Boceprevir and Telaprevir: We Hardly Knew Ye
When I was finishing up pharmacy school (2013), the landscape of Hep-C therapy was drastically changing. Two new drugs, boceprevir and telaprevir, were fresh on the market and were "game changers" according to any and everyone. In fact--I presented these new protease inhibitors (in all their majesty) during my residency interviews.
Now it's 2016 and they're both gone.
What happened? A new belle of the ball (Sofosbuvir) was released. Sofosbuvir was so effective compared to everything else, that telaprevir and boceprevir were removed entirely from the Hep C Guidelines. What happens when a drug that only treats Hep C is removed from the Hep C Guidelines? Well....telaprevir was pulled from market in 2014. And boceprevir only made it until 2015
All dressed up and nowhere to go.
Remember how throughout school you've been told how quickly medicine can change? This is an example of that.
Moving on. Boceprevir and telaprevir will always have a special place in my heart. We formed a close bond created during my residency interview preparation. A lot of work went into my "Updates in Hepatitis C" presentation (which was irrelevant about 2 months after I finished interviews). So I thought we'd pay a little tribute to them today on tl;dr pharmacy.
There were some fun counseling points with these drugs.
You took each drug 3 times daily with meals. The pill burden was insane. Boceprevir's, dose was 800mg TID.....taken as four 200mg capsules. For the life of me, I may never understand why you'd formulate a 200mg capsule if the dose is 800mg. Why stop at 200mg? Why not 100mg? Or 50mg?
Anyway, there was a lot of pills to take (and this is in addition to the ridiculous ribavirin pill burden). Then there was the adherence thing. Resistance to HCV protease inhibitors was a big concern. Boceprevir and telaprevir were a new way of fighting Hep C. We didn't want to lose them to a resistant strain of the virus gone rogue. So there was a sort of "unwritten" rule that if a patient missed more than 1 week of the therapy (for any reason), then they would be discontinued for life.
Yeah, people were pretty worried about resistance.
And last but not least were the dietary requirements. Boceprevir and telaprevir didn't absorb too well into the system unless taken with a fatty meal. Remember, you're taking these medications 3 times daily. "No big deal," you say. "I'll just take them with a glass of whole milk and be on my way."
Nope.
You needed to take these medications with at least 20 grams of fat. So, at a minimum, you're asking patients to eat 60 grams of fat per day. How much is 20 grams of fat? Allow me to show you....
A Few Examples of 20 Grams of Fat
It's not so much that eating this amount of fat is that difficult over a few days. But these were 48 week durations of treatment. This was your diet for about 11 months.
What's the Lesson Here?
The landscape of medicine changes quickly. It doesn't normally change as quickly as Hep C seems to, but preferred therapies come and go. Practice changes. Patients and prescribers will be looking to you to stay up to date. The profession of pharmacy doesn't exist in suspended animation. It will not continue to look the same way it does when you graduate. Hep C is an example of that, but every disease state changes. Hyperlipidemia has also taken a bit of a tangent from how it was taught "when I was your age."
Anyway, to end the rant. At some point in your career, you will probably find yourself wondering "Gee, what ever happened to that one drug?"
<Shameless Plug> All the more reason to frequent tl;dr pharmacy, I'd say.