Inhibitors of the human immunodeficiency virus type 1 (HIV-1) protease have entered clinical study as potential therapeutic agents for HIV-1 infection. The clinical efficacy of HIV-1 reverse transcriptase inhibitors has been limited by the emergence of resistant viral variants. Similarly, variants expressing resistance to protease inhibitors have been derived in cell culture. We now report the characterization of resistant variants isolated from patients undergoing therapy with the protease inhibitor MK-639 (formerly designated L-735,524). Five of these variants, isolated from four patients, exhibited cross-resistance to all members of a panel of six structurally diverse protease inhibitors. This suggests that combination therapy with multiple protease inhibitors may not prevent loss of antiviral activity resulting from resistance selection. In addition, previous therapy with one compound may abrogate the benefit of subsequent treatment with a second inhibitor.

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Derivatives of pyridinones were found to inhibit human immunodeficiency virus type 1 (HIV-1) reverse transcriptase (RT) activity and prevent the spread of HIV-1 infection in cell culture without an appreciable effect on other retroviral or cellular polymerases. 3-{[(4,7-Dimethyl-1,3-benzoxazol-2-yl)methyljamino}-5-ethyl-6methylpyridin-2(LH)-one (L-697,639) and 3-{[(4,7-dichloro-1,3-benzoxazol-2-yl)methylJamino}-5-ethyl--methylpyridin-2(IH)-one (L-697,661) Infection with the human immunodeficiency virus type 1 (HIV-1) causes progressive destruction of the immune system, which ultimately results in AIDS. An essential step in the life cycle of HIV-1 is reverse transcription of the viral RNA genome to produce a double-stranded DNA copy. This process is mediated by the virally encoded reverse transcriptase (RT). Thus, RT is a potential therapeutic target and, indeed, nucleoside analog inhibitors of RT, such as 3'-azido-3'-deoxythymidine (AZT) and dideoxyinosine (ddI), are clinically effective drugs for treating HIV-1 infection (1, 2). However, their effectiveness is limited by toxicities, which may reflect inhibition of cellular polymerases and/or alteration of nucleoside pools, given that the nucleoside analogs are phosphorylated (in competition with natural nucleosides) to their active form by cellular kinases (3, 4). The emergence of AZT-resistant virus (5) further emphasizes the need to develop selective RT inhibitors that can be used either alone or in combination with nucleoside analogs. The development of specific RT inhibitors is the subject ofthis communication. (L-697,661) were synthesized by alkylation of 3-amino-5-ethyl-6-methylpyridin-2(1H)-one with either N-hydroxymethylphthalimide or the appropriate 2-halomethylbenzoxazole. Requisite aminopyridinone was obtained from condensation of 3-formyl-2-pentanone with nitroacetamide followed by catalytic reduction.Synthesis of ethylene derivative 5-ethyl-6-methyl-3-(2-phthalimidoethyl)pyridin-2(1H)-one (L-693,593) began with the condensation of 3-formyl-2-pentanone and cyanoacetamide to give 3-cyano-5-ethyl-6-methylpyridin-2(1H)-one. Reaction of this cyanopyridinone with POCl3 followed by methanolysis and reduction with diisobutylaluminum hydride led to 5-ethyl-2-methoxy-6-methylpyridine-3-carboxaldehyde. The aldehyde function was treated with trimethylsilyl cyanide, and the resulting cyanohydrin was reduced with lithium aluminum hydride to the amino alcohol. After conversion of the amino group to phthalimide, demethylation ofthe 2-methoxy group and alcohol dehydration was accomplished in one step by heating with pyridine hydrochloride. Catalytic reduction of the olefin formed yielded ethylene analog L-693,593. The structures of all pyridinones synthesized are consistent with their NMR spectra, and all compounds gave an acceptable combustion analysis (within 0.4%).H1V-1 RT Assays. rC-dG.

A series of HIV protease inhibitors possessing a hydroxylaminepentanamide transition state isostere have been developed. Incorporation of a basic amine into the backbone of the L-685,434 (2) series provided antiviral potency combined with a highly improved pharmacokinetic profile in animal models. Guided by molecular modeling and an X-ray crystal structure of the inhibited enzyme complex, we were able to design L-735,524. This compound is potent and competitively inhibits HIV-1 PR and HIV-2 PR with Ki values of 0.52 and 3.3 nM, respectively. It also stops the spread of the HIV-1IIIb-infected MT4 lymphoid cells at concentrations of 25-50 nM. To date, numerous HIV-PR inhibitors have been reported, but few have been studied in humans because they lack acceptable oral bioavailability. L-735,524 is orally bioavailable in three animals models, using clinically acceptable formulations, and is currently in phase II human clinical trials.

Indinavir (IDV) (also called CRIXIVAN, MK-639, or L-735,524) is a potent and selective inhibitor of the human immunodeficiency virus type 1 (HIV-1) protease. During early clinical trials, in which patients initiated therapy with suboptimal dosages of IDV, we monitored the emergence of viral resistance to the inhibitor by genotypic and phenotypic characterization of primary HIV-1 isolates. Development of resistance coincided with variable patterns of multiple substitutions among at least 11 protease amino acid residues. No single substitution was present in all resistant isolates, indicating that resistance evolves through multiple genetic pathways. Despite this complexity, all of 29 resistant isolates tested exhibited alteration of residues M-46 (to I or L) and/or V-82 (to A, F, or T), suggesting that screening of these residues may be useful in predicting the emergence of resistance. We also extended our previous finding that IDV-resistant viral variants exhibit various patterns of cross-resistance to a diverse panel of HIV-1 protease inhibitors. Finally, we noted an association between the number of protease amino acid substitutions and the observed level of IDV resistance. No single substitution or pair of substitutions tested gave rise to measurable viral resistance to IDV. The evolution of this resistance was found to be cumulative, indicating the need for ongoing viral replication in this process. These observations strongly suggest that therapy should be initiated with the most efficacious regimen available, both to suppress viral spread and to inhibit the replication that is required for the evolution of resistance.