Conditions: Hepatitis C Cryoglobulinemia
Keywords: Hepatitis C Cryoglobulinemia
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 10
Healthy volunteers: yes

Brief summary:
10 patients with chronic genotype 1 HCV infection and mixed cryoglobulinemia will be treated with Ledipasvir/Sofosbuvir 90mg/400 mg FDC once daily for 12 weeks (naïve subjects or non-cirrhotic treatment experienced subjects) or 24 weeks (treatment experienced subjects with cirrhosis).

The researchers anticipate that approximately 20% of subjects may have cirrhosis.

Detailed description:
The treatment of extrahepatic disease manifestations of HCV has largely paralleled that of hepatic disease. Interferon was reported to have efficacy for MC even before linkage of the syndrome to HCV in 1989, and successful combination therapy with ribavirin was found to eliminate virus and lead to the resolution of immunologic abnormalities associated with extrahepatic disease. In addition, \~75% of HCV-associated indolent asymptomatic lymphoproliferative diseases remit with successful antiviral therapy. However, in many instances, MC (notably cutaneous vasculitis) will relapse with recurrence of virus, and may occasionally persist even after clearance. In particular, side effects of Interferon alpha, including the uncovering of frank autoimmune disease, theoretically may mitigate response of extrahepatic disease to treatment. Peg-interferon increased the response rate of MC, and decreased the duration of treatment, but side effects remained problematic.

An alternative approach to the treatment of MC has been the use of immunomodulatory agents. In particular, B-cell expansion in peripheral blood and in lymphoid follicles in the liver prevalent amongst HCV-infected persons provided a rationale for the use of depletion as a therapeutic strategy. Rituximab (anti-CD20) monotherapy has been used mostly for treatment failures/intolerance or in the setting NHL, and has yielded response rates in the setting of involvement of skin (73%); MPGN (70%); joint (53%); and nerve (36%). However, this monoclonal antibody (MAb) has the potential to form immune-complexes with mixed cryoglobulin RF and cause clinical vasculitis in patients with high cryocrits, and may raise the HCV RNA level in rare patients, causing cytotoxicity. Following Rituximab with Peg-IFN plus ribavirin achieved greater than a 60% complete response (CR) in patients resistant to combination treatment alone. Other approaches include the use of Aldesleukin, an inducer of regulatory T-cell activity, MAbs targeted to specific B-cell subsets or costimulatory signal molecules (e.g. BAFF) or agents inhibiting the interaction of HCV core antigen with C1q in cryoprecipitates via the receptor for the globular domain of C1q (gC1qR).

The development of low molecular weight inhibitors of the non-structural proteins (NSPs) elaborated by HCV, in particular 5A, 5B nucleoside and non-nucleoside polymerase inhibitors, and inhibitors of 3/4A serine proteases; to selectively inhibit HCV replication has raised the prospect of "all-oral" treatment for both hepatic and extrahepatic manifestations of disease. However, the use of first generation direct-acting antiviral agents (Telaprevir® and Boceprevir® linear NS3/4A protease inhibitors) was limited by frequent escape mutants, efficacy restricted to genotype-1, need to retain protocols including PegIFN and ribavirin, potential for significant drug interactions, and serious side effects. In a trial of combination therapy including Telaprevir® for 13 patients with MC, all had significant AEs, including asthenia (92%), anemia (84%), neutropenia and bacterial infection (54%). Approval of an uridine nucleoside analogue that selectively inhibits HCV NS5B RNA-dependent RNA polymerase (Sofosbuvir) by the FDA late 2013 has led to proof-of-concept trials in which combination all-oral therapy has proven effective for both genotype 1 and other genotypes, with a number of other regimens under development. In particular, the combination of Sobosbuvir (SOF) and Ledipasvir (LDV) has been reported to have almost universal efficacy in a 12 week regimen for genotype 1, and the combination of SOF and Ribavirin (RBV) for genotypes 2-6 in a 24 week regimen. However, persistence of cryoglobulinemia even after viral clearance with the newer regimens has also raised the question of whether longer treatment regimens may be appropriate in the setting of significant extrahepatic disease. Thus, the timing is right to initiate a trial of all-oral treatment to rigorously evaluate the effect on extrahepatic disease, and to re-establish the efficacy of antiviral therapy in halting the direct and indirect role of HCV in driving autoimmune disease and lymphoproliferation. Using an interferon-sparing regimen to treat patients with HCV-related cryoglobulinemia will help answer the question as to whether immunomodulating therapy plays a role at all in eradicating cryoglobulins long-term, and whether antiviral therapy alone is adequate. If the latter, appreciable morbidity and mortality may be saved in avoiding treating these potentially sick, often cirrhotic patients, with immunomodulatory therapies.

Arms:
arm 1: Participants treated with either Harvoni or Epclusa

* Harvoni 90mg/400 mg FDC once daily. Subjects will take 1 tablet daily with or without food.
* Epclusa 400mg/100mg 400mg/100mg FDC once daily

Interventions: intervention 1: Harvoni intervention 2: Epclusa
Intervention descriptions: intervention 1: 12 weeks for naïve subjects or non-cirrhotic treatment experienced subjects; or 24 weeks for treatment experienced subjects with cirrhosis intervention 2: once daily for 12 weeks (naïve subjects, non-cirrhotic treatment experienced or treatment experienced subjects with compensated cirrhosis) for genotype 1-6 subjects.

Protocol document:
Prot_SAP_000.pdf: 
Study Title: Efficacy of All-Oral Anti-Viral Therapy for Symptomatic Hepatitis C Virus Infection-Related
Cryoglobulinemia 
PI: Peter Gorevic, M.D. 
NCT02825212 
Protocol Version/Date: 10 March 2017 


HCV and Cryoglobulinemia Study 
Protocol IND-US-337-1716 
PI: Peter Gorevic, MD 
                                                                                    
Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
Page 1 of 70 
 
CLINICAL STUDY PROTOCOL 
 
Study Title: Efficacy of All-Oral Anti-Viral Therapy for Symptomatic Hepatitis C Virus 
Infection-Related Cryoglobulinemia 
 
Clinicaltrials.gov identifier: NCT02825212 
 
Indication: Hepatitis C Infection and Cryoglobulinemia 
 
Principal Investigator (PI): Peter Gorevic, M.D. 
Co-PI: Thomas Schiano, M.D. 
 
Protocol ID: IND-US-337-1716 
 
Protocol Version/Date: 10 March 2017  
 
 
 


HCV and Cryoglobulinemia Study 
Protocol IND-US-337-1716 
PI: Peter Gorevic, MD 
                                                                                    
Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
Page 2 of 70 
 
TABLE OF CONTENTS 
 
PROTOCOL SYNOPSIS  
GLOSSARY OF ABBREVIATIONS AND DEFINITION OF TERMS 
1. INTRODUCTION 
1.1. 
Background  
1.2. 
Rationale for the Current Study 
2. OBJECTIVES 
3. STUDY DESIGN 
3.1. 
Treatment plan and regimen 
3.2. 
Visits schedule 
3.3. 
Virologic Response-Based Stopping Criteria  
3.4. 
Cryoglobulinemia Response-Based Stopping Criteria 
3.5. 
Treatment Discontinuation Criteria 
3.6. 
Discontinuations 
4. SUBJECT POPULATION 
4.1. 
Number of Subjects  
4.2. 
Inclusion Criteria 
4.3. 
Exclusion criteria 
5. INVESTIGATIONAL MEDICINAL PRODUCTS 
5.1. 
Treatment Codes  
5.2. 
Description and Handling of Ledipasvir/Sofosbuvir and Sofosbuvir/Velpatasvir 
5.2.1. Formulation 
5.2.2. Packaging and Labeling 
5.2.3. Storage and Handling 
5.3. 
Study Drug Adherence and Drug Accountability 
5.4. 
Concomitant Medications 
6. STUDY PROCEDURES 
7. TOXICITY MANAGEMENT 
7.1. 
Dose Modification Due to Toxicity 
7.2. 
Toxicity Stopping Criteria 
8. ADVERSE EVENTS MANAGEMENT 
8.1. 
Definitions of Adverse Events, Adverse Reactions, and Serious Adverse 


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Events 
8.1.1. Classification of Adverse Events 
8.1.1.1. 
Serious Adverse Events 
8.1.2. Clinical Laboratory Abnormalities and Other Abnormal Assessments as 
Adverse Events or Serious Adverse Events 
8.2. 
Assessment of Adverse Events and Serious Adverse Events 
8.2.1.1. 
Assessment of Causality for Study Drugs and Procedures 
8.2.1.2. 
Assessment of Severity 
8.3. 
Investigator Requirements and Instructions for Reporting Adverse Events and 
Serious Adverse Events  
8.4. 
Special Situations Reports 
8.4.1.1. 
Definitions of Special Situations 
8.4.1.2. 
Instructions for Reporting Special Situations 
8.4.1.2.1. Instructions for Reporting Pregnancies 
8.5. 
Warnings and Precautions 
9. STATISTICAL CONSIDERATIONS 
10. INVESTIGATOR RESPONSIBILITIES 
10.1. Good Clinical Practice 
10.2. Institutional Review Board (IRB) Approval 
10.3. Informed Consent 
10.4. Confidentiality 
10.5. Study Files and Retention of Records 
10.6. Electronic Case Report Forms (eCRF) 
10.7. Protocol Compliance 
10.8. Protocol modifications 
10.9. Study report and Publications 
10.10. Access to Information for Auditing or Inspections  
10.11. Study Discontinuation 
10.12. Inspections 
11. REFERENCES 
12. APPENDIX 
12.1. Appendix 1a. Procedures and visits 
12.2. Appendix 1b. Laboratory tests per visits 


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12.3. Appendix 2. Common Terminology Criteria for Adverse Events (CTCAE) 
version 4.0. 
12.4. Appendix 4. Epclusa patient information 
12.5. Appendix 5a. Epclusa package insert 
12.6. Appendix 5b. Harvoni package insert  
12.7. Appendix 6. Birminham Vasculitis Activity Score 
12.8. Appendix 7. Health Assessment Questionnaire (HAQ-DI) 
12.9. Appendix 8. Visual Analog Scale (VAS) 
 
 
 
 


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PROTOCOL SYNOPSIS  
 
Study Title: Efficacy of All-Oral Anti-Viral Therapy for Symptomatic Hepatitis C Virus 
Infection-Related Cryoglobulinemia 
 
Clinicaltrials.gov identifier: NCT02825212 
Study Centers: One site at the Icahn School of Medicine at Mount Sinai with anticipated 
referrals from other institutions within the system. The Mount Sinai Health Care System 
includes:  
• 
Mount Sinai Hospital  
• 
Mount Sinai Beth Israel  
• 
Mount Sinai Saint Luke’s Roosevelt  
 
Patients will be identified at these additional sites but will be referred to the Icahn School 
of Medicine at Mount Sinai where the study will be conducted and the IRB will be based. 
All visits, as well as clinical and laboratory-based studies will be performed at Mount 
Sinai Health Care System. 
 
Target Population:  
Adults with chronic genotypes 1-6 hepatitis C virus (HCV) infection and 
cryoglobulinemia. 
 
Objectives:  
The primary objectives of this study are: 
• 
To assess the efficacy of new direct acting oral antivirals: LDV/SOF FDC (Harvoni®) 
or SOF/VEL FDC (Epclusa®) in patients with chronic HCV infection and MC, 
measuring the proportion of subjects who attain SVR at 4 and 24 weeks after 
cessation of treatment.  
• 
To assess efficacy of new direct acting oral antivirals: LDV/SOF FDC  (Harvoni®) or 
SOF/VEL FDC (Epclusa®) in patients with mixed cryoglobulinemia (MC) secondary 
to chronic HCV infection:  


HCV and Cryoglobulinemia Study 
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o A complete response is defined as disappearance of arthropathy or kidney 
involvement, and/or purpura, and >50% reduction in IgM-RF and cryocrit. 
o A partial response is a 10-50% reduction in cryocrit and one (but not all) 
clinical and laboratory signs of systemic vasculitis. 
 
The secondary objectives of this study are: 
• 
To assess immunological response of MC to new direct acting oral antivirals: 
LDV/SOF (Harvoni®) or SOF/VEL FDC (Epclusa®) treatment measuring:  
o FACS/CyTOF analysis of PBMC to determine the effect of DAA treatment on 
cell-surface markers or MC  
o analysis of isolated mixed cryoglobulins for localization of viral RNA, the 
presence of HCV core antigen, C1q protein, C1q binding activity and soluble 
gC1qR. 
o accumulate kinetic data to address the issues of (a) redistribution of viral 
RNA and core protein between cryoprecipitable and noncryoprecipitable 
immune complexes with treatment (27) (b) persistence of  cryoglobulins and 
cryoglobulinemic vasculitis following apparent clearance of virus (13,14,28); 
and (c) persistence of virus in PBMC or cryoprecipitates following apparent 
systemic clearance (i.e. occult infection) (29). 
• 
To assess safety and tolerability of new direct acting oral antivirals: LDV/SOF FDC 
(Harvoni®) or SOF/VEL FDC (Epclusa®) in patients with chronic HCV infection and 
MC.  
 
Treatment Duration:  
Subjects that have been enrolled and started treatment under protocol version 1 will 
continue and complete the planned treatment with LDV/SOF FDC (Harvoni®): 
• 
Treatment-naïve subjects will be treated for 12 weeks 
• 
Treatment-experienced non-cirrhotic subjects will be treated for 12 weeks  
• 
Treatment-experienced compensated cirrhotic subjects will be treated for 24 weeks 
Subjects enrolled under protocol version 2 will receive SOF/VEL FDC (Epclusa®): 
• 
Treatment-naïve subjects will be treated for 12 weeks 
• 
Treatment-experienced non-cirrhotic subjects will be treated for 12 weeks  


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• 
Treatment-experienced compensated cirrhotic subjects will be treated for 12 weeks 
 
Study Design: 10 patients with chronic HCV infection and mixed cryoglobulinemia will 
be treated with new direct acting oral antivirals:  
• 
Ledipasvir/Sofosbuvir 90mg/400 mg FDC once daily for 12 weeks (naïve subjects,  
non-cirrhotic treatment experienced subjects) or 24 weeks (treatment experienced 
subjects with compensated cirrhosis)for genotype 1 subjects already enrolled in 
protocol version 1. 
• 
Sofosbuvir/Velpatasvir 400mg/100mg 400mg/100mg FDC once daily for 12 weeks 
(naïve subjects, non-cirrhotic treatment experienced or treatment experienced 
subjects with compensated cirrhosis) for genotype 1-6 subjects enrolled in protocol 
version 2.  
 
We anticipate that approximately 20% of subjects may have cirrhosis. 
 
Diagnosis and Main Eligibility Criteria: 
Chronic genotypes 1-6 HCV infected, male and non-pregnant female subjects, ages 18 
or older with cryoglobulinemia. 
Refer to Sections 4.2 and 4.3 for detailed Inclusion and Exclusion Criteria. 
 
Study Procedures/Frequency: 
Screening assessments will be completed within 30 days of the Baseline/Day 1 visit. The 
screening window can be extended to 42 days for subjects requiring liver biopsy or 
additional HCV genotype testing. 
All subjects will complete the following study visits: Screening, Baseline/Day 1, on-
treatment visits at the end of Weeks 2, 4, 8 and 12 . Subjects who were already enrolled 
in the study and receiving 12 weeks treatment with Harvoni® will complete the same 
visits and schedule of events as subjects receiving Epclusa® (detailed in the current 
protocol version 2). Subjects that receiving 24 weeks treatment with Harvoni® will also 
complete treatment visits at week 20 and 24. All subjects will complete the post 
treatment Week 4, 12 and 24 visits.  
Screening assessments will include physical examination, medical history, height, 
weight, vital signs, 12-lead ECG, adverse events related to screening procedures, 


HCV and Cryoglobulinemia Study 
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concomitant medications, safety laboratory tests (including hematology, chemistry, and 
coagulation), HCV genotype and HCV RNA, serology (HIV, HCV, HBV), assessment of 
the presence or absence of cirrhosis, screening for hepatocellular carcinoma if cirrhosis 
is present, serum β-hCG (females of child bearing potential only), IL28B genotyping, 
urinalysis, analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement, HCV core ELISA and FACS (appendix 1). 
On-treatment assessments include adverse events (AEs), concomitant medications, 
study medication pill count, physical examination, weight, vital signs, safety laboratory 
tests (hematology, chemistry, coagulation), HCV RNA (after Baseline/Day1), urine 
pregnancy tests (females of child bearing potential only), urinalysis, analysis of 
cryoglobulinemia measuring cryoglobulins, analyzing cross reactive idiotypes, analysis 
of complement, HCV core ELISA and clonality/lymphoproliferation / FACS (appendix 1). 
Post treatment assessments include AEs, concomitant medications, vital signs, safety 
laboratory tests, HCV RNA, urine pregnancy tests (females of child bearing potential 
only) and analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross reactive 
idiotypes, analysis of complement, HCV core ELISA and clonality/lymphoproliferation / 
FACS (appendix 1). 
 
Test Product, Dose, and Mode of Administration: 
• 
Ledipasvir/Sofosbuvir (HARVONI®) is manufactured as a 90mg/400 mg FDC tablet 
for oral administration. Subjects will take 1 tablet daily with or without food.  
• 
SOF/VEL FDC (Epclusa®) is manufactured as a 400 mg / 100 mg FDC tablet for oral 
administration. Subjects will take 1 tablet daily with or without food.  
 
 
Evaluation Criteria:  
• 
Efficacy:  
o Efficacy of treatment on MC will be assessed as follows:  
▪ 
Complete response is defined as disappearance of arthropathy or 
kidney involvement, and/or purpura, and >50% reduction in IgM-RF 
and cryocrit. 
▪ 
Partial response is a 10-50% reduction in cryocrit and one (but not all) 
clinical and laboratory signs of systemic vasculitis. 


HCV and Cryoglobulinemia Study 
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o Efficacy of treatment on HCV infection will be evaluated using scheduled 
assessments of HCV RNA performed using COBAS® TaqMan® HCV Test, 
v2.0 for use with Ampliprep.  
• 
Safety: AEs and laboratory tests will be collected throughout the study. 
 
Statistical Methods:  
 
This is a pilot study in which 10 patients will be enrolled to explore the efficacy of all-oral 
anti-viral therapy for symptomatic hepatitis C virus infection-related cryoglobulinemia. 
With 10 patients in the study we will be able to estimate the rate of patients who obtain 
an SVR with a margin of error of approximately 15%. 
We will use frequency table and 95% confidence interval to describe the rate of SVR in 
the total sample and the two subgroups of interest. 
Results will be compared to previous published studies (28), as well as unpublished 
experience, that have delineated the natural history of type 2 cryoglobulinemia, and the 
response to immunomodulatory therapies, including IFN/Peg-IFN, Ribavirin and 
Rituximab (27). 
 
 
This study will be conducted in accordance with the guidelines of Good Clinical 
Practice (GCP) 
 
 


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PI: Peter Gorevic, MD 
                                                                                    
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GLOSSARY OF ABBREVIATIONS AND DEFINITION OF TERMS 
 
ACR American College of Rheumatology 
AE Adverse event 
ALT Alanine aminotransferase 
AST Aspartate aminotransferase 
BW Body weight  
CLcr Creatinine Clearance  
CR complete response 
CRF case report form(s) 
DAAs Direct-acting antiviral agents 
eCRF Electronic case report form(s) 
EOT end of treatment 
ET early termination 
EU European Union 
EudraCT European clinical trials database 
FDA (United States) Food and Drug Administration 
FLC Free Light Chain 
GCP Good Clinical Practice (Guidelines) 
HAQ Health Assessment Questionnaire 
HBV Hepatitis B virus  
HCC Hepatocellular carcinoma 
HCV Hepatitis C virus 
HDPE high density polyethylene 
HIV human immunodeficiency virus 
ICH International Conference on Harmonisation 
IFN Interferon 
IL28B Interleukin 28B gene 
IND Investigational New Drug (Application) 
IRB Institutional review board 
IU International unit 
LDV Ledipasvir 


HCV and Cryoglobulinemia Study 
Protocol IND-US-337-1716 
PI: Peter Gorevic, MD 
                                                                                    
Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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LLoQ Lower limit of quantification 
MAb monoclonal antibody 
MC Mixed cryoglobulinemia 
mL Milliliter 
MPGN membranoproliferative glomerulonephritis 
N Number 
NHL Non-Hodgkins Lymphoma  
NSPs non-structural proteins  
PBMC Peripheral blood mononuclear cell 
PEG-IFN Pegylated interferon 
PI Protease inhibitor or principal investigator 
PT Prothrombin time  
RBC Red blood cell count  
RBV Ribavirin 
RNA ribonucleic acid 
Scr serum creatinine  
SAE Serious adverse event 
SOF Sofosbuvir 
SOF/VEL Sofosbuvir/Velpatasvir 
LDV/SOF Ledipasvir/Sofosbuvir 
SUSAR Suspected Unexpected Serious Adverse Reaction 
SVR Sustained virologic response 
ULN upper limit of the normal range 
VEL Velpatasvir 
WBC White blood cell count 
 
 
 
 


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Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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1. INTRODUCTION 
 
1.1. 
Background  
Hepatitis C Virus (HCV) is a major cause of both hepatic and extrahepatic disease. The 
former includes the spectrum of autoimmune hepatitis extending to cirrhosis, liver failure, 
and a long-term increased incidence of Hepatocellular Carcinoma. Cryoglobulinemia 
includes a group of overlapping syndromes (arthropathy, cutaneous vasculitis, 
nephropathy, sicca syndrome, and neuropathy) and a long-term increased incidence of 
Non-Hodgkin Lymphoma (NHL) (1). Extrahepatic disease is significantly associated with 
chronicity and the presence in blood of easily detectable cold-precipitable rheumatoid 
factors (i.e. mixed cryoglobulins) (2). In addition, rarer organ-specific disease 
manifestations that may be associated with HCV include cutaneous (lichen planus), 
neuromuscular (fibromyalgia), hematologic (autoimmune thrombocytopenia), and 
endocrine (diabetes mellitus) disorders (3). Although the disease burden of HCV has 
been estimated to be 3-4M for the United States and ~170-180M worldwide, the exact 
prevalence of extrahepatic HCV is less certain and has only been studied to a limited 
extent to include countries in which genotype distribution differs from that found in North 
America, or among populations in the United States (e.g. HIV co-infected persons, the 
homeless, the incarcerated) known to have an increased prevalence of clinical diseases 
that may mimic the overlapping syndromes of mixed cryoglobulinemia (MC) noted 
above. In one study of ~34,000 HCV-positive veterans versus controls, there was an 11-
fold increased incidence of cryoglobulinemia, a 7-fold increase in membranoproliferative 
glomerulonephritis (MPGN), a 20-30% increase in NHL, and a 2-fold increase in lichen 
planus compared to HCV-negative controls (4). In addition, both the laboratory finding of 
mixed cryoglobulins and the clinical syndromes of cryoglobulinemic vasculitis may occur 
with only minimal or no liver pathology, and may be uncovered in the course of 
evaluations of MPGN, leukocytoclastic vasculitis, rheumatoid-like arthritis, Sjogren’s 
syndrome, or autoimmune neuropathy (5). 
We have a long-standing interest in the cryopathies,  including early recognition of the 
prevalence of hepatic disease among patients affected by purpura, arthralgias and 
MPGN, progression to liver failure in some patients with long-term follow-up (15), 
characterization of the clonality of  the IgMk component of type 2 cryoglobulins, 
phlogistic activity of mixed cryoglobulins with regard to complement and other mediators 


HCV and Cryoglobulinemia Study 
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PI: Peter Gorevic, MD 
                                                                                    
Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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(16), and methodology for the accurate isolation of characterization of cold-precipitable 
RFs (17). Our current data base includes 180 patients with the syndrome of MC with 
long-term follow-up of 40 patients spanning 1960-2010. The cohort of MC since the 
description of HCV in 1989 is 55% female, with an overall incidence of 68% cutaneous 
disease, 56% arthropathy, 35% nephropathy, 58% neuropathy, 60% type 2/40% type 3 
mixed cryoglobulins, and 60% HCV. In addition, we recently completed a retrospective 
chart review of 51 HCV-positive patients with MC seen at our medical center between 
2003-2013, 60% having genotype 1, 14% genotype 2 and 10% genotype 3, in which we 
specifically analyzed the efficacy of current antiviral therapy and Rituximab in this cohort 
with regard to progression of liver disease to transplantation and MPGN to end-stage 
renal disease requiring dialysis (16). This experience may be compared to a very recent 
report from Italywhich noted a ~30% incidence of genotype 2 among their MC patients 
receiving direct acting antivirals (DAA) treatment (19).  
Mount Sinai Health Care System is a major referral center for HCV-infected patients, 
many of whom are being uncovered as a result of mandated screening, because of our 
free-standing Hepatology division, specialized HIV, hemophilia, and common variable 
immunodeficiency patient populations, and our active liver transplantation program. 
Ongoing clinical studies are testing the efficacy all-oral antiviral therapy in co-infected 
patients and in post-transplant patients susceptible to recurrence of disease. A review of 
the morphologic features of extrahepatic disease in this patient population has recently 
been published from our institution (5). The laboratory of Dr. Gorevic has extensive 
experience in the performance of the immunologic and rheumatologic procedures and 
techniques that are proposed. Dr. Gorevic also has extensive experience in performing 
the clinical assessments for clinical MC. Drs. Schiano and Branch have significant 
experience in the use of DAAs for HCV, including participation in the ASTRAL-4 study of 
Sofosbuvir and Velpatasvir for HCV in patients with decompensated cirrhosis (20), and 
the validation of efficacy of Sofosbuvir and Ledispasvir for recurrent Hepatitis C in liver 
transplant recipients (21). Lastly, Dr. Branch’s laboratory has published studies of the 
basic virology of HCV, including hepatitis core antigen, HCV quasi-species, and cell 
surface markers in established and treated disease. 
 
1.2. 
Rationale for the Current Study 


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The treatment of extrahepatic disease manifestations of HCV has largely paralleled that 
of hepatic disease. Interferon was reported to have efficacy for MC even before linkage 
of the syndrome to HCV in 1989, and successful combination therapy with ribavirin was 
found to eliminate virus and lead to the resolution of immunologic abnormalities 
associated with extrahepatic disease (1). In addition, ~75% of HCV-associated indolent 
asymptomatic lymphroproliferative diseases remit with successful antiviral therapy (6). 
However, in many instances, MC (notably cutaneous vasculitis) will relapse with 
recurrence of virus, and may occasionally persist even after clearance (7). In particular, 
side effects of Interferon alpha, including the uncovering of frank autoimmune disease, 
theoretically may mitigate response of extrahepatic disease to treatment (8). Peg-
interferon increased the response rate of MC, and decreased the duration of treatment, 
but side effects remained problematic (1). 
 
An alternative approach to the treatment of MC has been the use of immunomodulatory 
agents. In particular, B-cell expansion in peripheral blood and in lymphoid follicles in the 
liver prevalent amongst HCV-infected persons provided a rationale for the use of 
depletion as a therapeutic strategy. Rituximab (anti-CD20) monotherapy has been used 
mostly for treatment failures/intolerance or in the setting NHL, and has yielded response 
rates in the setting of involvement of skin (73%); MPGN (70%); joint (53%); and nerve 
(36%). However, this monoclonal antibody (MAb) has the potential to form immune-
complexes with mixed cryoglobulin RF and cause clinical vasculitis in patients with high 
cryocrits, and may raise the HCV RNA level in rare patients, causing cytotoxicity.  
Following Rituximab with Peg-IFN plus ribavirin achieved greater than a 60% complete 
response (CR) in patients resistant to combination treatment alone (9). Other 
approaches include the use of Aldesleukin, an inducer of regulatory T-cell activity, MAbs 
targeted to specific B-cell subsets or costimulatory signal molecules (e.g. BAFF) or 
agents inhibiting the interaction of HCV core antigen with C1q in cryoprecipitates via the 
receptor for the globular domain of C1q (gC1qR) (1). 
 
The development of low molecular weight inhibitors of the non-structural proteins (NSPs) 
elaborated by HCV, in particular 5A, 5B nucleoside and non-nucleoside polymerase 
inhibitors, and inhibitors of 3/4A serine proteases; to selectively inhibit HCV replication 
has raised the prospect of “all-oral” treatment for both hepatic and extrahepatic 


HCV and Cryoglobulinemia Study 
Protocol IND-US-337-1716 
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Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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manifestations of disease. However, the use of first generation direct-acting antiviral 
agents (Telaprevir® and Boceprevir® linear NS3/4A protease inhibitors) was limited by 
frequent escape mutants, efficacy restricted to genotype-1, need to retain protocols 
including PegIFN and ribavirin, potential for significant drug interactions, and serious 
side effects. In a trial of combination therapy including Telaprevir® for 13 patients with 
MC, all had significant AEs, including asthenia (92%), anemia (84%), neutropenia and 
bacterial infection (54%) (10). Approval of an uridine nucleoside analogue that 
selectively inhibits HCV NS5B RNA-dependent RNA polymerase (Sofosbuvir) by the 
FDA late 2013 has led to proof-of-concept trials in which combination all-oral therapy  
has proven effective for both genotype 1 and other genotypes, with a number of other 
regimens under development. In particular, the combination of Sobosbuvir (SOF) and 
Ledipasvir (LDV) has been reported to have almost universal efficacy in a 12 week 
regimen for genotype 1, and the combination of SOF and Ribavirin (RBV) for genotypes 
2-6 in a 24 week regimen (11,12). Most recently, the combination of Sofosbuvir and 
Velpatasvir (SOF/VEL), Epclusa®, has been shown to have pan-genotypic efficacy in 
pivotal studies (23,24) and is rapidly becoming standard-of care for chronic HCV 
infection (25).  Inclusion of genotypes 1-6 in our study will allow us to correlate possible 
confounding factors (e.g. specific extra-hepatic disease manifestations, immunoglobulin 
V-region gene usage; IL28B genotype; HCV Core gene mutations) compared to the 
published experience for Sofosbuvir and Velpasavir for other genotypes (23,24). It will 
also allow us to increase enrollment from a diminishing pool of patients who have yet to 
undergo treatment with 12 week course of Epclusa® (sofosbuvir/velpatasvir) in 
compensated patients (Child-Pugh A).In addition, persistence of cryoglobulainemia even 
after viral clearance with the newer regimens has also raised the question of whether 
longer treatment regimens may be appropriate in the setting of significant extrahepatic 
disease (13). To date, only limited published experience exists with regard to the “post-
viral” phase of HCV MC, consisting of retrospective analyses involving various 
genotypes and differing regimens of DAAs (19,26). Thus, the timing is right for a 
prospective trial of all-oral treatment with Epclusa® (SOF/VEL) to rigorously evaluate the 
effect on extrahepatic disease manifestations in patients with MC of all genotypes, and 
to re-establish the efficacy of antiviral therapy in halting the direct and indirect role of 
HCV in driving autoimmune disease and lymphoproliferation. Using an interferon-sparing 
regimen to treat patients with HCV-related cryoglobulinemia will help answer the 


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Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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question as to whether immunomodulating therapy plays a role at all in eradicating 
cryoglobulins long-term, and whether antiviral therapy alone is adequate. If the latter, 
appreciable morbidity and mortality may be saved in avoiding treating these potentially 
sick, often cirrhotic patients, with immunomodulatory therapies. 
 
 
 
 
 
 
 
 
 
 
 


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2. OBJECTIVES 
 
The primary objectives of this study are: 
• 
To assess the efficacy of new direct acting oral antivirals: LDV/SOF FDC (Harvoni®)  
or SOF/VEL FDC (Epclusa®) in patients with chronic HCV infection and MC, 
measuring the proportion of subjects who attain SVR at 4 and 24 weeks after 
cessation of treatment.  
• 
To assess efficacy of new direct acting oral antivirals: LDV/SOF FDC (Harvoni®)  or 
SOF/VEL FDC (Epclusa®) in patients with MC secondary to chronic HCV infection:  
o A complete response is defined as disappearance of arthropathy or kidney 
involvement, and/or purpura, and >50% reduction in IgM-RF and cryocrit. 
o A partial response is a 10-50% reduction in cryocrit and one (but not all) 
clinical and laboratory signs of systemic vasculitis (see below) (33)  
 
Clinical Responses: 
• 
For patients whose predominant clinical manifestation is a rheumatoid-like 
arthritis, the primary evaluation will be a joint count in order to conform to 
American College of Rheumatology (ACR) outcome criteria (34). 
• 
For patients whose predominant clinical manifestation is vasculitis, cutaneous 
disease will be assessed as number and distribution (scored as 1=<10; 
2=>10; 3=upper and lower extremity; 4=complicated by ulcerations, gangrene 
or both) of purpuric lesions. Systemic vasculitis will be evaluated by a 
modification of the Birmingham Vasculitis Activity Score (35).  
• 
Glomerulonephritis is defined as the presence of hematuria, proteinuria and 
red blood cell casts (i.e. an active urinary sediment) by urinalysis, further 
quantitated as total mg  proteinuria, >300mg (upper limits of normal) on a 24 
hour collection, or as the protein/creatinine ratio of a spot sample of urine. 
Concomitant renal insufficiency is defined as a serum creatinine >2.0mg/dL. 
Most patients will have also had renal biopsies showing typical features of 
membranoproliferative glomerulonephritis associated with cryoglobulinemia 
(36) 


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• 
Neuropathy is evaluated as being symmetrical or asymmetrical, pure sensory 
or sensorimotor, and further defined as number of extremities involved. 
Neuropathy may be corroborated by electrophysiologic testing as indicated 
(37). 
• 
Functional outcome is evaluated as the Health Assessment Questionnaire 
(HAQ) . 
 
Virologic Responses: 
• 
Measure of HCV antigens in un-dissociated cryocomplexes relative to serum 
by sandwich ELISA for core antigen (31). The presence of HCV RNA in 
mixed cryoglobulins will be correlated with the presence of core antigen as a 
measure of un-encapsulated virus and nucleocapsid antigens. 
 
Immunologic Responses: 
• 
Kinetics of response with regard to compartmentalization of viral RNA and 
core antigen between cryoprecipitible and non-cryoprecipitible immune 
complexes. 
• 
Serial quantitation of cryoprecipitates and correlation with RF titers 
determined by nephelometry, and C4 levels measured in freshly collected 
serum. 
• 
C1q and C1q binding assays are available through our clinical immunology 
laboratory, and will be compared to our previously published experience in 
MC with these assays. Quantitation of soluble forms of the receptor for the 
globular domain of C1q (gC1qR) is available through the laboratory of Dr. 
Berhane Ghebrehiwet (State University of New York, Stony Brook) (32). 
• 
Regression 
of 
clonality 
assessed 
by 
immunofixation 
of 
isolated 
cryoprecipitates, and kappa/lambda Free Light Chain (FLC) measurements in 
blood. 
• 
Regression of clonality and lymphoproliferation assessed by FACS analysis 
for specific B-cell subsets and MC cross-reactive idiotypes. 
• 
Isolation PMBCs for analyzing by FACS/ Cytometry cell-surface markers 
during and after DAA treatment 


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Results will be compared to previous published studies, as well as unpublished 
experience, that have delineated the natural history of type 2 cryoglobulinemia, 
and the response to immunomodulatory therapies, including IFN, Ribavirin and 
Rituximab (27, 38). 
 
The secondary objectives of this study are: 
• 
To assess immunological response of MC to new direct acting oral antivirals:  
SOF/VEL FDC (Harvoni®) or SOF/VEL FDC (Epclusa®) treatment measuring:  
o FACS/CyTOF analysis of PBMC  
o analysis of isolated mixed cryoglobulins for localization of viral RNA, the 
presence HCV core antigen, C1q protein, C1q binding activity and soluble 
gC1qR. 
o accumulate kinetic data to address the issues of:  
▪ 
(a) 
redistribution 
of 
viral 
RNA 
and 
core 
protein 
between 
cryoprecipitable and noncryoprecipitable immune complexes with 
treatment (27);  
▪ 
(b) persistence of  cryoglobulins and cryoglobulinemic vasculitis 
following apparent clearance of virus (13,28 ,29); and  
▪ 
(c) persistence of virus in PBMC or cryoprecipitates following 
apparent systemic clearance (i.e. occult infection) (29). 
• 
To assess safety and tolerability of new direct acting oral antivirals: LDV/SOF FDC  
(Harvoni®) LDV/SOF FDC (Harvoni®) or SOF/VEL FDC (Epclusa®) in patients with 
chronic HCV infection and MC.  
 
 


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Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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3. STUDY DESIGN 
 
3.1. 
Treatment plan and regimen 
This is a single-center, open-label study to evaluate the safety, tolerability and efficacy of 
new direct acting oral antivirals:  
• 
Ledipasvir/Sofosbuvir 90mg/400 mg FDC (LDV/SOF;Harvoni®, for those subjects 
enrolled under protocol version 1 only) in patients with genotype 1 HCV infection and 
MC already enrolled in protocol version 1 or  
• 
Sofosbuvir/Velpatasvir 400mg/100mg FDC (SOF/VEL; Epclusa®, for all subjects 
enrolled under protocol version 2) in patients with chronic genotypes 1-6 HCV 
infection and MC. All subjects enrolled in protocol version 2 will receive Epclusa® 
who have failed or only partially responded to other MC therapies. 
 
Treatment duration is as follows:  
Subjects that have been already enrolled and started treatment under protocol version 1 
will continue and complete the planned treatment with LDV/SOF FDC (Harvoni®): 
• 
Treatment naïve subjects will be treated for 12 weeks. 
• 
Treatment experienced non-cirrhotic subjects will be treated for 12 weeks. 
• 
Treatment experienced compensated cirrhotic subjects will be treated for 24 
weeks. 
Subjects enrolled under protocol version 2 will receive SOF/VEL FDC (Epclusa®): 
• 
Treatment-naïve subjects will be treated for 12 weeks 
• 
Treatment-experienced non-cirrhotic subjects will be treated for 12 weeks  
• 
Treatment-experienced compensated cirrhotic subjects will be treated for 12 weeks 
 
Approximately 20% of subjects may have cirrhosis.  
 
3.2. 
Visits schedule 
All subjects will complete screening, on-treatment, and post treatment assessments. 
Screening assessments will be completed within 30 days of the Baseline/Day 1 visit, 42 
days if liver biopsy is required.  


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All subjects will complete the following study visits: Screening, Baseline/Day 1, on-
treatment visits at Weeks 2, 4, 8 and 12 (for all patients) and weeks 20 and 24 (for those 
patients receiving 24 weeks of Harvoni® treatment).  
 
Visits 
Screening 
Baseline / 
Day 1 
Week 2 
Week 4 
Week 8 
Week 
12 
Week 
20 
Week 
24 
12 weeks 
(Harvoni® or 
Epclusa®) 
treatment 
arm 
X 
X 
X 
X 
X 
X 
 
 
24 weeks 
(Harvoni®) 
treatment 
arm 
X 
X 
X 
X 
X 
X 
X 
X 
 
All subjects will complete post treatment Week 4, 12 and 24 visits. 
The assessments performed at each visit are described in Section 6 and shown in 
Appendix 1. 
 
3.3. 
Virologic Response-Based Stopping Criteria  
The following on-treatment virologic response-based treatment stopping criteria will be 
utilized: 
• 
Confirmed HCV RNA ≥ LLoQ after 2 consecutive HCV RNA <LLoQ. 
• 
Confirmed >1 log10 increase in HCV RNA from on-treatment nadir. 
• 
HCV RNA ≥LLoQ through 8 weeks of treatment. 
Confirmation should be performed as soon as possible and must occur no later than 2 
weeks after an initial observation indicating virologic failure during the on-treatment 
phase. 
All subjects who terminate treatment early will complete the early termination (ET) visit 
and post treatment 12 and 24 visits. 
 


HCV and Cryoglobulinemia Study 
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3.4. 
Cryoglobulinemia Response-Based Stopping Criteria 
The following on-treatment response-based treatment stopping criteria will be utilized: 
• 
Unacceptable side effect of the drug (i.e. hypersensitivity reaction, abnormal liver 
function tests; gastrointestinal side effects).  
• 
Paradoxical effect on the disease manifestations (i.e. increased of systemic 
vasculitis, renal failure). 
 
3.5. 
Treatment Discontinuation Criteria 
Study drug(s) must be discontinued in the following instances: 
• 
Unacceptable toxicity, as defined in Section 7 of the protocol, or toxicity that, in the 
judgment of the investigator, compromises the ability to continue study-specific 
procedures or is considered to not be in the subject’s best interest. 
• 
Intercurrent illness that would, in the judgment of the Investigator, affect 
assessments of clinical status to a significant degree. 
• 
Pregnancy of female subject during the study 
• 
Lack of efficacy (virologic failure) as defined in Section 3.3 and Section 3.4. 
• 
Significant protocol violation. 
• 
Subject request to discontinue for any reason; it is important to determine whether 
the withdrawal of consent is primarily due to an AE, lack of efficacy or other reason. 
• 
Discontinuation of the study at the request of Gilead Sciences, principal investigator, 
regulatory agency or an Institutional Review Board (IRB). 
All subjects who terminate early will be asked to complete the (ET) visit and post 
treatment Week 12 visits and week 24. 
 
3.6. 
Discontinuations 


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Subjects discontinuing treatment prior to completion of the assigned dosing period 
should complete an Early Termination (ET) visit (see Section 6.2.7). All subjects who 
terminate treatment early will complete the Early Termination (ET) visit and post 
treatment 12 and 24 visits. 
  
 
 


HCV and Cryoglobulinemia Study 
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4. SUBJECT POPULATION 
 
4.1. 
Number of Subjects  
Ten patients will be enrolled in this study.  
 
4.2. 
Inclusion Criteria 
Subjects must meet all of the following inclusion criteria to be eligible for participation in 
this study. 
1. Willing and able to provide written informed consent 
2. Male or female, age ≥18 years 
3. HCV RNA ≥ 15 IU/mL at Screening 
4. All HCV genotypes (1 to 6)  
5. Chronic HCV infection (≥ 6 months) documented by prior medical history or liver 
biopsy 
6. Classification as treatment naïve or treatment experienced: 
a) Treatment naïve is defined as having never been exposed to approved or 
experimental HCV-specific direct-acting antiviral agents or prior treatment of HCV 
with interferon or ribavirin or DAAs (except for SOF-containing regimens). 
b) Treatment experienced is defined as prior treatment failure or relapse to a 
regimen containing interferon either with or without RBV or DAAs  that was 
completed at least 8 weeks prior to Baseline/Day 1.  
The subject’s medical records must include sufficient detail of prior virologic failure to 
allow for categorization of prior response (Reference Section 4.2), as either: 
a. Non-Responder: Subject did not achieve undetectable HCV RNA levels 
while on treatment, or 
b. Relapse/Breakthrough: Subject achieved undetectable HCV RNA levels 
during treatment or within 4 weeks of the end of treatment but did not 
achieve SVR. 
7. Cirrhosis determination (approximately 20% of subjects may have cirrhosis) 
a. Cirrhosis is defined as any one of the following: 
i) 
Any previous liver biopsy showing cirrhosis (e.g., Metavir score = 4 or 
Ishak score ≥5) 


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ii) FibroMeter® score >0.442 or an AST:platelet ratio index (APRI) >2 during 
Screening 
iii) Fibroscan with a result of >12.5 kPa at any time prior to or during 
screening.   
b. Absence of cirrhosis is defined as any one of the following: 
i) 
Liver biopsy within 2 years of Screening showing absence of cirrhosis 
ii) FibroMeter® score <0.442 or APRI ≤ 1 performed during Screening 
iii) Fibroscan with a result of ≤12.5 kPa within 6 months of Baseline/Day 1 
Fibroscan results will supersede FibroMeter® /APRI; liver biopsy results will 
supersede FibroMeter® /APRI or Fibroscan results and be considered definitive. 
8. Liver imaging (ultrasound, CT scan or MRI) within 6 months of screening is required 
in patients with cirrhosis to exclude hepatocellular carcinoma (HCC) 
9. Presence of mixed cryoglobulinemia (please see criteria on the note below).  
10. Null or partial response to previous therapies for MC, including corticosteroids, 
cytotoxic 
agents 
(cyclophosphamide, 
azathioprine), 
hydroxycloroquine, 
methotrexate, mono- or combination therapy with IFNα/PEG-IFN and ribavirin, 
and/or CD20 depletion with Rituximab.  
a. Patients can be on ongoing treatment with one of the drugs described 
above at inclusion unless there is significant DDI. 
11. Subjects has the following laboratory parameters at screening: 
a) ALT <10 x the upper limit of normal (ULN) 
b) AST <10 x ULN 
c) Adequate bone marrow function as indicated hematologic parameters listed 
below and/or bone marrow cellularity >60-70% average for age. 
a. WBC >1500 /uL 
b. Platelets > 50,000/uL 
d) Direct bilirubin >2 x ULN 
e) INR >1.5 x ULN unless subject has known hemophilia or is stable on an 
anticoagulant regimen affecting INR 
12. Females of childbearing potential (as defined in Appendix 3) must have a negative 
serum pregnancy test at Screening and a negative urine pregnancy test on 
Baseline/Day 1 prior to treatment. 


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13. Male subjects and female subjects of childbearing potential who engage in 
heterosexual intercourse must agree to use protocol specified method(s) of 
contraception as described in Appendix 3. 
14. Lactating females must agree to discontinue nursing before the study drug is 
administered. 
15. Subject must be of generally good health, with the exception of chronic HCV 
infection, as determined by the Investigator. 
16. Subject must be able to comply with the dosing instructions for study drug 
administration and able to complete the study schedule of assessments. 
 
Note: Definition of Mixed Cryoglobulinemia (patients must meet one of the five 
overlapping syndromes listed below and the presence/documentation of cold-
precipitable immune complexes in blood on two different occasions. 
 
• 
Clinical evidence of cryoglobulinemia, overlapping syndromes: 
1. Cutaneous vasculitis (Raynaud's phenomenon, purpura, skin ulcers, livedo, 
acrocyanosis) 
2. Glomerulonephritis (hypertension, hematuria, nephrotic syndrome) 
3. Arthropathy (arthralgias, arthritis) 
4. Neuropathy (peripheral and/or central nervous system, distal sensorimotor, 
mononeuritis multiplex) 
5. Sicca syndrome (xerostomia, xerophthalmia) 
 
Other factors that will be assessed / recorded in patients with MC will be: 
1. Associated laboratory abnormalities including: 
• 
Positive HCV serology (recombinant immunoblot assay), viral nucleic acid 
quantitation diagnostic for HCV infection, and reflex genotyping. 
• 
Evidence of 
glomerulonephritis, 
including an 
active 
urinary sediment, 
hypoalbuminemia 
(albumin 
<3gm/dL) 
and/or 
significant 
proteinuria 
(>300mg/day). 
• 
Abnormal nerve conduction testing. 
 


HCV and Cryoglobulinemia Study 
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2. Pathologic evidence of cryoglobulinemia including: 
• 
Leukocytoclastic vasculitis. 
• 
Membranoproliferative glomerulonephritis. 
• 
Vasculopathy and/or mononuclear cell infiltrates on sural nerve biopsy. 
• 
Lip biopsy suggestive for Sjogren’s syndrome. 
 
3. Laboratory evidence of cryoglobulinemia including:  
• 
Characterization of cryoprecipitable material in serum by immunofixation, 
cryocrit, and/or quantitation of protein. 
• 
Associated immunological abnormalities, such as depressed levels of 
complement, elevated titers of rheumatoid factor, abnormal immunoglobulin 
quantitations, and serum immunofixation carried out on serum and/or isolated 
cryoglobulins. 
 
4. Laboratory evidence of B-cell clonality, including: 
• 
IgMk determined by immunofixation of serum and/or cryoglobulin, and kappa 
excess >2.65:1 on Free Light Chain (FLC) assay  
 
4.3. 
Exclusion criteria 
1. Chronic liver disease of a non-HCV etiology (e.g., alcoholic liver disease, hepatotoxic 
drug exposure, autoimmune hepatitis hemochromatosis, Wilson’s disease, alfa-1 
antitrypsin deficiency, cholangitis). 
2. Infection with hepatitis B virus (HBV) or human immunodeficiency virus (HIV). 
3. Patients with cirrhosis and Child-Pugh class B or C (Child-Pugh score will be 
calculated using laboratory parameters from screening visit). 
4. Current or prior history of any of the following: 
4.1. Clinically-significant illness (other than HCV) or any other major medical disorder 
that in the opinion of the Investigator may interfere with subject treatment, 
assessment or compliance with the protocol; subjects currently under evaluation 
for a potentially clinically-significant illness (other than HCV) are also excluded. 
5. Difficulty with blood collection and/or poor venous access for the purposes of 
phlebotomy. 


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6. Clinical hepatic decompensation (i.e. ascites, encephalopathy or variceal 
hemorrhage). 
7. Solid organ transplantation. 
8. Clinically significant pulmonary disease, cardiac disease or psychiatric disease that 
in the opinion of the investigator renders the subject a poor risk for inclusion into the 
study. 
9. Malignancy within the 5 years prior to screening, with the exception of specific 
cancers that have been cured by surgical resection (basal cell skin cancer, etc). 
Subjects under evaluation for possible malignancy are not eligible. 
10. Significant drug allergy (such as anaphylaxis or hepatotoxicity). 
11. Pregnant (serum pregnancy test to be performed for all women of childbearing 
potential at screening and urine pregnancy test at baseline); nursing female or 
unwillingness to practice birth control. Patients are expected to maintain adequate 
birth control to prevent pregnancy for 30 days post-completion of the drug (appendix 
3). 
12. Known hypersensitivity to SOF, VEL or formulation excipients. 
13. Participation in an investigational trial of a drug or device (excluding observational 
studies) within 30 days prior to screening and through the duration of study 
participation. 
 
 
 
 
 


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5. INVESTIGATIONAL MEDICINAL PRODUCTS 
 
5.1. 
Treatment Codes  
Each patient will receive a treatment code after the screening visit. This treatment code 
will be a correlative number of 2 digits.  
 
5.2. 
Description and Handling of Ledipasvir/ Sofosbuvir and 
Sofosbuvir/Velpatasvir 
5.2.1. Formulation 
The LDV/SOF (90mg/400 mg) tablets are orange colored, diamond shaped, film-coated 
tablet debossed with “GSI” on one side and “7985” on the other side of the tablet. In 
addition to the active ingredient, LDV/SOF tablets contain the following inactive 
ingredients: colloidal silicon dioxide, copovidone, croscarmellose sodium, lactose 
monohydrate, magnesium stearate, and microcrystalline cellulose. 
The tablet film-coat contains: FD&C yellow #6/sunset yellow FCF aluminum lake, 
polyethylene glycol, polyvinyl alcohol, talc, and titanium dioxide.  
The SOF/VEL (400mg/100mg) tablets are orange colored, diamond shaped, film-coated 
tablet debossed with “GSI” on one side and “7916” on the other side of the tablet. In 
addition to the active ingredient, SOF/VEL tablets contain the following inactive 
ingredients: 
copovidone, 
croscarmellose 
sodium, 
magnesium 
stearate, 
and 
microcrystalline cellulose. The tablets are film-coated with a coating material containing 
the following inactive ingredients: iron oxide red, polyethylene glycol, polyvinyl alcohol, 
talc, and titanium dioxide.  
 
5.2.2. Packaging and Labeling 
LDV/SOF 90mg/400 mg tablets are packaged in white, high density polyethylene 
(HDPE) bottles. Each bottle contains 28 tablets and polyester packing material. Each 
bottle is enclosed with a white, continuous thread, child-resistant screw cap with an 
induction-sealed, aluminum-faced liner. 
SOF/VEL 400mg/100mg tablets are packaged in white, high density polyethylene 
(HDPE) bottles. Each bottle contains 28 tablets and polyester packing material. Each 
bottle is enclosed with a white, continuous thread, child-resistant screw cap with an 
induction-sealed, aluminum-faced liner. 


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LDV/SOF 90mg/400 mg and SOF/VEL 400mg/100mg bottles shall be labeled to meet all 
applicable requirements of the US Food and Drug Administration (FDA) and/or other 
local regulations as applicable.  
Subjects will be provided with 2 bottles of medication (Harvoni or Epclusa) on Day 1 and 
another one on Week 4 visit. Thus, subjects will receive a total of 3 bottles of medication 
(28 tablets*3 bottles= 84 tables), enough to complete the 12 weeks of treatment (84 
days).  
Subjects that are receiving 24 weeks of treatment with Harvoni will be provided with 2 
bottles of medication on Day, another one on Week 4 visit, another one on week 8 and 2 
bottles on week 12. Thus, subjects will receive a total of 6 bottles of medication (28 
tablets*6 bottles= 168 tables), enough to complete the 24 weeks of treatment (84 days). 
 
 
Day 1 
Week 4 
Week 8 
Week 12 
Week 20 
Week 24 
12 weeks 
treatment 
2 bottles 
1 bottle 
- 
Return all 
bottles 
 
 
24 weeks 
treatment  
2 bottles 
1 bottle 
1 bottle 
2 bottles 
- 
Return all 
bottles 
 
5.2.3. Storage and Handling 
LDV/SOF and SOF/VEL bottles should be stored at controlled room temperature until 
required for administration. Controlled room temperature is defined as below 30°C 
(86°F); excursions are permitted between 15°C and 30°C (59°F to 86°F). 
All drug products should be stored in a securely locked area, accessible only to 
authorized site personnel. To ensure the stability of the study drug and to ensure proper 
product identification, the drug product should not be stored in a container other than the 
container in which they are supplied. Consideration should be given to handling, 
preparation, and disposal through measures that minimize drug contact with the body. 
Appropriate precautions should be followed to avoid direct eye contact or exposure 
through inhalation when handling LDV/SOF or SOF/VEL. 
Sufficient quantities of LDV/SOF and SOF/VEL tablets to complete the entire study will 
be shipped to the investigator or qualified designee from Gilead Sciences Materials & 
Logistics (or its designee). 
5.3. 
Study Drug Adherence and Drug Accountability 


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Subjects must be instructed to bring back all bottles of study medication(s) in the original 
container at every post-baseline study visit through the end of treatment. 
Study medications will be reconciled using medication pill count at all on treatment visits 
by the investigator or designee (i.e. study coordinator) in order to monitor the subject’s 
adherence with the medication regimen. 
5.4. 
Concomitant Medications 
After oral administration of LDV/SOF, sofosbuvir is rapidly absorbed and subject to 
extensive first-pass hepatic extraction. In clinical pharmacology studies, both sofosbuvir 
and the inactive metabolite GS-331007 were monitored for purposes of pharmacokinetic 
analyses. 
Use of HARVONI® with amiodarone is not recommended. Coadministration with 
amiodarone may result in serious symptomatic bradycardia.  
Ledipasvir is an inhibitor of the drug transporters P-gp and breast cancer resistance 
protein (BCRP) and may increase intestinal absorption of coadministered substrates for 
these transporters. 
Ledipasvir and sofosbuvir are substrates of drug transporters P-gp and BCRP while GS-
331007 is not. P-gp inducers (e.g., rifampin or St. John’s wort) may decrease ledipasvir 
and sofosbuvir plasma concentrations, leading to reduced therapeutic effect of 
LDV/SOF, and the use with P-gp inducers is not recommended with LDV/SOF. 
Concomitant medications taken within 30 days prior to Screening, up to and including 30 
days after the last dose of study drug need to be recorded in the source documents and 
eCRFs. 
After oral administration of SOF/VEL, sofosbuvir is rapidly absorbed and subject to 
extensive first-pass hepatic extraction. In clinical pharmacology studies, both sofosbuvir 
and the primary circulating metabolite GS-331007, were monitored for purposes of 
pharmacokinetic analyses. 
Use of Epclusa® with amiodarone is not recommended. Coadministration with 
amiodarone may result in serious symptomatic bradycardia.  
Concomitant use of certain medications or herbal/natural supplements (inhibitors or 
inducers of drug transporters i.e., P-gp) with study drug(s) may result in pharmacokinetic 
interactions resulting in increases or decreases in exposure of study drug(s) or these 
medications. Velpatasvir is an inhibitor of P-gp, organic anion-transporting polypeptides 
(OATPs) and CYP 2B6, CYP 2C8, and CYP 3A4 and may increase intestinal absorption 


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of coadministered substrates for these transporters. P-gp inducers (e.g., rifampin or St. 
John’s wort) may decrease sofosbuvir plasma concentrations, leading to reduced 
therapeutic effect, and the use with P-gp inducers is not recommended with Epclusa®. 
Concomitant medications taken within 30 days prior to Screening, up to and including 30 
days after the last dose of study drug need to be recorded in the source documents and 
eCRFs. 
 
Table 1 provides a listing of established or potentially clinically significant drug 
interactions. The drug interactions described are based on studies conducted with either 
LDV/SOF or SOF/VEL, the components as individual agents, or are predicted drug 
interactions that may occur with LDV/SOF or SOF/VEL. The use of the following agents 
is prohibited from 15 days prior to Baseline/Day 1 through the end of treatment. 
 
Table 1a. Potentially Significant Drug Interactions. Harvoni®  


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Table 1b. Potentially Significant Drug Interactions. Epclusa® 
 


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6. STUDY PROCEDURES 
 
Study visits will occur at Screening, Baseline/Day 1, and on-treatment at Weeks 2, 4, 8, 
and 12 (weeks 20 and 24 for 24 weeks treatment period subjects). Post treatment Visits 
will occur at Weeks 4, 12, and 24 following the last dose of study medications. 
Information on the specific laboratory parameters to be measured and clinical 
assessments to be performed are described below and in Appendix 1. 
 
6.1. 
Screening assessments  
6.1.1. Screening Visits (Day -30/-42 to Day 0) 
Screening assessments will be completed within 30 days of the Baseline/Day 1 visit. The 
screening window can be extended to 42 days for subjects requiring liver biopsy or 
additional HCV genotype testing. 
The following procedures will be performed and documented: 
• 
Obtain written informed consent 
• 
Obtain a detailed medical history  
• 
Determine inclusion eligibility including cirrhosis determination (Reference Section 
4.2) 
o If the presence of cirrhosis is determined, then appropriate diagnostic 
imaging (CT or Ultrasound) should have been performed in the last 6 months 
prior to screening or should be performed during the screening period to 
exclude the presence of hepatocellular carcinoma (HCC) 
• 
Obtain HCV and MC medical history 
o Regarding HCV, if treatment-experienced, record the duration of the prior 
treatment and the type of interferon and/or ribavirin and/or DAA administered. 
▪ 
Record 
whether 
the 
subject 
had 
a 
Non-response 
or 
Relapse/Breakthrough during prior treatment 
• 
Non-Response: Subject did not achieve undetectable HCV 
RNA while on treatment. 
• 
Relapse/Breakthrough: Subject achieved undetectable HCV 
RNA during treatment or within 4 weeks of the end of 
treatment, but did not achieve SVR. 


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o Regarding 
MC, 
record 
date 
of 
diagnosis, 
clinical 
manifestations, 
investigations done and previous treatments. 
• 
Obtain details of adverse events (AE) related to screening procedures 
• 
Obtain details of concomitant medications taken within 30 days of screening visit 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Perform complete physical examination, including vasculitis and joint evaluation 
• 
12-lead ECG 
• 
Complete neurological evaluation. Those subjects with neuropathy associated 
cryoglobulinemia 
must 
have 
acomplete 
physical 
examination 
and 
electrophysiological tests (Mount Sinai Hospital Neurology Department).  
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Sicca evaluation: evaluation by medical history and physical examination for subjects 
with Sicca syndrome. 
o Sicca evaluation: evaluation of xerostomia (saliva elicited from Stenson’s duct 
after sucking on a lemondrop) and xerophtalmia (Schirmer test). 
• 
Glomerulonephritis evaluation (urine sample and quantitation of serum creatinine) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Assessment of cirrhosis. Presence of absence of cirrhosis will be assessed by 
Fibroscan or APRI score or FibroMeter®.  
• 
Obtain blood samples for tests:  
o Hematology profile  
o Chemistry profile 
o Coagulation profile 
o HIV 1/2 antibody and Hepatitis B surface antigen. If patient has a negative 
serology performed in the last 6 months, it does not need to be repeated. 
o HCV antibody and HCV RNA 
o Determination of genotype and subtype of HCV infection 
o IL28B genotype. All patients will have genotype determined and screened for 
IL28B genotype CC in order to corroborate previous studies of patients with 


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MC with regard to both, and with regard to response to treatment (20). If 
patient has an historical IL28B, it does not need to be repeated.  
o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement and HCV core ELISA.  
o Serum β -hCG pregnancy test for females of childbearing potential only 
o CRP and ESR 
• 
Obtain urine sample for: 
o Urinalysis and urine creatinine 
• 
Subjects meeting all of the inclusion criteria and none of the exclusion criteria will 
return to the clinic for the Baseline/Day 1 visit assessments. 
 
6.2. 
Treatment Assessments 
6.2.1. Baseline/Day 1 assessments  
The following baseline tests and procedures must be completed prior to first dose of 
study drug(s): 
• 
Confirm eligibility 
• 
Perform a detailed medical history  
• 
Assessment of AEs and concomitant medications 
• 
Pregnancy prevention counseling and confirmation of contraception 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Perform complete physical examination, including vasculitis, joint, neuropathy 
examination and sicca syndrome (for subjects with Sicca syndrome) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine) for subjects with 
glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Obtain blood samples for:  
o Hematology profile 
o Chemistry profile 
o Coagulation profile 


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o ESR and CRP 
o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement, HCV core ELISA and 
Clonality/Lymproliferation / FACS. 
• 
Obtain urine sample for: 
o Urine  pregnancy test for females of childbearing potential only 
o Urinalysis and urine creatinine 
• 
Subject completes Health Assessment Questionnaire 
• 
Drug Administration  
o Dispense study drugs  
o Instruct the subject on the packaging, storage, compliance and administration 
of all study drugs (Epclusa® patient information. Appendix 4). 
o Observe the subject taking the first dose of study drugs and record the time 
of first dose and whether it was taken with or without food.  
 
6.2.2. Treatment assessments (week 2 +/-3 days) 
The following procedures/assessments are to be completed at the end of Week 2. 
• 
Perform a detailed medical history  
• 
Assessment of AEs and concomitant medications 
• 
Pregnancy prevention counseling and confirmation of contraception 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Perform complete physical examination, including vasculitis, joint, neuropathy 
examination and sicca syndrome (for subjects with Sicca syndrome) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine sample) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Obtain blood samples for: 
o Hematology profile 
o Chemistry profile 


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o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement and HCV core ELISA. 
• 
Obtain urine sample for: 
o Urinalysis and urine creatinine 
• 
Subject completes Health Assessment Questionnaire  
• 
Review study drug compliance and drug administration instructions with subject 
 
6.2.3. Treatment assessments (week 4+/-7 days) 
• 
Perform a detailed medical history  
• 
Assessment of AEs and concomitant medications 
• 
Pregnancy prevention counseling and confirmation of contraception 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine sample) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Perform complete physical examination, including vasculitis, joint, neuropathy 
examination and sicca syndrome (for subjects with Sicca syndrome) 
• 
Obtain blood samples for: 
o Hematology profile 
o Chemistry profile 
o Coagulation profile 
o HCV RNA 
o ESR and CRP 
o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement, HCV core ELISA and FACS 
• 
Obtain urine sample for: 
o Urine pregnancy test for females of childbearing potential only 
o Urinalysis and urine creatinine 
• 
Subject completes Health Assessment Questionnaire  


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• 
Review study drug compliance and drug administration instructions with subject 
• 
Drug Administration: 
o Dispense study drug  
o Review study drug compliance 
 
6.2.4. Treatment assessments (week 8+/-7 days and week 20+/-7 for those 
subjects on Harvoni 24 weeks) 
• 
Perform a detailed medical history  
• 
Assessment of AEs and concomitant medications 
• 
Pregnancy prevention counseling and confirmation of contraception 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine sample) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Perform complete physical examination, including vasculitis, joint, neuropathy 
examination and sicca syndrome (for subjects with Sicca syndrome) 
• 
Obtain blood samples for: 
o Hematology profile 
o Chemistry profile 
o Coagulation profile 
o ESR and CRP 
o HCV RNA 
• 
Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross reactive 
idiotypes, analysis of complement and HCV core ELISA  
• 
Obtain urine sample for: 
o Urine pregnancy test for females of childbearing potential only 
o Urinalysis and urine creatinine 
• 
Subject completes Health Assessment Questionnaire  
• 
Review study drug compliance and drug administration instructions with subject 


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• 
Review study drug compliance 
 
6.2.5. End of treatment (week 12 or week 24 +/-7 days) 
The following procedures/assessments are to be completed at the end of 
treatment(week 12 or week 24, depending on treatment arm): 
• 
Perform a detailed medical history  
• 
Assessment of AEs and concomitant medications 
• 
Pregnancy prevention counseling and confirmation of contraception 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine sample) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Perform complete physical examination, including vasculitis, joint, neuropathy 
examination and sicca syndrome (for subjects with Sicca syndrome) 
• 
Subject completes Health Assessment Questionnaire  
• 
Obtain blood samples for: 
o Hematology profile 
o Chemistry profile 
o Coagulation profile 
o HCV RNA 
o ESR and CRP 
o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement, HCV core ELISA and 
Clonality/Lymphoproliferation / FACS  
• 
Obtain urine sample for: 
o Urine pregnancy test for females of childbearing potential only 
o Urinalysis and urine creatinine 
• 
Complete medication pill count. 
 


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6.3. 
Post-treatment assessments  
The post treatment Week 4, 12 and 24 visits should be timed from the date of last 
administration of study drugs.  
6.3.1. Post Treatment Week 4 (+/- 7 days) 
The following procedures/assessments are to be completed for all subjects, 4 weeks 
after taking the last dose of study drugs: 
• 
Perform a detailed medical history  
• 
Assessment of AEs and concomitant medications 
• 
Pregnancy prevention counseling 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine sample) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Perform complete physical examination, including vasculitis, joint, neuropathy 
examination and sicca syndrome (for subjects with Sicca syndrome) 
• 
Subject completes Health Assessment Questionnaire  
• 
Obtain blood samples for: 
o Hematology profile 
o Chemistry profile 
o Coagulation profile 
o ESR and CRP 
o HCV RNA 
o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement, HCV core ELISA and FACS. 
• 
Obtain urine sample for: 
o Urine pregnancy test  
o If a positive urine pregnancy test is reported, the subject will be asked to 
return to the clinic for a confirmatory serum pregnancy test. 
o Urinalysis and urine creatinine 


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6.3.2. Post Treatment Week 12 and 24 (+/- 7 days) 
The following procedures/assessments are to be completed for the post treatment Week 
12 and 24 Visits: 
• 
Perform a detailed medical history  
• 
Assessment of SAEs and concomitant medications 
• 
Obtain body height and weight 
• 
Obtain vital signs (resting blood pressure, pulse and temperature) 
• 
Vasculitis activity score (Birmingham vasculitis score) for subjects with vasculitis. 
• 
Glomerulonephritis evaluation (urine sample and serum creatinine sample) for 
subjects with glomerulonephritis 
• 
ACR20-70 score (for subjects with Rheumatoid arthritis). This score includes a 
physical exam, a HAQ and a blood sample to evaluate ESR or CRP.  
• 
Perform complete physical examination, including vasculitis, joint and neuropathy 
examination.  
• 
Sicca evaluation: evaluation by medical history and physical examination (for 
subjects with Sicca syndrome). 
o Sicca evaluation: evaluation of xerostomia (saliva from Stensen’s duct) and 
xerophtalmia (Schirmer tests) will be performed at PT week 24. 
• 
For those subjects with neuropathy associated to cryoglobulinemia: A complete 
neurological examination will be performed (Mount Sinai Hospital Department of 
Neurology) will be performed at Post treatment week 24. 
• 
Obtain blood samples for: 
o Hematology profile 
o Chemistry profile 
o Coagulation profile 
o ESR and CRP 
o HCV RNA 
o Analysis of cryoglobulinemia measuring cryoglobulins, analyzing cross 
reactive idiotypes, analysis of complement, HCV core ELISA and 
clonality/lymphoproliferation / FACS. 
• 
Obtain urine sample for: 


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o urinalysis and urine creatinine 
• 
Subject completes Health Assessment Questionnaire  
 
6.4. 
Procedures and Specifications 
Fasting is not required for any of the procedures except for Fibroscan that requires 6 
hour fasting.  
 
6.4.1. Clinical Laboratory Analytes 
• 
Hematology profile: Hematocrit, Hemoglobin (Hb), Platelet count, Red blood cell 
count (RBC), White blood cell count (WBC) with differential (absolute and 
percentage) including Lymphocytes, Monocytes, Neutrophils, Eosinophils, Basophils, 
Reticulocyte count and MCV. These studies will be performed at Core Laboratory at 
Mount Sinai Hospital. 
• 
Coagulation profile: INR, Prothrombin time (PT), Activated partial thromboplastin 
time (APTT). These studies will be performed at Core Laboratory at Mount Sinai 
Hospital. 
• 
Chemistry 
profile: 
Alanine 
aminotransferase 
(ALT/SGPT), 
Aspartate 
aminotransferase (AST/SGOT), Albumin, Alkaline phosphatase, Creatine Kinase, 
Creatinine, Total Bilirubin (reflex to Direct Bilirubin), Glucose, Lipase, Potassium, 
Sodium; Fibrotest® /APRI calculation, and Direct Bilirubin at Screening only. These 
studies will be performed at Core Laboratory at Mount Sinai Hospital.  
• 
Urinalysis: Appearance, Blood, Color, Glucose, Leukocyte esterase, pH, Protein, 
Urobilinogen. These studies will be performed at Core Laboratory at Mount Sinai 
Hospital. 
• 
Urine creatinine level. This study will be performed at Core Laboratory at Mount Sinai 
Hospital. 
• 
Virological Tests: Serologies for HCV, HBV and HIV. HCV RNA will be measured 
using the COBAS® TaqMan® HCV Test, v2.0 for use with Ampliprep. HCV genotype 
and subtype will be determined using the Siemens VERSANT® HCV Genotype 
INNO-LiPA 2.0 Assay. These studies will be performed at Core Laboratory at Mount 
Sinai Hospital. 


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• 
IL28B genotype will be determined by polymerase chain reaction (PCR) amplification 
of the SNP, rs12979860, with sequence specific forward and reverse primers and 
allele specific fluorescently labeled TaqMan® MGB probes. These studies will be 
performed at Core Laboratory at Mount Sinai Hospital. 
• 
Pregnancy Tests: Serum β-hCG or Urine β-hCG.  
 
6.4.2. Medical History 
Medical history including details regarding illnesses and allergies, date(s) of onset, and 
whether condition(s) is currently ongoing, and medication history, including prior HCV 
treatment history (only applicable for treatment experienced subjects), will be collected 
on all subjects during screening. 
Obtain HCV treatment history as per Section 4.2. 
Obtain MC treatment history as per Section 4.2. 
 
6.4.3. Complete Physical Examination 
A complete physical examination will include source documentation of general 
appearance, and the following body systems: Head: eyes, ears, nose, throat, mouth and 
tongue; Neck Range of motion (ROM, thyroid, cervical nodes Chest: (excluding breasts); 
respiratory; Cardiovascular: heart rate and rhythm, murmurs and gallops Lymph nodes: 
axillary, inguinal Abdomen: tenderness, organomegaly Skin: rashes, hair, nails Joints: 
tenderness, ROM, heat, swelling  Musculoskeletal: muscle strength and tenderness 
Neurological. Physical examination will also include evaluation of the amount of saliva 
and tear production by visual inspection of the salivary and lacrimal glands. 
 
6.4.4. Vital Signs 
Assessment of vital signs will include measurement of resting blood pressure, pulse, 
respiratory rate, and temperature. 
Blood pressure will be measured using the following standardized process: 
• 
Subject should sit for ≥5 minutes with feet flat on the floor and measurement arm 
supported so that the midpoint of the manometer cuff is at heart level; 
• 
Use a mercury sphygmomanometer or automatic blood pressure device with an 
appropriately sized cuff with the bladder centered over the brachial artery; 


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• 
Measure and record the blood pressure to the nearest 2 mmHg mark on the 
manometer or to the nearest whole number on an automatic device. 
 
6.4.5. Creatinine Clearance (CLcr) 
Creatinine clearance is calculated by the Cockcroft-Gault equation {2202} using actual 
body weight (BW). 
Male: CLcr (mL/min) = [140 - age (years)] x BW(kg) / 72 s Scr 
Female: CLcr (mL/min) = [140 - age (years)] x BW(kg) x0.85 / 72 x Scr 
Scr = serum creatinine (mg/dL) 
 
6.4.6. 12-Lead ECGs 
Subjects will be required to rest in a supine position for ≥5 minutes prior to making a 
recording.  
The investigator (or qualified designee) should review the ECG traces recorded in real 
time for clinically significant abnormalities.  
 
6.4.7. Viral RNA Sequencing / Phenotyping Sample 
Plasma samples will be collected at Baseline/Day 1 and each visit thereafter for viral 
sequence analysis. At any unscheduled visit initiated for the purpose of confirming 
virologic breakthrough, a viral sequence analysis plasma sample must be collected. 
 
6.4.8. Pregnancy Testing 
All females of childbearing potential will have urine pregnancy testing every 4 weeks 
during the dosing period and 30 days after last dose of study drug. 
Definition of childbearing potential is described in Appendix 3.  
If a positive urine pregnancy test is reported, the subject will be asked to return to the 
clinic for a confirmatory serum pregnancy test. 
 
6.4.9. Other procedures 
• 
Vasculitis activity score (Birmingham vasculitis score). This score includes the 
following items: (1) general, (2) cutaneous, (3) mucous membranes/eyes, (4) ENT, 
(5) chest, (6) cardiovascular, (7) Abdominal, (7) renal, (8) Nervous system, (9) other. 
This score is based on patient self-report, medical history, physical examination 


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serum creatinine, urine creatinine and urinalysis (proteinuria, hematuria). Appendix 
6. Only for subjects with vasculitis. 
• 
Sicca syndrome evaluation. This will be assessed by PI in all visits based on patient 
self-report and physical examination to assess amount of saliva and tears. On 
screening and post treatment week 24 visits Dr Gorevic will perform a Schirmer test 
to assess xerophtalmia and will measure saliva from Stensen’s duct to assess 
xerostomia (39,40). Only for subjects with sicca syndrome. 
• 
ACR20-70 score. This score includes the assessment following items: 1) at swollen 
joint counts, 2) tender joint counts, 3) patient-assessed global disease activity (i.e. by 
VAS), 4) evaluator-assessed global disease activity (i.e. by VAS), 5) patient pain 
assessment (i.e. by VAS), 6) functional disability (i.e. by HAQ), 7) acute phase 
response (ESR or PCR). A 20 and 70 percent response (ACR20-70) represents 
improvement of at least 20 or 70 percent (41). Only for subjects with Rheumatoid 
arthritis. 
• 
Glomerulonephritis evaluation. This will be assessed by 1) the presence of 
hematuria, proteinuria and red cell casts by urinalysis, 2) quantification of proteinuria 
on a 24 hour collection or as the protein/creatinine ratio of a spot sample of urine and 
3) concomitant renal insufficiency is defined as serum creatinine >2.0mg/dL. Only for 
subjects with glomerulonephritis.  
• 
Neuropathy evaluation will be evaluated by complete and detailed physical 
examination performed by Dr Gorevic in every visit. For those subjects with 
neuropathy associated cryoglobulinemia, on screen and post-treatment week 24 
visits this will be performed by Dr Jessica Robinson-Papp, and neuropathy will be 
corroborated by electrophysiologic testing.  
• 
Complement studies: 
o MBL, Generation attack complex (C5-9), Rheumatoid factor, IgM, C3, C4 and 
C4a analysis will be performed through the Core Laboratory at Mount Sinai 
Health Care System. 
o C1q, C1q binding assays and gC1qR will be performed at our clinical 
immunology laboratory, and in the Laboratory of Dr Berhane Ghebrehiwet 
(State University of New York, Stony Brook).   
• 
Cryoprecipitation characterization studies: 


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o Analysis of MC and of cross-reactive idiotypes (CRI) will be separated and 
frozen to be analyzed on a later date at the Flow Cytometry Laboratory at 
Mount Sinai Health Care System. 
  
• 
Regression of clonality/lymphoproliferation and FACS analysis, this includes:  
o B-cell surface antigens, kappa/lambda light chain on B cells, CLL lymphoma 
panel and CD81, that will be performed at the Flow Cytometry Shared 
Resource Core Facility and at our Clinical Immunology Laboratory  
o Isolate PBMCs for CyTOF analysis to investigate the patients mononuclear 
cellular immunity profile during and after DAA treatment cell populations to be 
analyzed by CyTOF. Samples will be frozen and and analysis on a later date. 
  
• 
HCV core ELISA: this includes: 
o Compartmentalization of viral RNA and core antigen between cryoprecipitible 
and non-cryoprecipitible immune complexes will be performed with support 
from our institutional Human Immune Monitoring Core Facility.  
o HRP conjugated HCV core Ag antibodies will be obtained commercially with 
assays to be performed with support from our Human Immune Monitoring 
Core Facility.  
o FITC-conjugated secondary antibodies will be obtained commercially and 
tested for optimal resolution in our institutional Flow Cytometry Shared 
Resource Core Facility. 
 
 


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7. TOXICITY MANAGEMENT 
 
7.1. 
Dose Modification Due to Toxicity 
There is no option for dose reduction or modification of LDV/SOF or SOF/VEL. 
 
7.2. 
Toxicity Stopping Criteria 
Administration of all study medication(s) may be discontinued in the event of a clinical or 
laboratory event. The PI must be consulted prior to dose discontinuation of LDV/SOF or 
SOF/VEL unless the investigator believes that immediate action is warranted to ensure 
the continued safety of the subject. Subjects who meet any of the following laboratory 
criteria must stop all study medication(s): 
• 
Elevation of ALT and/or AST >5x Baseline/Day 1 or nadir, confirmed by immediate 
repeat testing 
• 
Abnormal elevation of ALT >3x Baseline/Day 1 and total bilirubin >2 x ULN, 
confirmed by immediate repeat testing 
• 
Elevation of ALT >15 x ULN, confirmed by immediate repeat testing 
• 
Any Grade 3 or greater rash associated with constitutional symptoms 
• 
Any Grade 4 adverse event or laboratory abnormality assessed (and confirmed by 
immediate repeat testing) as related to LDV/SOF or to SOF/VEL. 
• 
Any unacceptable side effect of the drug (i.e. hypersensitivity reaction, abnormal 
Liver function tests; gastrointestinal side effects) in the judgment of the Investigator 
compromises the ability to continue study specific procedures or is considered to not 
be in the subject’s best interest.  
• 
A paradoxic effect on the disease manifestations (i.e. increased or systemic 
vasculitis, renal failure) 
 
 
 


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8. ADVERSE EVENTS MANAGEMENT 
8.1. 
Definitions of Adverse Events, Adverse Reactions, and Serious Adverse 
Events 
An adverse event (AE) is any untoward medical occurrence in a clinical study subject 
administered a medicinal product, which does not necessarily have a causal relationship 
with the treatment. An AE can therefore be any unfavorable and/or unintended sign, 
symptom, or disease temporally associated with the use of a medicinal product, whether 
or not considered related to the medicinal product. AEs may also include pre- or post-
treatment complications that occur as a result of protocol specified procedures, lack of 
efficacy, overdose, drug abuse/misuse reports, or occupational exposure. Pre-existing 
events that increase in severity or change in nature during or as a consequence of 
participation in the clinical study will also be considered AEs. 
An AE does not include the following: 
• 
Medical or surgical procedures such as surgery, endoscopy, tooth extraction, and 
transfusion. The condition that led to the procedure may be an adverse event and 
must be reported. 
• 
Pre-existing diseases, conditions, or laboratory abnormalities present or detected 
before the screening visit that do not worsen. 
• 
Situations where an untoward medical occurrence has not occurred (e.g., 
hospitalization for elective surgery, social and/or convenience admissions). 
• 
Overdose without clinical sequelae. 
• 
Any medical condition or clinically significant laboratory abnormality with an onset 
date before the consent form is signed and not related to a protocol-associated 
procedure is not an AE. It is considered to be pre-existing and should be 
documented on the medical history CRF. 
 
8.1.1. Classification of Adverse Events 
8.1.1.1. 
Serious Adverse Events 
A serious adverse event (SAE) is defined as an event that, at any dose, results in the 
following: 
• 
Death 


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• 
Life-threatening (Note: The term “life-threatening” in the definition of “serious” refers 
to an event in which the subject was at risk of death at the time of the event; it does 
not refer to an event that hypothetically might have caused death if it were more 
severe.) 
• 
In-patient hospitalization or prolongation of existing hospitalization 
• 
Persistent or significant disability/incapacity 
• 
A congenital anomaly/birth defect 
• 
A medically important event or reaction: such events may not be immediately life-
threatening or result in death or hospitalization but may jeopardize the subject or 
may require intervention to prevent one of the other outcomes constituting SAEs. 
Medical and scientific judgment must be exercised to determine whether such an 
event is a reportable under expedited reporting rules. Examples of medically 
important events include intensive treatment in an emergency room or at home for 
allergic bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization; and development of drug dependency or drug abuse. For the 
avoidance of doubt, infections resulting from contaminated medicinal product will be 
considered a medically important event and subject to expedited reporting 
requirements. 
 
8.1.2. Clinical Laboratory Abnormalities and Other Abnormal Assessments as 
Adverse Events or Serious Adverse Events 
Laboratory abnormalities without clinical significance are not recorded as AEs or SAEs. 
However, laboratory abnormalities (e.g., clinical chemistry, hematology, and urinalysis) 
that require medical or surgical intervention or lead to study drug interruption, 
modification, or discontinuation must be recorded as an AE, as well as an SAE, if 
applicable. 
In 
addition, 
laboratory 
or 
other 
abnormal 
assessments 
(e.g., 
electrocardiogram, x-rays, vital signs) that are associated with signs and/or symptoms 
must be recorded as an AE or SAE if they meet the definition of an AE or SAE as 
described. If the laboratory abnormality is part of a syndrome, we will record the 
syndrome or diagnosis (e.g., anemia), not the laboratory result (i.e., decreased 
hemoglobin). 
 
8.2. 
Assessment of Adverse Events and Serious Adverse Events 


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The investigator or qualified sub-investigator is responsible for assessing AEs and SAEs 
for causality and severity, and for final review and confirmation of accuracy of event 
information and assessments. 
 
8.2.1.1. 
Assessment of Causality for Study Drugs and Procedures 
The investigator or qualified sub-investigator is responsible for assessing the relationship 
to therapy using clinical judgment and the following considerations: 
• 
No: Evidence exists that the adverse event has an etiology other than the drug. For 
SAEs, an alternative causality must be provided (e.g., pre-existing condition, 
underlying disease, intercurrent illness, or concomitant medication). 
• 
Yes: There is reasonable possibility that the event may have been caused by the 
investigational medicinal product. 
It should be emphasized that ineffective treatment should not be considered as causally 
related in the context of adverse event reporting. 
The relationship to study procedures (e.g., invasive procedures such as venipuncture or 
biopsy) should be assessed using the following considerations: 
• 
No: Evidence exists that the adverse event has an etiology other than the study 
procedure. 
• 
Yes: The adverse event occurred as a result of protocol procedures (eg., 
venipuncture) 
 
8.2.1.2. 
Assessment of Severity 
The severity grading of AEs will be assessed as Grade 1, 2, 3, or 4 using the GSI 
Grading Scale for Severity of Adverse Events and Laboratory Abnormalities (Appendix 
2). For AEs associated with laboratory abnormalities, the event should be graded on the 
basis of the clinical severity in the context of the underlying conditions; this may or may 
not be in agreement with the grading of the laboratory abnormality. 
 
8.3. 
Investigator Requirements and Instructions for Reporting Adverse Events 
and Serious Adverse Events 
Requirements for collection prior to study drug initiation: 


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After informed consent, but prior to initiation of study medication, the following types of 
events should be reported on the case report form (CRF/eCRF): all SAEs and adverse 
events related to protocol-mandated procedures. 
Adverse Events 
Following initiation of study medication, all AEs, regardless of cause or relationship, until 
4 weeks after last administration of study drug must be collected and reported on the 
CRF/eCRF database as instructed. 
All AEs should be followed up until resolution or until the adverse event is stable, if 
possible.  
Serious Adverse Events 
All SAEs, regardless of cause or relationship, that occur after the subject first consents 
to participate in the study (i.e., signing the informed consent) and throughout the 
duration of the study, including the protocol-required post treatment follow-up period, will 
be reported to the CRF/eCRF database and to the FDA. This also includes any SAEs 
resulting from protocol-associated procedures performed after informed consent is 
signed. 
Any SAEs and deaths that occur after the post treatment visit, regardless of causality, 
will also be reported. 
Investigators are not obligated to actively seek SAEs after the protocol-defined follow up 
period. However, if the investigator learns of any SAEs that occur after study 
participation has concluded and the event is deemed relevant to the use of study drug, 
this will be promptly documented, and the event reported to the FDA. 
• 
All AEs and SAEs will be recorded in the CRF/eCRF database within the timelines 
outlined in the CRF/eCRF completion guideline and will be reported within 24 hours. 
SAEs will be reported accordingly to FDA guidelines. As soon as it is possible to do 
so, any SAE reported via paper will be transcribed into the eCRF Database 
according to instructions in the eCRF completion guidelines. 
• 
For fatal or life-threatening events, copies of hospital reports, autopsy reports, and 
other documents will also be submitted by e-mail or fax when requested and 
applicable. Transmission of such documents should occur without personal subject 
identification, maintaining the traceability of a document to the subject identifiers. 
• 
Additional information may be requested to ensure the timely completion of accurate 
safety reports. 


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• 
Any medications necessary for treatment of the SAE will be recorded onto the 
concomitant medication section of the subject’s CRF/eCRF, and the event 
description section of the SAE form. 
• 
The investigator will notify the IRB of SUSAR reports as soon as practical, where this 
is required by local regulatory agencies, and in accordance with the local institutional 
policy. 
 
8.4. 
Special Situations Reports 
8.4.1.1. 
Definitions of Special Situations 
Special situation reports include all reports of medication error, abuse, misuse, 
overdose, reports of adverse events associated with product complaints, and pregnancy 
reports regardless of an associated AE. 
• 
Medication error is any unintentional error in the prescribing, dispensing, or 
administration of a medicinal product while in the control of the health care provider, 
subject, or consumer. 
• 
Abuse is defined as persistent or sporadic intentional excessive use of a medicinal 
product by a subject. 
• 
Misuse is defined as any intentional and inappropriate use of a medicinal product 
that is not in accordance with the protocol instructions or the local prescribing 
information. 
• 
An overdose is defined as an accidental or intentional administration of a quantity of 
a medicinal product given per administration or cumulatively which is above the 
maximum recommended dose as per protocol or in the product labeling (as it applies 
to the daily dose of the subject in question). In cases of a discrepancy in drug 
accountability, overdose will be established only when it is clear that the subject has 
taken the excess dose(s). Overdose cannot be established when the subject is 
unable to account for the discrepancy, except in cases in which the investigator has 
reason to suspect that the subject has taken additional dose(s).  
o No specific antidote is available for overdose with Harvoni® or Epclusa®. If 
overdose occurs the patient must be monitored for evidence of toxicity. 
Treatment of overdose with HARVONI® or Epclusa® consists of general 
supportive measures including monitoring of vital signs as well as observation 


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of the clinical status of the patient. Hemodialysis is unlikely to result in 
significant removal of ledipasvir since ledipasvir is highly bound to plasma 
protein. Hemodialysis can efficiently remove the predominant circulating 
metabolite of sofosbuvir, GS-331007, with an extraction ratio of 53%. 
Hemodialysis is unlikely to result in significant removal of velpatasvir since 
velpatasvir is highly bound to plasma protein. 
• 
Product complaint is defined as complaints arising from potential deviations in the 
manufacture, packaging, or distribution of the medicinal product. 
 
8.4.1.2. 
Instructions for Reporting Special Situations 
8.4.1.2.1. Instructions for Reporting Pregnancies 
The investigator will report pregnancies in female study subjects that are identified after 
initiation of study medication and throughout the study, including the post study drug 
follow-up period. 
Pregnancy itself is not considered an AE, nor is an induced elective abortion to terminate 
a pregnancy without medical reason. 
Any premature termination of pregnancy (e.g., a spontaneous abortion, an induced 
therapeutic abortion due to complications or other medical reasons) will be reported 
within 24 hours as an SAE. The underlying medical reason for this procedure will be 
recorded as the AE term. 
A spontaneous abortion is always considered to be an SAE and will be reported as 
described above. Furthermore, any SAE occurring as an adverse pregnancy outcome 
post study will be reported to the FDA. 
The subject should receive appropriate monitoring and care until the conclusion of the 
pregnancy. The outcome will be reported to the FDA using the pregnancy outcome 
report form. If the end of the pregnancy occurs after the study has been completed, the 
outcome will be reported directly to the FDA.  
 
Pregnancies of female partners of male study subjects exposed to study drugs will also 
be reported, and relevant information submitted to the FDA using the pregnancy and 
pregnancy outcome forms within 24 hours. Monitoring of the subject will continue until 
the conclusion of the pregnancy. If the end of the pregnancy occurs after the study has 
been completed, the outcome will be reported directly to the FDA,  


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Refer to Appendix 4 for Pregnancy Precautions, Definition for Female of Childbearing 
Potential, and Contraceptive Requirements. 
 
Any inappropriate use of concomitant medications prohibited by this protocol should not 
be reported as “misuse,” but may be more appropriately documented as a protocol 
deviation. 
 
8.5. 
Warnings and Precautions 
Refer to HARVONI® (Ledipasvir/sofosbuvir) package insert for additional information 
(Appendix 5b).  
 
Refer to Epclusa® (Sofosbuvir/Velpatasvir) package insert for additional information 
(Appendix 5b).  
 
 


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9. STATISTICAL CONSIDERATIONS  
 
This is a pilot study in which 10 patients will be enrolled to explore the efficacy of all-oral 
anti-viral therapy for symptomatic hepatitis C virus infection-related cryoglobulinemia. 
With 10 patients in the study we will be able to estimate the rate of patients who obtain 
an SVR with a margin of error of approximately 15%. 
We will use frequency table and 95% confidence interval to describe the rate of SVR in 
the total sample and the two subgroups of interest. 
Results will be compared to previous published studies (28), as well as unpublished 
experience, that have delineated the natural history of type 2 cryoglobulinemia, and the 
response to immunomodulatory therapies, including IFN/Peg-IFN, Ribavirin and 
Rituximab (27). 
 
 
10. INVESTIGATOR RESPONSABILITIES 
10.1. Good Clinical Practice  
The investigator will ensure that this study is conducted in accordance with the principles 
of the “Declaration of Helsinki” (as amended in Edinburgh, Tokyo, Venice, Hong Kong, 
and South Africa), International Conference on Harmonisation (ICH) guidelines, or with 
the laws and regulations of the country in which the research is conducted, whichever 
affords the greater protection to the study subject. For studies conducted under a United 
States IND, the investigator will ensure that the basic principles of “Good Clinical 
Practice,” as outlined in 21 CFR 312, subpart D, “Responsibilities of Sponsors and 
Investigators,” 21 CFR, part 50, 1998, and 21 CFR, part 56, 1998, are adhered to. These 
standards are consistent with the requirements of the European Community Directive 
2001/20/EC.  
 
10.2. Institutional Review Board (IRB) Approval 
This protocol and any accompanying material to be provided to the subject (such as 
advertisements, subject information sheets, or descriptions of the study used to obtain 
informed consent) will be submitted by the investigator to an IRB. Approval from the IRB 
must be obtained before starting the study and should be documented in a letter to the 


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investigator specifying the protocol number, protocol version, protocol date, documents 
reviewed, and date on which the committee met and granted the approval. 
Any modifications made to the protocol after receipt of IRB approval must also be 
submitted to the IRB for approval before implementation. 
 
10.3. Informed Consent 
The PI or designee is responsible for obtaining written informed consent from each 
individual participating in this study after adequate explanation of the aims, methods, 
objectives, and potential hazards of the study and before undertaking any study-related 
procedures. The investigator will utilize an IRB-approved consent form for documenting 
written informed consent. Each informed consent will be appropriately signed and dated 
by the subject or the subject’s legally authorized representative and the person obtaining 
consent prior to performing any study procedures. 
 
10.4. Confidentiality 
The investigator assures that subjects’ anonymity will be strictly maintained, and that 
their identities are protected from unauthorized parties. Only subject initials, date of birth, 
(or dummy initials/date of birth if local regulations do not permit collection of this data) 
and an identification code (i.e., not names) will be recorded on any form or biological 
sample submitted to the Sponsor, IRB, or laboratory. The investigator will keep a 
screening log showing codes, names, and addresses for all subjects screened and for all 
subjects enrolled in the trial. 
 
10.5. Study Files and Retention of Records 
The investigator must maintain adequate and accurate records to enable the conduct of 
the study to be fully documented and the study data to be subsequently verified. These 
documents should be classified into at least the following two categories: (1) 
investigator’s study file, and (2) subject clinical source documents. 
The investigator’s study file will contain the protocol/amendments, CRF and query forms, 
IRB and governmental approval with correspondence, informed consent forms, drug 
records, staff curriculum vitae and authorization forms, and other appropriate documents 
and correspondence. 


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The required source data are listed in the Source Data verification Plan, and should 
include sequential notes containing at least the following information for each subject: 
• 
subject identification (name, date of birth, gender); 
• 
documentation that subject meets eligibility criteria, i.e., history, physical 
examination, and confirmation of diagnosis (to support inclusion and exclusion 
criteria); 
• 
participation in trial (including trial number); 
• 
trial discussed and date of informed consent; 
• 
dates of all visits; 
• 
documentation that protocol specific procedures were performed; 
• 
results of efficacy parameters, as required by the protocol; 
• 
start and end date (including dose regimen) of trial medication (preferably drug 
dispensing and return should be documented as well); 
• 
record of all adverse events and other safety parameters (start and end date, and 
preferably including causality and intensity); 
• 
concomitant medication (including start and end date, dose if relevant; dose changes 
should be motivated); 
• 
date of trial completion and reason for early discontinuation, if applicable. 
All clinical study documents will be retained by the investigator until study publication.  
 
10.6. Electronic Case Report Forms (eCRF, RedCap) 
For each subject enrolled, an eCRF will be completed and signed by the principal 
investigator or sub-investigator (as appropriate) within a reasonable time period after 
data collection. This also applies to records for those subjects who fail to complete the 
study (even during a screening period if an eCRF was initiated). If a subject withdraws 
from the study, the reason must be noted on the eCRF. If a subject is withdrawn from 
the study because of a treatment-limiting adverse event, thorough efforts will be made to 
clearly document the outcome. 
REDCap platform will be used for our eCRF (http://www.project-redcap.org). 
 
10.7. Drug accountability 


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The investigator or designee (i.e., study coordinator) is responsible for ensuring 
adequate accountability of all used and unused investigational medicinal product. This 
includes acknowledgment of receipt of each shipment of study product (quantity and 
condition), subject dispensing records, and returned or destroyed study product. 
Dispensing records will document quantities received from Gilead Sciences and 
quantities dispensed to subjects, including lot number, date dispensed, subject identifier 
number, subject initials, and the initials of the person dispensing the medication. 
Drug may be returned or destroyed on an ongoing basis during the study if appropriate. 
At the end of the study, following final drug inventory reconciliation, the study site will 
dispose of and/or destroy all unused investigational medicinal product supplies, including 
empty containers, according to these procedures. Destruction or return of unused 
investigational medicinal product supplies will be destroyed at on site Pharmacy. 
All drug supplies and associated documentation will be periodically reviewed and verified 
by the study team over the course of the study. 
 
10.8. Protocol compliance 
The investigator is responsible for ensuring the study is conducted in accordance with 
the procedures and evaluations described in this protocol. 
 
10.9. Protocol Modifications 
Protocol modifications, except those intended to reduce immediate risk to study 
subjects, may be made only by Principal Investigator. All protocol modifications must be 
submitted to the IRB in accordance with local requirements. Approval must be obtained 
before changes can be implemented. 
 
10.10. Study Report and Publications 
A clinical study report will be prepared and provided to the regulatory agency(ies). 
Principal Investigator will ensure that the report meets the standards set out in the ICH 
Guideline for Structure and Content of Clinical Study Reports (ICH E3). Note that an 
abbreviated report may be prepared in certain cases. 
After conclusion of the study investigators in this study may communicate, orally present, 
or publish in scientific journals or other scholarly media. 


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The investigator will submit any proposed publication or presentation along with the 
respective scientific journal or presentation forum at least 7 days and 30 days before 
submission of the abstract or publication, respectively.  
 
10.11. Access to Information for Auditing or Inspections 
Representatives of regulatory authorities may conduct inspections or audits of the 
clinical study. The investigator agrees to provide to representatives of a regulatory 
agency access to records, facilities, and personnel for the effective conduct of any 
inspection or audit.  
 
10.12. Study Discontinuation 
The investigator reserves the right to terminate the study at any time. Should this be 
necessary, both parties will arrange discontinuation procedures and notify the 
appropriate regulatory authority(ies) and IRBs. In terminating the study, the investigator 
will assure that adequate consideration is given to the protection of the subjects’ 
interests. 
 
 
 


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11. REFERENCES 
 
(1) Therapy for hepatitis C virus-related cryoglobulinemic vasculitis. Dammacco F, 
Sansonno D. N Engl J Med. 2013;369:1035-45. 
(2) The diagnosis and classification of the cryoglobulinemic syndrome. Damoiseaux J. 
Autoimmun Rev. 2014;13:359-62. 
(3) Manifestations of chronic hepatitis C virus infection beyond the liver. Jacobson IM, 
Cacoub P, Dal Maso L, Harrison SA, Younossi ZM. Clin Gastroenterol Hepatol. 
2010;8:1017-29. 
(4) Risk of non-Hodgkin lymphoma and lymphoproliferative precursor diseases in US 
veterans with hepatitis C virus. Giordano TP, Henderson L, Landgren O, Chiao EY, 
Kramer JR, El-Serag H, Engels EA. JAMA. 2007;297:2010-7. 
(5) Morphologic features of extrahepatic manifestations of hepatitis C virus infection. Ko 
HM, Hernandez-Prera JC, Zhu H, Dikman SH, Sidhu HK, Ward SC, Thung SN. Clin Dev 
Immunol. 2012;2012:740138 
(6) Cryoglobulinemia.Dispenzieri A, Gorevic PD.Hematol Oncol Clin North Am. 
1999;13:1315-49 
(7) Rheumatoid factor, complement, and mixed cryoglobulinemia. Gorevic PD. Clin Dev 
Immunol. 2012;2012:439018. 
(8) Autoimmune disease complicating antiviral therapy for hepatitis C virus 
infection.Wilson LE, Widman D, Dikman SH, Gorevic PD. Semin Arthritis Rheum. 2002; 
32:163-73 
(9) Hepatitis C virus-induced vasculitis: therapeutic options. Cacoub P, Terrier B, 
Saadoun D. Ann Rheum Dis. 2014;73:24-30. 
(10) Peg-IFNα/ribavirin/protease inhibitor combination in hepatitis C virus associated 
mixed cryoglobulinemia vasculitis: results at week 24. Saadoun D, Resche Rigon M, 
Thibault V, Longuet M, Pol S, Blanc F, Pialoux G, Karras A, Bazin-Karra D, Cazorla C, 
Vittecoq D, Musset L, Decaux O, Ziza JM, Lambotte O, Cacoub P. Ann Rheum Dis. 
2014;73:831-7 
(11) Ledipasvir and sofosbuvir for 8 or 12 weeks for chronic HCV without cirrhosis. 
Kowdley KV, Gordon SC, Reddy KR, Rossaro L, Bernstein DE, Lawitz E, Shiffman ML, 
Schiff E, Ghalib R, Ryan M, Rustgi V, Chojkier M, Herring R, Di Bisceglie AM, Pockros 
PJ, Subramanian GM, An D, Svarovskaia E, Hyland RH, Pang PS, Symonds WT, 


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Page 65 of 70 
 
McHutchison JG, Muir AJ, Pound D, Fried MW; ION-3 Investigators. N Engl J Med. 
2014;370:1879-88 
(12) Ledipasvir and sofosbuvir for untreated HCV genotype 1 infection. Afdhal N, 
Zeuzem S, Kwo P, Chojkier M, Gitlin N, Puoti M, Romero-Gomez M, Zarski JP, Agarwal 
K, Buggisch P, Foster GR, Bräu N, Buti M, Jacobson IM, Subramanian GM, Ding X, Mo 
H, Yang JC, Pang PS, Symonds WT, McHutchison JG, Muir AJ, Mangia A, Marcellin P; 
ION-1 Investigators. N Engl J Med. 2014;370:1889-98 
(13) Cornella SL, Stine JG, Kelly V, Caldwell SH, Shah NL Persistence of mixed 
cryoglobulinemia despite cure of hepatitis C with new oral antiviral therapy including 
direct-acting antiviral sofosbuvir: A case series. Postgrad Med. 2015;127:413-7. 
(14) Persistent mixed cryoglobulinaemia vasculitis despite hepatitis C virus eradication 
after interferon-free antiviral therapy. Sollima S, Milazzo L, Peri AM, Torre A, Antinori S, 
Galli M. Rheumatology (Oxford). 2016 Jun 23. 
(15) Liver involvement in the syndrome of mixed cryoglobulinemia. Levo Y, Gorevic 
PD, Kassab HJ, Tobias H, Franklin EC. Ann Intern Med. 1977;87:287-92 
(16) Gorevic PD “Mixed Cryoglobulinemia Cross-reactive Idiotypes: Structural and 
Clinical Significance” Cryoglobulinemia & Hepatitis C Infection, Dammacco, F (Editor); 
Springer Verlag, 2012, p. 99-107. 
(17)  Gorevic, PD and.Galanakis, DK "Cryoglobulinemia, Cryofibrinogens and 
Pyroglobulinemia", Manual of Clinical Laboratory Immunology, 8th Ed., ASM Press, 
2016, on line. 
(18) Diagnosis and treatment of HCV-related mixed cryoglobulinemia over the last 
decade at a Liver Referral Center Ando, Y, Gorevic, PD, Schiano TD. Hepatology 58 
2013 : 1443 abstract 
(19) Prospective study of guideline-tailored therapy with direct-acting antivirals for 
hepatitis C virus-associated mixed cryoglobulinemia. Gragnani L, Visentini M, Fognani 
E, Urraro T, De Santis A, Petraccia L, Perez M, Ceccotti G, Colantuono S, Mitrevski M, 
Stasi C, Del Padre M, Monti M, Gianni E, Pulsoni A, Fiorilli M, Casato M, Zignego AL. 
Hepatology. 2016 Aug 2 
(20) Sofosbuvir and Velpatasvir for HCV in Patients with Decompensated Cirrhosis. 
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E, Flamm SL, Schiano T, Teperman L, Fontana R, Schiff E, Fried M, Doehle B, An D, 


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PI: Peter Gorevic, MD 
                                                                                    
Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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12. APPENDICES 
 
• 
Appendix 1a. Study procedures and study visits table. 
 
• 
Appendix 1b. Laboratory tests per visits table 
 
• 
Appendix 2. Common Terminology Criteria for Adverse Events (CTCAE). GSI 
grading scale for severity of adverse events and laboratory abnormalities.  
 
• 
Appendix 3. Pregnancy Precautions, definition for female of childbearing potential 
and contraceptive requirements.  
 
• 
Appendix 4. Epclusa® patient information.  
 
• 
Appendix 5a. Epclusa package insert. 
 
• 
Appendix 5b. Harvoni® patient package insert. 
 
• 
Appendix 6. Birmingham vasculitis score.  
 
• 
Appendix 7. Health Assessment Questionnaire (HAQ-DI) 
 
• 
Appendix 8. Visual Analog Scale (VAS) 
 
 
 


HCV and Cryoglobulinemia Study 
Protocol IND-US-337-1716 
PI: Peter Gorevic, MD 
                                                                                    
Co-I: Thomas Schiano, MD                                                                                              Protocol Version 2.0 
 
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PRINCIPAL INVESTIGATORS STATEMENT 
 
This is an investigator initiated trial. The sponsor is Mount Sinai.  
I have read this Protocol and agree that it contains all necessary details for carrying out 
the study described. I understand that it must be reviewed by the Institutional Review 
Board or Independent Ethics Committee overseeing the conduct of the study and 
approved or given favorable opinion before implementation.  
My signature below constitute my approval of this protocol and proved the necessary 
assurances that this study will be conducted according to the Declaration of Helsinki, 
GCP, ICH guidelines, local legal and regulatory regulations as well as to all stipulations 
of the protocol in both the clinical and administrative sections, including statements 
regarding confidentiality.  
 
_________________________________   
 
_________________  
Investigator’s printed name and signature   
 
Date  
 
 
_________________________________   
 
_________________  
Co-Investigator’s printed name and signature  
 
Date  
 
 
Protocol Number: IND-US-337-1716  
Version Number/Version Date: v2.0  
Version date: 10-March-2017