{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,31]],"date-time":"2026-10-31T02:31:05Z","timestamp":1793413865892,"version":"4.5.0"},"reference-count":89,"publisher":"National Academy of Sciences","issue":"16","license":[{"start":{"date-parts":[[2025,4,17]],"date-time":"2025-04-17T00:00:00Z","timestamp":1744848000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100010269","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["223103\/Z\/21\/Z"],"award-info":[{"award-number":["223103\/Z\/21\/Z"]}],"id":[{"id":"10.13039\/100010269","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000009","name":"Foundation for the NIH","doi-asserted-by":"publisher","award":["R37 AI054503"],"award-info":[{"award-number":["R37 AI054503"]}],"id":[{"id":"10.13039\/100000009","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Maurice Wilkins Centre for Molecular Biodiscovery and the Marsden Fund","award":["UOO1807"],"award-info":[{"award-number":["UOO1807"]}],"id":[{"id":"https:\/\/ror.org\/0327mmx61","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["www.pnas.org"],"crossmark-restriction":true},"short-container-title":["Proc. Natl. Acad. Sci. U.S.A."],"published-print":{"date-parts":[[2025,4,22]]},"abstract":"<jats:p>\n                    Bedaquiline is the cornerstone of a new regimen for the treatment of drug-resistant tuberculosis. However, its clinical use is threatened by the emergence of bedaquiline-resistant strains of\n                    <jats:italic>Mycobacterium tuberculosis<\/jats:italic>\n                    . Bedaquiline targets mycobacterial ATP synthase but the predominant route to clinical bedaquiline resistance is via upregulation of the MmpS5L5 efflux pump due to mutations that inactivate the transcriptional repressor\n                    <jats:italic>Rv0678<\/jats:italic>\n                    . Here, we show that the MmpS5L5 efflux pump reduces susceptibility to bedaquiline as well as its new, more potent derivative TBAJ-876 and other antimicrobial substrates, including clofazimine and the DprE1 inhibitors PBTZ-169 and OPC-167832. Furthermore, the increased resistance of\n                    <jats:italic>Rv0678<\/jats:italic>\n                    mutants stems entirely from increased MmpS5L5 expression. These results highlight the potential of a pharmacological MmpS5L5 inhibitor to increase drug efficacy. Verapamil, primarily used as a calcium channel inhibitor, is known to inhibit diverse efflux pumps and to potentiate bedaquiline and clofazimine activity in\n                    <jats:italic>M. tuberculosis<\/jats:italic>\n                    . Here, we show that verapamil potentiates the activity of multiple diverse MmpS5L5 substrates. Using biochemical approaches, we demonstrate that verapamil does not exert this effect by acting as a disruptor of the protonmotive force used to power MmpS5L5, as previously proposed, suggesting that verapamil inhibits the function of the MmpS5L5 pump. Finally, norverapamil, the major verapamil metabolite, which has greatly reduced calcium channel activity, has equal potency in reducing resistance to MmpS5L5 substrates. Our findings highlight verapamil\u2019s potential for enhancing bedaquiline TB treatment, for preventing acquired resistance to bedaquiline and other MmpS5L5 substrates, while also providing the impetus to identify additional MmpS5L5 inhibitors.\n                  <\/jats:p>","DOI":"10.1073\/pnas.2426827122","type":"journal-article","created":{"date-parts":[[2025,4,17]],"date-time":"2025-04-17T11:47:36Z","timestamp":1744890456000},"update-policy":"https:\/\/doi.org\/10.1073\/pnas.cm10313","source":"Crossref","is-referenced-by-count":21,"title":["Verapamil and its metabolite norverapamil inhibit the\n                    <i>Mycobacterium tuberculosis<\/i>\n                    MmpS5L5 efflux pump to increase bedaquiline activity"],"prefix":"10.1073","volume":"122","author":[{"given":"Adam J.","family":"Fountain","sequence":"first","affiliation":[{"name":"Medical Research Council Laboratory of Molecular Biology","place":["Cambridge, United Kingdom"]},{"name":"Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge","place":["Cambridge, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natalie J. E.","family":"Waller","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Immunology, University of Otago","place":["Dunedin, New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chen-Yi","family":"Cheung","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Immunology, University of Otago","place":["Dunedin, New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William","family":"Jowsey","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Immunology, University of Otago","place":["Dunedin, New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael T.","family":"Chrisp","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Immunology, University of Otago","place":["Dunedin, New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Troll","sequence":"additional","affiliation":[{"name":"Medical Research Council Laboratory of Molecular Biology","place":["Cambridge, United Kingdom"]},{"name":"Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge","place":["Cambridge, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4069-5279","authenticated-orcid":false,"given":"Paul H.","family":"Edelstein","sequence":"additional","affiliation":[{"name":"Medical Research Council Laboratory of Molecular Biology","place":["Cambridge, United Kingdom"]},{"name":"Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge","place":["Cambridge, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8349-1500","authenticated-orcid":false,"given":"Gregory M.","family":"Cook","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Immunology, University of Otago","place":["Dunedin, New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7747-7745","authenticated-orcid":false,"given":"Matthew B.","family":"McNeil","sequence":"additional","affiliation":[{"name":"Department of Microbiology and Immunology, University of Otago","place":["Dunedin, New Zealand"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0692-5533","authenticated-orcid":false,"given":"Lalita","family":"Ramakrishnan","sequence":"additional","affiliation":[{"name":"Medical Research Council Laboratory of Molecular Biology","place":["Cambridge, United Kingdom"]},{"name":"Molecular Immunity Unit, Cambridge Institute of Therapeutic Immunology and Infectious Diseases, Department of Medicine, University of Cambridge","place":["Cambridge, United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"341","published-online":{"date-parts":[[2025,4,17]]},"reference":[{"key":"e_1_3_4_1_2","unstructured":"WHO. Global tuberculosis report 2022 (2022)."},{"key":"e_1_3_4_2_2","volume-title":"WHO Consolidated Guidelines on Tuberculosis. Module 4: Treatment\u2014Drug-Resistant Tuberculosis Treatment, 2022 Update","author":"WHO","year":"2022","unstructured":"WHO, WHO Consolidated Guidelines on Tuberculosis. Module 4: Treatment\u2014Drug-Resistant Tuberculosis Treatment, 2022 Update (World Health Organization, 2022)."},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1901814"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2117166"},{"key":"e_1_3_4_5_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2213-2600(23)00389-2"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1126\/science.1106753"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0102135"},{"key":"e_1_3_4_8_2","doi-asserted-by":"publisher","DOI":"10.1183\/09031936.00142914"},{"key":"e_1_3_4_9_2","doi-asserted-by":"publisher","DOI":"10.1093\/jacamr\/dlac029"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(21)00470-9"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pgph.0002283"},{"key":"e_1_3_4_12_2","doi-asserted-by":"publisher","DOI":"10.5588\/ijtld.21.0670"},{"key":"e_1_3_4_13_2","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/ciaa1002"},{"key":"e_1_3_4_14_2","doi-asserted-by":"publisher","DOI":"10.1183\/13993003.02383-2019"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.3201\/eid3003.240134"},{"key":"e_1_3_4_16_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.01611-09"},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.1038\/s41598-023-36955-y"},{"key":"e_1_3_4_18_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2666-5247(21)00175-0"},{"key":"e_1_3_4_19_2","doi-asserted-by":"publisher","DOI":"10.1038\/s41467-023-37184-7"},{"key":"e_1_3_4_20_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.00037-14"},{"key":"e_1_3_4_21_2","volume-title":"Catalogue of Mutations in Mycobacterium Tuberculosis Complex and Their Association with Drug Resistance","author":"WHO","year":"2023","unstructured":"WHO, Catalogue of Mutations in Mycobacterium Tuberculosis Complex and Their Association with Drug Resistance (World Health Organization, Geneva, ed. 2, 2023).","edition":"2"},{"key":"e_1_3_4_22_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.00826-16"},{"key":"e_1_3_4_23_2","doi-asserted-by":"publisher","DOI":"10.1111\/mmi.13306"},{"key":"e_1_3_4_24_2","doi-asserted-by":"publisher","DOI":"10.1128\/mSphere.00985-20"},{"key":"e_1_3_4_25_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cell.2019.01.003"},{"key":"e_1_3_4_26_2","doi-asserted-by":"publisher","DOI":"10.1074\/jbc.M113.473371"},{"key":"e_1_3_4_27_2","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.1700062114"},{"key":"e_1_3_4_28_2","doi-asserted-by":"publisher","DOI":"10.1099\/mic.0.000498"},{"key":"e_1_3_4_29_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.chembiol.2015.07.013"},{"key":"e_1_3_4_30_2","doi-asserted-by":"publisher","DOI":"10.3390\/microorganisms7030070"},{"key":"e_1_3_4_31_2","doi-asserted-by":"publisher","DOI":"10.1128\/mSphere.00518-20"},{"key":"e_1_3_4_32_2","doi-asserted-by":"publisher","DOI":"10.1128\/aac.01629-22"},{"key":"e_1_3_4_33_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.ppat.1003120"},{"key":"e_1_3_4_34_2","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.1311402111"},{"key":"e_1_3_4_35_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.02020-19"},{"key":"e_1_3_4_36_2","doi-asserted-by":"publisher","DOI":"10.1128\/aac.00904-22"},{"key":"e_1_3_4_37_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.00292-19"},{"key":"e_1_3_4_38_2","doi-asserted-by":"publisher","DOI":"10.1128\/aac.00052-23"},{"key":"e_1_3_4_39_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2666-5247(23)00002-2"},{"key":"e_1_3_4_40_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2666-5247(23)00172-6"},{"key":"e_1_3_4_41_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.bmc.2019.02.026"},{"key":"e_1_3_4_42_2","unstructured":"Global Alliance for TB Drug Development. A Phase 2 Partially-blinded Randomised Trial Assessing the Safety and Efficacy of TBAJ-876 or Bedaquiline in Combination with Pretomanid and Linezolid in Adult Participants with Newly Diagnosed Drug-sensitive Smear-positive Pulmonary Tuberculosis [Internet]. clinicaltrials.gov; [cited 2024 Dec 18]. Report No.: NCT06058299. (2024) https:\/\/clinicaltrials.gov\/study\/NCT06058299."},{"key":"e_1_3_4_43_2","unstructured":"Global Alliance for TB Drug Development. Phase 1 Partially Blinded Placebo-Controlled Randomized Combined Single Ascending Dose with Food Effect Cohort Trial and Multiple Ascending Dose Trial to Evaluate the Safety Tolerability and PK of TBAJ-587 in Healthy Adults [Internet]. clinicaltrials.gov; [cited 2024 Dec 18]. Report No.: NCT04890535. (2023) https:\/\/clinicaltrials.gov\/study\/NCT04890535."},{"key":"e_1_3_4_44_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.01412-21"},{"key":"e_1_3_4_45_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.02418-20"},{"key":"e_1_3_4_46_2","doi-asserted-by":"publisher","DOI":"10.1038\/nmicrobiol.2016.274"},{"key":"e_1_3_4_47_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.00629-19"},{"key":"e_1_3_4_48_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.04019-14"},{"key":"e_1_3_4_49_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.02530-18"},{"key":"e_1_3_4_50_2","doi-asserted-by":"publisher","DOI":"10.1093\/infdis\/jiu095"},{"key":"e_1_3_4_51_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.02107-17"},{"key":"e_1_3_4_52_2","first-page":"1967","article-title":"Overcoming of vincristine resistance in P388 leukemia in vivo and in vitro through enhanced cytotoxicity of vincristine and vinblastine by verapamil","volume":"41","author":"Tsuruo T.","year":"1981","unstructured":"T. Tsuruo , Overcoming of vincristine resistance in P388 leukemia in vivo and in vitro through enhanced cytotoxicity of vincristine and vinblastine by verapamil. Cancer Res. 41, 1967\u20131972 (1981).","journal-title":"Cancer Res."},{"key":"e_1_3_4_53_2","doi-asserted-by":"publisher","DOI":"10.1074\/jbc.M100407200"},{"key":"e_1_3_4_54_2","doi-asserted-by":"publisher","DOI":"10.1038\/ncomms8995"},{"key":"e_1_3_4_55_2","doi-asserted-by":"publisher","DOI":"10.1038\/s41594-023-01017-4"},{"key":"e_1_3_4_56_2","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.2215512120"},{"key":"e_1_3_4_57_2","doi-asserted-by":"publisher","DOI":"10.1016\/0006-2952(95)00174-X"},{"key":"e_1_3_4_58_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0022-5347(24)06111-1"},{"key":"e_1_3_4_59_2","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.93.20.10668"},{"key":"e_1_3_4_60_2","doi-asserted-by":"publisher","DOI":"10.1529\/biophysj.106.089581"},{"key":"e_1_3_4_61_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.bcp.2016.08.013"},{"key":"e_1_3_4_62_2","doi-asserted-by":"publisher","DOI":"10.1099\/00221287-147-4-1017"},{"key":"e_1_3_4_63_2","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.0711697105"},{"key":"e_1_3_4_64_2","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dkv054"},{"key":"e_1_3_4_65_2","doi-asserted-by":"publisher","DOI":"10.1016\/S2666-5247(24)00149-6"},{"key":"e_1_3_4_66_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.cell.2011.02.022"},{"key":"e_1_3_4_67_2","doi-asserted-by":"publisher","DOI":"10.1128\/AAC.01692-17"},{"key":"e_1_3_4_68_2","doi-asserted-by":"publisher","DOI":"10.32607\/actanaturae.11610"},{"key":"e_1_3_4_69_2","doi-asserted-by":"publisher","DOI":"10.1289\/ehp.9087213"},{"key":"e_1_3_4_70_2","doi-asserted-by":"publisher","DOI":"10.1038\/clpt.1981.125"},{"key":"e_1_3_4_71_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF03189707"},{"key":"e_1_3_4_72_2","first-page":"9","article-title":"The bioavailability of a slow-release verapamil formulation","volume":"42","author":"Norris R. J.","year":"1985","unstructured":"R. J. Norris , The bioavailability of a slow-release verapamil formulation. Br. J. Clin. Pract. Suppl. 42, 9\u201316 (1985).","journal-title":"Br. J. Clin. Pract. Suppl."},{"key":"e_1_3_4_73_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0090-9556(24)15345-7"},{"key":"e_1_3_4_74_2","doi-asserted-by":"publisher","DOI":"10.1016\/0009-9236(95)90195-7"},{"key":"e_1_3_4_75_2","doi-asserted-by":"publisher","DOI":"10.1080\/004982500237857"},{"key":"e_1_3_4_76_2","doi-asserted-by":"publisher","DOI":"10.1159\/000138185"},{"key":"e_1_3_4_77_2","doi-asserted-by":"publisher","DOI":"10.1007\/s002280000253"},{"key":"e_1_3_4_78_2","doi-asserted-by":"publisher","DOI":"10.1046\/j.1365-2125.1999.00923.x"},{"key":"e_1_3_4_79_2","doi-asserted-by":"publisher","DOI":"10.1007\/BF00169164"},{"key":"e_1_3_4_80_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.clpt.2005.11.001"},{"key":"e_1_3_4_81_2","doi-asserted-by":"publisher","DOI":"10.1093\/jac\/dku171"},{"key":"e_1_3_4_82_2","doi-asserted-by":"publisher","DOI":"10.1002\/cpt.3108"},{"key":"e_1_3_4_83_2","doi-asserted-by":"publisher","DOI":"10.1128\/mBio.01245-14"},{"key":"e_1_3_4_84_2","doi-asserted-by":"publisher","DOI":"10.1007\/978-1-4939-2450-9_10"},{"key":"e_1_3_4_85_2","doi-asserted-by":"publisher","DOI":"10.1093\/jacamr\/dlae086"},{"key":"e_1_3_4_86_2","doi-asserted-by":"publisher","DOI":"10.1038\/s41467-024-54072-w"},{"key":"e_1_3_4_87_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2958.1990.tb02040.x"},{"key":"e_1_3_4_88_2","doi-asserted-by":"publisher","DOI":"10.1128\/JB.181.1.270-283.1999"},{"key":"e_1_3_4_89_2","doi-asserted-by":"publisher","DOI":"10.1128\/mBio.01093-14"}],"container-title":["Proceedings of the National Academy of Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/pnas.org\/doi\/pdf\/10.1073\/pnas.2426827122","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,4,17]],"date-time":"2025-04-17T11:48:00Z","timestamp":1744890480000},"score":1,"resource":{"primary":{"URL":"https:\/\/pnas.org\/doi\/10.1073\/pnas.2426827122"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,17]]},"references-count":89,"journal-issue":{"issue":"16","published-print":{"date-parts":[[2025,4,22]]}},"alternative-id":["10.1073\/pnas.2426827122"],"URL":"https:\/\/doi.org\/10.1073\/pnas.2426827122","relation":{},"ISSN":["0027-8424","1091-6490"],"issn-type":[{"value":"0027-8424","type":"print"},{"value":"1091-6490","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,4,17]]},"assertion":[{"value":"2024-12-26","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-02-26","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2025-04-17","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e2426827122"}}