news and views
Nusinersen, an antisense oligonucleotide drug for
spinal muscular atrophy
David R Corey
Nusinersen (Spinraza) is a recently approved drug for treating spinal muscular atrophy. Approval of nusinersen may
signal new opportunities for using antisense oligonucleotides as treatments for devastating neurological diseases.
Progressive neurological diseases slowly
rob patients of physical abilities and hope.
Treatments are urgently needed, but tradi-
tional small molecule drug discovery is often
difficult. An alternative approach is to use
synthetic antisense oligonucleotides (ASOs)
to modulate the expression of genes that influ-
ence disease. Recent data from phase 2 and
phase 3 clinical trials1,2 have demonstrated
that nusinersen (Spinraza), an ASO drug, is
effective for treating spinal muscular atrophy
(SMA). The open question is whether this suc-
cess can be translated to the control of other
disease genes in the CNS.
SMA refers to several different motor neu-
ron diseases3. SMA is most commonly asso-
ciated with mutations in the survival motor
neuron 1 (SMN1) gene. These mutations are
the most frequent genetic cause of death in
children, affecting one in ten thousand. The
disease varies in severity, with many chil-
dren beginning to meet developmental mile-
stones until selective degeneration of spinal
neurons halts progress and leads to an
inevitable decline.
Fortunately, humans possess a second SMN
gene, SMN2. SMN2 and SMN1 are related by
an inverted gene duplication. SMN2 contains a
C-to-T mutation in exon 7 that redirects alter-
native splicing to exclude exon 7 and leads to an
unstable mature protein that cannot substitute
for mutant SMN1 (ref. 4). One potential thera-
peutic strategy is to identify agents to prevent
this splicing event and thus increase the pro-
duction of stable SMN protein to compensate
for the loss of function of the SMN1 gene.
David R. Corey is in the Departments of Pharmacology
and Biochemistry, UT Southwestern, Dallas,
Texas, USA.
e-mail: david.corey@utsouthwestern.edu
nature neuroscience volume 20 | number 4 | april 2017 497
How can splicing be altered? One poten-
tial approach is to use ASOs to target critical
regions near intron exon junctions5. ASOs can
bind to pre-mRNA by Watson-Crick base-
pairing, block recognition of splicing factors
and control formation of mature mRNA. In cell
culture, this approach is robust and provides a
general approach for redirecting splicing5.
For SMA, work began with cell culture
experiments designed to test the linked
hypotheses that, first, ASOs could trigger
inclusion of exon 7 and, second, the SMN2
gene could be induced to make stable SMN
protein (Fig. 1). These experiments identified
ASOs that were able to promote increased pro-
duction of full-length SMN2 in cell-free splic-
ing assays and in cultured cells6,7. Subsequent
in vivo experiments extended these findings to
transgenic mice, showing that an ASO could
increase SMN protein levels, rescue the mutant
phenotype and reduce symptoms of disease8.
The successful animal studies encouraged
phase 1 clinical trials of nusinersen spon-
sored by Biogen and Ionis Pharmaceuticals9.
Drug was administered to 28 patients using
intrathecal administration by lumbar punc-
ture. Subjects ranging in age from 2 to 14
years were given a single dose. This prelimi-
nary study suggested that the drug could be
administered without serious adverse events
related to the drug itself and provided some
hints of efficacy.
The research next moved on to a phase 2,
open-label, dose-escalation study1. This study
was performed in 20 infants aged between
3 weeks and 7 months. The drug was deliv-
ered by intrathecal dosing through lumbar
puncture on days 1, 15, 85 and 253, with
follow-up treatments every 4 months. Either
6 or 12 mg of nusinersen were administered
per dose, with most subjects receiving 12 mg
every dose.
The trial yielded several promising results.
While all subjects had adverse events, most
were mild. The serious events were consid-
ered to be most likely related to the disease, not
drug treatment. While four infants died dur-
ing the study, nusinersen was not implicated
as a cause. Of key importance, three families
generously agreed to allow molecular charac-
terization of autopsied tissue. Examination of
this tissue revealed a two- to sixfold increase in
full-length SMN, providing molecular support
for the conclusion that splice correction was
being achieved in humans. While no control
group was included, modest improvements in
motor milestones were observed in 16 of 19
participants relative to the expected progres-
sion of the disease.
The promising results in the phase 2 study
encouraged larger phase 3 studies whose
results have now been disclosed2. These stud-
ies enrolled 173 patients. Some patients were
part of an open-label study, but 121 patients
participated in a multicenter, randomized,
double-blind, sham-controlled investigation,
and this provided the pivotal data.
As part of the approved study plan, the
FDA had instructed the sponsors to conduct
an interim analysis. This interim analysis
was conducted on 82 patients who had been
treated for at least 183 days. Forty percent of
the nusinersen-treated patients achieved a
motor milestone response versus none of the
sham-treated patients. Only 4% showed sub-
stantial worsening compared to baseline versus
40% in the control group. While improvement
was modest for many patients, five patients
achieved substantial milestones, independent
sitting (in four cases) and standing (in one),
that are almost never observed in the natural
history of the disease. Because patients had
been treated with nusinersen for varying
lengths of time, it is possible that even more
news and views

a Healthy individual
C to T
1 2a 2b 3 4 5 6 7 8
SMN2 gene
1 2a 2b 3 4 5 6 8
mRNA, exon 7 deleted
Protein unstable
b SMA patient
C to T
1 2a 2b 3 4 5 6 7
1 2a 2b 3 4 5 6 8
mRNA, exon 7 deleted
Protein unstable
c SMA patient, treated with nusinersen
C to T
1 2a 2b 3 4 5 6 7
ASO
1 2a 2b 3 4 5 6 7 8
mRNA, exon 7 included
Protein active
Figure 1 Alteration of SMN2 splicing by an ASO. (a) In a normal individual, a C-to-T mutation in the
SMN2 gene leads to exclusion of exon 7 from the spliced mRNA and expression of an inactive protein.
However, the SMN1 gene is fully functional and produces a full length protein that is active. (b) In an
SMA patient, the SMN1 gene is affected by a mutation or deletion. These changes reduce or abolish
protein expression, leading to SMA with varying severity. (c) The ASO nusinersen binds to SMN pre-
mRNA to direct alternative splicing and increase inclusion of exon 7 in SMN2. This increases the
amount of SMN protein.
striking efficacy will be noted in follow-up
studies. Most serious adverse events were due
to the disease itself, not nusinersen.
The strong results from the interim analy-
sis were sufficiently persuasive to lead to
accelerated FDA approval10. Nusinersen will
now be marketed by Biogen. The improve-
ment in patient health may reduce the costs
of supportive care and compensate for the
projected high price of the drug. The clinical
study is continuing, so we can expect to learn
whether the striking improvements observed
in many children continue over the longer
the mode of drug administration. Whether
patients continue to see a favorable benefit-
1 2a 2b 3 4 5 6 7 8 to-risk ratio will be the most critical bench-
SMN1 gene mark of future success for those following the
future prospects of the drug.
The use of ASOs for therapeutic develop-
1 2a 2b 3 4 5 6 7 8 ment is often met with skepticism11. The con-
mRNA, exon 7 included cept of using ASOs has been around since the
1970s, and success has seemed “right around
the corner” since the 1990s. The FDA has
approved two ASO drugs, but neither has been
commercially successful or widely used. For
Protein active the first ASO drug approved by the FDA, fomi-
virsen to treat retinitis caused by cytomega-
lovirus, the patient population dwindled as a
8 1 2a 2b 3 4 5 6 7 8 result of improved treatment of AIDS patients
with antiretroviral drugs. For the second drug,
mipomersen to treat familial hypercholester-
olemia, side effects and competition from
Mutations disrupt expression a small molecule drug that was approved
or lead to unstable or simultaneously have kept the drug from find-
inactive protein
ing a significant market. In addition to the lack
of commercial success for the two approved
drugs, many clinical trials have failed over the
years. It is fair to ask why the obvious concept
of using a synthetic oligomer to recognize
mRNA has not had a bigger impact.
The short answer is that oligonucleotides
are large, negatively charged molecules. ASOs
8 1 2a 2b 3 4 5 6 7 8 are different from most drugs, which are small
(less than 500 Da) and hydrophobic. Unlike
antibodies (which are also macromolecules),
Mutations disrupt expression
ASOs must cross cell membranes and enter
cells to have an effect. Before ASOs could
or lead to unstable or
inactive protein begin to reach their potential, it was necessary
to develop new methods for their synthesis,
identify optimal chemical modifications to
their nucleotide building blocks, and under-
stand their pharmacology and pharmacoki-
netics. In other words, an entire field of drug
development needed to be invented. That
development process is not yet fully mature,
but approval of nusinersen represents a cul-
mination of years of steady progress and offers
encouraging evidence that ASOs are almost
ready to live up to their promise as broad and
effective therapeutic agents.
The current clinical data suggest that nusin-
term and whether more lengthy periods of ersen will have a major favorable impact on
dosing will increase the number of children young patients and their families, who until
who show a substantial benefit from the drug. now had little hope of treatment. The signifi-
The clinical studies did reveal adverse events, cance of nusinersen, however, goes beyond
but the type and number of these events was the impact it will have on patients with SMA.
not surprising given that SMA is a serious Nusinersen has laid the foundation for a new
disease and that ASO administration requires class of drugs to treat diseases of the CNS
lumbar puncture. Future experience will and has the potential to broadly influence
reveal whether adverse events become worse drug development.
over time or more prevalent. In particular, ASO’s bind their targets by Watson-Crick
it will be important to establish conclusively base-pairing, an infinitely versatile approach
to what extent adverse events are related to for recognizing and modulating any RNA.
nusinersen relative to those expected from ASOs therefore have the potential to change

498 volume 20 | number 4 | april 2017 nature neuroscience


the expression of most disease genes (the
exception being genes that are epigenetically
silenced). ASOs can, in theory, affect the
course of many diseases where too much or
too little expression of an RNA or a protein is
known to cause a disease.
The striking finding from the nusinersen
trials is that ASOs can function in the human
CNS well enough to alleviate disease. For
those familiar with standard models for small
molecule drug development and the ‘rule of
five’—plausible drug candidates should have
no more than five hydrogen bond donors, no
more than ten hydrogen bond acceptors, a
molecular weight of less than 500 kDa and a
log of the octanol/water partition coefficient
no greater than five—the notion that a large
polyanion could be administered to the CNS,
enter cells, effectively modulate gene expres-
sion and do so without crippling toxicity might
have seemed absurd. Nusinersen demonstrates
that this potential is a reality.
What are key issues moving forward?
Nusinersen has shown remarkable efficacy
in infants and small children. It remains to be
seen whether long-term toxicity will be a prob-
lem. It will also be interesting to learn whether
the efficacy observed in children can also
be achieved in the adult CNS. Nusinersen
succeeded because exceptionally insightful
basic science identified a susceptible molecu-
lar target and led to a strategy for manipulating
expression of full-length SMN2. Further suc-
cess in broadening the use of ASOs will require
identifying other gene targets. For example,
clinical trials are now underway using ASOs
that reduce expression of huntingtin protein,
Cocaine, cadherins and synaptic plasticity
Kristina Valentinova & Manuel Mameli
Addictive substances hijack the reward system partly via synaptic plasticity onto dopamine neurons. Cadherins may
contribute to cocaine-evoked adaptations, supporting the notion that drug addiction is a synaptic disease.
Pre- and postsynaptic compartments are so
close in space as to almost touch. This inti-
macy partly relies on the ability of adhesion
molecules such as cadherins to cling together
and stabilize the connection between axons
terminals and postsynaptic sites. Cadherins
Kristina Valentinova and Manuel Mameli are in
the Department of Fundamental Neuroscience,
University of Lausanne, Lausanne, Switzerland;
and at Inserm UMR-S 839, Institut du Fer a Moulin,
Paris, France.
e-mail: manuel.mameli@unil.ch
nature neuroscience volume 20 | number 4 | april 2017 499
the cause of Huntington’s disease, and data
from these trials should provide a useful first
view of the potential of ASOs to treat disease
in the adult CNS. Finally, by establishing a new
standard of care, the approval of nusinersen
may complicate future clinical trials of other
agents designed to treat SMA.
What makes a good target for an ASO?
Currently, administration of ASOs to the CNS
requires lumbar puncture (likely necessary
for the life of the patient, or until a better
delivery strategy is devised), and there-
fore a disease should be sufficiently severe
to justify that mode of administration. It
may be difficult for a large molecule like
an ASO to compete with a traditional small
molecule drug, so ideal targets should be
‘undruggable’ by small molecules. Finally,
there should be a compelling rationale why
reducing expression of a protein, activating
its expression or altering its splicing should
produce a therapeutic effect. One bonus of
using ASOs is that many ASO designs are
chemically similar. As a result, their synthe-
sis and pharmacology will also be similar.
While the experience with nusinersen will
not be a perfect guide, it will offer powerful
lessons for the development of any chemi-
cally similar ASO drug intended for use in
the CNS and lower the investment necessary
for preliminary feasibility studies. To provide
one very recent example, an ASO was shown
to reduce human tau mRNA and protein and
yield favorable effects in a transgenic mouse
model of Alzheimer's disease12.
Drug development for neurological
diseases is often difficult. The success of
shape synaptic function, but their contribution
to synaptopathologies such as drug addiction
remains understudied.
Plasticity at excitatory synapses onto mid-
brain dopamine neurons is a core cellular pro-
cess that follows exposure to addictive drugs,
and it is crucial for drug-driven behavioral
modifications. The membrane redistribution
of AMPA and NMDA receptors represents
an important mechanism in drug-evoked
synaptic adaptations (Fig. 1). Work over the
last 15 years has elucidated some of the cel-
lular requirements for drug-evoked synaptic
plasticity. Cocaine, as well as other addictive
news and views
nusinersen demonstrates that ASOs are a
feasible option. Researchers should watch
how nusinersen performs as a prescribed
drug and critically evaluate how it is toler-
ated in patients. In the short term, investi-
gators interested in potential target genes
can consider whether modulating the gene
expression of a therapeutic target by ASOs
can provide a new route to treating patients
with neurological disease.
Published online 13 February 2017;
doi:10.1038/nn.4508
COMPETING FINANCIAL INTERESTS
The author declares competing financial interests:
details are available in the online version of the paper.
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substances, promotes a surge in dopamine
in the mesolimbic system, suggesting that
dopamine signaling is a crucial feature of
drug consumption1. In addition, pharmaco-
logical and genetic approaches suggest that
NMDA receptor activation is a requirement
for cocaine-evoked synaptic modifications2–4.
Taken together, these data indicate that dop-
amine release and NMDA receptors are per-
missive for cocaine-evoked synaptic plasticity.
A remaining question is how the resulting syn-
aptic alterations are maintained.
An intriguing article in this issue of Nature
Neuroscience implicates cadherin adhesion