A higher incidence of anemia has been observed during the treatment of hepatitis C virus genotype 1 (HCV-1) infection with pegylated alpha interferon (pegIFN-␣), ribavirin, and telaprevir. We assessed the impacts that concomitant administration of telaprevir and changes in the glomerular filtration rate have on ribavirin plasma levels. The minimum concentrations of ribavirin in plasma (ribavirin C min ) determined during triple therapy including telaprevir were compared with those observed after telaprevir withdrawal and those observed in the same subjects and in a large cohort during a previous course of pegIFN-␣ plus ribavirin. Intensive pharmacokinetic sampling for ribavirin was performed at steady state during the triple-therapy phase. Ribavirin levels were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS). Twenty-seven HCV-1/HIV-coinfected patients were enrolled. The median ribavirin C min for triple therapy (4.08 g/ml; range, 2.14 to 5.56 g/ml) was higher than that observed after telaprevir withdrawal (1.96 g/ml; range, 0.41 to 3.45 g/ml) (P < 0.001) and that observed for 125 HCV-1/HIV-coinfected patients treated only with pegIFN-␣ plus ribavirin (1.65 g/ml; range, 0.41 to 5.56 g/ml) (P < 0.001). The estimated glomerular filtration rate (eGFR) decreased >20% from the baseline value in 11 of 27 patients and became normal after telaprevir removal in almost all cases. There was a negative correlation between eGFR and ribavirin clearance (r 2 ؍ 0.257; P ؍ 0.064) but not the ribavirin area under the concentration-time curve from 0 to 12 h (AUC 0 -12 ) (r 2 ؍ 0.001; P ؍ 0.455). Thus, there is a significant pharmacokinetic interaction between telaprevir and ribavirin that results in very high ribavirin levels, which explains the excess of toxicity observed with this drug combination. A blockade of the proximal tubular transporters might be implicated in both the increase in plasma creatinine and the high ribavirin levels. (This study has been registered at ClinicalTrials.gov under registration no. NCT01818856.) T here is an extensive amount of literature on the pharmacokinetics and pharmacodynamics of ribavirin (Rbv) showing discordant data about the relationship between Rbv plasma concentrations and efficacy during dual therapy (DT) with pegylated alpha interferon (pegIFN-␣) plus Rbv. However, all studies agree about the association between Rbv plasma levels and the occurrence and severity of anemia (1-13). In the recent past, the NS3/4A protease inhibitors boceprevir and telaprevir (TVR) were incorporated into the armamentarium for the treatment of chronic hepatitis C virus genotype 1 (HCV-1) infection. The recommended Rbv dosing during triple therapy (TT) was the same as in DT, since pharmacological interactions between pegIFN-␣, Rbv, and TVR were not expected (14, 15). However, a higher incidence and severity of anemia were observed in both mono-and HCV/HIV-coinfected patients during the course of TT. Initially, the higher anemia rates were ascribed to an additive effect of Rbv and...