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670 Nelfinavir Overcomes Proteasome Inhibitor Resistance in Multiple Myeloma By Modulating Membrane Lipid Bilayer Composition and Fluidity

Program: Oral and Poster Abstracts
Type: Oral
Session: 652. Myeloma: Pathophysiology and Pre-Clinical Studies, excluding Therapy
Hematology Disease Topics & Pathways:
multiple myeloma, Diseases, Biological Processes, Technology and Procedures, Plasma Cell Disorders, Lymphoid Malignancies, gene editing, metabolomics, molecular interactions, proteomics
Monday, December 7, 2020: 12:45 PM

Andrej Besse1*, Lenka Besse1*, Sara C. Stolze2,3*, Amin Sobh, PhD4, Esther A. Zaal5,6*, Alwin J van der Ham7*, Mario Ruiz8*, Santosh Phuyal9*, Lorina Büchler1*, Marc Sathianathan1*, Bogdan I. Florea2*, Jan Borén10*, Marcus Ståhlman10*, Alex Loguinov11*, Bart Everts7*, Celia R. Berkers5,6*, Marc Pilon8*, Hesso Farhan9*, Chris D. Vulpe11*, Herman S. Overkleeft2* and Christoph Driessen, MD1

1Clinics for Medical Oncology and Haematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
2Leiden Institute of Chemistry, Leiden University, Leiden, Netherlands
3Protein Mass Spectrometry Group, Max Planck Institute for Plant Breeding Research, Cologne, Germany
4DEPARTMENT OF MEDICINE, University of Florida, Gainesville, FL
5Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
6Biomolecular Mass Spectrometry and Proteomics, Bijvoet Centre for Biomolecular Research, Utrecht University, Utrecht, Netherlands
7Department of Parasitology, Leiden University Medical Center, Leiden, Netherlands
8Department of Chemistry and Molecular Biology, University of Gothenburg, Gothenburg, Sweden
9Institute of Basic Medical Sciences, Department of Molecular Medicine, University of Oslo, Oslo, Norway
10Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
11Department of Physiological Sciences, University of Florida, Gainesville, FL


Nelfinavir is a highly lipophilic, first generation HIV-protease inhibitor (HIV-PI) approved for HIV treatment. It has largely been replaced by next-generation HIV-PI with increased specificity and efficacy for HIV therapy, partly reflecting the significant rate of the off-target activity of nelfinavir. Increasing preclinical and clinical evidence shows that nelfinavir has broad anti-cancer activity as a single agent and in combination, potentially related to its off-target activity in mammalian cells. Nelfinavir is particularly effective in the treatment of proteasome inhibitor-refractory multiple myeloma (MM), where the combination of nelfinavir+bortezomib+dexamethasone yielded an overall response rate (ORR, PR or better) > 65% in a Phase II clinical trial. The targets and molecular mechanism of action of nelfinavir in MM are unknown. This hampers both, a rational clinical repositioning and development of nelfinavir as antineoplastic drug, as well as the design, synthesis and testing of next generation nelfinavir-like compounds with optimized antineoplastic activity and improved specificity or pharmacologic properties. We therefore aimed to take an unbiased target-identification approach to identify molecular targets of nelfinavir in human malignant cells and link them to cell biological processes and mechanisms that mediate sensitivity or resistance to nelfinavir treatment.


Proteome-wide affinity-purification of targets binding the nelfinavir active site was combined with genome-wide CRISPR/Cas9-based screening to identify protein partners interacting with nelfinavir and candidate genetic contributors affecting nelfinavir cytotoxicity. Multiple intracellular reporter systems including RUSH system, ATP/ADP constructs; FRAP microscopy, Seahorse measurements, flow cytometry, qPCR, metabolic labelling, lipidomics and viability assays were used to dissect functional alterations in pathways related to nelfinavir targets.


We identified a common set of proteins interacting specifically with the active site of nelfinavir. These proteins are embedded in intracellular, lipid-rich membranes of mitochondria (VDAC1,2,3, ANT2), endoplasmic reticulum (BCAP31, CANX, SRPRB) and nuclear envelope (PGRMC2) and are consistent across multiple cancer cell types. ADIPOR2, a key regulator gene of membrane lipid fluidity, was identified as a key nelfinavir resistance gene, while genes involved in fatty acids (FAs) and cholesterol metabolism, vesicular trafficking and mitochondria biogenesis are candidate sensitivity genes. We further show that via binding to proteins in lipid-rich membranes nelfinavir affects membrane composition and reduces membrane fluidity, leading to induction of FAs synthesis and the unfolded protein response (UPR). Via its structural interference with membrane fluidity, nelfinavir impairs the function and mobility of a diverse set of membrane-associated proteins and processes, such as glucose flux and processing, mitochondria respiration, energy supply, transmembrane vesicular transport and ABCB1-mediated drug efflux, as we show in different reporter systems in live MM cells. These functional effects are prevented by addition of metabolically inert lipids to be incorporated in membranes, supporting a direct structural activity of nelfinavir. The adaptive biology of proteasome inhibitor (PI)-resistant myeloma relies on metabolic reprogramming and changes in lipid composition, drug export and down-modulation of the UPR. Modulation of membrane fluidity and depletion of FAs/cholesterol is synergistic with proteasome inhibitors in PI-resistant MM. Thus, the mechanism of action of nelfinavir perfectly matches with the biology of PI-resistant MM, serving as a molecular rational for its significant clinical activity.


We here demonstrate in vitro that the activity of nelfinavir against MM cells is triggered through changes in lipid metabolism and the fluidity of lipid-rich membranes. Pharmacologic targeting of membrane fluidity is a novel, potent mechanism to achieve anti-cancer activity, in particular against PI-refractory MM. This mechanism explains the clinical activity of nelfinavir in MM treatment as well as the key side effects of nelfinavir during antiretroviral therapy.

Disclosures: No relevant conflicts of interest to declare.

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