Some medically important viruses-including retroviruses, flaviviruses, coronaviruses, and herpesviruses-code for a protease, which is indispensable for viral maturation and pathogenesis. Viral protease inhibitors have become an important class of antiviral drugs. Development of the first-in-class viral protease inhibitor saquinavir, which targets HIV protease, started a new era in the treatment of chronic viral diseases. Combining several drugs that target different steps of the viral life cycle enables use of lower doses of individual drugs (and thereby reduction of potential side effects, which frequently occur during long term therapy) and reduces drug-resistance development. Currently, several HIV and HCV protease inhibitors are routinely used in clinical practice. In addition, a drug including an inhibitor of SARS-CoV-2 main protease, nirmatrelvir (co-administered with a pharmacokinetic booster ritonavir as Paxlovid®), was recently authorized for emergency use. This review summarizes the basic features of the proteases of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and SARS-CoV-2 and discusses the properties of their inhibitors in clinical use, as well as development of compounds in the pipeline.

• MeSH
• Antiviral Agents pharmacology   therapeutic use   MeSH
• COVID-19 * MeSH
• HIV Infections * drug therapy   MeSH
• Humans MeSH
• SARS-CoV-2 MeSH
• Viral Proteases MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Review MeSH
• Names of Substances
• Antiviral Agents MeSH
• nirmatrelvir and ritonavir drug combination MeSH Browser
• Viral Proteases MeSH

Viral proteases are indispensable for successful virion maturation, thus making them a prominent drug target. Their enzyme activity is tightly spatiotemporally regulated by expression in the precursor form with little or no activity, followed by activation via autoprocessing. These cleavage events are frequently triggered upon transportation to a specific compartment inside the host cell. Typically, precursor oligomerization or the presence of a co-factor is needed for activation. A detailed understanding of these mechanisms will allow ligands with non-canonical mechanisms of action to be designed, which would specifically modulate the initial irreversible steps of viral protease autoactivation. Binding sites exclusive to the precursor, including binding sites beyond the protease domain, can be exploited. Both inhibition and up-regulation of the proteolytic activity of viral proteases can be detrimental for the virus. All these possibilities are discussed using examples of medically relevant viruses including herpesviruses, adenoviruses, retroviruses, picornaviruses, caliciviruses, togaviruses, flaviviruses, and coronaviruses.

• Keywords
• Human Immunodeficiency Virus (HIV), Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), activation, adenoviruses, autoprocessing, flaviviruses, herpesviruses, precursor, protease,
• MeSH
• Antiviral Agents pharmacology   MeSH
• Flavivirus drug effects   metabolism   MeSH
• Herpesviridae drug effects   metabolism   MeSH
• HIV-1 drug effects   MeSH
• Viral Protease Inhibitors pharmacology   MeSH
• Humans MeSH
• Adenoviruses, Human drug effects   metabolism   MeSH
• SARS-CoV-2 drug effects   metabolism   MeSH
• Virus Diseases drug therapy   MeSH
• Viral Proteases biosynthesis   metabolism   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Review MeSH
• Names of Substances
• Antiviral Agents MeSH
• Viral Protease Inhibitors MeSH
• Viral Proteases MeSH

During the last few decades, the treatment of HIV-infected patients by highly active antiretroviral therapy, including protease inhibitors (PIs), has become standard. Here, we present results of analysis of a patient-derived, multiresistant HIV-1 CRF02_AG recombinant strain with a highly mutated protease (PR) coding sequence, where up to 19 coding mutations have accumulated in the PR. The results of biochemical analysis in vitro showed that the patient-derived PR is highly resistant to most of the currently used PIs and that it also exhibits very poor catalytic activity. Determination of the crystal structure revealed prominent changes in the flap elbow region and S1/S1' active site subsites. While viral loads in the patient were found to be high, the insertion of the patient-derived PR into a HIV-1 subtype B backbone resulted in reduction of infectivity by 3 orders of magnitude. Fitness compensation was not achieved by elevated polymerase (Pol) expression, but the introduction of patient-derived gag and pol sequences in a CRF02_AG backbone rescued viral infectivity to near wild-type (wt) levels. The mutations that accumulated in the vicinity of the processing sites spanning the p2/NC, NC/p1, and p6pol/PR proteins lead to much more efficient hydrolysis of corresponding peptides by patient-derived PR in comparison to the wt enzyme. This indicates a very efficient coevolution of enzyme and substrate maintaining high viral loads in vivo under constant drug pressure.

• MeSH
• Cell Line MeSH
• gag Gene Products, Human Immunodeficiency Virus genetics   MeSH
• pol Gene Products, Human Immunodeficiency Virus genetics   MeSH
• Genes, gag MeSH
• Genes, pol MeSH
• HEK293 Cells MeSH
• HIV Infections drug therapy   virology   MeSH
• HIV-1 genetics   isolation & purification   physiology   MeSH
• HIV Protease chemistry   genetics   metabolism   MeSH
• HIV Protease Inhibitors therapeutic use   MeSH
• Crystallography, X-Ray MeSH
• Humans MeSH
• Molecular Sequence Data MeSH
• Mutation MeSH
• Peptide Fragments genetics   MeSH
• Drug Resistance, Viral genetics   MeSH
• Viral Load MeSH
• Antiretroviral Therapy, Highly Active MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH
• Research Support, U.S. Gov't, Non-P.H.S. MeSH
• Names of Substances
• gag protein p1, Human immunodeficiency virus MeSH Browser
• gag Gene Products, Human Immunodeficiency Virus MeSH
• pol Gene Products, Human Immunodeficiency Virus MeSH
• HIV Protease MeSH
• HIV Protease Inhibitors MeSH
• p2 gag peptide, Human immunodeficiency virus 1 MeSH Browser
• Peptide Fragments MeSH

The design, development and clinical success of HIV protease inhibitors represent one of the most remarkable achievements of molecular medicine. This review describes all nine currently available FDA-approved protease inhibitors, discusses their pharmacokinetic properties, off-target activities, side-effects, and resistance profiles. The compounds in the various stages of clinical development are also introduced, as well as alternative approaches, aiming at other functional domains of HIV PR. The potential of these novel compounds to open new way to the rational drug design of human viruses is critically assessed.

• Keywords
• HAART, HIV protease, alternative inhibitors, pharmacokinetic boosting, protease dimerization, protease inhibitors, resistance development,
• Publication type
• Journal Article MeSH