HCV Protease Inhibitors

Question: A 33 year old male with HCV, genotype 1, stage II fibrosis has just completed twelve weeks of telaprevir, peg-interferon and ribavirin. His viral load was detected at < 43 IU/mL at week #4, and undetectable at week 8 and 12.  How long should you continue the remainder of his medications?

A. continue all 3 medications for an additional 12 weeks

B. continue only the peginterferon and ribavirin for an additional 12 weeks

C. continue only the peginterferon and ribavirin for a total of 48 weeks

D. stop all medications; the positive viral load at week #4 suggests he will ultimately be a relapser

 

Answer: Knowing the STOP rules for telaprevir is important.  Patients get excited knowing that treatment may only last 24 weeks even if they have genotype 1.  However, in order to stop at 24 weeks, the viral load has to be completely negative at weeks 4, 8 and 12.  This patient had a detectable virus at week 4.  Even though telaprevir will stop at week #12, the other two medications should be continued for the full 48 weeks instead of 24. 

I would recommend stopping all medications only if the viral load was still positive at week #12.  Continuing the other two medications for another 12 weeks (total of 24 weeks) is appropriate if all viral loads were negative.  With telaprevir, you should not continue it for more than 12 weeks, so the first answer choice is also incorrect. 

Instead of a 70-75% chance of SVR, this patient will have a 60-65% chance of SVR, after continuing the peginterferon and ribavirin for a total of 48 weeks.

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