NA interference (RNAi) therapeutics use an endogenous mechanism whereby short interfering RNAs (siRNAs) direct the RNA-induced silencing complex (RISC) to sequence matched target transcripts for knockdown 1 . Both lipid nanoparticles and N-acetylgalactosamine (GalNAc) conjugates are clinically validated and approved delivery strategies for liver targets [2][3][4][5][6][7][8] . Building on nearly 2 decades of siRNA design and chemistry optimization [9][10][11][12] , we demonstrate here that, with suitable delivery solutions, the RNAi pathway can be harnessed in extrahepatic tissues, such as the central nervous system (CNS), eye and lung. Multiple CNS diseases, representing some of the highest unmet medical needs and greatest therapeutic challenges, have been associated with dominant gain-of-function mutations, making them suitable candidates for an RNAi-based silencing approach. As such, chemically modified siRNAs have demonstrated potent and sustained silencing in rodents and non-human primates (NHPs); however, using an invasive intracerebroventricular (ICV) administration approach 13 that is not suitable for repeated dosing in humans. Furthermore, technologies enabling siRNA delivery across the blood-brain barrier following a less challenging systemic administration are similarly being explored [14][15][16][17] , which are, however, still in early stages of discovery. In the eye, intravitreal (IVT) dosing of siRNAs has been evaluated in late-stage clinical studies, with few safety concerns, but did not advance further due to lack of efficacy 18 . Recently, the Coronavirus Disease 2019 (COVID-19) pandemic has highlighted the importance of optimizing siRNA delivery to the lung for the treatment of emergent viral respiratory diseases. Although earlier programs have already shown potential clinical benefits of siRNA-based therapeutics in the lung 19 , 2′-O-hexadecyl (C16) conjugates demonstrate enhanced delivery and siRNA uptake into the alveolar and bronchiolar epithelium. Taken together, this work highlights that the combination of a C16 lipophilic modification with our fully chemically modified, metabolically stable siRNAs achieves efficient delivery to the CNS, eye and lung, resulting in a robust and durable gene silencing in rodents and NHPs, with a favorable safety profile. We think that these advances have the potential to generate multiple candidates for investigating clinical safety and efficacy in humans. ResultsOptimization of the siRNA conjugate design. Lipophilic moieties represent one of the earliest approaches to improve cellular uptake and delivery of antisense oligonucleotides (ASOs) and siRNAs to the liver and various other organ systems 20 , including the CNS [21][22][23] . We reasoned that, by carefully optimizing the lipophilicity of chemically modified siRNAs, we could enhance intracellular delivery without compromising broad biodistribution, potency and safety. We used the 2′ position of the ribose sugar backbone to introduce

Various chemical modifications have been identified that enhance potency of small interfering RNAs (siRNAs) and that reduce off-target effects, immune stimulation, and toxicities of metabolites of these therapeutic agents. We previously described 5′-C-methyl pyrimidine nucleotides also modified at the 2′ position of the sugar. Here, we describe the synthesis of 2′-position unmodified 5′-(R)- and 5′-(S)-C-methyl guanosine and evaluation of these nucleotides in the context of siRNA. The (R) isomer provided protection from 5′ exonuclease and the (S) isomer provided protection from 3′ exonuclease in the context of a terminally modified oligonucleotide. siRNA potency was maintained when these modifications were incorporated at the tested positions of sense and antisense strands. Moreover, the corresponding 5′ triphosphates were not substrates for mitochondrial DNA polymerase. Models generated based on crystal structures of 5′ and 3′ exonuclease oligonucleotide complexes with 5′-(R)- and 5′-(S)-C-methyl substituents attached to the 5′- and 3′-terminal nucleotides, respectively, provided insight into the origins of the observed protections. Structural properties of 5′-(R)-C-methyl guanosine incorporated into an RNA octamer were analysed by X-ray crystallography, and the structure explains the loss in duplex thermal stability for the (R) isomer compared with the (S) isomer. Finally, the effect of 5′-C-methylation on endoribonuclease activity has been explained.

Toward the goal of evaluation of carbocyclic ribonucleoside-containing oligonucleotide therapeutics, we developed convenient, scalable syntheses of all four carbocyclic ribonucleotide phosphoramidites and the uridine solid-support building block. Crystallographic analysis confirmed configuration and stereochemistry of these building blocks. Duplexes with carbocyclic RNA (car-RNA) modifications in one strand were less thermodynamically stable than duplexes with unmodified RNA. However, circular dichroism spectroscopy indicated that global conformations of the duplexes containing car-RNAs were similar to those in the unmodified duplexes.

RNA interference (RNAi) therapeutics are a new class of medicines that can address unmet medical needs by silencing disease-causing gene transcripts. While delivery of short interfering RNAs (siRNAs) to hepatocytes has yielded multiple drug approvals, novel delivery solutions are needed to expand the reach of RNAi therapeutics. Here we report that conjugation of 2'-O-hexadecyl (C16) to siRNAs enables efficient silencing in the central nervous system (CNS), eye, and lung of multiple nonclinical species with broad cell type specificity. Intrathecally delivered C16-siRNAs are active across CNS regions and cell types, with sustained silencing for at least three months, which is an especially important outcome considering the challenging dosing route. Similarly, intravitreal and intranasal administration of C16-siRNAs resulted in potent and sustained knockdown in the eye and lung, respectively. Efficient delivery facilitated through C16 conjugation to optimized siRNA designs has enabled candidate selection for investigational human clinical trials assessing therapeutic silencing beyond the liver with infrequent (e.g. bi-annual) dosing.

Homology Directed Repair (HDR)-based genome editing is an approach that could permanently correct a broad range of genetic diseases. However, its utility is limited by inefficient and imprecise DNA repair mechanisms in terminally differentiated tissues. Here, we tested ″Repair Drive″, a novel method for improving targeted gene insertion in the liver by selectively expanding correctly repaired hepatocytesin vivo. Our system consists of transient conditioning of the liver by knocking down an essential gene, and delivery of an untargetable version of the essential genein ciswith a therapeutic transgene. We show that Repair Drive dramatically increases the percentage of correctly targeted hepatocytes, up to 25%. This resulted in a five-fold increased expression of a therapeutic transgene. Repair Drive was well-tolerated and did not induce toxicity or tumorigenesis in long term follow up. This approach will broaden the range of liver diseases that can be treated with somatic genome editing.