access to telaprevir and was not intended to evaluate a specific statistical hypothesis, all patients received open-label telaprevir in addition to PR. As such, no inferential statistical analyses were planned. Analyses were performed for descriptive purposes and were conducted using descriptive statistics to determine odds ratios along with 95% confidence intervals (CIs) by univariate and multivariate analyses. In total, 2,034 patients were screened for the EAP, and 262 patients were excluded due to the study inclusion/exclusion criteria, withdrawal of consent or other reasons. The analysis was performed on the intent-to-treat set (N = 1,772), defined as all enrolled patients who received at least one dose of telaprevir. Patients with any major protocol deviation that plausibly affected efficacy or patients with HCV RNA under LLOQ at end-of-treatment and without any HCV Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 4/15 RNA follow-up assessment within the week 24 follow-up visit window (and who did not relapse before) were excluded from the efficacy evaluable set. For the analysis of safety data, FibroScan was tested for association with four adverse events: anemia (hemoglobin 10 g/dL), grade 1–4 infections, serious AEs and telaprevir discontinuation because of AEs. FibroScan results were divided into quartiles, and the number of events corresponding to each quartile are presented separately for the 4 endpoints. The P values presented in these analyses were derived from the Wald Chi-square test for the univariate and multivariate predictors of SVR, the Chi-square test for the assessment of safety by Liver Stiffness Measurement and the univariate and multivariate predictors of anemia. The P values for the correlation between baseline FibroScan values and baseline laboratory parameters were derived from the Pearson Correlation Test. Statistical analysis was performed using SAS 1 version 9.2 (SAS Institute Inc., Cary, NC, USA). End points This study evaluated the usefulness of baseline FibroScan values for predicting SVR and the occurrence of anemia and other severe adverse events in HCV genotype 1 patients with advanced fibrosis (F3) or compensated cirrhosis (F4), treated with telaprevir-based triple therapy in the EAP. Results Patient characteristics A total of 2,034 patients were screened and 1,772 were enrolled in the HEP3002 trial (Fig 1). Of these 1,772 patients, 1,282 (72%) had disease stage assessed by FibroScan and were included in Fig 1. Patient disposition. Showing numbers of patients screened, enrolled and treated, and with baseline FibroScan results. doi:10.1371/journal.pone.0138503.g001 Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 5/15 the analyses. Among those who had liver fibrosis assessed by FibroScan 557 patients were classified as F3 (43%) at baseline and 724 (57%) as F4. Demographics and baseline characteristics of the ITT population are shown in Table 1. Overall, the mean (SD) age of the patients was 53 (9.5) years; 1,121 patients (63%) were male and 1,741 (98%) were white. HCV genotype 1a was present in 379 patients (21%) and 1,172 (66%) had HCV RNA greater than or equal to 800,000 IU/mL at baseline. In total, 355 patients (20%) were treatment naive, 586 (33%) were prior treatment relapsers, 234 (13%) were prior partial responders, 495 (28%) were prior null responders and 49 (3%) had had a viral breakthrough. The response to prior therapy was unknown for one patient and 52 patients had had an unspecified previous non-response. Mean MELD score was 7.4 (1.4). In patients who had had liver fibrosis assessment by means of FibroScan, mean FibroScan result was 19.1 kPa. IL28B genotyping results were missing in the majority of patients. Of the 416 patients who had IL28B genotyping results, 77 (19%) had the IL28B genotype CC. The CT and TT genotypes were seen in 256 (62%) and 83 (20%) patients, respectively. Virologic response and correlation between FibroScan and SVR In the ITT population, SVR24 was achieved by 70% (568/807) of patients with bridging fibrosis and 59% (566/959) of patients with cirrhosis (Table 2). In total, 78% (760/973) of patients who achieved eRVR went onto achieve SVR (Table 2). The percentage of treatment-naive patients who achieved SVR was 74% whereas, among treatment-experienced patients, 78% of treatment relapsers, 60% of partial responders, 44% of null responders achieved a cure (S1 Table). Multiple parameters were tested for their association with SVR (Table 3). By univariate analysis, higher baseline FibroScan values, analyzed as a continuous log 10 transformed variable, were predictive of lower SVR rates (Odds Ratio = 0.58, 95% CI = 0.46–0.74, p<0.0001). Other parameters significantly associated with a lower chance of SVR were HCV genotype 1a (p = 0.0003), baseline log 10 alfa fetoprotein (p<0.0001), baseline log 10 platelets (p<0.0001) and prior null response (p<0.0001). HCV genotype 1b, previous relapse or previous partial response were not predictive of SVR. Multivariate analysis identified the following three independent predictors of lower SVR rates: genotype 1a (p = 0.0012), alfa fetoprotein (p<0.0001), log 10 platelets (p = 0.0373), age (p = 0.0407) and prior null response (<0.0001). FibroScan was no longer statistically significant as an independent SVR predictor. Correlation between FibroScan and baseline laboratory parameters FibroScan scores were tested for correlations with baseline laboratory parameters: platelets count, alfa fetoprotein, albumin, bilirubin and international normalized ratio (INR). All of the laboratory parameters tested were correlated with FibroScan, but the correlations were quite weak (correlation coefficients <0.4). More precisely, higher FibroScan score correlated with lower platelets and albumin and higher alfa fetoprotein, bilirubin and INR with a p value <0.0001 for each comparison. Safety AEs observed in this study were consistent with telaprevir-based therapy known side effects, namely anemia (observed in 56% of patients), rash (30%), and pruritus (16%). As previously described, the most common serious side effect was, by far, anemia (26%). Overall, 12% of patients discontinued due to AEs, 4% due to rash and 3% due to anemia (Table 4). Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 6/15 Table 1. Baseline and treatment characteristics of patients in the intent-to-treat population. Characteristic*Bridging fibrosis (N = 813) † Cirrhosis (N = 959) Overall (N = 1772) Age year—mean (SD; range) 52 (10.1;22–73) 54 (8.8;19–75) 53 (9.5;19–75) Body mass index (BMI) ‡ —mean (SD) 26 (3.7) 27 (4.1) 27(4.0) BMI—range 18–42 18–47 18–47 Males sex—no. (%) 494 (61) 627 (65) 1121 (63) Race or ethnic group—no. (%) § White 801 (99) 940 (98) 1741 (98) Black, Asian or other 12 (1) 19 (2) 31 (2) HCV-1 subtype—no. (%) 1a 173 (21) 206 (21) 379 (21) 1b 610 (75) 681 (71) 1291 (73) Missing or unknown 30 (4) 72 (8) 102 (6) HCV RNA log 10 —IU/mL ¶ 6.1±0.66 6.1±0.73 6.1±0.70 HCV RNA 800,000 IU/mL—no. (%) 545 (67) 627 (65) 1172 (66) Model for End Stage Liver Disease score (range) 7.1 (6–14) 7.6 (6–20) 7.4 (6–20) Liver stiffness measurement,—mean kPa (SD) 11.4 (2.82) 24.9 (12.66) 19.1 (11.78) α-Fetoprotein—μg/L 8.8±11.2 16.5±25.0 13.0±20.3 Albumin—g/L 44.0±4.0 42.3±4.4 43.1±4.3 Bilirubin—μmol/L 12.7±6.4 14.7±7.1 13.7±6.8 Creatine—μmol/L 70.0±15.0 70.0±14.9 70.0±15.0 Glucose—mmol/L 5.5±1.6 5.9±2.0 5.7±1.8 Hemoglobin—g/L 150±13.8 149±13.3 150±13.5 Neutrophils–×10 9 /L 3.5±1.4 3.2±1.9 3.3±1.7 Platelets–×10 9 /L 190±57.9 154±54.4 171±58.9 Prothrombin intl. normalised ratio 1.03±0.10 1.08±0.13 1.06±0.12 IL28B genotype—no. (%) Missing or unknown 627 (77) 729 (76) 1356 (77) CC 23 (3) 54 (6) 77 (4) CT 127 (16) 129 (13) 256 (14) TT 36 (4) 47 (5) 83 (5) Previous type of response—no. (%) Total non-responders †† 322 (40) 459 (48) 781 (44) Prior null responder 198 (24) 297 (31) 495 (28) Prior partial responder 103 (13) 131 (14) 234 (13) Relapsers 288 (35) 298 (31) 586 (33) Treatment naive 176 (22) 179 (19) 355 (20) Viral breakthrough 26 (3) 23 (3) 49 (3) Unknown 1 (0) 0 (0) 1 (0) *Values are means±SD unless otherwise indicated. Percentages may not total 100 because of rounding. † Includes six F0–F2 patients. ‡ BMI is the weight in kilograms divided by the square of the height in meters. § Race or ethnic group was self-reported. Patients of any race could also identify themselves as Hispanic. ¶ Log 10 values for HCV RNA are means±SE. †† Includes prior null responders, prior partial responders and non-responders-unspecified. doi:10.1371/journal.pone.0138503.t001 Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 7/15 The statistical analysis showed that higher FibroScan values were significantly correlated with anemia (p = 0.0365), occurrence of grade 1–4 infections (p = 0.0472) and SAEs (p<0.0001) but not with telaprevir discontinuation due to AEs (p = 0.0602) (Table 5). FibroScan and the risk of anemia Multiple parameters were tested for their association with anemia, defined as hemoglobin 10 g/dL and severe anemia defined as hemoglobin 8.5 g/dL (Table 6). In univariate analysis of anemia, among other parameters, the baseline FibroScan score was predictive of telaprevirbased treatment-related anemia (p = 0.0072). By multivariate stepwise logistic-regression analysis, independent predictors were older age (p<0.0001), female sex (p<0.0001), lower baseline hemoglobin (p<0.0001), and ribavirin dosing (p<0.0001), while FibroScan was no longer statistically significant. Table 2. Efficacy outcome for each subgroup of patients with respect to fibrosis stage and to extended rapid virologic response (eRVR) in the intent-to-treat population. n (%) Bridging fibrosis (N = 813 † ) Cirrhosis (N = 959) Overall (N = 1772) SVR 573 (70) 566 (59) 1139 (64) Virologic failure Relapse 69 (9) 125 (13) 194 (11) Viral breakthrough 79 (10) 138 (14) 217 (12) Met a stopping rule 27 (3) 27 (3) 53 (3) Other 1 (<1) 3 (<1) 4 (<1) n/N (%) SVR in all patients who achieved eRVR, 394/468 (84) 366/505 (72) 760/973 (78) SVR in patients who did not achieve eRVR 179/345 (52) 200/454 (44) 379/799 (47) † Includes six F0–F2 patients. doi:10.1371/journal.pone.0138503.t002 Table 3. Univariate and multivariate predictors of SVR. Univariate analysis Multivariate analysis Factor OR 95% CI P value OR 95% CI P value α-Fetoprotein (log 10 μg/L) 0.20 0.15–0.28 <0.0001 0.28 0.19–0.39 <0.0001 Prior null response 0.29 0.22–0.37 <0.0001 0.34 0.26–0.44 <0.0001 Liver stiffness measurement >18 kPa 0.58 0.46–0.74 <0.0001 - - - Genotype subtype 1a 0.60 0.45–0.79 0.0003 0.60 0.44–0.82 0.0012 Age 65 years 0.80 0.51–1.24 0.3114 0.60 0.37–0.98 0.0407 HCV RNA 800,000 UI/mL 0.83 0.64–1.07 0.1515 - - - BMI (log 10 kg/m 2 ) 1.00 0.97–1.03 0.9176 - - - Hemoglobin (log 10 g/L) 1.01 1.00–1.02 0.0889 - - - Initial dose of ribavirin 1.04 0.98–1.11 0.1905 - - - Male sex 1.14 0.90–1.46 0.2808 - - - PEG-IFN alfa 2a 1.21 0.85–1.72 0.2952 1.46 1.00–2.14 0.0522 Platelets (log 10 n/L) 10.1 4.41–23.1 <0.0001 2.69 1.06–6.84 0.0373 All variables analysed in the univariate analysis were included in the initial multivariate model. Variables only remained in both models if they reached a significance level of the Wald chi-squared of 0.1 in the multivariate model. This analysis consisted of 1189 observations. doi:10.1371/journal.pone.0138503.t003 Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 8/15 Table 4. Reasons for discontinuation of telaprevir and incidence of the most common AEs and Grade 3–4 AEs during the telaprevir phase in the intent-to-treat population. n (%) Patients with bridging fibrosis*(N = 813) Patients with cirrhosis (N = 959) All patients(N = 1772) Patients with at least one AE†662 (81) 804 (84) 1466 (83) Anaemia‡435 (54) 562 (59) 997 (56) Rash‡230 (28) 305 (32) 535 (30) Pruritus‡114 (14) 163 (17) 277 (16) Asthenia 74 (9) 80 (8) 154 (9) Nausea 62 (8) 85 (9) 147 (8) Thrombocytopenia 38 (5) 92 (10) 130 (7) Anal Pruritus 36 (4) 64 (7) 100 (6) Patients with at least one Grade 3 or 4 AE§ 274 (34) 344 (36) 618 (35) Anaemia 203 (25) 253 (26) 456 (26) Rash 26 (3) 27 (3) 53 (3) Asthenia 15 (2) 17 (2) 32 (2) Thrombocytopenia 4 (<1) 25 (3) 29 (2) Hemoglobin Decreased 9 (1) 9 (<1) 18 (1) Neutropenia 5 (<1) 12 (1) 17 (1) Reason for discontinuation¶ Any AE 91 (11) 130 (14) 221 (12) Rash 32 (4) 36 (4) 68 (4) Anaemia 17 (2) 33 (3) 50 (3) Asthenia 8 (1) 10 (1) 18 (1) Vomiting 8 (1) 10 (1) 18 (1) Nausea 7 (<1) 10 (1) 17 (1) Pruritus 3 (<1) 11 (1) 14 (<1) Abdominal Pain 1 (<1) 8 (<1) 9 (<1) Infections 1 (<1) 5 (<1) 6 (<1) Investigations 3 (<1) 3 (<1) 6 (<1) Fatigue 3 (<1) 2 (<1) 5 (<1) Pyrexia 2 (<1) 3 (<1) 5 (<1) Thrombocytopenia 1 (<1) 4 (<1) 5 (<1) *Includes six F0–F2 patients. † Listed are drug-related AEs that occurred in at least 5% of the overall population during the telaprevir phase. ‡ Included in this category are all related events that were described with a variety of descriptive terms. § Listed are grade 3–4 drug-related AEs that occurred in at least 1% of the overall population during the telaprevir phase. ¶ Listed are discontinuations that occurred in at least 5 patients. These figures are the number of patients who discontinued telaprevir; patients may have continued treatment with pegylated interferon plus ribavirin. AE, adverse event. doi:10.1371/journal.pone.0138503.t004 Table 5. Safety based on Liver Stiffness Measurement in patients with baseline FibroScan values. Liver Stiffness Measurement (kPa) P value n/N (%) 11.3 11.4–14.6 14.7–21.9 >21.9 Anemia (<10 g/dL) 140/321 (44) 132/296 (45) 164/315 (52) 161/306 (53) 0.0365 Grade 1–4 infections 6/334 (2) 7/307 (2) 13/322 (4) 17/318 (5) 0.0472 SAEs 26/334 (8) 19/307 (6) 47/322 (15) 53/318 (17) <0.0001 Telaprevir discontinuation due to AE 35/334 (10) 34/307 (11) 54/322 (17) 46/318 (14) 0.0602 doi:10.1371/journal.pone.0138503.t005 Telaprevir EAP: Fibroscan as a Predictor of Safety and Efficacy in HCV PLOS ONE | DOI:10.1371/journal.pone.0138503 September 23, 2015 9/15