O.13 Using out-of-frame exon skipping to induce IRES-driven expression of an N-truncated dystrophin isoform for 5’ DMD mutations

Frame-truncating mutations within the first five exons of the DMD gene typically do not result in Duchenne muscular dystrophy, but instead result in milder dystrophinopathy syndromes. This was first demonstrated in individuals carrying the c.9G > A (p.Trp3X) mutation, a North American founder allele associated with clinical severity ranging from a very mild Becker muscular dystrophy phenotype to a complete absence of symptoms. We have previously shown that the mild phenotype associated with this and similar 5’ exon mutations is due to alternative initiation of translation from methionines encoded in exon 6, a process mediated by the presence of a muscle-specific and glucocorticoid-inducible internal ribosomal entry site (IRES) found within exon 5. The resultant N-truncated dystrophin protein lacks the first calponin homology domain of the canonical actin binding domain 1. Nevertheless, it is highly functional, raising the possibility of the therapeutic use of this isoform. We hypothesized that disruption of the mRNA open reading frame via exon skipping – resulting in a downstream premature termination codon – would stimulate IRES utilization. The feasibility of this approach is supported by the recent identification of an asymptomatic patient harbouring an exon 2 deletion, and we designed U7snRNA vectors targeting exon 2 for use in both patient-derived cell lines and in a new DMD mouse model harbouring an exon 2 duplication. Both in vitro and in vivo we can stimulate IRES activity, and by combining exon-skipping and glucocorticoid treatment we are able to restore expression of a properly localized yet N-truncated dystrophin. These results not only provide evidence for the functionality of the dystrophin IRES – and, hence, for the presence of a novel N-truncated dystrophin isoform under yet to be clarified physiologic conditions – but also suggest that out-of-frame skipping is a promising therapeutic approach for DMD patients harbouring 5’ mutations.