Precision therapeutics. Ongoing research in precision therapies in neurological disorders, including 15q-related disorders, is occurring in three spaces: 1) gene therapy, 2) anti-sense oligonucleotides (ASOs), and 3) small molecules (repurposing existing drugs or generating new drugs), where the latter is primarily focused on addressing the symptoms of genetic disorders (i.e. seizures) rather than the cause (i.e gene dysfunction). Each of these forms of therapy has particular challenges, including, critically, the delivery method. The blood-brain barrier (doing its job well) restricts the access of large or hydrophilic medications to the central nervous system (CNS), therefore scientists building these drugs must not only consider efficacy and safety of the drug itself, but also efficacy and safety of the delivery method to the CNS. Below we explore ASOs and gene therapies and their application in 15q-related disorders in more depth. We will not discuss small molecule therapies here as the topic is too broad in scope for the purposes of this post, and we would like to focus primarily on genetically-based therapies.
One region, three disorders. The following blogpost serves as a partner to this week’s earlier post on the genomic idiosyncrasies of the 15q11-13 region. We hope that the discussion of the clinical aspects of disorders rooted in this region will further illustrate the vast complexity of the genome. Below we describe the three clinical syndromes associated with this region.
ATP1A2. We have previously written about ATP1A3, one of the neuronal ATPases, which, together with ATP1A2, actively works to maintain the electrochemical gradient across cell membranes. In our previous post, we likened ATP1A3 to Sisyphus, who was punished by the gods to spend eternity exerting his strength to push a boulder up a hill, only for the boulder to roll back down, over and over again. Similarly, the ATPases utilize energy (ATP) to transport Na+ out of the cell and K+ into the cell, even while other voltage-gated channels effortlessly open to allow Na+ and K+ to move in the opposite direction, forcing the boulder back down the hill. However, from another perspective we can see that far from being Sisyphus, the ATPases are the noblest of facilitators, proudly maintaining the membrane electrochemical gradient in order to enable all other cell processes to function. If you will allow me further anthropomorphization of submicroscopic proteins – far from being inconsiderate to the task of the ATPases, our voltage-gated Na+, K+, and Ca++ channels are reliant on these stoic transporters to get their jobs done. It is because of the electrochemical gradient that cells are able to propagate action potentials down an axon, signal axon terminals to release neurotransmitters, and continue to send electrochemical signals on to subsequent cells. Both ATP1A2 and ATP1A3 code for subunits of the Na+-K+ ATPase, where ATP1A2 codes for the α2 subunit and ATP1A3 for the α3 subunit. Both ATP1A3 and ATP1A2 are expressed in neurons during embryonal brain development, and while ATP1A3 remains neuronal postnatally, ATP1A2 is relegated to the glial cells postnatally and into adulthood. In addition to their role in active ion transport, Na+-K+ ATPases are thought to play a part in regulating signaling pathways and gene transcription. Given its localization to astrocytes, which act as a so-called “glutamate sink” to prevent glutamate excitotoxicity within the synapse, ATP1A2 is thought to be critical for the process of glutamate clearance and prevention of excitotoxicity (Du et al 2020).
ATP1A3. The ATPases are the “Sisphyean” workhorses of cells, perpetually bound to utilize energy generated by mitochondria to pump ions across cell membranes. This is essential to the maintenance of the intra/extracellular electrochemical gradient. ATP1A3 codes for the α3 subunit of the Na+-K+ ATPase, which utilizes ATP to actively transport sodium out of the cell and potassium into the cell. In the brain, this gradient is critical for cell signaling and for maintaining electrochemical stability, enabling cell excitation and action potential propagation. Both ATP1A3 and one of its counterparts, ATP1A2, are expressed in neurons during embryonal brain development, and ATP1A3 is also thought to contribute to regulation of non-ionic neuronal transporters and receptors. However, whereas ATP1A2 is primarily expressed in glial cells postnatally and into adulthood, ATP1A3 continues to be expressed primarily in neurons, with particular enrichment in excitatory neurons. Here is a brief overview of the clinical spectrum of ATP1A3-related disorders.