Current and emerging therapeutic strategies for mitochondrial disorders

Chaoping Hu , Xiaolei Wang , Fang Fang , Taosheng Huang

Journal of Translational Genetics and Genomics ›› 2026, Vol. 10 ›› Issue (3) : 524 -44.

PDF
Journal of Translational Genetics and Genomics ›› 2026, Vol. 10 ›› Issue (3) :524 -44. DOI: 10.20517/jtgg.2026.44
Review
Current and emerging therapeutic strategies for mitochondrial disorders
Author information +
History +
PDF

Abstract

Mitochondrial diseases are a group of inherited metabolic disorders caused by defects in mitochondrial DNA (mtDNA) or nuclear DNA leading to oxidative phosphorylation dysfunction. Clinical manifestations are highly heterogeneous, typically involving high-energy-demand organs (brain, muscle, heart, etc.), and curative treatments remain largely unavailable. This review examines the literature over the past decades on mitochondrial disease treatments, including traditional Cocktail therapy, target therapy, multidisciplinary management, gene therapy, mtDNA base editing, and mitochondrial replacement therapy. Although most current treatments remain symptomatic, breakthrough advances in gene therapy and base editing over recent years have brought new hope for precision medicine in mitochondrial diseases.

Keywords

Mitochondrial disorder / therapy / gene mutation / therapeutic principle / multidisciplinary

Cite this article

Download citation ▾
Chaoping Hu, Xiaolei Wang, Fang Fang, Taosheng Huang. Current and emerging therapeutic strategies for mitochondrial disorders. Journal of Translational Genetics and Genomics, 2026, 10 (3) : 524-44 DOI:10.20517/jtgg.2026.44

登录浏览全文

4963

注册一个新账户 忘记密码

References

[1]

Gorman GS,Ng Y.Prevalence of nuclear and mitochondrial DNA mutations related to adult mitochondrial disease.Ann Neurol2015;77:753-9 PMCID:PMC4737121

[2]

Mcfarland R,Turnbull DM.A neurological perspective on mitochondrial disease.Lancet Neurol2010;9:829-40

[3]

Heath O,Achleitner MT.Mitochondrial disorder diagnosis and management- what the pediatric neurologist wants to know.Eur J Paediatr Neurol2025;54:75-88

[4]

Wen H,Li B.Mitochondrial diseases: from molecular mechanisms to therapeutic advances.Sig Transduct Target Ther2025;10:9 PMCID:PMC11724432

[5]

Dimauro S,Carelli V.The clinical maze of mitochondrial neurology.Nat Rev Neurol2013;9:429-44 PMCID:PMC3959773

[6]

Stewart JB.The dynamics of mitochondrial DNA heteroplasmy: implications for human health and disease.Nat Rev Genet2015;16:530-42

[7]

Gorman GS,Dimauro S.Mitochondrial diseases.Nat Rev Dis Primers2016;2:16080

[8]

Smeitink J,Dimauro S.The genetics and pathology of oxidative phosphorylation.Nat Rev Genet2001;2:342-52

[9]

Calame DG.Functional genomics and small molecules in mitochondrial neurodevelopmental disorders.Neurotherapeutics2024;21:e00316 PMCID:PMC10903096

[10]

Klopstock T,Yilmaz A,Distelmaier F.Mitochondrial disorders.Dtsch Arztebl Int2021;118:741-8 PMCID:PMC8830351

[11]

Finsterer J.Genetic, pathogenetic, and phenotypic implications of the mitochondrial A3243G tRNALeu(UUR) mutation.Acta Neurol Scand2007;116:1-14

[12]

Youle RJ.Mitochondrial fission, fusion, and stress.Science2012;337:1062-5 PMCID:PMC4762028

[13]

Zheng Y,Li X.Mitochondria at the crossroads: quality control mechanisms in neuronal senescence and neurodegeneration.Neurobiol Dis2025;208:106862

[14]

Mclaughlin KL,Fisher-Wellman KH.Bioenergetic consequences of compromised mitochondrial DNA repair in the mouse heart.Biochem Biophys Res Commun2018;504:742-8 PMCID:PMC6173612

[15]

Dautant A,Hahn A,Di Rago J.ATP synthase diseases of mitochondrial genetic origin.Front Physiol2018;9:329 PMCID:PMC5893901

[16]

Bazil JN,Dash RK.Determining the origins of superoxide and hydrogen peroxide in the mammalian NADH:ubiquinone oxidoreductase.Free Radic Biol Med2014;77:121-9 PMCID:PMC4258523

[17]

Andreyev AY,Murphy AN.Mitochondrial ROS metabolism: 10 years later.Biochemistry2015;80:517-31 PMCID:PMC4511471

[18]

Turrens JF.Mitochondrial formation of reactive oxygen species.J Physiol2003;552:335-44 PMCID:PMC2343396

[19]

Bhatti JS,Reddy PH.Mitochondrial dysfunction and oxidative stress in metabolic disorders — A step towards mitochondria based therapeutic strategies.Biochim Biophys Acta2017;1863:1066-77 PMCID:PMC5423868

[20]

Panov AV.Cardiolipin, perhydroxyl radicals, and lipid peroxidation in mitochondrial dysfunctions and aging.Oxid Med Cell Longev2020;2020:1-14 PMCID:PMC7499269

[21]

Zanfardino P,Perrone M.The balance of MFN2 and OPA1 in mitochondrial dynamics, cellular homeostasis, and disease.Biomolecules2025;15:433 PMCID:PMC11940761

[22]

Candé C,Daugas E.Apoptosis-inducing factor (AIF): a novel caspase-independent death effector released from mitochondria.Biochimie2002;84:215-22

[23]

Kim R,Tanabe K.Role of mitochondria as the gardens of cell death.Cancer Chemother Pharmacol2005;57:545-53

[24]

Ahola S.Mitochondria setting the stage for ferroptosis.Trends Endocrinol Metab2026;S1043276026001505

[25]

Kolotova A,Kutsev S.The role of apoptosis and ferroptosis in primary mitochondrial diseases: mechanisms and pathogenesis.Int J Mol Sci2026;27:5931 PMCID:PMC13361126

[26]

Kim J,Chung JH.Molecular mechanisms of mitochondrial DNA release and activation of the cGAS-STING pathway.Exp Mol Med2023;55:510-9 PMCID:PMC10037406

[27]

Horssen J, Van Schaik P, Witte M. Inflammation and mitochondrial dysfunction: a vicious circle in neurodegenerative disorders?.Neurosci Lett2019;710:132931

[28]

Aguilar K,Zorzano A.Primary mitochondrial diseases: the intertwined pathophysiology of bioenergetic dysregulation, oxidative stress and neuroinflammation.Eur J Clin Investig2024;54:e14217

[29]

Barcelos I,Ganetzky RD.Mitochondrial medicine therapies: rationale, evidence, and dosing guidelines.Curr Opin Pediatr2020;32:707-18 PMCID:PMC7774245

[30]

Parikh S,Koenig MK.Diagnosis and management of mitochondrial disease: a consensus statement from the Mitochondrial Medicine Society.Genet Med2015;17:689-701 PMCID:PMC5000852

[31]

De Vries MC,Allen ME.Safety of drug use in patients with a primary mitochondrial disease: an international Delphi‐based consensus.J Inherit Metab Dis2020;43:800-18 PMCID:PMC7383489

[32]

Sue CM,Bratkovic D.Patient care standards for primary mitochondrial disease in Australia: an Australian adaptation of the Mitochondrial Medicine Society recommendations.Intern Med J2021;52:110-20 PMCID:PMC9299181

[33]

Pfeffer G,Turnbull DM,Chinnery PF.Cochrane Neuromuscular GroupTreatment for mitochondrial disorders.Cochrane Database Syst Rev2012;2012 PMCID:PMC7201312

[34]

Reetz K,Dogan I.Friedreich's ataxia—a rare multisystem disease.Lancet Neurol2025;24:614-24

[35]

Lee A.Omaveloxolone: first approval.Drugs2023;83:725-9

[36]

Lynch DR,Delatycki MB.Safety and efficacy of omaveloxolone in friedreich ataxia (MOXIeStudy).Ann Neurol2020;89:212-25 PMCID:PMC7894504

[37]

Reid Thompson W,Manuel R.A phase 2/3 randomized clinical trial followed by an open-label extension to evaluate the effectiveness of elamipretide in Barth syndrome, a genetic disorder of mitochondrial cardiolipin metabolism.Genet Med2021;23:471-8 PMCID:PMC7935714

[38]

Thompson WR,Abbruscato A.Long-term efficacy and safety of elamipretide in patients with Barth syndrome: 168-week open-label extension results of TAZPOWER.Genet Med2024;26:101138

[39]

Hornby B,Almuqbil M.Natural history comparison study to assess the efficacy of elamipretide in patients with Barth syndrome.Orphanet J Rare Dis2022;17:336 PMCID:PMC9438322

[40]

Shirley M.Elamipretide: first approval.Drugs2025;86:377-83

[41]

Karaa A,Goldstein A,Weaver WD.Randomized dose-escalation trial of elamipretide in adults with primary mitochondrial myopathy.Neurology2018;90:e1212-21 PMCID:PMC5890606

[42]

Karaa A,Goldstein A,Cohen BH.A randomized crossover trial of elamipretide in adults with primary mitochondrial myopathy.J Cachexia Sarcopenia Muscle2020;11:909-18 PMCID:PMC7432581

[43]

Karaa A,Carelli V.Efficacy and safety of elamipretide in individuals with primary mitochondrial myopathy: the MMPOWER-3 randomized clinical trial.Neurology2023;101:e238-52

[44]

Karaa A,Carelli V.Genotype-specific effects of elamipretide in patients with primary mitochondrial myopathy: a post hoc analysis of the MMPOWER-3 trial.Orphanet J Rare Dis2024;19:431 PMCID:PMC11583740

[45]

Blair HA.Doxecitine and doxribtimine: first approval.Pediatr Drugs2026;28:209-15 PMCID:PMC13038758

[46]

Domínguez-González C,Colson A.Pyrimidine Nucleos(t)ide therapy in patients with thymidine kinase 2 deficiency: a multicenter retrospective chart review study.Neurology2025;105:e213908 PMCID:PMC12413740

[47]

Bermejo-Guerrero L,Serrano-Lorenzo P.Remarkable clinical improvement with oral nucleoside treatment in a patient with adult-onset TK2 deficiency: a case report.Mitochondrion2024;76:101879

[48]

Berrahmoune S,Pekeles H.Investigating the safety and efficacy of deoxycytidine/deoxythymidine in mitochondrial DNA depletion disorders: phase 2 open-label trial.J Neurol2025;272:307

[49]

Johnson SC,Kayser E.mTOR inhibition alleviates mitochondrial disease in a mouse model of leigh syndrome.Science2013;342:1524-8 PMCID:PMC4055856

[50]

Sage‐schwaede A,Salazar R.Exploring mTOR inhibition as treatment for mitochondrial disease.Ann Clin Transl Neurol2019;6:1877-81 PMCID:PMC6764630

[51]

Repp BM,Alston CL.Clinical, biochemical and genetic spectrum of 70 patients with ACAD9 deficiency: is riboflavin supplementation effective?.Orphanet J Rare Dis2018;13:120 PMCID:PMC6053715

[52]

Plantone D,Rinaldi G.Riboflavin in neurological diseases: a narrative review.Clin Drug Investig2021;41:513-27

[53]

Xu C,Li J.Deficiency of the NAD(P)HX metabolic repair system: a treatable mitochondrial disease.Orphanet J Rare Dis2026;21:63 PMCID:PMC12910793

[54]

Invernizzi F,Chiapparini L.Thiamine-responsive disease due to mutation of tpk1: importance of avoiding misdiagnosis.Neurology2017;89:870-1

[55]

Alcázar-Fabra M,Brea-Calvo G.Clinical syndromes associated with Coenzyme Q10 deficiency.Essays Biochem2018;62:377-98

[56]

Montini G,Salviati L.Early coenzyme Q10 supplementation in primary coenzyme Q10 deficiency.N Engl J Med2008;358:2849-50

[57]

Distelmaier F,Jiménez-Sánchez L.Preclinical and first-in-human evidence of 4-hydroxybenzoic acid for mitochondrial COQ2 deficiency.Brain2026;149:1784-97 PMCID:PMC13140534

[58]

Canda E,Coker M.Biotinidase deficiency: prevalence, impact and management strategies.Pediatric Health Med Ther2020;11:127-33

[59]

Jiang H,Fu S.Identification and characterization of novel MPC1 gene variants causing mitochondrial pyruvate carrier deficiency.J Inherit Metab Dis2022;45:264-77

[60]

Pata S,Gil A.Clinical improvements after treatment with a low-valine and low-fat diet in a pediatric patient with enoyl-CoA hydratase, short chain 1 (ECHS1) deficiency.Orphanet J Rare Dis2022;17:340 PMCID:PMC9446769

[61]

Sato-Shirai I,Arisaka A.Valine-restricted diet for patients with ECHS1 deficiency: divergent clinical outcomes in two Japanese siblings.Brain Dev2021;43:308-13

[62]

Yang H.Clinical, biochemical and metabolic characterization of patients with short-chain enoyl-CoA hydratase(ECHS1) deficiency: two case reports and the review of the literature.BMC Pediatr2020;20:50 PMCID:PMC6996175

[63]

Xu Y,Yu K.A therapeutic regimen for 3-hydroxyisobutyryl-CoA hydrolase deficiency with exercise-induced dystonia.Eur J Paediatr Neurol2019;23:755-9

[64]

Parikh S,Karaa A.Patient care standards for primary mitochondrial disease: a consensus statement from the Mitochondrial Medicine Society.Genet Med2017;19:1380-97 PMCID:PMC7804217

[65]

Orsucci D,Montano V,Mancuso M.Mitochondrial stroke-like episodes: the search for new therapies.Pharmacol Res2022;180:106228

[66]

Mancuso M,Ng YS.Management of seizures in patients with primary mitochondrial diseases: consensus statement from the InterERNs Mitochondrial Working Group.Eur J Neurol2024;31:e16275 PMCID:PMC11235721

[67]

Na J.Therapeutic approach to epilepsy in patients with mitochondrial diseases.Yonsei Med J2025;66:131 PMCID:PMC11865870

[68]

Varughese R.Endocrine dysfunction in primary mitochondrial diseases.Endocr Rev2025;46:376-96 PMCID:PMC12063101

[69]

Chaudhry A,Chanoine JP.Diabetes management in maternally inherited diabetes and deafness (MIDD): a review and a proposed treatment algorithm.Diabetes Obes Metab2025;28:826-39 PMCID:PMC12803549

[70]

Sue CM,Crimmins DS.Cochlear origin of hearing loss in MELAS syndrome.Ann Neurol2004;43:350-9

[71]

O'toole J.Renal manifestations of genetic mitochondrial disease.Int J Nephrol Renovasc Dis2014;7:57-67

[72]

Madsen S,Blackford R.Ketogenic diet therapy in pyruvate dehydrogenase deficiency: global clinical practice from literature and survey data.Mol Genet Metab2026;148:110190

[73]

Huang L,Zhong J.Efficacy and safety of the ketogenic diet for mitochondrial disease with epilepsy: a prospective, open-labeled, controlled study.Front Neurol2022;13:880944 PMCID:PMC9377015

[74]

Keshavan N,Viscomi C.Gene therapy for mitochondrial disorders.J Inherit Metab Dis2024;47:145-75

[75]

Crystal RG,Kaminsky SM.AAVrh.10hFXN gene therapy for the cardiomyopathy of friedreich ataxia: a nonrandomized clinical trial.JAMA Cardiol2026;11:709 PMCID:PMC13276668

[76]

Faria R,Sousa Â.Delivery systems for mitochondrial gene therapy: a review.Pharmaceutics2023;15:572 PMCID:PMC9964608

[77]

Chen BS.From bench to bedside—delivering gene therapy for leber hereditary optic neuropathy.Cold Spring Harb Perspect Med2022;12:a041282 PMCID:PMC9310952

[78]

Sahel J,Yu-Wai-Man P,Blouin L.Neuropathie optique héréditaire de Leber: amélioration bilatérale de la vision après thérapie génique par injection unilatérale.Med Sci2021;37:712-5

[79]

Yu-Wai-Man P,Biousse V.Five-year outcomes of lenadogene nolparvovec gene therapy in leber hereditary optic neuropathy.JAMA Ophthalmol2025;143:99

[80]

Newman NJ,Subramanian PS.Randomized trial of bilateral gene therapy injection for m.11778G>A MT-ND4 Leber optic neuropathy.Brain2023;146:1328-41

[81]

Newman NJ,Yu-Wai-Man P.Meta-analysis of treatment outcomes for patients with m.11778G>A MT-ND4 Leber hereditary optic neuropathy.Surv Ophthalmol2025;70:283-95

[82]

Mok BY,Zeng J.A bacterial cytidine deaminase toxin enables CRISPR-free mitochondrial base editing.Nature2020;583:631-7 PMCID:PMC7381381

[83]

Cho S,Mok YG.Targeted A-to-G base editing in human mitochondrial DNA with programmable deaminases.Cell2022;185:1764-76.e12

[84]

Lei Z,Liu L.Mitochondrial base editor induces substantial nuclear off-target mutations.Nature2022;606:804-11

[85]

Lee S,Baek G.Precision mitochondrial DNA editing with high-fidelity DddA-derived base editors.Nat Biotechnol2022;41:378-86 PMCID:PMC10017512

[86]

Mok YG,Chung E.Base editing in human cells with monomeric DddA-TALE fusion deaminases.Nat Commun2022;13:4038 PMCID:PMC9276701

[87]

new therapeutics with precision mitochondrial editing.Nat Biotechnol2025;43:831-2

[88]

Zhang X,Ren J.Precise modelling of mitochondrial diseases using optimized mitoBEs.Nature2025;639:735-45

[89]

Chen L,Luan C.Efficient mitochondrial A-to-G base editors for the generation of mitochondrial disease models.Nat Biotechnol2025;44:418-29

[90]

Chen L,Hong M.A mitochondrial disease model is generated and corrected using engineered base editors in rat zygotes.Nat Biotechnol2025;44:382-6

[91]

Du S,Zhou Y.Transplantation of encapsulated mitochondria alleviates dysfunction in mitochondrial and Parkinson’s disease models.Cell2026;189:2821-33.e23

[92]

Zhang J,Luo S.Live birth derived from oocyte spindle transfer to prevent mitochondrial disease.Reprod Biomed Online2017;34:361-8

[93]

Hyslop LA,Aushev M.Mitochondrial donation and preimplantation genetic testing for mtDNA disease.N Engl J Med2025;393:438-49 PMCID:PMC7617940

[94]

Mcfarland R,Feeney C.Mitochondrial donation in a reproductive care pathway for mtDNA disease.N Engl J Med2025;393:461-8 PMCID:PMC7617939

[95]

Li W,Lin K.Earlier second polar body transfer and further mitochondrial carryover removal for potential mitochondrial replacement therapy.MedComm2023;4:e217 PMCID:PMC10167372

[96]

Liao X,Lin K.Significant decrease of maternal mitochondria carryover using optimized spindle-chromosomal complex transfer.PLoS Biol2023;21:e3002313 PMCID:PMC10553349

[97]

Sato Y,Higuchi I,Naito E.Mitochondrial myopathy and familial thiamine deficiency.Muscle Nerve2000;23:1069-75

[98]

Bernsen P,Ruitenbeek W.Treatment of complex I deficiency with riboflavin.J Neurol Sci1993;118:181-7

[99]

Glover EI,Maher A,Moran GR.A randomized trial of coenzyme Q10 in mitochondrial disorders.Muscle Nerve2010;42:739-48

[100]

Neugebauer J,Bellusci M.Current global vitamin and cofactor prescribing practices for primary mitochondrial diseases: Results of a European reference network survey.J Inherit Metab Dis2024;48:e12805 PMCID:PMC11670042

[101]

Panetta J,Boneh A.Effect of high‐dose vitamins, coenzyme Q and high‐fat diet in paediatric patients with mitochondrial diseases.J Inherit Metab Dis2004;27:487-98

[102]

Gimenes A,Nápolis L.Effect of L-carnitine on exercise performance in patients with mitochondrial myopathy.Braz J Med Biol Res2015;48:354-62 PMCID:PMC4418367

[103]

Ikawa M,Koga Y.Arginine therapy in mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes.Curr Opin Clin Nutr Metab Care2020;23:17-22 PMCID:PMC6903379

[104]

Koga Y,Inoue E.Therapeutic regimen of l-arginine for MELAS: 9-year, prospective, multicenter, clinical research.J Neurol2018;265:2861-74 PMCID:PMC6244654

[105]

Ortigoza-escobar JD,Arias A.Treatment of genetic defects of thiamine transport and metabolism.Expert Rev Neurother2016;16:755-63

[106]

Raha SJ,Attri SV.Profound biotinidase deficiency as a treatable cause of pediatric diffuse leukoencephalopathy and diffusion restriction.J Child Neurol2026;08830738261424538

PDF

1

Accesses

0

Citation

Detail

Sections
Recommended

/

〈 〉