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Vincik LY, Dautel AD, Staples AA, Lauck LV, Armstrong CJ, Howard JT, McGregor D, Ahmadzadeh S, Shekoohi S, Kaye AD. Evolving Role of Viltolarsen for Treatment of Duchenne Muscular Dystrophy. Adv Ther 2024; 41:1338-1350. [PMID: 38376743 DOI: 10.1007/s12325-024-02801-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/22/2024] [Indexed: 02/21/2024]
Abstract
Duchenne muscular dystrophy (DMD) is one of the most prevalent X-linked inherited neuromuscular disorders, with an estimated incidence between 1 in 3500 and 5000 live male births. The median life expectancy at birth is around 30 years due to a rapid and severe disease progression. Currently, there is no cure for DMD, and the standard of care is mainly palliative therapy and glucocorticoids to mitigate symptoms and improve quality of life. Recent advances in phosphorodiamidate morpholino antisense oligonucleotide (PMO) technology has proven optimistic in providing a disease-modifying therapy rather than a palliative treatment option through correcting the primary genetic defect of DMD by exon skipping. However, as a result of the high variance in mutations of the dystrophin gene causing DMD, it has been challenging to tailor an effective therapy in most patients. Viltolarsen is effective in 8% of patients and accurately skips exon 53, reestablishing the reading frame and producing a functional form of dystrophin and milder disease phenotype. Results of recently concluded preclinical and clinical trials show significantly increased dystrophin protein expression, no severe adverse effects, and stabilization of motor function. In summary, viltolarsen has provided hope for those working toward giving patients a safe and viable treatment option for managing DMD. This review summarizes an overview of the presentation, pathophysiology, genetics, and current treatment guidelines of DMD, pharmacological profile of viltolarsen, and a summary of the safety and efficacy with additional insights using recent clinical trial data.
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Affiliation(s)
- LeighAnn Y Vincik
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Alexandra D Dautel
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Abigail A Staples
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Lillian V Lauck
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Catherine J Armstrong
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Jeffery T Howard
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - David McGregor
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Shahab Ahmadzadeh
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA.
| | - Alan D Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
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2
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Szwec S, Kapłucha Z, Chamberlain JS, Konieczny P. Dystrophin- and Utrophin-Based Therapeutic Approaches for Treatment of Duchenne Muscular Dystrophy: A Comparative Review. BioDrugs 2024; 38:95-119. [PMID: 37917377 PMCID: PMC10789850 DOI: 10.1007/s40259-023-00632-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/04/2023]
Abstract
Duchenne muscular dystrophy is a devastating disease that leads to progressive muscle loss and premature death. While medical management focuses mostly on symptomatic treatment, decades of research have resulted in first therapeutics able to restore the affected reading frame of dystrophin transcripts or induce synthesis of a truncated dystrophin protein from a vector, with other strategies based on gene therapy and cell signaling in preclinical or clinical development. Nevertheless, recent reports show that potentially therapeutic dystrophins can be immunogenic in patients. This raises the question of whether a dystrophin paralog, utrophin, could be a more suitable therapeutic protein. Here, we compare dystrophin and utrophin amino acid sequences and structures, combining published data with our extended in silico analyses. We then discuss these results in the context of therapeutic approaches for Duchenne muscular dystrophy. Specifically, we focus on strategies based on delivery of micro-dystrophin and micro-utrophin genes with recombinant adeno-associated viral vectors, exon skipping of the mutated dystrophin pre-mRNAs, reading through termination codons with small molecules that mask premature stop codons, dystrophin gene repair by clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (CRISPR/Cas9)-mediated genetic engineering, and increasing utrophin levels. Our analyses highlight the importance of various dystrophin and utrophin domains in Duchenne muscular dystrophy treatment, providing insights into designing novel therapeutic compounds with improved efficacy and decreased immunoreactivity. While the necessary actin and β-dystroglycan binding sites are present in both proteins, important functional distinctions can be identified in these domains and some other parts of truncated dystrophins might need redesigning due to their potentially immunogenic qualities. Alternatively, therapies based on utrophins might provide a safer and more effective approach.
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Affiliation(s)
- Sylwia Szwec
- Institute of Human Biology and Evolution, Faculty of Biology, Adam Mickiewicz University, ul. Uniwersytetu Poznańskiego 6, 61-614, Poznań, Poland
| | - Zuzanna Kapłucha
- Institute of Human Biology and Evolution, Faculty of Biology, Adam Mickiewicz University, ul. Uniwersytetu Poznańskiego 6, 61-614, Poznań, Poland
| | - Jeffrey S Chamberlain
- Department of Neurology, University of Washington School of Medicine, Seattle, WA, 98109-8055, USA
- Senator Paul D. Wellstone Muscular Dystrophy Specialized Research Center, University of Washington School of Medicine, Seattle, WA, 98109-8055, USA
- Department of Biochemistry, University of Washington School of Medicine, Seattle, WA, 98109-8055, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98109-8055, USA
| | - Patryk Konieczny
- Institute of Human Biology and Evolution, Faculty of Biology, Adam Mickiewicz University, ul. Uniwersytetu Poznańskiego 6, 61-614, Poznań, Poland.
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3
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Lessl AL, Pöhmerer J, Lin Y, Wilk U, Höhn M, Hörterer E, Wagner E, Lächelt U. mCherry on Top: A Positive Read-Out Cellular Platform for Screening DMD Exon Skipping Xenopeptide-PMO Conjugates. Bioconjug Chem 2023; 34:2263-2274. [PMID: 37991502 PMCID: PMC10739591 DOI: 10.1021/acs.bioconjchem.3c00408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
Phosphorodiamidate morpholino oligomers (PMOs) are a special type of antisense oligonucleotides (ASOs) that can be used as therapeutic modulators of pre-mRNA splicing. Application of nucleic-acid-based therapeutics generally requires suitable delivery systems to enable efficient transport to intended tissues and intracellular targets. To identify potent formulations of PMOs, we established a new in vitro-in vivo screening platform based on mdx exon 23 skipping. Here, a new in vitro positive read-out system (mCherry-DMDEx23) is presented that is sensitive toward the PMO(Ex23) sequence mediating DMD exon 23 skipping and, in this model, functional mCherry expression. After establishment of the reporter system in HeLa cells, a set of amphiphilic, ionizable xenopeptides (XPs) was screened in order to identify potent carriers for PMO delivery. The identified best-performing PMO formulation with high splice-switching activity at nanomolar concentrations in vitro was then translated to in vivo trials, where exon 23 skipping in different organs of healthy BALB/c mice was confirmed. The predesigned in vitro-in vivo workflow enables evaluation of PMO(Ex23) carriers without change of the PMO sequence and formulation composition. Furthermore, the identified PMO-XP conjugate formulation was found to induce highly potent exon skipping in vitro and redistributed PMO activity in different organs in vivo.
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Affiliation(s)
- Anna-Lina Lessl
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
| | - Jana Pöhmerer
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
| | - Yi Lin
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
| | - Ulrich Wilk
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
| | - Miriam Höhn
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
| | - Elisa Hörterer
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
| | - Ernst Wagner
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
- Center
for NanoScience (CeNS), LMU Munich, 80799 Munich, Germany
| | - Ulrich Lächelt
- Pharmaceutical
Biotechnology, Department of Pharmacy, LMU
Munich, Butenandtstrasse 5-13, 81377 Munich, Germany
- Center
for NanoScience (CeNS), LMU Munich, 80799 Munich, Germany
- Department
of Pharmaceutical Sciences, University of
Vienna, Josef-Holaubek-Platz 2, 1090 Vienna, Austria
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Watanabe N, Tone Y, Nagata T, Masuda S, Saito T, Motohashi N, Takagaki K, Aoki Y, Takeda S. Exon 44 skipping in Duchenne muscular dystrophy: NS-089/NCNP-02, a dual-targeting antisense oligonucleotide. MOLECULAR THERAPY. NUCLEIC ACIDS 2023; 34:102034. [PMID: 37854955 PMCID: PMC10579524 DOI: 10.1016/j.omtn.2023.102034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 09/15/2023] [Indexed: 10/20/2023]
Abstract
Exon-skipping therapy mediated by antisense oligonucleotides is expected to provide a therapeutic option for Duchenne muscular dystrophy. Antisense oligonucleotides for exon skipping reported so far target a single continuous sequence in or around the target exon. In the present study, we investigated antisense oligonucleotides for exon 44 skipping (applicable to approximately 6% of all Duchenne muscular dystrophy patients) to improve activity by using a novel antisense oligonucleotide design incorporating two connected sequences. Phosphorodiamidate morpholino oligomers targeting two separate sequences in exon 44 were created to target two splicing regulators in exon 44 simultaneously, and their exon 44 skipping was measured. NS-089/NCNP-02 showed the highest skipping activity among the oligomers. NS-089/NCNP-02 also induced exon 44 skipping and dystrophin protein expression in cells from a Duchenne muscular dystrophy patient to whom exon 44 skipping is applicable. We also assessed the in vivo activity of NS-089/NCNP-02 by intravenous administration to cynomolgus monkeys. NS-089/NCNP-02 induced exon 44 skipping in skeletal and cardiac muscle of cynomolgus monkeys. In conclusion, NS-089/NCNP-02, an antisense oligonucleotide with a novel connected-sequence design, showed highly efficient exon skipping both in vitro and in vivo.
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Affiliation(s)
- Naoki Watanabe
- Discovery Research Laboratories in Tsukuba, Nippon Shinyaku Co., Ltd, Tsukuba, Ibaraki, Japan
| | - Yuichiro Tone
- Discovery Research Laboratories in Tsukuba, Nippon Shinyaku Co., Ltd, Tsukuba, Ibaraki, Japan
| | - Tetsuya Nagata
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
- Department of Neurology and Neurological Science, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoru Masuda
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
| | - Takashi Saito
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
| | - Norio Motohashi
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
| | - Kazuchika Takagaki
- Discovery Research Laboratories in Tsukuba, Nippon Shinyaku Co., Ltd, Tsukuba, Ibaraki, Japan
| | - Yoshitsugu Aoki
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
| | - Shin’ichi Takeda
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Tokyo, Japan
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Imai S, Suda Y, Mori J, Sasaki Y, Yamada T, Kusano K. Prediction of Human Pharmacokinetics of Phosphorodiamidate Morpholino Oligonucleotides in Duchenne Muscular Dystrophy Patients Using Viltolarsen. Drug Metab Dispos 2023; 51:1428-1435. [PMID: 37468285 DOI: 10.1124/dmd.123.001425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/21/2023] Open
Abstract
Several modified antisense oligonucleotides (ASOs) have recently been approved for clinical use. Some are phosphorodiamidate morpholino oligomers (PMOs), which, unlike other nucleic acids, are not negatively charged. Thus, PMOs differ from other ASOs in their pharmacokinetic (PK) properties. Drugs with a PMO backbone have been administered to Duchenne muscular dystrophy pediatric patients; however, appropriate methodologies are not currently available to predict their human PK from nonclinical data. In this study, we used viltolarsen as a representative PMO to investigate the applicability of the allometric scaling approach to human PK prediction. We first summarized the nonclinical and clinical PK data for viltolarsen as showing high total clearance, low serum protein binding, metabolic resistance, and urinary excretion as the unchanged drug in both animals and humans. We then investigate the PK of viltolarsen in mice, rats, cynomolgus monkeys, and dogs and used the results, with body weight, to extrapolate to humans by several methods. The estimate of human total clearance obtained from cynomolgus monkeys was the best, and body weight may be the key factor in accurately predicting human total clearance. In contrast, all of the well-known prediction methods for the volume of distribution at steady state gave underestimates. However, the human PK profiles predicted from the PK parameters in cynomolgus monkeys fit the observed human plasma concentrations well. These results are expected to contribute to the further development of PMOs. SIGNIFICANCE STATEMENT: We investigated how to predict the human PK of phosphorodiamidate morpholino oligomers from nonclinical data. The estimates of human PK parameters and profiles determined from cynomolgus monkeys by an allometric scaling approach were the most suitable, and the cynomolgus monkey body weight may be the key factor in accurately predicting human total clearance.
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Affiliation(s)
- Shunji Imai
- Drug Metabolism and Pharmacokinetics Research Department, Discovery Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
| | - Yusuke Suda
- Drug Metabolism and Pharmacokinetics Research Department, Discovery Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
| | - Jumpei Mori
- Drug Metabolism and Pharmacokinetics Research Department, Discovery Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
| | - Yoshihiro Sasaki
- Drug Metabolism and Pharmacokinetics Research Department, Discovery Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
| | - Tetsuhiro Yamada
- Drug Metabolism and Pharmacokinetics Research Department, Discovery Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
| | - Kazutomi Kusano
- Drug Metabolism and Pharmacokinetics Research Department, Discovery Research Laboratories, Nippon Shinyaku Co., Ltd., Kyoto, Japan
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6
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Ohara H, Hosokawa M, Awaya T, Hagiwara A, Kurosawa R, Sako Y, Ogawa M, Ogasawara M, Noguchi S, Goto Y, Takahashi R, Nishino I, Hagiwara M. Branchpoints as potential targets of exon-skipping therapies for genetic disorders. MOLECULAR THERAPY. NUCLEIC ACIDS 2023; 33:404-412. [PMID: 37547287 PMCID: PMC10403725 DOI: 10.1016/j.omtn.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
Fukutin (FKTN) c.647+2084G>T creates a pseudo-exon with a premature stop codon, which causes Fukuyama congenital muscular dystrophy (FCMD). We aimed to ameliorate aberrant splicing of FKTN caused by this variant. We screened compounds focusing on splicing regulation using the c.647+2084G>T splicing reporter and discovered that the branchpoint, which is essential for splicing reactions, could be a potential therapeutic target. To confirm the effectiveness of branchpoints as targets for exon skipping, we designed branchpoint-targeted antisense oligonucleotides (BP-AONs). This restored normal FKTN mRNA and protein production in FCMD patient myotubes. We identified a functional BP by detecting splicing intermediates and creating BP mutations in the FKTN reporter gene; this BP was non-redundant and sufficiently blocked by BP-AONs. Next, a BP-AON was designed for a different FCMD-causing variant, which induces pathogenic exon trapping by a common SINE-VNTR-Alu-type retrotransposon. Notably, this BP-AON also restored normal FKTN mRNA and protein production in FCMD patient myotubes. Our findings suggest that BPs could be potential targets in exon-skipping therapeutic strategies for genetic disorders.
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Affiliation(s)
- Hiroaki Ohara
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
- Department of Drug Discovery for Intractable Diseases, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Motoyasu Hosokawa
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Tomonari Awaya
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
- Laboratory of Tumor Microenvironment and Immunity, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Atsuko Hagiwara
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Ryo Kurosawa
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Yukiya Sako
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
| | - Megumu Ogawa
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
| | - Masashi Ogasawara
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
| | - Satoru Noguchi
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
| | - Yuichi Goto
- Department of Mental Retardation and Birth Defect Research, National Institute of Neurology, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo 187-8502, Japan
| | - Masatoshi Hagiwara
- Department of Anatomy and Developmental Biology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan
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7
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Ishizuka T, Komaki H, Asahina Y, Nakamura H, Motohashi N, Takeshita E, Shimizu‐Motohashi Y, Ishiyama A, Yonee C, Maruyama S, Hida E, Aoki Y. Systemic administration of the antisense oligonucleotide
NS
‐089/
NCNP
‐02 for skipping of exon 44 in patients with Duchenne muscular dystrophy: Study protocol for a phase I/
II
clinical trial. Neuropsychopharmacol Rep 2023. [DOI: 10.1002/npr2.12335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Affiliation(s)
- Takami Ishizuka
- Clinical Research and Education Promotion Division National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Hirofumi Komaki
- Clinical Research and Education Promotion Division National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
- Department of Child Neurology National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Yasuko Asahina
- Clinical Research and Education Promotion Division National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Harumasa Nakamura
- Clinical Research and Education Promotion Division National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Norio Motohashi
- Department of Molecular Therapy National Institute of Neuroscience, National Center of Neurology and Psychiatry Tokyo Japan
| | - Eri Takeshita
- Department of Child Neurology National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Yuko Shimizu‐Motohashi
- Department of Child Neurology National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Akihiko Ishiyama
- Department of Child Neurology National Center Hospital, National Center of Neurology and Psychiatry Tokyo Japan
| | - Chihiro Yonee
- Department of Pediatrics, Graduate School of Medical and Dental Sciences Kagoshima University Kagoshima City Kagoshima Japan
| | - Shinsuke Maruyama
- Department of Pediatrics, Graduate School of Medical and Dental Sciences Kagoshima University Kagoshima City Kagoshima Japan
| | - Eisuke Hida
- Department of Biostatistics and Data Science, Graduate School of Medicine Osaka University Osaka Japan
| | - Yoshitsugu Aoki
- Department of Molecular Therapy National Institute of Neuroscience, National Center of Neurology and Psychiatry Tokyo Japan
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Abstract
Viltolarsen is a phosphorodiamidate morpholino antisense oligonucleotide (PMO) designed to skip exon 53 of the DMD gene for the treatment of Duchenne muscular dystrophy (DMD), one of the most common lethal genetic disorders characterized by progressive degeneration of skeletal muscles and cardiomyopathy. It was developed by Nippon Shinyaku in collaboration with the National Center of Neurology and Psychiatry (NCNP) in Japan based on the preclinical studies conducted in the DMD dog model at the NCNP. After showing hopeful results in pre-clinical trials and several clinical trials across North America and Japan, it received US Food and Drug Administration (FDA) approval for DMD in 2020. Viltolarsen restores the reading frame of the DMD gene by skipping exon 53 and produces a truncated but functional form of dystrophin. It can treat approximately 8-10% of the DMD patient population. This paper aims to summarize the development of viltolarsen from preclinical trials to clinical trials to, finally, FDA approval, and discusses the challenges that come with fighting DMD using antisense therapy.
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Affiliation(s)
- Rohini Roy Roshmi
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Toshifumi Yokota
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
- The Friends of Garrett Cumming Research & Muscular Dystrophy Canada, HM Toupin Neurological Science Research Chair, Edmonton, Canada.
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9
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Kaburagi H, Nagata T, Enomoto M, Hirai T, Ohyagi M, Ihara K, Yoshida-Tanaka K, Ebihara S, Asada K, Yokoyama H, Okawa A, Yokota T. Systemic DNA/RNA heteroduplex oligonucleotide administration for regulating the gene expression of dorsal root ganglion and sciatic nerve. MOLECULAR THERAPY - NUCLEIC ACIDS 2022; 28:910-919. [PMID: 35694210 PMCID: PMC9167871 DOI: 10.1016/j.omtn.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/03/2022] [Indexed: 11/24/2022]
Abstract
Neuropathic pain, a heterogeneous condition, affects 7%–10% of the general population. To date, efficacious and safe therapeutic approaches remain limited. Antisense oligonucleotide (ASO) therapy has opened the door to treat spinal muscular atrophy, with many ongoing clinical studies determining its therapeutic utility. ASO therapy for neuropathic pain and peripheral nerve disease requires efficient gene delivery and knockdown in both the dorsal root ganglion (DRG) and sciatic nerve, key tissues for pain signaling. We previously developed a new DNA/RNA heteroduplex oligonucleotide (HDO) technology that achieves highly efficient gene knockdown in the liver. Here, we demonstrated that intravenous injection of HDO, comprising an ASO and its complementary RNA conjugated to α-tocopherol, silences endogenous gene expression more than 2-fold in the DRG, and sciatic nerve with higher potency, efficacy, and broader distribution than ASO alone. Of note, we observed drastic target suppression in all sizes of neuronal DRG populations by in situ hybridization. Our findings establish HDO delivery as an investigative and potentially therapeutic platform for neuropathic pain and peripheral nerve disease.
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Clemens PR, Rao VK, Connolly AM, Harper AD, Mah JK, McDonald CM, Smith EC, Zaidman CM, Nakagawa T, Hoffman EP. Long-Term Functional Efficacy and Safety of Viltolarsen in Patients with Duchenne Muscular Dystrophy. J Neuromuscul Dis 2022; 9:493-501. [PMID: 35634851 PMCID: PMC9398057 DOI: 10.3233/jnd-220811] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Duchenne muscular dystrophy (DMD) is a rare, genetic disease caused by mutations in the DMD gene resulting in an absence of functional dystrophin protein. Viltolarsen, an exon 53 skipping therapy, has been shown to increase endogenous dystrophin levels. Herein, long-term (>2 years) functional outcomes in viltolarsen treated patients were compared to a matched historical control group. Objective: To evaluate long-term efficacy and safety of the anti-sense oligonucleotide viltolarsen in the treatment of patients with DMD amenable to exon 53 skipping therapy. Methods: This trial (NCT03167255) is the extension of a previously published 24-week trial in North America (NCT02740972) that examined dystrophin levels, timed function tests compared to a matched historical control group (Cooperative International Neuromuscular Research Group Duchenne Natural History Study, CINRG DNHS), and safety in boys 4 to < 10 years (N = 16) with DMD amenable to exon 53 skipping who were treated with viltolarsen. Both groups were treated with glucocorticoids. All 16 participants elected to enroll in this long-term trial (up to 192 weeks) to continue evaluation of motor function and safety. Results: Time to stand from supine and time to run/walk 10 meters showed stabilization from baseline through week 109 for viltolarsen-treated participants whereas the historical control group showed decline (statistically significant differences for multiple timepoints). Safety was similar to that observed in the previous 24-week trial, which was predominantly mild. There have been no treatment-related serious adverse events and no discontinuations. Conclusions: Based on these results at over 2 years, viltolarsen can be a new treatment option for patients with DMD amenable to exon 53 skipping.
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Affiliation(s)
- Paula R. Clemens
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
| | - Vamshi K. Rao
- Division of Neurology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Anne M. Connolly
- Division of Neurology, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Amy D. Harper
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Jean K. Mah
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Craig M. McDonald
- Department of Physical Medicine and Rehabilitation, Department of Pediatrics, UC Davis Health, University of California, Davis, Sacramento, California
| | | | - Craig M. Zaidman
- Department of Neurology, Washington University at St Louis, St Louis, Missouri
| | | | - Eric P. Hoffman
- Department of Pharmaceutical Sciences, State University of New York at Binghamton, Binghamton, New York
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Saifullah, Motohashi N, Tsukahara T, Aoki Y. Development of Therapeutic RNA Manipulation for Muscular Dystrophy. Front Genome Ed 2022; 4:863651. [PMID: 35620642 PMCID: PMC9127466 DOI: 10.3389/fgeed.2022.863651] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/12/2022] [Indexed: 11/16/2022] Open
Abstract
Approval of therapeutic RNA molecules, including RNA vaccines, has paved the way for next-generation treatment strategies for various diseases. Oligonucleotide-based therapeutics hold particular promise for treating incurable muscular dystrophies, including Duchenne muscular dystrophy (DMD). DMD is a severe monogenic disease triggered by deletions, duplications, or point mutations in the DMD gene, which encodes a membrane-linked cytoskeletal protein to protect muscle fibers from contraction-induced injury. Patients with DMD inevitably succumb to muscle degeneration and atrophy early in life, leading to premature death from cardiac and respiratory failure. Thus far, the disease has thwarted all curative strategies. Transcriptomic manipulation, employing exon skipping using antisense oligonucleotides (ASO), has made significant progress in the search for DMD therapeutics. Several exon-skipping drugs employing RNA manipulation technology have been approved by regulatory agencies and have shown promise in clinical trials. This review summarizes recent scientific and clinical progress of ASO and other novel RNA manipulations, including RNA-based editing using MS2 coat protein-conjugated adenosine deaminase acting on the RNA (MCP-ADAR) system illustrating the efficacy and limitations of therapies to restore dystrophin. Perhaps lessons from this review will encourage the application of RNA-editing therapy to other neuromuscular disorders.
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Affiliation(s)
- Saifullah
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Norio Motohashi
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
| | - Toshifumi Tsukahara
- Area of Bioscience and Biotechnology, School of Materials Science, Japan Advanced Institute of Science and Technology (JAIST), Ishikawa, Japan
- Division of Transdisciplinary Science, Japan Advanced Institute of Science and Technology (JAIST), Ishikawa, Japan
| | - Yoshitsugu Aoki
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan
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12
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Roshmi RR, Yokota T. Pharmacological Profile of Viltolarsen for the Treatment of Duchenne Muscular Dystrophy: A Japanese Experience. Clin Pharmacol 2021; 13:235-242. [PMID: 34938127 PMCID: PMC8688746 DOI: 10.2147/cpaa.s288842] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/12/2021] [Indexed: 01/11/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is a fatal, X-linked recessive disorder characterized by progressive muscle loss and cardiorespiratory complications. Mutations in the DMD gene that eliminate the production of dystrophin protein are the underlying causes of DMD. Viltolarsen is a drug of phosphorodiamidate morpholino oligomer (PMO) chemistry, designed to skip exon 53 of the DMD gene. It aims to produce truncated but partially functional dystrophin in DMD patients and restore muscle function. Based on a preclinical study showing the ability of antisense PMOs targeting the DMD gene to improve muscle function in a large animal model, viltolarsen was developed by Nippon Shinyaku and the National Center of Neurology and Psychiatry in Japan. Following clinical trials conducted in Japan, Canada, and the United States showing significant improvements in muscle function, viltolarsen was approved for medical use in Japan in March 2020 and the United States in August 2020, respectively. Viltolarsen is a mutation-specific drug and will work for 8% of the persons with DMD who carry mutations amenable to exon 53 skipping. This review summarizes the pharmacological profile of viltolarsen, important clinical trials, and challenges, focusing on the contribution of Japanese patients and researchers in its development.
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Affiliation(s)
- Rohini Roy Roshmi
- Department of Medical Genetics, University of Alberta, Edmonton, Alberta, Canada
| | - Toshifumi Yokota
- Department of Medical Genetics, University of Alberta, Edmonton, Alberta, Canada
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13
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Singh S, Singh T, Kunja C, Dhoat NS, Dhania NK. Gene-editing, immunological and iPSCs based therapeutics for muscular dystrophy. Eur J Pharmacol 2021; 912:174568. [PMID: 34656607 DOI: 10.1016/j.ejphar.2021.174568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/25/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
Muscular dystrophy is a well-known genetically heterogeneous group of rare muscle disorders. This progressive disease causes the breakdown of skeletal muscles over time and leads to grave weakness. This breakdown is caused by a diverse pattern of mutations in dystrophin and dystrophin associated protein complex. These mutations lead to the production of altered proteins in response to which, the body stimulates production of various cytokines and immune cells, particularly reactive oxygen species and NFκB. Immune cells display/exhibit a dual role by inducing muscle damage and muscle repair. Various anti-oxidants, anti-inflammatory and glucocorticoid drugs serve as potent therapeutics for muscular dystrophy. Along with the above mentioned therapeutics, induced pluripotent stem cells also serve as a novel approach paving a way for personalized treatment. These pluripotent stem cells allow regeneration of large numbers of regenerative myogenic progenitors that can be administered in muscular dystrophy patients which assist in the recovery of lost muscle fibers. In this review, we have summarized gene-editing, immunological and induced pluripotent stem cell based therapeutics for muscular dystrophy treatment.
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Affiliation(s)
- Shagun Singh
- Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda-151001, Punjab, India
| | - Tejpal Singh
- Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda-151001, Punjab, India
| | - Chaitanya Kunja
- Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda-151001, Punjab, India
| | - Navdeep S Dhoat
- Department of Pediatrics Surgery, All India Institute of Medical Sciences, Bathinda, 151001, Punjab, India
| | - Narender K Dhania
- Department of Human Genetics and Molecular Medicine, School of Health Sciences, Central University of Punjab, Bathinda-151001, Punjab, India.
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14
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Abstract
Duchenne muscular dystrophy (DMD) is a devastating, rare disease. While clinically described in the 19th century, the genetic foundation of DMD was not discovered until more than 100 years later. This genetic understanding opened the door to the development of genetic treatments for DMD. Over the course of the last 30 years, the research that supports this development has moved into the realm of clinical trials and regulatory drug approvals. Exon skipping to therapeutically restore the frame of an out-of-frame dystrophin mutation has taken center stage in drug development for DMD. The research reviewed here focuses on the clinical development of exon skipping for the treatment of DMD. In addition to the generation of clinical treatments that are being used for patient care, this research sets the stage for future therapeutic development with a focus on increasing efficacy while providing safety and addressing the multi-systemic aspects of DMD.
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Affiliation(s)
- Shin'ichi Takeda
- Honorary Director General, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), Kodaira, Japan
| | - Paula R Clemens
- Professor and Vice Chair of VA Affairs, Department of Neurology, University of Pittsburgh School of Medicine, Division Chief, Neurology, Medical Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA USA
| | - Eric P Hoffman
- Professor, Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University - State University of New York, Binghamton, NY USA
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15
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Restoring Protein Expression in Neuromuscular Conditions: A Review Assessing the Current State of Exon Skipping/Inclusion and Gene Therapies for Duchenne Muscular Dystrophy and Spinal Muscular Atrophy. BioDrugs 2021; 35:389-399. [PMID: 34097287 DOI: 10.1007/s40259-021-00486-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 02/06/2023]
Abstract
The debilitating neuromuscular disorders Duchenne muscular dystrophy (DMD) and spinal muscular atrophy (SMA), which harm 1 in 5000 newborn males and 1 in 11,000 newborns, respectively, are marked by progressive muscle wasting among other complications. While DMD causes generalized muscle weakness due to the absence of the dystrophin protein, SMA patients generally face motor neuron degeneration because of the lack of the survival motor neuron (SMN) protein. Many of the most promising therapies for both conditions restore the absent proteins dystrophin and SMN. Antisense oligonucleotide-mediated exon skipping and inclusion therapies are advancing clinically with the approved DMD therapies casimersen, eteplirsen, golodirsen, and viltolarsen, and the SMA therapy nusinersen. Existing antisense therapies focus on skeletal muscle for DMD and motor neurons for SMA, respectively. Through innovative techniques, such as peptide conjugation and multi-exon skipping, these therapies could be optimized for efficacy and applicability. By contrast, gene replacement therapy is administered only once to patients during treatment. Currently, only onasemnogene abeparvovec for SMA has been approved. Safety shortcomings remain a major challenge for gene therapy. Nevertheless, gene therapy for DMD has strong potential to restore dystrophin expression in patients. In light of promising functional improvements, antisense and gene therapies stand poised to elevate the lives of patients with DMD and SMA.
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16
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Clemens PR, Rao VK, Connolly AM, Harper AD, Mah JK, Smith EC, McDonald CM, Zaidman CM, Morgenroth LP, Osaki H, Satou Y, Yamashita T, Hoffman EP. Safety, Tolerability, and Efficacy of Viltolarsen in Boys With Duchenne Muscular Dystrophy Amenable to Exon 53 Skipping: A Phase 2 Randomized Clinical Trial. JAMA Neurol 2021; 77:982-991. [PMID: 32453377 PMCID: PMC7251505 DOI: 10.1001/jamaneurol.2020.1264] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Question What are the safety, tolerability, and efficacy of viltolarsen in boys with Duchenne muscular dystrophy (DMD) amenable to exon 53 skipping? Findings Results of this 4-week randomized clinical trial for safety followed by a 20-week open-label treatment period in 16 patients with DMD indicated significant drug-induced dystrophin production in both viltolarsen groups (40 mg/kg per week and 80 mg/kg week) after 20 to 24 weeks of treatment. Timed function tests provided supportive evidence of treatment-related clinical improvement, and viltolarsen was well tolerated. Meaning Viltolarsen may provide a new therapeutic option for patients with DMD amenable to exon 53 skipping. Importance An unmet need remains for safe and efficacious treatments for Duchenne muscular dystrophy (DMD). To date, there are limited agents available that address the underlying cause of the disease. Objective To evaluate the safety, tolerability, and efficacy of viltolarsen, a novel antisense oligonucleotide, in participants with DMD amenable to exon 53 skipping. Design, Setting, and Participants This phase 2 study was a 4-week randomized clinical trial for safety followed by a 20-week open-label treatment period of patients aged 4 to 9 years with DMD amenable to exon 53 skipping. To enroll 16 participants, with 8 participants in each of the 2 dose cohorts, 17 participants were screened. Study enrollment occurred between December 16, 2016, and August 17, 2017, at sites in the US and Canada. Data were collected from December 2016 to February 2018, and data were analyzed from April 2018 to May 2019. Interventions Participants received 40 mg/kg (low dose) or 80 mg/kg (high dose) of viltolarsen administered by weekly intravenous infusion. Main Outcomes and Measures Primary outcomes of the trial included safety, tolerability, and de novo dystrophin protein production measured by Western blot in participants’ biceps muscles. Secondary outcomes included additional assessments of dystrophin mRNA and protein production as well as clinical muscle strength and function. Results Of the 16 included boys with DMD, 15 (94%) were white, and the mean (SD) age was 7.4 (1.8) years. After 20 to 24 weeks of treatment, significant drug-induced dystrophin production was seen in both viltolarsen dose cohorts (40 mg/kg per week: mean [range] 5.7% [3.2-10.3] of normal; 80 mg/kg per week: mean [range] 5.9% [1.1-14.4] of normal). Viltolarsen was well tolerated; no treatment-emergent adverse events required dose reduction, interruption, or discontinuation of the study drug. No serious adverse events or deaths occurred during the study. Compared with 65 age-matched and treatment-matched natural history controls, all 16 participants treated with viltolarsen showed significant improvements in timed function tests from baseline, including time to stand from supine (viltolarsen: −0.19 s; control: 0.66 s), time to run/walk 10 m (viltolarsen: 0.23 m/s; control: −0.04 m/s), and 6-minute walk test (viltolarsen: 28.9 m; control: −65.3 m) at the week 25 visit. Conclusions and Relevance Systemic treatment of participants with DMD with viltolarsen induced de novo dystrophin production, and clinical improvement of timed function tests was observed. Trial Registration ClinicalTrials.gov Identifier: NCT02740972
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Affiliation(s)
- Paula R Clemens
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
| | - Vamshi K Rao
- Division of Neurology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anne M Connolly
- Division of Neurology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus
| | - Amy D Harper
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond
| | - Jean K Mah
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Edward C Smith
- Division of Pediatric Neurology, Duke University Medical Center, Durham, North Carolina
| | - Craig M McDonald
- Department of Physical Medicine and Rehabilitation, Department of Pediatrics, UC Davis Health, University of California, Davis, Sacramento
| | - Craig M Zaidman
- Department of Neurology, Washington University at St Louis, St Louis, Missouri
| | - Lauren P Morgenroth
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | - Eric P Hoffman
- AGADA BioSciences, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Pharmaceutical Sciences, State University of New York at Binghamton
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17
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Maruyama R, Yokota T. Antisense Oligonucleotide Treatment in a Humanized Mouse Model of Duchenne Muscular Dystrophy and Highly Sensitive Detection of Dystrophin Using Western Blotting. Methods Mol Biol 2021; 2224:203-214. [PMID: 33606217 DOI: 10.1007/978-1-0716-1008-4_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Duchenne muscular dystrophy (DMD) is a devastating X-linked muscle disorder affecting many children. The disease is caused by the lack of dystrophin production and characterized by muscle wasting. The most common causes of death are respiratory failure and heart failure. Antisense oligonucleotide-mediated exon skipping using a phosphorodiamidate morpholino oligomer (PMO) is a promising therapeutic approach for the treatment of DMD. In preclinical studies, dystrophic mouse models are commonly used for the development of therapeutic oligos. We employ a humanized model carrying the full-length human DMD transgene along with the complete knockout of the mouse Dmd gene. In this model, the effects of human-targeting AOs can be tested without cross-reaction between mouse sequences and human sequences (note that mdx, a conventional dystrophic mouse model, carries a nonsense point mutation in exon 23 and express the full-length mouse Dmd mRNA, which is a significant complicating factor). To determine if dystrophin expression is restored, the Western blotting analysis is commonly performed; however, due to the extremely large protein size of dystrophin (427 kDa), detection and accurate quantification of full-length dystrophin can be a challenge. Here, we present methodologies to systemically inject PMOs into humanized DMD model mice and determine levels of dystrophin restoration via Western blotting. Using a tris-acetate gradient SDS gel and semi-dry transfer with three buffers, including the Concentrated Anode Buffer, Anode Buffer, and Cathode Buffer, less than 1% normal levels of dystrophin expression are easily detectable. This method is fast, easy, and sensitive enough for the detection of dystrophin from both cultured muscle cells and muscle biopsy samples.
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Affiliation(s)
- Rika Maruyama
- Faculty of Medicine and Dentistry, Department of Medical Genetics, University of Alberta, Edmonton, AB, Canada
| | - Toshifumi Yokota
- Faculty of Medicine and Dentistry, Department of Medical Genetics, University of Alberta, Edmonton, AB, Canada. .,The Friends of Garrett Cumming Research & Muscular Dystrophy Canada HM Toupin Neurological Science Research Chair, Edmonton, AB, Canada.
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18
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Andreana I, Repellin M, Carton F, Kryza D, Briançon S, Chazaud B, Mounier R, Arpicco S, Malatesta M, Stella B, Lollo G. Nanomedicine for Gene Delivery and Drug Repurposing in the Treatment of Muscular Dystrophies. Pharmaceutics 2021; 13:278. [PMID: 33669654 PMCID: PMC7922331 DOI: 10.3390/pharmaceutics13020278] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/07/2021] [Accepted: 02/14/2021] [Indexed: 12/11/2022] Open
Abstract
Muscular Dystrophies (MDs) are a group of rare inherited genetic muscular pathologies encompassing a variety of clinical phenotypes, gene mutations and mechanisms of disease. MDs undergo progressive skeletal muscle degeneration causing severe health problems that lead to poor life quality, disability and premature death. There are no available therapies to counteract the causes of these diseases and conventional treatments are administered only to mitigate symptoms. Recent understanding on the pathogenetic mechanisms allowed the development of novel therapeutic strategies based on gene therapy, genome editing CRISPR/Cas9 and drug repurposing approaches. Despite the therapeutic potential of these treatments, once the actives are administered, their instability, susceptibility to degradation and toxicity limit their applications. In this frame, the design of delivery strategies based on nanomedicines holds great promise for MD treatments. This review focuses on nanomedicine approaches able to encapsulate therapeutic agents such as small chemical molecules and oligonucleotides to target the most common MDs such as Duchenne Muscular Dystrophy and the Myotonic Dystrophies. The challenge related to in vitro and in vivo testing of nanosystems in appropriate animal models is also addressed. Finally, the most promising nanomedicine-based strategies are highlighted and a critical view in future developments of nanomedicine for neuromuscular diseases is provided.
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Affiliation(s)
- Ilaria Andreana
- Laboratoire d’Automatique, de Génie des Procédés et de Génie Pharmaceutique, Université Claude Bernard Lyon 1, CNRS UMR 5007, 43 bd 11 Novembre 1918, 69622 Villeurbanne, France; (I.A.); (M.R.); (D.K.); (S.B.)
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, 10125 Torino, Italy;
| | - Mathieu Repellin
- Laboratoire d’Automatique, de Génie des Procédés et de Génie Pharmaceutique, Université Claude Bernard Lyon 1, CNRS UMR 5007, 43 bd 11 Novembre 1918, 69622 Villeurbanne, France; (I.A.); (M.R.); (D.K.); (S.B.)
- Department of Neurosciences, Biomedicine and Movement Sciences, Anatomy and Histology Section, University of Verona, Strada Le Grazie 8, 37134 Verona, Italy; (F.C.); (M.M.)
| | - Flavia Carton
- Department of Neurosciences, Biomedicine and Movement Sciences, Anatomy and Histology Section, University of Verona, Strada Le Grazie 8, 37134 Verona, Italy; (F.C.); (M.M.)
- Department of Health Sciences, University of Eastern Piedmont, Via Solaroli 17, 28100 Novara, Italy
| | - David Kryza
- Laboratoire d’Automatique, de Génie des Procédés et de Génie Pharmaceutique, Université Claude Bernard Lyon 1, CNRS UMR 5007, 43 bd 11 Novembre 1918, 69622 Villeurbanne, France; (I.A.); (M.R.); (D.K.); (S.B.)
- Hospices Civils de Lyon, 69437 Lyon, France
| | - Stéphanie Briançon
- Laboratoire d’Automatique, de Génie des Procédés et de Génie Pharmaceutique, Université Claude Bernard Lyon 1, CNRS UMR 5007, 43 bd 11 Novembre 1918, 69622 Villeurbanne, France; (I.A.); (M.R.); (D.K.); (S.B.)
| | - Bénédicte Chazaud
- Institut NeuroMyoGène, University of Lyon, INSERM U1217, CNRS UMR 5310, 8 Avenue Rockefeller, 69008 Lyon, France; (B.C.); (R.M.)
| | - Rémi Mounier
- Institut NeuroMyoGène, University of Lyon, INSERM U1217, CNRS UMR 5310, 8 Avenue Rockefeller, 69008 Lyon, France; (B.C.); (R.M.)
| | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, 10125 Torino, Italy;
| | - Manuela Malatesta
- Department of Neurosciences, Biomedicine and Movement Sciences, Anatomy and Histology Section, University of Verona, Strada Le Grazie 8, 37134 Verona, Italy; (F.C.); (M.M.)
| | - Barbara Stella
- Department of Drug Science and Technology, University of Turin, Via P. Giuria 9, 10125 Torino, Italy;
| | - Giovanna Lollo
- Laboratoire d’Automatique, de Génie des Procédés et de Génie Pharmaceutique, Université Claude Bernard Lyon 1, CNRS UMR 5007, 43 bd 11 Novembre 1918, 69622 Villeurbanne, France; (I.A.); (M.R.); (D.K.); (S.B.)
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19
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Takizawa H, Takeshita E, Sato M, Shimizu-Motohashi Y, Ishiyama A, Mori-Yoshimura M, Takahashi Y, Komaki H, Aoki Y. Highly sensitive screening of antisense sequences for different types of DMD mutations in patients' urine-derived cells. J Neurol Sci 2021; 423:117337. [PMID: 33610829 DOI: 10.1016/j.jns.2021.117337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/03/2021] [Accepted: 02/02/2021] [Indexed: 11/30/2022]
Abstract
Exon skipping using short antisense oligonucleotides (AONs) is a promising treatment for Duchenne muscular dystrophy (DMD). Several exon-skipping drugs, including viltolarsen (NS-065/NCNP-01), have been approved worldwide. Immortalized human skeletal muscle cell lines, such as rhabdomyosarcoma cells, are frequently used to screen efficient oligonucleotide sequences. However, rhabdomyosarcoma cells do not recapitulate DMD pathophysiology as they express endogenous dystrophin. To overcome this limitation, we recently established a direct human somatic cell reprogramming technology and successfully developed a cellular skeletal muscle DMD model by using myogenic differentiation 1 (MYOD1)-transduced urine-derived cells (MYOD1-UDCs). Here, we compared in vitro drug screening systems in MYOD1-UDCs and rhabdomyosarcoma cells. We collected UDCs from patients with DMD amenable to exon 51 skipping, and obtained MYOD1-UDCs. We then compared the efficiency of exon 51 skipping induced by various morpholino-based AONs, including eteplirsen in differentiated MYOD1-UDCs (UDC-myotubes) and rhabdomyosarcoma cells. Exon skipping was induced more efficiently in UDC-myotubes than in rhabdomyosarcoma cells even at a low AON concentration (1 μM). Furthermore, exon 51 skipping efficiency was higher in UDC-myotubes with a deletion of exons 49-50 than in those with a deletion of exons 48-50, suggesting that the skipping efficiency may vary depending on the DMD mutation pattern. An essential finding of this study is that the sequence of eteplirsen consistently leads to much lower efficiency than other sequences. These findings underscore the importance of AON sequence optimization by our cellular system, which enables highly sensitive screening of exon skipping drugs that target different types of DMD mutations.
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Affiliation(s)
- Hotake Takizawa
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan; Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan.
| | - Eri Takeshita
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Mitsuto Sato
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuko Shimizu-Motohashi
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Akihiko Ishiyama
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Madoka Mori-Yoshimura
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yuji Takahashi
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Yoshitsugu Aoki
- Department of Molecular Therapy, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan.
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20
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Ceccarello E, Tabaglio T, Koh S, Oei V, Teo W, Jonathan OJ, Pavesi A, Chen Q, Bertoletti A, Wee KB, Guccione E. Splice-Switching Antisense Oligonucleotides as a Targeted Intrinsic Engineering Tool for Generating Armored Redirected T Cells. Nucleic Acid Ther 2021; 31:145-154. [PMID: 33567222 PMCID: PMC7997720 DOI: 10.1089/nat.2020.0905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Modification of specificity of T cells for the use in adoptive transfer (CAR- or TCR-redirected T cells) has revolutionized the therapy of liquid tumors and some infectious diseases. However, several obstacles are still hampering the efficacy of such potent therapy, hence concurrent modification of the function is also required to obtain successful results. Here we show the use of splice-switching antisense oligonucleotides (SSOs) as a tool to transiently modify T cell function. We demonstrate the possibility to transfect SSOs and an exogenous TCR into primary human T cells in the same electroporation reaction, without affecting viability and function of the transfected T lymphocytes. Moreover, we show that SSOs targeting T cell-specific mRNAs induce the skipping of the targeted exons, and the reduction of the protein and consequent modification of T cell function. This technical work paves the way to the use of SSOs in immune cells, not only for the knockdown of the functional isoform of the targeted proteins, but also for the protein manipulation by elimination of specific domains encoded by targeted exons.
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Affiliation(s)
- Erica Ceccarello
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,IMMUNOA Pte Ltd, Singapore, Singapore
| | - Tommaso Tabaglio
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Sarene Koh
- Lion TCR Pte Ltd, Singapore, Singapore.,Singapore Immunology Network, Agency for Science and Technology (A*STAR), Singapore, Singapore
| | - Vincent Oei
- Duke-NUS Medical School, Singapore, Singapore
| | - Winnie Teo
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Owen Julianto Jonathan
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Andrea Pavesi
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Qingfeng Chen
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | | | - Keng Boon Wee
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Ernesto Guccione
- Institute of Molecular and Cell Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore.,Department of Oncological Sciences and Pharmacological Sciences, Center for Therapeutics Discovery, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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21
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Abstract
Viltolarsen (Viltepso® in Japan) is a phosphorodiamidate morpholino antisense oligonucleotide being developed by Nippon Shinyaku, in collaboration with the National Center of Neurology and Psychiatry (NCNP), for the treatment of Duchenne muscular dystrophy (DMD). Viltolarsen binds to exon 53 of the dystrophin mRNA precursor and restores the amino acid open-reading frame by skipping exon 53, resulting in the production of a shortened dystrophin protein that contains essential functional portions. In March 2020, intravenous viltolarsen received its first global approval in Japan for the treatment of DMD in patients with confirmed deletion of the dystrophin gene that is amenable to exon 53 skipping. Viltolarsen is under regulatory review in the USA and clinical trials continue in the USA, Canada and globally. This article summarizes the milestones in the development of viltolarsen leading to the first approval for DMD.
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Affiliation(s)
- Sohita Dhillon
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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22
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Sheikh O, Yokota T. Developing DMD therapeutics: a review of the effectiveness of small molecules, stop-codon readthrough, dystrophin gene replacement, and exon-skipping therapies. Expert Opin Investig Drugs 2021; 30:167-176. [PMID: 33393390 DOI: 10.1080/13543784.2021.1868434] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder caused by mutations in the dystrophin (DMD) gene. Most patients die from respiratory failure or cardiomyopathy. There are significant unmet needs for treatments for DMD as the standard of care is principally limited to symptom relief through treatments including steroids. AREAS COVERED This review summarizes safety and efficacy in promising areas of DMD therapeutics - small molecules, stop codon readthrough, gene replacement, and exon skipping - under clinical examination from 2015-2020 as demonstrated in the NIH Clinical Trials and PubMed search engines. EXPERT OPINION Currently, steroids persist as the most accessible medicine for DMD. Stop-codon readthrough, gene replacement, and exon-skipping therapies all aim to restore dystrophin expression. Of these strategies, gene replacement therapy has recently gained momentum while exon-skipping retains great traction. The FDA approval of three exon-skipping antisense oligonucleotides illustrate this regulatory momentum, though the effectiveness and sequence design of eteplirsen remain controversial. Cell-penetrating peptides promise to more efficaciously treat DMD-related cardiomyopathy.The recent success of antisense therapies, however, poses major regulatory challenges. To fully realize the benefits of exon-skipping, including cocktail oligonucleotide-mediated multiple exon-skipping and oligonucleotide drugs for very rare mutations, regulatory challenges need to be addressed in coordination with scientific advances.
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Affiliation(s)
- Omar Sheikh
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Canada
| | - Toshifumi Yokota
- Department of Medical Genetics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Canada
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23
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Scaglioni D, Catapano F, Ellis M, Torelli S, Chambers D, Feng L, Beck M, Sewry C, Monforte M, Harriman S, Koenig E, Malhotra J, Popplewell L, Guglieri M, Straub V, Mercuri E, Servais L, Phadke R, Morgan J, Muntoni F. The administration of antisense oligonucleotide golodirsen reduces pathological regeneration in patients with Duchenne muscular dystrophy. Acta Neuropathol Commun 2021; 9:7. [PMID: 33407808 PMCID: PMC7789286 DOI: 10.1186/s40478-020-01106-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 12/17/2022] Open
Abstract
During the last decade, multiple clinical trials for Duchenne muscular dystrophy (DMD) have focused on the induction of dystrophin expression using different strategies. Many of these trials have reported a clear increase in dystrophin protein following treatment. However, the low levels of the induced dystrophin protein have raised questions on its functionality. In our present study, using an unbiased, high-throughput digital image analysis platform, we assessed markers of regeneration and levels of dystrophin associated protein via immunofluorescent analysis of whole muscle sections in 25 DMD boys who received 48-weeks treatment with exon 53 skipping morpholino antisense oligonucleotide (PMO) golodirsen. We demonstrate that the de novo dystrophin induced by exon skipping with PMO golodirsen is capable of conferring a histological benefit in treated patients with an increase in dystrophin associated proteins at the dystrophin positive regions of the sarcolemma in post-treatment biopsies. Although 48 weeks treatment with golodirsen did not result in a significant change in the levels of fetal/developmental myosins for the entire cohort, there was a significant negative correlation between the amount of dystrophin and levels of regeneration observed in different biopsy samples. Our results provide, for the first time, evidence of functionality of induced dystrophin following successful therapeutic intervention in the human.
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24
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Lyu P, Yoo KW, Yadav MK, Atala A, Aartsma-Rus A, van Putten M, Duan D, Lu B. Sensitive and reliable evaluation of single-cut sgRNAs to restore dystrophin by a GFP-reporter assay. PLoS One 2020; 15:e0239468. [PMID: 32970732 PMCID: PMC7514106 DOI: 10.1371/journal.pone.0239468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/08/2020] [Indexed: 12/31/2022] Open
Abstract
Most Duchenne muscular dystrophy (DMD) cases are caused by deletions or duplications of one or more exons that disrupt the reading frame of DMD mRNA. Restoring the reading frame allows the production of partially functional dystrophin proteins, and result in less severe symptoms. Antisense oligonucleotide mediated exon skipping has been approved for DMD, but this strategy needs repeated treatment. CRISPR/Cas9 can also restore dystrophin reading frame. Although recent in vivo studies showed the efficacy of the single-cut reframing/exon skipping strategy, methods to find the most efficient single-cut sgRNAs for a specific mutation are lacking. Here we show that the insertion/deletion (INDEL) generating efficiency and the INDEL profiles both contribute to the reading frame restoring efficiency of a single-cut sgRNA, thus assays only examining INDEL frequency are not able to find the best sgRNAs. We therefore developed a GFP-reporter assay to evaluate single-cut reframing efficiency, reporting the combined effects of both aspects. We show that the GFP-reporter assay can reliably predict the performance of sgRNAs in myoblasts. This GFP-reporter assay makes it possible to efficiently and reliably find the most efficient single-cut sgRNA for restoring dystrophin expression.
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Affiliation(s)
- Pin Lyu
- Wake Forest Institute for Regenerative Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina, United States of America
| | - Kyung Whan Yoo
- Wake Forest Institute for Regenerative Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina, United States of America
| | - Manish Kumar Yadav
- Wake Forest Institute for Regenerative Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina, United States of America
| | - Anthony Atala
- Wake Forest Institute for Regenerative Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina, United States of America
| | | | | | - Dongsheng Duan
- Department of Molecular Microbiology and Immunology, School of Medicine, University of Missouri, Columbia, Missouri, United States of America
| | - Baisong Lu
- Wake Forest Institute for Regenerative Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina, United States of America
- * E-mail:
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25
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Wang L, Okamura H, Sasaki S, Taniguchi Y. Enhancements in the utilization of antigene oligonucleotides in the nucleus by booster oligonucleotides. Chem Commun (Camb) 2020; 56:9731-9734. [PMID: 32815931 DOI: 10.1039/d0cc04240d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We recently found the translocation of double-stranded DNA into the nucleus. We herein describe the concept of novel booster oligodeoxynucleotides including 2'-deoxy uridine, which release antigene oligonucleotides in the nucleus by enzymatic digestion. This system exhibited stronger hTERT mRNA expression inhibitory activity than single-stranded antigene oligonucleotides.
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Affiliation(s)
- Lei Wang
- Graduate School of Pharmaceutical Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan.
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26
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[A predictive analysis of the association between clinical phenotypes and genotypes in children with Becker muscular dystrophy/Duchenne muscular dystrophy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 32571459 PMCID: PMC7390220 DOI: 10.7499/j.issn.1008-8830.1912133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To study the association between clinical phenotypes and genotypes in children with Becker muscular dystrophy (BMD)/Duchenne muscular dystrophy (DMD) so as to provide a theoretical basis for disease management, gene therapy, and prenatal diagnosis. METHODS A retrospective analysis was performed for the clinical data and gene detection results of 52 children with BMD/DMD. Multiplex ligation-dependent probe amplification (MLPA) was used to detect the DMD gene. The children with negative results of MLPA were further screened by exon chip capture combined with next-generation sequencing (NGS). The mothers of 20 probands were validated by sequencing. RESULTS The pathogenic genes for BMD/DMD were detected in 50 children by MLPA and NGS, with a detection rate of 96%. Among the 52 children, 36 (69%) had gene deletion, 7 (13%) had duplication, and 7 (13%) had micromutation. Among the 43 children with deletion/duplication, 32 had DMD and 11 had BMD; 37 children (86%) met the reading frame rule, among whom 27 (96%) had DMD and 10 (67%) had BMD. All 7 children with micromutation had DMD. CONCLUSIONS The reading frame rule has an extremely high predictive value for DMD but a limited predictive value for BMD.
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27
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Dzierlega K, Yokota T. Optimization of antisense-mediated exon skipping for Duchenne muscular dystrophy. Gene Ther 2020; 27:407-416. [DOI: 10.1038/s41434-020-0156-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/28/2020] [Accepted: 05/01/2020] [Indexed: 12/19/2022]
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28
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Scaglioni D, Ellis M, Catapano F, Torelli S, Chambers D, Feng L, Sewry C, Morgan J, Muntoni F, Phadke R. A high-throughput digital script for multiplexed immunofluorescent analysis and quantification of sarcolemmal and sarcomeric proteins in muscular dystrophies. Acta Neuropathol Commun 2020; 8:53. [PMID: 32303261 PMCID: PMC7165405 DOI: 10.1186/s40478-020-00918-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/16/2020] [Indexed: 12/21/2022] Open
Abstract
The primary molecular endpoint for many Duchenne muscular dystrophy (DMD) clinical trials is the induction, or increase in production, of dystrophin protein in striated muscle. For accurate endpoint analysis, it is essential to have reliable, robust and objective quantification methodologies capable of detecting subtle changes in dystrophin expression. In this work, we present further development and optimisation of an automated, digital, high-throughput script for quantitative analysis of multiplexed immunofluorescent (IF) whole slide images (WSI) of dystrophin, dystrophin associated proteins (DAPs) and regenerating myofibres (fetal/developmental myosin-positive) in transverse sections of DMD, Becker muscular dystrophy (BMD) and control skeletal muscle biopsies. The script enables extensive automated assessment of myofibre morphometrics, protein quantification by fluorescence intensity and sarcolemmal circumference coverage, colocalisation data for dystrophin and DAPs and regeneration at the single myofibre and whole section level. Analysis revealed significant variation in dystrophin intensity, percentage coverage and amounts of DAPs between differing DMD and BMD samples. Accurate identification of dystrophin via a novel background subtraction method allowed differential assessment of DAP fluorescence intensity within dystrophin positive compared to dystrophin negative sarcolemma regions. This enabled surrogate quantification of molecular functionality of dystrophin in the assembly of the DAP complex. Overall, the digital script is capable of multiparametric and unbiased analysis of markers of myofibre regeneration and dystrophin in relation to key DAPs and enabled better characterisation of the heterogeneity in dystrophin expression patterns seen in BMD and DMD alongside the surrogate assessment of molecular functionality of dystrophin. Both these aspects will be of significant relevance to ongoing and future DMD and other muscular dystrophies clinical trials to help benchmark therapeutic efficacy.
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29
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Grages SM, Bell M, Berlau DJ. New and emerging pharmacotherapy for duchenne muscular dystrophy: a focus on synthetic therapeutics. Expert Opin Pharmacother 2020; 21:841-851. [DOI: 10.1080/14656566.2020.1732350] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sharon M. Grages
- Department of Pharmaceutical Sciences, Regis University School of Pharmacy, Denver, Colorado
| | - Michael Bell
- Department of Pharmaceutical Sciences, Regis University School of Pharmacy, Denver, Colorado
| | - Daniel J. Berlau
- Department of Pharmaceutical Sciences, Regis University School of Pharmacy, Denver, Colorado
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30
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Abstract
Drug development and pharmacotherapy of rare pediatric diseases have significantly expanded over the last decade, in part due to incentives and financial support provided by governments, regulators, and nonprofit foundations. Duchenne muscular dystrophy (DMD) is among the most common rare pediatric disorders, and clinical trials of therapeutic approaches have seen dramatic expansion. Pharmacotherapeutic standard of care has been limited to off-label prescription of high-dose, daily corticosteroids (prednisone, deflazacort). Deflazacort received FDA approval for DMD in 2016, although the price increases associated with formal FDA approval and the severe side effects associated with corticosteroid use have limited patient/physician uptake and insurance coverage in the USA. In Europe, EMA has given conditional marketing authorization for prescription of Translarna (a stop codon read-through drug prescribed to ~10% of DMD patients), although there is not yet evidence of clinical efficacy. The FDA awarded conditional approval to etiplirsen, an exon-skipping oligonucleotide drug, based on accelerated pathways (increased dystrophin production in patient muscle). Evidence of clinical efficacy remains the focus of post-marketing studies. There are many innovative pharmacotherapies under clinical development for DMD (Phase I, II, and III clinical trials). All are "disease modifying" in the sense that none seek to replace the full-length, normal DMD gene or dystrophin protein, but instead either seek to introduce an abnormal "Becker-like" version of the gene or protein or target pathophysiological pathways downstream of the primary defect. It is envisioned that the most significant benefit to DMD patients will be through multidrug approaches simultaneously aiming to introduce partially functional dystrophin in patient muscle while also targeting both chronic inflammation and the fibrofatty replacement of muscle.
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Affiliation(s)
- Eric P Hoffman
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, Binghamton University State University of New York, Binghamton, NY, USA.
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31
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Barthélémy F, Wang RT, Hsu C, Douine ED, Marcantonio EE, Nelson SF, Miceli MC. Targeting RyR Activity Boosts Antisense Exon 44 and 45 Skipping in Human DMD Skeletal or Cardiac Muscle Culture Models. MOLECULAR THERAPY-NUCLEIC ACIDS 2019; 18:580-589. [PMID: 31678734 PMCID: PMC6838898 DOI: 10.1016/j.omtn.2019.09.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/23/2022]
Abstract
Systemic delivery of antisense oligonucleotides (AO) for DMD exon skipping has proven effective for reframing DMD mRNA, rescuing dystrophin expression, and slowing disease progression in animal models. In humans with Duchenne muscular dystrophy treated with AOs, low levels of dystrophin have been induced, and modest slowing of disease progression has been observed, highlighting the need for improved efficiency of human skipping drugs. Here, we demonstrate that dantrolene and Rycals S107 and ARM210 potentiate AO-mediated exon skipping of exon 44 or exon 45 in patient-derived myotube cultures with appropriate mutations. Further, dantrolene is shown to boost AO-mediated exon skipping in patient-derived, induced cardiomyocyte cultures. Our findings further validate the ryanodine receptors (RyR) as the likely target responsible for exon skip boosting and demonstrate potential applicability beyond exon 51 skipping. These data provide preclinical support of dantrolene trial as an adjuvant to AO-mediated exon-skipping therapy in humans and identify a novel Rycal, ARM210, for development as a potential exon-skipping booster. Further, they highlight the value of mutation-specific DMD culture models for basic discovery, preclinical drug screening and translation of personalized genetic medicines.
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Affiliation(s)
- Florian Barthélémy
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, and College of Letters and Sciences, University of California, Los Angeles, Los Angeles, CA, USA; Center for Duchenne Muscular Dystrophy, University of California, Los Angeles, Los Angeles, CA, USA
| | - Richard T Wang
- Center for Duchenne Muscular Dystrophy, University of California, Los Angeles, Los Angeles, CA, USA; Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher Hsu
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, and College of Letters and Sciences, University of California, Los Angeles, Los Angeles, CA, USA; Center for Duchenne Muscular Dystrophy, University of California, Los Angeles, Los Angeles, CA, USA
| | - Emilie D Douine
- Center for Duchenne Muscular Dystrophy, University of California, Los Angeles, Los Angeles, CA, USA; Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Stanley F Nelson
- Center for Duchenne Muscular Dystrophy, University of California, Los Angeles, Los Angeles, CA, USA; Department of Human Genetics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Eli & Edythe Broad Center of Regenerative Medicine & Stem Cell Research, University of California Los Angeles, Los Angeles, CA, USA; Molecular Biology Institute, University of California Los Angeles, Los Angeles, CA, USA; Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - M Carrie Miceli
- Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, and College of Letters and Sciences, University of California, Los Angeles, Los Angeles, CA, USA; Center for Duchenne Muscular Dystrophy, University of California, Los Angeles, Los Angeles, CA, USA; Eli & Edythe Broad Center of Regenerative Medicine & Stem Cell Research, University of California Los Angeles, Los Angeles, CA, USA; Molecular Biology Institute, University of California Los Angeles, Los Angeles, CA, USA; Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, CA, USA.
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32
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Uaesoontrachoon K, Srinivassane S, Warford J, Mekhssian K, Montpetit H, Beauvois R, Keyhani A, Hathout Y, Yamashita T, Satou Y, Osaki H, Praest M, Moraca M, Malbasic M, Ross W, MacKinnon A, Rowsell J, Mullen A, Matyas M, Mummidivarpu S, Nagaraju K, Hoffman EP. Orthogonal analysis of dystrophin protein and mRNA as a surrogate outcome for drug development. Biomark Med 2019; 13:1209-1225. [PMID: 31379197 DOI: 10.2217/bmm-2019-0242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Detection of drug-induced dystrophin in patient muscle biopsy is a surrogate outcome measure for Duchenne muscular dystrophy. We sought to establish and validate an orthogonal approach to measurement of dystrophin protein and RNA in muscle biopsies. Materials & methods: Validated methods were developed for dystrophin western blotting, mass spectrometry, immunostaining and reverse transcriptase PCR of biopsy mRNA using muscle biopsy standards. Results: Both western blotting and mass spectrometry validated methods demonstrated good linearity, and acceptable precision and accuracy with a lower limit of quantitation at 1%. Immunostaining and reverse transcriptase PCR methods were shown to be reliable. Conclusion: The described orthogonal approach is sufficient to support measures of dystrophin as a surrogate outcome in a clinical trial.
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Affiliation(s)
| | | | - Jordan Warford
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | | | | | | | | | | | | | | | | | - Molly Praest
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | - Marina Moraca
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | - Maja Malbasic
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | - William Ross
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | | | - Joyce Rowsell
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | - Amanda Mullen
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | - Mark Matyas
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada
| | | | - Kanneboyina Nagaraju
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada.,Binghamton University, SUNY. Binghamton, NY 13902, USA
| | - Eric P Hoffman
- AGADA BioSciences Inc., Halifax, Nova Scotia B3H0A8, Canada.,Binghamton University, SUNY. Binghamton, NY 13902, USA
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33
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Guiraud S, Edwards B, Babbs A, Squire SE, Berg A, Moir L, Wood MJ, Davies KE. The potential of utrophin and dystrophin combination therapies for Duchenne muscular dystrophy. Hum Mol Genet 2019; 28:2189-2200. [PMID: 30990876 PMCID: PMC6586144 DOI: 10.1093/hmg/ddz049] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/18/2019] [Accepted: 02/26/2019] [Indexed: 01/01/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is a lethal neuromuscular disorder caused by loss of dystrophin. Several therapeutic modalities are currently in clinical trials but none will achieve maximum functional rescue and full disease correction. Therefore, we explored the potential of combining the benefits of dystrophin with increases of utrophin, an autosomal paralogue of dystrophin. Utrophin and dystrophin can be co-expressed and co-localized at the same muscle membrane. Wild-type (wt) levels of dystrophin are not significantly affected by a moderate increase of utrophin whereas higher levels of utrophin reduce wt dystrophin, suggesting a finite number of actin binding sites at the sarcolemma. Thus, utrophin upregulation strategies may be applied to the more mildly affected Becker patients with lower dystrophin levels. Whereas increased dystrophin in wt animals does not offer functional improvement, overexpression of utrophin in wt mice results in a significant supra-functional benefit over wt. These findings highlight an additive benefit of the combined therapy and potential new unique roles of utrophin. Finally, we show a 30% restoration of wt dystrophin levels, using exon-skipping, together with increased utrophin levels restores dystrophic muscle function to wt levels offering greater therapeutic benefit than either single approach alone. Thus, this combination therapy results in additive functional benefit and paves the way for potential future combinations of dystrophin- and utrophin-based strategies.
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Affiliation(s)
- Simon Guiraud
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Benjamin Edwards
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Arran Babbs
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Sarah E Squire
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Adam Berg
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Lee Moir
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Matthew J Wood
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
| | - Kay E Davies
- MDUK Oxford Neuromuscular Centre, Department of Physiology, Anatomy and Genetics, Oxford, UK
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34
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Pitout I, Flynn LL, Wilton SD, Fletcher S. Antisense-mediated splice intervention to treat human disease: the odyssey continues. F1000Res 2019; 8. [PMID: 31164976 PMCID: PMC6534073 DOI: 10.12688/f1000research.18466.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 12/24/2022] Open
Abstract
Recent approvals of oligonucleotide analogue drugs to alter gene expression have been welcomed by patient communities but not universally supported. These compounds represent a class of drugs that are designed to target a specific gene transcript, and they include a number of chemical entities to evoke different antisense mechanisms, depending upon the disease aetiology. To date, oligonucleotide therapeutics that are in the clinic or at advanced stages of translation target rare diseases, posing challenges to clinical trial design, recruitment and evaluation and requiring new evaluation paradigms. This review discusses the currently available and emerging therapeutics that alter exon selection through an effect on pre-mRNA splicing and explores emerging concerns over safety and efficacy. Although modification of synthetic nucleic acids destined for therapeutic application is common practice to protect against nuclease degradation and to influence drug function, such modifications may also confer unexpected physicochemical and biological properties. Negatively charged oligonucleotides have a strong propensity to bind extra- and intra-cellular proteins, whereas those analogues with a neutral backbone show inefficient cellular uptake but excellent safety profiles. In addition, the potential for incorporation of chemically modified nucleic acid monomers, yielded by nuclease degradation of exogenous oligonucleotides, into biomolecules has been raised and the possibility not entirely discounted. We conclude with a commentary on the ongoing efforts to develop novel antisense compounds and enhance oligonucleotide delivery in order to further improve efficacy and accelerate implementation of antisense therapeutics for human disease.
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Affiliation(s)
| | - Loren L Flynn
- Murdoch University, Murdoch, WA, 6150, Australia.,The University of Western Australia, Nedlands, WA, 6009, Australia.,Perron Institute, Nedlands, WA, 6009, Australia
| | - Steve D Wilton
- Murdoch University, Murdoch, WA, 6150, Australia.,The University of Western Australia, Nedlands, WA, 6009, Australia.,Perron Institute, Nedlands, WA, 6009, Australia
| | - Sue Fletcher
- Murdoch University, Murdoch, WA, 6150, Australia.,The University of Western Australia, Nedlands, WA, 6009, Australia.,Perron Institute, Nedlands, WA, 6009, Australia
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