you and I want to thank the organizers for inviting me to participate. I'll be addressing current treatment criteria and when we can stop nucleotide analog therapies, who, when, and how. I'm Nora Tero from the University of Southern California. Here are my disclosures. The decision on who to treat is based on three criteria, ALT, HBV DNA, and fibrosis severity. Shown here are the AASLD criterion and although there's some modest variability across guidance documents, such as easel and apposal, in the concepts that these three components are important are consistent across all guidance. For ASLD, the ALT level greater than two times upper limit of normal. In HBV DNA, using thresholds of greater than 20,000, I use per ml for e-antigen positive and greater than 2,000 for e-antigen negative are the primary criteria used. But in individuals who do not have those criteria, the presence of fibrosis or cirrhosis is also important. All patients with cirrhosis should be treated. As well, any individuals with significant fibrosis and or inflammation should also be strongly considered for treatment, even if ALT and HBV DNA levels don't meet the thresholds listed here. Other factors may be important, including older age, with older typically considered those over the age of 40, and also a positive family history of either liver cancer or cirrhosis would be strongly brought into consideration for treatment in the appropriate individual. So these recommendations in terms of treatment reflect the active phases of disease. So shown here in this figure is the recognized phases of infection. We recognize that not all patients move through all of these phases over their lifetime, but when you see a patient, you are to identify where they are so that you can make not only a decision about do you need to treat, but also have some sense of what their future may look like. So starting on the left is the immune tolerant or chronic hepatitis B infection phase where ALT levels are normal, but HBV DNA levels are very high. And then over time, typically around the age of 30, people will transition into the immune active phase and may remain there for a variable period of time, ultimately with treatment or spontaneously transition to inactive chronic hepatitis B. And then about a third of patients will reactivate to E antigen negative chronic hepatitis B. Ultimately, what we hope is that patients will ultimately resolve their infection, although we know that that's relatively infrequent with current therapies. But just to make the point that it's the individuals who have E antigen positive and E antigen negative chronic hepatitis B who are the current target groups for treatment, because these individuals are at highest risk of development of liver complications in the absence of treatment. There are a couple of groups that I want to comment on that specifically do not need treatment and to provide some rationale or comments about why that's still so. On the left, immune tolerant or chronic hepatitis B infection. This is, I think, quite controversial. It always comes up for discussion, mainly because of the recognition of the association with high levels of virus and the risk for future complications. But nonetheless, there are very good data that suggests that this is a group that's at low risk for complications, at least in the short and intermediate term. It's unknown if treatment would reduce, say, future cancer risk. And more importantly is we don't have good therapies for this group. There's really a lack of effective therapies with very low rates of E antigen loss or S antigen loss with currently available new or peg interferon therapy. So the approach to this patient group is to be vigilant for when they're transitioning to immune active disease, especially over the age of 30 as they should be transitioning and to use fibrosis and inflammation as a potential other factor that would motivate you to treat them even if they don't meet the ALT criteria. The other group that's, I think, interesting and sometimes challenging is the E antigen negative patient who doesn't quite fit into the inactive hepatitis B category, meaning either their HPV DNA level or their ALT level is higher than expected for inactive hepatitis B, and yet they're not high enough to qualify for treatment as immune active E antigen negative disease. So in that group, the recommendations are still not to treat, but really first and foremost to look for other causes if it's a low HPV DNA coupled with a high ALT. Evaluate for whether they have significant fibrosis or inflammation, which may motivate you to treat them in the absence of other criteria, and then to follow them serially. It's important to note that there's been several natural history studies recently that suggest that if you leave these untreated gray zone patients and follow them over years, most of them, the vast majority of them, will ultimately transition to inactive chronic hepatitis B, but it's important to follow them and serial assessment is the current recommendation. Now I'm going to shift to discussing treatment withdrawal, and I want to set the stage for that by highlighting that there has been a shift in HPV treatment paradigm, and shown on the left is our current approach, which is largely suppressive and long-term NA therapy, but there's absolutely a shift towards thinking more about functional cure, about having off-treatment HPV DNA suppression, and ultimately having finite course of treatment, and that has set the stage for thinking much more about withdrawal these days and in more recent years. This is current ASLD recommendations regarding when to stop NA therapy and e-antigen positive patients. I'm going to start with this group. In those with cirrhosis, it's recommended they be treated indefinitely or until it has surface antigen loss, but in those without cirrhosis, the current recommendation is treat until you get e-antigen serial conversion, have one year of consolidation, and then stop, and alternatively you can treat until you get surface antigen loss. So what is the outcome of patients who stop leukocyte analogs after having achieved serial conversion and had consolidation? Here I'm showing you one representative study in which e-antigen positive patients were followed for virological relapse, clinical relapse, and S antigen loss after stopping leukocyte analog therapy when they met the criteria to stop, meaning they achieved serial conversion and had a phase of consolidation. You can see that encouragingly 20% have lost surface antigen when you look at them eight years later, and about 50% of them have had virological and clinical relapse. And if you look across studies, about 50% rate of relapse is what's described, and you can see that for the most part that relapse occurs generally within the first year after stopping the treatment and then sort of plateaus. Are there factors that influence the likelihood of having a durable response versus having a clinical relapse? The answer is yes. Age appears to be important, and so too does the duration of consolidation. Those that are younger when they achieve e-antigen serial conversion are more likely to remain off treatment. Here is the looking at clinical relapse, and you can see that it's higher in those that are older and those that have shorter duration of consolidation. In this study, a similar pattern is seen. They're looking at virological recurrence here, but again, the lowest rate of virological recurrence is seen in those that are younger under the age of 40 and with longer periods of consolidation. So the age of your patient should influence your decision as to whether to stop, and may also influence how long you want to do consolidation therapy. There's also data that highlight a difference in outcomes in those that are treated with tenofoviruses in tachyvere. I think this is interesting data. I want to see more, but just to bring it to your attention that we have two studies that have shown that the likelihood of needing retreatment or in this case having clinical relapse was higher in tenofovir treated patients than patients treated with in tachyvere. And importantly, the level of HPV DNA while on treatment may be an important predictor of clinical relapse. This is an interesting study where they were treating with tempevidine and adefavir. They treated patients until they got e-antigen seroconversion and then for an additional 48 weeks had to have HPV DNA levels less than 300. And what they looked at here in terms of the cumulative risk of clinical relapse and then on this side, e-antigen seroreversion, two markers of an undesirable outcome. You can see that it's the patients that had quantifiable levels of virus that had higher rates versus those that had target not detected. The very lowest rates of clinical outcomes was in those that were target not detected rather than having levels less than 20. So maybe a deeper form of remission if we want to say by having HPV DNA levels that are not quantifiable. So just to summarize the data we have thus far on NA withdrawal and e-antigen positive chronic hepatitis B, there's definitely a rate of surface antigen loss that is seen after discontinuation. It appears to be about 20% with follow-up in most studies of five years or longer. Low surface antigen levels, I didn't show you this data, but they have been associated with the likelihood of this occurring. I think the primary benefit of NA withdrawal is the ability to have this finite duration of therapy and certainly about 50% of patients who achieve e-antigen seroconversion and have at least one year of consolidation therapy will sustain this response off treatment. So that's a substantial number of patients. The factors that are emerging in terms of predicting sustained response and avoiding retreatment include younger age at the time of seroconversion. So I think we should be encouraged to consider withdrawal in those that are under the age of 40 at the time of seroconversion, longer duration of consolidation therapy. So perhaps more than one year is desirable. And then the new and emerging factors may be an undetectable versus low level HPV DNA at and on treatment. And whether the nucleoside versus nucleotide analog matters is something I think warrants further study. Turning now to e-antigen negative chronic hepatitis B and recommendations regarding stopping NA therapy. Shown here are the ASLD guidance, which in short indicates that treatment should be indefinite and thus is not recommending discontinuation. But the ESL and APOSL guidance is more inclusive of a consideration of NA discontinuation. ESL recommends that you can treat for at least four years with undetectable HPV DNA for at least 18 months and then consider stopping. And APOSL recommends treatment for at least two years with undetectable HPV DNA for 18 months and then consider stopping. ESL recommends this only in patients without cirrhosis, whereas APOSL suggests that it may be considered in those with compensated cirrhosis. That's the only guidance that would support that. Most guidances recommend indefinite therapy for those with cirrhosis, but this does open up the possibility of doing withdrawal of NA therapy. So what's the data to support this recommendation? Shown here is the typical course when you withdraw an individual from nucleoside analog therapy. And it's to highlight that initially the HPV and ALT levels, of course, are well controlled on treatment. You stop treatment and there's a lag phase of several months before you first see rise in HPV DNA levels and then ALT. So during this reactivation phase, which can have an onset anytime from one to 12 months after stopping treatment. And during this time, you see the ALT flares that can be severe in some cases. And this is the period of time where close monitoring is necessary to ensure that individuals with severe flare undergo appropriate retreatment. But whether this period of time of reactivation without need for retreatment, those individuals over time will move to consolidate their response. And ultimately, the beneficial outcomes that can be achieved are twofold. One is you can see individuals who lose surface antigen. And secondly, you can identify individuals who have a sustained virological response, so-called inactive chronic hepatitis B. And in the studies that I'm going to share with you, it's those two endpoints that are equally relevant and important in terms of being a reason to discontinue antitherapy. The importance of discontinuation in achieving surface antigen loss is highlighted by this study. It's a modest size, but a nice study in which we have a group in which tenofovir is stopped versus one in which it was continued. And it's following surface antigen levels over a period of a year. And you can see that it's only in those that stopped tenofovir that we see that there can be a decline in surface antigen and ultimate loss, whereas that is not occurring in patients who continue tenofovir therapy. So certainly in the antigen negative patients in which we know that surface antigen loss is very infrequent with long-term NA therapy, this is a strategy that can be used to achieve more S antigen loss. There have been a number of studies that have looked at withdrawal and the outcome, both surface antigen loss as one outcome and the ability to remain off treatment and to have an inactive carrier status. In this table, I've shown studies that had follow-up of at least three years, because it's clear that to see the full benefits of having done withdrawal, that you need longer periods of follow-up after withdrawal. And you can see that the nucleoside analog therapy used across these studies is quite variable. And really, the point of this table is just to highlight heterogeneity, both particularly in the ability to achieve surface antigen loss. You'll see a wide range of reported rates of surface antigen loss from zero to 55. The median across these studies is 18% at three to five years. In terms of the proportion that are able to remain off treatment, there seems to be more consistency across studies with approximately 50 to maybe as high as 75% of patients who are withdrawn able to remain off treatment and to have that inactive chronic hepatitis B status or achievement of surface antigen loss. The heterogeneity across studies is in part related to differences in the patient characteristics, differences in the NA therapy used, both the duration of treatment, the type of NA. Criteria for restarting vary across studies, whether they restart for virological versus clinical relapse. And also the duration of follow-up seems to be very important in terms of assessing, especially for surface antigen loss. And that is highly variable across studies. So that makes it difficult for us to ascertain the specific benefits of this treatment and to apply it across a broad array of patients. Looking at the studies that have focused on factors that may influence the rate of clinical relapse and need for retreatment, I'll first share with you studies that have looked at the type of NA. The emerging data suggests that when patients have been on tenofovir that the relapse is earlier in terms of virological and clinical relapse. Here's the clinical relapse shown here. It's earlier with tenofovir treated patients, but ultimately when you are out several years from treatment that the rates of virological and or clinical relapse tend to become very similar with very minimal differences between the two NA treatments. Surface antigen quantitation is the best studied in terms of a marker for sustained response and absence of retreatment. It's also important as a marker of ultimately losing surface antigen. That's not too surprising. I'm showing you two pieces of data here. On the left is a study in which they looked at level of surface antigen quantitation and risk for cumulative rate of retreatment. You can see that those at the end of treatment had a surface antigen level less than 150, had a retreatment rate of approximately half that of patients who had higher hepatitis B surface antigen quantitative levels at the end of treatment. Then shown on the right is a summary of a systematic review of 11 studies of 1,700 Asian patients. The outcome they looked at here was off-treatment clinical relapse rates. Looking at how often do you see clinical relapse when patients have been off treatment for at least 12 months. Similarly, surface antigen quantitation is important here. You can see that the antigen level at the end of treatment, if it's under 100, that the rate of clinical relapse was 15 to 30 percent. Whereas again, it's approximately double that rate if the surface antigen quantitation was higher than 100 at the end of treatment. Whether it's 100 or 150, whether it's 200, I think that needs more study, but obviously a lower level of surface antigen quantitation predicts a better outcome after withdrawal. There's an interesting study that tried to bring multiple factors into play and show that that can be helpful. Shown here is combining the surface antigen quantitation, the duration of treatment, and then the duration of consolidation. Really highlighting that all are important with the very lowest rate of clinical relapse and those that had surface antigen quantitation under 1,000 in this case, a duration of treatment greater than three years in consolidation, meaning an HPV DNA level that's undetectable for 2.25 years. Whereas the highest rate of clinical relapse is in those that did not have those factors. So what I can say about the nucleoside withdrawal in the antigen negative chronic hepatitis B is it's more strongly endorsed by oposthalmies than ASLD guidance. There is this ability to achieve functional cure in up to maybe 20 percent of patients with three to five years of follow-up, but recognize it's highly variable across studies. This is likely influenced by the type of NA, perhaps the duration of suppression follow-up afterwards. All of these contribute to the variability that we're seeing. Reactivation or flares are important, both from the point of view of being relevant to achieving the outcomes of interest, but remember that they can sometimes be harmful flares and our ability to predict a beneficial versus harmful flares is actually quite poor. The other benefit of NA withdrawal is that you identify those that are inactive carriers and the study suggests that after withdrawal, 50 to 75 percent of patients will remain inactive carriers when you evaluate them at periods of three to five years after withdrawal. So this does allow us to have more finite treatment in a substantial proportion of our e-antigen negative patients. I think we really need better markers. Certainly low quantitative surface antigen is one factor, but I think many more studies are needed to help inform and predict those that are going to benefit from withdrawal versus those that are better served by staying on treatment. So the key takeaways, there's a shift. While there's been no changes in how we start treatment, there is a shift in our thinking about when to stop treatment with consideration of more finite duration and the goal of achieving surface antigen loss. NA withdrawal strategies offer an opportunity for finite therapy, but the main challenge is in monitoring and managing the ALT flares, and we're certainly in need of better predictors of those flares and who is best served by withdrawal. Keep in mind that for most of the guidance statements emphasize the importance of this only being done in non-cirrhotics. And NA withdrawal achieves surface antigen loss at higher levels than continued treatment, but the overall success, I would emphasize, is still quite modest with 20% at three to five years, and therefore there's still much room for improvement in terms of enhancing the rate of surface antigen loss. And that really sets the stage for subsequent talks, which are going to focus on additional strategies and drugs to achieve functional cure. Thank you very much. Hello. I first would like to thank the organizers of ASLD for inviting me to give this talk on the management of the older patients with chronic hepatitis B regarding comorbidities and specifically is fatty liver on that in concurrent hepatitis B and non-alcoholic fatty liver disease. This is my disclosure. So first I would like to discuss and review the general trend of advancing age and comorbidity in the data that we have around the world, and then focusing on some of the more relevant specific comorbidities and management issues. So we reviewed this data from nationwide data of about 45 million enrollees, and in here we have about 14,000 patients with chronic hepatitis B in the commercial and the Medicare, which is a government insurance for older people in the U.S. And in this, we found that the age of the average age of the hepatitis B patient had increased from 48 to 52 years old over a course of 10 years, so this is the 2015 data. So if we could project it, this age is probably approaching closer to the mid-50s now in terms of median age. And as of 2015, we could see here that in about 42 patients, 42% patients are 55 years or older. And as expected, when we look at both the commercial and Medicare as well as the Medicaid population, which is a little bit younger, and this is a government insurance for people with lower income, so the median age for this group is younger than the other group. However, you could see that in both populations, the rate of comorbidities are fairly comparable here and they are all increasing with time. And more specifically, when we look at the prevalence and the incidence of chronic kidney disease, comparing hepatitis B patients with MATCH control over this time period in 2006 to 2010 here, we found that both the prevalence and the incidence of CKD increased with time and it also is higher in hepatitis B patients compared to MATCH controls. And we found also fairly similar trend in osteopenia, osteoporosis, and non-pathologic bone fractures. Now in terms of the advancing age, the data from Japan, another fairly low prevalence country for hepatitis B, the aging is even more remarkable. We can see here that 60% in 2016 were 65 years or older, 62%. So that is fairly high and the comorbidity index is also increasing. Pretty much we found similar trends in the metabolic comorbidities, kidney disease, and metabolic bone disease in the National Health Insurance Database of Korea. And so we found a fairly consistent pattern globally here. And the median age of the Korean hepatitis B populations are more similar to the U.S. In 2016, the median age was 52, so pretty much the same as the U.S. and younger than what was seen in the Japan population. Encouragingly, the rate of complications such as cirrhosis, decompensated cirrhosis, have been going down while the HCC rates are going up and this is probably a reflection of antiviral therapy, as well as advancing age and higher HCC incidence. Taiwan database also is a large national insurance database covering almost the entire Taiwanese population. The data is a little bit older, but going from 2011 to 2001, compared to 2001, the trend is quite consistent. And as you know, Taiwan is one of the early countries that instituted the vaccine, a universal vaccination policy. So it is no wonder that this trend is increasing and was seen even earlier. And in the Hong Kong real-world data, and this also contains the vast majority of the Hong Kong territory population, and we see a fairly similar trend. And the median age is a little bit, in 2017, is about the same, a little bit older than the U.S. population. One thing that is also very encouraging here is that compared to 2000, 2014, 2000, 2004, 10 years later data, 2014, 2017, half of the population of hepatitis B in this database have some type of antiviral therapy. So at least the ones with hepatitis B diagnosis, this is quite much higher than what we see in the U.S. where we only have less than 5% of the patients with hepatitis B diagnosis with antiviral therapy use. So this could be a reflection of higher antiviral therapy usage, or it could be that there are patients who don't meet criteria for hepatitis B that are not diagnosed and registered in this database. So going into some of the more specific comorbidities and management issues, I will start first with renal insufficiency and osteoporosis. So it is fairly well established that the renal function would decline with age, and this is the logic, about 8 mL per minute per 1.73 meters squared per decade after about 50 years of age. And then we also have the various comorbidity related renal decline, and the very common one is diabetes, hypertension, and fatty liver disease. There are data to show that patient fatty liver disease is an independent risk for developing kidney disease, independent of hypertension and diabetes. And the key thing is that we should screen for renal function in older patients or patients at risk, and this would be like about at least 50% of the current hepatitis B population now. And the key thing is to screen with estimated GFR and not just with serum creatinine, because a young person with a creatinine of 1.3 may be in the normal range, but a 60-year-old with a creatinine of 1.3 actually could have at least mild CKD according to the CKD stages. Less than 90 would be stage 2, which is mild renal insufficiency, and between 60 and 90 would be moderate, with the GFR between less than 60 would be more moderate to severe. And currently, there are no standard guidance for osteoporosis screening in chronic hepatitis B, but ESO guideline 2017 gives fairly specific recommendations that if the patient with hepatitis B requiring a long-term loop therapy, we should consider Entecavia or TAP over TDF because of the better renal and bone safety data with TAP from both registration trials as well as from the more recent data from switch therapy between TDF to TAP. So age older than 60, people with high risk for bone disease, chronic steroid use, history of fracture or osteoporosis, people with renal alteration, GFR less than 60, or have evidence of significant albuminuria, low phosphate, and obviously patients who have established kidney disease on hemodialysis. So in the US, the criteria for screening for osteoporosis with EXA is actually quite simple and minimal, as you could see here from the US Preventive Service Task Force 2018. So the task force only recommends screening patients for osteoporosis for women 65 years or older, and postmenopausal women younger than 65 at increased risk, and there's no recommendation for men at all. And the additional risk that is mentioned here would be alcohol, smoking, history, family history of hip fracture, low body weight. So very few. Though we know that in liver disease, we know that there is pretty established risk of osteoporosis in many conditions, cirrhosis, the post-transplant population, and chronic polystasis. And for these populations, at least for the post-transplant and the chronic polystatic conditions, there are guidance from professional societies to screen these patients with DEXA. The frequency is more variable. In general, every two years, but there are some who advocate for screening post-transplant or very high-risk patients even every year. But in general, probably every two to three years. So now let's switch gears to metabolic disease and NAFLD. So the global prevalence of NAFLD among the general population, according to this meta-analysis by Yunossi and colleagues in 2016, the overall prevalence was 24%. But as you could see, the data is variable, pretty low in Africa, but I would want to caution you that the data is pretty sparse. Very few studies in Africa. The vast majority of the data actually come from Asia, and next to it would be Europe and North America with fairly scant data from other regions. But as a representation of what we have, you could see there are a lot of regional differences in terms of fatty liver disease prevalence. Data from both Asia and the U.S. clearly show, however, that the prevalence has increased in the past one, two decades. Now the other thing that we should also recognize is that not everyone with NAFLD are overweight or obese. So recently we also performed a systematic review and meta-analysis looking at the prevalence of lean NAFLD among those with NAFLD, and we found that on average, the pool prevalence for lean NAFLD is about 40% among the NAFLD populations globally. And similar to the meta-analysis seen earlier for the global general prevalence, the vast majority of the data also come from East Asia. So diabetes, and how about the newly proposed MAFLD, Metabolic Associated Fatty Liver Disease, that has been published in Gastro, as well as Journal of Hepatology and Hepatology International by Dr. Aslam and colleagues and the international expert group. So diabetes is very important for many reasons that should really be screened for and managed in patients with any diseases, and especially hepatitis B. The prevalence of NAFLD in type 2 diabetes is 55%, and this is a fairly recent meta-analysis performed by UNOSI and colleagues published last year in Journal of Hepatology. And diabetes is an independent risk factor for HCC in chronic hepatitis B patients receiving nukes, and this has been shown and validated in risk scores by two groups. Most of these data have been in Asian patients. Now what is MAFLD? So the main difference between MAFLD and MAFLD is that in MAFLD, the diagnosis does not require exclusion of all other chronic liver diseases, including alcohol. And the strict definition of non-alcoholic fatty liver disease tend to require imaging or biopsy, whereas this proposal clearly stated that the diagnosis can be biopsy, imaging, or serum markers like fatty liver index to diagnose hepatic steatosis, plus components of metabolic disease, overweight obesity, diabetes, or evidence of metabolic dysregulation. And there are fairly comprehensive table in this reference to list the many criteria to qualify for metabolic dysregulation. So with this, there would be a new group of MAFLD patients that earlier would not have been diagnosed with MAFLD, and this may help increase the screening, surveillance, as well as management, because this diagnosis or this proposal can bring in the metabolic experts like endocrinologists that traditionally is not really managing liver disease. Now is that all bad? So I think that we all would expect patients with two liver diseases would have worse outcomes than one liver disease, and we have seen this in viral co-infection, or people with hepatitis C and drinks alcohol, for example. So this is a study that evaluated about 1,000 hepatitis B patients who underwent liver biopsy at two highly specialized centers in Toronto and Rotterdam. And this study shows that overall, there's higher risk of liver complications, including HCC, decompensated liver disease, as well as liver transplant, if the patients have hepatitis B and NASH. So the key thing here is that these patients have NASH and not just the generic, general, or simple hepatic steatosis. But even in this study, with a highly selected population undergoing liver biopsy at tertiary care centers, the main difference is between hepatitis B and NASH with advanced fibrosis, comparing to hepatitis B with advanced fibrosis only. In the multivariate analysis model here, the statistical significance was found for the NASH advanced fibrosis and hepatitis B patients compared to those without NASH or advanced fibrosis. It's not very clear why antiviral therapy was not included in the multivariate analysis here, and this could limit some of this conclusion. So in the systematic review and meta-analysis that we screened more than 2,500 articles, we identified 59 articles in about 33,000 patients who were diagnosed as hepatic steatosis by imaging, and the POM prevalence here is about 33%. And in this analysis, we found no significant association between hepatic steatosis and increased fibrosis. So I want to emphasize again that this study evaluated all hepatic steatosis together and see if there's association between hepatic steatosis and increased fibrosis. And this is different from the study that I just showed you in the last slide. In that study, everyone included or analyzed as a fatty liver group already got NASH. That's quite different. And in another study, and this is a study about 500 patients, all of these patients are on MOOCs, and we found that fatty liver, and again, this is not just NASH, fatty liver in general is diagnosed by ultrasound imaging. We found that the patients with NAFUD was not any less likely to have lower rates of complete response to oral antiviral therapy, and this includes both virologic suppression as well as complete normalization of ALT defined as less than 35 for men and less than 25 for women. So in the patients with hepatitis B and fat found on ultrasound, we should expect the patient to have fairly similar response, both biologic and biochemical, if they have compared to patient with that. Now, how about the long-term outcome of patient with chronic hepatitis B and hepatic steatosis diagnosed by imaging, usually ultrasound, in the vast majority, because this is how we survey patients with chronic hepatitis B. So this is data from Stanford and from the review cohort. And in this study, we also found the prevalence of fatty liver is about 31%, and we found that in the overall cohort of close to 7,000 patients, we found that patients with bowel-fatty liver disease actually have higher rates of cirrhosis, HCC, and lower HBs, IgG, seroclearance. So this is quite unexpected. So we tried to stratify the patients and tried to find the source of associated factors that influence the observation. So we stratified the patient by antiviral treatment, without antiviral treatment, and with antiviral treatment, and we performed profanity score matching for several relevant baseline factors here. And we found that in the untreated groups, as you could expect, the incidence of HCC and cirrhosis were both low, and there was no significant difference between the fatty liver and non-fatty liver group. And surface antigen seroclearance incidence is much higher and also similar between these two groups. However, among the treated patients, so again, we are probably selecting here for sicker patients, older patients, more advanced patients, and in this, we surprisingly still found that the non-fatty liver patients have higher incidence of cirrhosis and HCC compared to the fatty liver patients, and also the reverse with surface antigen seroclearance. And on regression analysis, we found that among the treated patients with oral nucs, then fatty livers, are actually an independent risk factor for lower risk of HCC and cirrhosis. So the key points here to remember is that by now, probably about half of the CHB populations in the US and many parts of Asia are over 55 and much higher than this in some areas such as Japan. And older CHB patients are at higher risk for renal, bone, and metabolic complications and should be screened for these. And tachyvere and TAF should be used in older patients, high-risk patients who require antiviral therapy, and hepatitis B with diabetes are at higher risk for HCC. About one-third of hepatitis B patients have fatty liver and hep B patients with NASH and advanced fibrosis, biopsy-proven, are at higher risk for liver complications. Hepatitis B patients receiving antiviral therapy with fatty liver disease have lower risk of cirrhosis and HCC, but they should respond to antiviral therapy at similar rates in regards to complete response with biologic and biochemical response. So further studies are needed to confirm this and to investigate possible mechanisms for the interactions between fatty liver disease and chronic hepatitis B, especially in the treated populations and in the non-NASH, non-advanced liver fibrosis patients. Thank you. First of all, I would like to thank ASLD for such a kind invitation to deliver this very specialized topic entitled Biologic and Immunologic Targets for HPV Cure. Here are my disclosures. Although we can now eradicate hepatitis C infection, we are by far long away from hepatitis B. Unlike hepatitis C, hepatitis B has viral reservoir and has both cytoplasmic and nuclear phases in its life cycle. This makes total eradication not a practical goal for hepatitis B virus. Instead, we talk cascade or level of cure in hepatitis B infection. With the existing treatment, we can achieve all patients with viral suppression, maybe one third of patients with partial cure after stopping treatment, but they still have low-grade myelemia. Only a few percent of patients can achieve functional cure even on long-term therapy. So our treatment goal now is through whatever means to increase the chance of functional cure. However, as already mentioned, functional cure occurs at a very low rate in patients using anti-viral therapy. With nuclear site analog therapy, anticoagulant leads to around 3.5 to 5% over five to seven years. Terinoprofia, 1.3% for E-negative patients and 12% for E-positive patients. But those are mainly in Caucasian population. For interferon, again, less than 10% for sure. Since hepatitis B replication goes through different intermediate steps, it provides us a chance to suppress the virus by direct agents adding against this step specifically. There are several possible sites of actions. First, we can inhibit viral entry to hepatocytes. We can lock down the mRNA transcription activities. We can interfere core protein functions to affect the viral encapsulation and CCC DNA replenishment. Finally, we can consider to inhibit surface entry release from the cells. I would illustrate all this possible anti-viral actions one by one now. It has been shown that these agents can compete with hepatitis B virus for binding to the NTCP receptors on the hepatocytes. The trial agent is called Microdex or Blevatide. The lower left diagram showed the 24 weeks of Blevatide had no effect on surface entry level. As shown in the middle and the right figures, adding Blevatide to interferon has no additional surface entry reductive effects when compared to monotherapy using interferon. However, the effect of Blevatide was further studied by combining the original cohorts and new cohorts with extension to 48 weeks and 72 weeks. It was found that there was no meaningful surface entry reduction in either Blevatide monotherapy arm or a combination arm with tenofovir. However, there were more patients achieving greater than one log surface entry reduction in Blevatide combining with interferon compared to none in interferon monotherapy group. Paradoxically, the best results were seen in the lowest dosing group using 2mg. In that group, 27% lost surface entry at week 72. A more promising new agent, in my opinion, is RNA inhibition using either short-interfering RNA or antisense or nucleotide illustrated in green and yellow boxes and arrows respectively in these slides. As illustrated by the arrows in the left and the white lower diagram, sRNA degrades the viral RNA by weights in the cytoplasm, whereas ASO degrades the viral RNA by RNAase both in the cytoplasm and in the nucleus. There are many investigational agents adding on X over open meeting frame and or surface over open meeting frame of the virus. Again, I will illustrate them to you one by one. J and J3989 with two targets, with two trigger targeting both the X and S open meeting frames given at three monthly doses result in a profound and sustained surface entry reduction till 48 weeks after treatment. For the responder, the median surface entry reduction was greater than two knots. Even for the study design defined from responders, the surface entry reduction was greater than on five knots. You can also appreciate the corresponding responses in the RNA, E antigen, and also COVID antigen. A new coma is VR2218, targeting X open meeting frame. Two monthly injections with different increasing doses resulted in dose proportional response in the surface entry reduction. The surface entry reductive effect still continues until 16 weeks after the last dose. For example, the highest mean reduction of surface entry was more than 1.5 knot in patients receiving 200 milligrams at 16 weeks after the last dose. Another new SRNA, RG6346, which synchronously targets the surface entry open meeting frame also showed very promising surface entry reductive effect. Patients receiving four monthly injections with three or six milligrams per kilogram would have approximately 1.8 knot surface entry reduction. The effect was sustained at the last assessment at 20 weeks after the last dose. In fact, the available longer follow-up time as illustrated by the light blue line, we observed the effect still maintains at 36 weeks after the last dose. My last illustration of RNA inhibition is antisense molecule nucleotide, GSK836. Given with six doses within four weeks resulted in a profound suppression of the surface energy. In a tumor naive population, the mean surface entry reduction was around 1.6 knot. In a tumor experienced patients, it was 2.5 knot. Four patients from both groups had undetectable surface entry shortly after the last dose. Six patients from both groups of 16 patients had greater than three knot surface entry reduction. Now I turn to core protein allosteric modulator, CPAM. Because of the multifunctionality of the core protein, CPAM in addition to inhibiting p-genomic RNA encapsulation and also DNA replication, it can also affect the CCCDNA formation and also amplification. There are two groups of CPAM as shown in the lower right diagram. Class I CPAM results in aberrant nuclear acids, whereas class II CPAM results in empty nuclear acid without housing the genomic contents. The first prototype of CPAM is NVR3778 and it showed that CPAM was able to reduce DNA as well as RNA with the effects and the effects were dose proportional. The magnitude of both DNA and RNA reduction could be augmented by combining the CPAM with the PEC interview one as illustrated by the red lines in the two diagrams. After the initial positive results of the first CPAM, there are more potent CPAMs being developed. 28 days of rebirth care will lead to more than two knot reductions of HVDNA and also more than 1.5 knot reduction for RNA. In this study, four weeks of RO9389 treatment resulted in a median of three knot reduction of HVDNA and also 2.5 knot reduction of HPV RNA. More than 80% of E-negative patients would have unstable DNA by week four. Assessment of CPAM needed to be extended to more long-term. In this study, patients were randomized into Antikyphia alone or Antikyphia plus Rubicafia for the first 24 weeks before they all were given Antikyphia plus Rubicafia from 24 weeks onwards. In the first 24 weeks, combination of Antikyphia and Rubicafia resulted in a significant greater reduction of HVDNA and also RNA compared to the monotherapy group of using Antikyphia. Once the monotherapy group was added with Rubicafia, the DNA and also the RNA suppression could still be achieved at the same level as of the patients receiving combination therapy at the beginning. Unlike the previous studies treating patients for four weeks, more long-term Rubicafia treatment could result in meaningful viral antigen reduction, namely the surface antigen, E antigen and also COVID antigen, although they were mainly seen in E-positive treatment naive population. Another CPAM JNJ6379 has also demonstrated more long-term effects. Instead of bothering you the details of the study, I would like to ask you to concentrate on the dotted boxes, the blue boxes in the two lower diagrams. Combination of JNJ6379 with nucleoside analogs induced a marked RNA reduction compared to nucleoside analog therapy alone, both in the treatment naive as well as the virological suppressed patient, although more profound effect was seen in the former group. Again, very similar to the previous result seen and Rubicafia, we start to see meaningful surface antigen reduction in E-positive patients treatment naive. And in this study, 36% of these patients had greater than 0.5 log reduction of surface antigen at 24 weeks. So far, the CPAM results I presented to you will all belong to class two. These studies show that HVDNA, RNA, co-related antigens were all more reduced by combining a class one CPAM in GLS4 with Antikyphia compared to Antikyphia alone. In a E-positive treatment naive group, combination of therapy resulted in considerable proportion of patients with good surface antigen reduction. 47% of patients had greater than 0.5 log reduction of surface antigen at week 24. H2158 is the newest CPAM now being studied in the clinic. Just 14 days of treatment will result in 2.3 to 2.7 log reduction of surface DNA and more than two log reduction in RNA. At present, there are more upcoming CPAM in the pipeline and should be in the clinic for testing. And this will make the field more interesting and exciting. Before I change the topic to immunological targets, the last group of direct antiviral agents is the surface antigen release inhibitor. Again, without bothering you the details of the coming two studies, which will quite compress, I just want to mention that treatment with tenofofir plus peculated iniferon plus this nucleoacetate nucleoacetate polymers would result for more than 48 weeks would bring 24 out of 40 patients achieving functional cure at the end of treatment. And this was maintained in 14 patients at 48 weeks after of treatment. With further follow up and combining with more cohorts, functional cure was observed in 18 out of 52 patients. Using a tenfold more sensitive surface antigen, all these 18 patients still have undetectable surface antigen and they were all having unquantifiable RNAs and also correlated antigen. Now moving on to immunologic targets to control hepatitis B virus. Studies on this aspect are in fact relatively few comparing to direct antiviral agents. Nonetheless we can broadly classify into three approaches. Stimulation of innate immunity using total receptor agonist, blockade of immunosuppressive therapy using NTPD1 or NTPDL1, and production of neutralizing antibodies using therapeutic vaccine. Although this is still at a very early phase of chemical studies. This study used a total receptor agonist sulcantolamide given with two doses for 24 weeks in virally suppressed patient. After 24 weeks all patient will continue antiviral agents with another assessment at week 48. The waterfall plot showed that the reduction of the surface antigen at week 24 and week 48 for patients receiving sulcantolamide and nucleoside analogue therapy. The red bars represent 3 milligram good and the green bars represent 1.5 milligram good. There was some reduction although mostly less than 0.3 logs seen in both groups at both time points. One patient that is 5% achieved functional cure in each group as assessed at week 48. It seems that total receptor had mild effect on surface antigen reduction on its own. Blocking the immunosuppressive therapy is one of the possible maneuvers to enhance functional cure. In this initial study one dose of 0.3 milligram per kilogram of liponema or without therapeutic vaccine resulted in slight reduction of the surface antigen levels. The mean reduction at 24 weeks were 0.48 and 0.25 respectively. There was one patient out of 22 that is around 5% achieved functional cure in this group of patients. So ladies and gentlemen my conclusions are many upcoming novel agents with different modes of action have established their antiviral efficacy and initial safety profiles. The effects of more suppression of HPDNA, novel suppression of pyjonomic RNA and surface antigen bring new hope for functional cure. The challenge remains how to combine these agents. Should we combine different DAA, dual versus triple? Should we combine different DAAs with different immunomodulators and with what? We also have a challenge of determining the number of doses. For example in case of sRNA, ASO, PD-1 or NTPD-L1. We also need to define the duration of the new treatment. For example in the case of total receptor and Zika. But one thing for sure is that the chronic hepatitis B treatment paradigm will soon be changed. With that I would like to thank for the attention. Dear chairs, ladies and gentlemen, my name is Harry Jensen. I'm from Toronto and I'm very happy and honored to present the presentation strategies for combination therapy to reach HPV cure. Here are my disclosures. So important considerations for HPV cure and combination therapy are first of all that nucleoside analogs are highly effective and generally well tolerated but with low rates of successful discontinuation. That we have that long-term nucleoside analogs reduce cirrhosis liver failure and HCC. That CCC DNA is very persistent and hard to reach so that might make hepatitis B difficult to treat. And that HPV immune reactivity unlike in hepatitis C for instance is likely important for cure but could definitely result in flares. So the bottom line is it won't be easy to cure HPV at least not as easy as it was for hepatitis C. With an effective suppressive therapy around we have to be very very careful. So here are the different combination treatment strategies that we currently use. You could either start a combinate both drugs or triple drugs at the same time. You could add on a specific treatment to an already existing therapy. You could switch therapy or you could give what we call response guided therapy which means that we adapt at a certain stage during therapy based on results. And in the past for instance we did that with rather weak nucleoside analogs like lamivudine where we at a certain time point added on or switched to stronger drugs such as tenofovir and tedafovir. So what are the approaches to therapy that we have in our hands? And I would like to divide them into viral targets and immune targets. So the viral targets are really viral entry, CCC DNA formation, transcription and degradation, RNA intermediates that could be tackled and capsidation, DNA replication, assembly and release. And on the right side of this slide you see the immune modulators which you can really divide into trying to I would say attack the innate immune response or try to work on the adaptive immune response. And the innate immune response we have Pag interferon in our hands which is not often used anymore in clinical practice but could actually be revitalized in the setting of drug development of hepatitis B. There's still like receptor agonists, regi agonists, sting agonists, pattern recognition receptor drugs which have been and are being investigated currently. And then there's the adaptive immune response where we could use checkpoint inhibitors PD-1, PD-L1 blocking agents for instance which are highly used as most of you will know in the setting of cancer and are also now being used for hepatitis B to revitalize the immune response. And then there's therapeutic vaccination. So it's interesting to say that there's sometimes a view between virologists and immunologists. If you're in an ad board or otherwise talking about new treatments there's different views and we likely might need to have both types of target engagements to cure hepatitis B. But there is a kind of a difference in view I would say. If you look at the virology part, virologists not seldom say that blocking the viral replication at multiple steps and elimination of CCC DNA will eventually cure HPV. There will just be no infected hepatocyte left. We would need assays though to detect a very low level of replication way below the current lower limit of detection to determine efficacy. Intense inhibition of protein and virus production may by itself mount an effective immune response that can cure the disease. And we know that modification of antiviral therapy may lead to an effective immune response for example stopping nucleoside analogues. Then on the other side there are the humanologists that may claim that the virus integrates into the host genome and will always remain present in the hepatocytes or elsewhere even. And proof of that is that HPV relapse or even S-antigen seroreversion can occur during immune suppression as we all know. Another argument is that effective immune control is most likely delivered by immune modulation, for example PEC interferon currently. So the question is how to combine these new agents with, should we start with patients who are on nucleoside analogues or not. So we have a population with treatment naive and we have a population which is virally suppressed. So the treatment naive patients are typically younger, have active disease and these patients might be more likely to accept finite therapy. We will be better able to evaluate the viral dynamics and immune activity through ALT, better able to assess independent contribution of each new drug and we may need inflammation, in fact immune priming to generate an effect to get cure. On the other hand you have virally suppressed patients with nucleoside analogues and they have a safe and very effective therapy with reduction of HCC and improved survival in their hands. And many patients who are on these typical drugs might have objections for experimental therapy and say doctor I'm on this specific therapy now for 10 years, why do you want to uproot my life with experimental therapy. Nucleoside analogues can give a partial immune restoration which may benefit immune modifying therapy, you might have a better protection against flares and a reduced risk of drug resistance. So there's pros and cons for both options really. So if you look at the different potential combinations that we have in our hands, I think we have to focus on a combination of HPV, so viral suppression, viral protein depletion and immunotherapy. Those would be the three pillars and underneath you see different drugs which could reach an effect in those different pillars. For instance HPV DNA suppression, we know that nukes and capsid assembly modulators can help their entry inhibitors and RNA interference. RNA interference also work for both viral protein depletion and other drugs like nucleic acid polymers and CCCD and interference could help there as well. And on the right side of the slide you see the immunotherapy that I've kind of just mentioned to you in one of the previous slides. And it's important to state that we may need to mix and match all these three classes of drugs to come to a good result. So what if we combine drugs which have viral targets, so combination therapy with antivirals. Again there's pros and cons. The pros would be that we have a higher barrier to resistance. Another important point is that targeting different steps in the viral lifecycle may lead to a deeper or even complete suppression of replication with also the potential to tackle leaks in the viral suppression just like CCCD and reinfection of the hepatocytes which for instance prevent nucleoside analogs from curing hepatitis B. We might have better reduction of the viral loads and proteins which would and thereby better tackle the immune suppressive effects of HPV and a safety as I mentioned in the context of nucleoside analog suppressive therapy. On the other hand there's also cons of multiple viral targets. If you would have the same target the treatment is only as good as the most potent one is. We may still require a long-term therapy of years to clear existing infected hepatocytes. Combining two drugs and more antiviral agents can be challenging because you would have to assess the monotherapy of each. You might have to negotiate with different companies to get a good combination. We likely need assays to detect low-level very low level replication. You could not have synergy but even antagonism with multiple viral targets and safety can be an issue as well. So here is an example of dual therapy with antivirals in this case a capsid assembly modulator and a nucleoside analog. This is on JNJ 637 Johnson & Johnson and on the left two panels on the upper part of your screen you see HPV DNA values in patients being treated with the combination of the capsid modulator and nucleoside analogs. Where in gray you have the patients only being treated with the nucleoside analogs and in green and blue you have patients treated with the combination therapy with different doses of the cam. And if you look at HPV DNA again left side e antigen positive middle panel e antigen negative you really see that there's not much difference there between the viral load decline. However if you look at the right side of this slide and you look at patients and you look at HPV RNA values and in naive patients you see that there is a profound difference really in the HPV RNA decline of patients treated with the cam or page and nucleoside analogs versus patients only treated with the nucleoside analogs. Others have shown that with deeper HPV HPV RNA suppression are kind of reached with this combination rather than with nucleoside analogs alone so also beyond or below I would say the current thresholds of these assays in fact assembly develops very sensitive even more sensitive assays for HPV DNA and HPV RNA that they've used. So overall different biomarkers that's another conclusion from this slide different biomarkers have a different importance in different treatment modalities. Here is another example of two antivirals and here we're talking about RNA interference or gene silencing which you can achieve as was already mentioned by a small interferon RNA or an antisense oligonucleotide and here this is combined with a nucleoside analog. An HPV is susceptible to RNA interference as it replicates for by an RNA intermediate and RNA interference using sRNA or antisense oligonucleotides can really knock down the production of all HPV genes and thereby significantly decrease the number of infectious particles and antigens. So in these three panels you see three patients being treated with an antisense oligonucleotides and where in red you see the HBS antigen which is very quickly and profoundly declining in all of these three patients based mainly on the effect of the antisense I think and and then and you see in blue the ALT values and and the interesting part of of what is shown here in these three patients is that if you have this such a profound and quick decline of S antigen you see a flare occurring which could be indicative of an immune response which might hopefully be effective in patients to ensure off-treatment sustained response and functional cure. So what if you don't combine two viral targets but a viral and an immune target? So theoretically that's a very attractive option because these agents are complementary to each other. HPV impairs innate and adaptive immune function as I've said through continued viral application and protein production and the viral inhibition first of all could lead to improve immune reactivity and then the immune therapy might be able to tip the balance really or to give the knockout punch to the virus and get it cured. However in general immunotherapies have a smaller therapeutic window so if you give too little it doesn't work at all on the virus if you give too much you you might get side effects like cytokine storms or things like that which we really don't want and the other thing about immunotherapy is that they give a more heterogeneous response than drugs which target the virus directly. So some patients do not seem to respond at all and others do very very well. So if combination of viral target engagement with triple therapy for instance of a new cam and an siRNA will not result in functional therapy, immunotherapy would definitely be needed. Here is an example of a combination of antiviral and immune modifying therapy. This is patients who are nucleoside analog suppressed who have been treated with nivolumab which is a checkpoint inhibitor extensively used in the field of cancer and in one of the arms actually a therapeutic vaccine was added GS4774 in this case. So this is triple therapy and the nivolumab dose if you look at the left upper panel of this slide are rather on the low side if you compare it to what is used in cancer therapy. It's 0.1 milligram per kilogram in the lower dose and then 0.3 in the two higher dose arms whereas the purple arm really had the therapeutic vaccine in addition to these other two drugs. And then on the right side you see the HPS antigen change from baseline and here it's also quite clear that some people just don't do anything to immunotherapy and some patients react very well. So overall there was a high receptor occupancy despite a relatively low dose. This is only one single shot of nivolumab mind you. It was overall well tolerated. There was a modest S reduction in all treatment arms and one patient became HPS antigen negative. So the last point I want to want to talk about ladies and gentlemen is the assessment of safety and given the well-established safety of the nukes the safety of new therapies will need to be close or at least comparable. So in my view it would be acceptable that we would give a combination therapy of for instance 12 to 24 weeks which has more side effects than nucleoside analogues but not much more. I think we're willing to accept that in the setting that this is a finite treatment and the patient will be cured and do not need any treatment beyond that. If additional risk is anticipated it should be well justified. As I've mentioned drug-drug interactions are important to consider especially in older patients and a major concern of HPV drug development in particular in combination therapy is the occurrence of ALT flares. So in conclusion ladies and gentlemen a combination therapy is most likely needed to gain functional cure. Target engagement can be the viral life cycle and immune system. There's multiple promising therapeutic approaches of dual and triple therapy around. Combining therapy is important mainly to improve viral suppression and prevent replenishment of CCC DNA so to get the best viral inhibition at different steps at the life cycle and it's also important particularly to promote immune clearance whether or not with immune modifying agents. Combinations of improved antiviral therapy like nucleoside analogues, CAMs and viral depletion with siRNAs may lead to S antigen loss but if that is not sustained we likely have to add or replace one of these drugs with immune modifying compounds. New biomarkers can help to dissect the mechanism of action of these new drugs and we have to very carefully move forward balancing the efficacy and the safety issues of these new compounds and the safety issues mainly ALT flares. Thank you very much for your attention.

Chronic hepatitis B

Older patients

Comorbidities

Renal insufficiency

Osteoporosis

Metabolic diseases

NAFLD

Screening

Antiviral therapy

MAFLD

Liver complications

Dual liver diseases