A key step in the retroviral life cycle is activation of the viral protease. This protease is required for cleavage of the Gag precursor proteins and generation of infectious virus particles. One of the major advances in the fight against AIDS is the use of combination therapy with compounds that inhibit HIV-1 protease. However, a side effect of protease-inhibitor therapy is the development of insulin resistance in many patients. The primary function of insulin is to regulate glucose uptake into cells. This is normally accomplished by translocation of the GLUT4 glucose transporter from intracellular vesicles to the plasma membrane. Most of the glucose in our bodies is removed by the GLUT4 protein in skeletal muscle, and glucose uptake through this transporter is the rate-limiting step for glucose utilization in humans.Murata et al.1xSee all References1 hypothesized that the molecular basis for insulin resistance during protease-inhibitor therapy might involve defective glucose transport. To test this, they examined the effect of the HIV-1 protease inhibitor indinavir on sugar uptake into cells. A rapid and reversible inhibition of insulin-stimulated glucose transport was observed, with approximately 25% inhibition at 10 μm indinivar, a concentration similar to that achieved in vivo in patients. There was little effect on the basal rate of transport, which is controlled by the GLUT1 transporter. Indinavir did not alter the ability of the insulin receptor to transmit signals to downstream signaling molecules, nor was there an effect on GLUT4 translocation to the plasma membrane. The authors then tested whether protease inhibitors work directly on GLUT4 by expressing this glucose transporter in Xenopus laevis oocytes. Here, they observed 50% inhibition of the intrinsic glucose transport activity of GLUT4 by 100 μm indinavir, as well as two other protease inhibitors.These findings have led the authors to suggest that specific inhibition of the GLUT4 glucose transporter might account for the insulin resistance in AIDS patients treated with HIV-1-protease inhibitors. It is interesting to note however, that GLUT4 knockout mice also develop moderate insulin resistance. Additionally, these mice exhibit reduced fat tissue deposits, an effect observed after protease-inhibitor treatment of humans. Both man and mouse might therefore compensate for the decrease in glucose uptake by increasing utilization of endogenous fatty acid stores. Alternatively, decreased fat storage could reflect the paucity of intracellular glucose when GLUT4 is inhibited or absent. Taken together, these studies pave the way for the development of second-generation drugs that control HIV infection without altering glucose transport. For both scientists and clinicians, the current lineup of protease inhibitors could prove to be useful tools for specifically inhibiting GLUT4, and for characterizing the insulin resistant state in type 2 diabetes.
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