Pharmacological issues relating to viral resistance

Anti-HIV drug regimens can fail for a number of reasons including virological resistance, difficulties of adherence and poor tolerability. However, this brief review focuses on the development of "pharmacological'' resistance as an area of great importance in drug failure. For nucleoside reverse transcriptase inhibitors (NRTIs) this is related to the possible down-regulation of the intracellular phosphorylation of an NRTI with time. For protease inhibitors the concern is cells expressing transmembrane energy-dependent transporters (such as p-glycoprotein, p-gp; or multi-drug resistance protein, MRP) which efflux drug (particularly protease inhibitors) out of the cell so that intracellular concentrations of drug are insufficient for antiviral effect.