It is estimated that more than 170 million people are infected with hepatitis C virus (HCV) worldwide1,2. Clinical trials have demonstrated that, for the first time in human history, the potential exists to eradicate a chronic viral disease using combination therapies that contain only direct-acting antiviral agents3. HCV non-structural protein 5A (NS5A) is a multifunctional protein required for several stages of the virus replication cycle4. NS5A replication complex inhibitors, exemplified by daclatasvir (DCV; also known as BMS-790052 and Daklinza), belong to the most potent class of direct-acting anti-HCV agents described so far, with in vitro activity in the picomolar (pM) to low nanomolar (nM) range. The potency observed in vitro has translated into clinical efficacy, with HCV RNA declining by ~3–4 log10 in infected patients after administration of single oral doses of DCV. Understanding the exceptional potency of DCV was a key objective of this study. Here we show that although DCV and an NS5A inhibitor analogue (Syn-395) are inactive against certain NS5A resistance variants, combinations of the pair enhance DCV potency by >1,000-fold, restoring activity to the pM range. This synergistic effect was validated in vivo using an HCV-infected chimaeric mouse model. The cooperative interaction of a pair of compounds suggests that NS5A protein molecules communicate with each other: one inhibitor binds to resistant NS5A, causing a conformational change that is transmitted to adjacent NS5As, resensitizing resistant NS5A so that the second inhibitor can act to restore inhibition. This unprecedented synergistic anti-HCV activity also enhances the resistance barrier of DCV, providing additional options for HCV combination therapy and new insight into the role of NS5A in the HCV replication cycle.

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We thank J. Pizzano for conducting in vivo experiments and K. Snow for bioanalytical support.

Author information


  1. Department of Virology, Bristol-Myers Squibb Research and Development, 5 Research Parkway, Wallingford, Connecticut 06492, USA

    • Jin-Hua Sun
    • , Donald R. O’Boyle II
    • , Robert A. Fridell
    • , Chunfu Wang
    • , Susan B. Roberts
    • , Peter Nower
    • , Mengping Liu
    • , Karen Rigat
    • , Mark Cockett
    • , Julie A. Lemm
    •  & Min Gao
  2. Computer-Assisted Drug Design, Bristol-Myers Squibb Research and Development, 5 Research Parkway, Wallingford, Connecticut 06492, USA

    • David R. Langley
  3. Pharmaceutical Candidate Optimization, Bristol-Myers Squibb Research and Development, 5 Research Parkway, Wallingford, Connecticut 06492, USA

    • Benjamin M. Johnson
    • , Frederic Moulin
    • , Michelle J. Nophsker
    •  & Melissa Kramer
  4. Leads Discovery and Optimization, Bristol-Myers Squibb Research and Development, 5 Research Parkway, Wallingford, Connecticut 06492, USA

    • Ying-Kai Wang
  5. Discovery Chemistry, Bristol-Myers Squibb Research and Development, 5 Research Parkway, Wallingford, Connecticut 06492, USA

    • Yong Tu
    • , Piyasena Hewawasam
    • , John Kadow
    • , Nicholas A. Meanwell
    •  & Makonen Belema


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J.-H.S. and M.G. initiated synergy combination experiments. J.-H.S., D.R.O., R.A.F., C.W., S.B.R., P.N., M.B., Y.-K.W., M.L., K.R., J.A.L. and M.G. designed and performed the replicon screen for identifying synergy compounds, experiments with infectious HCV, genotype coverage, colony elimination, inhibitor-binding, isolation and mapping of resistant variants, and in vitro combination studies. M.G., M.B., J.K., N.A.M. and M.C. designed the overall virology studies and provided input to the overall research direction. D.R.L. constructed models of HCV NS5A and D.R.L., N.A.M. and M.G. contributed to the development of mechanistic hypotheses. B.M.J., F.M., M.J.N., M.B. and M.K. designed and interpreted in vivo studies. Y.T., P.H., M.B. and N.A.M. designed and synthesized the discussed compounds.

Competing interests

The authors are or were, at the time this work was conducted, employees of Bristol-Myers Squibb, a company that markets antiviral therapies for the treatment of HCV.

Corresponding author

Correspondence to Min Gao.

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