Curriculum
Module 10 · 70 min

Beyond CRISPR: ASO, siRNA, mRNA, AAV, and Cell Therapy

The full nucleic-acid pharmacopoeia in 2026 — and how to choose between modalities.

ClinicalResearch
Core topics

What's covered

  • T01ASO chemistries (PMO, gapmer, splice-switching) — Spinraza, eteplirsen, mipomersen, milasen
  • T02siRNA + GalNAc conjugation: patisiran, givosiran, lumasiran, inclisiran
  • T03mRNA therapeutics beyond vaccines: cancer neoantigen vaccines, intratumoral, replacement
  • T04AAV gene replacement: Luxturna, Zolgensma, Hemgenix, Roctavian, Elevidys
  • T05Engineered T-cells: CAR-T (Kymriah, Yescarta, Abecma, Carvykti), allogeneic, in-vivo CAR generation
  • T06Modality decision framework: dominant vs recessive, tissue, durability, immunogenicity
Learning objectives

By the end of this module you will be able to

  • L01Match disease class (loss-of-function recessive, gain-of-function dominant, heme-trafficking, neuromuscular) to the most appropriate genetic-medicine modality.
  • L02Explain why GalNAc-conjugated siRNAs are now first-line for several hepatic targets.
  • L03Discuss durability and re-dosing constraints for AAV vs LNP-delivered platforms.
Key takeaways

What you should walk away believing

  • GalNAc-siRNA (inclisiran) is now a maintenance-dose subcutaneous lipid-lowering therapy with twice-yearly dosing — a generic chemistry transformed cardiovascular pharmacology.
  • AAV gene therapy is durable but typically single-dose due to neutralizing antibodies; pre-existing immunity excludes 30–60% of patients depending on serotype.
  • Cancer neoantigen mRNA vaccines (Moderna mRNA-4157 in melanoma, BioNTech BNT122 in pancreatic) have moved from concept to phase 3 with provocative early signals.
  • In-vivo CAR-T generation (Capstan, Umoja, Orna) using LNP-mRNA could collapse the manufacturing burden of cell therapy if safety holds.
Lesson · Foundations emphasis

What this means at your level

Foundations

CRISPR is one tool among many. Antisense oligonucleotides (ASOs) and small interfering RNAs (siRNAs) silence or modify gene expression without changing DNA. mRNA and AAV deliver new genetic material. CAR-T cells are patient cells re-engineered to fight cancer. Choosing the right tool depends on the disease's genetics, the target tissue, and how durable the effect needs to be.

Clinician deep-dive

Decision heuristic: Loss-of-function recessive in liver → AAV or siRNA-based replacement strategies; loss-of-function recessive in CNS → ASO or AAV; dominant gain-of-function → ASO/siRNA/CRISPR knockdown; splice modulation → splice-switching ASO; B-cell malignancy → CAR-T (and increasingly autoimmune indications via CD19 CAR-T per Schett group). Always check antibody titres before AAV; pre-existing neutralizing antibodies remain the dominant exclusion.

Research note

Conjugation chemistries beyond GalNAc (CNS-penetrating, muscle-targeting via TfR) are extending the siRNA/ASO playbook beyond hepatocytes. tRNA suppressor therapies (Alltrna, hC Bioscience) could read through nonsense mutations across many recessive diseases. In-vivo CAR-T via Treg-targeting LNPs (CTX112, CABA-201, Capstan CPTX) could open lupus, MS, and refractory autoimmune indications. Allogeneic 'off-the-shelf' CAR-T platforms (Allogene, Caribou) trade durability for accessibility.

Myth-buster

Gene therapy means a one-time cure.

Reality

Some AAV products (Zolgensma, Luxturna) achieve durable single-dose effect in non-dividing tissue. Others (Roctavian for haemophilia A) show clinically meaningful but waning expression over years. Hepatic targets that require ongoing protein production face dilution by hepatocyte turnover. Single-dose ≠ permanent.

Evidence-graded claims

What the data say

A
Inclisiran (GalNAc-siRNA against PCSK9) achieves sustained LDL-C lowering with twice-yearly dosing
ORION-9/10/11 phase 3 trials; ~50% LDL-C reduction.
Audit grade A in this module →
A
Patisiran improves polyneuropathy and quality-of-life outcomes in hereditary ATTR amyloidosis
APOLLO trial, NEJM 2018.
Audit grade A in this module →
A
Onasemnogene abeparvovec (Zolgensma) preserves motor function in pre-symptomatic SMA when given before 6 weeks
SPR1NT trial; treatment timing is decisive.
Audit grade A in this module →
B
Personalized neoantigen mRNA vaccines reduce melanoma recurrence post-resection
KEYNOTE-942 phase 2 (mRNA-4157 + pembrolizumab) HR ~0.56; phase 3 ongoing.
Audit grade B in this module →
C
CD19 CAR-T induces durable remissions in refractory autoimmune disease (SLE, myositis, systemic sclerosis)
Schett group case series and small trials are striking; no controlled phase 3 yet.
Audit grade C in this module →
F
AAV gene therapy is generally re-dosable
Pre-existing and induced neutralizing antibodies preclude conventional re-dosing for current capsids; engineered evader capsids and IgG-cleaving enzymes are research-stage.
Audit grade F in this module →
See all claims for this module in the Evidence Grader →
Quick check

Test yourself

Q1A patient with hATTR-PN seeks an alternative to chronic patisiran infusions. The closest approved equivalent with subcutaneous dosing is:
Q2Best modality for a CNS recessive loss-of-function disease where target tissue is post-mitotic neurons:
Glossary

Key terms & abbreviations

ASOAntisense Oligonucleotide
Single-stranded modified DNA/RNA that binds target RNA to trigger RNase H cleavage (gapmer) or splice modulation (steric blocker).
siRNASmall Interfering RNA
Double-stranded RNA loaded into RISC to silence target mRNA via Argonaute2 cleavage.
GalNAcN-Acetylgalactosamine
Triantennary sugar conjugate that targets ASGPR on hepatocytes — the breakthrough chemistry behind hepatic siRNA/ASO drugs.
CAR-TChimeric Antigen Receptor T cell
Patient or donor T cells engineered to express a synthetic receptor (typically scFv-CD28/4-1BB-CD3ζ) targeting a tumor antigen.
Further reading

Anchor references

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