Conditions: Liver Disease Hepatitis D
Keywords: Hepatitis D Hepatitis D Virus Cirrhosis
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 26
Healthy volunteers: no

Brief summary:
Background:

Infection with hepatitis D virus leads to a chronic liver disease with no effective treatment. Lonafarnib has improved hepatitis D virus levels in blood, but the medication still needs more research. Ritonavir makes other drugs more effective and is used with lonafarnib to make it more effective. Lambda interferon stimulates the body s response to viruses. Researchers want to see if combining these drugs fights hepatitis D and helps the liver.

Objectives:

To see if combining lonafarnib, ritonavir, and lambda interferon is safe and effective to treat chronic hepatitis D infection.

Eligibility:

Adults at least 18 years old with chronic hepatitis D infection

Design:

Participants will be screened with a physical exam, medical history, and blood and urine tests.

Throughout the study, all participants will:

* Follow rules for medicine, food, and contraception
* Take hepatitis B medicine
* Have weight checked
* Have routine blood and urine tests
* Give stool samples
* Female participants will have pregnancy tests.

Participants will have 3 visits before treatment. They will repeat screening tests and have a heart test and liver scan.

Participants will have a 5-day inpatient stay. They will:

* Baseline blood and urine tests
* Have eye tests
* Answer health questions
* Have a liver sample taken and liver blood pressure measured. Participants will be sedated.
* Have reproductive tests
* Start the study drugs and have blood draws

Over 24 weeks of treatment, participants will:

-Take 2 study drugs by mouth every day and 1 as a weekly injection

Detailed description:
Chronic delta hepatitis is a serious form of chronic liver disease caused by infection with the hepatitis D virus (HDV), a small RNA virus that requires farnesylation of its major structural protein (HDV antigen) for replication. Based on previous and ongoing clinical trials demonstrating effectiveness against HDV, we propose to treat 26 adult patients with chronic delta hepatitis using the combination of the farnesyltransferase inhibitor (FTI) lonafarnib (LNF), the protease inhibitor ritonavir (RTV) and peginterferon lambda-1a(lambda). In this phase 2a open label study, the safety and antiviral effects of triple therapy with LNF, RTV and lambda for a period of 6 months. After dosing, all patients will be monitored for 24 weeks off therapy. Nucleos(t)ide analogue therapy will be instituted/continued during this study to prevent the possibility of hepatitis B virus (HBV) reactivation/flare for the duration of participation in this clinical trial. Patients with quantifiable HDV RNA in serum will be enrolled. At each clinic visit, patients will be questioned about side effects, symptoms and quality of life, undergo focused physical examination, and have blood drawn for complete blood counts, HDV RNA, and routine liver tests (including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, direct and total bilirubin, and albumin). At the end of the treatment, patients will be admitted to the clinical center and will undergo repeat liver biopsy and hepatic venous pressure gradient (HVPG) measurements, repeat physical examination, assessment of symptoms (using a symptom scale questionnaire), complete blood counts, routine liver tests, and hepatitis B and D viral markers. The primary therapeutic endpoint will be a decline of HDV RNA viral titer of 2 logs at the end of therapy. The primary safety endpoint will be the ability to tolerate the drugs at the prescribed dose for the full course of therapy. This clinical trial is designed as a phase 2a study assessing the antiviral activity, safety and tolerance of fixed doses of lonafarnib, ritonavir and peginterferon lambda.

Arms:
arm 1: Treatment with Lonafarnib, Ritonavir, and Peginterferon lambda

Interventions: intervention 1: Peg-interferon lambda intervention 2: Lonafarnib intervention 3: Ritonavir
Intervention descriptions: intervention 1: Peg-interferon Lambda is a covalent conjugate of human recombinant non- pegylated interferon (IFN) lambda and a 20-kDa linear pegylated (PEG) chain. intervention 2: Oral prenylation inhibitor intervention 3: Booster of lonafarnib action

Protocol document:
Prot_SAP_000.pdf: 
1
NATIONAL INSTITUTE OF DIABETES AND DIGESTIVE AND KIDNEY 
DISEASES
VERSION DATE:
  
05/11/2020
PROTOCOL#:
18DK0123
TITLE: 
Treatment of Chronic Delta Hepatitis with Lonafarnib, Ritonavir and 
Lambda Interferon.
SHORT TITLE: 
Lonafarnib, Ritonavir and Lambda Interferon for Delta 
Hepatitis
IDENTIFYING WORDS: Antiviral agents, Viral Hepatitis, Hepatitis D Virus, Delta 
Hepatitis, Chronic Hepatitis, Cirrhosis, Farnesyltransferase inhibitors, Lambda interferon, 
interferon, Lonafarnib, Prenylation inhibitors
PRINCIPAL INVESTIGATOR:  
NIH Principal Investigator:
Christopher Koh, MD MHSc
Liver Disease Branch
NIDDK Institute
Building 10, Rm 5-2740
9000 Rockville Pike
Bethesda, MD 20892
Phone: 301-443-9402
E-mail: christopher.koh@nih.gov
Investigational Agents (if applicable):
Drug Name:
Lonafarnib
Lambda interferon 
IND Number:
113,137
Sponsor:
NIDDK
Manufacturer:
Eiger Pharmaceuticals
ESTIMATED DURATION OF STUDY:  2 years
NUMBER AND TYPE OF PATIENTS: 
 patients with chronic delta hepatitis, ages greater than or equal to 18 years, both male and 
female.
SUBJECTS OF STUDY:
Number
Sex
Age Range
Patients
32
Male & Female
 18 years
Volunteers
None
PROJECT USES IONIZING RADIATION: Yes, for medically indicated reasons only.
PROJECT USES “DURABLE POWER OF ATTORNEY”: No
OFF-SITE PROJECT:  No
MULTI-INSTITUTIONAL PROJECT:  No


2
PRECIS
Chronic delta hepatitis is a serious form of chronic liver disease caused by infection with 
the hepatitis D virus (HDV), a small RNA virus that requires farnesylation of its major 
structural protein (HDV antigen) for replication. Based on previous and ongoing clinical 
trials demonstrating effectiveness against HDV, we propose to treat 26 adult patients with 
chronic delta hepatitis using the combination of the farnesyltransferase inhibitor (FTI) 
lonafarnib (LNF), the protease inhibitor ritonavir (RTV) and peginterferon lambda-
1a(lambda).  In this phase 2a open label study, the safety and antiviral effects of triple 
therapy with LNF, RTV and lambda for a period of 6 months. After dosing, all patients 
will be monitored for 24 weeks off therapy.  Nucleos(t)ide analogue therapy will be 
instituted/continued during this study to prevent the possibility of HBV reactivation/flare 
for the duration of participation in this clinical trial. Patients with quantifiable HDV RNA 
in serum will be enrolled. At each clinic visit, patients will be questioned about side 
effects, symptoms and quality of life, undergo focused physical examination, and have 
blood drawn for complete blood counts, HDV RNA, and routine liver tests (including 
ALT, AST, alkaline phosphatase, direct and total bilirubin, and albumin). At the end of 
the treatment, patients will be admitted to the clinical center and will undergo repeat liver 
biopsy and HVPG measurements, repeat physical examination, assessment of symptoms 
(using a symptom scale questionnaire), complete blood counts, routine liver tests, and 
hepatitis B and D viral markers. The primary therapeutic endpoint will be a decline of 
HDV RNA viral titer of 2 logs at the end of therapy.  The primary safety endpoint will be 
the ability to tolerate the drugs at the prescribed dose for the full course of therapy. This 
clinical trial is designed as a phase 2a study assessing the antiviral activity, safety and 
tolerance of fixed doses of lonafarnib, ritonavir and peginterferon lambda.


3
BACKGROUND
Chronic Delta Hepatitis
The hepatitis D virus (HDV) is an incomplete RNA virus, which is composed of a 1.7 kb 
single-stranded circular genomic RNA, virally encoded small and large delta antigens, 
and a surrounding lipid envelope.1 HDV only infects persons who are also infected with 
hepatitis B virus (HBV), because its lipid envelope is embedded with HBV surface 
antigen (HBsAg).2–4The HBsAg envelope protein provided by HBV protects the HDV 
nucleocapsid antigen and provides a means for the virus to enter and exit the hepatocyte.   
HBV and its antigens are not necessary for the replication of HDV once it has entered the 
cell, but they are necessary for spread of the infection to other cells, the development of 
acute and chronic hepatitis D and transmission of delta hepatitis to others.5
Delta hepatitis is the most severe and dreaded form of human viral hepatitis.  HDV 
infection leads to chronic hepatitis in a high proportion of persons, is associated with 
progression to cirrhosis in 5 to 10 years in up to 80% of cases and poor outcomes.6 
Because of the unique nature of HDV and its requirement for the helper function of HBV 
infection, delta hepatitis occurs only in persons who also have hepatitis B.  HDV 
infection is found worldwide2 but most commonly in Central Africa, the Amazon Basin 
of South America, Mongolia, and in Eastern European countries.  In the United States, 
delta hepatitis is most common among immigrants from areas of the world where HDV 
infection is endemic and in persons who have multiple exposures to hepatitis, particularly 
injection drug users and persons with hemophilia who received blood products before 
1986.  Delta hepatitis occurs either as co-infection with acute hepatitis B or as super-
infection in patients with pre-existing chronic HBV infection.7epatocellular carcinoma 
may develop as a complication of cirrhosis in some cases6. The complications associated 
with hepatitis B and D are identical except that the progression to cirrhosis is more rapid 
in hepatitis D.  Thus, delta hepatitis shares epidemiological patterns and clinical features 
with hepatitis B, but tends to be more severe and more rapidly progressive. The 
seriousness of chronic hepatitis D has led to attempts to develop therapies for this chronic 
viral infection.
Currently, there is no satisfactory therapy for HDV infection, nor is there any FDA 
approved therapy.  Several studies have shown a lack of efficacy of nucleos(t)ide 
analogues used in chronic HBV infection for chronic HDV. 8–10The American 
Association for the Study of Liver Diseases (AASLD) guidelines suggest therapy with 
alpha interferon for chronic HDV infection, however recent results have identified the 
need for alternative therapies. In a large multicenter randomized clinical trial, the Hep-
Net/International Delta Hepatitis Intervention Trial (HIDIT-1), sustained HDV RNA 
clearance with interferon based therapy with or without adefovir for 48 weeks was 
successful in only about a quarter of patients with chronic HDV infection.11 In a follow-
up study, HIDIT-2, which increased treatment duration up to 96 weeks with peginterferon 
plus tenofovir or placebo, more than one third of patients, experienced a post-treatment 
relapse.11 Additionally, the Liver Diseases Branch of the NIDDK has recently published 
its long-term peginterferon HDV study, which evaluated increasing the doses of 
peginterferon (up to 360 mcg/wk) for up to 5 years.  In this study, only 39% achieved the 
primary endpoint of histological improvement or loss of serum HDV and HBsAg at 3 


4
years and at the end of the study, only 23% seroconverted HBsAg.12 Thus, given the 
unsatisfactory results of interferon-based therapies against chronic HDV infection, 
alternative therapies have been sought.13
Interaction between HBV and HDV during therapy
Patients with chronic delta hepatitis have both HDV and HBV infection, yet most patients 
with delta hepatitis have detectable serum HBsAg with negative HBeAg, and have low 
levels of HBV DNA in serum.  It seems that HDV replication competes with, and inhibits 
HBV replication.  An important consideration, however, is that therapeutic inhibition of 
one virus may be accompanied by an increase in replication of the other. At the present 
time, a 4 to 6-month course of alpha interferon therapy is an approved therapy of chronic 
hepatitis B.14,15 Therapy is recommended only for patients with elevated serum 
aminotransferase activity chronic hepatitis on liver biopsy and either HBeAg or high 
levels of HBV DNA in serum.  Pegylated interferon alfa-2a has also been approved for 
treatment of chronic HBV in the United States and has been suggested to have similar or 
slightly improved efficacy with more convenient administration then standard alpha 
interferon.15 The recommended treatment duration with peginterferon alfa- 2a in patients 
with chronic HBV is for 48 weeks.
Other approved therapies for chronic hepatitis B include oral nucleoside/nucleotide 
analogues: lamivudine (Epivir-HBV, 3TC), adefovir dispivoxil (bis-POM PMEA, 
Hepsera), tenofovir disoproxil fumarate (Viread), entecavir (Baraclude), and L-
deoxythymidine (Telbivudine/LdT, Tyzeka). Currently, Entecavir or Tenofovir are 
considered first line therapies for chronic hepatitis B. 15These agents are potent inhibitors 
of the HBV polymerase and reduce serum levels of HBV DNA, which is usually 
followed by improvements in serum aminotransferase levels and liver histology. 
Lamivudine monotherapy has been evaluated in chronic hepatitis D by the Liver Diseases 
Branch (95-DK-199) and by investigators in Europe 16 and shown to be without 
beneficial effect.  Lamivudine resulted in rapid decreases in HBV DNA levels (which 
were low to begin with) but had no effect on HDV RNA levels, serum aminotransferase 
levels, or histology.  Similarly, short-term combination therapy of alpha interferon and 
lamivudine has been found to be largely ineffective.17 A possible use of lamivudine in 
chronic delta hepatitis, however, is the uncommon patient with high levels of HBV DNA.  
The pattern of high HBV DNA levels despite chronic delta hepatitis is found in 
approximately 20% of patients with this disease seen at the Clinical Center of the NIH.  
In these patients, inhibition of HBV may be important particularly because suppression of 
HDV RNA may be followed by rises in HBV DNA levels. In 19 patients with 
HIV/HDV18 long term exposure to nucleotide analog tenofovir lead to significantly 
reduced HDV RNA in addition to completely suppressing HBV DNA13. In this current 
study, clinically approved nucleoside analogues for chronic HBV infection will be used 
to prevent the possibility of on-therapy and post-therapy HBV flares.  
Prenylation Inhibitors
Prenylation is a post-translational lipid modification that involves the covalent addition of 
either farnesyl or geranylgeranyl prenyl lipids derived from mevalonic acid to conserved 


5
cysteine residues at or near the C-terminus of proteins.1 These reactions are catalyzed by 
farnesyltransferase (FTase) or the geranylgeranyltransferases (GGTases).19,20 The 
substrate for FTase or GGTase I is a characteristic tetrapeptide found in the amino acid 
sequence of the protein referred to as a CXXX box motif (where C is a cysteine and X is 
one of the last three amino acids at the C-terminus of the protein).20 The effect of 
prenylation is to promote membrane association of the modified protein.  Prenylation also 
plays a major role in protein-protein interactions.20 
The novel idea of prenylation inhibition was originally developed as a therapeutic 
approach for cancer, as exemplified by the farnesyltransferase inhibitor (FTI) BZA-5B to 
prevent prenylation of the farnesylated oncogene RAS.19 Various phase I/II/III trials in 
oncology with FTIs have revealed a favorable side effect profile, with good safety and 
relative lack of toxicity, and ease of administration as they are taken orally.19
Prenylation Inhibitors in Chronic Delta Hepatitis
Prenylation plays a vital role in the viral life cycle of HDV, which allows for therapeutic 
opportunities for eradication.  The HDV genome has a single open-reading frame that can 
encode two proteins: a small or a large delta antigen.  The large delta antigen differs from 
the small one by having an additional 19 amino acids on its C-terminus. The production 
of small and large delta antigens is dependent upon editing of the HDV RNA to change 
the stop codon which ends the production of small delta antigen and allows “read 
through” to the next stop codon which produces the large delta antigen.  The small delta 
antigen is essential for genome replication, whereas the large delta antigen (LHDAg) 
performs other functions such as transactivation of various genes and mediation of 
assembly and release of HBsAg-enveloped particles.5 In both cell-free translation 
reactions and in intact cells, it has been shown that the LHDAg is subject to 
prenylation.19 Genetic disruption of the CXXX box prevents prenylation of LDHAg and 
its ability to interact with, and form secreted particles with, HBsAg.20 Thus, prevention of 
prenylation is a reasonable approach to blocking the HDV life cycle.  Use of prenylation 
inhibitors has been evaluated with success in vitro in cell culture as well as in vivo in a 
mouse model of HDV replication.1,19,20 
Initial studies in mice with the FTI BZA-5B in HDV have shown it to be a potent 
inhibitor of large delta antigen prenylation and able to specifically inhibit the prenylation-
dependent production of HDV virus-like particles in a dose-dependent manner.1 
Continued evaluation with both BZA-5B and FTI-277 revealed no effect on general 
protein synthesis; however, there was significant prenylation inhibition on the production 
of complete, infectious HDV virions.5 More recently, in an in vivo mouse model of HDV, 
these compounds were able to completely clear HDV viremia to below the limit of 
detection.5These results demonstrate that prenylation inhibitors can indeed effectively 
inhibit HDV viremia and may prove to be an important therapeutic target in patients with 
hepatitis D infection.  Lonafarnib is an orally bioavailable tricyclic farnesyltransferase 
inhibitor that is metabolized by the cytochrome P-450 (3A4) system and has been shown 
to have anti-tumor activity in various phase I, II and III trials and anti-HDV properties in 
preclinical models.  


6
In a first-in-humans for HDV proof-of-concept (POC) study, the Liver Diseases Branch 
of the NIDDK completed a phase 2a double-blinded, randomized, placebo-controlled, 
evaluating the safety and utility of the prenylation inhibitor, Lonafarnib (LNF) dosed for 
4 weeks, in patients with chronic HDV (12-DK-0046).  In this POC study, compared to 
patients who received placebo, patients receiving lonafarnib 100 mg orally twice daily for 
4 weeks experienced mean HDV RNA declines of 0.73 log IU/ml declines in serum 
(p=0.04) and patients who received lonafarnib 200 mg orally twice daily for 4 weeks 
experienced a 1.54 log IU/ml decline of HDV RNA in serum (p=0.002) (Figure 1).  Mean 
lonafarnib serum concentrations significantly correlated with mean change HDV RNA 
from baseline to the end of therapy (R2=0.76, p<0.0001) (Figure 2). As expected, since 
lonafarnib works on host machinery, there was no evidence of viral resistance. In the 
lonafarnib 100 mg BID group, side effects included mild nausea (25%), diarrhea (37.5%), 
anorexia (12.5%), and abdominal bloating (12.5%). In the lonafarnib 200 mg BID group, 
side effects included nausea (75%), diarrhea (75%), anorexia (62.5%), dyspepsia (75%), 
vomiting (37.5%), mean weight loss of 4kg (75%).  There were no grade 3 or 4 adverse 
events nor serious adverse events.
Figure 1 HDV RNA decline after 28 days of therapy
Placebo
100mg BID
200mg BID
-0.5
0.0
0.5
1.0
1.5
2.0
2.5
Log HDV RNA Decline
IU/mL
p=0.04
p=0.01
p=0.002
Lonafarnib Dose
0.13
0.73
1.54


7
Figure 2 Correlation between serum lonafarnib levels with change in serum HDV 
RNA.
0
1000
2000
3000
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
0.5
 Mean Serum Lonafarnib Concentration (ng/mL)
Mean Change HDV RNA From
Baseline to Day 28 (log IU/mL)
r2=0.78
After the completion of this study, colleagues from the University of Ankara Medical 
School performed a single center, phase 2 pilot study called LOWR HDV-1 (LOnafarnib 
With and without Ritonavir in HDV-1) to further explore the utility of LNF in chronic 
HDV infected patients (NCT02430181).   This study was designed as a 7-arm, parallel, 
open-label clinical trial designed to dose 21 patients across 7 groups (3 patients per 
group) as follows: Group 1: LNF 200 mg BID for 12 weeks; Group 2: LNF 300 mg BID 
for 12 weeks; Group 3: LNF 100 mg TID for 8 weeks; Group 4: LNF 100 mg BID + 
ritonavir (RTV) 100 mg daily for 8 weeks; Group 5: LNF 100 mg BID + Pegylated 
interferon (PEG-IFN) alpha 2a 180 mcg weekly for 8 weeks; Group 6: LNF 200 mg BID 
+ PEG-IFN alpha 180 mcg weekly for 8 weeks; and Group 7: LNF 300 mg BID + PEG-
IFN alpha 180 mcg weekly for 8 weeks.
In this study, all subjects receiving LNF experienced an HDV RNA viral load decline.  In 
the LNF monotherapy groups (Group 1, 2 and 3), subjects in group 1 experienced mean 
viral load declines of -1.6, -1.0, and 0 at weeks 4, 8 and 12, respectively.  Subjects in 
group 2 experienced mean viral load declines of -2.0, -2.0, and -1.8, at weeks 4, 8 and 12 
respectively.  All subjects in groups 1 and 2 did not demonstrate evidence of viral 
resistance no changes in HDV viral sequences were seen at end of treatment and 4 weeks 
post-treatment compared to baseline.  Group 3 subjects were discontinued at week 5 due 
to unforeseen circumstances related to drug supply, however demonstrated mean declines 
of 1.4 logs of HDV RNA at week 4.  The adverse events in the monotherapy groups 
(groups 1-3) were noted to be similar to what was demonstrated in the NIDDK POC 
study and were predominantly GI related (anorexia, nausea, diarrhea and weight loss).  
Adverse events were grade 1 and 2 (CTCAE), without any grade 3 or 4, and severity of 
AEs worsened with higher doses. 
In subjects that received LNF combination regimens, group 4 subjects (LNF 100 mg BID 
+ RTV 100 mg daily for 8 weeks) demonstrated 2.4 log reduction in HDV RNA after 4 
weeks of therapy and 3.2 log reduction after 8 weeks of therapy (Figure 3).  In addition to 


8
this viral decline, all subjects demonstrated normalization of alanine aminotransferase 
(ALT) levels while on therapy (Figure 4).  Compared to the same LNF dosing in the 
NIDDK POC study (group 1 – LNF 100 mg twice daily), subjects receiving the same 
dose with ritonavir boosting demonstrated higher mean serum LNF concentrations with 
resultant greater HDV RNA declines by week 4 of therapy (Figure 5). 
Figure 3: HDV RNA viral load decline in subjects receiving LNF 100 mg BID + 
RTV 100 mg daily for 8 weeks
  Log HDV-RNA VL Decline
Figure 4:  Alanine aminotransferase patterns of subjects receiving LNF 100 mg BID 
+ RTV 100 mg daily for 8 weeks.  All subjects normalized ALT levels during 
therapy
ALT (U/L)


9
Figure 5: Mean serum lonfarnib concentrations in subjects receiving LNF 100 mg + 
RTV 100 mg twice daily for 8 weeks (LOWR-1, Group 4) in red and LNF 100 mg 
twice daily for 4 weeks (NIDDK POC, Group 1) in blue
Mean LNF Serum Conc (ng/mL)
The remaining combination groups in this study (groups 5-7) received varying doses of 
LNF (100 mg, 200 mg, 300 mg daily with PEG-IFN alpha). Group 5 subjects receiving 
LNF 100 mg + PEG-IFN alpha 180 mcg weekly demonstrated a mean HDV RNA 
decline of 3 logs along with declines in ALT.  Unfortunately, higher doses of LNF (200 
and 300 mg daily) with PEG-IFN alpha in groups 6 and 7 were poorly tolerated and 
resulted in discontinuations in all subjects within 4 weeks of initiation.  Subjects 
receiving the lower dose of LNF in group 5 experienced grade 1 and 2 adverse events 
which was less severe than those in group 6 and 7 (Figure 6)
Figure 6: GI adverse events observed with different treatment regimens in the 
LOWR-1 study.
As a follow-up to the LOWR-1 study, the Ankara University School of Medicine initiated 
the LOWR-2 study which was a phase 2 dose-optimization study in hopes of identifying 
optimal combination regimens of LNF and RTV+/- PEG-IFN alpha.   This single center 
study evaluated dosing combinations of LNF + RTV with and without PEG-IFN alpha 
for 12, 24 or 48 weeks.  In this study, aside from the varying doses of LNF ranging from 


10
25 mg BID to 100 BID plus ritonavir, 20 subjects received LNF 25 mg (low dose) or 50 
mg (high dose) BID with RTV 100 mg BID for 24 or 48 weeks and 14 subjects received 
the same dosing (25 mg or 50 mg LNF BID + RTV 100 mg BID) with PEG-IFN alpha 
180 mcg weekly for 24 or 48 weeks.  In subjects that received therapy for 24 weeks, both 
low and high doses of LNF with RTV resulted in 5 of 14 subjects (36%) achieving an 
HDV RNA level below the lower limit of quantification (LLOQ) and one subject 
achieving HDV RNA PCR negativity at week 24.  However, the response rates were 
notably improved with the addition of PEG-IFN alpha to the low and high doses of LNF 
with RTV (Figure 7), with 4 of 5 (80%) of patients achieving <LLOQ at week 24 and 3 
of 5 (60%) of patients becoming HDV RNA PCR negative at week 24.  Additionally, 60-
78% of subjects normalized their ALT levels at week 24.  Adverse events were 
predominantly grade 1 and 2 with most common side effects being nausea, diarrhea, 
fatigue, weight loss, anorexia and vomiting, similar to what was seen in the NIDDK POC 
and LOWR-1 studies.
Figure 7: Comparison of HDV RNA responses in serum in the LOWR-2 study based 
25mg or 50 mg of LNF with RTV with and without PEG-IFN alpha
In conjunction with the clinical trials performed at Ankara University, the Liver Diseases 
Branch, NIDDK recently completed the all-oral combination study (LOWR-3) which 
evaluated the safety and utility of once-daily ritonavir-boosted lonafarnib at doses of 50, 
75 and 100 mg once daily for 12 and 24 weeks (15-DK-0170). This phase 2a double-
blinded, placebo controlled, clinical trial randomized 21 patients into one of six groups: 
LNF 50, 75, or 100mg + RTV 100mg once daily for 24 weeks (12 patients) or 12 weeks 
of placebo followed by LNF 50, 75, or 100mg + RTV 100mg once daily for 12 weeks (9 
patients). Additionally, all subjects were maintained or initiated on hepatitis B nucleoside 
analogue therapy to prevent the possibility of HBV related flares. After 12 weeks of 
therapy, median HDV RNA decline from baseline was 1.60 log IU/mL (LNF 50 mg), 
1.33 (LNF 75 mg) and 0.83 (LNF 100 mg) (p=0.001). In subjects treated for 24 weeks, 
HDV RNA levels significantly differed from placebo.  During the course of the study 6 
subjects achieved HDV RNA levels below 125 IU/mL where 3 were below the lower 


11
limit of quantification (<14 IU/mL) and 1 achieved HDV RNA negativity.  LNF serum 
concentrations correlated with ritonavir levels (R=0.45, p<0.0001). Adverse events were 
mild to moderate and included nausea, vomiting, dyspepsia, anorexia, diarrhea, and 
weight loss and were all CTCAE grade 1 or 2.  There were no treatment discontinuations 
for adverse events.  (unpublished data- manuscript in process).
Ritonavir boosting of Lonafarnib
Through inhibition of metabolic enzymes including cytochrome P-450 CYP3A4 and drug 
transporters, ritonavir has been utilized as a booster mechanism to increase the 
bioavailability of concomitant drugs.21 Ritonavir has historically been used in HIV as a 
booster to enhance the bioavailability and efficacy of other protease inhibitors to yield 
increased and improved penetration into HIV reservoirs. This effect is achieved through 
ritonavir’s ability to inhibit the cytochrome P450 CYP3A4 enzyme, thereby reducing the 
metabolism of concomitant administered protease inhibitors leading to changes their 
pharmacokinetic parameters, including area under the curve (AUC), maximum 
concentration, minimum concentration and half-life.22 The use of ritonavir as a 
therapeutic booster in patients with chronic liver disease and chronic hepatitis B and/or C 
have been evaluated successfully in multiple previous studies.23,24 In hepatitis C, one such 
successful example of the use of ritonavir with Danoprevir, which successfully enhanced 
the pharmacokinetic parameters of Danoprevir, thus allowing a lower dose of danoprevir 
and enabling higher plasma trough concentrations with lesser exposure to Danoprevir.25–
27 Ritonavir significantly inhibited Danoprevir metabolism, including the production of 
reactive metabolites, which reduced the risk of alanine aminotransferase elevation that 
was observed with high dose unboosted Danoprevir.26
In HDV infection, lonafarnib metabolism is also mediated via the cytochrome P450 
CYP3A4 system.  The ability of ritonavir to boost lonafarnib levels has been 
demonstrated in the already completed HDV LOWR-1 (Figure 5 above), LOWR-2 and 
LOWR-3 (Figure 8 below) studies performed in Ankara, Turkey and the NIDDK.  The 
use of ritonavir boosted LNF has demonstrated the ability to substantially increase serum 
drug levels of LNF while minimizing the drug exposure to the gastrointestinal tract.  In 
the LOWR-3 study performed by at the NIH Clinical Center, the combination of LNF 
and RTV were well tolerated and safe for 24 weeks without electrocardiographic changes 
or pancreatitis.   


12
Figure 8: Pharmacokinetic comparison of the NIH POC study doses (Lonafarnib 
100 mg BID and 200 mg BID) and the LOWR-3 study doses (Lonafarnib 50/75/100 
mg daily with ritonavir 100 mg daily)
714
1787
881
1151
1178
0
200
400
600
800
1000
1200
1400
1600
1800
2000
100 mg BID
200 mg BID
50 mg QD
75 mg QD
100 mg QD
PK Comparison
Dosage
Mean PK
POC
LOWR-3
In the LOWR-HDV-2 study in Ankara, Turkey, which evaluated differing doses of 
lonafarnib and ritonavir (LNF/RTV 100/50 mg twice daily, LNF/RTV 100/100 mg once 
daily, LNF/RTV 150/100 mg once daily and LNF/RTV 100/100 mg twice daily) for 3 
months, a mean HDV RNA decline >1.5 log IU/ml was demonstrated in 8 patients after 1 
month of therapy. Notably, the dosing of LNF/RTV 100/100 mg once daily showed a 
continuous HDV RNA decline with a mean decline of  >3log HDV RNA IU/ml . 
Therefore, ritonavir has demonstrated success as a pharmacokinetic booster of lonafarnib 
as it  optimizes the pharmacokinetic profile of lonafarnib while allowing for a lower dose 
(with less side effects) and still maintaining the antiviral activity of lonafarnib.
Peginterferon lambda therapy in chronic viral hepatitis
IFN-lambda is a type III of IFN with different structural features, receptor characteristics, 
and biological activities than IFN- (Type I). IFN-lambda was first reported in the early 
2000s28. IFN-lambdaand IFN- share the common interferon-stimulated gene (ISG) 
induction pathway that leads to broad-spectrum antiviral activities (Figure 9). The 
biological activity of Lambda is derived from its recombinant human IFN λ1 moiety. 
Lambda binds to the human Type III IFN receptor leading to receptor dimerization. 
Receptor dimerization activates multiple intracellular signal transduction pathways 
initially mediated by the JAK/STAT (Janus kinase/signal transducer and activator of 
transcription) pathway. 


13
Figure 9:
Mechanism Action of Type I and Type III Interferons 
Lambda is a covalent conjugate of human recombinant non-pegylated  IFN lambda 
(IFN ) and a 20-kDa linear PEG chain. Lambda has been investigated extensively in the 
treatment of CHB and CHC, and is now being investigated in CHD.  
As of March 2017, over 3,700 subjects (including 237 healthy subjects; 197 subjects with 
HBV; 3,276 subjects with HCV; and 12 subjects with HDV) have received Lambda or 
comparator in 19 Phase 1, 2, or 3 clinical trials.  These studies that have evaluated the 
antiviral activity of lambda IFN and chronic hepatitis B and hepatitis C infection.  
In chronic HBV infection, lambda interferon was evaluated as monotherapy in a dose 
finding study in interferon naïve patients (LIRA-B)22.  Subjects were randomized to 
receive weekly lambda 180 or 240 µg or interferon alpha at 180 µg for 48 weeks.  The 
240 µg dose was discontinued for development during the study and only 13 patients 
received this dose.  Hepatitis B e antigen seroconversion rates were comparable for 
interferon lambda and alpha groups at week 48 (17.5% versus 16.9%, respectively) 
however lambda noninferiority was not met at week 24 post-treatment. (13.8% versus 
30.1%, respectively; lambda versus alpha 80% CI).  Lambda was well tolerated at single 
subcutaneous doses of up to 5 mcg/kg and multiple subcutaneous doses of up to 180 µg 
administered weekly for 48 weeks.  Interestingly, known side-effects of interferon alpha 
(constitutional symptoms, neurologic events, flulike symptoms, musculoskeletal 
symptoms, and psychiatric events) were lower in the interferon lambda 180 ug group 
(50%) compared to the IFN alpha group (72.3%).  
The antiviral activity of lambda interferon against HCV has had the most extensive 
patient experience amounting to >3700 subjects in various phase 2 and 3 studies.  In 
HCV, lambda interferon has been administered with various oral combination therapies 
including Ribavarin plus daclatasvir and Ribavarin plus asunaprevir. 29,30   Treatment 
durations have ranged from 24-48 weeks and lambda interferon dosing has  ranged from 
80, 120, 184 to 240 µg per week23,24.  In patients with HCV genotype 1 and 4 infection, 


14
there was a significant relationship between lambda exposure (based on AUC or C Max) 
and undetectable HCV RNA at week 4, with the largest difference between ages and dose 
levels between the 120 and 180 µg exposure ranges. Episodes of anemia and neutropenia 
were significantly less frequent in subjects receiving lambda interferon compared to 
alpha interferon across all doses and exposure duration.  Based on promising phase 2 
HCV studies, phase 3 studies in chronic HCV infection were performed evaluating fixed 
180 µg doses of lambda in combination with Ribavirin and daclatasvir and telaprevir for 
24–48 weeks in genotype is ¼ infection and 12–24 weeks in genotype 2/3 infection31.
In general, lambda interferon has been generally well tolerated by patients in clinical 
studies. Compared to alpha interferon, there is a lower frequency of musculoskeletal 
(myalgia, arthralgia, and back pain) and flu-like symptoms (chills, pyrexia, and pain) and 
a notable lack of hematologic toxicity in the WBC or platelet lineages in subjects 
receiving Lambda interferon based regimens.  Laboratory abnormalities have generally 
been of low grade and self-limited. When study regimens included concomitant RBV 
administration, decreases in hemoglobin levels were observed as expected; however, 
anemia was less frequent and milder with Lambda/RBV than with alfa/RBV. 
Hematologic toxicity was also reported less frequently in groups treated with Lambda 
compared with alfa.
Lambda Inteferon in Chronic HDV Infection
Lambda has demonstrated in vivo activity against hepatitis D and hepatitis B viruses. In 
an HBV/HDV-infected human liver chimeric mouse model, Lambda reduced HDV and 
HBV viremia by 1.2-log and serum HBsAg level by 2.5-fold after 4 weeks of treatment.24 
The 4 weeks of Lambda treatment also decreased intrahepatic genomic/antigenomic 
HDV RNA by 6.1/2.2-fold and intrahepatic HBV RNA by 8.6-fold in the mice. 
In a first-in-humans for HDV, multicenter, phase 2 clinical trial, Lambda interferon 
monotherapy is currently being explored (NCT:02765802) in New Zealand, Pakistan and 
Israel.  The Lambda Interferon MonoTherapy study (LIMT) study, has completed 
enrollment and initiation of dosing in 33 patients that are randomized to receive either 
120 μg or 180 μg of weekly administered lambda interferon for 48 weeks followed by 24 
weeks of post-therapy follow-up.  At the AASLD liver meeting in October 2017, the 
study investigators reported interim results 32 describing that 10 of 33 patients had 
reached 24 weeks of therapy.  6 of 10 patients were responders, achieving >/= 2 log 
decline or below the lower limit of quantitation in HDV RNA at week 24 (Figure 9).  
Preliminary results also demonstrated that lambda interferon had comparable anti-HDV 
activity to historical peginterferon alpha at 24 weeeks of therapy.  These preliminary 
results appear comparable to peginterferon alpha therapy at similar time points where 15 
of 91 subjects (16%) achieved HDV RNA negativity by week 8 and 19 of 91 subjects 
(21%) achieved HDV RNA negativity by week 12 of therapy in the HIDIT-2 clinical 
trial12.  Adverse effects have included grade 3 elevations in ALT in 3 patients and 
jaundice in 3 patients, two of which required permanent drug discontinuation and 1 
required temporary interruption and resumption at a reduced dose. Constitutional 
symptoms were much milder and less frequent than historical data with IFN alfa.


15
Figure 9: Mean viral load change from baseline to week 24 for peginterferon 
lambda.
Role of intestinal microbiome in chronic liver diseases
With increasing appreciation of the gut-liver axis, the role of the intestinal microbiome 
and bacterial translocation on the pathogenesis of liver disease and its progression 
including inflammation and fibrosis has been a recent focus of investigators. 
In patients with chronic hepatitis B, investigators have described extensive differences 
between patients with and without cirrhosis regarding the fecal microbiota community 
and altered composition of intestinal Bifidobacterium with a shift from beneficial species 
to opportunistic pathogens in patients with cirrhosis.33 Further studies have described that 
the existence of cirrhosis (regardless of etiology) is associated with microbial dysbiosis 
and changes in intestinal microbial composition.  Specifically, in patients with cirrhosis, 
pathogenic species appear to be more likely to translocate across the gut wall34. 
In addition to the data in cirrhotic patients, emerging data suggests bacterial translocation 
(BT) may occur at earlier stages of compensated liver disease and can also contribute to 
progression of liver disease. Kupffer cells (KC) express Toll-like Receptors (TLRs) that 
are highly sensitive to lipopolysacharide LPS-triggered TLR activation. Additionally, 
KC, are also potent activators of hepatic stellate cells (HSC) which play a vital role in 
hepatic fibrogenesis. 35 In an in vivo mouse model, Seki et al reported a mechanism that 
promotes the pro-fibrogenic response where LPS binds to TLR-4 on the HSC which, in 
turn, leads to KC chemotaxis as well as to sensitization of HSC to TGF-β signaling.36 
Henao-Mejia and Elinav in another landmark study described that bacterial translocation 
through TLR-4 and TLR-9 dependent pathways drove non-alcoholic fatty liver disease 


16
(NAFLD) and its progression to steatohepatitis37. These and other studies outline the role 
of microbial products in activation of key intracellular events involved in liver 
inflammation and fibrosis, thus conceptually establishing a link between BT to the portal 
system and liver disease progression. Other studies have also suggested that BT to the 
systemic circulation may occur in earlier stages of liver fibrosis. 38,39 In the serum of 
chronic hepatitis B and C patients in different stages of liver fibrosis, elevated levels of 
soluble CD14 (sCD14), a macrophage-derived marker of LPS bioreactivity were 
identified. 45 In addition, evidence of portosystemic shunting and decreased Kupffer cell 
function was described in pre-cirrhotic HCV patients using highly sensitive quantitative 
liver function tests and SPIO-MRI imaging respectively27,40.
Microbiome diversity and bacterial translocation in chronic HDV patients has not been 
described in the literature. We plan to assess the fecal microbiota diversity and its 
bacterial translocation in chronic hepatic D (HDV) and their changes during treatment 
with lonafarnib, ritonavir and lambda. The initial focus would be to recapitulate the 
findings of dysbiosis seen in other liver diseases in patients with HDV.
HYPOTHESIS AND AIMS
Therapy with lonafarnib plus ritonavir and lambda interferon will lead to a significant 
decline in hepatitis D virus levels.
ASSESSMENT OF RESPONSE TO THERAPY
Primary Therapeutic End Point:
Decrease of HDV RNA by >2 log from baseline at 24 weeks of therapy with lonafarnib 
plus ritonavir and lambda interferon.  
Primary Safety End Point:
The ability to tolerate lonafarnib plus ritonavir with lambda interferon therapy for 24 
weeks of therapy. Discontinuation of the medication by the clinical team or patient will 
be considered a failure to tolerate the medicine.
Secondary End Points:. 
1. Sustained undetectable HDV RNA in serum at weeks 12 and 24 post treatment follow 
up. 
2. Reduction in histologic inflammatory scores (modified HAI) by at least two points 
with no progression in histologic fibrosis (Ishak) at week 24 post-treatment follow-
up.
3. Normalization of serum ALT (ALT <20 in females and ALT <31 in males) at the end 
of therapy, at week 12 of post-therapy follow-up and at week 24 of post-therapy 
follow-up, OR reduction in serum ALT by >50% of baseline at week 12 of post 
therapy follow up and week 24 of post therapy follow up. 
4. Reduction in hepatic venous pressure gradient (HVPG) measurements by >25% of 
baseline OR normalization of HVPG (<5 mm Hg) at end of therapy.
5. Reduction in Fibroscan® transient elastography values by >25% of baseline at end of 
therapy. 


17
6. Loss of HBsAg from the serum at the end of therapy, at week 12 of post-therapy 
follow-up or at week 24 of post-therapy follow-up. 
7. Changes in quantitative HBsAg levels at the end of therapy and at week 24 of post 
therapy follow up, compared to baseline. 
8. Changes in symptom scale measurements and quality of life before, during and after 
therapy.
9. Changes in the fecal microbiome before and after treatment.
STUDY PROCEDURES AND SCHEDULE
This is an open-label clinical trial treating 26 adult patients with chronic delta hepatitis 
with lonafarnib plus ritonavir and lambda interferon for 24 weeks. Patients will undergo 
baseline testing including blood draws, imaging, safety consults, and liver biopsy with 
portal pressure measurements prior to starting therapy.  During therapy, all patients will 
be monitored with quantitative HDV RNA and HBV DNA levels as well as routine safety 
measures and liver function tests.  After 24 weeks, therapy will be stopped and patients 
will again undergo repeated testing including blood draws, imaging, and safety consults. 
After stopping therapy, patients will be followed for an additional 24 weeks. At the end 
of the 24 weeks of post-therapy follow-up, patients will be re-admitted to the NIH 
Clinical Center and will undergo repeat testing including blood draws, imaging, as well 
as a transjugular liver biopsy with hepatic venous pressure gradient measurements. 
STUDY ENTRY CRITERIA
Inclusion Criteria:
1. Age 18 years or above, male or female.
2. Presence of anti-HDV in serum. 
3. Presence of quantifiable HDV RNA in serum at three time pre-treatment points 
with a mean HDV RNA level >2 log10 above the lower limit of quantification 
(LLOQ) of the HDV RNA assay. 
4. Demonstration of chronicity as evidenced by the presence of HDV RNA in serum 
for >/= 6 months, or presence of Anti-HDV antibody >/= 6months.  
Exclusion Criteria:
1. Decompensated liver disease, defined by bilirubin >4mg/dL, albumin <3.0 
gm/dL, prothrombin time >2 sec prolonged, or history of bleeding esophageal 
varices, ascites or hepatic encephalopathy. Laboratory abnormalities that are not 
thought to be due to liver disease may not necessarily require exclusion. Patients 
with ALT levels greater than 1000 U/L (>25 times ULN) will not be enrolled but 
may be followed until three determinations are below this level. Patients with an 
absolute neutrophil count <1000/dL and platelets <75,000/dL will be excluded 
from the study as well. 
2. Pregnancy, active breast-feeding, or inability to practice adequate contraception, 
in women of childbearing potential or in partners of such women. Adequate 


18
contraception is defined as vasectomy in male sexual partners of female 
participants, tubal ligation in women, or use of two contraceptive methods such as 
condoms and spermicide combination with an intrauterine device or Depo-
Provera, or Norplant.
3. Significant systemic or major illnesses other than liver disease, including, but not 
limited to, congestive heart failure, renal failure (eGFR <50 ml/min), organ 
transplantation, serious psychiatric disease or depression (only if felt to be at high 
risk by the NIH psychiatric consultation service), or active coronary artery 
disease.
4. Systemic immunosuppressive therapy within the previous 2 months before 
enrollment. 
5. Evidence of another form of liver disease in addition to viral hepatitis (for 
example autoimmune liver disease, primary biliary cirrhosis, primary sclerosing 
cholangitis, Wilson disease, alcoholic liver disease, ongoing drug induced liver 
disease, nonalcoholic steatohepatitis (but not steatosis), hemochromatosis, or 
alpha-1-antitrypsin deficiency). 
6. Active substance abuse, such as alcohol, inhaled or injection drugs within the 
previous year.
7. Evidence of hepatocellular carcinoma. This will be determined on the basis of 
imaging with ultrasound/ CT scan or MRI performed a maximum of 6 months 
prior to enrollment. Elevated AFP levels will be evaluated clinically and further 
imaging may be performed if felt necessary. 
8. Evidence of concurrent hepatitis C infection with positive serum HCV RNA.
9. Any experimental therapy or pegylated interferon therapy within 6 months prior 
to enrollment.
10. Active, serious autoimmune disease such as systemic lupus erythematosus, 
ulcerative colitis, Crohn’s disease or rheumatoid arthritis, that is in the opinion of 
the investigators might be exacerbated by therapy with lambda interferon. This 
will be evaluated at baseline and during follow-up laboratory testing (including 
blood and urine studies) in addition to described symptoms at each outpatient 
visit. 
11. Diagnosis of malignancy in the five years prior to the enrollment with exception 
granted to superficial dermatologic malignancies.
12. Evidence of HIV co-infection; HIV 1/2 antibody positivity on serum testing.
13. Concurrent usage of statins as these drugs inhibits mevalonate synthesis, which 
reduces protein prenylation.
14. Concurrent usage of moderate and strong CYP3A inhibitors and inducers.
15. Concurrent usage of alpha 1 adrenoreceptor antagonist, antiarrhythmic, pimozide, 
sildenafil, sedative and hypnotics, ergot and St. John’s Wort due to possible effect 
of ritonavir on hepatic metabolism of these drugs resulting in potentially life-
threatening side effects. 


19
16. Clinically significant baseline EKG abnormalities such as QTc interval >450 ms 
and/or prolonged PR interval. 
17. Uncontrolled elevated triglycerides (>500 mg/dL). Patients on lipid lowering 
therapy other than statins will be eligible for this study. 
18. History of pancreatitis from causes other than gallstone pancreatitis. Subjects with 
a baseline amylase and/or lipase level >3 ULN will be excluded from the study. 
19. Inability to understand or sign informed consent.
20.  Any other condition, which in the opinion of the investigators would impede the 
patient’s participation or compliance in the study.
STUDY PROCEDURES/EVALUATIONS
Study Procedures

Physician Visit – history and physical, vital signs, review of symptoms, 
concomitant medications, symptom questionnaire and review of medication 
compliance while on treatment. 

History and Physical – 
o
Full H&P : A full history and physical examination will be performed at 
the screening visit as well as inpatient visits. 
o
Interim H&P : An interim history and physical covering liver and 
medication related symptoms as well as a limited physical exam will be 
performed during all other visits. 

Concomitant medication query (including dose and indication for each).  
Documentation of concomitant medication, which may be CYP3A, 2C9, and P-gp 
substrates, will be performed.

Hepatitis B Treatment To prevent the possibility of a hepatitis B flare during the 
study, all patients will be treated with nucleos(t)ide analogues while on the study 
(24 weeks of entacavir or tenofovir + lonafarnib/ritonavir/lambda and 24 weeks of 
entacavir or tenofovir during the post-therapy monitoring phase). Patients who are 
not on nucleos(t)ide analogues prior to starting lonafarnib/ritonavir/lambda will 
be started on either entecavir or tenofovir (which are first-line nucleos(t)ide 
analogues recommended by the AASLD and EASL for the treatment of HBV) 
prior to instituting HDV therapy (to reduce the risk of a hepatitis B flare). HBV 
viral loads will be monitored after starting nucleoside analogue therapy at each 
outpatient visit during the entire course of study participation.  Adequate HBV 
suppression (serum HBV DNA level <20 IU/mL or undetectable) must be 
achieved on nucleoside analogue therapy prior to starting HDV therapy which 
will allow for improved determination of response to experimental HDV therapy.  
Patients will be informed about the possible adverse effects of these medications 
during their pretreatment clinic visits and via the package insert that is provided 
with the medication.  Patients will also be offered multiple opportunities to ask 
questions about these medications during their clinic visits. For patients started on 


20
nucleos(t)ide analogue therapy as a result of their participation in this protocol, 
the medication will be administered under this protocol after the consent has been 
signed and eligibility is determined. If the patient has been taking a nucleos(t)ide 
analogue prior to enrolling in this study, the specific nucleos(t)ide(s) analogue 
will be continued. The currently approved nucleoside analogues for hepatitis B 
include: lamivudine, adefovir, tenofovir, entecavir and telbivudine.20   At the 
conclusion of participation in this study, subjects that were prescribed nucleoside 
analogue therapy by their outside practitioners will be continued on therapy (if 
clinically indicated) and they will receive this therapy from their outside 
physicians.  For subjects that are started on nucleoside analogue therapies for the 
purposes of participation in this study, nucleoside analogue therapy may be 
continued after completion of this study if clinically indicated.  If this is the case, 
therapy will be continued under the 91-DK-0214 protocol, with encouragement 
that therapy should be received from their outside physicians.  Otherwise, if not 
clinically indicated, nucleoside therapy will be discontinued at the conclusion of 
participation in this study.   

Symptom Questionnaire provides information on categorical presence of 
symptoms as well as their severity, pattern and frequency (Appendix 1)

EKG – Patients will undergo electrocardiogram (EKG) evaluations collected in 
digital format due to the rare instances of asymptomatic bradycardia, PR 
prolongation48 and QT/QTc interval prolongation described in oncologic trials 
with use of lonafarnib.48, 49  

Imaging
o
Ultrasound and Fibroscan -  An abdominal ultrasound with sheer wave 
elastography and vibration controlled transient elastography (Fibroscan ®) 
will be performed for clinical staging of liver disease and to evaluate for 
hepatocellular carcinoma, masses or any other findings that may preclude 
a safe transjugular liver biopsy with hepatic venous pressure gradient 
measurements.  
o
MRI A structural examination of the liver will be performed via magnetic 
resonance imaging with gadolinium. An MRI without contrast will be 
performed in the event that contrast cannot be administered.

Liver Biopsy with Hepatic Venous Pressure Gradient (HVPG) 
Measurements
o
Transjugular Liver Biopsy with HVPG : A transjugular liver biopsy 
will be performed in the interventional radiology suite with measurement 
of hepatic venous pressure gradient. If size of core during one pass 
permits, a small piece of liver will be flash frozen at -80 C for further 
analysis.
o
Percutaneous Liver Biopsy – in the event that the transjugular liver 
biopsy cannot be performed (ie: technical difficulty), a percutaneous liver 
biopsy will be performed. 


21

Consults
o
Reproductive - A reproductive endocrinology or urological consultation 
for evaluation of current and future reproductive potential, the potential of 
reversibility in the event that reproductive toxicity occurs, and guidance 
on potential contraceptive methods will be obtained. Sperm samples will 
be obtained, wherever possible, based on the recommendations of the 
consult.  Sperm sampling will be offered and if obtained, given that the 
normal spermatogenesis cycle is 90 days, a repeat sperm sample will be 
evaluated at 90 days after therapy has been completed. Patients will also 
be provided the opportunity to store sperm or eggs at an outside facility of 
their own choosing and at their own cost prior to starting therapy.
o
Opthalmologic – an ophthalmogic evaluation including vision testing as 
well as retinal exams will be performed. 

Medication Compliance Assessment Compliance with drug dosing will be 
monitored through patient diaries and pill counts at outpatient visits.  Patients will 
be asked to complete drug diaries as they take their study medication including 
the date and time. They will be asked to bring unused medication with them and 
the residual pills will be counted and retained. If compliance falls below 90%, the 
patient will be counseled about the importance of complying with drug therapy 
and made aware that if compliance falls below 80% their participation in the 
study may end.  If compliance falls eblow 80%, the patient may be withdrawn 
from the study.  Reasons for non-compliance will be assessed and documented in 
the patients record.
LABORATORY PROCEDURES/EVALUATIONS

Baseline Labs - prothrombin time (PT/INR), partial thromboplastin time (PTT), 
reticulocyte count, plasma haptoglobin level, anti-HBc.

Routine Labs - complete blood count (CBC with differential), acute care panel 
(sodium, potassium, chloride, bicarbonate, creatinine, glucose, urea nitrogen, 
eGFR ), mineral panel (albumin, calcium, magnesium, phosphorus), hepatic panel 
(alkaline phosphatase, ALT, AST, total bilirubin, direct bilirubin), lipid panel 
(total cholesterol, triglycerides, HDL, LDL), LDH, CK, serum uric acid and total 
protein, urinalysis. 

Monthly Labs - PT, thyroid panel, pregnancy test

Serology Labs - HBsAg, anti-HBs, HBeAg, and anti-HBe, anti-HDV, 
quantitative HBsAg levels.

Pancreatitis Monitoring: amylase, lipase

Viral Kinetic and Pharmacokinetic Assessment (VK and PK): includes HDV 
RNA and HBV DNA qualitative tests via polymerase chain reaction assay (PCR) 
or a quantitative PCR (qPCR) for viral titer.  One red top tube (10 mL) will be 
obtained and stored in -80 for pharmacokinetic (PK) analysis of lonafarnib, 
ritonavir and lambda.  


22

Reproductive Panel - In males, AM levels of inhibin B, luteinizing hormone 
(LH), total and free testosterone, and follicle stimulating hormone (FSH) will be 
obtained. In females, AM levels of luteinizing hormone (LH), estradiol, 
progesterone, antimullerian hormone, follicle-stimulating hormone (FSH), 
dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), 
testosterone, sex hormone binding globulin (SHBG) and 17-hydroxyprogesterone 
(17-OHP) will be obtained.

Immunological Studies -  30 - 50 ml of whole blood will be collected for 
immunological studies at specified time points described in table 1.    5 mm of 
liver tissue at baseline and end of therapy will also be collected for 
immunological studies, provided sufficient liver tissue is available after the 
required amount is obtained for histopathology.  An additional pass will not be 
performed to obtain additional tissue for immunological studies.

Research Blood for Storage - 7 ml of serum will be collected and stored at -80 
C in the NIDDK clinical core lab. 
Fecal Microbiome and Bacterial Translocation (BT) analysis - we plan to utilize pyro-
sequencing techniques to survey microbial diversity in patients’ fecal samples. Patients 
may refuse the microbiome portion of the study and still participate in other portions of 
this study.  Prior to stool sample collection, all the patients will continue their routine 
diets.  At each visit, a specific medication history (including prescription and OTC 
medications) and dietary recordings (appendix 2) will be taken. Samples (stool and 
serum) will be elicited at the time points shown in Table 2 and stored in -80C for future 
analysis.
SPECIMEN PREPARATION, HANDLING AND STORAGE
When appropriate, blood will be drawn in pediatric tubes and the amount of blood that 
will be drawn from adult patients (i.e., those persons 18 years of age or older) for 
research purposes shall not exceed NIH Clinical Center rules over any eight-week period.  

HDV RNA testing will be done by quantitative PCR. Quantification will be 
performed at The Doctors Laboratories (TDL).  TDL has performed the HDV 
RNA quantification for previous lonafarnib studies including LOWR-1 through 
LOWR-4 and the LIMT (lambda interferon for HDV) study.  There currently is a 
lack of standardization across available HDV RNA quantitative assays and no 
commercially approved assay exists in the United States. The lower limit of 
quantification (LLOQ) for this test is 14 IU/mL and the limit of detection (LOD) 
is 2 IU/mL . If the test does not detect the virus, the result will be reported as 
“<LLOQ, target not detected.” If the test detects the presence of the virus but was 
not able to accurately quantify the number of copies, the result will be reported as 
“<LLOQ, target detected.”.  

HBV DNA will be tested at the NIH Clinical Center utilizing the COBAS 
Ampliprep/COBAS Taqman HBV v2.0 test, which is an FDA approved assay 
intended for the use as an aid in the management of chronic HBV infection.  


23

Resistance monitoring will include determination of baseline isolate sequence 
analysis to enable identification and monitoring of changes in viral genome 
sequences as a function of treatment duration. Analysis of drug-treated patients 
will enable an assessment of background genomic variability. Any clinical 
evidence of breakthrough or rebound (defined as a greater than 1 log increase 
above an observed viral load nadir or HDV RNA that becomes quantifiable 
following a reduction to <LLOQ, target not detected) will prompt a more in-depth 
analysis that will focus first on the region encoding the CXXX box, as changes in 
the prenylation substrate sequence represent a logical potential mechanism of 
escape from prenylation-inhibiting drugs such as lonafarnib. Because other 
unanticipated mechanisms of resistance could theoretically be operative, however, 
we would anticipate also performing full genome sequencing to enable maximally 
unbiased assessment for candidate resistance mutations. Samples for analysis of 
potential host polymorphisms in the farnesyl transferase gene wil be collected 
from all subjects.  We will also have the ability to engineer any identified 
candidate resistance mutation back into an HDV vector competent for in vitro 
replication, in order to confirm that the mutation is indeed causative of any 
suspected decreased sensitivity to lonafarnib.

Immunological Studies – 
o
Chronic delta hepatitis is characterized by a lymphomononuclear infiltrate 
of the liver.  The relative composition of this cellular infiltrate (HDV-
specific T cells versus HBV-specific T cells versus nonspecific bystander 
cells), the antigenic targets within HDV that are recognized by these T 
cells and the contribution of the HDV-specific T cell response to disease 
progression are not known.  
o
We aim to define the HDV-specific T cell response in blood samples of 
HDV/HBV-coinfected patients in the chronic stage of disease prior to 
treatment. Peripheral blood mononuclear cells (PBMC) will be isolated 
from blood samples.  The HDV-specific CD4 and CD8 T cell response to 
recombinant delta antigen will be assessed by measuring cytokines (IFN, 
TNF, IL-2) by multicolor flow cytometry and enzyme-linked 
immunospot assays.  Individual responses will be mapped with 41 
overlapping peptides spanning the delta antigen and minimal optimal 
epitopes will be defined.  The quality and strength of the HDV-specific T 
cell response will be compared to the quality and strength of the HBV core 
and surface antigen-specific response.
o
We also plan to take advantage of the fact that the prenylation inhibitor is 
a potent antiviral drug with no direct effect on the immune system.   We 
will also evaluate whether a reduction of HDV viral or antigen load 
determined by treatment with the prenylation inhibitor causes a qualitative 
or quantitative change of the T cell response in the peripheral blood, and 
specifically, the emergence of HDV-specific memory T cells that we have 
identified in a rare case of a patient who spontaneously recovered from 
HDV infection (Heller, Rehermann, unpublished).   


24

Fecal Microbiome and Bacterial Translocation (BT) Bacterial DNA will be 
extracted from patient serum and stool using QIAamp DNA mini kit (Qiagen) 
according to the manufacturer’s protocol. Patients’ dietary history of the day prior 
to stool sample collection and any changes made in medication use since 
screening visit will be recorded.  Polymerase chain reaction (PCR) for a 
conserved region of the 16S rRNA gene will be performed with two universal 
primers, forward primers (27F-Bac, 5’-AGAGTTTGATCMTGGCTCAG-3’) and 
reverse primers (543R-Bac, 5’-ATTACCGCGGCTGCTGGC-3’) to detect and 
identify the bacterial DNA. For each sample, uniquely barcoded universal primers 
will be used for multiplexing. Amplified PCR products will be analyzed by 
agarose gel electrophoresis and then be pooled for pyrosequencing. Amplicons 
will undergo deep sequencing to be performed at SAIC-Frederick Inc. Sequences 
with a minimum length of 200 bp will be analyzed using mothur (version 1.21.0) 
for 16S rRNA gene sequence analysis. Taxonomic classification will be done 
using the RDP Classifier and phylogenetic tree will be generated using the 
Clearcut program. Blood will be drawn and used to measure microbial cell wall 
products, (LPS, peptidoglycan and beta-D-glucan), host response markers and 
selected cytokines. 
Specimen Shipment
Specimens will be shipped using Federal Express in insulated and refrigerated specimen 
boxes. 
STUDY SCHEDULE
Screening 
Before admission to the NIH Clinical Center to start therapy, patients will undergo an 
evaluation for eligibility in this protocol. During the eligibility evaluation, patients will 
undergo a thorough explanation of this protocol, be provided this protocol’s consent for 
review, and be given multiple opportunities to ask questions about this study. This will be 
documented in the patient’s chart. Female subjects of reproductive potential and male 
subjects with female partners of reproductive potential will be informed and educated that 
two reliable forms of contraception as described in the exclusion criteria from the start of 
the study until 6 months from the end of lonafarnib, ritonavir and lambda dosing must be 
utilized. Women will be instructed that they may not breastfeed during their participation 
in this study.
After signing consent, patients will begin screening for the study.  Results for labs drawn 
within the prior six months may be used to determine eligibility.  Screening will include:
A. History and physical 
B. Review of concomitant medications
C. Blood draw to include:
1. Hepatic panel 
2. Mineral panel 


25
3. PT/INR
4. AFP
5. Anti-HDV
6. HDV RNA
7. HDV and HBV genotyping
8. HCV RNA
9. Pregnancy test
10.  ANA, ASMA, AMA,  ceruloplasmin, ferritin, alpha 1 antitrypsin. 
11. Ultrasound and Fibroscan
12. EKG
13. Anti-HIV 1/2
14. Lipid panel
Baseline Evaluation and Initiation of Treatment (within 6 months of screening)
If found to be eligible, the patient will be admitted to the NIH Clinical Center and 
undergo the following evaluation shortly before starting therapy. 
If the patient was on HBV therapy prior to consenting to the study, they will continue on 
treatment for HBV. If the patient was not on HBV therapy, they will start on approved 
nucleos(t)ide treatment for a sufficient period of time prior to starting study medication in 
order for to demonstrate adequate suppression of HBV (serum HBV DNA of  <2000 
IU/mL).
Upon admission the patient will undergo the following:
1. Continuation of HBV therapy
2. MD Visit
3. Routine labs
4. Baseline labs 
5. Pancreatic labs 
6. Monthly labs 
7. Reproductive labs
8. Serology panel
9. Immunological studies
10. Viral kinetics, pharmacokinetics 
11. Microbiome studies
12. EKG


26
13. Ophthalmology, reproductive endocrine/urology, and nutrition consults 
(can occur prior to admission per patient’s preference)
14. MRI 
15. Fibroscan
16. Liver biopsy with hepatic venous pressure gradient measurements prior to 
starting therapy
Initiation of Treatment
All patients will be initiated on lonafarnib 50 mg orally twice daily, ritonavir 100 mg 
orally twice daily and lambda 180 mcg subcutaneously weekly.  Eiger 
BioPharmaceuticals, Inc will supply the lonafarnib, ritonavir and lambda interferon under 
a clinical trials agreement.  Patients will be initiated on therapy one or two days after the 
liver biopsy and will remain in the clinical center for 72 hours after induction of therapy 
for observation of side effects, administration of medication, and timed blood draws to 
facilitate analysis of virological response kinetics and pharmacokinetic analysis. During 
the admission, frequent blood sampling will be performed (0, 6, 12, 18, 24, 36, 48 and 72 
hours after, the first dose) for viral kinetics, pharmacokinetics and storage.
Monitoring on Therapy
After induction of therapy, and completion of the inpatient stay as described above, 
patients will be treated as outpatients and followed on a regular basis in the outpatient 
clinic at the NIH Clinical Center. 
Treatment Weeks 1, 2 and 3 (+/- 3 days)
Patients will be scheduled as outpatients to undergo the following:
1. Continuation of HBV therapy
2. MD visit
3. Monitoring of vital signs and weight (>10% weight loss from baseline would 
result in a follow-up nutrition consult).
4. Routine labs
5. Pancreatic labs
6. Serology
7. Viral kinetics, pharmacokinetics and storage
8. EKG
Treatment Weeks 4, 8, 12, 16 and 20 (+/- 3 days)
Patients will undergo the following as outpatients:
1. Continuation of HBV therapy
2. Continuation of study medication


27
3. MD Visit
4. Monitoring of vital signs and weight (>10% weight loss from baseline would 
result in a follow-up nutrition consult).
5. Routine labs
6. Pancreatic labs
7. Serology
8. Monthly labs
9. Reproductive labs
10. Immunological testing
11. Viral kinetics, pharmacokinetics and blood draw for storage
12. Microbiome studies
13. EKG
End of Therapy
At the end of therapy (week 24), patients will be be seen at  the NIH Clinical Center for 
an evaluation as follows:
1. Continuation of HBV therapy
2. Discontinuation of study therapy
3. MD Visit
4. Monitoring of vital signs and weight (>10% weight loss from baseline would 
result in a follow-up nutrition consult).
5. Routine labs
6. Pancreatic labs
7. Serology
8. Baseline labs
9. Monthly labs
10. Consults
11. Reproductive labs
12. Immunological testing
13. Viral kinetics, pharmacokinetics and blood for storage
14. Microbiome
15. Imaging
16. Fibroscan 
17. EKG


28
Post Treatment Monitoring 
Patients will return for outpatient visits per the following schedule.  As interferon alpha is 
the only recommended therapy for HDV, if a patient has been previously treated with 
interferon, there is no additional therapy to be offered.  It is not planned to routinely offer 
interferon alpha to all patients after participating in this study.  However, if a prolonged 
HDV flare with significant liver damage is demonstrated, rescue therapy with interferon 
alpha will be offered. Patients failing experimental therapy will not be excluded from 
therapy with standard interferon alpha. 
Post Treatment Weeks 1 and 2 (+/- 3 Days)
After discontinuation of therapy at week 24, patients will be monitored on an outpatient 
basis and followed off-therapy for follow-up and blood testing:
1. Continuation of HBV therapy
2. MD Visit
3. Monitoring of vital signs and weight 
4. Routine labs
5. Serology panel
6. Viral kinetics, pharmacokinetics and blood for storage
Post Treatment Weeks 4, 8, 12, 16, 20 (+/- 5 days)
1. Continuation of HBV therapy
2. MD Visit
3. Monitoring of vital signs and weight 
4. Routine labs
5. Serology Panel
6. Monthly labs
7. Reproductive labs
8. Immunological testing (weeks 4, 8 and 16)
9. Viral kinetics, pharmacokinetics and blood for storage
10. Microbiome studies (window for microbiome is +/- 5 days)
Post Treatment Week 24
At the end of study followup (week 24 post treatment), patients will be readmitted to the 
NIH Clinical Center for an evaluation as follows:
1. Continuation of HBV therapy
2. MD Visit


29
3. Monitoring of vital signs and weight (>10% weight loss from baseline would 
result in a follow-up nutrition consult).
4. Routine labs
5. Pancreatic labs
6. Serology
7. Baseline labs
8. Monthly labs
9. Consults
10. Reproductive labs
11. Immunological testing
12. Viral kinetics, pharmacokinetics and blood for storage
13. Microbiome
14. Imaging
15. Fibroscan
16. EKG
17. Liver biopsy
Unscheduled Visits
Data from unscheduled visits may be used in the study analysis.  Unscheduled visits may 
occur due to the development of unexpected symptoms, laboratory abnormalities, or side 
effects which may require clinical follow-up outside of the scheduled visits.  Additional 
evaluations, including laboratory, radiologic and EKG evaluations may be performed 
based on presenting symptoms or clinical suspicion.
Remote Visits
In the event that circumstances beyond our control preclude the travel of one or more of 
the study participants to the NIH Clinical Center for a visit, or otherwise would put their 
health at greater risk (i.e. epidemic or pandemic), we will endeavor to establish 
capabilities for remote visits. Specifically, for safety visits, the study team will arrange 
for local laboratory studies to be done, which include comprehensive metabolic panel, 
Liver function tests (including Tbili, AST and ALT), CBC with diff, PT/INR, HBV DNA 
quantitative and HDV quantitative measurements and conduct a telehealth visit with the 
patient. This telehealth visit will adhere to HHS guidance 
(https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-
preparedness/notification-enforcement-discretion-telehealth/index.html) and can use all 
telehealth modalities under the good faith provision during a pandemic/epidemic as 
allowed by HHS for care of study participants. Unscheduled visits, due to safety, may 
also be conducted remotely through telehealth and/or offsite laboratory and radiologic 
studies and/or in conjunction with a local physician with the supervision of the study PI. 
The laboratory studies will be performed through Quest or LabCorp or with the local 
physician, and results will be sent to the study team for safety monitoring and 


30
oversight.  Radiology studies, when needed, will be arranged through a local, non-study 
physician, or directly by the study team, at a site close to the participants home area if 
travel to the NIH is not possible.  As per FDA guidance, The study team will attempt to 
collect research blood at these visits to be sent to the NIH Clinical Center when possible, 
to address study outcome measures. During a pandemic affecting patient travel, serial 
missed research collections will not be considered major study deviations and will be 
reported to the IRB at the time of continuing review.
Monitoring of Patients Discontinuing Therapy
Therapy will be stopped for intolerance to lonafarnib, ritonavir and/or lambda (which is 
carefully defined in table 4). Patients who stop therapy due to intolerance, withdraw 
because of an adverse event, self-discontinue therapy or drop out from the study will be 
considered as treatment failures. Patients in whom therapy is stopped early or who 
discontinue treatment on their own will initially be followed in the same manner as those 
who do not respond as defined in the protocol.  After treatment is discontinued, the 
patient will be followed for at least 24 weeks with visits to the outpatient clinic as per the 
post-treatment monitoring schedule described above.  Thereafter, patients may be 
followed on an unscheduled basis under protocol 91-DK-0214 as is typical for patients 
who have participated in studies done by the Liver Diseases Branch.


31
Table 1: Study Design
 
 
 
Day 0 
Study Weeks (+/- 3 days)
Study Weeks (+/-5 
days)
 
Study 
Week/Procedures
Baseline 
Evaluation
Start 
Treatment
1, 2, 3
4, 8, 12, 
16, 20
24
25, 26
28, 32, 36, 
40, 44
48
Lonafarnib, Ritonavir, 
Lambda
HDV Therapy
 
x
x
x
x
 
 
HBV Flare Prophylaxis
HBV Therapy
x
x
x
x
x
x
x
X
H&P
Vital signs
Review of symptoms
Concommitant meds
Symptom 
Questionnaire
Review of medication 
compliance
MD Visit
x
 
x
x
x
x
x
X
CBC + diff
acute
mineral
lipid
hepatic
LDH
CK
Serum uric acid
total protein
Routine labs
x
 
x
x
x
x
x
X
amylase
lipase
Pancreatic labs
x
 
x
x
x
 
 
X
HBsAg
anti-HBs
HBeAg
anti-Hbe
Serology Panel
x
 
x
x
x
x
x
X
PT/INR
PTT
Reticulocyte count
Plasma Haptoglobin
anti HBc
Baseline Labs
x
 
 
 
x
 
 
X
PT
Thyroid panel
Pregnancy test
Monthly labs
x
 
 
x
x
 
x
X
Ophthalmology exam
Reproductive consult
Consults
x
 
 
 
x
 
X
LH
FSH
estradiol
Progesterone
AMH
DHEA
DHEAS
Androstenedione
Reproductive labs - 
Females
x
 
 
x
x
 
28, 32, 36
X


32
Fecal microbiome and Bacterial Translocation (BT) analysis
With the recent introduction of highly sensitive analytical methods, the ability to 
meticulously describe the intestinal microbiome in health and disease has allowed for 
identification of fecal microbial dysbiosis.  More recently, investigators have begun 
evaluating associations between the fecal microbiome and bacterial translocation in 
chronic liver disease, advanced liver disease and its potential contribution in poor 
outcomes in liver disease. 
In this study, for research related purposes, we plan to utilize pyro-sequencing techniques 
to survey microbial diversity in patients’ fecal samples. Patients may refuse the 
microbiome portion of the study and still participate in other portions of this study.  Prior 
to stool sample collection, all the patients will continue their routine diets.  At each visit, 
a specific medication history (including prescription and OTC medications) and dietary 
recordings (appendix 2) will be taken. Samples (stool and serum) will be elicited at the 
time points shown in Table 2 and stored in -80C for future analysis.
Testosterone
Free testosterone
SHBG
17-OHP
Inhibin B
LH
FSH
Free testosterone
total testosterone
Reproductive labs - 
Males
x
 
 
x
x
 
28, 32, 36
X
30-50 mL serum for 
immunology.
Immunological Testing
x
0, 24 hours 
 
4, 8, 12
x
 
28, 32, 36
X
10 mL red top for PK
HBV DNA
HDV RNA
7 mL whole blood for 
storage
VK, PK and Storage
0, 6, 12, 18, 
24, 36, 48, 72 
hours
x
x
x
x
x
X
Blood
Stool
Dietary questionnaire
Microbiome Studies
x
 
 
x
x
 
x
X
MRI
Ultrasound
Fibroscan
Imaging
X
 
 
 
x
 
 
X
EKG
EKG
x
 
x
x
x
 
 
X
Transjugular liver 
biopsy with portal 
pressure 
measurements or 
percutaneous liver 
biopsy
Liver Biopsy
x
 
 
 
 
 
X


33
At the time of analysis, we intend to evaluate the relationship between specific 
microbiome maps and the occurrence of BT. In addition, species homology between 
blood and fecal samples will be determined by deep sequencing. 
Bacterial DNA will be extracted from patient serum and stool using QIAamp DNA mini 
kit (Qiagen) according to the manufacturer’s protocol. Patients’ dietary history of the day 
prior to stool sample collection and any changes made in medication use since screening 
visit will be recorded.  Polymerase chain reaction (PCR) for a conserved region of the 
16S rRNA gene will be performed with two universal primers, forward primers (27F-
Bac, 5’-AGAGTTTGATCMTGGCTCAG-3’) and reverse primers (543R-Bac, 5’-
ATTACCGCGGCTGCTGGC-3’) to detect and identify the bacterial DNA. For each 
sample, uniquely barcoded universal primers will be used for multiplexing. Amplified 
PCR products will be analyzed by agarose gel electrophoresis and then be pooled for 
pyrosequencing. Amplicons will undergo deep sequencing to be performed at SAIC-
Frederick Inc. Sequences with a minimum length of 200 bp will be analyzed using 
mothur (version 1.21.0) for 16S rRNA gene sequence analysis. Taxonomic classification 
will be done using the RDP Classifier and phylogenetic tree will be generated using the 
Clearcut program. Stool samples will be collected at the beginning of study, every 4 
weeks, at the end of treatment week 24 and every 4 weeks of post treatment. (Table  2)
Blood will be drawn and used to measure microbial cell wall products, (LPS, 
peptidoglycan and beta-D-glucan), host response markers and selected cytokines. This 
blood samples will be collected whenever we collect the stool sample. (Table 2).
Table 2. Time points for collection of samples for Microbiome & Bacterial 
Translocation Analysis
Time
Therapy
Blood and stool 
sample for 
bacterial 
translocation and 
blood sample for 
cytokines
Baseline Time = -2 
to 0
None
*
On Tx Week 
4,8,12,16,20
Lonafarnib/Ritonavir 
and lambda IFN
*
End of Tx Week 24 
Lonafarnib/Ritonavir 
and lambda IFN
*
Post Tx week 4, 
8,12, 16, 20, 24
None
*
An acceptable deviation for collection of these samples is +/- 5 days.
All microbiome related testing is intended for research purposes.
Immunologic Analysis
Chronic delta hepatitis is characterized by a lymphomononuclear infiltrate of the liver.  
The relative composition of this cellular infiltrate (HDV-specific T cells versus HBV-
specific T cells versus nonspecific bystander cells), the antigenic targets within HDV that 


34
are recognized by these T cells and the contribution of the HDV-specific T cell response 
to disease progression are not known.  
We aim to define the HDV-specific T cell response in blood samples of HDV/HBV-
coinfected patients in the chronic stage of disease prior to treatment. Peripheral blood 
mononuclear cells (PBMC) will be isolated from blood samples.  The HDV-specific CD4 
and CD8 T cell response to recombinant delta antigen will be assessed by measuring 
cytokines (IFN, TNF, IL-2) by multicolor flow cytometry and enzyme-linked 
immunospot assays.  Individual responses will be mapped with 41 overlapping peptides 
spanning the delta antigen and minimal optimal epitopes will be defined.  The quality and 
strength of the HDV-specific T cell response will be compared to the quality and strength 
of the HBV core and surface antigen-specific response.
We also plan to take advantage of the fact that the prenylation inhibitor is a potent 
antiviral drug with no direct effect on the immune system.   We will also evaluate 
whether a reduction of HDV viral or antigen load determined by treatment with the 
prenylation inhibitor causes a qualitative or quantitative change of the T cell response in 
the peripheral blood, and specifically, the emergence of HDV-specific memory T cells 
that we have identified in a rare case of a patient who spontaneously recovered from 
HDV infection (Heller, Rehermann, unpublished).   
Design of the Trial/Statistical considerations
This study is designed as a phase 2a FDA regulated clinical study evaluating the utility of 
combination triple therapy of lonafarnib, ritonavir and lambda interferon in patients with 
chronic HDV infection. This study should show if HDV suppression is possible; assist in 
suggesting if this dose is effective for viral suppression; and how well lonafarnib, 
ritonavir and lambda interferon are tolerated. Thus, assessment of virologic response is 
the primary therapeutic endpoint and safety/tolerability is the primary safety endpoint.   
Measurement of HDV RNA levels will be performed in two batches, the first batch will 
be analysed after the last patient has completed treatment, and the second batch when the 
last patient completes post-therapy follow-up. 
In order to achieve a primary virologic response goal of a 2-log decline in HDV RNA in 
serum at end of 24 weeks of therapy, a total of 26 patients will be enrolled.  This 
designation was made based on a power calculation with a statistical power designated at 
0.9, alpha at 0.05, and two tailed testing, the effect size was found to be -1.1.  
𝑒𝑓𝑓𝑒𝑐𝑡 𝑠𝑖𝑧𝑒=
2672.231 ― 267223.1 
240500.8
= ―1.1
Based off prior interferon based studies, we would also include a potential drop out rate 
of 30%.  Thus, the sample size desired will be 26 subjects.  
HAZARDS AND DISCOMFORTS
The hazards associated with this study are the following.
1. The risks and discomforts of frequent phlebotomy.  To document stable levels of 
biochemical and serologic markers of chronic hepatitis and to monitor the effects 


35
and toxicities of the therapy, frequent blood sampling will be required.  Patients 
will have between 30-32 venipuncture during their course of participation.  The 
amount of blood that will be drawn from adult patients (i.e., those persons 18 
years of age or older) for research purposes shall not exceed 10.5 mL/kg or 550 
mL, whichever is smaller, over any eight-week period.
2. The risks and hazards of liver biopsy. Patients will undergo liver biopsy as part of 
this study (as described above).  The major side effects of liver biopsy are pain, 
infection and bleeding. 
a.
Transjugular Liver Biopsy: Localized neck pain, hematoma and bleeding 
are reported in 6.5% of patients that undergo transjugular liver biopsy.50 
This is transient (lasting one to twelve hours) and is usually mild, rarely 
requiring analgesics. Severe pain requiring prolongation of the 
hospitalization occurs in approximately 1 in 500 cases.  Organs that have 
been reported to be punctured during routine liver biopsies include lung, 
colon, gall bladder, kidney, or adrenal gland. Bacteremia occurs in 1-2% 
of persons undergoing liver biopsy.  In the absence of bile duct 
obstruction, this is almost always self-limited and is rarely symptomatic.  
Significant bleeding after liver biopsy is the most serious side effect of this 
procedure.  In the absence of a blood coagulation defect or hepatic 
malignancy, significant bleeding is rare, occurring in less than one in a 
thousand cases of liver biopsy.  A transjugular liver biopsy will not be 
performed if patients have evidence of coagulopathy unresponsive to 
vitamin K (INR >1.5) or low platelets (Platelets < 50,000 k/uL) which 
may place them at a potentially higher risk for bleeding.  Death due to 
bleeding after liver biopsy has been reported to occur in less than 1 in 
10,000 cases.51 
At the NIH Clinical center, over 150 transjugular liver biopsies have been 
performed in the past 7 years on various patient populations, and there 
have been 2 reported complications. One of the complications was bile 
leak that required endoscopic retrograde cholangiopancreatography 
(ERCP) and stenting to fix the leak. The patient recovered without long-
term sequelae. After this, the technique of transjugular liver biopsy at the 
clinical center was changed to minimize the risk of this happening again. 
A second patient developed mild itching after intravenous contrast 
administration. This resolved with Benadryl administration and the 
procedure was completed without further complication. Patients will be 
monitored for 24 hours post procedure to observe clinical symptoms such 
as abdominal pain and bilious vomiting that may suggest presence of a 
leak. If this occurs, appropriate intervention will be performed. 
b. Percutaneous Liver Biopsy: In this protocol, it is intended that most 
patients will undergo a transjugular liver biopsy.  However, there may be 
rare instances when a transjugular liver biopsy cannot be performed for 
technical reasons.  An example of this would be due to rare anatomical 
variations of the hepatic vein that do not allow for advancement of the 
liver biopsy needle and catheter into a suitable position for acquisition of 


36
liver tissue.  In these instances, a percutaneous liver biopsy will be 
performed given the importance of acquisition of liver tissue per research 
protocol. This determination will be made by the interventional radiologist 
at the time of performing the liver biopsy and HVPG measurements.  A 
percutaneous liver biopsy will not be performed if patients have evidence 
of coagulopathy unresponsive to vitamin K (INR >1.5) or low platelets 
(Platelets < 75,000 k/uL) which may place them at a potentially higher 
risk for bleeding. As such, the transjugular liver biopsy, percutaneous liver 
biopsy and HVPG measurements will be described in depth (along with 
the intended choice to perform either the transjugular liver biopsy or 
percutaneous liver biopsy) to the patient with an opportunity to ask 
questions prior to the intended schedule procedure.  The required NIH 
Clinical Center procedural consents will also be completed for all 
procedures as well.   
A thorough description of the percutaneous liver biopsy and its hazards 
and discomforts will also be included in the general consent form for 
patient reference as well.  A percutaneous liver biopsy is performed by 
passing an aspiration needle through the skin and subcutaneous tissues 
over the lower right side of the chest, through the intercostal muscles and 
into the liver.  The needle is quickly withdrawn applying suction pressure.  
Local anesthesia as well as sedation (usually with midazolam) is typically 
used.  The biopsy is done with the patient lying on his/her back with the 
right arm above the head.  Sterile technique is used and the optimal site for 
the biopsy is chosen on the basis of physical examination for maximal 
liver dullness as well as ultrasound to demonstrate the position of the liver, 
gall bladder, and kidneys.  The biopsy itself is done using an in-and-out 
motion with the needle being in the liver for less than one second.  
However, the biopsy requires approximately 30 minutes of preparation 
and monitoring of blood pressure and pulse regularly over the next 12-24 
hours.  In clinical practice, liver biopsies are usually done as an outpatient 
procedure; in the Liver Diseases Branch, we prefer to keep the patient 
overnight after the biopsy.  The major hazards and discomforts of 
percutaneous liver biopsy are pain, fainting, bacteremia, puncture of 
another internal organ, and bleeding.  The discussion below is supported 
by the ongoing quality assurance analysis of complications of liver 
biopsies performed by the members of the Liver Diseases Branch of the 
NIH.  At the NIH, Medical Staff Fellows or Senior Staff of the Liver 
Diseases Branch, all of who are fully trained and credentialed in 
performing liver biopsies, performs liver biopsies.  Furthermore, all liver 
biopsies by the Hepatology or Gastroenterology fellows are physically 
supervised by a member of the Senior Staff.  The staff are quite proficient 
at liver biopsy technique since an average of 2 to 10 liver biopsies are 
done each month.  Two of the complications of liver biopsy can be 
considered common (pain and fainting), the remaining are quite rare 
(bacteremia, puncture of another organ, severe bleeding).  (1) Local pain 
and discomfort at the liver biopsy site occurs in about 20% of persons 


37
undergoing percutaneous liver biopsy.  This is transient (lasting one to 
twelve hours) and is usually mild, rarely requiring analgesics.  (2) Fainting 
or a vasovagal attack occurs in about 2% of patients undergoing liver 
biopsy.  Patients who faint after liver biopsy are typically those who faint 
after blood drawing or traumatic experiences.  The vasovagal attack 
occurs within 1 to 2 minutes of the biopsy and can occur even in a 
completely sedated patient (who appears to be asleep). Serious 
complications of vasovagal attacks have not been reported but they can be 
quite distressing to the patient and staff.  (3) Asymptomatic bacteremia 
occurs in 1-2% of persons undergoing liver biopsy.  In the absence of bile 
duct obstruction, this is almost always self-limited and is rarely 
symptomatic. Of 3357 biopies performed at the NIH over the past 36 
years, omplications occurred in 135 (4%) biopsies with 33 (1%) resulting 
in major complications. Severe pain occurred in 78 (2.3%) subjects and 
bleeding occurred in 21 (0.6%) subjects. Biliary injury occurred in 8 
(0.2%) biopsies. Three subjects died as a result of massive intraperitoneal 
bleeding.41 
3. The risks of hepatic venous pressure gradient (HVPG) measurements: The 
hepatic venous pressure gradient (HVPG) will be measured during transjugular 
liver biopsy as a combined procedure in patients that participate in this study. 
Portal pressure measurements will not be performed if the patient has evidence of 
coagulopathy unresponsive to vitamin K (INR >1.5) or low platelets (Platelets < 
50,000 k/uL) which may place them at a potentially higher risk for bleeding. 
Portal pressure measurements will be repeated at the end of therapy (week 24).  
This will be done as a direct measure for portal hypertension and is expected to 
provide a more dynamic, functional assay of the direction of change in liver 
disease to follow the evolution of disease and the need for additional clinical 
intervention. Portal pressure measurements were initially used as a diagnostic test 
for portal hypertension and as part of the work up of patients with chronic liver 
diseases.52 Normal gradients are less than 5mmHg. It is accepted that decreasing 
the gradient to 12 mmHg or less will prevent variceal bleeding. It has also become 
clear that portal pressures convey prognostic information, which is an 
independent predictor of mortality in patients with liver disease related to 
cirrhosis.42–44 The commonest current use in North America for portal pressure 
measurements is related to placement of transjugular intrahepatic portosystemic 
shunts by interventional radiology. 
There are various ways to measure portal pressure. The simplest and safest way is 
by measuring the hepatic venous wedged pressure with a balloon catheter and 
subtracting the free hepatic vein pressure to obtain a gradient. The main drawback 
of this technique is that presinusoidal portal hypertension may be underestimated. 
The hepatic venous pressure gradient is the current standard for measuring portal 
pressures.
Hepatic venous pressure gradient measurements are typically performed by 
interventional radiologists. They are normally performed as combined procedures 
along with a liver biopsy to further aid in staging of liver disease.  Aside from the 


38
inherent risks of each individual procedure (percutaneous liver biopsy or 
transjugular liver biopsy or portal pressure measurements), there is no published 
added risk (in adults or pediatrics) in performing the combined procedure of 
portal pressure measurements with a liver biopsy. We are not aware of any series 
describing complications of this technique in detail. It is a technique that the 
clinical center interventional radiologists have considerable experience with, as it 
is essentially cannulation of a central vein. Furthermore, the remainder of the 
procedure is very similar to venous sampling, a technique used to locate 
endocrine tumors, again a common procedure at the clinical center. At the clinical 
center interventional radiology practice involves central venous cannulation and is 
done under ultrasound guidance and not the Seldinger technique. As such it is 
expected that complications at the puncture site would be less common.  
The most likely, although rare, risks of portal pressure measurement are bleeding, 
thrombosis, and arrhythmias. Other complications are far less likely. It is 
estimated that the most likely complications would, at most, occur in less than 5% 
of procedures and the less likely complications would, at most, occur in less than 
1% of procedures. 
a) Bleeding is most likely to occur at the site of catheterization and 
typically manifests as a hematoma. It can occur at the time of the procedure or a 
few hours later (rebleeding). Very rarely the measurement catheter can tear or 
rupture the vein internally and cause internal bleeding. This may necessitate 
surgical repair or transfusion. 
b) Thrombosis occurs as a result of introducing a catheter into a vessel 
and is uncommon. Anticoagulants can be given during the procedure at the 
discretion of the radiologist, however this increases the risk of bleeding. 
Anticoagulants can be used to treat thrombosis, if necessary, and also rarely 
thrombolytics. 
c) Arrhythmias are caused by cardiac irritation as the catheter is passed 
through the heart to the liver. Patients will be monitored throughout the procedure 
by continuous telemetry. Arrhythmias are usually aborted just by moving the 
catheter to a less sensitive area. Should abnormal rhythms persist they will be 
treated appropriately. 
d) Highly unlikely risks include the introduction of infection, pain, 
pneumothorax, arterial puncture, vocal cord paralysis, compression of adjacent 
structures by a hematoma, pseudoaneurysim formation, cardiac rupture, cardiac 
tamponade, and death. 
4.  Risk of ionizing radiation: The only exposure to radiation in this study is from 
fluoroscopy which will be utilized during the transjugular liver biopsy and portal 
pressure measurements. The potential amount of radiation to be received in this 
study is 2.5 rem that is below the guideline of 5 rem per year allowed for adult 
research subjects by the NIH Radiation Safety Committee.
5.  The risks and discomfort of vibration controlled transient elastography 
(Fibroscan®): The Fibroscan® procedure is very similar to a regular ultrasound 


39
examination and both are considered to be procedures with less than minimal risk 
to patients. Fibroscan® measures how quickly the wave is transmitted through the 
liver, which gives a measurement of the liver stiffness. The vibration and 
measurement of liver stiffness is repeated a total of 10 times and takes 5 to 10 
minutes to complete.  In 5 to 10 percent of persons, the test is not successful. The 
most common causes for failure include a large amount of fat over the rib cage, or 
a narrow space between the ribs or fluid in the abdomen. 
Although there is minimal risk to patients, rarely, patients may experience mild 
discomfort between the ribs from having the tip of the probe placed there.  This 
discomfort resolves when the probe is taken off the skin.  Fibroscan has been 
performed on thousands of patients and no adverse effects have been reported.  
6. Magnetic Resonance Imaging Scan (MRI):  MRI scanning may cause anxiety in 
some patients since current equipment used at the Clinical Center uses a closed 
tube. Patients will be offered sedatives such as Valium if they express concern 
about being in a closed space. The MRI will be performed for clinical purposes 
will be used to screen for hepatocellular carcinoma. 
7. Risk of Gadolinum: Gadolinum can cause an allergic reaction and nephrogenic 
systemic fibrosis (NSF). NSF causes fibrosis of the skin and connective tissues 
throughout the body. Patients develop skin thickening that may prevent bending 
and extending joints, resulting in decreased mobility of joints. Patients at risk are 
those with acute or chronic severe renal (kidney) insufficiency (glomerular 
filtration rate < 30 mL/min/1.73m2). The eGFR will have to be greater than >30 
ml/min/1.73 m2 body surface area for MRI to be performed.  In the event that an 
MRI cannot be performed with gadolinium, an MRI without contrast will be 
performed. 
8. Risks related to clinical relevance: Standard clinical tests that are performed by 
the Clinical Center laboratories will be placed in the medical record and 
appropriately discussed with the subject.  Clinical tests not performed at the NIH 
will be reviewed as part of the medical record review.  Other non-CLIA certified 
tests will not be included in the medical record or routinely discussed with the 
patient.  In view of the research nature of this protocol, the non-CLIA certified 
results can not be meaningfully interpreted outside of the narrow focus of this 
study.
9. Risks related to the use of questionnaires:  The quality of life questionnaires will 
be distributed to all subjects in this study.  These questionnaires will not be 
analyzed in real time but will be analyzed in batch form at a later date.  There are 
no risks to completing the questionnaires and we do not expect to uncover 
additional medical problems with these questionnaires that would not otherwise 
be evaluated during routine clinical visits during the course of participation in this 
study.  
10. The risks and hazards of lonafarnib therapy.   Lonafarnib is an orally bio-
available tricyclic farnesyl transferase inhibitor that has been shown to have anti-
tumor activity in various phase I and II trials and anti-HDV properties in various 
preclinical models and five recently completed phase 2 clinical studies performed 


40
at several centers, including the NIH clinical center.45,46 Multiple phase 1 and 2 
and 3 studies have been completed with lonafarnib alone or in combination with a 
variety of chemotherapeutic regimens. This has amounted to the administration of 
lonafarnib to >7000 subjects.   Specifically, the administration of lonafarnib to 
patients with known liver disease and chronic HDV infection is >120 subjects, to 
date.
In initial animal studies, lonafarnib was well tolerated and had no major end-
organ toxicities at repeated doses of 15 mg/kg up to 6 months in rats and 10 
mg/kg up to 1 year in monkeys; these doses result in systemic exposures that are 
less than those attained at a clinical dose of 200 mg twice per day (BID).  At 
higher doses, representing animal to human exposure multiples similar to that 
seen in humans at 200 mg BID, the key side effects included bone marrow 
suppression and testicular toxicity in rats and monkeys, lymphoid and kidney 
changes in rats, and diarrhea and electroretinographic changes in monkeys.  The 
no-effect doses for reproductive effects on fertility (10 mg/kg in rats) and embryo-
fetal development (15 mg/kg in rats and <10 mg/kg in rabbits) result in systemic 
exposures less than those attained at a clinical dose of 200 mg BID.   The no-
effect dose for peri- and postnatal development in rats was >20 mg/kg, the highest 
dose evaluated.  Lonafarnib was not mutagenic or clastogenic.  
Metabolism studies conducted in vitro have shown that cytochrome P450 
enzymes, CYP3A4, and CYP3A5, were mainly responsible for the oxidative 
metabolism of lonafarnib.  This metabolism was studied extensively in vivo and 
the principle metabolic pathways were similar in rats, monkeys and humans and 
primarily involved oxidation or dehydrogenation, and combinations of these two 
processes.  No metabolites specific to humans were detected in vitro or in vivo. 
The main route of excretion was fecal, with urinary excretion representing <2% of 
the administered dose.  Lonafarnib also causes mixed induction/inhibition of 
hepatic drug-metabolizing enzymes in rats and monkeys when administered once 
daily for 3 months in toxicology studies.  In vitro studies in human liver 
microsomes showed that lonafarnib inhibited the activity of CYP3A4 and, to a 
lesser extend CYP2C9.  Neither of these systems is used in the metabolism of 
currently approved drugs to treat HBV.  Multiple co-administered doses of the 
P450 inhibitor ketoconazole resulted in a 5-fold increase in exposure to 
lonafarnib.
In clinical studies, phase 1 dose-finding studies have shown that doses ranging 
from 25 mg to 200 mg twice daily (BID) are safe and well tolerated.  Doses of 
100, 200 and 300 mg BID have been employed in various phase II studies 
involving solid tumors and hematologic malignancies47,48 In the initial dose-
finding phase 1 trial, minor hematologic and non-hematologic side effects were 
seen.48 The hematologic side effects included transient reversible neutropenia and 
transient reversible thrombocytopenia.  At doses of less than 200 mg twice daily, 
these grade 1 toxicities (NCI common toxicity criteria) were seen in 3 of 12 
patients.47 At the 200 mg twice-daily dose level, no toxicities were seen.  At 
higher doses, 300 mg BID and 400 mg BID, 2 of 6 individuals experienced grade 
4 dose limiting toxicities of neutropenia and 1 of 6 experienced grade 4 dose 


41
limiting toxicity of thrombocytopenia during a median treatment duration of 40 
days.47
The major non-hematologic side effects that were observed were gastrointestinal 
and consisted of diarrhea, nausea, vomiting and anorexia which were mild and did 
not require intervention (grade 1 and 2) within the 200 mg twice daily group. 
Other toxicities that were observed included grade 1 or 2 elevation of liver 
enzymes; reversible grade 1 or 2 elevated plasma creatinine levels. At the higher 
doses of 300-400 mg twice daily, toxicities observed included; transient fever 
(grade 2), asymptomatic sinus bradycardia (55 beats/min) resolving at the end of 
therapy, reversible (grade 3) neurocortical toxicity consisting of disorientation and 
confusion. During the above-mentioned phase 1 study, no toxicity greater than 
grade 1 in both hematologic and non-hematologic categories was recorded at the 
200 mg twice-daily administration level.
Subsequent phase II studies, at doses of 200 mg twice daily, have replicated 
similar grade 1 and 2 side effects of; diarrhea, nausea, vomiting, dyspepsia, 
anorexia, asthenia, fever/infection, hemorrhage, increase of serum creatinine, 
increased liver function tests and rash.49,50 In the first study, patients were treated 
for a median duration of 185 days. Currently, there are various phase I, II and III 
investigational studies ongoing (www.clinicaltrials.gov) with no significant safety 
alerts (www.fda.gov). 
To date, lonafarnib has been administered to >120 subjects with chronic liver 
disease and chronic HDV infection at doses ranging from 50 mg once daily to 300 
mg twice daily.  In the NIDDK studies (proof-of-concept study (12-DK-0046) and 
the LOWR-3 (15-DK-0170)), patients underwent digitized electrocardiography 
(baseline, each study visit during therapy, and 1-2 weeks after stopping therapy), 
ophthalmologic examinations with retinal photography (baseline, 4 weeks, 12 
weeks and 24 weeks while on therapy, and 24 weeks post-therapy) and 
evaluations for reproductive toxicity (specialist consultations, serological testing 
and transvaginal ultrasounds on day 3 of menstrual cycle for females (12-DK-
0046 only)).  No patients were found to have any significant changes in these 
parameters at any time during participation in these studies.  
In our proof-of-concept, lonafarnib was administered at doses of 100 mg BID and 
200 mg BID in a total of 12 patients.  During this study, patients underwent 
digitized electrocardiography (at baseline, weekly while on therapy and weeks 1 
and 2 after stopping therapy), ophthalmologic examination with retinal 
photography (at baseline, end of therapy and 24 weeks post-therapy) and 
evaluations (specialist consultations, serologic testing and transvaginal 
ultrasounds on day 3 of menstrual cycle for females) for reproductive toxicity (at 
baseline, end of therapy and 24 weeks post-therapy). No patients were found to 
have any significant changes in these parameters at any time during participation 
in this study. Regarding symptoms encountered in this study, side effects of 
lonafarnib included mild nausea (25%), diarrhea (37.5%), anorexia (12.5%), and 
abdominal bloating (12.5%) in the lonafarnib 100mg bid group. In the lonafarnib 
200 mg BID group, nausea (75%), diarrhea (75%), anorexia (62.5%), dyspepsia 


42
(75%), vomiting (37.5%) and mean weight loss of 4kg (75%) were found. There 
were no grade 3 or 4 adverse events or serious events. 
As there are no HDV-specific therapies, lonafarnib appears to potentially be the 
first direct acting anti-HDV agent by compromising the RNA replication complex 
through inhibition of prenylation at the level of the farnesyl transferase.  A risk 
associated with the use of direct acting antiviral agents would be the development 
of resistance by the virus. However, because prenylation is a host function not 
coded for by the HDV genome, the risk of resistance development could be 
mitigated. As proof of absence of viral resistance with prenylation inhibitors in 
HDV, population-based sequencing of LDAg (codons 115-215) at baseline, end 
of therapy and 24 weeks after end of therapy was performed in our recently 
completed study (12-DK-0046).  Analysis at these time points revealed no 
changes in viral sequences thus confirming the absence of viral resistance. 
An additional risk that may be encountered with the therapy of HDV includes an 
increase in liver function tests during and after therapy, the risk of a flare in HBV 
(≥2 log increase and a total HBV DNA over 2,000 IU/mL) as the HDV viral load 
goes down, and an increase in HDV viral load after therapy is ended.  Flares in 
liver function tests are not uncommon with the start of treatment of HBV disease 
and necessitate a careful and frequent review of liver function tests.  We will treat 
all the patients with nucleoside analogues for HBV, the selection being made by 
the investigator based on the subject’s condition and history of prior anti-HBV 
therapy. It should also be noted, that lonafarnib has undergone extensive analysis 
and has exhibited neither synergy nor antagonism in combination with the 5 
available HBV antiviral medications. A flare in HDV viral load after termination 
of lonafarnib will be monitored closely and interferon therapy may be started as 
determined by the investigator.  It should be noted that when interferon is used for 
HDV it is typically given for a year, and cessation of therapy may be associated 
with flares of HDV. 
11. The risks and hazards of Ritonavir therapy. Ritonavir is an orally bio-available 
protease inhibitor, which was used as a pharmacokinetic booster 
(coadministration of 100mg Ritonavir) of second protease inhibitor or other anti-
retroviral agents. In this study, ritonavir will be used as a pharmacokinetic booster 
of Lonafarnib. The most common side effects (>10%) of ritonavir are nausea, 
diarrhea, vomiting, altered sense of taste (taste perversion), abdominal pain, 
arthralgia, back pain, cough and loss of appetite. If it is used more than 60 days, 
there is increase in cholesterol levels and triglycerides, as well as blood sugar, 
potentially resulting in the development of diabetes mellitus. The increase in 
cholesterol and triglycerides can occur within one week of taking this medication. 
Lipid profile should be monitored prior to initiating therapy and at periodic 
intervals during therapy. After the completion of the study, cholesterol and 
triglyceride levels should return to baseline.
a.
Elevation of AST/ALT can exceed 5 times the upper limit of normal, 
clinical hepatitis and jaundice in patients receiving Ritonavir alone or in 
combination with other antiretroviral drugs. 48 Dosage adjustment is not 
necessary in patients who have mild (Child- Pugh Class A) to moderate 


43
(Child-Pugh Class B) hepatic impairment. There is no safety data 
available for severe (Child- Pugh Class C) hepatic impairment patients. 
Ritonavir is not recommended in patients who have severe hepatic 
impairment. As we are not going to enroll decompensated liver disease 
patients, it should not be a problem. 
b. Pancreatitis has been observed in those who developed 
hypertriglyceridemia. If clinical symptoms or laboratory abnormalities 
(increased serum amylase or lipase), pancreatitis should be considered. 
Patients should be evaluated and Ritonavir should be discontinued if a 
diagnosis of pancreatitis is made. 
c.
Allergic reaction/Hypersensitivity including urticarial, mild skin eruptions, 
bronchospasm and angioedema have been reported. Cases of anaphylaxis, 
toxic epidermal necrolysis, Stevens-Johnson syndrome have also been 
reported. We will discontinue treatment if severe reactions develop.
d. Prolong PR interval in some patients. Post-marketing cases of second or 
third degree atrioventricular block have been reported in patients. The 
effect on PR interval of co-administrating with other drugs that prolong 
PR interval (calcium channel blockers, beta blockers, digoxin and 
atazanavir) has not been studied. But caution should be undertaken when 
co-administration of Ritonavir with these drugs, especially with those 
drugs metabolized by CYP3A.
e.
Metabolism of Ritonavir is mainly through cytochrome P450 CYP3A4. 
21Concurrent usage of other moderate and strong CYP3A inhibitors and 
inducers will lead to change in plasma concentration of concomitant 
medications, resulting prolonged therapeutic or adverse effects. Patients 
who are taking these medications should be excluded. 
12. The risks of the combination of Lonafarnib and Ritonavir. In the LOWR-2 study, 
the combination of lonafarnib (25 mg and 50 mg BID) and ritonavir, a total of 18 
patients were treated, with 7 patients reporting grade 1 adverse events (GI adverse 
events namely nausea, diarrhea, fatigue, weight loss, anorexia and vomiting.) with 
lonafarnib 50 mg BID with ritonavir and 4 reporting grade 1 GI AEs with 
lonafarnib 20 mg BID. 2 patients on lonafarnib 50 mg BID and 1 patient on 
lonafarnib 25 mg BID suffered grade 2 GI AEs. Only 1 patient on the 25 mg BID 
group experienced grade 3 adverse events.   In the LOWR-4 study, 5 patients had 
post-treatment ALT flares with normal liver function. AEs were mostly grade 1-2 
intermittent diarrhea; 4 patients had grade 3 AE (2 diarrhea; 1 asthenia, 1 weight 
loss). There was 1 SAE (traumatic jaw fracture, unrelated to LNF). 
13. The risks of the combination of Lonafarnib, Ritonavir and HBV therapy. During 
the NIDDK study 12-DK-0046, 5 of 14 patients were on nucleos(t)ide analogues 
while on lonafarnib monotherapy.  During this 28-day study, there were no 
additional side effects that could be attributed to the use of a nucleos(t)ide 
analogue in combination with lonafarnib. Similarly, in the LOWR-2,3 and 4 
studies, nucleos(t)ide analogues were used in combination with lonafarnib and 
ritonavir with no adverse events pertinent to the combination noted.  Ritonavir has 


44
been used in combination with nucleos(t)ide analogues in HIV approved therapies 
and is thought to be safe. Nucleos(t)ide analogues for hepatitis B function through 
a different mechanism of action and have different pharmacokinetics and side 
effect profile.  As such, it is believed that there is no added risk of the 
combination of lonafarnib, ritonavir and a nucleos(t)ide analogue for hepatitis B.    
14. The risks and hazards of lambda interferon therapy
Lambda has been generally well tolerated in clinical studies. A lower frequency 
of musculoskeletal (myalgia, arthralgia, and back pain) and flu-like symptoms 
(chills, pyrexia, and pain) was observed across Phase 2 studies in subjects 
receiving IFN regimens containing Lambda compared with alfa. In addition, there 
was a notable lack of hematologic toxicity in the WBC or platelet lineages in 
subjects receiving Lambda regimens.
Laboratory abnormalities have generally been of low grade and self-limited. 
When study regimens included concomitant RBV administration, decreases in 
hemoglobin levels were observed as expected; however, anemia was less frequent 
and milder with Lambda/RBV than with alfa/RBV. Hematologic toxicity was also 
reported less frequently in groups treated with Lambda compared with alfa.
The main safety finding associated with Lambda treatment has been the higher 
frequency of transaminase elevations, accompanied, in some cases, by increases 
in total and conjugated (direct) bilirubin, but without evidence for impaired liver 
synthetic function such as decreased albumin or increased INR. The 
hyperbilirubinemia cases resolved with no laboratory evidence of sustained 
hepatic dysfunction following dose reduction or discontinuation of study drug. 
In one study, 3 cases of concurrent ALT and TBILI elevations in patients with 
HCV treated with Lambda/RBV/asunaprevir (ASV) met program-defined criteria 
for pDILI; this led to discontinuation of this regimen in future development plans. 
Frequencies of concurrent ALT/AST and TBILI elevations across studies were as 
follows: 18.2% for Lambda/RBV/ASV, 3.6% for Lambda/RBV, 2.3% for alfa-
2a/RBV/ASV, and 3.5% for alfa-2a/RBV. 
In another study in patients with HBV, 4 subjects (5.0%) in the Lambda 180-g 
group and 1 subject (7.7%) in the 240 g group, and 1 subject (1.2%) in the alfa 
group met the laboratory criteria for pDILI. In 5 of the 6 cases, an alternative 
explanation (early, on-treatment, host-mediated ALT flare) was identified.
In vitro data did not suggest a hypothesis-driven metabolism- or transporter-
related rationale for the clinically observed differences in rates of 
hyperbilirubinemia between subjects treated with alfa-2a or Lambda, but 
retrospective analysis of safety data from the EMERGE study (Zwirtes 2016) 
found that hyperbilirubinemia events occurred within the first 12 weeks of 
treatment, and the temporal pattern of mean total bilirubin level in the Alfa/RBV 
group was similar to that observed in the Lambda 120 and 180 mg groups 
(although with lower quantitative values for Alfa), suggesting a similar 
underlying mechanism of hyperbilirubinemia, probably RBV-induced hemolysis, 
for Lambda and Alfa treatments during the first 4–6 weeks of therapy.  For the 


45
Lambda 240 mg group, however, a second peak occurred after week 12 
suggesting additional reasons for increases in bilirubin levels, probably as a result 
of direct toxicity to hepatocytes with that dose.
Decompensation of cirrhosis has been observed with Lambda, as with alfa  IFNs. 
A total of 4 cases have been reported. One subject with baseline cirrhosis and 
Gilbert’s disease developed Grade 1 hepatic decompensation and ascites while 
receiving Lambda 120 μg in the EMERGE Phase 2b study. The events resolved 
with drug interruption, and the subject subsequently resumed therapy at a lower 
dose. In the Phase 3 study (AI452017) in GT-2, -3 HCV-infected subjects, 3 of 
approximately 70 randomized subjects with preexisting compensated cirrhosis 
developed decompensated cirrhosis while on treatment with Lambda. All 3 
subjects were Child- Pugh Class A at entry and had evidence of portal 
hypertension. Two of these subjects subsequently recovered; however, 1 subject 
died of infectious complications. Based on these data, Lambda appears to be 
associated with decompensation of cirrhosis especially in the context of portal 
hypertension. Enrollment of cirrhotic subjects in current studies is restricted to 
compensated cirrhotic subjects (Child-Pugh Class A) without evidence of portal 
hypertension.
In analyses of the cardiac effects of Lambda, no evidence of a clinically 
meaningful impact on QT/QTc interval or other key ECG parameters was 
detected in 32 healthy subjects given a single dose of Lambda 80 to 240 g or in 
176 patients with HBV treated with Lambda 180 g for 24 weeks. A slight 
increase in mean ΔQTcF was seen in the HBV patients. Lambda was not 
associated with AEs of ventricular arrhythmias or QT/QTc prolongation.
15. The risks of the combination of Lonafarnib, Ritonavir, Lambda Interferon 
and HBV therapy: The risk of combination therapy with lonafarnib, ritonavir 
and lambda interferon are not known Lonafarnib, in combination with ritonavir 
was administered along with alpha interferon to 11 patients in the LOWR-2 study 
in Turkey. In the LIRA-B study, where patient with mono-infection with chronic 
hepatitis B were randomized to treatment with either interferon alpha or lambda 
interferon, overall adverse events, serious adverse events and discontinuation 
rates were comparable between arms however the AE spectra differed, with more 
cytopenias, flu-like and musculoskeletal symptoms in the alpha group and more 
ALT flares and bilirubin elevations seen in lambda.  
Adverse Events and Modification of Dose of Prenylation Inhibitor and Ritonavir
Patients will be monitored for side effects.  The use of statins will be prohibited during 
the course of the study as are the use of moderate and strong CYP3A inhibitor and 
inducers.  Discontinuation of lonafarnib, ritonavir and lambda interferon will be based 
upon the scoring of adverse events as shown in table 5. The scoring of toxicity will be 
performed from the CTCAE Version 4.03 with modifications for leukocytes, platelets, 
prothrombin time, partial thromboplastin time, ALT, AST and bilirubin.  These variables 
have been modified because the National Cancer Institute (NCI) designed the original 
version with use for cancer trials and not for clinical trials in liver disease.  The modified 


46
version to be utilized for this clinical trial accounts for accepted variations of liver tests 
used in various other liver disease clinical trials by the Liver Diseases Branch. Factors 
that will lead to discontinuation of lonafarnib, ritonavir and lambda interferon include 
pregnancy, any grade 3 or any grade 4 adverse events or any adverse event, which, in the 
opinion of the investigator, places the patient at increased risk.  Drug discontinuation may 
also be based on individual clinical presentations of each subject.  For example, AST and 
ALT values will be evaluated in the context of each individual’s baseline values.  Rather 
than utilizing specific cutoff values, which may not be in the best interest of each subject, 
if the investigator identifies a significant elevation in liver related laboratory tests which 
may jeopardize the patient’s safety, the drug may be discontinued. This is further defined 
below.  If the female becomes pregnant, the patient’s obstetrician will be provided with 
the standard of care guidelines to prevent HBV transmission. Medications will be stopped 
if pregnancy occurs, with the exception of HBV therapy, given the risk of hepatitis B 
flare during pregnancy.  Lonafarnib, ritonavir and lambda interferon will not be restarted 
unless another cause for the abnormality or symptom is found.
Table 3: Dose reduction plan for Lambda/Lonafarnib intolerability 
Starting Dose
Dose Reduction
(DR1)
Assigned 
Treatment
Dose
Dose 
Lambda
180 g
120 g
Lonafarnib
50 mg
25 mg
Table 4: Guidelines for Treatment Interruption or Discontinuation and Dose 
Modification
Toxicity
Management, Monitoring, and Dose 
Modification
Discontinuation of Drug
Immediate Actions/Resolution
Adverse Events
Lambda
AE  Grade 3, considered at 
least possibly related to study 
drug and clinically significant, 
and no specific guidance given 
below
Interrupt dosing and monitor weekly
Resolution: If event resolves to  Grade 1 or 
baseline value, restart dosing at DR1
If event does not resolve in 
2 weeks (missed 
2 consecutive doses of 
drug)
or
If event recurs at DR1, 
discontinue drug
Lonfarnib
AE  Grade 3, considered at 
least possibly related to study 
drug and clinically significant, 
and no specific guidance given 
below
Interrupt dosing and monitor weekly
Resolution: If event resolves to  Grade 1 or 
baseline value, restart dosing at DR1
If event does not resolve in 
2 weeks (missed 
14 consecutive doses of 
drug)
or
If event recurs at DR1, 
discontinue drug


47
Toxicity
Management, Monitoring, and Dose 
Modification
Discontinuation of Drug
Lambda
AE  Grade 3, considered at 
least possibly related to study 
drug and not clinically 
significant, and no specific 
guidance given below
Discuss with medical monitor. Not all Grade 3 AEs 
will require dose modification.
Lonafarnib
AE  Grade 3, considered at 
least possibly related to study 
drug and not clinically 
significant, and no specific 
guidance given below
Discuss with medical monitor. Not all Grade 3 AEs 
will require dose modification.
Lambda
Depression
See Table 5 and CTCAE neurologic definitions for 
mild/moderate/severe depression
Interrup dosing.
Obtain psychiatric consult
Lambda
New ocular symptoms: New 
decrease or loss of vision or 
other clinically significant ocular 
sign or symptom
Interrupt dosing.
Obtain complete eye examination performed by an 
ophthalmologist.
Discuss further management with the medical 
monitor prior to restarting therapy.
Hematologic abnormalities
Lambda
ANC
750/mm3
Maintain dose
< 750/mm3
Interrupt dosing
Resolution: If ANC > 500/mm3, restart dosing at 
DR1
If event does not resolve in 
4 weeks (missed 4 
consecutive doses)
or
If event recurs (confirmed) 
at DR1, discontinue drug
Platelets
< 40,000
Reduce dose to DR1
< 25,000
If event is confirmed, 
discontinue drug


48
Toxicity
Management, Monitoring, and Dose 
Modification
Discontinuation of Drug
Hepatobiliary abnormalities
Lambda
ALT/AST/TBILI 
CTCAE grade 2
Repeat tests within 48-72 hours and monitor 
weekly.
Monitor ALT, AST, TBili, DB, Albumin, PT/INR
Involve medical monitor
Resolution:  CTCAE <grade 2, return to routine 
monitoring.
ALT/AST 
CTCAE grade 3
Interrupt dosing
Monitor ALT, AST, TBILI, DB, albumin, PT/INR 
weekly
Involve medical monitor
Resolution: If ALT/AST <CTCAE grade  3, restart 
dosing at DR1 if agreed upon with medical monitor 
with weekly monitoring for the first 4 weeks.  If 
stable after 4 weeks of monitoring can resume 
regular per protocol monitoring.
If event does not resolve in 
4 weeks (missed 4 
consecutive doses)
or
If event recurs (confirmed) 
at DR1, discontinue drug
TBILI   CTCAE grade 3
Interrupt dosing
Monitor ALT, AST, AP, TBILI, DB, albumin, 
PT/INR weekly
Involve medical monitor
Resolution: If TBILI CTCAE  grade 3, restart 
dosing at DR1 if agreed upon with medical monitor 
with weekly monitoring for the first 4 weeks.  If 
stable after 4 weeks of monitoring can resume 
regular per protocol monitoring.
If event does not resolve in 
2 weeks (missed 2 
consecutive doses)
or
If event recurs (confirmed) 
at DR1, discontinue drug
                Lonafarnib
ALT/AST/TBILI 
CTCAE grade 2
Repeat tests within 48-72 hours and monitor 
weekly.  
Monitor ALT, AST, TBili, DBili, Albumin, PT/INR
Involve medical monitor
Resolution: CTCAE <grade 2, return to routine 
monitoring.
ALT/AST 
CTCAE grade 3
Interrupt dosing
Monitor ALT, AST, TBILI, DB, albumin, PT/INR 
weekly
Involve medical monitor
Resolution: If ALT/AST <CTCAE grade  3, restart 
dosing at DR1 if agreed upon with medical monitor 
with weekly monitoring for the first 4 weeks.  If 
stable after 4 weeks of monitoring can resume 
regular per protocol monitoring.
If event does not resolve in 
2 weeks (missed 14 
consecutive doses)
or
If event recurs (confirmed) 
at DR1, discontinue drug


49
Toxicity
Management, Monitoring, and Dose 
Modification
Discontinuation of Drug
TBILI   CTCAE grade 3
Interrupt dosing
Monitor ALT, AST, AP, TBILI, DB, albumin, 
PT/INR weekly
Involve medical monitor
Resolution: If TBILI <CTCAE grade  3, restart 
dosing at DR1 if agreed upon with medical monitor 
with weekly monitoring for the first 4 weeks.  If 
stable after 4 weeks of monitoring can resume 
regular per protocol monitoring.
If event does not resolve in 
2 weeks (missed 14 
consecutive doses)
or
If event recurs (confirmed) 
at DR1, discontinue drug
Renal function abnormalities 
(lonafarnib AND lambda)
Creatinine clearance 
< 50 mL/min
Discontinue drug
In addition to the above rules, all subjects who meet criteria for a treatment related 
liver event will undergo the following clinical work up:

Ultrasound of the liver should be performed, including doppler, for 
subjects with a bilirubin level greater than 1.5 times baseline 

If clinically feasible, a liver biopsy should be performed. 
o When a percutaneous biopsy is contraindicated, a 
transjugular biopsy may be discussed. 

Liver and chemistry labs should be performed weekly (minimally 
include ALT, AST, bilirubin, INR, alkaline phosphatase, albumin 
and gamma-GT) until the bilirubin returns to baseline value. 

HBV DNA and HDV RNA should be monitored weekly 

5 ml of serum plus 5 ml of plasma should be collected for possible 
later biomarker analysis 

Autoimmune markers (antinuclear antibody [ANA], anti-smooth 
muscle antibody [anti-SMA], anti-LC1, anti-SLA liver kidney 
microsome type 1 and type III antibody [anti-LKM1,3]), 

_C3, C4 and CH50, 

_Acute viral hepatitis, 
o Serologies for acute hepatitis A and E (IgM); 
o PCR for HCV, hepatitis E (stool and blood), 
o Cytomegalovirus (CMV), PCR 
o Epstein-Barr virus (EBV), PCR 
o Herpes simplex viruses 1 and 2 (HSV), PCR 
• _Review of pre-existing hepatic disease (excluding HBV), 


50

Review of concomitant medication(s), or herbal medications 
and substances known to be hepatotoxic, tests for alcohol and 
acetaminophen and drugs of abuse, if indicated 
Table 5.  Scoring of toxicity for dose modification.  Scoring of toxicity from the 
CTCAE Version 4.03, with modifications for leukocytes, platelets, prothrombin time, 
partial thromboplastin time, ALT, AST and bilirubin.  Normal ranges for values at the 
NIH Clinical Center are used.
Scoring of toxicity for dose modification
Grade
Adverse 
Event
Short 
Name
1
2
3
4
5
Allergic 
reaction/ 
hypersensiti
vity 
(including 
drug fever)
Allergic 
reaction
Transient 
flushing or 
rash; drug 
fever <38 C 
(<100.4 F)
Rash; 
flushing; 
urticarial; 
dyspnea; drug 
fever >38 C 
(>100.4 F)
Symptomatic 
bronchospasm, 
with or 
without 
urticarial; 
parenteral 
medication(s) 
indicated; 
allergy-related 
edema/angioe
dema; 
hypotension
Anaphyla
xis
Death
Anorexia
Anorexia
Loss of 
appetite 
without 
alteration in 
eating habits
Oral intake 
altered without 
significant 
weight loss or 
malnutrition; 
oral nutritional 
supplements 
indicated
Associated 
with 
significant 
weight loss or 
malnutrition 
(e.g., 
inadequate 
oral caloric 
and/or fluid 
intake); IV 
fluids, tube 
feedings or 
TPN indicated
Life 
threatenin
g 
conseque
nces
Death
Nausea
Nausea
Loss of 
appetite 
without 
alteration in 
eating habits
Oral intake 
decreased 
without 
significant 
weight loss, 
dehydration or 
malnutrition; 
Inadequate 
oral caloric or 
fluid intake; 
IV fluids, tube 
feedings, or 
TPN indicated 
>24 hrs
Life 
threatenin
g 
conseque
nces
Death


51
IV fluids 
indicated <24 
hrs
Fatigue 
(asthenia, 
lethargy, 
malaise)
Fatigue
Mild fatigue 
over baseline
Moderate or 
causing 
difficulty 
performing 
some ADL
Severe fatigue 
interfering 
with ADL
Disabling
-----
Diarrhea
Diarrhea
Increase of 
<4 stools per 
day over 
baseline; mild 
increase in 
ostomy 
output 
compared to 
baseline
Increase of 4-6 
stools per day 
over baseline; 
IV fluids 
indicated <24 
hrs; moderate 
increase in 
ostomy output 
compared to 
baseline; not 
interfering 
with ADL
Increase of >6 
stools per day 
over baseline; 
incontinence; 
IV fluids >24 
hrs; 
hospitalization
; sever 
increase in 
ostomy output 
compared to 
baseline; 
interfering 
with ADL 
Life 
threatenin
g 
conseque
nces (e.g. 
hemodyna
mic 
collapse)
Death
Distention/
bloating, 
Abdominal
Distention
Asymptomati
c
Symptomatic, 
but not 
interfering 
with GI 
function
Symptomatic 
interfering 
with GI 
function
-----
-------
Vomiting
Vomiting
1 episode in 
24 hrs
2-5 episodes 
in 24 hrs; IV 
fluids 
indicated <24 
hrs
>5 episodes in 
24 hrs; IV 
fluids, or TPN 
indicated >24 
hrs
Life 
threatenin
g 
conseque
nces
Death
Depression
Depression
Mild 
depressive 
symptoms
Moderate 
depressive 
symptoms, 
limiting 
instrumental 
ADL
Severe 
depressive 
symptoms, 
limiting self 
care ADL, 
hospitalization 
not indicated
Life 
threatenin
g 
conseque
nes, 
threats of 
harm to 
self or 
others, 
hospitalis
ation 
indicated
Death
Creatinine
Creatinine
>ULN – 1.5 
X ULN
> 1.5 – 2.0 X 
ULN
> 2.0 – 6.0 X 
ULN
>4.0 X 
ULN
Death


52
Glomerular 
Filtration 
Rate
GFR
<75-60% 
LLN
<60-40% LLN
<40% LLN, 
chronic 
dialysis not 
indicated
Chronic 
dialysis or 
renal 
transplant
ation 
indicated
Death
Glucose, 
serum-low 
(hypoglyce
mia)
Hypoglyce
mia
<LLN – 55 
mg/dL
<LLN – 3.0 
mmol/L
<55 – 40 
mg/dL
<3.0 – 2.2 
mmol/L
<40-30 mg/dL
<2.2-1.7 
mmol/L
<30 
mg/dL
<1.7 
mmol/L
Death
Triglycerid
e, serum- 
high 
(hypertrigly
ceridemia)
Hypertrigly
ceridemia
>ULN – 2.5 
X ULN
>2.5 – 5.0 X 
ULN
>5.0 – 10 X 
ULN
>10 X 
ULN
Death
Cholesterol, 
serum high
(Hyperchol
esterolemia
)
Hyperchole
sterolemia
>ULN - 300 
mg/dL; 
>ULN - 7.75
mmol/L
>300 - 400 
mg/dL; >7.75 
- 10.34
mmol/L
>400 - 500 
mg/dL; >10.34 
-
12.92 mmol/L
>500 
mg/dL; 
>12.92 
mmol/L
-----
Pain – 
Headache
Pain – 
Headache
Mild pain not 
interfering 
with function
Moderate 
pain; pain or 
analgesics 
interfering 
with function, 
but not 
interfering 
with ADL
Severe pain; 
pain or 
analgesics 
severely 
interfering 
with ADL
Disabling
-----
Pain – 
Abdominal
Pain – 
Abdominal
Mild pain not 
interfering 
with function
Moderate 
pain; pain or 
analgesics 
interfering 
with function, 
but not 
interfering 
with ADL
Severe pain; 
pain or 
analgesics 
severely 
interfering 
with ADL
Disabling
-----
Infection- 
Upper 
Airway 
NOS
Infection – 
Upper 
Airway 
NOS
Mild
Moderate
Severe
Life – 
threatenin
g; 
disabling
Death
Infection – 
Nasopharyn
gitis
Infection – 
Nasopharyn
gitis
Mild 
Moderate
Severe
Life-
threatenin
g; 
disabling
Death
Hemoglobi
n
Hemoglobi
n
<LLN – 10.0 
g/dL
< 10.0 – 8.0 
g/dL
<8.0 – 6.5 
g/dL
<6.5 g/dL
Death


53
<LLN – 6.2 
mmol/L
<LLN – 100 
g/L
<6.2 – 4.9 
mmol/L
<100 – 80 g/L
<4.9 – 4.0 
mmol/L
<80 – 65 g/L
<4.0 
mmol/L
<65 g/L
Granulocyt
es
Granulocyt
es
Leukocytes 
(total 
WBC)
Leukocytes
<2000/mm3
<2.0 X 109/L
<1500 – 
1000/mm3
<1.5 – 1.0 X 
109/L
<1000 – 
500/mm3
1.0 – 0.5 X 
109/L
<500/mm
3
<0.5 X 
109/L
Death
Platelets
Platelets
<70,000/mm3
-60,000/mm3 
<70.0 – 60.0 
X 109/L
<60,000 – 
40,000/mm3
<60.0 – 40.0 X 
109/L
<40,000 – 
25,000/mm3 
<40.0 – 25.0 X 
109/L
<25,000/
mm3
<25.0 X 
109/L
Death
INR 
(Internation
al 
Normalized 
Ratio of 
prothrombi
n time)
INR
>1 – 1.5 X 
ULN
>1.5 – 2 X 
ULN
>2 X ULN
------
-----
PTT Partial 
Thrombopl
astin time)
PTT
>1 – 1.5 X 
ULN
>1.5 – 2 X 
ULN
>2 X ULN
------
-----
Bicarbonate
, serum-low
Bicarbonate
, serum-low
<LLN – 18 
mmol/L
<18 – 15 
mmol/L
<15-11 
mmol/L
<11 
mmol/L
Death
Acidosis 
(metabolic 
or 
respiratory)
Acidosis
pH < normal, 
but >7.3
-----
pH <7.3
pH <7.3 
with life 
threatenin
g 
conseque
nces
Death
Alkaline 
Phosphatas
e (U/L)
Alkaline 
Phosphatas
e
>ULN – 2.5 
X ULN
>2.5 0 5.0 X 
ULN
>5.0 – 20.0 X 
ULN
>20.0 X 
ULN
-----
Bilirubin 
(hyperbiliru
binemia)
Bilirubin
>ULN – 1.5 
X ULN
>1.5 – 3.0 X 
ULN
>3.0 – 10.0 X 
ULN
>10.0 X 
ULN
-----
Albumin, 
serum-low 
(hypoalbum
inemia)
Hypoalbum
inemia
<LLN – 3 
g/dL
<LLN – 30 
g/L
<3 – 2 g/dL
<30 – 20 g/L
<2 g/dL
<20 g/L
------
Death
AST, 
SGOT 
(serum 
glutamic 
AST
>3 – 5 X 
patient’s 
baseline 
values
>5-10 X 
patient’s 
baseline 
values
>10 – 20 X 
patient’s 
baseline 
values
>20 X 
patient’s 
baseline 
values
Death


54
oxaloacetic 
transaminas
e)
ALT, SGPT 
(serum 
glutamic 
pyruvic 
transaminas
e)
ALT
>3-5 X 
patient’s 
baseline 
values
>5-10 X 
patient’s 
baseline 
values
>10 – 20 X 
patient’s 
baseline 
values
>20 X 
patient’s 
baseline 
values
Death
Pancreatitis
Pancreatitis
Enzyme 
elevation or 
radiologic 
finding only
Severe pain; 
vomiting; 
medical
intervention 
indicated (e.g.,
analgesia, 
nutritional 
support)
Life-
threatenin
g 
conseque
nces;
urgent 
interventi
on 
indicated
Death
DEFINITION AND MANAGEMENT OF ON-TREATMENT ALT FLARES
On treatment flares will be managed per guidelines defined in Table 4. Post treatment 
ALT flares are defined as ALT ≥ grade 2 CTCAE score, and participants will be followed 
every 4 weeks till ALT falls below grade 2 CTCAE score. Severe post-treatment flares 
are defined as ALT  ≥ grade 3 CTCAE score. Participants with post treatment severe 
ALT flares will be evaluated every week with until ALT decreases below CTCAE grade 
3, then will be seen every 4 weeks for ALT between CTCAE grades 2-3, after which 
scheduled visits will resume per study protocol. 
Subjects who experience post-treatment flares may undergo an evaluation for other 
causes of liver disease, as well as may be initiated on Peg-interferon alpha per discretion 
of the study investigator. 
Table 6: Post treatment ALT flare management schedule
ALT (CTCAE grade)
Intervention/Management
Follow up schedule
≥ 2-3
Labs per protocol
1. Liver panel
2. CBC
3. PT/INR
Every 4 weeks, till ALT < 
Grade 2 CTCAE, then 
resume visits per study 
protocol. 
≥3
Labs per protocol
1. Liver panel
2. CBC
3. PT/INR
Every week, till ALT < 
Grade 3 CTCAE, then 
every 4 weeks till ALT < 
Grade 2 CTCAE, then 
resume visits per study 
protocol.


55
DATA AND SAFETY MONITORING
The Principal Investigator will function as the data and safety monitor and report any 
adverse events to the IRB.   The Principal and Associate Investigators in this protocol 
will monitor data and safety.  The Liver Diseases Branch, NIDDK, reviews data and 
safety weekly in clinical research rounds.  These rounds are separate from regular clinical 
rounds and consist of review of all study patients including flow sheets of major safety 
and efficacy measurements.  Additionally, an outside data/safety monitor will be utilized.  
Dr. Sasan Sakiani, MD from the Division of Gastroenterology and Hepatology at the 
University of Maryland Medical Center, Baltimore, MD will serve as the data/safety 
monitor and will review data every two weeks during the course of the study, or sooner 
based on clinical necessity. Yearly reports are made to the NIDDK/NIAMS IRB 
regarding safety and efficacy. 
DATA MANAGEMENT PLAN
Data will be maintained electronically on electronic case report forms (eCRF). Data 
reported in the eCRF derived from source documents should be consistent with the 
source documents or the discrepancies should be explained and captured in a progress 
note and maintained in the participant’s official electronic study record. Clinical data 
(including AEs, concomitant medications, and expected adverse reactions data) and 
clinical laboratory data will be entered into CRIS, which is 21CFR Part 11 compliant,  
and into to REDCap, both of which are maintained at the NIH Clinical Center. The data 
systems include password protection and internal quality checks, such as automatic range 
checks, to identify data that appear inconsistent, incomplete, or inaccurate. Clinical data 
will be entered directly from the source documents. Information derived from patient 
interview will be entered to eCRFs and considered source documents.
REPORTING OF ADVERSE EVENTS, UNANTICIPATED PROBLEMS AND 
DEVIATIONS
Reportable events will be tracked and submitted to the IRB as outlined in Policy 801.
FDA AND SPONSOR REPORTING REQUIREMENTS
The study investigator will immediately report to the sponsor any serious adverse event, 
whether or not considered study intervention related, including those listed in the 
protocol or investigator brochure and must include an assessment of whether there is a 
reasonable possibility that the study intervention caused the event. Study endpoints that 
are serious adverse events (e.g., all-cause mortality) must be reported in accordance with 
the protocol unless there is evidence suggesting a causal relationship between the study 
intervention and the event (e.g., death from anaphylaxis). In that case, the investigator 
must immediately report the event to the sponsor.
All serious adverse events (SAEs) will be followed until satisfactory resolution or until 
the site investigator deems the event to be chronic or the participant is stable. 
The study sponsor will be responsible for notifying the Food and Drug Administration 
(FDA) of any unexpected fatal or life-threatening suspected adverse reaction as soon as 
possible, but in no case later than 7 calendar days after the sponsor's initial receipt of the 


56
information.  In addition, the sponsor must notify FDA and all participating investigators 
in an Investigational New Drug (IND) safety report of potential serious risks, from 
clinical trials or any other source, as soon as possible, but in no case later than 15 
calendar days after the sponsor determines that the information qualifies for reporting.
REGULATORY REQUIREMENTS
The IND associated with this study (113137), in which the NIDDK is the sponsor, is 
associated with lonafarnib and lambda interferon.  The FDA has not requested an IND for 
the use of ritonavir in combination with lonafarnib. Study procedures will be subject to 
audits and/or monitoring visits to ensure compliance with the protocol and applicable 
regulatory requirements consistent with the NIDDK quality assurance program plan and 
applicable FDA guidelines.  Audit and/or monitoring visit results will be reported to the 
Principal Investigator for further reporting as appropriate.   Study documents and 
pertinent hospital or clinical records will be reviewed to verify that the conduct of the 
study is consistent with the protocol plan.
RECRUITMENT STRATEGY
We will advertise on the NIH web site and through letters sent to local physicians and 
clinics for patients.  
Recruitment of Women, Minority Individuals and Children.
Delta hepatitis is a rare disease in the general population.  The major risk factors are 
injection drug use and hemophilia.  It is rare to find the disease in childhood, the majority 
of children with delta hepatitis being immigrants from areas of the world where it is 
common (Eastern Europe, Amazon Basin).  In addition, hepatitis is often mild in 
children.  Finally, FTIs have not been adequately evaluated for safety and efficacy in 
children. We therefore do not plan to recruit children below the age of 18.
Women are less likely to have HDV, as one of the risk factors, hemophilia is a disease of 
males.  Notwithstanding this, every effort will be made to  find both women and 
members of minorities with HDV.  To increase the representation of both women and 
minority individuals in this trial, we plan to advertise widely. 
CONSENT PROCESS
Informed consent begins with the initial approach of an investigator to a potential subject 
(for example through a flyer or advertisement) and continues (a) until the completion of 
the research study, (b) until the individual completes study participation, (c) the subject 
withdraws him/herself from the study or (d) the subject is withdrawn from the study by 
the investigator. 
Written informed consent will be obtained from the participant prior to any screening 
visits, study procedures or treatments. The Principal Investigator or other designated 
qualified protocol investigators will explain the study in language understandable to the 
subject. Sufficient time and opportunity will be given for discussion of the research as 
well as to answer any questions they may have, taking care to minimize or eliminate the 
perception of coercion or undue influence. The participant and the investigator will sign 


57
the current IRB-approved informed consent document. A copy of the consent will be 
given to the subject for future reference. The signed documents will be sent to the 
Medical Records Department for placement in the subject's permanent CC medical 
record. The consent process will additionally be documented in the electronic medical 
record (CRIS).
RESEARCH USE, STORAGE AND DISPOSITION OF HUMAN SUBJECT’S 
SAMPLES AND DATA.
Patients will have serum and stool stored from selected time points during this study.  
The serum specimens will be used for repeat virological testing and special tests as 
needed and the stool tests will be used for microbiome analysis.   Samples may be used to 
assess factors associated with response or non-response to therapy.    These samples will 
be tested in the Liver Diseases Branch or the routine clinical services of the Clinical 
Center.  Residual samples may be used for future research related to liver disease and its’ 
associated conditions.  If residual samples are evaluated by outside collaborators in the 
future, this will be done so only after all identifying data have been removed from all 
samples and all applicable tech transfer are initiated.   ARUP and The Doctors 
Laboratory will perform all HDV RNA quantitative testing for this protocol. All samples 
sent to outside collaborators, ARUP and The Doctors Laboratory will be numbered and a 
key to the number system will be stored and backed up by the principal investigator of 
this study.  Research records and data as well as sera will be stored indefinitely in our 
locked offices and freezers, the medical record department and the pathology department.  
These materials will be protected and tracked by standard operating procedures in the 
medical record as well as a compulsive filing system in our locked offices and freezers.  
There will be redundant storage of clinical information in the medical record department 
and our offices. Computer files will be maintained on password-protected computers and 
servers.  Serum samples will be processed and stored by the NIDDK core laboratory 
facility.  These samples will be stored in locked freezers inside locked rooms.  Access to 
these samples will require written approval from the Liver Diseases Branch chief, and 
will be recorded by the LDB and by the core laboratory.  This should minimize the risk of 
loss or destruction of information and specimens.  If that were to occur we would report it 
to the IRB.  We do not plan to destroy this personal medical information or research 
subject sera after completion of the study because it may be critically important for 
physicians (here or elsewhere) to have access to this information when caring for these 
patients in the future.  If requested, Eiger Biopharmaceuticals (who will be providing the 
Lonafarnib, Ritonavir and Lambda), will have access to the clinical data only after all 
personal identifiers have been removed.  They will also be included in all serious adverse 
event notifications.
Data Sharing: 
After obtaining consent for data sharing, de-identified data collected from  demographic, 
dietary, quality of life, and symptom questionnaires, biochemical testing of urine, serum, 
radiological and liver biopsy samples of study participants will be made available without 
cost to researchers and analysts through NIH/ NIDDK data repositories. Data will be 
submitted at the time of publication. Users must agree to the conditions of use governing 
access to the public release data, including limitation of research to investigations 


58
consistent with the participants’ consent, restrictions against attempting to identify study 
participants, destruction of the data after analyses are completed, reporting 
responsibilities, restrictions on redistribution of the data to third parties, and proper 
acknowledgement of the data resource. 
Study Alternatives: 
Alternatives to the study may be offered at the NIH or at outside medical centers and are 
routine therapy with interferon for 12 months, being monitored on no therapy, or 
awaiting results of this or other studies of therapy of chronic delta hepatitis. Patients who 
choose to enroll in this clinical trial, if not previously treated, may delay therapy with 
interferon for up to 48 weeks.  For this reason, if a patient has advanced disease, the study 
investigators may choose to recommend treatment with interferon before enrollment 
(either by the Liver Diseases Branch under protocol 91-DK-0214 or outside of the NIH).
REMUNERATION/COMPENSATION
No compensation is offered to study participants.


59
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with cirrhosis  and esophageal varices. Gastroenterology 102, 973–979 (1992).
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infection: a proof-of-concept randomised, double-blind, placebo-controlled phase 
2A trial. Lancet. Infect. Dis. 15, 1167–1174 (2015).
46.
Koh, C. et al. HHS Public Access. 15, 1167–1174 (2016).
47.
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transferase inhibitor SCH  66336 given twice daily to patients with advanced solid 
tumors. J. Clin. Oncol. 19, 1167–1175 (2001).


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inhibitor SCH 66336 given once daily to patients with advanced solid tumours. 
Eur. J. Cancer 38, 2272–2278 (2002).
49.
Feldman, E. J. et al. On the use of lonafarnib in myelodysplastic syndrome and 
chronic myelomonocytic leukemia. Leukemia 22, 1707–1711 (2008).
50.
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myelodysplastic syndrome or secondary acute myeloid leukaemia: a phase II 
study. Ann. Hematol. 87, 881–885 (2008).


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Lonafarnib/Ritonavir/Lambda Interferon for Chronic Hepatitis Delta 
Patient Name ________________________________
Enrollment Criteria
No
Criteria
Yes/No
Comment
1
Is patient 18 years or above?
Age = _____  years
2
Is anti-HDV present in serum?
Date of sample:  ___/ ___/ ___
3
Is HDV RNA positive at three time 
points?
Date of samples: ___/___/___
                               ___/ ___/ ___
                               ___/ ___/ ___
4
Is 
chronic 
HDV 
infection 
demonstrated by the present oc HDV 
RNA in serum >/= 6 months, or 
presence of anti-HDV antibody for 
>/= 6 months
5
Is consent form signed?
Date of signature ___/___/___
The answers to these questions 
should all be yes for the patient to be 
enrolled in this study.


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The answers to the above questions are all yes.  
  ______________________________
Signature 
and 
Date


65
PRENYLATION INHIBITORS FOR CHRONIC HEPATITIS D
Patient Name _______________________________
Exclusion Criteria
No
Criteria
Yes/No
Comment
1
Are any of the last 3 ALT levels > 
1000U/L?  
2
Is serum bilirubin > 4 mg%?
Bilirubin = 
3
Is serum albumin < 3 gm%?
Albumin =
4
Is protime > 2 seconds prolonged or 
INR >1.7?
Protime =
INR
5
Are triglycerides >500 mg/dL
6
Is PR or QTc interval prolonged on 
EKG?
6
Is there a history of bleeding 
varices, ascites or encephalopathy?
7
For females with childbearing 
potential: Is the patient pregnant, 
actively breast-feeding, or unable to 
practice birth control?
Not applicable if patient has had a 
tubal ligation ____
8
For males: Is the patient able to 
practice birth control?
Not applicable if patient has had a 
vasectomy _____
9
Are there significant other medical 
illnesses such as CHF, renal failure, 
transplant, psychiatric dx, and angina?
10
Has the patient been on systemic 
immunosuppressive therapy within the 
previous 2 months?
11
Does the patient have another form of 
liver disease in addition to coinfection 
of HBV and HDV?
12
Has the patient undergone any 
experimental therapy or pegylated 
interferon within 6 months prior to 
starting the study?


66
13
Has the patient had a diagnosis of 
malignancy within 5 years prior to 
enrollment with the exception of 
superficial dermatologic 
malignancies?
14
Has patient had active substance abuse 
in the last one year?
Alcohol, inhaled or injection drugs
15
Does the patient have evidence of HIV 
co-infection?
Date of test: date __/__/__
16
Is AFP > 200 ng/ml and does the 
ultrasound/MRI/CT show evidence of 
a mass in the liver?
AFP = _____ 
US/MRI/CT date __/__/__
17
Is the patient currently on statin 
medications?
18
Is the patient currently on medications 
that would alter metabolism of 
ritonavir?
Alpha-1-adrenoreceptor antagonist
Antiarrythmic medications
Pimozide
Sildinafil
Sedative and hynotics
Ergot
St. John’s Wort
The answer to all of the above questions is no:  
_________________________________
                                     Signature and Date


67
Appendix 1
SYMPTOM SCALE: Delta Hepatitis
Name:__________________________________ Date:(M/D/Yr)____/____/____  
For the following questions, please respond by circling one of the numbers from 1 to 7.  
The numbers designate the following answer:
1. All of the time
2. Most of the time
3. A good bit of the time
4. Some of the time
5. A little of the time
6. Hardly any of the time
7. None of the time
1. How much of the time since your last visit have you been troubled by a feeling of 
abdominal bloating? 
2. How much of the time have you been tired or fatigued since your last visit?
3. How much of the time since your last visit have you experienced bodily pain?
4. How often since your last visit have you felt sleepy during the day?
5. How much of the time since your last visit have you experienced abdominal pain?  
6. How much of the time since your last visit has shortness of breath been a problem for 
you in your daily activities? 
7. How much of the time since your last visit have you not been able to eat as much as 
you would like? 
8. How much of the since your last visit have you been bothered by having decreased 
strength? 
9. How often since your last visit have you felt anxious?
10. How often since your last visit have you felt a decreased level of energy? 
11. How much of the time since your last visit have you felt unhappy? 
12. How often since your last visit have you felt drowsy?
13. How often since your last visit have you been irritable? 
14. How much of the time since your last visit have you had difficulty sleeping at night? 


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15. How much of the time since your last visit have you been troubled by a feeling of 
abdominal discomfort? 
16. How much of the time since your last visit have you had mood swings? 
17. How much of the time since your last visit have you been unable to fall asleep at 
night? 
18. How often since your last visit have you had muscle cramps? 
19. How much of the time since your last visit have you felt depressed?
20. How much of the since your last visit have you had problems concentrating? 
21. How much of the time have you been troubled by itching since your last visit? 
22. Since your last visit have you had any excessive hair loss?
23. Since your last visit have you had any rashes?


69
Appendix 2
Microbiome Monthly Intake Questionnaire: Delta Hepatitis
Name: _________________________________ Date: (M/D/Yr) _____/______/______
1. Over past month, have you taken any new antibiotic medications prescribed by a 
doctor?
 
Yes [  ]           No [   ]
If yes, when was the last time you took the antibiotic?   ________________
Name of antibiotic                ________________________________
Duration of treatment           _________________________________
   
2. Over past month, have you taken any probiotics?   
Yes [   ]          No  [   ]
If yes, when was the last time you took probiotic?       _________________
         Name of probiotic                    _______________________________
         How long have you been taking probiotics?        _________________ 
3. Over past month, have you eaten any yogurt?                        Yes [  ]          No  [  ]
If yes, when was the last time you ate yogurt?     ______________________
           Name of yogurt                                          ______________________
           Does yogurt have probiotics in it?                     Yes [  ]          No  [  ]


70