Tools for eradicating HIV in the brain: prodrug dimeric inhibitors of P-gp

Despite positive developments with the use of combination antiretroviral therapy, a major impediment to limiting the neurocognitive effects of HIV and eradicating HIV brain reservoirs is the penetration of these therapies across the blood-brain barrier (BBB). The focus of our work, therefore, has been to develop tools to significantly improve the penetration of antiretroviral agents to sites of HIV reservoirs, with an emphasis on the CNS. To this end, we have developed an innovative chemical approach--dimeric prodrugs of the antiretroviral agents themselves with a traceless tether. These dimeric prodrugs were designed to serve two purposes: inhibition of P-gp, the major drug efflux protein at the BBB, by occupying two substrate binding sites in the transporter; and prodrug dimers that gain entry into the endothelial cells at the BBB would revert to their monomeric forms in the reducing environment of the cytosol due to breakdown of the traceless tether, thus delivering the therapy. We have demonstrated the feasibility of this design by dimerizing the P-gp substrate and antiviral agent abacavir with a traceless tether. Abacavir dimers displayed potent inhibition of P-gp in two different cellular settings and reverted to active abacavir in the reducing environment of HIV-infected T cells, also leading to antiviral activity. Overall, these experiments point to the excellent promise for future use of dimeric prodrug inhibitors of P-gp for brain penetration of a wide range of CNS-active agents that are substrates of P-gp.