There is wide support for the pathogenesis model in which gain-of-function of the DUX4 gene in skeletal muscle cells underlies FSHD progression. DUX4 is a transcription factor whose expression is normally restricted to early embryonic development. Expression of DUX4 in muscle tissue of FSHD patients initiates a transcription cascade ultimately resulting in overt pathology. Drug discovery efforts in FSHD have been hampered by the very low and stochastic expression of DUX4 in a small percentage of myonuclei. Because the regulatory pathways involved in the activation of DUX4 are largely unknown, we implemented a phenotypic approach to identify novel small molecules and drug targets to repress DUX4. In order to build a predictive and translatable assay, we used primary patient-derived myocytes to develop and validate a high-content screening assay allowing automated sensitive detection and quantification of endogenous, non-stimulated DUX4 protein and myotube fusion efficiency. Our assay confirmed that the expression of DUX4 is dynamically regulated during myogenic differentiation and showed that effects on fusion are associated with potentially false-positive signals on the DUX4 readout. The excellent assay performance enabled high-throughput screening, resulting in the discovery and optimization of multiple hit series with confirmed activity in secondary assays. RNA-seq studies with selected compounds revealed normalization of the FSHD transcription signature. We applied a number of chemoproteomic approaches to deconvolute the mode of action of the phenotypic hit series, resulting in the discovery of novel targets to repress DUX4. In order to support the pharmacokinetic/pharmacodynamic strategy, we developed a xenograft animal model in which we could demonstrate in vivo repression of DUX4 after oral dosing of a selected lead compound from one of the series. Together, these results form the basis for building a diverse FSHD-focused product pipeline.
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