A splice-switching antisense oligonucleotide approach for pediatric genetic epilepsies

Variants in ion channel genes are common causes of pediatric epilepsy, often leading to intractable seizures, developmental delay and other comorbidities, which increases risk of death. Pathogenic variants in the SCN8A gene, which encodes a voltage-gated sodium channel critical for action potential generation in the brain, account for ∼1% of genetic epilepsies. The voltage sensor in SCN8A domain 1 is encoded by one of two developmentally-regulated mutually exclusive alternative exons, 5N and 5A. We observe that variants in these exons are more likely to cause infantile spasms, a severe seizure type, than variants elsewhere in SCN8A , and that some pathogenic variants affect exon 5 splicing, impacting patient phenotype. Molecular and evolutionary analyses implicate the exon sequences of these and other voltage-gated ion channel alternative exons in splicing regulation. We identified antisense oligonucleotides (ASOs) that shift splicing of SCN8A exon 5N to 5A or vice versa. These ASOs normalize neuronal activity in patient-derived iPSC neurons, and reduce seizures and motor impairment and extend lifespan in a new exon 5N mutant mouse model. Our results demonstrate that splice-switching ASOs can effectively reduce the expression of pathogenic isoforms and rescue both seizure and non-seizure phenotypes. Similar approaches should be applicable to pediatric genetic epilepsies caused by mutations in other ion channel alternative exons.