Krithika Subramanian, PhD

Duchenne muscular dystrophy (DMD) is among the most severe forms of inherited muscular dystrophies and the most common hereditary neuromuscular disease, affecting approximately 1 in 5000 live male births.

 DMD is a recessive X-linked disorder that arises from the absence of functional dystrophin protein in the skeletal muscle membrane, which is driven by mutations in the DMD gene located on chromosome Xp21.

 Dystrophin, a member of the spectrin superfamily of cytoskeletal proteins, is expressed mainly in skeletal and cardiac muscle, and to a lesser extent in the brain. In healthy muscles, dystrophin is found on the intracellular surface of the sarcolemma, along with the sarcomeres. Along with the other proteins that form the dystrophin-associated protein complex (DAPC), dystrophin is important for maintenance of membrane stability in striated muscle cells.

 Loss-of-function mutations in DMD or in the genes encoding other proteins in the DAPC, triggers instability of the plasma membrane, calcium ion influx, and myofiber loss, leading to repeated cycles of myonecrosis and regeneration associated with inflammation and repair, ulti- mately rendering muscles more vulnerable to mechanical injury.

DMD is usually diagnosed in children between 2 and 5 years of age, with the appearance of motor developmental delay and an abnormal “waddling” gait, calf muscle pseudohypertrophy, and weakened proximal muscles.

 As the patient ages, progressive muscle degeneration occurs, resulting in loss of ambulation when the child is aged between 8 and 12 years.

 In addition, respiratory insufficiency, musculoskeletal deformities, and cardiomyopathy also progress with age.

 Cognitive impairment and behavior problems are also present, although these effects are not progressive.

 Respiratory and cardiac complications in patients with DMD lead to premature death at 20 to 30 years of age.

Mutations in the DMD gene form the basis of dystrophin dysfunction and loss in DMD. Dystrophin dysfunction is profound in most patients with DMD, who typically have less than 5% of the normal level of the dystrophin protein.

 The DMD gene is the largest gene in the human genome, with one of the highest spontaneous mutation rates.

 DMD, which contains 79 exons and 2.5 Mb of DNA, encodes the 427-kDa dystrophin protein.3 Dystrophin protein has an N-terminal actin-binding domain, a central rod domain, and a C-terminal domain that binds to the DAPC at the plasma membrane.

 The rod domain is composed of 24 spectrin-like repeats, interspersed with 4 hinge domains.

Many different DMD mutations have been reported in patients with DMD; de novo DMD mutations occur often, in an estimated 12% to 33% of patients.

 Most mutations (70% to 80%) are deletions or duplications; 69% of patients with DMD carry large deletions

in DMD, whereas 11% have large duplications.

 Point mutations are seen in 20% to 30% of patients, whereas 10% have nonsense mutations, 7% have missense mutations or small indels, and 3% have intronic or other mutations.

 A model of DMD pathogenesis is predicated on the hypothesis that deletions that disrupt the reading frame are likely to result in a more severe DMD phenotype, whereas those that maintain the reading frame result in milder DMD phenotypes or Becker muscular dystrophy; this model has been validated in about 91% of patients with DMD.

 This reading-frame hypothesis has clinical significance not only due to its implications for the phenotypic variability of DMD presentation but also because some clinical interventions that have gained recent regulatory approval or are under development incorporate a strategy called exon skipping. These interventions involve the use of synthetic antisense oligonucleotides that cause an exon adjacent to a deletion mutation to be spliced out during mRNA processing. Although the resulting dystrophin protein is slightly shortened, the change prevents disruption of the reading frame, thus avoiding the worse fate of a drastically truncated or unstable protein.

The phenotypic variability in DMD is thought to stem not only from the wide range of mutations but also from genetic pathways interacting with and modifying the effects of the primary DMD mutation. Environmental influences such as exercise and nutri- tion are thought to affect phenotypic variability as well. DMD disease modifiers identified using combinations of transcriptome and genome profiling include SPP1 (which encodes osteopontin), LTBP4 (encoding latent transforming growth factor β—binding protein 4), Anxa6 (encoding annexin A6), THBS1 (encoding throm- bospondin-1), ACTN3 (encoding α-actinin 3), and more recently, CD40 (encoding the immune costimulatory receptor CD40, an activator of the nuclear factor κB [NF-κB] pathway).

 A minor allele in the 5&#697;-untranslated region of CD40 was associated with earlier loss of ambulation, a clinically meaningful measure of DMD severity.

 SPP1, LTBP4, CD40, and THBS1 have been implicated in several interconnected pathways that modulate inflammatory response to muscle damage, regeneration, and fibrosis, whereas a common truncation of the ACTN3 gene reduces muscle power and sprint performance.

 These modifiers may be of clinical interest in DMD treatment, as actionable targets, to improve the function of the dystrophin pathway in patients with DMD.

Current and Emerging Pharmacological Management of DMD Currently, there is no medical cure for DMD, and the disease has a poor prognosis.

 DMD treatment is centered on glucocorticoid therapy, prevention of contractures, and medical care of cardiomyopathy and respiratory compromise.

 Glucocorticoid steroids, such as prednisone or deflazacort, are the mainstay of DMD treatment; however, tolerance to chronic use, toxicity with long-term use, and heterogeneous treatment response are some critical disadvantages of glucocorticoid therapy in DMD4 despite improvement in muscle function and reduced need for scoliosis surgery, among other improved clinical outcomes.

Current and emerging treatments for DMD rely on 2 major strategies: They either target the primary defect, such as therapies that seek to restore dystrophin expression and function, or they seek to mitigate the secondary and downstream consequences of dystrophin loss, such as treatments that target NF-κB—mediated inflammation, fibrosis, or muscle wasting (TABLE 1).

The NF-κB Pathway in Dystrophic Pathogenesis

NF-κB is a multifunctional, ubiquitously expressed transcription factor with pleiotropic functions in cell survival, apoptosis, growth, and differentiation. NF-κB is also involved in modulating cellular responses to stress, as well as immune/inflamma- tory responses and skeletal and muscle development.

 During canonical NF-κB activation, the p65 transactivation subunit of the NF-κB p50/p65 heterodimer is tightly regulated by the inhibitory protein IκB. Upon activation of the NF-κB pathway, the upstream inhibitor of NF-κB kinase kinase (IKK) is phosphorylated, and in turn it phosphorylates IκB.

 Subsequent proteasomal degradation of IκB unmasks a nuclear localization site on p65, allowing NF-κB to translocate to the nucleus, bind to target genes and activate their expression.

The activation of the NF-κB inflammatory pathway mediates the infiltration of immune cells into dystrophic muscles; indeed, immunoreactivity for activated NF-κB was reported in all regenerating fibers and signif- icant proportions (20%-40%) of necrotic fibers in DMD muscles.

 The key role of this inflammatory pathway in DMD has been demonstrated in preclinical cellular and animal model studies. For instance, in the mdx mouse, a model of DMD lacking dystrophin, skeletal muscle—specific activation of NF-κB was shown to precede the onset of dystrophic damage.23 NF-κB–mediated overexpression of inflammatory cytokines has been reported in dystrophic muscles; for instance, the levels of tumor necrosis factor-α were approximately 1000 times higher in serum samples from patients with DMD than in those from controls.

 Mouse model studies also showed that p65 haplo- insufficiency was associated with increased cell proliferation and myogenic differentia- tion; moreover, pharmacologic inhibition of the IKK/NF-κB pathway enhanced myogenic differentiation, improving muscle regeneration.

 NF-κB activation in skeletal muscle in DMD is a consequence of the loss of sarcolemmal dystrophin. This activation has been shown to be an early event in DMD pathology, even occurring in the muscles of infants with DMD prior to the onset of fibrosis or clinical manifestations.

 Suppression of NF-κB activation (even by only 50%) in animal models of DMD, via pharmacological inhi- bition or genetic manipulation, improves histology, function, and regeneration of muscle. This suggests that inhibition of this inflammatory pathway may help mitigate secondary muscle-directed effects in patients with DMD.

 Two agents that target NF-κB— mediated inflammation, vamorolone and edasalonexent, are currently in advanced-phase clinical trials.

Anti-inflammatory NF-κB—targeted Agents in DMD

Inhibition of NF-κB—mediated inflammatory responses is one of the primary mechanisms underlying the clinical effects of the steroidal agents that are the currently accepted mainstay of DMD treatment.

 However, due to the adverse effects associated with chronic and long-term use of glucocorticoids, and increasing knowledge and availability of agents that can target the NF-κB pathway, devel- opment of inhibitors of this pathway with potential clinical efficacy and acceptable safety profiles is of interest in DMD treatment. Orally bioavailable NF-κB inhibitors, including edasalonexent and the steroid analogue vamorolone, are currently being investigated in clinical studies in patients with DMD (TABLE 2).16,26-28

Edasalonexent is an orally administered, novel, small-molecule inhibitor of NF-κB in which salicylic acid and docosahexaenoic acid (DHA) are covalently conjugated through an ethylenediamine linker that is hydrolyzed intracellularly only by the fatty acid amide hydrolase.

 Preclinical studies have demonstrated that salicylic acid prevents NF-κB—mediated muscle atrophy; DHA suppresses NF-κB–mediated inflammation and is metabolized intracellularly to anti-inflammatory eicosanoids, which can also improve muscle fiber regeneration.

 The design of this agent allows for synergistic action of its linked compounds to inhibit NF-κB, likely enabling the higher potency of edasalonexent compared with that of each of its individual components.

Data from a phase 1 clinical program for edasalonexent, which included 3 placebo-controlled studies in adults, were recently reported.

 The data showed that edasalonexent was safe and well tolerated and that it inhibited NF-κB pathway activation, with significant decreases in the expression of genes associated with the NF-κB pathway and proteasome in peripheral mononuclear cells (P = .02 and P = .002, respectively) after 2 weeks of edasalonexent treatment.

 A subsequent phase 1 study evaluated the safety, tolerability, pharmacokinetics, and exploratory pharmacodynamics of 3 doses of edasa- lonexent in pediatric patients (ambulatory males aged between 4 and <8 years) with genetically confirmed DMD.

 In this 1-week, open-label, multiple-dose study with 3 sequential ascending doses (33, 67, and 100 mg/kg/day) of edasalonexent, all doses were well tolerated, with no serious adverse events, no drug discontinuations, and no dose reductions. Moreover, levels of NF-κB—regulated genes and serum proteins were decreased following treatment with edasalonexent for

7 days. Given that the edasalonexent-mediated inhibition of NF-κB is independent of the underlying DMD mutation, the authors noted that this agent might have broad applicability in all patients with DMD and may provide clinical efficacy either as a monotherapy or in combina- tion with dystrophin-restoration therapies. Along these lines, a recent report outlined delivery of NF-κB/p65-directed small hairpin RNA in combination with mini-dystrophin replacement gene therapy on the same adenoviral vector in a mouse DMD model

; improvement in overall health of the double-knockout mice was observed, suggesting that combining dystrophin-remediation therapies with NF-κB— targeted agents might enable additive therapeutic effects in DMD.

Vamorolone is a first-in-class steroidal drug with a high degree of chemical and 3-dimensional structural homology to glucocorticoids.

Although vamorolone also binds glucocorticoid receptors (GRs) and mineralocorticoid receptors with an affinity similar to that of glucocorticoids, vamorolone/GR complexes do not dimerize and exhibit decreased gene transcriptional activity compared with glucocorticoid/GR complexes.

 Due to these key mechanistic differences, vamorolone is thought to exert membrane-stabilizing and anti-inflammatory properties, including inhibition of NF-κB, without the significant immunosuppressive and hormonal effects that are char- acteristic of glucocorticoids. Phase 1 clinical studies have indicated that the typical adverse effects of steroids were greatly attenuated in patients treated with this novel steroid analogue

; for instance, suppression of the adrenal axis was 10-fold lower with vamorolone than with prednisone.

 In a 2-week, open-label, phase 2, multiple ascending-dose study (0.25, 0.75, 2.0, and 6.0 mg/kg/day), vamorolone’s clinical safety, pharmacokinetics, and pharmacody-namic biomarkers were evaluated in 48 boys with DMD (aged 4 to <7 years).

 Vamorolone was safe and well tolerated through the highest dose tested, with a pharmacokinetic profile comparable to that of prednisolone. Moreover, biomarker analysis indicated an improved safety profile compared with glucocorticoids, including reduction of insulin resistance, beneficial changes in bone turnover, and a reduc- tion in adrenal suppression.

 A subsequent study found that the 2.0 mg/kg/day dosage group met the primary efficacy outcome of improved muscle function (time to stand; 24 weeks of vamorolone treatment vs natural history controls) without evidence of most of the adverse effects seen with glucocorticoids.

The emergence of clinically useful NF-κB—targeted agents with the potential to arrest or reverse inflammatory responses and muscle degeneration in patients with DMD, without the adverse events associated with glucocorticoids, provides a novel option for DMD treatment that is agnostic to the primary DMD mutation. Such agents hold significant promise as monotherapy or in combination with other classes of agents for the treatment of all patients with DMD, a possibility that provides new hope for tackling this currently incurable progressive disease.

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Articles

An in-depth analysis of the genetics of DMD and disease modifiers such as the NF-kB pathway in patients with Duchenne muscular dystrophy. 

Targeting the NF-&#954;B Pathway in Duchenne Muscular Dystrophy

Mutliple sclerosis (MS) the most common neuroinflammatory and neurodegenerative disease in young adults, affecting over 2 million patients worldwide.

 Although the existence of regions of inflammation has been known since the initial anatomical descriptions of MS in the 19th century, the pathophysiology of MS is currently understood to involve autoreactive T and B cells mediating autoimmune damage to the myelin sheath of neurons, which causes chronic neuroinflammation and, finally, degeneration of the axon. This process ultimately affects the brain, spinal cord, and optic nerves.

 The central nervous system (CNS) inflammation that characterizes MS is also associated with gliosis, oligodendrocyte loss, and eventual brain volume decrease, with axonal degeneration thought to be responsible for progressive neurological dysfunction.

The clinical manifestations of MS vary depending on the affected part of the CNS and may include sensory abnormalities such as paresthesia, movement disorders, muscle weakness, muscle cramps, sphincter dysfunction, visual disturbances, speech disorder, and cognitive impairment.

 Although there are no cures for MS at present, the treatment landscape has changed significantly, with over a dozen approved disease-modifying therapies (DMTs) representing multiple classes of agents with different mechanisms of action.

 DMTs attempt to alter the disease course by improving function, managing symptoms, and preventing or slowing disease progression, as well as preventing new episodes of MS-associated dysfunction and arresting the development of further neurological disabilities.

 Although previously underappreciated, B cells, as key mediators of humoral immunity, have emerged as a central target of effective MS therapeutics. The current place of B cell—targeted agents in MS is highlighted by the significant clinical benefit observed with anti-CD20–mediated B-cell depletion in clinical studies of patients with MS.

The precise mechanistic and causal underpinnings of MS are currently incompletely understood; however, a combination of effects mediated by infectious agents, environmental exposures, and genetic factors are thought to affect MS pathogenesis. For instance, observational studies suggest association of increased MS risk with lower sun exposure in childhood and lower 25-hydroxyvitamin D levels in white populations.

 Other factors that have been considered in studies of MS susceptibility and prognosis include viral infections, obesity, and tobacco exposure, with strong associations noted for prior Epstein-Barr virus infection and cigarette smoking.

Among genetic factors, certain human leukocyte antigen (HLA) class I and II alleles have been shown to contribute to MS susceptibility, with the HLA-DRB1*15:01 allele exhibiting one of the strongest associations with MS risk (odds ratio, ~3).

 Genome-wide studies have identified gene variants encoding proteins involved in immune responses as important contributors to MS development, further substantiating the view of MS as an immune-medi- ated disorder.

 Currently, over 100 non—major histocompatibility complex variants associated with MS risk have been identified at 103 genetic loci through genome-wide association studies. The cumulative contribution of these genetic variants to MS risk is estimated at 30%, although this may be revised with discovery of additional loci and variants.

The disease course of MS has been described based on 4 basic clinical types, with associated modifiers, by the United States—based National Multiple Sclerosis Society. These include clinically isolated syndrome, which is the first episode of neurologic symptoms characteristic of MS (CNS inflammation and demyelination) but does not fulfill the diagnostic criteria for MS because no further episodes may occur; relapsing-remitting MS (RRMS), the most common disease course, characterized by clearly defined episodes of new

or increasing neurologic symptoms (relapses or exacerbations), followed by remissions; primary progressive MS (PPMS), characterized by worsening neurologic function from symptom onset in the absence of early relapses or remissions (ie, no initial RRMS course); and secondary progressive MS (SPMS), which involves progressive worsening of neurologic function following an initial RRMS course.

 Disease course modifiers indicate whether activity (clinical relapses and/or new lesions on magnetic resonance imaging [MRI]) and progression (clinically evaluated level of disability) are present within 1 of the above 4 clinical types.

 The goal of adding modifiers to the clinical types is improved assessment of progres- sion and the development of an appropriate therapeutic plan, with greater activity/progression and increasing number or frequency of relapses warranting escalation of treatment.

The role of B cells in MS pathophysiology has long been supported by several key findings: B cells are present in MS plaques and in meningeal follicles of patients with SPMS; oligoclonal bands (OCBs) are secreted by B and plasma cells and are present in the cerebrospinal fluid (CSF) of over 90% of patients with MS, where they persist throughout the course of the disease; and variants of some B cell— specific genes, such as TNFSF13B, which encodes the BAFF cytokine, have been associated with increased MS risk.

 These emerging concepts describe a broader and more central antibody-indepen- dent role of B cells in MS pathogenesis and progression.

Peripheral mature B cells can cross the blood—brain barrier (BBB) into the CNS and also traverse the blood–CSF barrier.

 In the CNS, a restricted number of expanded clones of B cells and plasma cells are thought to generate immunoglobulins and form the OCBs characteristic of MS.

 These B-cell clones persist within the CNS and can undergo dynamic shuttling between different CNS compartments and the periphery, enabling transport, processing, and presentation of CNS antigens, and trigger CNS-targeted inflammatory responses (

B cells mediate MS pathogenesis through several mechanisms, including antibody production, antigen presentation, activation of T cells, cytokine production, and formation of ectopic germinal centers.

 Antibodies in the OCBs characteristic of MS primarily recognize ubiquitous intracellular proteins, rather than specific antigens that are shared across MS patients, suggesting that a B cell—driven humoral response to debris from dead cells, and not a primary pathogenic response, is involved in MS pathogenesis.

Despite the lack of a pathogenic contribution of B cell—derived antibodies, B cells may help generate and maintain pathogenic T-cell repertoires in patients with MS through promotion of T-cell tolerance and autoproliferation, via their antigen-presenting functions.

 Autoproliferation of T cells was found to be higher in patients with MS, driven by memory B cells in an HLA-DR haploype—dependent manner; this effect could be counteracted by treatment with anti-CD20 therapy.

 Myelin-reactive memory B cells have been detected in peripheral blood samples of patients with MS, acting as antigen-presenting cells in response to the presence of myelin antigens such as myelin basic protein and myelin oligodendrocyte glycoprotein, supporting the role of this B-cell subset in MS pathogenesis.

 Memory B cells also express high levels of CD20, and CD20-directed antibody treatment has been shown to deplete these cells, followed by gradual repopula- tion, coincident with attenuation of MS-specific disease activity in treated patients.

 In addition, aberrant B-cell cytokine responses to stimuli and abnormally high production of proinflammatory cytokines have been reported in patients with MS. The inflammatory imbalance driven by abnormal cytokine secretion can enhance B cell—mediated autoimmune responses and promote further inflammation driven by T cells and myeloid cells.

The traditional perspective of most DMTs has centered on a T cell— based mechanism of action; however, a growing body of data indicates that these DMTs also demonstrate immunomodulatory effects on B cells, even in therapies that do not explicitly target B-cell functions in MS (

 The clinical activity of antibodies that target CD20 has helped cement the role of B cells in MS pathogenesis and management. CD20, a cell-surface antigen, is mainly expressed by cells of the B-cell lineage—encompassing B-cell precursors and mature B cells but not hematopoietic stem cells or plasma cells&mdash;as well as by a small proportion of CD3+ T cells.

 Monoclonal antibodies that deplete B cells are the most effective and studied B cell-targeted therapies in MS. These agents are thought to act through various mechanisms, including antibody-dependent cellular cytotoxicity, complement-dependent cytotoxicity, and antibody-triggered apoptosis. Additional B-cell targets of interest in MS include B-cell cytokines or their receptors and inhibition of Bruton tyrosine kinase (BTK), which mediates B-cell receptor (BCR) signaling.

The first proof of concept for clinical utility of an anti-CD20 monoclonal for MS was data from the phase 2 HERMES study, which evaluated a single course of rituximab, a chimeric anti-CD20 antibody, in patients with RRMS; the data showed that rituximab reduced gadolinium (Gd)—enhancing inflammatory brain lesions and clinical relapses.

 Rituximab in MS is currently restricted to off-label use,

 with attention and interest having shifted to humanized or fully human anti-CD20 antibodies with greater potency and lower immunogenicity—ocrelizumab, ofatumumab, and ublituximab, of which ocrelizumab has gained FDA approval in MS.

 Key clinical data for these 3 antibodies are summarized in 

In addition to these antibody-based therapies, inhibitors of BTK, such as evobrutinib, a highly specific, irreversible oral agent, are being evaluated in clinical studies. Data from a phase 2 study of evobrutinib in patients with RRMS or SPMS with superimposed relapses showed a reduction in the number of Gd-containing lesions on MRI scans and a clinically relevant trend toward reduction in annualized relapse rate.

Monoclonal antibodies are now prominent therapeutic weapons in MS treatment. Continued development and optimization of these agents, such as by improving infusion times and providing subcutaneous administration options, is likely to maintain their prime status in the future.

 Therapies approved for other indications but with potential indications in MS include other antibodies, such as the CD19 (B-cell marker)—targeted inebilizumab and the CD38 (plasma-cell marker)–directed daratumumab (Darzalex), as well as inhibitors of BCR signaling pathway components, such as the BTK inhibitor ibrutinib (Imbruvica) and the PI3K inhibitor idelalisib (Zydelig). The latter agents may provide an additional advantage not found in monoclonal antibodies: the ability to cross the BBB.

 The therapeutic landscape of MS has progressed significantly in recent years, and a greater understanding of the mechanistic underpinnings of B cells in MS pathogenesis is expected to yield additional potential targets for management of this challenging disease.

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Although there are no cures for MS at present, the treatment landscape has changed significantly, with over a dozen approved disease-modifying therapies (DMTs) representing multiple classes of agents with different mechanisms of action.

Krithika Subramanian, PhD

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Targeting the NF-κB Pathway in Duchenne Muscular Dystrophy

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Targeting the NF-&#954;B Pathway in Duchenne Muscular Dystrophy

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