Mifepristone alone and in combination with scAAV9-SMN1 gene therapy improves disease phenotypes in Smn2B/-spinal muscular atrophy mice

Mifepristone alone and in combination with scAAV9-SMN1 gene therapy improves disease phenotypes in Smn2B/- spinal muscular atrophy mice | bioRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-M677548'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search New Results Mifepristone alone and in combination with scAAV9- SMN1 gene therapy improves disease phenotypes in Smn 2B/- spinal muscular atrophy mice Emma R Sutton , Eve McCallion , Joseph M Hoolachan , Özge Cetin , Paloma Pacheco-Torres , Sihame Bouhmidi , Lauren Churchill , Taylor Scaife , Helena Chaytow , Yu-Ting Huang , Stephanie Duguez , Bernard L Schneider , View ORCID Profile Thomas H. Gillingwater , Maria Dimitriadi , View ORCID Profile Melissa Bowerman doi: https://doi.org/10.1101/2025.02.17.638672 Emma R Sutton 1 School of Medicine, Keele University , Staffordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Eve McCallion 1 School of Medicine, Keele University , Staffordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Joseph M Hoolachan 1 School of Medicine, Keele University , Staffordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Özge Cetin 1 School of Medicine, Keele University , Staffordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Paloma Pacheco-Torres 2 School of Life and Medical Sciences, University of Hertfordshire , Hertfordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sihame Bouhmidi 2 School of Life and Medical Sciences, University of Hertfordshire , Hertfordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Lauren Churchill 3 School of Life Sciences, Keele University , Staffordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Taylor Scaife 3 School of Life Sciences, Keele University , Staffordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Helena Chaytow 4 Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh , Edinburgh, United Kingdom 5 Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh , Edinburgh, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Yu-Ting Huang 4 Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh , Edinburgh, United Kingdom 5 Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh , Edinburgh, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site Stephanie Duguez 6 Personalised Medicine Centre, School of Medicine, Ulster University , Derry, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bernard L Schneider 7 Bertarelli Platform for Gene Therapy, Swiss Federal Institute of Technology (EPFL) , Lausanne, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site Thomas H. Gillingwater 4 Centre for Discovery Brain Sciences, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh , Edinburgh, United Kingdom 5 Euan MacDonald Centre for Motor Neuron Disease Research, University of Edinburgh , Edinburgh, United Kingdom Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Thomas H. Gillingwater Maria Dimitriadi 2 School of Life and Medical Sciences, University of Hertfordshire , Hertfordshire, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site Melissa Bowerman 1 School of Medicine, Keele University , Staffordshire, UK 8 Wolfson Centre for Inherited Neuromuscular Disease, RJAH orthopaedic hospital , Oswestry, UK Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Melissa Bowerman For correspondence: m.bowerman{at}keele.ac.uk Abstract Full Text Info/History Metrics Supplementary material Preview PDF ABSTRACT Spinal muscular atrophy (SMA) is a neuromuscular disease caused by deletions or mutations in the survival motor neuron 1 ( SMN1 ) gene. SMA is characterised by alpha motor neuron loss in the spinal cord and subsequent muscle atrophy. There are currently three approved SMN-directed therapies for SMA patients. While these therapies have transformed what was once a life-limiting condition into one that can be managed and even improved, they are unfortunately not cures, highlighting the need for additional supporting second-generation therapies. These should not only target the neuromuscular system but also peripheral and metabolic perturbations that are present in both SMA models and patients. Krüppel-like factor 15 ( Klf15 ) is a transcription factor that maintains metabolic homeostasis and is involved in the glucocorticoid-glucocorticoid receptor (GR) signalling pathway, in several peripheral and metabolic tissues in SMA mice. Here, we used murine and human cellular models as well as SMA mice and Caenorhabditis Elegans (C. elegans) to assess the therapeutic potential of reducing Klf15 activity with mifepristone, a glucocorticoid antagonist, combined with SMN-targeted gene therapy. We report that mifepristone reduces Klf15 expression across several in vitro models, ameliorates neuromuscular pathology in SMA smn-1(ok355) C. elegans and improves survival of SMA Smn 2B/- mice. Furthermore, we show that combining mifepristone with an approved SMN-directed gene therapy (scAAV9- SMN1 ) results in improved tissue- and sex-specific responses to treatment. Our study demonstrates that a multi-tissue targeting SMN-independent drug, alone and in combination with an approved SMN-dependent therapy, has the potential to improve SMA disease pathology. INTRODUCTION Spinal muscular atrophy (SMA) is a neuromuscular disorder characterised by the loss of alpha motor neurons in the anterior horn of the spinal cord and subsequent muscle atrophy 1 . In addition to defects within the neuromuscular system; emerging studies have reported peripheral pathologies and metabolic perturbations in both human patients and mouse models 2 – 4 . SMA is caused by a significant depletion but not complete loss of the survival motor neuron (SMN) protein 5 , 6 . This is due to loss-of-function deletions and/or mutations in the survival motor neuron 1 ( SMN1 ) gene that are partially compensated by the presence of a second gene, the survival motor neuron 2 ( SMN2 ) gene, that is capable of producing ∼10% of fully functional SMN protein 1 , 7 . Ground-breaking and approved SMN1 and SMN2 -directed therapies for SMA (Spinraza, Zolgensma, Risdiplam) provide sustained improvement in motor function and increase lifespan of many patients, but these therapeutics are currently not a cure 8 . As a result, the field is now looking beyond SMN and the neuromuscular system for additional contributors to pathology that may be targeted to provide additional therapeutic benefits 9 . Peripheral pathologies in tissues such as the liver, heart, pancreas and skeletal muscle have been repeatedly reported in SMA mouse models and patients 4 , 10 – 12 . Interestingly, these tissues play an important role in maintaining systemic energy homeostasis and their intrinsic defects in SMA could have significant consequences on whole-body metabolic homeostasis. Indeed, perturbations in fatty acid, amino acid, and glucose metabolism have been observed in SMA mouse models and patients 3 , 10 , 13 , 14 . The fact that dietary supplementation improves lifespan of SMA mice 15 – 17 further supports the hypothesis that metabolic perturbations contribute to SMA pathology. More recently, we also demonstrated that providing an amino-based formula to children with SMA that had received an SMN2 -directed treatment, significantly reduced their persisting gastrointestinal issues 18 . Significant research also demonstrates additional peripheral comorbidities commonly reported in patients with SMA such as Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD; formally known as NAFLD) and type 1/ 2 diabetes 4 , 19 . These studies highlight the importance and relevance of tackling peripheral and metabolic phenotypes in SMA which combines approved SMN-directed treatments and second-generation interventions 20 , 21 . An interesting and potential SMN-independent target is the transcription factor Krüppel-like factor 15 ( Klf15 ) 3 . Transcriptional regulation is a main control mechanism of metabolic homeostasis and Klf15 , a member of the zinc finger transcription factors, has an overarching influence on metabolic processes including those that are perturbed in SMA models and patients (fatty acid, amino acid and glucose metabolism) 22 – 25 . The rhythmic expression of Klf15 over a 24 hr period is modulated by the circadian secretion of glucocorticoids (GCs) and activity of the glucocorticoid receptor (GR) 26 , 27 . Klf15 then modulates several metabolic pathways, including the utilization of branched-chain amino acids (BCAAs) valine, leucine and isoleucine 24 . We have previously shown an aberrant activity of the Klf15 -GC-GR-BCAA pathway in serum and metabolic tissues from severe Smn -/- ;SMN2 and intermediate Smn 2B/- SMA mice, whereby the levels of Klf15 and GCs were elevated and BCAAs depleted 3 . Importantly, modulation of the pathway by daily oral administration of BCAAs to Smn -/- ;SMN2 mice led to significant improvements in weight and survival 3 . The GC-GR- Klf15 -BCAA pathway therefore contributes to SMA pathogenesis and could be a potential therapeutic target to alleviate peripheral and metabolic pathologies in SMA. As modulating BCAA metabolism, a downstream component of the GC-GR- Klf15 signalling cascade, provided significant improvements in SMA mice, it is possible that targeting an upstream effector may lead to a more direct and specific modulation of the GC- Klf15 pathway and thus, greater benefits. In this study, we therefore examined the therapeutic potential of mifepristone, a commercially available GR antagonist, for the treatment of SMA, alone and in combination with an SMN-dependent gene therapy. Furthermore, mifepristone appeared in a list of therapeutic candidates in our recently published study combining multi-omics and bioinformatics approaches to identify repurposed drugs for the management of muscle pathologies and SMA 28 . Interestingly, mifepristone is currently being evaluated in clinical trials for several conditions including neurodegenerative and metabolic diseases such as cancer ( ClinicalTrials.gov ID NCT03225547 ), Cushing’s syndrome ( ClincalTrials.gov ID NCT00569582 ), Type 2 diabetes ( ClinicalTrials.gov ID NCT05772169 ) and Alzheimer’s disease ( ClinicalTrials.gov ID NCT00105105 ) 29 . In this study, we set out to determine the therapeutic potential of mifepristone in SMA. Our initial assessments found that mifepristone’s ability to reduce GC-induced Klf15 expression was dependent upon cell type and differentiation state across representative immortalized cells lines for different metabolic tissue types (muscle, brown adipose tissue (BAT and liver). Importantly, we found that mifepristone treatment across SMA animals models including severe Smn -/- ;SMN2 SMA mice, milder Smn 2B/- SMA mice and a severe C. elegans SMA model significantly improved disease phenotypes such as survival, muscle size and neuromuscular function. Finally, we assessed the potential synergistic activity of combining mifepristone with an SMN1 gene-based therapy and observed tissue- and sex-specific effects. Overall, our study supports the relevance of using GC-antagonist drugs as secondary therapies alongside SMN-dependent treatments for targeting both neuromuscular and metabolic pathologies in SMA. MATERIALS & METHODS CELL CULTURE Cell proliferation and differentiation C2C12 and 3T3-L1 cells were maintained in growth media consisting of Dulbecco’s Modified Eagle’s Media (DMEM) (Gibco, Cat. #2041859). FL83B cells were cultured in Kaighn’s modification of ham’s F-12 media (ATCC, Cat. #30-2004). All cells were supplemented with 10% FBS (Gibco, Cat. #2025814K) and 1% penicillin/streptomycin (Gibco, Cat. #15140122). Cells were cultured at 37 °C with 5% CO 2 . C2C12 cells were differentiated in DMEM containing 1% FBS for 7 days. 3T3-L1 cells were differentiated in DMEM containing 1.0 μM dexamethasone, 0.5 mM methylisobutylxanthine (IBMX) (Sigma, Cat. #STBG0799V) and 1.0 μg/ml insulin (Sigma, Cat. #SLBW1822) for 48 hours followed by DMEM containing 10% FBS and 1.0 μg/ml insulin for 10 days, replenished every 2-3 days. Cell drug treatment Dexamethasone (Merck, D4902-100 mg) and mifepristone (SLS, M8046-100 mg) were diluted in ethanol. Cells were treated with 1 μM, 5 μM and 10 μM dexamethasone for either 4, 8 or 24 hours. Optimal concentration of dexamethasone was combined with mifepristone at 1 μM, 5 μM and 10 μM for varying time points dependent on preliminary experiments (4, 8 or 24 hours). Lactate dehydrogenase (LDH)-Glo TM cytotoxicity assay Cell toxicity was determined using the Lactate dehydrogenase (LDH)-Glo TM assay kit (Promega) as per manufacturer’s instructions. Briefly, cells were treated with mifepristone (10 μM) and vehicle for either 24 or 72 hours. Controls included no cell control, vehicle only cell control and maximum LDH release control. Max LDH control cells were exposed to 10% Triton X-100 for 15 minutes. For all cell lines, a 1:300 dilution was used for undifferentiated cells and a 1:100 dilution was used for differentiated cells. The assay reaction was performed in the dark, at room temperature in 96-well opaque plates using 50 μl LDH detection reagent (1:200 reductase to detection enzyme mix) and 50 μl sample media (1:1). Luminescence was recorded after 60 minutes on a GloMax Explorer (Promega). Bromo-2-deoxyuridine (BrdU) assay Cell proliferation was determined by using 5-Bromo-2-deoxyuridine (BrdU) colorimetric system (Merck) as per manufacturer’s instructions. Briefly, cells were exposed to mifepristone (10 μM) or vehicle (ethanol) for 8 hours prior to BrdU assay. The cells were labelled with BrdU (1:2000) for 16 hours. Cells were exposed to an anti-BrdU fluorescence-labelled antibody. Using a spectrophotometric plate reader (GloMax Explorer (Promega)), BrdU absorbance was measured at dual wavelengths of 450-600 nm. ANIMALS AND PROCEDURES Study approval The Smn 2B/- mouse line was housed at the Keele University Biomedical Sciences Unit (BSU) and cared for according to Home Office Animal Scientific Procedures Act 1986 (ASPA) regulations (project license: P99AB3B95, personal license: IO376FCD7). All procedures were approved by the Keele University ethics committee (AWERB). Mouse models Smn 2B/- , Smn 2B/2B mice (obtained from Charles River) and Smn +/- mice (obtained from Jackson labs) were crossed to obtain Smn 2B/- and Smn 2B/+ mice. Smn +/- mice were crossed with Smn +/- mice to obtain C57BL/6J wild-type mice. Genotyping was performed on ear clips by PCR. Treatment groups were assigned at random, and animals of both sexes were used in all experiments. The FVB.cg- SMN1 tm1HungTg( SMN2 )2Hung/J mice were crossed with Smn +/- mice producing 50% SMA offspring ( Smn -/- ;SMN2tg/0 ) and 50% control carriers ( Smn -/+ ;SMN2tg/0 ) 30 . These ‘Taiwanese’ SMA mice were housed in the University of Edinburgh animal facilities, in a 14-hour/10 hour light/ dark cycle in individually ventilated cages. All procedures were conducted according to Home Office ASPA 1986 regulations (Project License: PP1567597; PILs: IAC4805FD and 7E4CB171). Drug administration in Smn 2B/- mice Mifepristone (RU486) (SLS, Cat. #M8046-100MG) was solubilised in 2ml 0.5% carboxymethylcellulose (CMC) and sonicated for 3 minutes at 37kHz. Mifepristone was administered by oral gavage at concentrations of 250 μg/g from post-natal day 8 (P8) or 500 μg/g starting from P5. The scAAV9- SMN1 vector was produced by transient transfection of HEK293 cells adapted to suspension culture (HEKExpress TM , ExcellGene SA) and the AAV9 particles were purified from the cell pellet and supernatant using affinity chromatography (POROS TM CaptureSelect TM AAV9 affinity resin; ThermoFisher Scientific) 31 . After concentration, the vector titer measured by dPCR was 1.4E13 VG/mL. The vector was administered by facial vein injections to post-natal P0 pups (1E11 VG/pup, 20μl volume/pup). Combinatorial treatment with scAAV9- SMN1 was administered by facial vein injections to P0 pups (1E11 VG/pup, 20μl volume/pup) combined with 500 μg/g mifepristone by daily oral gavage starting at P5 until P21. Phenotypic analysis of weight and righting reflex was conducted daily on all mice. Survival analyses were conducted on litters until defined humane endpoints were reached. For all experiments litters, containing males and females, were randomly assigned treatment. Triceps, tibialis anterior (TA), liver and BAT were harvested for molecular and histological analysis from Smn 2B/- mice and Smn 2B/+ healthy littermates. Drug administration in Taiwanese Smn -/- ;SMN2 mice Mifepristone was prepared as above. Phenotypic analyses were conducted daily on Smn -/- ;SMN2 mice. Litters undergoing daily 500 μg/g mifepristone treatment versus vehicle control were administered the drug on P3 by oral gavage up until animals reached their humane endpoint. Litters undergoing daily 500 μg/g mifepristone treatment were administered the drug on P3 by oral gavage up until animals reached their humane endpoint. Procedures were performed in a laminar flow hood in the animal facility by Helena Chaytow. C. elegans SMA model The LM99 smn-1 (ok355)/ hT2 strain, segregates into homozygotes smn-1 (ok355), lethal homozygotes hT2/hT2 , and heterozygotes smn-1(ok355)/hT2 . Homozygotes smn-1 (ok355) resemble a severe SMA model. Heterozygotes smn-1/hT2 were used as controls. These animals were maintained at 20◦C on Nematode Growth Medium (NGM) plates seeded with Escherichia coli OP50 bacteria 32 . Mifepristone (RU486) (SLS, Cat. #M8046-100MG) was dissolved in DMSO and added to the NGM agar solution at concentrations of 0, 1, 15 and 30 μM. Mifepristone was administered by to C. elegans by raising the animals on plates containing the vehicle or drug. Neuromuscular assays were performed on C. elegans that were 3 days old. The pharyngeal pumping assay was performed as previously described 33 . Notably, an Axio Cam ICc5 camera on a Discovery V8 SteREO microscope was used for both movement assays. The pharyngeal pumping assay was filmed using 150X objective at 175 frames/10 seconds. A grinder movement in any axis was defined as a pumping event. Pumps were manually counted using Zen Pro software v2.3. Locomotion assays were filmed using a 63X objective at 15 frames/second. Mobility forward time, for 5 minutes, was quantified using WormLab 1.1 software (MBF Bioscience). Laminin staining of skeletal muscle TA muscles were fixed in 4% paraformaldehyde (PFA) overnight. Tissues were mounted in cryomoulds and quickly frozen in liquid nitrogen. Tissues were sliced at 13 μM and stored at −20 °C. Briefly, sections were dipped in acetone for 5 minutes and left to air dry for 30 minutes and incubated for 2 hours in blocking buffer (0.3% triton X, 20% FBS, 20% BSA in PBS). Samples were incubated overnight at 4°C with a rat anti-laminin antibody (1:1000, L0663, Sigma Aldrich) in blocking buffer. Followed by goat-anti-rat IgG 488 secondary antibody (1:250, AlexaFluor488, ThermoFisher scientific) for one hour. Tissues were mounted in media containing DAPI (SLS, F6057-20ML). Images were taken with a fluorescence microscope. TA muscle fibre area was measured on at least100 fibres from 3-5 sections per animals using Fiji. Images were assigned a random ID number by another experimenter and true IDs were only revealed once quantification was finalised. Primary type III SMA human deltoid myoblasts Dr Stephanie Duguez (Ulster university) generously provided cell pellets and/or RNA samples from SMA Type III primary human myoblasts and age-matched healthy controls obtained from deltoid muscle biopsies. qPCR RNA was extracted from cells using the ISOLATE II RNA Mini Kit (Bioline), following manufacturer’s instructions. Tissues (triceps, BAT and liver) were homogenised in RLT buffer using 7 mm stainless steel balls (Qiagen) and the Tissue Lyser LT (Qiagen) set at 50 oscillations for 2 minutes. Extraction of RNA from skeletal muscle was conducted using the RNeasy Fibrous tissue kit (Qiagen). The ISOLATE II RNA mini kit (Qiagen) was used to extract RNA from liver, while BAT RNA was extracted using the RNeasy lipid tissue mini kit (Qiagen), as per manufacturer’s instructions. A Nanodrop 1000 spectrophotometer (ThermoScientific) was used to measure the RNA concentrations (ug/ul) of samples alongside a blank control sample using RNase-free water. cDNA was prepared using cDNA synthesis mix (4 μl) and 20x RTase (1 μl). cDNA was then produced by reverse transcription using a 3 Prime Thermocycler (Techne). qPCR was performed on StepOnePlus™ Real-time PCR system (ThermoFisher Scientific). PolJ was used as a housekeeping gene and relative gene expression was quantified using the Pfaffl method and primer efficiency was calculated using LinRegPCR V11.0 software. The list of mouse and human primers used can be found in Supplementary Table 1. Statistical analysis The most up to date GraphPad Prism software was used for data analysis and are presented as the mean ± standard error the mean. Appropriate statistical tests were used depending on data set, including unpaired t-test, one-way analysis of variance (ANOVA) and two-way ANOVA followed by post-hoc tests. Kaplan-Meier survival analysis was performed using the log-ran (Mantel-Cox) test. Statistical significance was found with P values less than 0.05 displayed as * P < 0.05, ** P < 0.01, ***P< 0.001, **** P < 0.0001. Outliers were identified using the GraphPad Grubb’s Test Individual data sets were all ran through the Grubbs’ test calculator, with the significance level set to alpha 0.05, to determine whether the most extreme value in the data set was a notable outlier compared to the other values. If this was the case, outliers were excluded from the analysis. RESULTS Mifepristone reduces Klf15 expression in cellular models of metabolic tissues We initially assessed mifepristone activity in immortalised cells that reflect metabolic tissues in which we had reported increased expression of Klf15 3 : the C2C12 cell line for skeletal muscle, the 3T3-L1 cell line for brown adipose tissue (BAT) and the FL83B cell line for liver tissue 34 – 36 . To model the increase in Klf15 expression seen in tissues of SMA mice 3 , we used a synthetic glucocorticoid, dexamethasone, to induce Klf15 expression. To determine the optimal dosing regimen for maximal expression of Klf15 , we treated cells with different concentrations of dexamethasone (1, 5 and 10 μM) across different time points (4, 8 and 24 hours) (Supplementary Figure 1A-C). We therefore determined that the optimal treatment regimens were: 10 μM for 24 hours for both differentiated C2C12 myotubes and FL83B hepatocytes as well as 10 μM for 4 hours for 3T3-L1 brown adipocytes (Supplementary Figure 1A-C). For each cell line, we assessed the expression of both GR isoforms, whereby GRα is the main mediator of GCs while GRβ inhibits GRα and induces GC resistance 37 , 38 . We then determined mifepristone’s ability to reduce Klf15 expression by adding it (1, 5 and 10 μM) before or after the previously determined optimal dexamethasone treatment. In addition, we evaluated the effect of mifepristone on cell death and proliferation, using the lactate dehydrogenase (LDH)-Glo™ assay and a Bromo-2-deoxyuridine (BrdU) colorimetric assay, respectively. In differentiated C2C12 myotubes (D7), we found a significant increase in the expression of both GRα and GRβ isoforms compared to proliferating myoblasts (D0) ( Figure 1A ), suggesting differential glucocorticoid sensitivities throughout muscle development. Next, we investigated the ability of mifepristone to reduce dexamethasone-induced Klf15 expression in C2C12 myotubes. We found that mifepristone treatment alone in differentiated C2C12 myotubes significantly reduced Klf15 levels at all three doses used when compared to untreated cells ( Figure 1B ). Interestingly, mifepristone, whether added before or after dexamethasone, did not reduce Klf15 expression in C2C12 myotubes when compared to dexamethasone-treated cells ( Figure 1C ). Finally, the highest dose of mifepristone (10 μM) did not significantly impact cell death of C2C12 myotubes ( Figure 1D ) or proliferation of C2C12 myoblasts ( Figure 1E ) as compared to untreated cells, suggesting that although mifepristone treatment was safe, it did not reduce Klf15 expression in GC-treated C2C12 myotubes. Download figure Open in new tab Figure 1. Mifepristone reduces Klf15 -induced expression in various cellular models of metabolically active tissues. A , GRα and GRβ isoform expression in C2C12 cells over a 7 day (D7) differentiation period. Data are mean ± SEM, N = 3 experimental repeats (3-4 wells/repeat), one-way ANOVA, * P <0.05, ** P <0.01. B , Klf15 expression following mifepristone treatment (1, 5 or 10 μM) for 8 hours in C2C12 myotubes (D7). Untreated cells served as control. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, **** P <0.0001. C , Klf15 expression following mifepristone (1, 5 or 10 μM) for 2 hours followed by dexamethasone (10 μM) for 8 hours or vice versa in C2C12 myotubes (D7). Untreated and vehicle-treated cells served as controls. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, **** P <0.0001. D , LDH assay (cell death assay) in C2C12 myotubes (D7) following 24 hours and 72 hours treatment with mifepristone (10 μM). No cells, untreated cells and max LDH served as controls. Data are mean ± SEM, N = 3-4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, **** P <0.0001. E , BrdU assay (proliferation assay) in C2C12 myoblasts (D0) following 72 hours treatment with mifepristone (10 μM). Blank, background and untreated cells served as controls. Data are mean ± SEM, N = 8 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, * P <0.05. F , GRα and GRβ isoform expression in 3T3-L1 pre-adipocytes and adipocytes. Data are mean ± SEM, N = 3-4 experimental repeats (3-4 wells/repeat), unpaired t-test , ns = not significant. G , Klf15 expression following mifepristone treatment (1, 5 or 10 μM) for 4 hours in 3T3-L1 adipocytes. Untreated cells served as control. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant. H , Klf15 expression following mifepristone (1, 5 or 10μM) for 2 hours followed by dexamethasone (10 μM) for 4 hours or vice versa in 3T3-L1 adipocytes. Untreated and vehicle-treated cells served as controls. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, ** P <0.01, *** P <0.001, **** P <0.0001. I , LDH assay (cell death assay) in 3T3-L1 adipocytes following 24 hours and 72 hours treatment with mifepristone (10 μM). No cells, untreated cells and max LDH served as controls. Data are mean ± SEM, N = 3-4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, **** P <0.0001. J , BrdU assay (proliferation assay) in 3T3-L1 pre-adipocytes following 72 hours treatment with mifepristone (10 μM). Blank, background and untreated cells served as controls. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, * P <0.05, ** P <0.01. K , GRα and GRβ isoform expression in FL83B cells. Data are mean ± SEM, N = 5-6 experimental repeats (3-4 wells/repeat), unpaired t-test , P = 0.0021. L , Klf15 expression following mifepristone treatment (1, 5 or 10 μM) for 24 hours in FL83B cells. Untreated cells served as control. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant. M , Klf15 expression following mifepristone (1, 5 or 10 μM) for 2 hours followed by dexamethasone (10 μM) for 24 hours or vice versa in FL83B cells. Untreated and vehicle-treated cells served as controls. Data are mean ± SEM, N = 4 experimental repeats (4 wells/repeat), one-way ANOVA, ns = not significant, ** P <0.01, *** P <0.001. N , LDH assay (cell death assay) in FL83B cells following 24 hours and 72 hours treatment with mifepristone (10 μM). No cells, untreated cells and max LDH served as controls. Data are mean ± SEM, N = 3-4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, **** P <0.0001. O , BrdU assay (proliferation assay) in FL83B cells following 72 hours treatment with mifepristone (10 μM). Blank, background and untreated cells served as controls. Data are mean ± SEM, N = 4 experimental repeats (3-4 wells/repeat), one-way ANOVA, ns = not significant, *** P <0.001, **** P <0.0001. In 3T3-L1 cells, there was no significant difference in GRα or GRβ expression between pre-adipocytes and differentiated adipocytes ( Figure 1F ). Mifepristone treatment alone had no effect on Klf15 levels in differentiated 3T3-L1 adipocytes when compared to untreated cells ( Figure 1G ). Interestingly, all three doses of mifepristone significantly reduced Klf15 expression when administered after dexamethasone in differentiated 3T3-L1 adipocytes when compared to dexamethasone treatment alone ( Figure 1H ), suggesting that mifepristone can reduce Klf15 levels in 3T3-L1 adipocytes only when Klf15 expression is in a hyperactivated state. We found that the highest dose of mifepristone (10 μM) did not significantly impact cell death of 3T3-L1 adipocytes when compared to untreated cells ( Figure 1I ). However, we did observe that the highest dose of mifepristone (10 μM) significantly reduced the proliferation of 3T3-L1 pre-adipocytes when compared to untreated cells ( Figure 1J ). As FL83B hepatocyte cells are already in a differentiated state, we directly compared expression of GR isoform and found that the levels of GRβ are significantly lower than GR α ( Figure 1K ). Mifepristone treatment alone in FL83B hepatocyte cells had no effect on Klf15 expression ( Figure 1L ). However, mifepristone significantly reduced Klf15 expression at the higher doses of 5 μM and 10 μM concentrations after dexamethasone treatment when compared to dexamethasone alone ( Figure 1M ). The highest dose of mifepristone (10 μM) applied prior to dexamethasone also significantly reduced Klf15 expression ( Figure 1M ).. Similar to 3T3-L1 cells, we found that the highest dose of mifepristone (10 μM) did not significantly impact cell death of FL83B hepatocyte cells ( Figure 1N ) but did significantly reduce proliferation of FL83B cells at the highest dose ( Figure 1O ). Combined, our in vitro experiments suggest that mifepristone’s effect on Klf15 expression, cell viability and proliferation differs between metabolic tissue cell types. Mifepristone treatment improves righting reflex and survival in Smn 2B/- SMA mice Having evaluated the activity of mifepristone in relevant cell types, we next wanted to assess its therapeutic potential in the Smn 2B/- intermediate SMA mouse model 39 . We first assessed the expression of Klf15 in triceps of symptomatic (post-natal day (P) 21) Smn 2B/- SMA mice and showed a significantly increased expression compared to age-matched wild type (WT) mice ( Figure 2A ), reproducing our previously published results 3 . Using human primary myoblasts isolated from deltoid biopsies, we also observed significantly elevated levels of Klf15 in myoblasts from SMA Type III patient samples compared to healthy controls ( Figure 2A ), again supporting our previous study reporting elevated Klf15 expression in human SMA muscle 3 . Both our past and current work therefore support the rationale behind reducing Klf15 activity in SMA. Download figure Open in new tab Figure 2. Mifepristone treatment improves disease phenotypes in Smn 2B/- mice. A , Klf15 expression in triceps of post-natal day (P) 21 WT and Smn 2B/- mice. Data are mean ± SEM, N = 5-8 animals per experimental group, unpaired t-test , * P <0.05. B , Klf15 expression in human control and SMA deltoid myoblasts, N = 4, unpaired t-test , * P <0.05. C , Survival curves of untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are Kaplan-Meier survival curves, N = 9-14 animals per experimental group, Log-rank (Mantel-Cox) test, * P <0.05, *** P <0.001. Survival data for selected optimal doses are repeated in supplemental figure 2A. D , Daily weights of untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 9-14 animals per experimental group, two-way ANOVA, */#P<0.05, **/##P<0.01, ****P<0.0001. E , Daily righting reflex of untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 9-14 animals per experimental group, one-way ANOVA, ns = not significant, *** P <0.001. F , Survival curves of untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are Kaplan-Meier survival curves, N = 11-14 animals per experimental group, Log-rank (Mantel-Cox) test, ns = not significant. G , Daily weights of untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are mean ± SEM, N = 11-14 animals per experimental group, two-way ANOVA, */#P<0.05, **/##P<0.01, ***/###P<0.001, ****P<0.0001. H, Daily righting reflex of untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 11-14 animals per experimental group, one-way ANOVA, ns = not significant, *** P <0.001. We initially conducted pilot studies to optimise the dosing regimen of mifepristone in Smn 2B/- mice, which determined that the best dosing regimens were 500 μg/g daily gavage starting at P5 and 250 μg/g daily gavage starting at P8 (Supplementary Figure 2A). We also found that the vehicle (0.5% carboxymethylcelluose (CMC)) did not affect weight, righting reflex or survival of Smn 2B/- SMA mice and Smn 2B /+ healthy littermates when compared to untreated animals (Supplementary Figure 2B-G). As demonstrated in the pilot studies, both optimal mifepristone dosing regimens (500 μg/g daily gavage starting at P5 and 250 μg/g daily gavage starting at P8) significantly increased the lifespan of Smn 2B/- SMA mice compared to untreated Smn 2B/- animals ( Figure 2C ), of which 500 μg/g improved life expectancy for longer. In contrast, the weights of Smn 2B/- SMA mice were significantly decreased across both mifepristone-treated compared to untreated Smn 2B/- mice ( Figure 2D ). Of note, this reduced weight occurred prior to treatment (P8) in the 250 μg/g experimental group suggesting that this may be due to smaller weights at birth in those treated litters. We also saw a significant decrease in the time it took 500 μg/g mifepristone-treated Smn 2B/- mice to right themselves during disease progression compared to untreated Smn 2B/- mice ( Figure 2E ). However, there was no significant difference in the righting reflex between 250 μg/g mifepristone-treated and untreated animals ( Figure 2E ), suggesting that timing and dose of mifepristone lead to differential effects in Smn 2B/- mice. The lifespan of Smn 2B/+ healthy control mice was not negatively affected by mifepristone ( Figure 2F ). However, similar to Smn 2B/- mice, both dosing regimens of mifepristone significantly decreased the weight of Smn 2B/+ animals ( Figure 2G ), which preceded the first dose (P8) in 250 μg/g mifepristone-treated litters, further supporting intrinsic smaller weights at birth in that experimental cohort. Interestingly, the time to right in Smn 2B/+ healthy littermates was significantly decreased following 250 μg/g mifepristone treatment, while there was no impact on righting reflex in 500 μg/g mifepristone-treated Smn 2B/+ mice when compared to untreated Smn 2B/+ animals ( Figure 2H ). As 250 μg/g mifepristone was administered at a later time point this could suggest that mifepristone’s effect in healthy control mice is treatment stage dependent. Mifepristone treatment is well tolerated but ineffective in the severe ‘Taiwanese’ SMA mouse model As there is a wide range of SMA mouse models with differing disease onsets and progression, we next wanted to investigate mifepristone treatment in a more severe mouse model. We treated severe Taiwanese Smn -/- ;SMN2 mice 40 with mifepristone daily starting at P3. An earlier start date (P3 vs P5 in Smn 2B/- mice) was selected due to the earlier and more severe disease onset in these mice. We found that there was no significant differences in survival, weight and righting reflex between vehicle-treated and mifepristone-treated Smn -/- ;SMN2 mice compared to untreated animals (Supplementary Figure 3A-C). In addition, no adverse effects were observed in mifepristone-treated Smn +/- ;SMN2 healthy littermates compared to untreated and vehicle-treated animals (Supplementary Figure 3D-F). Overall, our results highlight key differences between SMA mouse models in their response to mifepristone, specifically demonstrating the more aggressive nature of phenotypes in the Taiwanese model making it much harder to rescue. This is in line with previous studies demonstrating differential therapeutic effects of interventions in different SMA mouse models 3 , 41 . Mifepristone treatment ameliorates neuromuscular pathology in a severe C. elegans model of SMA Next, we investigated mifepristone in a validated severe SMA C. elegans invertebrate model 42 , 43 . The C. elegans nematode maintains functional conservation of neuronal processes and has high homology with the human genome 44 . C. elegans have a single smn-1 gene that, when diminished causes larval lethality, slowed growth and impaired neuromuscular function in pharyngeal pumping and mobility 33 . Here, SMA C.elegans smn-1 (ok355) and control C.elegans smn-1/hT2 nematodes were treated with increasing doses of mifepristone (1, 15 and 30 μM) and compared to vehicle. Interestingly, we observed that higher 15 and 30 μM concentrations of mifepristone significantly increased mobility forward time in C.elegans smn-1 (ok355) compared to vehicle-treated C.elegans smn-1 (ok355) ( Figure 3A ). Additionally, the highest dose of mifepristone (30 μM) significantly increased pharyngeal pumping in the C.elegans smn-1 (ok355) model compared to vehicle treated C.elegans smn-1 (ok355) ( Figure 3B ). Interestingly, mifepristone did not impact mobility forward time or pharyngeal pumping in the C.elegans smn-1/hT2 controls ( Figure 3C-D ), suggesting a disease specific effect of mifepristone on neuromuscular function in nematodes. Of note, other parameters such as distance travelled, speed and reversal times remained unchanged in both SMA C.elegans smn-1 (ok355) and control C.elegans smn-1/hT2 nematodes (Supplementary Figure 4). Download figure Open in new tab Figure 3. Mifepristone ameliorates the neuromuscular phenotype in a severe SMA C. elegans smn-1 (ok355) model. A , Mobility forward time filmed at 15 frames/second for 5 minutes in vehicle or mifepristone-treated (1, 15 or 30 μM) SMA C. elegans smn-1 (ok355). Data are mean ± SEM, N = 25 animals per experimental group, one-way ANOVA, ns = not significant, **P <0.01. B , Mobility forward time filmed at 15 frames/ second for 5 minutes in vehicle or mifepristone-treated (1, 15 or 30 μM) control C. elegans smn-1/hT2 . Data are mean ± SEM, N = 25 animals per experimental group, one-way ANOVA, ns = not significant. C , Pharyngeal pumping rates (pumps/minute) defined as grinder movements in any axis at 175 frames/10 seconds in vehicle or mifepristone-treated (1, 15 or 30 μM) SMA C. elegans smn-1 (ok355). Data are mean ± SEM, N = 25 animals per experimental group, one-way ANOVA, ns = not significant, * P <0.05. D , Pharyngeal pumping rates (pumps/minute) defined as grinder movements in any axis at 175 frames/10 seconds in vehicle or mifepristone-treated (1, 15 or 30 μM) control C. elegans smn-1/hT2 . One-way ANOVA was performed. Data are mean ± SEM, N = 25 animals per experimental group, one-way ANOVA, ns = not significant. Our data therefore support the beneficial effects of mifepristone in two different models of SMA. Mifepristone significantly downregulates the expression of Klf15 in BAT and increases myofiber area in skeletal muscle of Smn 2B/- mice Next, we wanted to investigate the effect of mifepristone at molecular and histological levels in metabolically active skeletal muscle, liver and BAT of Smn 2B/- SMA and Smn 2B/+ control mice. Firstly, we investigated Klf15 expression in tissues from P18 untreated, 250 μg/g (P8) and 500 μg/g (P5) mifepristone-treated mice. In Smn 2B/- mice, we observed that Klf15 expression in liver and triceps remained unchanged between untreated and mifepristone-treated Smn 2B/- animals ( Figure 4A-B ). However, both doses of mifepristone significantly reduced Klf15 expression in BAT from Smn 2B/- mice compared to untreated Smn 2B/- animals ( Figure 4C ). Similar results were found in liver, triceps and BAT of Smn 2B/+ mice ( Figure 4D -F), suggesting increased activity of the GR antagonist in adipose tissue, likely due to the increased metabolic rate of BAT. Download figure Open in new tab Figure 4. Mifepristone impacts disease phenotype in Smn 2B/- mice in a tissue and disease-state specific manner. A , Klf15 expression in liver from post-natal day (P) 18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 4-8 animals per experimental group, one-way ANOVA, ns = not significant. B , Klf15 expression in triceps from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 3-8 animals per experimental group, one-way ANOVA, ns = not significant. C , Klf15 expression in brown adipose tissue (BAT) from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 4-8 animals per experimental group, one-way ANOVA, ** P <0.01, *** P <0.001. D , Klf15 expression in liver from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are mean ± SEM, N = 6-8 animals per experimental group, one-way ANOVA, ns = not significant. E , Klf15 expression in triceps from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are mean ± SEM, N = 6-9 animals per experimental group, one-way ANOVA, ns = not significant. F , Klf15 expression in BAT from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are mean ± SEM, N = 6-9 animals per experimental group, one-way ANOVA, *** P <0.001, **** P <0.0001. G, Representative images of laminin-stained cross-sections of tibialis anterior (TA) muscles from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. H , Quantification of myofiber area of laminin-stained cross-sections of TA muscles from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are dot plot and mean, n = 3-4 animals per experimental group (>200 myofibers per experimental group), one-way ANOVA, * P <0.05, **** P <0.0001. I , Relative frequency distribution of myofiber size in TA muscles from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. J , Representative images of laminin-stained cross-sections of TA muscles from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. K , Quantification of myofiber area of laminin-stained cross-sections of TA muscles from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are dot plot and mean, n = 3-4 animals per experimental group (>200 myofibers per experimental group), one-way ANOVA, **** P <0.0001. L , Relative frequency distribution of myofiber size in TA muscles from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. M , Representative images of oil red O-stained liver sections from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. N , Quantification of oil red O staining intensity in liver sections P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/- mice. Data are mean ± SEM, N = 4-7 animals per experimental group, one-way ANOVA, ns = not significant. O , Representative images of oil red O-stained liver sections from P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. P , Quantification of oil red O staining intensity in liver sections P18 untreated and mifepristone-treated (250 μg/g starting at P8 or 500 μg/g starting at P5) Smn 2B/+ mice. Data are mean ± SEM, N = 3-7 animals per experimental group, one-way ANOVA, ns = not significant. As muscle atrophy is a canonical pathology of SMA, we next analysed myofiber area of the tibialis anterior (TA) muscle from P18 untreated, 250 μg/g and 500 μg/g mifepristone-treated Smn 2B/- and Smn 2B/+ mice. Treatment with both doses of mifepristone significantly increased myofiber size in mifepristone-treated Smn 2B/- mice when compared to untreated Smn 2B/- animals ( Figure 4G-I ). Interestingly, myofiber area in Smn 2B/+ healthy littermate controls was significantly decreased following 250 μg/g and 500 μg/g mifepristone treatment when compared to untreated Smn 2B/+ animals ( Figure 4J-L ), which may explain the reduction in body weight that is seen following mifepristone treatment in Smn 2B/+ mice. Finally, mifepristone has been successfully used to treat fatty liver disease in patients with CS 45 , therefore, we used an oil-red-O stain to assess whether mifepristone affected the previously reported lipid accumulation in the liver of Smn 2B/- mice 10 . Quantification of oil-red-O staining intensity showed no significant differences between untreated Smn 2B/- mice and mifepristone-treatment Smn 2B/- animals ( Figure 4M-N ). Similar results were observed in Smn 2B/+ mice where there is a noticeable absence of hepatic lipid accumulation ( Figure 4O -P). Overall, our molecular and histological analyses show tissue- and disease state-specific effects of mifepristone on skeletal muscle, liver and BAT. Combinatorial treatment of scAAV9- SMN1 with 500 μg/g mifepristone leads to selective synergistic effects in Smn 2B/- SMA mice To address the benefit of combinatorial therapy for SMA, we combined daily administration of mifepristone (from P5 to P21) with an Onasemnogene abeparvovec-like vector (scAAV9- SMN1 ) 46 given at P0 (day of birth) via facial intravenous injection (IV) with a scAAV9- GFP vector used as a control. Even though both doses of mifepristone improved survival of Smn 2B/- mice, 22% of mice survived an additional 10 days longer (to P35) following 500 μg/g compared to 250 μg/g mifepristone. Mifepristone (500 μg/g) produced a substantially greater improvement in motor function and myofiber hypertrophy than the alternative dose, without any adverse effects in healthy littermate controls. Furthermore, 500 μg/g mifepristone was administered at the earlier age of P5 (in contrast to 250 μg/g mifepristone (P8)), a translational time point likely to produce greater therapeutic outcome and correspond with administration to human patients with SMA. Taken together we moved forward with 500 μg/g mifepristone to assess combinatorial therapy. We assessed phenotypic outcomes, including weight, righting reflex and survival in Smn 2B/- and Smn 2B/+ mice. Daily weights were recorded from birth (P0) until P28 and weekly weights were recorded from P28 onwards. Of note, as scAAV9- GFP -injected Smn 2B/- SMA mice did not survive past weaning (P21), it was only possible to collect data from scAAV9- SMN1 and scAAV9- SMN1 + 500 μg/g mifepristone animals. In pre-weaned Smn 2B/- animals, we found no significant differences between scAAV9- SMN1 -injected animals compared to scAAV9- SMN1 + 500 μg/g mifepristone (Supplementary Figure 5A). However, scAAV9- GFP -injected Smn 2B/- SMA mice weighed significantly less than scAAV9- SMN1 -injected Smn 2B/- SMA mice and the scAAV9- SMN1 + 500 μg/g mifepristone Smn 2B/- SMA mice as disease progressed, due to the lack of therapeutic activity of this control vector (Supplementary Figure 5A). Interestingly, while the righting reflex of scAAV9- SMN1 -injected Smn 2B/- animals was similar to those treated with scAAV9- SMN1 + 500 μg/g mifepristone, there was a significant improvement of the righting reflex in scAAV9- SMN1 -injected Smn 2B/- SMA mice compared to the control vector, scAAV9- GFP -injected Smn 2B/- SMA mice (Supplementary Figure 5B). As weight differences become noticeable between the sexes post-weaning, we separated male and female mice from beyond this time-point. We observed no significant difference in weight between scAAV9- SMN1 -injected Smn 2B/- males and females compared to males and females treated with scAAV9- SMN1 + 500 μg/g mifepristone from P28 to humane endpoint (Supplementary Figure 5C-D). Similar analyses in Smn 2B/+ healthy control littermates revealed comparable weights and righting reflex between scAAV9- GFP -injected, scAAV9- SMN1 -injected and those treated with scAAV9- SMN1 + 500 μg/g mifepristone (Supplementary Figure 5E-H). We also undertook molecular and histological investigations in tissues from 6-month-old Smn 2B/- SMA mice and Smn 2B/+ control mice that either received a single injection of scAAV9- SMN1 or were treated with the combinatorial intervention of scAAV9- SMN1 + 500 μg/g mifepristone. We assessed Klf15 expression in liver, skeletal muscle (triceps) and BAT. In Smn 2B/- SMA mice Klf15 expression was significantly reduced in the liver ( Figure 5A ), while remaining unchanged in the triceps ( Figure 5B ) and BAT ( Figure 5C ) of animals treated with scAAV9- SMN1 + 500 μg/g mifepristone compared to scAAV9- SMN1 alone. In Smn 2B/+ control mice, Klf15 expression in liver ( Figure 5D ) and triceps ( Figure 5E ) remained unchanged in animals treated with scAAV9- SMN1 + 500 μg/g mifepristone compared to scAAV9- SMN1 alone, whereas there was a significant increase of Klf15 expression in BAT following scAAV9- SMN1 + 500 μg/g mifepristone when compared to scAAV9- SMN1 alone ( Figure 5F ). Our results therefore suggest disease state and tissue-specific effect the combinatorial intervention on Klf15 expression. Download figure Open in new tab Figure 5. Combinatorial treatment of scAAV9- SMN1 and mifepristone reduces Klf15 expression in the liver of Smn 2B/- mice and significantly increases myofiber area in females specifically. A , Klf15 expression in liver from 6-month-old Smn 2B/- mice following treatment with scAAV9- SMN1 at post-natal day (P) 0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 5 animals per experimental group, unpaired t-test , * P <0.05. B , Klf15 expression in triceps from 6-month-old Smn 2B/- mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 4 animals per experimental group, unpaired t-test , ns = not significant. C , Klf15 expression in brown adipose tissue (BAT) from 6-month-old Smn 2B/- mice following treatment with scAAV9- SMN1 at post-natal day (P) 0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 5 animals per experimental group, unpaired t-test , ns = not significant. D , Klf15 expression in liver from 6-month-old Smn 2B/+ mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 4-8 animals per experimental group, unpaired t-test , ns = not significant. E , Klf15 expression in triceps from 6-month-old Smn 2B/+ mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 and mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 4-8 animals per experimental group, unpaired t-test , ns = not significant. F , Klf15 expression in BAT from 6-month-old Smn 2B/+ mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 4-8 animals per experimental group, unpaired t-test , ** P <0.01. G , Representative images of laminin-stained cross-sections of tibialis anterior (TA) muscles from 6-month-old Smn 2B/- and Smn 2B/+ females following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). H , Quantification of myofiber area of laminin-stained cross-sections of TA muscles from 6-month-old Smn 2B/- and Smn 2B/+ females following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are dot plot and mean, n = 3-5 animals per experimental group (>200 myofibers per experimental group), one-way ANOVA, **** P <0.0001. I , Relative frequency distribution of myofiber size in TA muscles from 6-month-old Smn 2B/- and Smn 2B/+ females following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). J , Representative images of laminin-stained cross-sections of TA muscles from 6-month-old Smn 2B/- and Smn 2B/+ males following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). K , Quantification of myofiber area of laminin-stained cross-sections of TA muscles from 6-month-old Smn 2B/- and Smn 2B/+ males following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 and mifepristone (500 μg/g from P5-P21). Data are dot plot and mean, n = 3-5 animals per experimental group (>200 myofibers per experimental group), one-way ANOVA, ns = not significant. L , Relative frequency distribution of myofiber size in TA muscles from 6-month-old Smn 2B/- and Smn 2B/+ males following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). M , Representative images of oil red O-stained liver sections from 6-month-old Smn 2B/- mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). N , Quantification of oil red O staining intensity in liver sections from 6-month-old Smn 2B/- mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 5-6 animals per experimental group, unpaired t-test , ns = not significant. O , Representative images of oil red O-stained liver sections from 6-month-old Smn 2B/+ mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). P , Quantification of oil red O staining intensity in liver sections from 6-month-old Smn 2B/+ mice following treatment with scAAV9- SMN1 at post-natal P0 or a combination of scAAV9- SMN1 + mifepristone (500 μg/g from P5-P21). Data are mean ± SEM, N = 4-6 animals per experimental group, unpaired t-test , ns = not significant. Next, we assessed myofiber area, whereby the analyses were separated by sex. We observed that the combination treatment of scAAV9- SMN1 + 500 μg/g mifepristone significantly increased the myofiber area of both Smn 2B/- SMA mice and Smn 2B/+ control females compared to scAAV9- SMN1 alone ( Figure 5G-I ). In contrast, there were not significant differences in the myofiber area between treatment groups in males ( Figure 5J-L ), suggesting a sex-dependent effect of the combinatorial approach with mifepristone as an adjunct therapy. Finally, we investigated whether scAAV9- SMN1 +500 μg/g mifepristone impacted lipid accumulation in the liver, as assessed via oil red O staining intensity. Lipid accumulation remained unchanged in liver of both Smn 2B/- SMA mice and Smn 2B/+ control mice treated with either scAAV9- SMN1 or scAAV9- SMN1 +500 μg/g mifepristone ( Figure 5M-P ), supporting previous research demonstrating rescue of the fatty liver phenotype by scAAV9- SMN1 therapy 46 . DISCUSSION In this study, we addressed two key research questions. Firstly, whether targeting the GC-GR- Klf15 metabolic pathway via mifepristone could improve disease phenotypes in SMA animal models 3 . Secondly, whether combining an SMN1 -directed gene therapy with mifepristone could lead to additional benefits in peripheral and metabolic tissues compared to the gene therapy alone. Overall, we found that repurposing mifepristone for the treatment of SMA reduced Klf15 expression specifically in BAT, increased the lifespan and muscle size of treated Smn 2B/- mice, and improved motor function in a SMA C. elegans model. Furthermore, combining mifepristone with an scAAV9- SMN1 gene therapy resulted in tissue-, sex and disease state-specific improved pathological changes compared to the gene therapy alone. In the first part of this study, we evaluated mifepristone activity in cell models of peripheral tissues. Across all three models (C2C12 (muscle), 3T3-L1 (adipose) and FL83B (liver)), treatment with mifepristone reduced dexamethasone-induced Klf15 expression in a cell and differentiation state-dependent manner. Key players in mifepristone’s mode of action, are the isoforms of the GR (α and β), whereby GRα is the main mediator of GCs while GRβ inhibits GRα and induces GC resistance 37 , 38 . We found that expression of both GR isoforms (α and β) were increased in untreated C2C12 myotubes compared to C2C12 myoblasts, suggesting that the concomitant upregulation of GRβ in myotubes may counteract the aberrant activation of GRα. Previous research overexpressing GRβ (GRβOE) in C2C12 cells showed that GC-induced leucine zipper (GILZ), a target of GRα, was significantly reduced in GRβOE myoblasts, demonstrating a reduction in GRα activity when GRβ expression is elevated 41 . This could explain the inability of mifepristone to antagonise GRα and reduce dexamethasone-induced Klf15 expression in our treated C2C12 myotubes. Mifepristone’s inhibition of Klf15 expression may therefore work better when given early during muscle development. Interestingly, in FL83B hepatocyte-like cells, mifepristone reduced Klf15 expression regardless of dexamethasone treatment, which might be explained by the observation that FL83B cells displayed higher levels of GRα than GRβ in a differentiated state. Lower levels of GRβ suggests that mifepristone is able to actively bind GRα and antagonise transcriptional regulation without resistance from GRβ’s negative regulation 47 . In fact, previous research has shown that small GR antagonist molecules that are active in the liver can successfully ameliorate metabolic syndrome in rats 48 , suggesting that modulation of the GR pathway could help reduce known metabolic liver pathology in SMA 12 , 19 . A key finding from our molecular analyses of mifepristone-treated tissues is the selective downregulation of Klf15 expression in BAT of both Smn 2B/- SMA mice and Smn 2B/+ healthy littermate controls. The previously reported increased expression of Klf15 in BAT of SMA mice 3 may disrupt Klf15 ’s ability to maintain crucial processes such as lipid metabolism. Specifically, Klf15 has been demonstrated to regulate fuel switching between glucose and fatty acids in response to changes in energy status in BAT 49 . The imbalance of Klf15 levels in BAT of SMA mice may therefore contribute to aberrant gluconeogenesis and insulin resistance as a result of reduced metabolic flexibility 49 . Reducing Klf15 expression in BAT with mifepristone may potentially improve metabolic homeostasis in that tissue. Additionally, cross-talk occurs between BAT and pancreatic cells in obese mice, whereby the overexpression of Klf15 in BAT from obese mice enhanced insulin secretion from pancreatic β-cells 50 . As previous studies have reported a particular reduction in the pancreatic β-cells in Smn 2B/- mice 13 , we speculate that the increased expression of Klf15 seen in BAT of SMA mice could be a compensatory mechanism due to the reduced activity of pancreatic β-cells. 13 Mifepristone’s ability to reduce Klf15 in BAT of Smn 2B/- mice could thus improve insulin resistance and metabolic pathologies through crosstalk between adipose and pancreatic tissues 51 . Our in vivo studies also revealed a significant increase in myofiber area of Smn 2B/- SMA mice following mifepristone treatment. This increase in myofiber size is likely associated with the improved righting reflex times seen after mifepristone treatment (specifically 500 μg/g at P5) in Smn 2B/- mice. Klf15 plays a role in muscle physiology and exercise adaptation by regulating lipid flux, which could explain our current findings 25 , 52 . Furthermore, the knockdown of DDIT4 (REDD1), another GC regulated protein, boosts muscle mass supporting the concept that targeting GC pathways as an adjunct therapy may be beneficial for SMA 53 , 54 . Our in vivo work was conducted in both vertebrate and invertebrate models of SMA, which led to several key observations such as the ability of mifepristone to improve the survival of Smn 2B/- mice as well as improve neuromuscular pathology in both Smn 2B/- mice and C.elegans smn-1 (ok355) models. Our findings support previous work, from our group and others, that demonstrate that SMN-independent therapeutics alone can improve disease phenotypes, including lifespan 3 , 20 , 55 . In the current study, these improvements were seen when mifepristone was administered at the later time-points of P5 and P8 in Smn 2B/- mice, demonstrating that SMN-independent treatments can be administered later on during disease progression and still be able to attenuate pathology 56 . However, mifepristone did not improve the survival of severe Taiwanese mice, suggesting that peripheral pathologies may have a greater impact on disease phenotype in milder forms of SMA 56 . The adult population or patients with milder forms of SMA, including those now receiving therapy, may therefore benefit greatly from second-generation therapies 57 . Given that a single dose of scAAV9- SMN1 can significantly increase life expectancy, we combined scAAV9- SMN1 with 500 μg/g mifepristone in Smn 2B/- mice 58 . While delivery of SMN1 is sufficient to significantly improve lifespan in both mouse models and patients, this therapeutic approach does have limitations 46 , 59 . Indeed, as the longevity of this therapy is not yet known, it is possible that SMN1 cDNA will become diluted over time in dividing cells, thus preventing prolonged peripheral expression 60 . Furthermore, the amount of viral vector that be delivered is currently limited due to the viral affinity for the liver 60 . In fact, research has shown mifepristone can control expression of transgenes that are potentially toxic, as an activator in drug-dependent inducible systems 61 . Ultimately, there is wide clinical evidence demonstrating the safety of mifepristone following both acute and chronic dosing regimens and most patients will likely benefit from a combinatorial approach to their treatment 60 , 62 , 63 . In the current study, a combinatorial approach enabled us to determine any synergistic activities as well as evaluate whether we could expand the therapeutic benefit of scAAV9- SMN1 to further improve pathology by targeting metabolic perturbations in Smn 2B/- mice. While scAAV9- SMN1 combined with 500 μg/g mifepristone did not change the phenotypic outcomes of Smn 2B/- mice compared to gene therapy alone, molecular analyses of Klf15 expression in tissues revealed differences between mifepristone-treated Smn 2B/- and Smn 2B/+ mice. For instance, Klf15 levels were significantly reduced in the liver of scAAV9- SMN1 combined with 500 μg/g mifepristone-treated Smn 2B/- mice, but not Smn 2B/+ animals that received the same combinatorial treatment. This suggests that mifepristone may preferentially target the liver when combined with an SMN rescuing therapy in a diseased state. As Klf15 has been reported as a regulator of hepatic maturation, the decrease of Klf15 in Smn 2B/- livers following combinatorial treatment may be a sign of improved liver development following rescue of liver pathology by SMN1 restoration 64 , 65 . Additionally, mifepristone has been shown to reduce liver enzymes in patients with non-alcoholic fatty liver disease and could be beneficial knowing that scAAV9- SMN1 can cause liver toxicity 45 . Interestingly, we found an increase in myofiber area only in Smn 2B/- females following combinatorial treatment while there were no changes in males. This may be due to previously reported sex-dependent differences in both muscle metabolism and GC-GR activity 66 – 68 . Fundamentally, the beneficial effects of mifepristone have been associated with skeletal muscle pathology. We demonstrate that combinatorial therapy can improve certain aspects of disease pathology beyond that of treatment with the gene therapy alone in Smn 2B/- mice. As a result of its success so far, scAAV9- SMN1 now requires long-term assessment as it is possible that patients living longer may experience muscle and metabolic pathologies that need to be addressed therapeutically 69 . Metabolic pathologies in SMA have been reported, all be it to a limited extent, since before the genetic discovery of the SMN gene 4 . A more recent nutritional study found that nusinersen-treated patients still have gastrointestinal issues that can be modulated by an amino acid diet 18 . Additionally, therapies targeting complementary pathways that ultimately increase SMN in peripheral tissues prolong survival, demonstrating the importance of peripheral rescue beyond the canonical pathologies of SMA 70 . Along with the fact that the three approved gene therapies for SMA are unfortunately not cures for the disease, it is now clear that metabolic defects are often motor neuron-independent and should be autonomously addressed 71 . Notably, there are many commonalities in metabolic pathologies between Cushing’s syndrome (CS), a serious endocrine disorder, and SMA, including hyperglycaemia, fatty liver and muscle atrophy. FDA-approved mifepristone (Corlux ® ) is currently a widely used therapy for CS. In addition, both respiratory and digestive system dysfunctions have been associated with the prevalence of depression in SMA patients 72 . Psychological disorders including anxiety and depression often accompany chronic disease and mifepristone has been investigated for its therapeutic benefit in patients with psychotic depression. Mifepristone-treated patients had reduced psychotic symptoms compared to placebo-treated patients, with a large safety margin 73 . Consequently, mifepristone could address metabolic pathologies, mental health issues, and neural SMN independent pathologies, in SMA patients through its ability to cross the blood-brain barrier 74 . In summary, our results along with our previous work 3 , suggest that the GC-GR- Klf15 pathway is dysregulated in metabolic tissues of SMA patients and mouse models and could play a role in glucose, lipid and amino acid metabolic dysfunctions 3 . Following ground-breaking research and clinical trials, the approval of three gene-directed therapies has revolutionised the field of SMA. With that said, it is now time to utilise these therapies to maximise potential therapeutic benefit. Additional peripheral and metabolic pathologies are important targets for therapeutic interventions that have until recently received little focus 4 . Future investigations should therefore be aimed at furthering our understanding of SMN-independent contributors to SMA pathology. DATA AVAILABILITY STATEMENT All data associated with this study are available in the main text or supplementary materials. Raw data can be provided upon request. AUTHOR CONTRIBUTIONS Conceptualization: E.R.S, M.B; Methodology: E.R.S, P.P.T, M.D, S.D, B.L.S & M.B; Formal Analysis: E.R.S, P.P.T, M.D, H.C, Y.T.H & M.B; Investigation: E.R.S, E.M, J.M.H, O.C, P.P.T, M.D, H.C, Y.T.H, T.H.G, S.B, L.C, T.S, & M.B; Software: E.R.S; Visualisation: E.R.S; Resources: M,D, T.H.G & M.B; Writing – Original Draft: E.R.S, M.B; writing – Review and Editing: E.R.S, E.M, J.M.H, O.C, P.P.T, M.D, H.C, Y.T.H, T.H.G, S.B, L.C, T.S, S.D, B.L.S & M.B ; Supervision: M.B; Project Administration: M.B; Funding Acquisition: M.B. FUNDING This work was supported by a Muscular Dystrophy UK Ph.D. studentship (18GRO-PS48-0114) awarded to E.R.S and M.B. and funding from Action Medical Research and Spinal Muscular Atrophy UK (GN2754) awarded to M.B. J.M.H. received a Ph.D. studentship from the Keele University School of Medicine. E.M. was supported by an Academy of Medical Sciences grant (SBF006/1162). O.C. was supported by a Ph.D. studentship from the Republic of Turkey Ministry of National Education. Y-T.H, H.C. and T.H.G. received funding support from the European Union’s Horizon 202 research and innovation program (project SMABEYOND, No. 956185), My Name’5 Doddie Foundation (TRUST project grant) and LifeArc. DECLARATION OF INTERESTS STATEMENT T.H.G. has provided advisory services for Roche and Novartis. The remaining authors disclose no conflicts of interest. ACKNOWLEDGEMENTS The authors would like to thank the staff at the Biomedical Sciences Unit (BSU) facility at the University of Keele as well as Biological Research Resources (BRR) staff at the University of Edinburgh for excellent animal care and husbandry REFERENCES 1. ↵ Lefebvre S , Bürglen L , Reboullet S , Clermont O , Burlet P , Viollet L et al. Identification and characterization of a spinal muscular atrophy-determining gene . Cell 1995 ; 80 : 155 – 165 . 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Gillingwater , Maria Dimitriadi , Melissa Bowerman bioRxiv 2025.02.17.638672; doi: https://doi.org/10.1101/2025.02.17.638672 Share This Article: Copy Citation Tools Mifepristone alone and in combination with scAAV9- SMN1 gene therapy improves disease phenotypes in Smn 2B/- spinal muscular atrophy mice Emma R Sutton , Eve McCallion , Joseph M Hoolachan , Özge Cetin , Paloma Pacheco-Torres , Sihame Bouhmidi , Lauren Churchill , Taylor Scaife , Helena Chaytow , Yu-Ting Huang , Stephanie Duguez , Bernard L Schneider , Thomas H. 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