Modulating splicing in 5' untranslated regions to treat rare haploinsufficient disease

Rare genetic disorders collectively impact over 300 million people worldwide, yet around 95% have no specific treatments. For the many rare disorders caused by haploinsufficiency, effective therapies need to upregulate protein expression. However, therapeutic upregulation is often not straightforward. Increasing protein translation of the wildtype allele through inhibiting repressive upstream open reading frames (uORFs) has been proposed as a therapeutic approach for a few specific genes. The widespread success of steric-block antisense oligonucleotides (ASOs) for this purpose is, however, debated. Here, we explore an alternative approach, using splice-switching to exclude uORF-containing exons from the mRNA. Through a genome-wide computational screening approach, we identified 79 uORF-containing 5'UTR exons in haploinsufficient monogenic disease genes as candidate exon skipping targets. We demonstrate that removing the target exon significantly increased protein translation (between 1.4-5.5 fold) in a luciferase reporter assay for four of six prioritised target 5'UTR exons in neurodevelopmental disorder genes ( CTCF , GRIN2B , KRIT1 , and TSC1 ). Overall, this work supports the widespread application of 5'UTR exon skipping to boost translation of clinically relevant haploinsufficient genes.