1. Liver Institute of Virginia Education, Research and Treatment for Patients with Liver Disease IVer Bon Secours Health System WHY CHOOSE TELAPREVIR Mitchell L Shiffman, MD Liver Institute of Virginia Bon Secours Health System Richmond and Newport News, VA, USA

2. IVer TELAPREVIR TREATMENT NAÏVE AND RELAPSE HCV RNAUD RVR Telaprevir PEGINF Ribavirin PEGINF Ribavirin No RVR PEGINF-RBV Log HCV< 3 UD Stop Rule>3 + Week4812162024283236404448 ML Shiffman, R Estaban Liver Intl 2012; 32 (suppl 1):54-60.

3. IVer TELAPREVIR NON-RESPONSE AND CIRRHOSIS RVR HCV RNA Telaprevir PEGINF Ribavirin No RVR PEGINF-RBV Log HCV< 3 UD Stop Rule>3 + Week4812162024283236404448 ML Shiffman, R Estaban Liver Intl 2012; 32 (suppl 1):54-60.

4. IVer SVR RATES VERY COMPARABLE BoceprevirTelaprevir Treatment Naïve: eRVR Delayed response % with eRVR 96% 66-75% 56% 89-92% 64% 58-60% Retreatment: Relapse Partial response Null response INF sensitive (lead-in) INF insensitive (lead-in) 69-75% 40-52% NA 73-79% 33-34% 84-88% 56-61% 31-33% NA

5. IVer SVR RATES VERY COMPARABLE BoceprevirTelaprevir Treatment Naïve: eRVR Delayed response % with eRVR 96% 66-75% 56% 89-92% 64% 58-60% Retreatment: Relapse Partial response Null response INF sensitive (lead-in) INF insensitive (lead-in) 69-75% 40-52% NA 73-79% 33-34% 84-88% 56-61% 31-33% NA

6. IVer SVR RATES VERY COMPARABLE BoceprevirTelaprevir Treatment Naïve: eRVR Delayed response % with eRVR 96% 66-75% 56% 89-92% 64% 58-60% Retreatment: Relapse Partial response Null response INF sensitive (lead-in) INF insensitive (lead-in) 69-75% 40-52% NA 73-79% 33-34% 84-88% 56-61% 31-33% NA

7. IVer TELAPREVIR WHY CHOOSE THIS REGIMEN? It is just an easier treatment regimen

8. IVer TELAPREVIR ITS JUST EASIER All three medications are started at the same time All patients get 12 weeks of telaprevir Treatment naïve Prior relapse Prior non-response Cirrhosis

9. IVer TELAPREVIR ITS JUST EASIER If you have to stop telaprevir at week 8 for adverse events the SVR is only marginally reduced. 50% 54% Telaprevir PEGIFN-2a Ribavirin If NO eRVR: PEGINF + Ribavirin If eRVR: PEGINF + Ribavirin Telaprevir PEGIFN-2a Ribavirin 128 83% 89% Week of TPV 12 4824 Weeks 0 8 IM Jacobson et al. N Engl J Med 2011; 364:2405-16.

10. IVer TELAPREVIR ITS JUST EASIER Only 2 treatment durations Treatment naïve and prior relapsers: 24 weeks if achieve extended rapid response 48 weeks with delayed response Prior non-response and cirrhosis 48 weeks

11. IVer TELAPREVIR ITS JUST EASIER 60% achieve eRVR. Treated for 24 weeks 21% have delayed response. Treated 48 weeks. 81% of patients become HCV RNA undetectable during treatment

12. IVer TELAPREVIR ITS JUST EASIER Smaller pill burden 2 capsules TID = 6/day Randomized controlled trial suggests telaprevir can be dosed 3 capsules BID without impacting SVR = P Marcellin et al. Gastroenterol 2011; 140:459-468.

13. IVer TELAPREVIR ITS JUST EASIER Stop rules at weeks 4 and 12. Allows resistant virus to be recognized earlier. Resistance monitoring uses the same cutt-off. Week 4 >Log 3 Week 12 >Log Week 24 negative

14. IVer TELAPREVIR NEGATIVE FEATURES Side effects of therapy Side effects of peginterferon and ribavirin Side effects of telaprevir Anemia Rash GI symptoms

15. IVer RASH UNIQUE TO TELAPREVIR Appears in over half of patients treated with telaprevir Typically appears during first 4 weeks of treatment Worsens progressively during treatment Most patients never reach stage 3-4 If severe, can stop telaprevir a few weeks early The decline in SVR is minimal even in patients with delayed virologic response

16. IVer TELAPREVIR GRADE 2 RASH

17. IVer TELAPREVIR GRADE 3 RASH

18. IVer TELAPREVIR GRADE 4 RASH

19. IVer TELAPREVIR SIDE EFFCTS GI toxicity: Nausea Vomiting Diarrhea Anal-rectal burning

20. IVer TELAPREVIR SUMMARY To treat HCV with Incevik Is not a trick. Just start it with PEG and Riba together. Treat for 12 weeks and see it get better. If negative at week 4. Its virtually a cure. Continue PEG and riba for sure. Till week 24. And then dash straight through the door.

21. IVer TELAPREVIR SUMMARY However, If the response is delayed. Do not be dismayed. For if less than a thousand by month 3. A cure can still be. Adhere to the stop rules at 4 and 12 weeks. This is important and so do not cheat. And you will see. This rule will keep you mutant free.

22. IVer TELAPREVIR SUMMARY AEs include rash, anemia and a sore bum. This is not fun. This make patients glum. And their physicians run. And so my friends, When treating with telaprevir there is no reason to quiver. Because its dam good at getting HCV Out of the liver.