Development and future prospects of exon-skipping therapy for Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is an inherited progressive muscle disease that is caused by variants in the DMD gene. The development of therapies for DMD that promote dystrophin protein production or ameliorate dystrophin deficiency-induced pathology is currently underway. Therapies that promote dystrophin production are known as disease-modifying therapies, and include exon-skipping therapy using antisense oligonucleotides (AS-oligo). This therapy suppresses the function of a splicing enhancer sequence within an exon using AS-oligo and removes the exon from the mRNA, thereby converting an out-of-frame deletion (as occurs in DMD) to an in-frame deletion and inducing the expression of functional dystrophin protein. In 2016, eteplirsen, which induces exon 51 skipping, received accelerated approval in the United States. AS-oligo that induce the skipping of exons 45 and 53 are also currently being applied in clinical practice. AS-oligo that induce skipping of other exons are expected to be developed in the future, as well as modified nucleic acids that act more potently. Notably, however, the evaluation of the efficacy of these therapies in clinical practice after accelerated approval remains insufficient. In addition, many issues, such as the effectiveness of early treatment and the combination of these therapies with other novel therapeutic agents, need to be considered. It is therefore important to establish a system to follow-up the long-term efficacy and safety of treatment in the future. The establishment of an early diagnostic system may also need to be considered. The present review outlines the development and future challenges of exon-skipping therapy for DMD and the expansion of splice-switching therapy (a therapy that uses AS-oligo to control splicing), including exon-skipping therapy, to other diseases.