REVIEW

Hepatitis C Virus Drug Resistance–Associated

Substitutions: State of the Art Summary
Erik Lontok,1 Patrick Harrington,2 Anita Howe,3 Tara Kieffer,4 Johan Lennerstrand,5 Oliver Lenz,6
Fiona McPhee,7 Hongmei Mo,8 Neil Parkin,9 Tami Pilot-Matias,10 and Veronica Miller1

Hepatitis C virus (HCV) drug development has resulted in treatment regimens com-
posed of interferon-free, all-oral combinations of direct-acting antivirals. While the new
regimens are potent and highly efficacious, the full clinical impact of HCV drug resist-
ance, its implications for retreatment, and the potential role of baseline resistance test-
ing remain critical research and clinical questions. In this report, we discuss the viral
proteins targeted by HCV direct-acting antivirals and summarize clinically relevant
resistance data for compounds that have been approved or are currently in phase 3 clin-
ical trials. Conclusion: This report provides a comprehensive, systematic review of all
resistance information available from sponsors’ trials as a tool to inform the HCV drug
development field. (HEPATOLOGY 2015;62:1623-1632)

H
epatitis C virus (HCV) drug development has
resulted in treatment regimens composed of
interferon-free, all-oral combinations of direct-
acting antivirals (DAAs) in the United States, Europe,
Japan, and other countries.1 Current regimens are
potent and highly efficacious; however, the long-term
effects of drug resistance remain unclear—as opposed to
its importance in human immunodeficiency virus treat-
ment. The high error rate of the HCV polymerase
coupled with virion production that is 100-fold higher
than that of human immunodeficiency virus results in a
complex mixture of viral genetic populations (termed
“quasi-species”) that preexist within an infected individ-
ual before treatment initiation.2-4 While the selection of
preexisting viruses with reduced susceptibility to admin-
istered drugs plays a role in treatment failure, the full
clinical impact of HCV drug resistance, its implications
for retreatment, and the potential role of baseline resist-
ance testing remain critical research and clinical ques-
tions. Thus, a comprehensive summary of existing
information on clinically relevant HCV drug resistance
will facilitate a review of what is and will be observed in
postmarketing studies and clinical practice to help
address the needs of the upcoming cohort of patients
who do not achieve a sustained virological response
(SVR) outside the context of clinical trials.
This review by the Drug Resistance Working Group
of the Forum for Collaborative HIV Research’s HCV
Drug Development Advisory Group5 summarizes clini-
cally relevant HCV DAA resistance data to provide a
systematic review of all resistance information available
from sponsors’ trials. This report is an update from a
previously published version and includes DAAs
approved by regulatory bodies in the United States, the
European Union, and Japan as well as drugs in phase 3
clinical trials as of November 2014.6 The information is
presented in two formats: a graphic summary of
clinically relevant polymorphisms and substitutions
(Figs. 2-4) and abbreviated tables listing available phe-
notypic fold-changes in susceptibility compared to wild

Abbreviations: DAA, direct-acting antiviral; HCV, hepatitis C virus; PI, protease inhibitor; SVR, sustained virological response.
From the 1Forum for Collaborative HIV Research, University of California at Berkeley, Washington, DC; 2Center for Drug Evaluation and Research, Office of
Antimicrobial Products, Division of Antiviral Products, US Food and Drug Administration, Silver Spring, MD; 3Merck Research Laboratories, West Point, PA;
4
Vertex Pharmaceuticals, Inc., Boston, MA; 5Department of Medical Sciences, Uppsala University, Uppsala, Sweden; 6Janssen Infectious Diseases, Beerse, Belgium;
7
Bristol-Myers Squibb Research and Development, Wallingford, CT; 8Gilead Sciences, Inc., Foster City, CA; 9Data First Consulting, Inc., Belmont, CA; 10AbbVie,
Inc., Chicago, IL.
Received December 9, 2014; accepted June 6, 2015.
Additional Supporting Information may be found at http://onlinelibrary.wiley.com/doi/10.1002/hep27934/suppinfo.
E. Lontok’s current address is: FasterCures, A Center of the Milken Institute, Washington, DC
Supported by unrestricted grants received by the Forum for Collaborative HIV Research for the HCV Drug Development Advisory Group Project
(to E.L., V.M.).
Disclaimer: The views expressed in this report are those of the author and do not necessarily represent official policy of the US Food and Drug Administration.

1623
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1624 LONTOK ET AL. HEPATOLOGY, November 2015

type for HCV replicons carrying the resistance- Methodology

associated substitutions (Tables 1-3).
HCV Resistance to DAAs
Nonstructural proteins of HCV are the primary tar-
gets of DAAs that are either approved or in advanced
development: (1) NS3/4A protease inhibitors (PIs) bind
to the active site of the NS3/4A protease; (2) NS5A
inhibitors interact with domain 1 of the NS5A dimer,
although the exact mechanism of NS5A inhibition
remains to be fully elucidated; (3) nucleos(t)ide analog
NS5B polymerase inhibitors are incorporated into the
nascent RNA chain and result in chain termination by
compromising binding of the next incoming nucleotide;
(4) nonnucleoside NS5B polymerase inhibitors interact
with either the thumb 1, thumb 2, palm 1, or palm 2
domain of NS5B and inhibit polymerase activity by
allosteric mechanisms of action.7-10
The substitutions observed in treated individuals
described in this summary include variants isolated and
sequenced from patients who experienced on- or posttreat-
ment virological failure. The likelihood that a DAA will
select for and allow outgrowth of viral populations carry-
ing resistance-associated substitutions depends on the
DAA’s genetic barrier to resistance (the number and type
of base pair mutation[s] needed to result in amino acid
substitution[s] that confer resistance), the level of drug
exposure, and the viral fitness (replicative capacity) of the
resistant variant. Genetic barriers to resistance can vary
both within and between DAA classes and by HCV geno-
type and subtype.11,12 The prevalence of baseline polymor-
phisms, which are natural substitutions that may differ in
their prevalence by genotype, subtype, and subtype clade,
can also greatly affect the efficacy of specific DAAs.13
The HCV Drug Development Advisory Group Drug
Resistance Working Group is composed of a volunteer
panel of experts from academia, industry, patient advo-
cacy organizations, and regulatory agencies.14 Based on
working group consensus, industry sponsors were asked
to submit a pooled analysis of DAA resistance–associ-
ated substitutions from completed phase 2 and phase 3
trials. Amino acid substitutions detected in >1% of
patients whose treatment failed are included in the fig-
ures and ordered based on their prevalence in patients
whose treatment failed with detection in >10% or
<10% of patients (Fig. 1). Amino acid deletions are
designated with an X. The HCV genotype and subtype
are color-coded: 1a, red; 1b, blue; 2, brown; 3a, green;
4, orange. Resistance-associated protease substitutions
are illustrated in Fig. 2, NS5A substitutions are illus-
trated in Fig. 3, and NS5B substitutions are illustrated
in Fig. 4. Compounds approved for clinical use are des-
ignated by an asterisk.
Sponsors also provided available phenotypic charac-
terization of specific resistance substitutions for each
DAA, based on site-directed mutagenesis HCV replicon
assays. Tables 1-3 list the mean fold-changes in suscepti-
bility, relative to wild-type replicons, conferred by
resistance-associated substitutions. Of note, small differ-
ences in HCV replicon phenotype results between dif-
ferent drugs should be interpreted with caution as data
were generated by different sponsors using different
assay conditions and readouts (e.g., quantitative
polymerase chain reaction versus luciferase reporter, see
table footnotes). Nevertheless, reporting all site-directed
mutant replicon results relative to a wild-type replicon
reference should help account for some of these differen-
ces and allow reasonable comparisons to be made. The
Supporting Information contains more detailed

Address reprint requests to: Veronica Miller, Ph.D., Forum for Collaborative HIV Research, 1608 Rhode Island Ave, NW, Suite 212, Washington, DC 20036.
E-mail: veronicam@berkeley.edu; tel: 11-202-974-6290; fax: 11-202-872-4316.
Copyright VC 2015 by the American Association for the Study of Liver Diseases.

View this article online at wileyonlinelibrary.com.

DOI 10.1002/hep.27934
Potential conflict of interest: Dr. Pilot-Matias is employed by and owns stock in AbbVie; Dr. Mo is employed by and owns stock in Merck; Dr. Kieffer is
employed by and owns stock in Vertex; Dr. Lennerstrand consults for Medivir and received grants from Bristol-Myers Squibb; Dr. McPhee is employed by and owns
stock in Bristol-Myers Squibb; Dr. Parkin consults for Gilead, Monogram, and Abbott; Dr. Lenz is employed by and owns stock in Janssen; Dr. Howe is employed
by Merck; Dr. Lontok received grants from Abbott, AbbVie, Achillion, Alere, Astellas, Biogen, BioRAD, Boehringer Ingelheim, Bristol-Myers Squibb, Cenotron,
DDL Diagnostics, DiaPharma, Exalenz, Fibrogen, Galactin, Genentech, Genfit, Gilead, GlaxoSmithKline, HIVMA, Idenix, Illumina, Intercept, Janssen, Kaiser
Permanente, LabCorp, Lilly, Medscape, Medivir, Merck, Microbiotix, Monogram, Mylan, NGM, Novartis, Orasure, Pacific Biosciences, PPD, Presidio, Quest,
Quintiles, Resonance, Roche, Rooivant, SeraCare, Schinazi Family Foundation, Tobira, Vertex, ViiV, and VLVBio; Dr. Miller received grants from Abbott,
AbbVie, Achillion, Alere, Astellas, Biogen, BioRAD, Boehringer Ingelheim, Bristol-Myers Squibb, Cenotron, DDL Diagnostics, DiaPharma, Exalenz, Fibrogen,
Galactin, Genentech, Genfit, Gilead, GlaxoSmithKline, HIVMA, Idenix, Illumina, Intercept, Janssen, Kaiser Permanente, LabCorp, Lilly, Medscape, Medivir,
Merck, Microbiotix, Monogram, Mylan, NGM, Novartis, Orasure, Pacific Biosciences, PPD, Presidio, Quest, Quintiles, Resonance, Roche, Rooivant, SeraCare,
Schinazi Family Foundation, Tobira, Vertex, ViiV, and VLVBio.
 15273350, 2015, 5, Downloaded from https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.27934 by INASP - NEPAL, Wiley Online Library on [11/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Table 1. Mean Fold-Change in Resistance Compared to Wild-Type Replicon of Clinically Relevant NS3 Protease
Resistance–Associated Substitutions
Mean Fold Change in Resistance Compared to Wild-Type Replicon
HCV NS3 Protease Resistance-Associated Replicon Vector
AA and Position Substitution(s) Genotype Boceprevir* Telaprevir† Simeprevir‡ Asunaprevir§ Paritaprevirk Vaniprevir¶

V36 V36M 1a 3 2 2
V36M 1R155K 1a 55 79
V36M 1R155K 1b 64 72
T54 T54S 1a 2
T54S 1b 3
V55 V55A 1b 3 1
Y56 Y56H1D168V 1a 561
Y56H1D168V 1b 2472
Q80 Q80K 1a 11 3
Q80K1R155K 1a 1830 60
Q80H 1b 3
Q80K 1b 8 1
Q80R 1b 6 1
Q80K1R155K 1b 420
Q80H1D168E 1b 145
Q80R1D168A 1b 2660
Q80R1D168E 1b 418
Q80R1R155K 1b 305
S122 S122A 1b 0.9
S122G 1b 0.5
S122R 1b 21
I132 I132V 1a 2
R155 R155K 1a 5 86 21 37 >1000
V36M 1R155K 1a 55 79
Q80K1R155K 1a 1830 60
R155G 1b 7
R155K 1b 7 32
R155M 1b 5
R155T 1b 20
V36M 1R155K 1b 64 72
Q80K1R155K 1b 420
Q80R1R155K 1b 305
A156 A156F 1b >62
A156G 1b 19 16.0
A156N 1b >93
A156S 1b 13 9.6
A156T 1b >62 37
A156V 1b >62 196
D168 D168A 1a 23 50
D168E 1a 58 14
D168V 1a 373 96
D168Y 1a 622 219
Y561D168V 1a 561
D168A 1b 784 127 27
D168E 1b 38 78
D168H 1b 401 98
D168I 1b 1800
D168K 1b 882
D168N 1b 0.6 5.5
D168T 1b 334
D168V 1b 3100 280 159 725
D168Y 1b 651 238
Q80R1D168A 1b 2660
Y56H1D168V 1b 2472
Q80H1D168E 1b 145
Q80R1D168E 1b 418
V170 V170A 1b 7.9

Please see the Supporting Information for detailed site-directed mutagenesis data. Values were rounded to whole numbers; empty cells indicate no data available
from patients who experienced treatment failure.
*Boceprevir data were generated by quantitative polymerase chain reaction.
†
Telaprevir data were generated by quantitative polymerase chain reaction, branched DNA, and luciferase assays.
‡
Simeprevir data were generated by luciferase assay.
§
Asunaprevir data were generated by luciferase assay.
k
Paritaprevir data were generated by luciferase assay.
¶
Vaniprevir data were generated by quantitative polymerase chain reaction.
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1626 LONTOK ET AL. HEPATOLOGY, November 2015

Table 2. Mean Fold-Change in Resistance Compared to Wild-Type Replicon of Clinically Relevant NS5A Resistance–
Associated Substitutions
Mean Fold-Change in Resistance Compared
to Wild-Type Replicon
HCV NS5A Amino Resistance-Associated Replicon Vector
Acid and Position Substitution(s) Genotype Daclatasvir* Ledipasvir† Ombitasvir‡

M28 M28T 1a 205 61 8965

M28V 1a 58
Q30 Q30E 1a 7500 5458
Q30H 1a 435 183
Q30R 1a 365 632 800
Q30R1Y93C 1a 1046
L31 L31M 1a 105 554
L31V 1a 1000
L31M 1b 3
L31V 1b 15
L31M1Y93H 1b 4227
L31V1Y93H 1b 5425
H58 H58D 1a 1127 243
Y93 Y93C 1a 555 1602 1675
Y93H 1a 1600 1677 41,383
Y93N 1a 14,100 >14,706 66,740
Q30R1Y93C 1a 1046
Y93H 1b 12 77
L31M1Y93H 1b 4227
L31V1Y93H 1b 5425

Please see the Supporting Information for detailed site-directed mutagenesis data. Values were rounded to whole numbers; empty cells indicate no data available
from patients who experienced treatment failure.
*Daclatasvir data were generated by luciferase assay.
†
Ledipasvir data were generated by luciferase assay.
‡
Ombitasvir data were generated by luciferase assay.

phenotype assay information including replicon geno-
type/subtype, assay cell type, mean 50% effective con-
centration value, mean fold-change in resistance, and
assay readout.11,12,15-27
NS3/4A Protease Inhibitors
The NS3/4A serine protease cleaves the HCV poly-
protein at four major sites, generating the NS3, NS4A,
NS4B, NS5A, and NS5B nonstructural proteins.7 The
NS3 PIs function by interacting with the protease sub-
strate binding site and preventing viral polyprotein
cleavage. The HCV protease is characterized by a
solvent-exposed substrate binding site, requiring small
molecule inhibitors to rely on few specific interactions
to achieve tight binding with the enzyme.28 This
resulted in a low genetic barrier to resistance and consid-
erable cross-resistance within the first generation of PIs,
boceprevir and telaprevir, involving amino acid posi-
tions V36, T54, R155, and A156 (Fig. 2). More
recently developed PIs such as simeprevir, asunaprevir,
paritaprevir, and vaniprevir exhibit improved genetic
barriers to resistance and enhanced antiviral activity
against different HCV genotypes. However, the activ-
ities of these PIs are still substantially reduced by substi-
tutions at amino acids R155 and D168 (Fig. 2).13,28,29
Boceprevir (MK-3034). The NS3 amino acid sub-
stitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were V36M,
T54S, and R155K. The NS3 amino acid substitutions
most commonly observed in genotype 1b–infected
patients who did not achieve SVR were T54A/S, V55A,
A156S, and V170A.30,31
Telaprevir (VX-950). The NS3 amino acid substi-
tutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were V36M
and R155K. The NS3 amino acid substitutions most
commonly observed in genotype 1b–infected patients
who did not achieve SVR were V36A, T54A, and
A156S.16,32
Simeprevir (TMC-435). The most commonly
observed substitutions in genotype 1a–infected patients
who did not achieve SVR were R155K and D168E/V.
The NS3 amino acid substitutions most commonly
observed in genotype 1b–infected patients who did not
achieve SVR were Q80R and D168E/V. For both sub-
types, the substitutions Q80K/R, S122A/G/I/T, R155Q,
and D168F were not observed at the time of virological
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HEPATOLOGY, Vol. 62, No. 5, 2015 LONTOK ET AL. 1627

Table 3. Mean Fold-Change in Resistance Compared to Wild-Type Replicon of Clinically Relevant NS5B Polymerase
Resistance–Associated Substitutions
Mean Fold-Change in Resistance Compared to Wild-Type Replicon
Nucleotide Nonnucleoside Nonnucleoside Analog:
Analog Analog: Palm I Thumb Pocket I
HCV NS5B Polymerase Resistance-Associated Replicon Vector
Amino Acid and Position Substitution(s) Genotype Sofosbuvir* Dasabuvir† Beclabuvir‡

L159 L159F§ 3a 1
S282 S282T 2a 2
S282T 2b 16
C316 C316Y 1a 1472
C316Y 1b 1569
V321 V321A 3a 1
M414 M414I 1a 8
M414T 1a 32
Y448 Y448H 1a 975
P495 P495A 1a 12
P495L 1a 31
P495S 1a 67
A553 A553T 1a 152
G554 G554S 1a 198
S556 S556G 1a 30
S556G 1b 11

Please see the Supporting Information for detailed site-directed mutagenesis data. Values were rounded to whole numbers, while empty cells indicate no data
available from patients who experienced treatment failure.
*Sofosbuvir data were generated by luciferase assay.
†
Dasabuvir data were generated by luciferase assay.
‡
Beclabuvir data were generated by luciferase assay.
§
The mean fold change in EC50 values for L159F range from 1.2 to 1.8 versus wild-type across multiple genotypes.

failure alone but rather in combination with other substi-
tutions at positions 80, 122, 155, and/or 168.18,33-35
The presence of the Q80K polymorphism substan-
tially reduced SVR rates in genotype 1a–infected
patients treated with simeprevir in combination with
pegylated interferon alfa and ribavirin compared to
patients without the variant, while in a 12-week inter-
feron-free regimen the effect was less pronounced in
patients with cirrhosis and no effect of Q80K on SVR
rates was observed in patients who did not have cirrho-
sis. In patients with Q80K at baseline who did not
achieve SVR, additional resistance-associated substitu-
tions (mainly R155K) were selected during treatment
failure (Fig. 2).33,34,36-39
Asunaprevir (BMS-650032). The NS3 amino acid
substitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were R155K
and D168E. The NS3 amino acid substitutions most
commonly observed in genotype 1b–infected patients
who did not achieve SVR were D168E/V/Y.40-44
Paritaprevir (ABT-450). The NS3 amino acid sub-
stitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were D168A/
V/Y. The NS3 amino acid substitutions most commonly
observed in genotype 1b–infected patients who did not
achieve SVR were Y56H and D168V. The NS3 amino
acid substitution most commonly observed in genotype
4d–infected patients who did not achieve SVR was
D168V.24,45-49
Vaniprevir (MK-7009). The NS3 amino acid sub-
stitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were R155K
and D168T/V/Y. The NS3 amino acid substitutions
most commonly observed in genotype 1b–infected
patients who did not achieve SVR were D168H/T/
V.50,51
NS5A Inhibitors
The NS5A protein is involved in viral replication,
assembly and release of HCV particles, as well as several
host interactions.9,52,53 Localized on endoplasmic retic-
ulum–derived membranes, NS5A exists in basally phos-
phorylated (p56) and hyperphosphorylated (p58) forms.
The exact mechanism by which NS5A regulates viral
replication or participates in viral packaging and assem-
bly is unknown; as a result, the mechanism of action of
NS5A inhibitors is not fully understood. Current NS5A
inhibitors are characterized by their broad genotypic
coverage and relatively low barriers to resistance. Certain
key resistance-associated substitutions like Y93H are
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1628 LONTOK ET AL. HEPATOLOGY, November 2015

Fig. 1. Resistance figure notations. Wild-type amino acids and positions are placed above the viral protein image. Substitution positions
detected in <10% of patients whose treatment failed are visualized with an empty oval, while substitution positions detected in 10% are
visualized with a filled oval. Below the viral protein image, substitutions detected in <10% of patients whose treatment failed are listed, while
substitutions detected in 10% are listed and encircled. Amino acid deletions are designated with an X. Substitutions are ordered based on
their prevalence in patients who failed treatment, with 10% listed first, then in alphabetical order, followed by <10%, then in alphabetical
order. Substitutions are color-coded based on genotype and subtype: 1a, red; 1b, blue; 2, brown; 3a, green; 4, orange.

also detected as natural baseline polymorphisms in some
patients (Fig. 3).12,54-57
Daclatasvir (BMS-790052). The NS5A amino
acid substitutions most commonly observed in genotype
1a–infected patients who did not achieve SVR were
M28T, Q30E/H/R, L31M, H58D, and Y93H/N. The
NS5A amino acid substitutions most commonly
observed in genotype 1b–infected patients who did not
achieve SVR were L31M/V and Y93H. The NS5A
amino acid substitutions most commonly observed in
genotype 4–infected patients who did not achieve SVR
were Q30H/S.55,58,59
Ledipasvir (GS-5885). The NS5A amino acid
substitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were Q30E/
R, L31M, and Y93C/H/N. The NS5A amino acid

Fig. 2. NS3 resistance-associated substitutions observed with treatment. *Compounds approved for clinical use. Substitutions are color-coded
based on genotype and subtype: 1a, red; 1b, blue; 2, brown; 3a, green; 4, orange. See Fig. 1 legend.
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HEPATOLOGY, Vol. 62, No. 5, 2015 LONTOK ET AL. 1629

Fig. 3. NS5A resistance-associated substitutions observed with treatment. *Compounds approved for clinical use. Amino acid deletions are
designated with an X. Substitutions are color-coded based on genotype and subtype: 1a, red; 1b, blue; 2, brown; 3a, green; 4, orange (dacla-
tasvir 4, ombitasvir 4d). See Fig. 1 legend.

substitution most commonly observed in genotype 1b– NS5B Polymerase Inhibitors

infected patients who did not achieve SVR was
Y93H.60-62
Ombitasvir (ABT-267). The NS5A amino acid
substitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were M28T
and Q30R. The NS5A amino acid substitution most
commonly observed in genotype 1b–infected patients
who did not achieve SVR was Y93H. The NS5A amino
acid substitution most commonly observed in genotype
4d–infected patients who did not achieve SVR was
L28V.25,45-49
NS5B is the RNA-dependent RNA polymerase (cata-
lytic subunit) of the membrane-associated HCV replica-
tion complex.8 NS5B is structurally organized in a
characteristic “right-hand motif” containing palm and
thumb domains.63 Nucleos(t)ide inhibitors have broad
activity against different HCV genotypes, have a high
resistance barrier, and function by mimicking polymer-
ase nucleotide substrates that are incorporated into the
nascent RNA chain and result in chain termination.29,64
The NS5B nonnucleoside analog inhibitors bind

Fig. 4. NS5B resistance-associated substitutions observed with treatment. *Compounds approved for clinical use. Amino acid deletions are
designated with an X. Substitutions are color-coded based on genotype and subtype: 1a, red; 1b, blue; 2, brown; 3a, green. NS5B inhibitors are
subdivided based on site of interaction: sofosbuvir, nucleotide analog, NS5B active site; dasabuvir, nonnucleoside analog, NS5B palm 1 site;
beclabuvir, nonnucleoside analog, NS5B thumb pocket 1. See Fig. 1 legend.

1630 LONTOK ET AL.
outside of the polymerase active site and can be further
subclassified based on their allosteric binding sites (Palm
1, Palm 2, Thumb 1, and Thumb 2).10 Given their dif-
ferent mechanisms and sites of interaction, no cross-
resistance is observed across currently approved and
phase 3 nucleotide and nonnucleoside polymerase
inhibitors (Fig. 4).48,57
Sofosbuvir (GS-7977, Nucleotide Analog Inhibi-
tor). In the ELECTRON sofosbuvir monotherapy
study, the S282T substitution was detected in a patient
infected with HCV genotype 2 who relapsed at week 4
posttreatment.65 In a pooled analysis of sofosbuvir phase
3 trials involving patients infected with HCV genotype
3 who did not achieve SVR, the substitutions L159F
and V321A were selected postbaseline in several sub-
jects; however, these variants alone have been shown to
confer 1.2- to 1.6-fold reduced phenotypic susceptibility
to sofosbuvir in vitro and require further investigation to
elucidate their association with viral resistance (Table 3;
Supporting Information).66-68 C316N/H/F was present
at baseline in six subjects infected with HCV genotype
1b whose treatment failed and was observed on treat-
ment in one patient infected with HCV genotype 1a
who experienced relapse; however, more studies are
needed to assess the substitution’s role in resistance to
sofosbuvir.67
Dasabuvir (ABT-333, Nonnucleoside Analog
Inhibitor, Palm I). The NS5B amino acid substitu-
tions most commonly observed in genotype 1a–infected
patients who did not achieve SVR were M414T and
S556G. The N5SB amino acid substitution most com-
monly observed in genotype 1b–infected patients who
did not achieve SVR was S556G.26,45-48
Beclabuvir (BMS-791325, Nonnucleoside Analog
Inhibitor, Thumb Pocket I). The NS5B amino acid
substitutions most commonly observed in genotype 1a–
infected patients who did not achieve SVR were A421V
and P495L/S.43,69 To date, no patients infected with
genotype 1b have experienced virological escape.
Conclusion
This review provides a comprehensive and systematic
summary of resistance-associated substitutions for cur-
rent late-stage and approved HCV DAAs. Differences
between our findings and published resistance reviews
may rely on different methodologies for the compilation
of clinically relevant substitutions.70,71 Furthermore, the
conclusions in this review rely directly on data generated
by and provided by the sponsor, which include data not
previously available in the public domain.
15273350, 2015, 5, Downloaded from https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.27934 by INASP - NEPAL, Wiley Online Library on [11/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HEPATOLOGY, November 2015
As drugs enter clinical practice, the sponsor data pre-
sented here will be complemented and expanded in
phase 4 trials and observational cohorts such as the
Hepatitis C Therapeutic Registry and Research Net-
work.72 The extent to which detection of resistance-
associated substitutions may play a role in determining
the ideal retreatment regimen for HCV-infected indi-
viduals is an active field of research. Regimen selection
may need to take into account the differing half-lives
of resistant variants selected in patients who do not
achieve SVR on a DAA-based therapy. For example,
resistance-associated variants in patients who did not
achieve SVR with a telaprevir and pegylated interferon
alfa and ribavirin regimen were estimated to revert to a
predominantly wild-type population with a median
time of about 11 months posttreatment in genotype
1a–infected patients and about 1 month in genotype
1b–infected patients.16 On the other hand, NS5A
resistance-associated substitutions have been shown to
persist for at least 1 year posttreatment failure and may
impact retreatment with some NS5A inhibitor–con-
taining regimens.73
In this rapidly evolving field, coordination among
stakeholders to assess real-life treatment failure rates and
retreatment success rates is needed to inform the field as
efficiently as possible regarding regimen selection and
the potential need for baseline resistance testing. The
clinical recommendations developed by the American
Association for the Study of Liver Diseases, the Euro-
pean Association for the Study of the Liver, and the
Japan Society of Hepatology serve as the guides for best
clinical practice.74-76 It is the goal of the HCV Drug
Development Advisory Group Drug Resistance Work-
ing Group to contribute to these discussions with the
comprehensive data set provided here, while facilitating
the continued and breathtaking progress of HCV DAA-
only therapy.
Acknowledgment: We thank Rob J. Besaw, Dr.
Chansom Brumme, Dr. Richard Harrigan, Dr. Jules
O’Rear, and Nivedha Panneer for helpful manuscript
suggestions and discussion.
References
1. Chung RT, Baumert TF. Curing chronic hepatitis C–the arc of a medi-
cal triumph. N Engl J Med 2014;370:1576-1578.
2. Neumann AU, Lam NP, Dahari H, Gretch DR, Wiley TE, Layden
TJ, Perelson AS. Hepatitis C viral dynamics in vivo and the antiviral
efficacy of interferon-alpha therapy. Science 1998;282:103-107.
3. Mansky LM, Temin HM. Lower in vivo mutation rate of human
immunodeficiency virus type 1 than that predicted from the fidelity of
purified reverse transcriptase. J Virol 1995;69:5087-5094.

HEPATOLOGY, Vol. 62, No. 5, 2015
4. Ogata N, Alter HJ, Miller RH, Purcell RH. Nucleotide sequence and
mutation rate of the H strain of hepatitis C virus. Proc Natl Acad Sci
USA 1991;88:3392-3396.
5. Hutchison C, Kwong A, Ray S, Struble K, Swan T, Miller V. Accelerat-
ing drug development through collaboration: the hepatitis C drug
development advisory group. Clin Pharmacol Ther 2014;96:162-165.
6. HCV Phenotype Working Group of the HCV Drug Development
Advisory Group. Clinically Relevant HCV Drug Resistance Mutations
Fig. and Tables. Ann Forum Collab HIV Res 2012;14:10.
7. Lin C: HCV NS3-4A Serine Protease. In: Tan SL, ed. Hepatitis C
Viruses: Genomes and Molecular Biology. Norfolk (UK), 2006.
8. Ranjith-Kumar CT, Kao CC: Biochemical Activities of the HCV
NS5B RNA-Dependent RNA Polymerase. In: Tan SL, ed. Hepatitis C
Viruses: Genomes and Molecular Biology. Norfolk (UK), 2006.
9. Pawlotsky JM. NS5A inhibitors in the treatment of hepatitis C.
J Hepatol 2013;59:375-382.
10. Gerber L, Welzel TM, Zeuzem S. New therapeutic strategies in HCV:
polymerase inhibitors. Liver Int 2013;33 Suppl 1:85-92.
11. Fridell RA, Qiu D, Wang C, Valera L, Gao M. Resistance analysis of
the hepatitis C virus NS5A inhibitor BMS-790052 in an in vitro repli-
con system. Antimicrob Agents Chemother 2010;54:3641-3650.
12. Gao M. Antiviral activity and resistance of HCV NS5A replication
complex inhibitors. Curr Opin Virol 2013;3:514-520.
13. Paolucci S, Fiorina L, Piralla A, Gulminetti R, Novati S, Barbarini G,
Sacchi P, et al. Naturally occurring mutations to HCV protease inhibi-
tors in treatment-naive patients. Virol J 2012;9:245.
14. Kwong AD, Najera I, Bechtel J, Bowden S, Fitzgibbon J, Harrington P,
Kempf D, et al. Sequence and phenotypic analysis for resistance moni-
toring in hepatitis C virus drug development: recommendations from
the HCV DRAG. Gastroenterology 2011;140:755-760.
15. Tong X, Chase R, Skelton A, Chen T, Wright-Minogue J, Malcolm BA.
Identification and analysis of fitness of resistance mutations against the
HCV protease inhibitor SCH 503034. Antiviral Res 2006;70:28-38.
16. Kieffer TL, De Meyer S, Bartels DJ, Sullivan JC, Zhang EZ, Tigges A,
Dierynck I, et al. Hepatitis C viral evolution in genotype 1 treatment-
naive and treatment-experienced patients receiving telaprevir-based ther-
apy in clinical trials. PLoS One 2012;7:e34372.
17. Jiang M, Mani N, Lin C, Ardzinski A, Nelson M, Reagan D, Bartels
D, et al. In vitro phenotypic characterization of hepatitis C virus NS3
protease variants observed in clinical studies of telaprevir. Antimicrob
Agents Chemother 2013;57:6236-6245.
18. Lenz O, Verbinnen T, Lin TI, Vijgen L, Cummings MD, Lindberg J,
Berke JM, et al. In vitro resistance profile of the hepatitis C virus NS3/
4A protease inhibitor TMC435. Antimicrob Agents Chemother 2010;
54:1878-1887.
19. Liverton NJ, Carroll SS, Dimuzio J, Fandozzi C, Graham DJ, Hazuda
D, Holloway MK, et al. MK-7009, a potent and selective inhibitor of
hepatitis C virus NS3/4A protease. Antimicrob Agents Chemother
2010;54:305-311.
20. Lam AM, Espiritu C, Bansal S, Micolochick Steuer HM, Niu C,
Zennou V, Keilman M, et al. Genotype and subtype profiling of PSI-
7977 as a nucleotide inhibitor of hepatitis C virus. Antimicrob Agents
Chemother 2012;56:3359-3368.
21. Gao M, Nettles RE, Belema M, Snyder LB, Nguyen VN, Fridell RA,
Serrano-Wu MH, et al. Chemical genetics strategy identifies an HCV
NS5A inhibitor with a potent clinical effect. Nature 2010;465:96-100.
22. Poordad F, Lawitz E, Kowdley KV, Cohen DE, Podsadecki T,
Siggelkow S, Heckaman M, et al. Exploratory study of oral combina-
tion antiviral therapy for hepatitis C. N Engl J Med 2013;368:45-53.
23. McPhee F, Friborg J, Levine S, Chen C, Falk P, Yu F, Hernandez D,
et al. Resistance analysis of the hepatitis C virus NS3 protease inhibitor
asunaprevir. Antimicrob Agents Chemother 2012;56:3670-3681.
24. Pilot-Matias TJ, Tripathi, R.L., Dekhtyar, T, Menon, R.M., Gaultier,
I.A., Cohen, D.E., Podsadecki, T.J., Bernstein, B.M., Collins, C.A.
Genotypic and phenotypic characterization of NS3 variants selected in
HCV-infected patients treated with ABT-450. EASL 2011 Conference
2011:Abstract #1229.
15273350, 2015, 5, Downloaded from https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.27934 by INASP - NEPAL, Wiley Online Library on [11/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LONTOK ET AL. 1631
25. Krishnan P, Beyer, J., Mistry, N., Koev, G., Reisch, T., Mondal, R., Liu,
D., Pratt, J., DeGoey, D., Wagner, R., Maring, C., Kati, W., Molla, A.,
Campbell, A., Bernstein, B., Williams, L., Collins, C., Pilot-Matias, T.
Antiviral activity and resistance profiles for ABT-267, a novel HCV NS5A
inhibitor, in vitro and during 3-day monotherapy in HCV genotype-1
(GT1)-infected treatment-na€ıve subjects. AASLD 2012 Conference 2012.
26. Middleton T, He, Y., Beyer, J., Menon, R., Klein, C.E., Cohen, D.,
Collins, C. Resistance profile of ABT-333 and relationship to viral load
decrease in patients treated in combination with peg-interferon and rib-
avirin for 28 days. EASL 2010 Conference 2010.
27. Lemm JA, Liu M, Gentles RG, Ding M, Voss S, Pelosi LA, Wang YK,
et al. Preclinical characterization of BMS-791325, an allosteric inhibi-
tor of hepatitis C Virus NS5B polymerase. Antimicrob Agents Chemo-
ther 2014;58:3485-3495.
28. Romano KP, Ali A, Aydin C, Soumana D, Ozen A, Deveau LM, Silver
C, et al. The molecular basis of drug resistance against hepatitis C virus
NS3/4A protease inhibitors. PLoS Pathog 2012;8:e1002832.
29. Schinazi R, Halfon P, Marcellin P, Asselah T. HCV direct-acting antivi-
ral agents: the best interferon-free combinations. Liver Int 2014;34
Suppl 1:69-78.
30. Sarrazin C, Zeuzem S. Resistance to direct antiviral agents in patients
with hepatitis C virus infection. Gastroenterology 2010;138:447-462.
31. Welsch C, Jesudian A, Zeuzem S, Jacobson I. New direct-acting antivi-
ral agents for the treatment of hepatitis C virus infection and perspec-
tives. Gut 2012;61 Suppl 1:i36-46.
32. Sullivan JC, De Meyer S, Bartels DJ, Dierynck I, Zhang EZ, Spanks
J, Tigges AM, et al. Evolution of treatment-emergent resistant var-
iants in telaprevir phase 3 clinical trials. Clin Infect Dis 2013;57:
221-229.
33. Jacobson IM, Dore GJ, Foster GR, Fried MW, Radu M, Rafalsky VV,
Moroz L, et al. Simeprevir with pegylated interferon alfa 2a plus riba-
virin in treatment-naive patients with chronic hepatitis C virus geno-
type 1 infection (QUEST-1): a phase 3, randomised, double-blind,
placebo-controlled trial. Lancet 2014;384:403-413.
34. Manns M, Marcellin P, Poordad F, de Araujo ES, Buti M, Horsmans
Y, Janczewska E, et al. Simeprevir with pegylated interferon alfa 2a or
2b plus ribavirin in treatment-naive patients with chronic hepatitis C
virus genotype 1 infection (QUEST-2): a randomised, double-blind,
placebo-controlled phase 3 trial. Lancet 2014;384:414-426.
35. Forns X, Lawitz E, Zeuzem S, Gane E, Bronowicki JP, Andreone P,
Horban A, et al. Simeprevir with peginterferon and ribavirin leads to high
rates of SVR in patients with HCV genotype 1 who relapsed after previous
therapy: a phase 3 trial. Gastroenterology 2014;146:1669-1679 e1663.
36. US Food and Drug Administration. Simeprevir product insert. 2013;http://
www.accessdata.fda.gov/drugsatfda_docs/label/2013/205123s001lbl.pdf.
37. Lawitz E, Sulkowski MS, Ghalib R, Rodriguez-Torres M, Younossi
ZM, Corregidor A, DeJesus E, et al. Simeprevir plus sofosbuvir, with
or without ribavirin, to treat chronic infection with hepatitis C virus
genotype 1 in non-responders to pegylated interferon and ribavirin and
treatment-naive patients: the COSMOS randomised study. Lancet
2014;384:1756-1765.
38. Lenz O, Verbinnen T, Fevery B, Tambuyzer L, Vijgen L, Peeters M,
Buelens A, et al. Virology analyses of HCV isolates from genotype
1-infected patients treated with simeprevir plus peginterferon/ribavirin
in Phase IIb/III studies. J Hepatol 2014.
39. Kwo P, Lawitz E, al. e. A Phase 3, randomised, open-label study to
evaluate the efficacy and safety of 12 and 8 weeks of simeprevir(SMV)
plus sofosbuvir (SOF) in treatment-naive and -experienced patients
with chronic HCV genotype 1 infection with or without cirrhosis:
OPTOMIST-1/2. EASL 2015 Conference 2015:Poster LP14.
40. Manns M, Pol S, Jacobson IM, Marcellin P, Gordon SC, Peng CY,
Chang TT, et al. All-oral daclatasvir plus asunaprevir for hepatitis C virus
genotype 1b: a multinational, phase 3, multicohort study. Lancet 2014.
41. Lok AS, Gardiner DF, Hezode C, Lawitz EJ, Bourliere M, Everson
GT, Marcellin P, et al. Randomized trial of daclatasvir and asunaprevir
with or without PegIFN/RBV for hepatitis C virus genotype 1 null res-
ponders. J Hepatol 2014;60:490-499.

1632 LONTOK ET AL.
42. Lok AS, Gardiner DF, Lawitz E, Martorell C, Everson GT, Ghalib R,
Reindollar R, et al. Preliminary study of two antiviral agents for hepati-
tis C genotype 1. N Engl J Med 2012;366:216-224.
43. Everson GT, Sims KD, Rodriguez-Torres M, Hezode C, Lawitz E,
Bourliere M, Loustaud-Ratti V, et al. Efficacy of an interferon- and
ribavirin-free regimen of daclatasvir, asunaprevir, and BMS-791325 in
treatment-naive patients with HCV genotype 1 infection. Gastroenter-
ology 2014;146:420-429.
44. Bronowicki JP, Ratziu V, Gadano A, Thuluvath PJ, Bessone F,
Martorell CT, Pol S, et al. Randomized trial of asunaprevir plus pegin-
terferon alfa and ribavirin for previously untreated genotype 1 or 4
chronic hepatitis C. J Hepatol 2014;61:1220-1227.
45. Poordad F, Hezode C, Trinh R, Kowdley KV, Zeuzem S, Agarwal K,
Shiffman ML, et al. ABT-450/r-ombitasvir and dasabuvir with ribavirin
for hepatitis C with cirrhosis. N Engl J Med 2014;370:1973-1982.
46. Zeuzem S, Jacobson IM, Baykal T, Marinho RT, Poordad F, Bourliere
M, Sulkowski MS, et al. Retreatment of HCV with ABT-450/r-ombi-
tasvir and dasabuvir with ribavirin. N Engl J Med 2014;370:1604-
1614.
47. Feld JJ, Kowdley KV, Coakley E, Sigal S, Nelson DR, Crawford D,
Weiland O, et al. Treatment of HCV with ABT-450/r-ombitasvir and
dasabuvir with ribavirin. N Engl J Med 2014;370:1594-1603.
48. U.S. Food and Drug Administration. Viekira Pak product insert. 2014;
http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/206619lbl.pdf.
49. Schnell G TR, Beyer J, Reisch T, Krishnan P, Baykal T, Hall C, Vilchez,
Pilot-Matias T, Collins C. Identification and treatment of multiple sub-
types of HCV genotype 4 in the PEARL-I study with ombitasvir and
ABT-450/r 6 ribavirin. HEPATOLOGY 2014;60:1146A, Abstract 1954.
50. Barnard RJ, McHale CM, Newhard W, Cheney CA, Graham DJ,
Himmelberger AL, Strizki J, et al. Emergence of resistance-associated
variants after failed triple therapy with vaniprevir in treatment-
experienced non-cirrhotic patients with hepatitis C-genotype 1 infec-
tion: a population and clonal analysis. Virology 2013;443:278-284.
51. Lawitz E, Sulkowski M, Jacobson I, Kraft WK, Maliakkal B, Al-
Ibrahim M, Gordon SC, et al. Characterization of vaniprevir, a hepati-
tis C virus NS3/4A protease inhibitor, in patients with HCV genotype
1 infection: safety, antiviral activity, resistance, and pharmacokinetics.
Antiviral Res 2013;99:214-220.
52. McGivern DR, Masaki T, Williford S, Ingravallo P, Feng Z, Lahser F,
Asante-Appiah E, et al. Kinetic analyses reveal potent and early block-
ade of hepatitis C virus assembly by NS5A inhibitors. Gastroenterology
2014;147:453-462 e457.
53. Berger C, Romero-Brey I, Radujkovic D, Terreux R, Zayas M, Paul D,
Harak C, et al. Daclatasvir-Like Inhibitors of NS5A Block Early Bio-
genesis of Hepatitis C Virus-Induced Membranous Replication Facto-
ries, Independent of RNA Replication. Gastroenterology 2014.
54. Fridell RA, Wang C, Sun JH, O’Boyle DR, 2nd, Nower P, Valera L,
Qiu D, et al. Genotypic and phenotypic analysis of variants resistant to
hepatitis C virus nonstructural protein 5A replication complex inhibitor
BMS-790052 in humans: in vitro and in vivo correlations. HEPATOLOGY
2011;54:1924-1935.
55. Dore GJ, Lawitz E, Hezode C, Shafran SD, Ramji A, Tatum HA,
Taliani G, et al. Daclatasvir plus Peginterferon and Ribavirin is Non-
inferior to Peginterferon and Ribavirin Alone, and Reduces Duration
of Treatment for HCV Genotype 2 or 3 Infection. Gastroenterology
2014.
56. Lawitz E, Sullivan G, Rodriguez-Torres M, Bennett M, Poordad F,
Kapoor M, Badri P, et al. Exploratory trial of ombitasvir and ABT-
450/r with or without ribavirin for HCV genotype 1, 2, and 3 infec-
tion. J Infect 2014.
57. US Food and Drug Administration. Harvoni product insert. 2014; http://
www.accessdata.fda.gov/drugsatfda_docs/label/2014/205834s000lbl.pdf.
58. Europeans Medicines Agency. Daklinza European public assessment
report. 2014; http://www.ema.europa.eu/docs/en_GB/document_library/
EPAR_-_Product_Information/human/003768/WC500172848.pdf.
59. Nelson DR, Cooper JN, Lalezari JP, Lawitz E, Pockros PJ, Gitlin N,
Freilich BF, et al. All-oral 12-week treatment with daclatasvir plus
15273350, 2015, 5, Downloaded from https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep.27934 by INASP - NEPAL, Wiley Online Library on [11/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HEPATOLOGY, November 2015
sofosbuvir in patients with hepatitis C virus genotype 3 infection:
ALLY-3 phase III study. HEPATOLOGY 2015;61:1127-1135.
60. Lawitz EJ, Gruener D, Hill JM, Marbury T, Moorehead L, Mathias A,
Cheng G, et al. A phase 1, randomized, placebo-controlled, 3-day,
dose-ranging study of GS-5885, an NS5A inhibitor, in patients with
genotype 1 hepatitis C. J Hepatol 2012;57:24-31.
61. Wong KA, Worth A, Martin R, Svarovskaia E, Brainard DM, Lawitz
E, Miller MD, et al. Characterization of Hepatitis C virus resistance
from a multiple-dose clinical trial of the novel NS5A inhibitor GS-
5885. Antimicrob Agents Chemother 2013;57:6333-6340.
62. Afdhal N, Zeuzem S, Kwo P, Chojkier M, Gitlin N, Puoti M,
Romero-Gomez M, et al. Ledipasvir and sofosbuvir for untreated HCV
genotype 1 infection. N Engl J Med 2014;370:1889-1898.
63. Joyce CM, Steitz TA. Polymerase structures and function: variations on
a theme? J Bacteriol 1995;177:6321-6329.
64. Gentile I, Buonomo AR, Zappulo E, Coppola N, Borgia G. GS-9669:
a novel non-nucleoside inhibitor of viral polymerase for the treatment
of hepatitis C virus infection. Expert Rev Anti Infect Ther 2014:1-8.
65. Gane EJ, Stedman CA, Hyland RH, Ding X, Svarovskaia E, Symonds
WT, Hindes RG, et al. Nucleotide polymerase inhibitor sofosbuvir plus
ribavirin for hepatitis C. N Engl J Med 2013;368:34-44.
66. Zeuzem S, Dusheiko GM, Salupere R, Mangia A, Flisiak R, Hyland
RH, Illeperuma A, et al. Sofosbuvir and ribavirin in HCV genotypes 2
and 3. N Engl J Med 2014;370:1993-2001.
67. Donaldson EF, Harrington PR, O’Rear JJ, Naeger LK. Clinical evi-
dence and bioinformatics characterization of potential hepatitis C virus
resistance pathways for Sofosbuvir. HEPATOLOGY 2014.
68. Svarovskaia ES, Dvory-Sobol H, Parkin N, Hebner C, Gontcharova
V, Martin R, Ouyang W, et al. Infrequent Development of Resistance
in Genotype 1-6 Hepatitis C Virus-Infected Subjects Treated With
Sofosbuvir in Phase 2 and 3 Clinical Trials. Clin Infect Dis 2014.
69. Sims KD, Lemm J, Eley T, Liu M, Berglind A, Sherman D, Lawitz E,
et al. Randomized, Placebo-Controlled, Single-Ascending-Dose Study
of BMS-791325, a Hepatitis C Virus (HCV) NS5B Polymerase Inhibi-
tor, in HCV Genotype 1 Infection. Antimicrob Agents Chemother
2014;58:3496-3503.
70. Wyles DL. Antiviral resistance and the future landscape of hepatitis C
virus infection therapy. J Infect Dis 2013;207 Suppl 1:S33-39.
71. Poveda E, Wyles DL, Mena A, Pedreira JD, Castro-Iglesias A, Cachay
E. Update on hepatitis C virus resistance to direct-acting antiviral
agents. Antiviral Res 2014;108:181-191.
72. Gordon SC, Muir AJ, Lim JK, Pearlman B, Argo CK, Ramani A,
Maliakkal B, et al. Safety profile of boceprevir and telaprevir in chronic
hepatitis C: Real world experience from HCV-TARGET. J Hepatol 2014.
73. McPhee F. Clinical resistance to NS5A inhibitors: virologic escape and
long-term persistence. Antiviral Therapy 2014;19:A20, Abstract P18.
74. American Association for the Study of Liver Diseases. Recommendations for
Testing, Managing, and Treating Hepatitis C. 2014; http://hcvguidelines.
org/full-report/initial-treatment-hcv-infection-patients-starting-treatment.
75. European Association for the Study of the Liver. EASL Recommenda-
tions on the Treatment of Hepatitis C. 2014; http://files.easl.eu/easl-
recommendations-on-treatment-of-hepatitis-C/index.html.
76. Drafting Committee for Hepatitis Management Guidelines The Japan
Society of Hepatology. JSH Guidelines for the Management of Hepati-
tis C Virus Infection: A 2014 Update for Genotype 1. Hepatol Res
2014;44 Suppl S1:59-70.
Author names in bold designate shared co-first
authorship.
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