Reversable Acute Sedation Response of Phosphorothioate Antisense Oligonucleotides Following Local Delivery to the Central Nervous System

Antisense oligonucleotides (ASOs) locally delivered to the central nervous system (CNS) are being approved as therapies for neurological diseases. After intrathecal injection of some ASOs, transient toxicities have been reported, but considerable inconsistencies remain in classifying them and their underlying mechanisms. Here, we characterize an acute sedation response that can include loss of lower spinal reflexes, hypoactivity, paresis, sedation and ataxia, peaking ~3 hours post-intrathecal injection of some phosphorothioate ASOs and reversing by 24 hours with no sequelae. Acute sedation is distinct from acute activation, which is hyperactivity and muscle cramping that occurs immediately after administering oligonucleotides. Acute sedation translates across species from rodents to non-human primates and is sequence-, dose-, and chemistry dependent. Acute sedation can be mitigated by strategic placement of phosphorothioate backbone linkages in ASOs and by avoiding G-rich sequences. The acute sedation response can be modeled in primary neural cultures, with good predictability of in vivo response. Mechanistically, we demonstrate that acute sedation is caused by high extracellular ASO concentrations inhibiting synaptic transmission, which reverses as ASO is cleared from the extracellular space and taken up into cells. Our results provide a comprehensive framework for quantifying and mitigating acute sedation caused by some phosphorothioate ASOs.