Combinations of two drugs among NS3/4A inhibitors, NS5B inhibitors and non-selective antiviral agents are effective for hepatitis C virus with NS5A-P32 deletion in humanized-liver mice

J Gastroenterol. 2019 May;54(5):449-458. doi: 10.1007/s00535-018-01541-x. Epub 2019 Jan 25.


Background: The emergence of a deletion mutant at hepatitis C virus (HCV) NS5A-P32 (P32del) has recently been reported in a subset of chronic hepatitis C patients who experience virologic failure after direct-acting antiviral drug (DAA) treatment. This mutation confers extremely high resistance to NS5A inhibitors. No effective treatment has been established for cases with this mutation.

Methods: We used a JFH1-based recombinant virus with NS5A from a genotype 1b strain to introduce a P32del mutation. We inoculated human hepatocyte chimeric mice with sera from a patient with ledipasvir/sofosbuvir therapy failure carrying a genotype 1b HCV with NS5A L31M and P32del or from a DAA-naïve patient carrying wild-type virus.

Results: JFH1-based chimeric viruses with P32del showed sufficient levels of replication for in vitro assay despite the suppression of viral growth and infectious virus production. Variants with P32del exhibited severe resistance to all tested NS5A inhibitors, including daclatasvir, ledipasvir, elbasvir and velpatasvir, but were as susceptible to NS3/4A inhibitors, NS5B inhibitors, interferon alfa-2b, and ribavirin as wild-type viruses in the in vitro assay. The P32del mutant virus caused persistent infection in all inoculated chimeric mice with high viral titer and frequency. The virus was resistant to the ledipasvir/GS-558093 (a nucleotide analog inhibitor of NS5B polymerase) regimen but susceptible to either simeprevir plus GS-558093 or peg-interferon alfa-2b, compared to the wild-type virus.

Conclusion: Therapies combining at least two drugs among NS3/4A inhibitors, NS5B inhibitors and non-selective antiviral agents may be effective for HCV-infected patients with NS5A-P32del.

Keywords: Direct-acting antiviral drug (DAA); Humanized liver mice; Recombinant HCV; Resistance-associated substitutions (RASs); Thymidine kinase transgene (TK-NOG) mice.

MeSH terms

  • Aged
  • Animals
  • Antiviral Agents / pharmacology
  • Antiviral Agents / therapeutic use*
  • Benzimidazoles / pharmacology
  • Benzimidazoles / therapeutic use
  • Benzofurans / pharmacology
  • Carbamates / pharmacology
  • Cell Line
  • Chimera
  • Drug Resistance, Viral / genetics
  • Drug Therapy, Combination
  • Fluorenes / pharmacology
  • Fluorenes / therapeutic use
  • Guanosine Monophosphate / analogs & derivatives
  • Guanosine Monophosphate / pharmacology
  • Guanosine Monophosphate / therapeutic use
  • Hepacivirus / drug effects
  • Hepacivirus / genetics*
  • Hepatitis C / drug therapy*
  • Hepatocytes
  • Heterocyclic Compounds, 4 or More Rings / pharmacology
  • Humans
  • Imidazoles / pharmacology
  • Interferon alpha-2 / pharmacology
  • Interferon alpha-2 / therapeutic use
  • Interferon-alpha / pharmacology
  • Interferon-alpha / therapeutic use
  • Male
  • Mice
  • Middle Aged
  • Polyethylene Glycols / pharmacology
  • Polyethylene Glycols / therapeutic use
  • Recombinant Proteins / pharmacology
  • Recombinant Proteins / therapeutic use
  • Ribavirin / pharmacology
  • Sequence Deletion
  • Serine Proteases
  • Simeprevir / pharmacology
  • Simeprevir / therapeutic use
  • Viral Nonstructural Proteins / antagonists & inhibitors
  • Viral Nonstructural Proteins / genetics*


  • 2-((5-(2-amino-6-methoxypurin-9-yl)-4-fluoro-3-hydroxy-4-methyltetrahydrofuran-2-ylmethoxy)phenoxyphosphorylamino)propionic acid isopropyl ester
  • 2-(pyrrolidin-2-yl)-5-(2-(4-(5-(pyrrolidin-2-yl)-1H-imidazol-2-yl)phenyl)benzofuran-5-yl)-1H-imidazole
  • Antiviral Agents
  • Benzimidazoles
  • Benzofurans
  • Carbamates
  • Fluorenes
  • Heterocyclic Compounds, 4 or More Rings
  • Imidazoles
  • Interferon alpha-2
  • Interferon-alpha
  • NS-5 protein, hepatitis C virus
  • Recombinant Proteins
  • Viral Nonstructural Proteins
  • ledipasvir
  • Polyethylene Glycols
  • Ribavirin
  • Guanosine Monophosphate
  • Simeprevir
  • NS3-4A serine protease, Hepatitis C virus
  • Serine Proteases
  • peginterferon alfa-2b
  • velpatasvir
  • daclatasvir