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Frameworks for transformational breakthroughs in RNA-based medicines

Nature Reviews Drug Discovery (2024)Cite this article

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Abstract

RNA has sparked a revolution in modern medicine, with the potential to transform the way we treat diseases. Recent regulatory approvals, hundreds of new clinical trials, the emergence of CRISPR gene editing, and the effectiveness of mRNA vaccines in dramatic response to the COVID-19 pandemic have converged to create tremendous momentum and expectation. However, challenges with this relatively new class of drugs persist and require specialized knowledge and expertise to overcome. This Review explores shared strategies for developing RNA drug platforms, including layering technologies, addressing common biases and identifying gaps in understanding. It discusses the potential of RNA-based therapeutics to transform medicine, as well as the challenges associated with improving applicability, efficacy and safety profiles. Insights gained from RNA modalities such as antisense oligonucleotides (ASOs) and small interfering RNAs are used to identify important next steps for mRNA and gene editing technologies.

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Fig. 1: The composition of RNA drugs is based on desired pharmacology, overcoming biological barriers, and intended site of action.
Fig. 2: Platform development is a central framework for creating and improving RNA drugs.
Fig. 3: Evolution of siRNA and clinical development.
Fig. 4: Applications of mature and emerging RNA platforms across the disease landscape.
Fig. 5: Strategy for overcoming roadblocks in RNA drug discovery and development.

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Acknowledgements

The author expresses gratitude to D. Morrissey, M. Tadin-Strapps, M. Stewart, A. Barry and Y. Fu from Pfizer RNA Accelerator, as well as many other past and present colleagues, for their insights and helpful discussions that contributed to the creation of this manuscript. Biorender.com was used under paid subscription for initial figure creation; figures were redrawn by the journal for publication.

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  1. RNA Accelerator, Pfizer Inc, Cambridge, MA, USA

    John R. Androsavich

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J.R.A. was an employee and shareholder of Pfizer, Inc. at the time of this writing. He is an inventor on several patents related to RNA technologies and therapeutics.

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Glossary

Adeno-associated virus

(AAV). A small, non-pathogenic virus commonly used as a gene delivery vector in gene therapy, with a limited cargo capacity of approximately 4.7 to 5.0 kilobases.

Batten disease

A rare genetic disorder, also known as neuronal ceroid lipofuscinoses, caused by mutations in 1 of 13 genes that causes progressive neurological deterioration in children, leading to cognitive decline, seizures and loss of motor skills.

Cap analysis of gene expression

(CAGE). A method for identifying transcriptional start sites and the identity of 5′ ends of mRNA at single-base pair resolution using next-generation sequencing.

Closed-ended DNA

A non-viral capsid-free DNA vector with covalently closed ends used for gene transfer.

Duplex RNA

A molecule composed of two complementary RNA strands that have formed a double-stranded structure through base pairing.

Endosomes

Membrane-bound cellular organelles involved in the sorting, processing and trafficking of molecules within the cell, particularly during endocytosis.

Gapmer

An oligo designed for RNAase-H-based knockdown with a central DNA region flanked by modified nucleotides. Shorthand nomenclature is often used to designate the length (in nucleotides) of each segment and the modification used, for example, 5-10-5 methoxyethyl (MOE) gapmer.

Gymnosis

Refers to the still incompletely understood phenomenon by which molecules are delivered into cells without the use of any delivery vehicles or carriers.

Hereditary transthyretin amyloidosis

(hATTR). A heterogenous, multisystem condition caused by mutations in the transthyretin (TTR) gene leading to abnormal deposits of amyloid protein in the heart, nerves and other organs. hATTR has several phenotypes including cardiomyopathy (hATTR-CM) with symptoms of heart failure and enlarged heart, and peripheral neuropathy (hATTR-PN) experienced as pain, loss of sensation, or tingling in the hands and feet and damage to the digestive tract and other organs.

Internal ribosomal entry sites

(IRES). A structured RNA element that allows for translation initiation in a 5′ cap-independent manner, which means that ribosomes can bind directly to the IRES element within an RNA and initiate translation at or near this site.

Ligand conjugates

Consist of a ligand attached to another molecule, for example, an oligonucleotide, often used for targeted drug delivery or imaging purposes.

Lipid nanoparticle

(LNP). Formulations used to deliver nucleic acid-based therapeutics into cells, providing a protective and stable environment for efficient delivery to target cells and enhancing intracellular release into the cytoplasm.

Macropinocytosis

An actin-driven process in which cells take in extracellular fluid and its contents by forming vesicles at the cell surface.

Multivalency

Refers to the ability of a molecule to have multiple functions by interacting with or expressing multiple targets simultaneously.

Pattern recognition receptors

(PRRs). A class of proteins that play a crucial part in the innate immune system by identifying specific molecular patterns associated with pathogens, triggering an immune response.

Peripheral blood mononuclear cells

(PBMCs). Prepared from (human) whole blood containing lymphocytes, monocytes and progenitor populations.

Plug-and-play

Colloquial term for the theoretical pinnacle of drug platform performance in which new products can be swiftly developed using pre-established parameters.

Rapid amplification of cDNA ends

(RACE). A molecular biology technique used to obtain the sequence at the ends of an RNA transcript using reverse-transcription PCR amplification.

Ribonuclease H

(RNAse-H). An enzyme that catalyses the cleavage of RNA in RNA–DNA hybrids leading to the degradation of the RNA component.

Scrambled controls

Oligos generated with random or altered nucleotide arrangements that are used as experimental controls in an attempt to assess the specificity and biological effects of the original test oligo.

Shear stress

Refers to the force exerted by flowing blood on nanoparticles and cells that can impact surface interactions and cellular uptake.

Solid-phase synthesis

An efficient, automated production method in which oligonucleotides are assembled on a solid support, typically through controlled addition of nucleotide building blocks in a stepwise fashion.

Survivorship bias

Refers to the error that occurs when only successful or surviving individuals or entities are considered in an analysis, leading to an inaccurate representation of the entire population or sample.

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Androsavich, J.R. Frameworks for transformational breakthroughs in RNA-based medicines. Nat Rev Drug Discov (2024). https://doi.org/10.1038/s41573-024-00943-2

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