Duchenne muscular dystrophy, one of the most complicated diseases for gene therapy

Abstract

Gene therapy for Duchenne muscular dystrophy (DMD) is hindered by many pitfalls related in particular to the limitations of current technologies, the specificities of muscle and cardiac targets, and the disease itself, a chronic, multisystem, dystrophic and inflammatory disorder. Following RNA-based therapies, DNA gene transfer, mainly based on adeno-associated viral vectors, is now able to deliver therapeutic genetic sequences on a massive scale, and the first antisense and adeno-associated virus (AAV)-microdystrophin gene products are now reaching the marketing stage in Europe and/or in the US. However, only a subset of patients are eligible for those therapies. Many questions remain, such as the duration of the therapeutic effect, the burden of high doses of vectors, and the immunogenicity of viral capsids and therapeutic proteins, in the context of a disease-related inflammatory background. Evaluations of these treatments by the different biotech, pharma or non-for-profit sponsors also come up against the great clinical heterogeneity of patients. This review summarizes the significant progress made over the past three decades to optimize both the efficacy and safety of DMD gene therapies, as well as the remaining challenges, short-term prospects, and future directions such as more targeted vectors and combination therapies.

Keywords

AAV / antisense oligonucleotide (ASO) / DMD / microdystrophin / immune rejection / duchenne

References

[1] SalariN,ValipourE.Global prevalence of Duchenne and Becker muscular dystrophy: a systematic review and meta-analysis.J Orthop Surg Res2022;17:96 PMCID:PMC8848641

[2] DuanD,TakedaS,Aartsma-RusA.Duchenne muscular dystrophy.Nat Rev Dis Primers2021;7:13 PMCID:PMC10557455

[3] MercuriE,MuntoniF.Muscular dystrophies.Lancet2019;394:2025-38

[4] PaneM,SormaniMP.6 Minute walk test in Duchenne MD patients with different mutations: 12 month changes.PLoS One2014;9:e83400 PMCID:PMC3885414

[5] McDonaldCM,AbreschRT.PTC124-GD-007-DMD Study GroupThe 6-minute walk test and other clinical endpoints in duchenne muscular dystrophy: reliability, concurrent validity, and minimal clinically important differences from a multicenter study.Muscle Nerve2013;48:357-68

[6] TopalogluH.Duchenne muscular dystophy: a short review and treatment update.Iran J Child Neurol2021;15:9-15

[7] ElangkovanN.Gene therapy for Duchenne muscular dystrophy.J Neuromuscul Dis2021;8:S303-16 PMCID:PMC8673537

[8] MozinE,MournetasV.Dystrophin deficiency impairs cell junction formation during embryonic myogenesis.bioRxiv2024; PMCID:PMC10723310

[9] SohnJ,TangY,HuardJ.Activation of non-myogenic mesenchymal stem cells during the disease progression in dystrophic dystrophin/utrophin knockout mice.Hum Mol Genet2015;24:3814-29 PMCID:PMC4459395

[10] BostickB,YueY,DuanD.Systemic AAV-9 transduction in mice is influenced by animal age but not by the route of administration.Gene Ther2007;14:1605-9

[11] MendellJR,Rodino-KlapacL.Dystrophin immunity in Duchenne’s muscular dystrophy.N Engl J Med2010;363:1429-37

[12] BönnemannCG,BraunS,SinghT.Dystrophin immunity after gene therapy for Duchenne’s muscular dystrophy.N Engl J Med2023;388:2294-6

[13] BladenCL,MongesS.The TREAT-NMD DMD global database: analysis of more than 7,000 Duchenne muscular dystrophy mutations.Hum Mutat2015;36:395-402

[14] SunC,ZhangZ.Therapeutic strategies for Duchenne muscular dystrophy: an update.Genes2020;11:837 PMCID:PMC7463903

[15] DuanD,TakedaS.et al. Duchenne muscular dystrophy.Nat Rev Dis Primers2021;7:13 PMCID:PMC10557455

[16] EMA recommends non-renewal of authorisation of Duchenne muscular dystrophy medicine translarna. Available from: https://www.ema.europa.eu/en/news/ema-recommends-non-renewal-authorisation-duchenne-muscular-dystrophy-medicine-translarna-0 [Last accessed on 24 Jan 2025]

[17] BrunC,PauliC.U7 snRNAs induce correction of mutated dystrophin pre-mRNA by exon skipping.Cell Mol Life Sci2003;60:557-66 PMCID:PMC11138867

[18] TakedaS,HoffmanEP.Exon-skipping in Duchenne muscular dystrophy.J Neuromuscul Dis2021;8:S343-58 PMCID:PMC8673534

[19] LeckieJ,YokotaT.An updated analysis of exon-skipping applicability for Duchenne muscular dystrophy using the UMD-DMD database.Genes2024;15:1489 PMCID:PMC11593839

[20] NeriM,BrownS.Dystrophin levels as low as 30% are sufficient to avoid muscular dystrophy in the human.Neuromuscul Disord2007;17:913-8

[21] WellsDJ.What is the level of dystrophin expression required for effective therapy of Duchenne muscular dystrophy?.J Muscle Res Cell Motil2019;40:141-50

[22] RelizaniK,ZarroukiF.Palmitic acid conjugation enhances potency of tricyclo-DNA splice switching oligonucleotides.Nucleic Acids Res2022;50:17-34 PMCID:PMC8754652

[23] CochranM,AlbinT.Structure-activity relationship of antibody-oligonucleotide conjugates: evaluating bioconjugation strategies for antibody-phosphorodiamidate morpholino oligomer conjugates for drug development.J Med Chem2024;67:14868-84

[24] GushchinaLV,VetterTA.Persistence of exon 2 skipping and dystrophin expression at 18 months after U7snRNA-mediated therapy in the Dup2 mouse model.Mol Ther Methods Clin Dev2023;31:101144

[25] MuntoniF,SajeevG.Association Française Contre Les Myopathies; on behalf of Universitaire Ziekenhuizen Leuven GroupPRO-DMD-01The UK NorthStar Clinical NetworkCCHMCand The DMD Italian GroupDMD genotypes and motor function in Duchenne muscular dystrophy: a multi-institution meta-analysis with implications for clinical trials.Neurology2023;100:e1540-54

[26] ChemelloF,Bassel-DubyR.CRISPR-editing therapy for Duchenne muscular dystrophy.Hum Gene Ther2023;34:379-87 PMCID:PMC10210224

[27] LekA,KeelerA.Death after high-dose rAAV9 gene therapy in a patient with Duchenne’s muscular dystrophy.N Engl J Med2023;389:1203-10

[28] RomeroNB,BenvenisteO.Phase I study of dystrophin plasmid-based gene therapy in Duchenne/Becker muscular dystrophy.Hum Gene Ther2004;15:1065-76

[29] WooddellC.Dose response in rodents and nonhuman primates after hydrodynamic limb vein delivery of naked plasmid DNA.Hum Gene Ther2011;22:889-903

[30] FanZ,ValleyR.Safety and feasibility of high-pressure transvenous limb perfusion with 0.9% saline in human muscular dystrophy.Mol Ther2012;20:456-61 PMCID:PMC3278558

[31] FanZ,ValleyR.High-pressure transvenous perfusion of the upper extremity in human muscular dystrophy: a safety study with 0.9% saline.Hum Gene Ther2015;26:614-21 PMCID:PMC4575535

[32] BraunS.Gene-based therapies of neuromuscular disorders: an update and the pivotal role of patient organizations in their discovery and implementation.J Gene Med2013;15:397-413

[33] SchermanD. Advanced textbook on gene transfer, gene therapy and genetic pharmacology: principles, delivery and pharmacological and biomedical applications of nucleotide-based therapie. 2th ed. Daniel Scherman: Imperial College Press. 2014 pp 17-29.

[34] EnglandSB,JohnsonMA.Very mild muscular dystrophy associated with the deletion of 46% of dystrophin.Nature1990;343:180-2

[35] FortunatoF,FarnèM,FerliniA.DMD deletions underlining mild dystrophinopathies: literature review highlights phenotype-related mutation clusters and provides insights about genetic mechanisms and prognosis.Front Neurol2023;14:1288721 PMCID:PMC10823016

[36] DuanD.Systemic AAV micro-dystrophin gene therapy for Duchenne muscular dystrophy.Mol Ther2018;26:2337-56 PMCID:PMC6171037

[37] MorinA,PetrovaON.Dystrophin myonuclear domain restoration governs treatment efficacy in dystrophic muscle.Proc Natl Acad Sci U S A2023;120:e2206324120 PMCID:PMC9926233

[38] FDA expands approval of gene therapy for patients with Duchenne muscular dystrophy. Available from: https://www.fda.gov/news-events/press-announcements/fda-expands-approval-gene-therapy-patients-duchenne-muscular-dystrophy [Last accessed on 24 Jan 2025]

[39] ChamberlainJS,BraunS.Microdystrophin expression as a surrogate endpoint for Duchenne muscular dystrophy clinical trials.Hum Gene Ther2023;34:404-15 PMCID:PMC10210223

[40] BoehlerJF,BeatkaM.Clinical potential of microdystrophin as a surrogate endpoint.Neuromuscul Disord2023;33:40-9

[41] ShenW,OuL.rAAV immunogenicity, toxicity, and durability in 255 clinical trials: a meta-analysis.Front Immunol2022;13:1001263

[42] KwonJB,VankaraA.In vivo gene editing of muscle stem cells with adeno-associated viral vectors in a mouse model of Duchenne muscular dystrophy.Mol Ther Methods Clin Dev2020;19:320-9

[43] VulinA,GoyenvalleA.Muscle function recovery in golden retriever muscular dystrophy after AAV1-U7 exon skipping.Mol Ther2012;20:2120-33 PMCID:PMC3498802

[44] LeHir M,PeccateC.AAV genome loss from dystrophic mouse muscles during AAV-U7 snRNA-mediated exon-skipping therapy.Mol Ther2013;21:1551-8 PMCID:PMC3734654

[45] DupontJB,Renaud-GabardosE.AAV-mediated gene transfer restores a normal muscle transcriptome in a canine model of X-linked myotubular myopathy.Mol Ther2020;28:382-93 PMCID:PMC7000997

[46] LeGuiner C,TestaultI.More than nine year survival of a GRMD dog after injection of AAV-microdystrophin gene therapy.Mol Ther2023;31:pp53

[47] BoutinS,VeronP.Prevalence of serum IgG and neutralizing factors against adeno-associated virus (AAV) types 1, 2, 5, 6, 8, and 9 in the healthy population: implications for gene therapy using AAV vectors.Hum Gene Ther2010;21:704-12

[48] VermaS,RazdanR.Seroprevalence of adeno-associated virus neutralizing antibodies in males with duchenne muscular dystrophy.Hum Gene Ther2023;34:430-8 PMCID:PMC10210220

[49] ZygmuntDA,FlaniganKM.Comparison of serum rAAV serotype-specific antibodies in patients with Duchenne muscular dystrophy, Becker muscular dystrophy, inclusion body myositis, or GNE myopathy.Hum Gene Ther2017;28:737-46 PMCID:PMC5582585

[50] YangTY,LembkeW.Immunogenicity assessment of AAV-based gene therapies: an IQ consortium industry white paper.Mol Ther Methods Clin Dev2022;26:471-94 PMCID:PMC9418752

[51] GrossDA,LeborgneC.Overcoming the challenges imposed by humoral immunity to AAV vectors to achieve safe and efficient gene transfer in seropositive patients.Front Immunol2022;13:857276 PMCID:PMC9022790

[52] LeborgneC,AlexanderJM.IgG-cleaving endopeptidase enables in vivo gene therapy in the presence of anti-AAV neutralizing antibodies.Nat Med2020;26:1096-101

[53] MingozziF.Immune responses to AAV vectors: overcoming barriers to successful gene therapy.Blood2013;122:23-36 PMCID:PMC3701904

[54] McDouallRM,DubowitzV.Expression of class I and class II MHC antigens in neuromuscular diseases.J Neurol Sci1989;89:213-26

[55] FaustSM,CutlerBJ.CpG-depleted adeno-associated virus vectors evade immune detection.J Clin Invest2013;123:2994-3001 PMCID:PMC3696560

[56] VandenDriesscheT.Vector decoys trick the immune response.Sci Transl Med2013;5:194fs28

[57] MendellJR,LehmanK.et al. Assessment of systemic delivery of rAAVrh74.MHCK7.micro-dystrophin in children with Duchenne muscular dystrophy: a nonrandomized controlled trial.JAMA Neurol2020;77:1122-31 PMCID:PMC7296461

[58] LekA,LinB.Meeting report: 2023 nuscular dystrophy association summit on “safety and challenges in gene therapy of neuromuscular diseases”.J Neuromuscul Dis2024;11:1139-60

[59] YueY,BostickB.100-fold but not 50-fold dystrophin overexpression aggravates electrocardiographic defects in the mdx model of Duchenne muscular dystrophy.Mol Ther Methods Clin Dev2016;3:16045 PMCID:PMC4934459

[60] HartCC,XieJ.et al. Potential limitations of microdystrophin gene therapy for Duchenne muscular dystrophy.JCI Insight2024;9:e165869 PMCID:PMC11382885

[61] KodippiliK,PanX.Dual AAV gene therapy for Duchenne muscular dystrophy with a 7-kb mini-dystrophin gene in the canine model.Hum Gene Ther2018; 3:299-311

[62] AlbiniS,DuboisA,LostalW.Assessment of therapeutic potential of a dual AAV approach for Duchenne muscular dystrophy.Int J Mol Sci2023;24:11421 PMCID:PMC10380683

[63] ZhouY,XiaoW,HanR.Systemic delivery of full-length dystrophin in Duchenne muscular dystrophy mice.Nature Com2024;15:6141 PMCID:PMC11271493

[64] TinsleyJ.M., Davies K.E. Utrophin: a potential replacement for dystrophin?.Neuromuscul Disord1993;3:537-9

[65] SzwecS,ChamberlainJS.Dystrophin- and utrophin-based therapeutic approaches for treatment of Duchenne muscular dystrophy: a comparative review.BioDrugs2024;38:95-119 PMCID:PMC10789850

[66] XuR,ZygmuntDA.rAAVrh74.MCK.GALGT2 protects against loss of hemodynamic function in the aging mdx mouse heart.Mol Ther2019;27:636-49 PMCID:PMC6403484

[67] MartinPT,AshbrookA.Short-term treatment of golden retriever muscular dystrophy (GRMD) dogs with rAAVrh74.MHCK7.GALGT2 induces muscle glycosylation and utrophin expression but has no significant effect on muscle strength.PLoS One2021;16:e0248721 PMCID:PMC7997012

[68] FlaniganKM,SimmonsTR.A first-in-human phase I/IIa gene transfer clinical trial for Duchenne muscular dystrophy using rAAVrh74.MCK.GALGT2.Mol Ther Methods Clin Dev2022;27:47-60 PMCID:PMC9483573

[69] Notice regarding impairment loss for products under development. Available from: https://www.astellas.com/en/news/25731 [Last accessed on 24 Jan 2025]

[70] HordeauxJ,SongC.High-dose systemic adeno-associated virus vector administration causes liver and sinusoidal endothelial cell injury.Mol Ther2024;32:952-68 PMCID:PMC11163197

[71] WeinmannJ,SippelJ.Identification of a myotropic AAV by massively parallel in vivo evaluation of barcoded capsid variants.Nat Commun2020;11:5432 PMCID:PMC7595228

[72] HongAV,PetatE.An engineered AAV targeting integrin alpha V beta 6 presents improved myotropism across species.Nat Commun2024;15:7965 PMCID:PMC11390886

[73] PharesS,EmondSK.Managing the challenges of paying for gene therapy: strategies for market action and policy reform in the United States.J Comp Eff Res2024;13:e240118 PMCID:PMC11609966