Human glioblastoma multiforme cells demonstrate varying levels of sensitivity to tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-induced apoptosis. Endoplasmic reticulum (ER) stress has been shown to trigger cell death through apoptosis. We therefore pursued a strategy of integrating clinically relevant investigational agents that cooperate mechanistically through the regulation of ER stress and apoptosis pathways. Nelfinavir belongs to the protease inhibitor class of drugs currently used to treat patients with HIV and is in clinical trials as an anti-tumor agent. We found that Nelfinavir treatment led to ER stress-induced up-regulation of the DR5 receptor. This transactivation was mediated by the transcription factor CCAAT/enhancer binding protein homologous protein (CHOP). We also determined that ER stress-induced ATF4 up-regulation was responsible for modulation of CHOP. In contrast, DR4 receptor expression was unchanged by Nelfinavir treatment. Combining Nelfinavir with TRAIL led to a significantly enhanced level of apoptosis that was abrogated by siRNA silencing of DR5. We provide evidence that Nelfinavirinduced ER stress modulates DR5 expression in human glioblastoma multiforme cells and can enhance TRAIL efficacy. These studies provide a potential mechanistic rationale for the use of the Food and Drug Administration-approved agent Nelfinavir in combination with DR5 agonists to induce apoptosis in human malignancies.Malignant gliomas account for Ďł70% of the 22,500 new cases of malignant primary brain tumors that are diagnosed in adults in the United States each year (1). Glioblastoma multiforme is a high-grade, highly lethal, and frequent brain tumor in adults. Traditional treatments such as DNA damaging agents and radiotherapy have demonstrated modest effects on patient survival, likely because in part of an inherent high-level expression of anti-apoptotic proteins such as Bcl-2, Bcl-X L , and sFLIP (2, 3). Frequent gene amplification and overexpression of the death decoy receptor DcR3 have also been reported in glioblastoma (4). Therefore, new strategies to induce apoptosis may help to overcome therapeutic resistance and improve efficacy.Nelfinavir is an HIV protease inhibitor and has been used to treat HIV/AIDS patients for over a decade. Recently, several groups reported the anticancer activity of Nelfinavir in a wide range of human cancer cell lines and tumor xenografts. Nelfinavir induces ER 2 stress, the unfolded protein response, autophagy, apoptosis, and caspase-independent cell death in various cancer cells (5-9). Multiple mechanisms have been proposed to explain the anticancer activities of the drug, such as inhibition of AKT/protein kinase B (PKB) activation (10), the proteasome (9), or signal transducer and activator of transcription (STAT) 3 (11), and down-regulation of hypoxia-inducible factor 1⣠(HIF-1âŁ)/VEGF expression (8). However, the exact molecular mechanisms of Nelfinavir efficacy in human cancer cells remains unclear and may be cell type-specific. We currently have an...