The hepatitis C virus (HCV) RNA-dependent RNA polymerase NS5B is an important target for antiviral therapies. NS5B is able to initiate viral RNA synthesis de novo and then switch to a fast and processive RNA elongation synthesis mode. The nucleotide analogue 2-C-methyl CTP (2-C-Me-CTP) is the active metabolite of NM283, a drug currently in clinical phase II trials. The resistance mutation S282T can be selected in HCV replicon studies. Likewise, 2-O-Me nucleotides are active both against the purified polymerase and in replicon studies. We have determined the molecular mechanism by which the S282T mutation confers resistance to 2-modified nucleotide analogues. 2-C-Me-CTP is no longer incorporated during the initiation step of RNA synthesis and is discriminated 21-fold during RNA elongation by the NS5B S282T mutant. Strikingly, 2-Omethyl CTP sensitivity does not change during initiation, but the analogue is no longer incorporated during elongation. This mutually exclusive resistance mechanism suggests not only that "2-conformer" analogues target distinct steps in RNA synthesis but also that these analogues have interesting potential in combination therapies. In addition, the presence of the S282T mutation induces a general cost in terms of polymerase efficiency that may translate to decreased viral fitness: natural nucleotides become 5-to 20-fold less efficiently incorporated into RNA by the NS5B S282T mutant. As in the case for human immunodeficiency virus, our results might provide a mechanistic basis for the rational combination of drugs for low-fitness viruses.Hepatitis C virus (HCV) infection is the most common blood-borne infection and a major cause of chronic liver disease in developed countries. More than 170 million individuals in the world are infected with HCV, making these individuals at risk of developing liver cirrhosis and hepatocellular carcinoma. Persistent HCV infection can be controlled by antiviral therapy (30, 40) or even eradicated from infected patients (43).Current antiviral therapies rely on the combination of pegylated alpha interferon and the nucleoside analogue ribavirin (16,18,29). Less than 50% of treated patients respond when they are infected with the most prevalent HCV genotype, i.e., genotype 1 (23). The HCV RNA-dependent RNA polymerase (RdRp), the NS5B protein, plays an essential role in the replication of the viral genome and is thus an attractive target for the development of new antiviral drugs (36). Intensive drugscreening programs led to the discovery of two classes of HCV NS5B inhibitors, namely, nonnucleoside inhibitors (NNIs) and nucleoside inhibitors (NIs). NNIs have been described to bind to one of the three allosteric sites present at the NS5B surface (for a review, see reference 11). All of the NNIs are noncompetitive inhibitors relative to nucleoside triphosphate (NTP) incorporation and target the alloenzyme free of substrate. They are inactive when the enzyme has entered into the processive elongation phase (3,17,31,45,46) of in vitro RdRp reactions or when NS5B is c...