Development of rare resistance-associated variants that are extremely tolerant against NS5A inhibitors during daclatasvir/asunaprevir therapy by a two-hit mechanism
Development of rare resistance-associated variants that are extremely tolerant against NS5A inhibitors during daclatasvir/asunaprevir therapy by a two-hit mechanism
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DOI：
10.1111/hepr.12673
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发表时间：
2016-11-01
影响因子：
4.2
通讯作者：
Mochida, Satoshi
中科院分区：
文献类型：
--
作者：
Uchida, Yoshihito;Kouyama, Jun-ichi;Mochida, Satoshi
目的：评价口服达拉塔韦/阿索那韦二联疗法(包括西美普韦三联疗法)患者产生的耐药相关变异(RAV)的病毒学特征。方法：206例1b型丙型肝炎病毒感染者，其中5例曾接受西美普韦治疗，疗程为24周。使用循环探针实时聚合酶链式反应和直接测序相结合的方法评估基线和治疗期间/之后NS5A区域的耐药相关变异。结果：180例(87%)患者获得了持续的病毒学应答(SVR12)，无基础NS5A-RAV的患者的应答率为95%，携带NS5A-L31M、NS5A-Y93H/C和NS5A-R30Q/H/L变异的丙型肝炎病毒株的应答率分别为83%、59%和77%。多因素分析显示基线NS5A-R30Q/H/L突变和NS5A-Y93H突变是与SVR12相关的显著因素。所有5名接受西美普韦治疗的患者均发生病毒学失败，罕见的RAV(携带NS5A-R30H、NS5A-A92K、NS5A-P29del和NS5A-P32del的丙型肝炎病毒株)在病毒学失败时出现。超深测序显示，在西美普韦治疗后出现的丙型肝炎病毒株中，基线时没有NS5AP29del或NS5A-P32del株，在口服西美普韦后4周内出现NS5A-RAV。结论：基线水平的NS5A-R30Q/H/L和NS5A-Y93H突变决定了达拉塔韦/阿索那韦双重口服治疗的疗效，但在既往西美普韦治疗的患者中，罕见的NS5A-RAV频繁发生。这种RAV可能以两次打击的方式发展，西美普韦改变了NS5A区丙型肝炎病毒株的准种，导致在暴露于达拉他韦/阿索那韦尔期间出现带有NS5A-P29del和NS5A-P32del的丙型肝炎病毒株。
Aim: The virologic characteristics of resistance-associated variants (RAVs) developing in patients receiving dual oral therapy with daclatasvir/asunaprevir, including those with previous triple therapy with simeprevir, were evaluated.Methods: A total of 206 patients with genotype-1b HCV infection, including 5 patientswith previous simeprevir therapy, were treated with daclatasvir/asunaprevir for 24 weeks. Resistance-associated variants in the NS5A regions at baseline and during/after therapy were evaluated using cycling-probe real-time polymerase chain reaction combined with direct sequencing. The dynamics of rare RAVs were also assessed using ultra-deep sequencing.Results: A sustained virologic response (SVR12) was achieved in 180 patients (87%); the rates were 95% in patients without baseline NS5A-RAVs and 83%, 59%, and 77% in those with hepatitis C virus (HCV) strains carrying NS5A-L31M, NS5A-Y93H/C, and NS5A-R30Q/H/L mutations, respectively. A multivariate analysis revealed baseline NS5A-R30Q/H/L mutation and NS5A-Y93H mutations as significant factors associated with SVR12. Virologic failure developed in all 5 patients with previous simeprevir treatment, and rare RAVs (HCV strains with NS5A-R30H, NS5A-A92K, NS5A-P29del, and NS5A-P32del) developed at virologic failure. Ultra-deep sequencing revealed that HCV strains with NS5AP29del or NS5A-P32del were absent at baseline and emerged within 4 weeks of dual oral therapy among the strains appearing after simeprevir administration.Conclusion: NS5A-R30Q/H/L and NS5A-Y93H mutations at baseline determined the therapeutic efficacy of dual oral therapy with daclatasvir/asunaprevir, but rare NS5A-RAVs developed frequently in patients with previous simeprevir treatment. Such RAVs may develop in a two-hit manner, with simeprevir altering the quasispecies of HCV strains in the NS5A regions, leading to the emergence of HCV strains with NS5A-P29del and NS5A-P32del during exposure to daclatasvir/asunaprevir.