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Genetic Linkage

Can CRISPR Conquer Huntington’s?

In HD extended huntingtin protein builds up in medium spiny neurons in the striatum.
I set a high bar for writing about mouse studies. I don’t include them in my textbooks or news articles, and only rarely blog about them. But when experiments in mice shine a glimmer of hope on a horrific illness with a long history of failed treatments, I pay attention. That happened last week for a report on editing out of mice the human version of the mutant Htt gene that causes Huntington disease (HD), published in the Journal of Clinical Investigation.

HD affects about 30,000 people in the US, and more than 200,000 family members are “at-risk,” possibly having inherited the mutation. The disease arises from a repeat of the DNA triplet CAG beyond the 35 or fewer copies that most of us have, at the start of the gene that encodes the protein huntingtin. CAG specifies the amino acid glutamine, and the extra stretch of it clogs certain neurons in the striatum in the brain, affecting movement, cognition, and behavior.

Symptoms typically begin in adulthood, but 10 percent of cases are juvenile. Karli Mukka developed symptoms at age 5, and died within weeks of her father Karl, she just 14 years old, he 43, in 2010. Karli’s huntingtin gene did a loop-de-loop upon itself, giving her 99 CAG repeats to her father’s 47. I told her story here.

ONLY ONE TREATMENT, FOR ONE SYMPTOM
An expanding triplet repeat presents a thorny drug-targeting challenge. Countering it isn’t as simple as supplying a missing enzyme, depleting a biochemical buildup, unfolding and refolding an errant protein, or even introducing a functional gene with gene therapy.

Unlike other genes in which mutations remove a normal function, abnormal huntingtin protein confers a “toxic gain of function.” Having two mutations is no worse than having just one, which means that lacking the normal (wild type) allele has no effect, at least after birth – that’s important.

The only FDA-approved treatment for HD is tetrabenazine, a repurposed schizophrenia drug used in other nations for decades before its FDA approval to treat the movement (chorea) part of HD in 2008. An altered version (deutetrabenazine) became available in April 2017: “heavy” hydrogen atoms (deuterium) keep the drug circulating longer.

Researchers have for years thrown every tool imaginable at the formidable expanded Htt gene:
• Deploying small molecules to target RNA loops or metabolites.
• Manipulating growth factor levels.
• Implanting stem cells to replace neurons.
• Dampening expression of the mutant gene using RNAi or antisense nucleic acids.
New biomarkers, prediction studies, scans, and induced pluripotent stem cells track the onset of the disease, with the hope of eventual early intervention.

I once wrote reports for an organization that funds HD research. I learned a great deal about mouse models, treatment modalities, and ways of detecting the disease early and tracking its progression. Progress was slow. That gig ended in 2010 – before the debut of CRISPR/Cas9 gene editing. And now it’s beginning to sound like a whole different ballgame.

EDITING OUT MUTANT HTT
The peculiarities of HD make gene editing, which can add, replace, or remove a gene, the most logical therapeutic strategy. HD requires DNA to be jettisoned, not augmented.

While RNAi and antisense oligonucleotides can dampen expression of the extended gene, the effect isn’t permanent in the way that snipping out the repeat or even the entire gene would be. And a one-time or few-times editing out is preferable to a regular need for treatment, especially given the unsettled healthcare situation in the US.

Xiao-Jiang Li, MD, PhD, distinguished professor of human genetics at the Emory University School of Medicine, with colleagues there and at the Chinese Academy of Sciences, used CRISPR/Cas9 gene editing on mice that have the first exon (protein-encoding part) from the human Htt gene, including 140 CAG repeats – it’s called an HD140Q knockin (“Q” stands for polyglutamine). Specks of the toxic protein appear when the mice are 4 to 6 months old, aggregating by 9-10 months. The timetable is like that in people, because mice live about 2 years.

Technical details (jargon alert): CRISPR/Cas9 was delivered to the striata of two dozen 9-month-old mice in two batches of adeno-associated viruses: guide RNAs targeting exon 1 and the Cas9 enzyme that cleaves both DNA strands, removing the gene and triggering repair of the breaks. The guide RNA part included instructions for red fluorescent protein, and both batches were under different promoter (control) sequences, so that the researchers could compare delivery of the dual intervention to either alone. Both are required: find the target and cut it out.

For 3 months the mice were tested on the rotarod, the balance beam, and a device to assess grip strength. Although the sample was small, the findings were clear and compelling.
In the brain parts given both components of the treatment, levels of toxic protein fell, in lockstep with improving performance on the rotating rods, balance beams, and grippers. Weight loss slowed and astrocytes (another type of brain cell) became less reactive. The red marker glowed from the right places – the medium spiny neurons of the striatum – while protein markers for other neurological diseases as well as for cell death (apoptosis) and degrading used parts (autophagy) weren’t altered. The experiment was elegantly controlled.

Because the mice had two Htt mutations – unlike patients who typically have one – and removing both copies didn’t do harm, yanking both copies of the gene in people might work. That might mean a one-size-fits-all approach is feasible, rather than tweaking treatment to a specific repeat number. Normal Htt protein might be required in stem cells, though.

A major concern about CRISPR/Cas9 gene editing is off-target effects. This is relevant to tackling HD because expanded CAG repeats lie behind 7 other neurodegenerative diseases. What would ripping away the CAGs in these genes do? So far, the gene editing was restricted to Htt — the researchers sequenced the genomes of the mice to check.

Perhaps most importantly, the treated mice were middle-aged! So older neurons can still throw out their garbage if appropriately stimulated. That may mean, someday, that HD patients flinging themselves helplessly on the floor or bashing their heads might find relief from a possibly one-time treatment that trims the repeats.

THE BIG PICTURE
Of course it’s a long journey from rodents to patients. But when the only options for families with HD are tetrabenazine to dampen movements and embryo selection to avoid transmitting the mutation, a potential treatment for those in the throes of the illness is good news indeed.

The enormous potential of gene editing to treat intractable diseases is why the anti-CRISPR backlash troubles me. I fear that negative depictions and predictions about the technology could obstruct the quest to develop one-time treatments for genetic diseases with concerns that a lunatic will someday gene-edit an enhanced master race.

I wonder how many of the more than 6.5 million people who have clicked “like”
to "Genetic Engineering Will Change Everything Forever – CRISPR" have read the media reports on the Journal of Clinical Investigation article? People love to exaggerate and panic, to imagine the worst, especially when the details of a new technology are unfamiliar or require a base of scientific knowledge.

I hope that the current political climate doesn't stifle development of gene editing techniques, for they could provide "forever fixes." Meanwhile, the mouse experiments provide something priceless to the HD community: hope. Sums up Jane Mervar, who lost her daughter Karli to juvenile HD and is now caring for two other daughters, “CRISPR is my dream.”

This post first appeared on my blog DNA Science for Public Library of Science.

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