What We Have Learned from 10 Years of DMD Exon-Skipping Trials

  • Svitlana Pasteuning-Vuhman
  • Annemieke Aartsma-RusEmail author


Duchenne muscular dystrophy (DMD) is an X-linked recessive disorder caused by truncating mutations in the DMD gene. These result in the absence of the muscle fibre stabilizing dystrophin protein and progressive loss of muscle tissue and function. In-frame mutations with partially functional dystrophin generally lead to Becker muscular dystrophy (BMD) with a milder disease phenotype. This was the inspiration for the antisense-mediated exon-skipping approach that restores the dystrophin reading frame to allow production of a Becker-type dystrophin. This approach is mutation specific. Since exon 51 skipping is applicable to the largest group of DMD patients, two antisense compounds targeting exon 51 were developed first, i.e. drisapersen and eteplirsen. Ten years have passed since the first exon-skipping antisense compound was tested clinically in DMD patients. If objectively evaluated, initial trials were suboptimal with modest clinical success. Major hurdles were that, at the time of trial planning, natural history data and reliable outcome measures to detect clinical benefit were not available. Moreover, the levels of dystrophin that are restored in DMD patients are lower than those observed in BMD patients. This chapter looks back at the lessons that were learned during the development of DMD exon skipping so far, to allow for more optimal exon-skipping trials in the future.


Duchenne muscular dystrophy Exon skipping Clinical trial Dystrophin level Natural history Outcome measure Disease heterogeneity 


  1. 1.
    Mendell JR, Shilling C, Leslie ND, Flanigan KM, al-Dahhak R, Gastier-Foster J, Kneile K, Dunn DM, Duval B, Aoyagi A, Hamil C, Mahmoud M, Roush K, Bird L, Rankin C, Lilly H, Street N, Chandrasekar R, Weiss RB (2012) Evidence-based path to newborn screening for Duchenne muscular dystrophy. Ann Neurol 71(3):304–313. CrossRefPubMedGoogle Scholar
  2. 2.
    Moat SJ, Bradley DM, Salmon R, Clarke A, Hartley L (2013) Newborn bloodspot screening for Duchenne muscular dystrophy: 21 years experience in Wales (UK). Eur J Hum Genet 21(10):1049–1053. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Straub V, Balabanov P, Bushby K, Ensini M, Goemans N, De Luca A, Pereda A, Hemmings R, Campion G, Kaye E, Arechavala-Gomeza V, Goyenvalle A, Niks E, Veldhuizen O, Furlong P, Stoyanova-Beninska V, Wood MJ, Johnson A, Mercuri E, Muntoni F, Sepodes B, Haas M, Vroom E, Aartsma-Rus A (2016) Stakeholder cooperation to overcome challenges in orphan medicine development: the example of Duchenne muscular dystrophy. Lancet Neurol 15(8):882–890. CrossRefPubMedGoogle Scholar
  4. 4.
    Emery AE (2002) The muscular dystrophies. Lancet 359(9307):687–695. CrossRefPubMedGoogle Scholar
  5. 5.
    Bladen CL, Salgado D, Monges S, Foncuberta ME, Kekou K, Kosma K, Dawkins H, Lamont L, Roy AJ, Chamova T, Guergueltcheva V, Chan S, Korngut L, Campbell C, Dai Y, Wang J, Barisic N, Brabec P, Lahdetie J, Walter MC, Schreiber-Katz O, Karcagi V, Garami M, Viswanathan V, Bayat F, Buccella F, Kimura E, Koeks Z, van den Bergen JC, Rodrigues M, Roxburgh R, Lusakowska A, Kostera-Pruszczyk A, Zimowski J, Santos R, Neagu E, Artemieva S, Rasic VM, Vojinovic D, Posada M, Bloetzer C, Jeannet PY, Joncourt F, Diaz-Manera J, Gallardo E, Karaduman AA, Topaloglu H, El Sherif R, Stringer A, Shatillo AV, Martin AS, Peay HL, Bellgard MI, Kirschner J, Flanigan KM, Straub V, Bushby K, Verschuuren J, Aartsma-Rus A, Beroud C, Lochmuller H (2015) The TREAT-NMD DMD Global Database: analysis of more than 7,000 Duchenne muscular dystrophy mutations. Hum Mutat 36(4):395–402. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hoffman EP, Brown RH Jr, Kunkel LM (1987) Dystrophin: the protein product of the Duchenne muscular dystrophy locus. Cell 51(6):919–928CrossRefGoogle Scholar
  7. 7.
    Blake DJ, Weir A, Newey SE, Davies KE (2002) Function and genetics of dystrophin and dystrophin-related proteins in muscle. Physiol Rev 82(2):291–329. CrossRefPubMedGoogle Scholar
  8. 8.
    Aartsma-Rus A, van Ommen GJ (2007) Antisense-mediated exon skipping: a versatile tool with therapeutic and research applications. RNA 13(10):1609–1624. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Aartsma-Rus A (2010) Antisense-mediated modulation of splicing: therapeutic implications for Duchenne muscular dystrophy. RNA Biol 7(4):453–461CrossRefGoogle Scholar
  10. 10.
    Aartsma-Rus A, Fokkema I, Verschuuren J, Ginjaar I, van Deutekom J, van Ommen GJ, den Dunnen JT (2009) Theoretic applicability of antisense-mediated exon skipping for Duchenne muscular dystrophy mutations. Hum Mutat 30(3):293–299. CrossRefPubMedGoogle Scholar
  11. 11.
    Jarver P, O’Donovan L, Gait MJ (2014) A chemical view of oligonucleotides for exon skipping and related drug applications. Nucleic Acid Ther 24(1):37–47. CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Summerton J, Weller D (1997) Morpholino antisense oligomers: design, preparation, and properties. Antisense Nucleic Acid Drug Dev 7(3):187–195. CrossRefPubMedGoogle Scholar
  13. 13.
    Fletcher S, Honeyman K, Fall AM, Harding PL, Johnsen RD, Wilton SD (2006) Dystrophin expression in the mdx mouse after localised and systemic administration of a morpholino antisense oligonucleotide. J Gene Med 8(2):207–216. CrossRefPubMedGoogle Scholar
  14. 14.
    Heemskerk HA, de Winter CL, de Kimpe SJ, van Kuik-Romeijn P, Heuvelmans N, Platenburg GJ, van Ommen GJ, van Deutekom JC, Aartsma-Rus A (2009) In vivo comparison of 2′-O-methyl phosphorothioate and morpholino antisense oligonucleotides for Duchenne muscular dystrophy exon skipping. J Gene Med 11(3):257–266. CrossRefPubMedGoogle Scholar
  15. 15.
    Kinali M, Arechavala-Gomeza V, Feng L, Cirak S, Hunt D, Adkin C, Guglieri M, Ashton E, Abbs S, Nihoyannopoulos P, Garralda ME, Rutherford M, McCulley C, Popplewell L, Graham IR, Dickson G, Wood MJ, Wells DJ, Wilton SD, Kole R, Straub V, Bushby K, Sewry C, Morgan JE, Muntoni F (2009) Local restoration of dystrophin expression with the morpholino oligomer AVI-4658 in Duchenne muscular dystrophy: a single-blind, placebo-controlled, dose-escalation, proof-of-concept study. Lancet Neurol 8(10):918–928. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Gebski BL, Mann CJ, Fletcher S, Wilton SD (2003) Morpholino antisense oligonucleotide induced dystrophin exon 23 skipping in mdx mouse muscle. Hum Mol Genet 12(15):1801–1811CrossRefGoogle Scholar
  17. 17.
    Alter J, Lou F, Rabinowitz A, Yin H, Rosenfeld J, Wilton SD, Partridge TA, Lu QL (2006) Systemic delivery of morpholino oligonucleotide restores dystrophin expression bodywide and improves dystrophic pathology. Nat Med 12(2):175–177. CrossRefPubMedGoogle Scholar
  18. 18.
    van Deutekom JC, Janson AA, Ginjaar IB, Frankhuizen WS, Aartsma-Rus A, Bremmer-Bout M, den Dunnen JT, Koop K, van der Kooi AJ, Goemans NM, de Kimpe SJ, Ekhart PF, Venneker EH, Platenburg GJ, Verschuuren JJ, van Ommen GJ (2007) Local dystrophin restoration with antisense oligonucleotide PRO051. N Engl J Med 357(26):2677–2686. CrossRefPubMedGoogle Scholar
  19. 19.
    Goemans NM, Tulinius M, van den Akker JT, Burm BE, Ekhart PF, Heuvelmans N, Holling T, Janson AA, Platenburg GJ, Sipkens JA, Sitsen JM, Aartsma-Rus A, van Ommen GJ, Buyse G, Darin N, Verschuuren JJ, Campion GV, de Kimpe SJ, van Deutekom JC (2011) Systemic administration of PRO051 in Duchenne’s muscular dystrophy. N Engl J Med 364(16):1513–1522. CrossRefPubMedGoogle Scholar
  20. 20.
    Goemans NM, Tulinius M, van den Hauwe M, Kroksmark AK, Buyse G, Wilson RJ, van Deutekom JC, de Kimpe SJ, Lourbakos A, Campion G (2016) Long-term efficacy, safety, and pharmacokinetics of drisapersen in Duchenne muscular dystrophy: results from an open-label extension study. PLoS One 11(9):e0161955. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Goemans N, Tulinius M, Kroksmark AK, Wilson R, van den Hauwe M, Campion G (2016) Comparison of ambulatory capacity and disease progression of Duchenne muscular dystrophy subjects enrolled in the drisapersen DMD114673 study with a matched natural history cohort of subjects on daily corticosteroids. Neuromuscul Disord 27:203. CrossRefPubMedGoogle Scholar
  22. 22.
    Voit T, Topaloglu H, Straub V, Muntoni F, Deconinck N, Campion G, De Kimpe SJ, Eagle M, Guglieri M, Hood S, Liefaard L, Lourbakos A, Morgan A, Nakielny J, Quarcoo N, Ricotti V, Rolfe K, Servais L, Wardell C, Wilson R, Wright P, Kraus JE (2014) Safety and efficacy of drisapersen for the treatment of Duchenne muscular dystrophy (DEMAND II): an exploratory, randomised, placebo-controlled phase 2 study. Lancet Neurol 13(10):987–996. CrossRefPubMedGoogle Scholar
  23. 23.
    Economides C (March 17, 2014) Prosensa announces 48-week data from a U.S. phase II placebo-controlled study of drisapersen in 51 DMD boys.
  24. 24.
    Toth PP (2013) Emerging LDL therapies: mipomersen-antisense oligonucleotide therapy in the management of hypercholesterolemia. J Clin Lipidol 7(3 Suppl):S6–S10.
  25. 25.
    FDA briefing document peripheral and central nervous system drugs advisory committee meeting (November 24, 2015)Google Scholar
  26. 26.
    BioMarin announces data analysis demonstrating consistent efficacy of Kyndrisa™ (drisapersen) in comparable patients across three randomized studies (2015).
  27. 27.
  28. 28.
    BioMarin announces withdrawal of market authorization application for Kyndrisa™ (drisapersen) in Europe (2016).
  29. 29.
    Cirak S, Arechavala-Gomeza V, Guglieri M, Feng L, Torelli S, Anthony K, Abbs S, Garralda ME, Bourke J, Wells DJ, Dickson G, Wood MJ, Wilton SD, Straub V, Kole R, Shrewsbury SB, Sewry C, Morgan JE, Bushby K, Muntoni F (2011) Exon skipping and dystrophin restoration in patients with Duchenne muscular dystrophy after systemic phosphorodiamidate morpholino oligomer treatment: an open-label, phase 2, dose-escalation study. Lancet 378(9791):595–605. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Mendell JR, Rodino-Klapac LR, Sahenk Z, Roush K, Bird L, Lowes LP, Alfano L, Gomez AM, Lewis S, Kota J, Malik V, Shontz K, Walker CM, Flanigan KM, Corridore M, Kean JR, Allen HD, Shilling C, Melia KR, Sazani P, Saoud JB, Kaye EM (2013) Eteplirsen for the treatment of Duchenne muscular dystrophy. Ann Neurol 74(5):637–647. CrossRefPubMedGoogle Scholar
  31. 31.
    Mendell JR, Goemans N, Lowes LP, Alfano LN, Berry K, Shao J, Kaye EM, Mercuri E (2016) Longitudinal effect of eteplirsen versus historical control on ambulation in Duchenne muscular dystrophy. Ann Neurol 79(2):257–271. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Aartsma-Rus A, Krieg AM (2017) FDA approves eteplirsen for Duchenne muscular dystrophy: the next chapter in the eteplirsen saga. Nucleic Acid Ther 27:1. CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
  34. 34.
    Sarepta therapeutics announces FDA request for dystrophin data prior to making a decision on eteplirsen NDA (2016).
  35. 35.
  36. 36.
    FDA grants accelerated approval to first drug for Duchenne muscular dystrophy (2016).
  37. 37.
    Muntoni F (2010) The development of antisense oligonucleotide therapies for Duchenne muscular dystrophy: report on a TREAT-NMD workshop hosted by the European Medicines Agency (EMA), on September 25th 2009. Neuromuscul Disord 20(5):355–362. CrossRefPubMedGoogle Scholar
  38. 38.
    Aartsma-Rus A, Ferlini A, Goemans N, Pasmooij AM, Wells DJ, Bushby K, Vroom E, Balabanov P (2014) Translational and regulatory challenges for exon skipping therapies. Hum Gene Ther 25(10):885–892. CrossRefPubMedGoogle Scholar
  39. 39.
    Goemans N, Klingels K, van den Hauwe M, Boons S, Verstraete L, Peeters C, Feys H, Buyse G (2013) Six-minute walk test: reference values and prediction equation in healthy boys aged 5 to 12 years. PLoS One 8(12):e84120. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    McDonald CM, Henricson EK, Abresch RT, Florence JM, Eagle M, Gappmaier E, Glanzman AM, Spiegel R, Barth J, Elfring G, Reha A, Peltz S (2013) The 6-minute walk test and other endpoints in Duchenne muscular dystrophy: longitudinal natural history observations over 48 weeks from a multicenter study. Muscle Nerve 48(3):343–356. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Mercuri E, Signorovitch JE, Swallow E, Song J, Ward SJ (2016) Categorizing natural history trajectories of ambulatory function measured by the 6-minute walk distance in patients with Duchenne muscular dystrophy. Neuromuscul Disord 26(9):576–583. CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Mazzone ES, Pane M, Sormani MP, Scalise R, Berardinelli A, Messina S, Torrente Y, D’Amico A, Doglio L, Viggiano E, D’Ambrosio P, Cavallaro F, Frosini S, Bello L, Bonfiglio S, De Sanctis R, Rolle E, Bianco F, Magri F, Rossi F, Vasco G, Vita G, Motta MC, Donati MA, Sacchini M, Mongini T, Pini A, Battini R, Pegoraro E, Previtali S, Napolitano S, Bruno C, Politano L, Comi GP, Bertini E, Mercuri E (2013) 24 month longitudinal data in ambulant boys with Duchenne muscular dystrophy. PLoS One 8(1):e52512. CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Guideline on the clinical investigation of medicinal products for the treatment of Duchenne and Becker muscular dystrophy (2015).
  44. 44.
    Duchenne muscular dystrophy and related dystrophinopathies: developing drugs for treatment guidance for industry (2015).
  45. 45.
    van Putten M, Hulsker M, Nadarajah VD, van Heiningen SH, van Huizen E, van Iterson M, Admiraal P, Messemaker T, den Dunnen JT, ’t Hoen PA, Aartsma-Rus A (2012) The effects of low levels of dystrophin on mouse muscle function and pathology. PLoS One 7(2):e31937. CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    van den Bergen JC, Ginjaar HB, Niks EH, Aartsma-Rus A, Verschuuren JJ (2014) Prolonged ambulation in Duchenne patients with a mutation amenable to exon 44 skipping. J Neuromuscul Dis 1(1):91–94PubMedGoogle Scholar
  47. 47.
    Pane M, Mazzone ES, Sormani MP, Messina S, Vita GL, Fanelli L, Berardinelli A, Torrente Y, D’Amico A, Lanzillotta V, Viggiano E, D’Ambrosio P, Cavallaro F, Frosini S, Bello L, Bonfiglio S, Scalise R, De Sanctis R, Rolle E, Bianco F, Van der Haawue M, Magri F, Palermo C, Rossi F, Donati MA, Alfonsi C, Sacchini M, Arnoldi MT, Baranello G, Mongini T, Pini A, Battini R, Pegoraro E, Previtali SC, Napolitano S, Bruno C, Politano L, Comi GP, Bertini E, Morandi L, Gualandi F, Ferlini A, Goemans N, Mercuri E (2014) 6 minute walk test in Duchenne MD patients with different mutations: 12 month changes. PLoS One 9(1):e83400. CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Jearawiriyapaisarn N, Moulton HM, Buckley B, Roberts J, Sazani P, Fucharoen S, Iversen PL, Kole R (2008) Sustained dystrophin expression induced by peptide-conjugated morpholino oligomers in the muscles of mdx mice. Mol Ther 16(9):1624–1629. CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Jearawiriyapaisarn N, Moulton HM, Sazani P, Kole R, Willis MS (2010) Long-term improvement in mdx cardiomyopathy after therapy with peptide-conjugated morpholino oligomers. Cardiovasc Res 85(3):444–453. CrossRefPubMedGoogle Scholar
  50. 50.
    Moulton HM, Moulton JD (2010) Morpholinos and their peptide conjugates: therapeutic promise and challenge for Duchenne muscular dystrophy. Biochim Biophys Acta 1798(12):2296–2303. CrossRefPubMedGoogle Scholar
  51. 51.
    WAVE life sciences to advance next-generation nucleic acid therapies to address unmet need in Duchenne muscular dystrophy (2016).
  52. 52.
    Beroud C, Tuffery-Giraud S, Matsuo M, Hamroun D, Humbertclaude V, Monnier N, Moizard MP, Voelckel MA, Calemard LM, Boisseau P, Blayau M, Philippe C, Cossee M, Pages M, Rivier F, Danos O, Garcia L, Claustres M (2007) Multiexon skipping leading to an artificial DMD protein lacking amino acids from exons 45 through 55 could rescue up to 63% of patients with Duchenne muscular dystrophy. Hum Mutat 28(2):196–202. CrossRefPubMedGoogle Scholar
  53. 53.
    Aoki Y, Yokota T, Wood MJ (2013) Development of multiexon skipping antisense oligonucleotide therapy for Duchenne muscular dystrophy. Biomed Res Int 2013:402369. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Gazzoli I, Pulyakhina I, Verwey NE, Ariyurek Y, Laros JF, ’t Hoen PA, Aartsma-Rus A (2016) Non-sequential and multi-step splicing of the dystrophin transcript. RNA Biol 13(3):290–305. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Svitlana Pasteuning-Vuhman
    • 1
  • Annemieke Aartsma-Rus
    • 1
    Email author
  1. 1.Department of Human GeneticsLeiden University Medical CenterLeidenThe Netherlands

Personalised recommendations