ACS Central Science

The Apolipoprotein E4 (ApoE4) genotype is the most significant genetic risk factor for late-onset Alzheimers disease (AD). A key driver of ApoE4 cellular toxicity is the endo-lysosomal burden resulting from the excessive receptor-mediated uptake of ApoE4 lipoparticles. The high-affinity interaction between lipidated ApoE4 and the Low-Density Lipoprotein Receptor (LDLR) saturates the cellular degradation machinery, correlating with lysosomal alkalinization, lipid accumulation, and cell death. To target this critical interaction interface, which consists of 7 tandem ligand-binding type-A (LA) modules in the human LDLR, we present the design and evaluation of recombinant LDLR minireceptors comprising combinations of these LA modules to competitively antagonize ApoE4 endocytosis. We observe a distinct isoform-dependent uptake dynamic across multiple central nervous system (CNS) cell models, with ApoE4 showing significantly greater total intracellular accumulation than ApoE2. Furthermore, engineered LA peptides selectively bind ApoE4 over human serum LDL and differentially inhibit its uptake, revealing a distinct structural efficacy hierarchy of LA3456 [~] LA345 > LA456 [~] LA45 >> LA34. We establish the resilience of the LA45 minireceptor under physiological serum conditions and identify LA345 as the most stable truncated construct in vitro. Notably, molecular tagging orientation is critical for therapeutic engineering; C-terminal tagging completely preserves the inhibitory function of the minireceptors, whereas N-terminal tagging drastically reduces it. These findings provide a framework for scalable, deliverable inhibition of the ApoE4-LDLR interaction as a potential therapeutic target to mitigate endo-lysosomal accumulation in AD.

Antibody-drug conjugates (ADCs) represent a significant advancement in cancer therapy, yet their development remains constrained by high attrition rates driven by an incomplete understanding of how ADC chemical design interconnects with tumor biology. Compounding this challenge, the field has converged on a narrow set of redundant structural components, and current linker-payload systems that do not share a single mechanism of action. Existing drug response prediction frameworks cannot resolve this multidimensional complexity, relying predominantly on genomic inputs while protein-level biology is challenging to integrate. To address this, we developed a multimodal machine learning platform interconnecting ADC structural parameters with tumor cell biology across thousands of curated structure-activity datapoints, including multi-omics profiles from 1,479 human tumor cell lines and protein-level inputs from a unique model (GENCEP) that derives complete proteomic signatures. The model was validated through blinded retrospective evaluation and, critically, large coverage prospective prediction of cytotoxicity across 159 ADC-cell line combinations spanning five antigens, four mechanistically distinct linker-payload systems, and eight tumor types, most with no prior published associated ADC data. Performance surpassed industry benchmarks established for small molecule therapeutic modalities, demonstrating that protein-informed multimodal integrated framework is effective at capturing cytotoxic determinants at scale.

In this work we present antibody-metal conjugate as a new subclass of antibody-drug conjugates (ADC) for the chemodynamic therapy of cancer based on the rapid generation of reactive oxygen species (ROS) upon copper reduction. We used conventional therapeutic antibody trastuzumab and DOTA-NHS ester for the design and initial proof-of-concept. Thus, trastuzumab-DOTA-copper conjugate (TDCC) was synthesized. We demonstrate that TDCC retains specific binding to HER2-positive cancer cells with approximately native immunoreactivity and achieves stable copper incorporation with an average drug-to-antibody ratio of up to [~]8. In the presence of physiological reducing agents such as N-acetylcysteine or cysteine, TDCC generates substantial reactive oxygen species (ROS), leading to pronounced cytotoxicity and long-term suppression of clonogenic survival in HER2-positive SK-BR-3 and BT-474 cells. Notably, HER2-negative MDA-MB-231 cells and non-malignant HS5 fibroblasts remain largely unaffected, confirming target-dependent activity. The conjugate remains stable under storage conditions for up to 30 days, and the DOTA linker itself does not interfere with copper-mediated redox chemistry. Our findings identify TDCC as a novel class of targeted oxidative stress inducers that exploit the vulnerability of HER2-positive tumors to copper-mediated cytotoxicity. This strategy not only preserves the specificity of antibody-based delivery but also introduces a distinct mechanism of action capable of bypassing conventional resistance pathways, warranting further preclinical development. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=143 SRC="FIGDIR/small/721915v1_ufig1.gif" ALT="Figure 1"> View larger version (37K): org.highwire.dtl.DTLVardef@7ed6bdorg.highwire.dtl.DTLVardef@1442b2aorg.highwire.dtl.DTLVardef@6dff28org.highwire.dtl.DTLVardef@18aba16_HPS_FORMAT_FIGEXP M_FIG C_FIG

The design of radiotheranostic agents has been constrained by a fundamental chemical incompatibility: existing strategies for fluorine-18 incorporation -- nucleophilic substitution, silicon-fluoride exchange, aluminum fluoride chelation, and prosthetic conjugation -- either require conditions incompatible with macrocyclic metal coordination, consume the chelator site needed for radiometal labeling, or introduce non-native structural appendages that alter pharmacokinetic behavior. Here we show that sulfur(VI) fluoride exchange (SuFEx) chemistry and macrocyclic metal coordination define non-overlapping reactivity domains co-embeddable within a single peptide precursor. An aryl fluorosulfate on tyrosine accepts 18F under mildly basic conditions; a spatially distinct macrocyclic chelator, DOTA, NOTA, NODAGA, or any compatible macrocycle, independently coordinates diagnostic (68Ga, 64Cu) or therapeutic (177Lu) radiometals under mildly acidic conditions. The labeling pathways proceed independently under mutually compatible conditions, and both preserve receptor-binding affinity. Validated across PD-L1- and CD38-targeting scaffolds, this platform delivers nanomolar target affinity, high radiochemical yields, and matched pharmacokinetics, establishing isotopic orthogonality as a designable, intrinsic property of synthetic molecular radiopharmaceuticals.

While lipidation is a widely observed strategy to promote membrane permeation, whether the factors governing lipid-driven accumulation are shared across the divergent membranes of mammalian and Gram-negative cells remains unresolved. Here, we apply the Chloroalkane Azide-based Membrane Penetration (CHAMP) assay to a systematically designed library of lipid conjugates in both HeLa and E. coli cells. CHAMP, developed by our group, pairs a minimally disruptive azide tag with a cytosolically anchored HaloTag to quantify cytosolic accumulation directly. The two systems show divergent trends: most lipid modifications reduce E. coli accumulation, whereas larger, more hydrophobic conjugates, including medium-chain, cyclized, and heteroatom-containing lipids, are preferentially internalized by mammalian cells. Through targeted endogenous and exogenous modifications, we further resolve how charge, scaffold composition, and individual envelope barriers shape these patterns. Together, these results establish that lipidation is a context-dependent permeation principle that fundamentally diverges between mammalian and diderm envelopes. By showing that hydrophobic modifications routinely hinder Gram-negative cytosolic entry, this work explains the scarcity of lipidated Gram-negative antimicrobials, exposes the limits of lipophilicity-driven optimization, and redefines the physicochemical boundaries for penetrating the diderm envelope.

Targeted protein degradation (TPD) by PROteolysis TArgeting Chimeras (PROTACs) has emerged as a powerful chemical biology and therapeutic modality, yet many degraders exhibit incomplete target clearance and characteristic rebound kinetics despite continuous exposure. The mechanistic basis for this behavior remains poorly understood. Here we uncover protein age as a previously unrecognized determinant of PROTAC efficacy. Using CG{square}SLENP, a chemical genetics strategy that selectively labels newly synthesized and pre {square}existing proteins within the same living cell, we directly resolve PROTAC{square}induced degradation of distinct intracellular protein populations. Applying this approach to the bromodomain protein BRD4, we show that two mechanistically and structurally distinct PROTACs, dBET6 and MZ{square}1, preferentially degrade pre {square}existing BRD4, while newly synthesized BRD4 is degraded substantially more slowly and incompletely. This age{square}dependent degradation bias is observed in live{square}cell imaging, across compound concentrations and time scales, and for both reporter and endogenous BRD4. These findings reveal that PROTAC{square}mediated degradation is governed not only by target engagement and ternary complex formation, but also by the dynamic balance between protein synthesis and degradation. By identifying temporal proteostasis as a critical parameter in TPD, this work provides a mechanistic framework for incomplete degradation and rebound kinetics and establishes protein maturation state as an important consideration for degrader design and evaluation.

Targeting membrane receptors underlies the success of antibody-drug conjugates (ADCs), yet single-receptor formats can be limited by heterogeneous expression, compensatory signaling, and variable internalization. Here we developed Multivalent Interchangeable Nanobody Degradation System (MINDS), a modular nanobody-Fc chassis that co-engages multiple membrane receptors, promotes their lysosomal co-depletion, and enables delivery of diverse intracellular payloads. As a proof of concept, we generated Tritazumab, a trispecific nanobody-Fc targeting three oncogenic receptors EGFR, cMET, and TfR1. Tritazumab incorporates a high-affinity, non-transferrin-competing anti-TfR1 nanobody that drives efficient uptake and lysosomal trafficking, enabling coordinated depletion of all three receptors. Across non-small cell lung cancer models, Tritazumab achieved rapid and sustained multi-receptor surface loss with picomolar degradation potency, reaching near-maximal depletion within approximately 1.5 hours. Conjugation of Tritazumab to MMAE preserved receptor binding and produced substantially greater antiproliferative activity and improved tumor selectivity relative to clinical ADCs in matched cell models, along with potent in vivo tumor growth inhibition and acceptable tolerability in a xenograft model. Extending the platform beyond cytotoxic payloads, a BRD4 molecular glue conjugate improved the selectivity window by > 100-fold and showed marked in vivo efficacy, while an EZH2-targeting PROTAC conjugate achieved an approximately 1,000-fold increase in intracellular degradation potency relative to the free PROTAC. These findings establish MINDS as a modular multispecific degrader-payload platform that integrates receptor co-depletion to enhance anticancer selectivity and efficacy.

Despite intensive efforts, the ferroptosis gatekeeper glutathione peroxidase 4 (GPX4) remains difficult to selectively target due to stringent structural constraints surrounding its catalytic selenocysteine, which impose tight requirements on warhead reactivity and geometry. Here, leveraging a chemoproteomic approach, we characterize a potent and selective covalent GPX4 inhibitor featuring a pyrimidinylmethyl isourea warhead and define the chemical features underlying its proteome-wide selectivity. This chemotype enables tunable electrophile reactivity through steric and electronic modulation of leaving group ability, suggesting potential broader utility for targeting other recalcitrant proteins. Building on this scaffold, we further develop two selective GPX4 degraders - one CRBN-dependent and the other CRBN-independent - enabling complementary modulation of GPX4 through both inhibition and degradation. Together, these molecules expand the GPX4 chemical toolbox for more nuanced interrogation of GPX4 biology.

Bispecific antibodies deliver functional outcomes that monospecific antibodies cannot, yet emergent self-association, polyreactivity, and aggregation often degrade their developability relative to their parental arms. Whether bispecific developability inherits from the parents or is driven by the format has not been tested at scale. We characterized 160 bispecific antibodies and their 65 parental arms on a uniform knobs-into-holes CrossMab IgG1 scaffold across 10 assays on the PROPHET-Ab high-throughput platform. Bispecific developability separates into three classes of inheritance. Hydrophobicity and surface charge inherit cleanly from the parents (Spearman {rho} {approx} 0.85 to 0.95), so parental-level screening predicts bispecific fate. Self-association and polyreactivity inherit partially ({rho} {approx} 0.60 to 0.88), with mechanistically interpretable emergent outliers driven in part by Fv-Fv charge complementarity and a parental biophysical ceiling on the hydrophobicity (HIC) by surface-charge (HAC) plane. Thermostability is poorly predicted from parental antibodies ({rho} < 0.4), so it requires bispecific-level testing. The class framework yields actionable selection rules: triage hydrophobicity and charge at the parental level, avoid pairing two high-HIC x high-HAC arms, pair opposite-sign Fv charges to suppress self-association but re-validate at the formulation buffer, and measure thermostability on the bispecific itself. This work charts a tractable path from monospecific sequence to bispecific developability prediction. SignificanceBispecific antibodies are a fast-growing therapeutic class, yet the rational design of well-behaving bispecific antibodies from validated monospecific antibody building blocks remains challenging. A key bottleneck is the lack of comprehensive, high-quality public datasets linking parental antibody developability properties to corresponding bispecific antibody developability properties. We address this gap by releasing a dataset comprising 160 bispecific antibodies and the 65 parental monospecific antibodies profiled in 10 developability assays. The data show that bispecific antibody developability is complex. Some properties are easily predictable from the parents, whereas others emerge in the bispecific format or from the bispecific format itself. The factors that govern each property can be identified empirically and used to make practical selection decisions. The mechanistic explanations and predictive models reported here establish a compact set of actionable rules. Together, they define a framework for using computational pipelines to convert monospecific antibodies into bispecific antibodies with drug-like developability properties, enabling faster and more effective generation of high-quality bispecific antibodies for diverse therapeutic applications.

Cetuximab is a chimeric IgG1 monoclonal antibody that has been a cornerstone therapy for EGFR-driven malignancies for nearly two decades. Its therapeutic activity is governed by competitive displacement of endogenous EGFR ligands, making binding affinity a direct determinant of clinical efficacy. We applied ConvergeAB, a target-aware antibody design platform, in a fully zero-shot configuration to generate a biobetter version of cetuximab. The lead Converge-designed antibody binds EGFR with a mean KD of 315 pM -- approximately 2.1-fold tighter than cetuximab (673 pM) and 4.4-fold tighter than a recently published, computationally designed anti-EGFR antibody from Cradle Bio (1.38 nM). The affinity gain arises from six substitutions that leave the global paratope architecture intact (C RMSD 0.15 [A] vs cetuximab) and instead optimize the binding interface through localized packing and electrostatic adjustments. A panel of biophysical and developability assays -- HIC, DLS, DSF, and PSR ELISA -- shows that the Converge variant matches or exceeds cetuximab on monomericity, monodispersity, polyspecificity, and thermal stability, while remaining within a developable hydrophobicity envelope. Together, these data demonstrate that a single zero-shot ConvergeAB campaign can deliver a biobetter molecule with significantly improved affinity and a clean developability profile, without compromising the parental antibodys drug-like properties.

Antibiotic discovery has long relied on occupancy-driven inhibition, leaving a vast number of potential bacterial targets undrugged.1 Targeted protein degradation offers a mechanistically distinct alternative to inhibition, yet its application to antibacterial drug discovery remains largely unexplored.2-4 Here we describe the development of first-in-class heterobifunctional bacterial proteolysis targeting chimeras (BacPROTACs) directed against an essential Mycobacterium tuberculosis protein, 4-phosphopantetheinyl transferase (PptT).5 Leveraging the modular architecture of BacPROTACs, we repurposed PptT inhibitors by incorporating them into degraders, yielding compounds with markedly improved antimycobacterial activity. Integrating in vitro and cellular approaches, we developed a characterisation pipeline to assess protein degradation in bacteria, applicable to future BacPROTAC programmes. Our study establishes targeted protein degradation as a strategy for antibacterial drug discovery.

Activating KRAS mutations drive millions of cancers diagnosed worldwide,1 yet for decades this oncoprotein was deemed "undruggable", reflecting the challenge of discovering molecules capable of perturbing its complex biological functions, and of translating these discoveries into effective cancer therapeutics.2 Recent advances propelled by innovative screening have identified diverse modalities that bind at or near the switch-II pocket (SII-P) of RAS proteins, including molecular glues,3 macrocyclic peptides,4 fragment-derived small molecules,5 and approved therapies that covalently target KRASG12C.6,7 Unfortunately, resistance to approved therapies has emerged,8,9 highlighting the need for molecules that engage new or underexploited binding sites on RAS oncoproteins with mechanisms complementary to established SII-P inhibitors.10,11 Here we show that mirror-image mRNA display12 enabled the discovery of all-D macrocyclic peptide ligands targeting a cryptic RAS back pocket (CRB-P).13 These ligands engage KRAS(OFF) and KRAS(ON) with equal affinity, exploit a single-residue difference among isoforms to bind KRAS selectively, and successfully inhibit oncogenic signaling in KRAS-mutant cells through a mechanism distinct from SII-P binders. Mirror-image screening directly afforded nanomolar peptide ligands stable toward cellular proteolysis and delivered probes targeting distinct epitopes not accessible by homochiral peptide-display methods. Together, these findings establish the CRB-P as a specifically druggable and mechanistically differentiated site on KRAS with potential for combination with emerging RAS-targeting therapies and substantiate mirror-image mRNA display as a strategy for discovering stable all-D macrocyclic peptides targeting previously inaccessible epitopes on challenging targets.

The cysteine to serine mutation at residue 481 of Bruton's tyrosine kinase (BTK) is the most common mechanism of clinical resistance against ibrutinib for the treatment of mantle cell lymphoma and chronic lymphocytic leukemia. We report small molecule ligands containing chiral {beta}-lactone electrophiles to address this challenge. The asymmetric warhead enabled stereoselective covalent modification of wild-type and ibrutinib-resistant mutant BTK(C481S) through distinct sites of reactivity. Building on these findings, we developed kinase-directed {beta}-lactone probes and demonstrated that individual enantiomers preferentially engage distinct subsets of the kinome. These studies establish {beta}-lactones as stereochemically encodable covalent warheads whose stereochemistry can serve as a selectivity filter in covalent drug discovery.

Anti-staphylococcal lytic agents, such as lysostaphin (LSN), a glycyl-glycyl (Gly-Gly) peptidase, have long been considered for the management of chronic and complicated bacterial infections typically resistant to conventional antibiotics, but their use is restricted by poor pharmacokinetic properties. We generated half-life extended lysostaphin constructs by fusing the lysin - either alone or chimerized with an additional enzymatic cysteine, histidine-dependent amidohydrolases/peptidase (CHAP) domain - to the human IgG1 Fc fragment. The Fc-CHAP-LSN constructs retain high potency against Staphylococcus aureus and coagulase negative staphylococcal strains in vitro and are efficacious in S. aureus ex vivo biofilm models and in vivo sepsis models. A detailed investigation of the Fc-CHAP-LSN mode of action revealed that upon binding to the bacterial cell, but not in solution, LSN mediates its own release by cleaving the Gly-Gly CHAP-LSN linker. The bactericidal activity of Fc-CHAP-LSN is driven by the LSN-catalyzed and target cell-dependent release of free LSN. The half-life extended lysin acts as a pro-drug, unveiling a novel mechanism of targeted release and an alternative approach to half-life extension.

Glycosaminoglycans (GAGs) are polyanionic polysaccharides that co-localize with amyloid-{beta} (A{beta}) deposits in Alzheimers disease, yet their mechanistic contribution to A{beta} aggregation remains unclear. Here, we show that GAGs function as pH-responsive electrostatic scaffolds that selectively accelerate A{beta}(1-42) aggregation under mildly acidic, endosomal conditions but not at neutral extracellular pH. Combining experimental and computational approaches, we identify protonated N-terminal histidines as key determinants of GAG binding. Weak interactions between GAGs and the charged Nterminal region of A{beta} promote conformational rearrangements that bring peptides into proximity and expose adjacent hydrophobic aggregation-prone segments, thereby facilitating peptide clustering. Kinetic analyses reveal that aggregation is enhanced in a way consistent with an apparent increase in effective peptide concentration, accelerating nucleation without altering the dominant aggregation pathway. Systematic variation of GAG chain length and sulfation level further demonstrates that aggregation enhancement requires a threshold degree of multivalency, consistent with a clustering-driven mechanism. Together, these findings establish a framework in which pH-dependent electrostatic interactions with GAGs act as molecular triggers of amyloid nucleation, providing insight into how cellular microenvironments regulate the earliest stages of Alzheimers disease pathology.

Poor aqueous solubility remains a major obstacle to the translational development of targeted anticancer compounds. VS1, a first-in-class inhibitor of the cholesterol-transfer protein STARD3, has emerged as a promising chemosensitizing agent in colorectal cancer (CRC), but its clinical applicability is limited by its poor water solubility. Here, we combine structural biology, nanotechnology, and functional pharmacology to establish STARD3 inhibition as a delivery-enabled strategy to potentiate fluoropyrimidine therapy. To define the molecular basis of STARD3 inhibition, we solved the crystal structure of VS1 bound to the STARD3 ligand-binding domain at 2.1 [A] resolution, revealing direct occupation of the sterol-binding cavity. Molecular dynamics simulations confirmed a stable binding mode and identified the {Omega}1 loop as a dynamic gate regulating ligand binding and dissociation. To overcome the formulation barrier of VS1, we engineered carrier-free, albumin-coated nanocrystals through sonication-assisted nanocrystallization followed by surfactant exchange with human serum albumin. The resulting rod-shaped nanocrystals displayed nanometric size, narrow size distribution, sustained release, and improved aqueous dispersibility, increasing the apparent solubility of VS1 by more than 14-fold while preserving its molecular integrity and crystallinity. Biologically, VS1 selectively potentiated 5-fluorouracil (5-FU) in CRC cells, with synergistic effects restricted to 5-FU-sensitive models and associated with enhanced reactive oxygen species accumulation. Albumin-coated formulation retained the chemosensitizing activity of the free compound. In HCT-116 xenografts, combined treatment with albumin-coated VS1 nanocrystals and 5-FU significantly reduced tumor growth, prolonged tumor doubling time, and increased intratumoral necrosis without exacerbating systemic toxicity. Together, these findings establish that albumin-coated nanocrystals can overcome the delivery limitations of an insoluble STARD3 inhibitor and provide a formulation-enabled strategy to enhance fluoropyrimidine therapy in colorectal cancer.

-Synuclein (S), a protein that plays a central role in Parkinsons disease and related synucleinopathies, is an intrinsically disordered protein (IDP) whose functional interactions and aggregation behavior can be strongly influenced by post-translational modifications (PTMs). Phosphorylation, acetylation, and other PTMs regulate Ss interactions with lipid membranes and binding partners, whereas their dysregulation is associated with aggregation and neuronal toxicity. Despite significant progress through chemical and semi-synthetic approaches, investigating the combinatorial effects of PTMs has remained challenging due to the lack of accessible, site-specific methods. Here, we present an integrated strategy combining genetic code expansion, enzymatic modification, and intein-mediated click chemistry to generate S variants bearing multiple defined PTMs and a C-terminal fluorescent label. The resulting constructs enable direct evaluation of how individual and combined PTMs influence S structure, lipid binding, and cellular internalization. Our approach expands the molecular toolkit for dissecting PTM crosstalk in S and other aggregation-prone IDPs, advancing mechanistic understanding and supporting the development of therapeutic strategies for neurodegenerative disease.

Oligonucleotide therapeutics hold transformative potential, yet their clinical translation is hindered by delivery barriers, including rapid renal/hepatic clearance and poor organ specificity. Bottlebrush polymers conjugates have emerged as a promising vector to address these limitations, but conventional architectures with uniform backbones can only achieve an unmodifiable, rigid biodistribution profile. Here, we report a library of sequence-defined "digital" bottlebrush polymers, precisely engineered with controlled placements of chemical motifs that modify physiochemical properties - including lipids, cholesterol, and cationic groups - along a polyphosphodiester backbone. Systematic evaluation of the digital bottlebrush polymer library reveals distinct structure-property relationships and enables organ-biased systemic delivery to several traditionally difficult-to-reach tissues, including muscle and skin. In a mouse model of rheumatoid arthritis, a single dose of a spleen-homing polymer-conjugated antisense oligonucleotide targeting TNF- achieves potent knockdown and drives full functional recovery. These findings establish a versatile design framework for tailoring bottlebrush polymers to specific therapeutic applications.

Kinases have proven to be one of the most fertile target classes for new drug approvals. However, classical reversible inhibitors may not be capable of the levels of specificity or target modulation required across a broad spectrum of disease areas. Approaches that chemically modify kinase inhibitors in solvent exposed regions are unveiling a swathe of mechanisms to address kinase function in new ways. For example, by either covalently recruiting nucleophilic residues outside of the ATP-binding pocket to inhibit, or by recruiting secondary effector proteins to degrade. Here, we systematically assessed the impact of minimal electrophilic modifications to ATP-site binding scaffolds, leading us to identify molecules that can control the activity and abundance of the master autophagy regulator, Unc-51-like autophagy activating kinase 1 (ULK1).

Islatravir (ISL; 4'-ethynyl-2-fluoro-2'-deoxyadenosine (EFdA)), a first-in-class nucleoside reverse transcriptase (RT) translocation inhibitor (NRTTI), was recently approved by the FDA for the treatment of HIV-1 infection in combination with the non-nucleoside RT inhibitor (NNRTI), doravirine (DOR). Notably, the RT mutation F227C, which confers clinical resistance to multiple NNRTIs, including DOR, unexpectedly increases susceptibility to ISL. To elucidate the mechanistic basis of this hypersusceptibility, we determined a 1.8 angstrom crystal structure of F227C RT in complex with a ddGMP-terminated primer/template and ISL-triphosphate. The structure reveals conformational rearrangements that propagate into a cleft, thereby affecting ATP-mediated unblocking of chain-terminating antivirals. Complementary biochemical assays showed that although F227C does not significantly affect ISL incorporation, it alters RT translocation and impairs ATP-dependent phosphorolytic excision of ISL-terminated primers, thereby enhancing ISL susceptibility. These findings establish direct structural and mechanistic links between NNRTI resistance and ISL hypersusceptibility, providing a structural foundation for rationally designed, resistance-informed combination regimens that exploit this unique collateral sensitivity.