Series

Cystic Fibrosis 3
The future of cystic fibrosis treatment: from disease
mechanisms to novel therapeutic approaches
Simon Y Graeber, Marcus A Mall

With the 2019 breakthrough in the development of highly effective modulator therapy providing unprecedented Lancet 2023; 402: 1185–98
clinical benefits for over 90% of patients with cystic fibrosis who are genetically eligible for treatment, this rare disease Published Online
has become a front runner of transformative molecular therapy. This success is based on fundamental research, September 9, 2023
https://doi.org/10.1016/
which led to the identification of the disease-causing CFTR gene and our subsequent understanding of the disease S0140-6736(23)01608-2
mechanisms underlying the pathogenesis of cystic fibrosis, working together with a continuously evolving clinical
See Comment page 1113
research and drug development pipeline. In this Series paper, we focus on advances since 2018, and remaining
This is the third in a Series of
knowledge gaps in our understanding of the molecular mechanisms of CFTR dysfunction in the airway epithelium four papers about cystic fibrosis
and their links to mucus dysfunction, impaired host defences, airway infection, and chronic inflammation of the (papers 2 and 4 are published in
lungs of people with cystic fibrosis. We review progress in (and the remaining obstacles to) pharmacological The Lancet Respiratory Medicine).
All papers in the Series are
approaches to rescue CFTR function, and novel strategies for improved symptomatic therapies for cystic fibrosis,
available at www.thelancet.com/
including how these might be applicable to common lung diseases, such as bronchiectasis and chronic obstructive series/cystic-fibrosis-2023
pulmonary disease. Finally, we discuss the promise of genetic therapies and gene editing approaches to restore CFTR Department of Pediatric
function in the lungs of all patients with cystic fibrosis independent of their CFTR genotype, and the unprecedented Respiratory Medicine,
opportunities to transform cystic fibrosis from a fatal disease to a treatable and potentially curable one. Immunology and Critical Care
Medicine (S Y Graeber MD,
M A Mall MD) and Cystic
Introduction current focus lies on gene replacement strategies for the Fibrosis Center (S Y Graeber,
The discovery of the cystic fibrosis transmembrane approximately 10% of patients who are not eligible for M A Mall), Charité–
regulator (CFTR) gene in 1989 has provided a basis for (or do not tolerate) CFTR modulator therapy and, Universitätsmedizin Berlin,
corporate member of Freie
understanding the pathogenesis of chronic progressive therefore, have the highest unmet need. This endeavour
Universität Berlin and
lung disease, which is responsible for most of the disease will be supported by advances in genetic therapy Humboldt-Universität zu
burden and shortened life expectancy in patients with approaches. Other technological advances range from Berlin, Berlin, Germany;
cystic fibrosis. Over the past four decades, the cystic multi-omics technologies that enable comprehensive German Center for Lung
Research, associated partner
fibrosis community has been dedicated to basic and studies of gene expression and function at the single cell
site, Berlin, Germany
translational research addressing the mechanisms and level, to the establishment of patient-derived model (S Y Graeber, M A Mall); Berlin
consequences of CFTR dysfunction in the lung and its systems for preclinical research and precision medicine Institute of Health at Charité–
links to a characteristic pathogenetic cascade of airway approaches, and unprecedented opportunities for gene Universitätsmedizin Berlin,
Berlin, Germany (S Y Graeber,
mucus plugging, chronic bacterial infection, and editing with the prospect of a cure. Having been
M A Mall)
inflammation that determines the clinical phenotype incorporated since 2013 into basic and translational
Correspondence to:
and outcomes of the disease. In parallel, an exemplary cystic fibrosis research, these developments have already Prof Marcus A Mall, Department
drug development pipeline has been established to led to the novel insights into pathogenetic mechanisms of Pediatric Respiratory
translate basic research findings into novel therapies and progress with therapeutic strategies discussed in Medicine, Immunology and
Critical Care Medicine, Charité–
that target each step of this cascade. This collaborative this Review, and will be an important armamentarium
Universitätsmedizin Berlin,
effort first led to the approval of therapies that improve 13353 Berlin, Germany
mucus clearance and reduce bacterial burden in the Marcus.Mall@charite.de
lungs to ease symptoms, and more recently to highly Search strategy and selection criteria
effective small-molecule CFTR-modulator drugs that We searched PubMed and ClinicalTrials.gov from Jan 1, 2003,
address the underlying cause of the disease and provide to Feb 28, 2023, and updated the search through
unprecedented clinical benefits to an increasing patient July 20, 2023, with the search terms “cystic fibrosis”, “CFTR”,
population of currently approximately 90% of patients “CFTR function”, “cystic fibrosis and mucus”, “cystic fibrosis
with cystic fibrosis and responsive CFTR genotypes.1–4 and host defense”, “cystic fibrosis and inflammation”, “CFTR
Despite this breakthrough, important knowledge gaps modulators”, “cystic fibrosis and alternative ion channels”,
and challenges remain that have to be overcome to “cystic fibrosis and gene therapy”, “cystic fibrosis and genetic
develop effective therapies for all patients with cystic therapies”, “cystic fibrosis and anti-inflammatory”, and “cystic
fibrosis independent of their individual CFTR genotypes, fibrosis and anti-infective”. Only articles written in English
including patients with cystic fibrosis from minority were included. We largely selected relevant publications and
racial and ethnic groups who are less likely to be eligible clinical trials from 2018 to 2023, but also included original
for CFTR modulators on the basis of their genotypes.5 To descriptions and highly relevant older publications.
overcome the disparities in treatment options, the

www.thelancet.com Vol 402 September 30, 2023 1185

 Series

for achieving the ultimate goal of future cystic fibrosis channel that plays a key role in the transport of chloride
therapy that fully restores CFTR function and and bicarbonate across the apical membrane of epithelial
homeostasis to the lungs (and ideally other affected cells. Proper CFTR function is essential for maintaining
organs) in all people with cystic fibrosis. homeostasis in the airways and other affected organs,
including the exocrine pancreas, gastrointestinal tract,
Progress in understanding the molecular sweat glands.1,6 Early work on the structure and function
mechanisms of CFTR dysfunction of the CFTR anion channel revealed that it is composed
Breakthroughs in the development of therapies that of two transmembrane domains, two nucleotide binding
target the underlying cause of cystic fibrosis were made domains, and a regulatory domain; that it is activated by
For more on the Cystic Fibrosis
Mutation Database see http:// possible by the discovery that this disease is caused by protein kinase A-dependent phosphorylation and
www.genet.sickkids.on.ca/ mutations in the CFTR gene, which encodes an anion conductive for chloride and bicarbonate; and that CFTR-
mediated transport of these anions plays a key role in
homoeostatic regulation of fluid volume, pH, and salt
A concentration on the surface of the airways and other
Mucociliary clearance epithelia (figure 1).7–10 Over 2000 variants have been
Mucin crosslinking
identified in the CFTR gene and reported to the Cystic
HCO3– ENaC SLC26A9
Fibrosis Mutation Database, and approximately 700 have
S S been verified as disease-causing. On the basis of these
Cl– Na+ Cl– Cl– discoveries, understanding the basic molecular
mechanisms underlying how sequence variants in CFTR
can cause CFTR dysfunction became possible.11 These
CFTR TMEM16A
include deficient CFTR synthesis caused by nonsense,
frameshift, and canonical splicing mutations leading to
premature termination codons (class I mutations);
impaired folding and trafficking defects leading to few to
H20 H20 H20 H20 no CFTR channels at the cell membrane (class II
mutations); and impaired function of mutant CFTR
expressed at the cell membrane. This impaired function

CFTR
Figure 1: The molecular mechanisms and consequences of CFTR dysfunction
in cystic fibrosis airways
(A) In healthy airways, the CFTR chloride channel is mainly expressed in the
apical cell membrane of secretory cells, where it has an important role in anion
B (chloride and bicarbonate) and fluid secretion. CFTR is expressed with ENaC,
which constitutes the limiting pathway for sodium and fluid absorption.
Impaired mucociliary clearance Coordinated regulation of these processes is essential for the proper formation
of a thin protective mucus gel from mucins secreted by goblet cells and effective
Mucin crosslinking mucociliary clearance that provide an important, innate host defence
S
S
mechanism of the lung (in conjunction with macrophages patrolling airway
S
Class IV S surfaces). (B) In patients with cystic fibrosis, CFTR dysfunction can be caused by
S
S different molecular mechanisms. Mutations in CFTR can lead to premature
HCO3– ENaC SLC26A9
IL-1ß Proteases termination codons resulting in an absence of the full-length protein (class I
IL-8
Class III Cl– Na+ Cl– Cl– mutations), protein folding and trafficking defects leading to little functional
CFTR TNF-α CFTR at the apical cell membrane (class II mutations), impaired channel gating
resulting in reduced open probability (class III mutations), impaired channel
conductance (class IV mutations), a reduced number of CFTR channels caused by
alternative splicing (class V mutations), or a reduced stability and shortened
TMEM16A
half-life of CFTR channels expressed at the apical membrane (class VI
mutations). Deficient CFTR-mediated secretion of chloride, bicarbonate, and
Class VI fluid onto airway surfaces leads to the formation of hyperconcentrated and
highly viscoelastic mucus that impedes mucociliary clearance and sets the stage
H20 H20 H20 H20 for chronic bacterial infection with cystic fibrosis-associated pathogens such as
Pseudomonas aeruginosa. This infection triggers chronic airway inflammation,
including the activation of macrophages and recruitment of neutrophils into
Class II the airway lumen, leading to the release of proinflammatory cytokines
(eg, IL-1β, IL-8, and TNF-α), reactive oxygen species that further increase mucus
Class V viscoelasticity via disulfide mucin cross-linking, and proteases such as neutrophil
elastase, which play an important role in structural lung damage and lung
Class I function decline. Figure created with BioRender.com. CFTR=cystic fibrosis
transmembrane conductance regulator. ENaC=epithelial sodium channel.
SLC26A9=solute carrier family 26 member 9. TMEM16A=transmembrane
member 16A. IL=interleukin. TNF=tumour necrosis factor.

1186 www.thelancet.com Vol 402 September 30, 2023


can be due to defects in channel gating (class III
mutations), conductance (class IV mutations), abundance
(class V mutations), and stability (class VI mutations) of
the mutant CFTR protein (figure 1). The most common
mutation, F508del, which affects at least one allele in
approximately 85% of patients with cystic fibrosis is a
class II mutation that results in almost no CFTR channels
at the cell membrane. Besides elucidating the
pathogenesis of cystic fibrosis at the molecular level, this
classification already predicted that different therapeutic
approaches would be necessary to tackle CFTR
dysfunction caused by these different molecular
mechanisms, thus providing an important conceptual
framework for the development of CFTR modulators.
In this context, recognising that the most common
mutation, F508del, exhibits two distinct intramolecular
defects that independently impair folding (ie, instability of
nucleotide-binding domain 1 and impaired interdomain
assembly) was crucial, as this work predicted that
addressing both defects would be necessary to effectively
restore CFTR function.12,13 That particular mutations can
cause multiple molecular defects has also been increasingly
recognised, and this is exemplified by the most common
mutation, F508del, that not only affects protein folding
and plasma membrane expression, but also leads to
deficient channel gating and reduced stability at the
plasma membrane, as well as by other common mutations
including W1282X, R334W, A455E, R347P, N1303K, and
R117H, which were also found to cause multiple defects.14
Despite these insights that might at least partly explain the
heterogeneity in responsiveness of CFTR function to
pharmacological rescue, which has been observed among
distinct mutations belonging to the same class both in
vitro and in patients,15,16 the molecular and functional
consequences of many rare CFTR mutations remain
unknown. Facing these challenges, the concept of
theratyping has been introduced in cystic fibrosis research,
whereby CFTR mutations are classified according to their
responsiveness to CFTR-directed therapeutics in vitro.17
The implementation of this concept is strongly facilitated
by the development of patient-derived model systems since
2013, which use an individual’s rectal cells to generate
intestinal organoids or primary nasal or bronchial epithelial
cells to generate highly differentiated airway epithelia that
retain many of the properties of native patient tissues.18
These patient-derived models are expected to make
important contributions to personalised treatment for
patients with cystic fibrosis as they can be used to predict
responses to therapy in patients with rare mutations for
whom clinical trials are not feasible, and to individual
treatment optimisation as an increased number of
molecularly distinct CFTR-modulating drugs are entering
the clinical arena.
These advances are complemented by another
breakthrough in basic cystic fibrosis research, namely the
possibility of studying the structure of human wild-type and
F508del CFTR and the effects of current CFTR correctors
www.thelancet.com Vol 402 September 30, 2023
Series
with cryo-electron microscopy at an unprecedented
resolution. In 2022, with this approach, the correctors
tezacaftor and elexacaftor were shown to bind to distinct
sites on the F508del protein and the presence of both
correctors was shown to be required to synergistically rectify
interdomain assembly defects and rescue F508del channel
structure and function.19 This approach will provide
unprecedented opportunities to gain insights into the
molecular mechanisms and response to pharmacological
repair of rare CFTR mutations and enhance precision
medicine for patients with cystic fibrosis.
The expression of CFTR and alternative ion
channel targets in the airway epithelium
In the airway epithelium, CFTR works in concert with
other ion channels that participate in the homoeostatic
regulation of ion and fluid transport and pH on airway
surfaces (figure 1). The amiloride-sensitive epithelial
sodium channel (ENaC) has long received attention in
relation to the pathogenesis of cystic fibrosis lung disease
as this channel is rate limiting for sodium and fluid
absorption and its activity is increased in the airways of
patients with cystic fibrosis.20 On the basis of these results
and studies in mice with airway-specific overexpression
of ENaC, increased ENaC activity, in addition to CFTR
dysfunction, is predicted to be a key determinant of the
depletion of airway surface liquid and mucus
hyperconcentration characteristic of cystic fibrosis.21
More recently, two alternative chloride channels were
identified at the molecular level that might compensate
for CFTR dysfunction. First, transmembrane member
16A (TMEM16A) was identified22 in 2008 as the calcium-
activated chloride channel that is transiently activated by
purinergic signalling in healthy and cystic fibrosis
airways.23 Although TMEM16A function remains intact
in people with cystic fibrosis, a 2021 study24 found that
non-cystic fibrosis chronic rhinosinusitis with nasal
polyps is associated with impaired TMEM16A-mediated
epithelial chloride secretion, underscoring its potential
as a disease modifier and therapeutic target. The
molecular identification of TMEM16A also allowed for
the study of its localisation in the airway epithelium. This
chloride channel is mainly expressed in response to
inflammatory stimuli in the apical membrane of mucin-
producing goblet cells, indicating that TMEM16A-
mediated chloride and fluid secretion might be crucial
for proper secretion and clearance of mucins released
from goblet cells in inflamed airways.24 Second, solute
carrier family 26 member 9 (SLC26A9) was identified as
a constitutively active chloride channel that is coexpressed
with CFTR in the airways and several other organs
affected by cystic fibrosis.25 SLC26A9-mediated chloride
secretion is also induced by inflammatory stimuli,
suggesting a role in the coordinate secretion of fluid and
mucins to maintain mucus hydration and clearance
under conditions of mucus hypersecretion. Furthermore,
emerging evidence from functional and genetic studies
1187
 Series
suggests that SLC26A9 interacts with CFTR, and that a
SLC26A9 variant (Rs7512462) is associated with the
severity of lung disease and response to CFTR modulator
therapy in patients with cystic fibrosis.26 These alternative
chloride channels remain an active area of research,
including in emerging work on the functional cross-talk
between TMEM16A and SLC26A9 and CFTR, which was
reviewed in 2022.27,28 Collectively, these studies support
TMEM16A and SLC26A9 as potential disease modifiers
and novel therapeutic targets for cystic fibrosis.
In addition to the growing knowledge of alternative ion
channel targets, technological advances that enabled
studies of the transcriptome of single cells contributed
important novel insights into the cell type expression of
CFTR in the airway epithelium. Although CFTR was
initially assumed to be predominantly expressed in
ciliated respiratory epithelial cells, single-cell RNA
sequencing studies of freshly isolated epithelial cells
from large and small airways identified non-ciliated
secretory cells as the dominant CFTR-expressing cell
type in the superficial airway epithelium of the human
lung, followed by basal cells. CFTR expression in ciliated
cells was found to be infrequent and low.29 The highest
amount of CFTR expression per cell was found in
ionocytes, a rare cell type that constitutes less than 1% of
the airway epithelial cells along the tracheobronchial
tree. Although the functional relevance of CFTR
expression in ionocytes and the role of this rare cell type
in cystic fibrosis pathogenesis remains to be established,
the results of these studies provide important information
on the cell types in which CFTR expression needs to be
restored (eg, by gene replacement therapies), suggesting
a focus on the secretory cells of the superficial airway
epithelium.
Linking CFTR dysfunction to airway mucus
obstruction, impaired host defence, and chronic
inflammation
A striking and characteristic consequence of CFTR
dysfunction is the accumulation of highly viscoelastic
mucus that obstructs the airways, leads to airflow
limitation, and forms a nidus for chronic airway infection
and inflammation, which in turn produce progressive
lung damage in patients with cystic fibrosis (figure 1).30,31
The genesis of atypical mucus properties and impaired
mucociliary clearance in cystic fibrosis has been linked to
several different mechanisms. First, studies in bronchial
epithelial cultures and sputum from patients with cystic
fibrosis and mice with airway-specific overexpression of
ENaC showed that tipping the balance between CFTR-
mediated secretion and ENaC-mediated absorption
towards net fluid absorption leads to airway surface liquid
depletion and hyperconcentration of the mucus gel
covering airway surfaces from approximately 2% solids in
healthy individuals to approximately 10% solids in people
with cystic fibrosis.21,32,33 This increase in mucus
concentration was shown to produce an increase in the
1188
osmotic pressure of cystic fibrosis mucus to levels that
exceed those of the subjacent periciliary layer, causing
compression of the cilia and impaired mucociliary
clearance.34,35 Second, an increase in disulfide crosslinking
through the oxidation of free thiols contained in the large
secreted mucins MUC5B and MUC5AC, which is caused
by oxidant acids generated by the activity of peroxidases
secreted by neutrophils in chronic airway inflammation,
has been identified as an important mechanism
underlying the increased viscoelasticity and dysfunction
of the mucus gel in cystic fibrosis airways.36 Third, studies
in the cystic fibrosis pig model identified abnormalities in
mucus strands generated in the submucosal glands of the
large cartilaginous airways that also contribute to impaired
mucociliary clearance in cystic fibrosis. In the absence of
CFTR, the elasticity of these strands is also increased,
hindering their detachment from submucosal grand
ducts upon secretion into the airway lumen and
consequently the clearance of the inhaled particles bound
to these strands from the lung.37 These studies also
indicated that both deficient CFTR-mediated chloride and
bicarbonate secretion are implicated in the pathogenesis
of mucus dysfunction in cystic fibrosis. Before their
secretion, mucin macromolecules are densely packed in
secretory vesicles in the presence of high calcium
concentrations and acidic pH, and a 2019 in vitro study38
showed that removal of calcium and an increase in the pH
to 7·4 both facilitate mucin expansion from this compact
conformation.39 As bicarbonate chelates calcium ions and
is implicated in pH regulation, these results point to an
important role of impaired CFTR-mediated bicarbonate
secretion in atypical mucus structure and function in the
airways and other affected organs, including the intestine
and pancreas, in patients with cystic fibrosis.40 Collectively,
these results have greatly furthered our understanding of
the links between CFTR dysfunction and mucociliary
dysfunction that hinder proper host defences against
inhaled and aspirated irritants and pathogens and provide
the basis for chronic infection and inflammation in cystic
fibrosis airways.
Besides impaired mucociliary clearance, studies in
newborn pigs with cystic fibrosis showed that deficient
CFTR-mediated bicarbonate secretion turns the pH of the
airway surface liquid acidic, leading to reduced activity of
antimicrobial peptides, which makes pigs with cystic
fibrosis more susceptible to infection with pathogens
such as Staphylococcus aureus and Pseudomonas
aeruginosa.41,42 However, the clinical relevance of this
independent mechanism of impaired host defence
remains to be established, as measurements in 2017 in
humans gave similar values for airway pH in children
with and without cystic fibrosis.43 In addition, CFTR
dysfunction in monocytes and macrophages has been
implicated in impaired host defence in cystic fibrosis
airways, and this notion is supported by data showing
some improvement of impaired phagocytosis and the
killing of bacteria by the macrophages of patients with
www.thelancet.com Vol 402 September 30, 2023

cystic fibrosis given highly effective CFTR modulator
therapy.44–47 With technical advances in next generation
sequencing of bacterial genes, it has become clear that
chronic airway infection in cystic fibrosis is not only
caused by classic cystic fibrosis-associated pathogens,
such as P aeruginosa, but also by severe abnormalities of
the airway microbiome, including reduced diversity,
evenness, and richness of bacterial species that are
resilient to antibiotic therapy and associated with the
severity of cystic fibrosis lung disease.48–50 Studies in
young children with cystic fibrosis showed that
abnormalities in the airway microbiome develop early in
life and are associated with airway inflammation and the
development of bronchiectasis even before the detection
of cystic fibrosis-associated pathogens.51 Taken together,
these results indicate that, once established, this dysbiosis
is an important driver of chronic airway inflammation
leading to the recruitment and activation of neutrophils
into the airway lumen, which in turn results in the excess
release of neutrophil elastase and other neutrophil serine
proteases (eg, cathepsin G and proteinase 3) that play
important roles in progressive structural lung damage
and mucus hypersecretion and dysregulation of
inflammation and airway ion transport.52–54
In addition to bacterial triggers, emerging evidence
from the cystic fibrosis ferret model treated with broad-
spectrum antibiotics, and ENaC-overexpressing mice
reared under germ-free conditions suggests that mucus
plugging can induce airway inflammation in the absence
of bacterial infection, probably via the regional generation
of hypoxic conditions leading to the release of danger-
associated molecular patterns, such as interleukin (IL)-1
α from hypoxic epithelial cells triggering neutrophilic
inflammation via IL-1 receptor signaling.55–57 A recent
conundrum of relevance to CFTR-directed therapeutics
relates to observations indicating that airway
inflammation can have both detrimental and beneficial
effects on CFTR function. On one hand, in 2013,
neutrophil elastase was shown to degrade CFTR and
disable its channel function.58 On the other hand, in
2021, the exposure of epithelial cells in cystic fibrosis
airways to supernatant from mucopurulent material
collected from cystic fibrosis airways was found to
augment the biochemical and functional rescue of
F508del-CFTR by double or triple CFTR modulator
therapy.59 Research on the identification of the specific
factors mediating these divergent effects on CFTR might
lead to novel strategies for augmentation of mutant
CFTR function in patients treated with current CFTR
modulator therapies. Another pertinent issue in the era
of highly effective modulator therapy relates to the
question of to what extent chronic airway infection and
inflammation can be reversed and homoeostasis restored
upon pharmacological restoration of CFTR function.
Emerging data from observational studies in the post-
approval setting show that triple combination therapy
with elexacaftor–tezacaftor–ivacaftor (ETI) restores CFTR
www.thelancet.com Vol 402 September 30, 2023
Series
function in the airways of patients with at least one
F508del allele to approximately 50% of that measured in
healthy people, and that this degree of functional rescue
rapidly decreases sputum pathogen density and improves
microbiome composition and inflammation markers
during the first year of therapy in adolescent and adult
patients with cystic fibrosis.15,60,61 However, despite these
improvements, airway infection and inflammation
persist to a lesser degree that is probably more similar to
those observed in other chronic lung diseases such as
non-cystic fibrosis bronchiectasis.60,61 These results
indicate that with current CFTR modulator therapies
there will be a continued need for novel anti-infective
and anti-inflammatory therapies, at least for patients
with cystic fibrosis and established lung disease. To
tackle this problem, multi-omics technologies provide
unprecedented opportunities to study the alterations and
effects of pharmacological improvement of CFTR
function on gene expression, the epigenome, proteome,
and metabolome in single cells and supernatant from
airway samples (sputum and bronchoalveolar lavage) to
understand the pathways and molecular mechanisms
underlying residual infection and inflammation that
could lead to the identification of novel targets for the full
restoration of airway homoeostasis and other hallmarks
of health.62,63
Progress and the remaining challenges of
pharmacological approaches to restore CFTR
function
The development of highly effective CFTR modulator
therapy, which combines the restoration of the folding
and gating defects of mutant CFTR channels with
a combination of corrector and potentiator compounds,
has led to unprecedented improvements in lung
function and other clinical outcomes in eligible patients,
transforming the landscape of clinical care for patients
with cystic fibrosis.3 The current small molecule
combination therapy consisting of two distinct
correctors, the type III corrector elexacaftor and the
type I corrector tezacaftor, in combination with the
potentiator ivacaftor (ETI) has been studied most
extensively in patients with at least one copy of the
common F508del mutation (figure 2).64–70 With this triple
combination, as predicted by basic research,12,13,19 it
became possible to overcome the ceiling effect observed
for the pharmacological rescue of F508del with earlier
dual combination therapies that contained only one type
I corrector (lumacaftor or tezacaftor).71 The effect of this
advancement is apparent in observational studies
showing a statistically significant improvement in the
restoration of CFTR function in the airways and intestine
from approximately 10–20% in F508del-homozygous
patients treated with dual combination modulators to
approximately 40–50% of typical CFTR function in
patients with at least one F508del allele.15,72 As
a conceptually important advance, studies in patients
1189
 Series

Improved mucociliary clearance

approximately 50% of patients with cystic fibrosis and
no F508del allele responded clinically to ETI, including
a large subset of patients who carried a CFTR variant
Anti-infectives
Mucolytics S
Protease that is not currently approved for ETI. These approaches
S inhibitors
CFTR S
S are important for patients with extremely rare CFTR
S
HCO3– ENaC SLC26A9
S variants as they might establish a path to their eligibility
–
IL-1ß IL-8 Proteases for CFTR modulator therapy.17,18
Cl– ENaC Na+ Cl– TMEM16A Cl Cl–
Potentiator potentiator TNF-α Despite this breakthrough, there are still both
inhibitor
challenges and opportunities for further improvement
for this CFTR modulator-responsive patient population.3,4
TMEM16A Reported data in 2019, in ferrets with cystic fibrosis,
Enhancer suggest that starting CFTR modulator therapy already in
utero might have the greatest therapeutic effect on lung
mRNA therapy
lipid nanoparticle disease and extra-pulmonary manifestations of cystic
H20 H 20 H20 H20 fibrosis; however, a path for the clinical development of
Corrector 1
preventive treatment starting in utero does not exist yet.77
ASO Natural history studies have established a relationship
Corrector 2 between the degree of CFTR dysfunction and disease
Gene
editing severity,78,79 and emerging data from observational studies
show substantial residual airway infection and
Amplifier Readthrough DNA therapy inflammation at least in adult patients with chronic lung
agents viral vector
disease treated with ETI.60,61 These studies provide a
rationale for aiming to enhance the pharmacological
Figure 2: Current and future therapies to restore CFTR function and improve airway mucus clearance, restoration of mutant CFTR function further, ideally
infection, and inflammation in patients with cystic fibrosis
Highly effective modulator therapies address the underlying folding defects (with correctors) or gating defects towards the levels of healthy carriers, and several
(with potentiators) of the CFTR channel. Their efficacy might be further improved by increasing CFTR mRNA approaches are currently being pursued to achieve this
expression (with amplifiers) or by using molecules that enhance channel activity at the cell membrane. goal. First, additional small molecule correctors are being
Readthrough agents are currently being developed for CFTR nonsense mutations. Pharmacological targeting of developed on the basis of high-throughput screening
alternative ion channels, such as ENaC and the alternative chloride channels TMEM16A and SLC26A9, offers
mutation-agnostic approaches to compensate for CFTR dysfunction in the airways. Emerging gene therapies for campaigns. The novel corrector vanzacaftor is currently
cystic fibrosis include inhaled delivery of CFTR mRNA in lipid nanoparticles or CFTR cDNA in viral vectors as being tested in combination with tezacaftor and the more
mutation-agnostic approaches to restore CFTR function, and mutation-specific strategies, such as the modulation durable potentiator deutivacaftor in clinical trials in
of splicing with ASO and gene editing. Novel approaches to symptomatic therapies include the development of
patients with at least one F508del allele,80 and novel
mucolytic agents to reduce excess mucin crosslinking, phage therapy to tackle chronic Pseudomonas infection as a
novel anti-infective strategy, and protease inhibition to reduce inflammation and proteolytic damage of the cystic chemical entities have been identified that, in
fibrosis lung. Figure created with BioRender.com. ASO=antisense oligo nucleotides. CFTR=cystic fibrosis combination, lead to the functional correction of F508del
transmembrane conductance regulator. ENaC=epithelial sodium channel. SLC26A9=solute carrier family and other processing mutations up to 100% of wild-type
26 member 9. TMEM16A=transmembrane member 16A. IL=interleukin. TNF=tumour necrosis factor.
CFTR function in cell lines and primary human airway
epithelia in vitro.81 In addition to the development of
with one F508del allele and a gating or residual function modulators with enhanced efficacy, a new class of CFTR
mutation responsive to ivacaftor on the other allele amplifiers has been identified that enhances the efficiency
showed that treating both mutations affected by distinct of translation of CFTR mRNA, thereby increasing the
molecular mechanisms has additive therapeutic amount of mutant CFTR protein available for functional
benefits.73 In addition, in vitro studies in heterologous rescue by modulators.6 An alternative approach to
cells have identified 177 rare CFTR variants that respond enhance the effects of CFTR modulators was established
to ETI and contributed to its approval for patients with at in 2022 with the development of a PI3Kγ mimetic peptide.
least one of these responsive CFTR variants by the US In airway epithelial cells, PI3Kγ decreases intracellular
Food and Drug Administration (FDA), but not the cyclic adenosine monophosphate (cAMP) levels through
European Medicines Agency. As a result, over 90% of the kinase-dependent activation of phosphodiesterases,
patients with cystic fibrosis are now genetically eligible whereas treatment with a cell-permeable PI3Kγ mimetic
for highly effective modulator therapy. However, specific peptide leads to an increase in cAMP and protein kinase
mutations might be preferentially permeant to chloride A, thereby enhancing the phosphorylation and gating of
but not bicarbonate, and the effects of CFTR modulators both wild-type CFTR and F508del-CFTR rescued by
on the restoration of bicarbonate transport remain to be modulators.82 This PI3Kγ mimetic peptide was also
established.74 The list of responsive CFTR variants found, via a similar molecular mechanism, to have anti-
continues to grow on the basis of theratyping approaches inflammatory effects reducing neutrophilic inflam­mation
with patient-derived model systems75 and the assessment in mice, which might provide additional benefits to
of clinical responses used in 2023 in the French patients with cystic fibrosis. Although they are at early
Compassionate Program,76 which found that stages of development, these approaches hold promise to

1190 www.thelancet.com Vol 402 September 30, 2023

 Series

further enhance CFTR function and long-term clinical Globally, approximately 10% of individuals with cystic
benefits in patients eligible for CFTR modulator fibrosis (including a substantial subgroup of patients
treatment (figure 2). ineligible for modulator treatment) are affected by CFTR

Drug Clinical stage Clinical trial identifier Company

Restoration of CFTR function
CFTR modulator Vanzacaftor–tezacaftor– Phase 3 NCT05033080; NCT05076149 Vertex Pharmaceuticals
deutivacaftor
Readthrough agent ELX-02 Phase 2 NCT04135495; NCT04126473 Eloxx Pharmaceuticals
CFTR modulator SION-638 Phase 1 NA Sionna Therapeutics
Readthrough agent Preclinical ·· Icagen
CFTR enhancer (PI3Kγ KIT2014 Preclinical ·· Kither Biotech
mimetic peptide)
CFTR modulator Preclinical ·· Reata Pharmaceuticals
Readthrough agent SRI-41315 Preclinical ·· Southern Research
Mucociliary clearance
ENaC inhibitor ETD001 Phase 1 NCT04926701 Enterprise Therapeutics

TMEM16A potentiator GDC-6988 (formerly ETD002) Phase 1 NCT04488705 Roche (Genentech)

Mucolytic (thiol-modified Aer-01 (formerly MUC-31) Preclinical ·· Aer Therapeutics
carbohydrate)
Genetic therapy
CFTR DNA therapy via 4D-710 Phase 1 NCT05248230 4D Molecular Therapeutics
adeno-associated virus
vector
CFTR messenger RNA LUNAR-CF (ARCT-032) Phase 1 NCT05712538 Arcturus Therapeutics
therapy via lipid
nanoparticles
CFTR messenger RNA VX-522 mRNA Phase 1 NCT05668741 Vertex Pharmaceuticals
therapy via lipid
nanoparticles
Antisense oligonucleotide SPL84 Phase 1 NA SpliSense
for splicing modulation
CFTR DNA therapy via CGT-001 Preclinical ·· Carbon Biosciences
adeno-associated virus
vector
CFTR DNA therapy via Preclinical ·· Spirovant Sciences
adeno-associated virus
vector
CFTR DNA therapy via BI 3720931 Preclinical ·· Boehringer Ingelheim
lentivirus vector
CFTR DNA therapy via non- Preclinical ·· Carmine Therapeutics
viral extracellular vesicles
CFTR DNA therapy via Preclinical ·· Gensaic
bacteriophage-derived
particles
CFTR messenger RNA Preclinical ·· Nanite
therapy via polymer
nanoparticles
CFTR messenger RNA Preclinical ·· ReCode Therapeutics
therapy via lipid
nanoparticles
Integration of donor DNA Preclinical ·· SalioGen Therapeutics
via helper RNA that encodes
for saliogase
Antisense oligonucleotide SPL23 Preclinical ·· SpliSense
for splicing modulation
Transfer RNA therapy via Preclinical ·· The University of Hamburg and
lipid nanoparticles for Arcturus Therapeutics
splicing modulation
(Table continues on next page)

www.thelancet.com Vol 402 September 30, 2023 1191

 Series
For more on the Cystic Fibrosis
Foundation Therapeutic
Development Network see
https://www.cff.org/researchers/
therapeutics-development-
network
For more on the European Cystic
Fibrosis Society Clinical Trial
Network see https://www.ecfs.
eu/ctn
1192
Drug Clinical stage Clinical trial identifier Company
(Continued from previous page)
Anti-inflammatory
Cathepsin C inhibitor Brensocatib Phase 2 NCT05090904 Insmed
Normalising lipid imbalance LAU-7b Phase 2 NCT03265288 Laurent Pharmaceuticals
Cathepsin C inhibitor BI 1291583 Phase 1 NCT05833035 Boehringer Ingelheim
Neutrophil elastase inhibitor Lonodelestat (formerly Phase 1 NCT03748199 Santhera
POL6014)
Anti-infective
Disruption of bacterial cell Inhaled Colistin (ColiFin) Phase 2 NA Spexis and PARI Pharma
membrane
Disruption of bacterial iron Inhaled gallium (AR-501; Phase 2 NCT03669614 Aridis Pharmaceuticals
metabolism Panaecin)
Disruption of bacterial iron Intravenous gallium Phase 2 NCT04294043 Cystic Fibrosis Foundation
metabolism
Phage therapy AP-PA02 Phase 2 NCT04596319 Armata Pharmaceuticals
Phage therapy BX004-A Phase 2 NCT05010577 BiomX
Destruction of bacterial cell Inhaled nitric oxide (LungFit Phase 2 NCT04685720 Beyond Air
wall GO)
Triazol antifungal agent Opelconazole Phase 2 NCT05037851 Pulmocide
Inhibition of bacterial ACG-701 (formerly ARV-1801) Phase 2 NCT05641298 Aceragen
protein synthesis
Inhibition of bacterial Lefamulin (Xenleta) Phase 1 NCT05225805 Nabriva Therapeutics
protein synthesis
Inhibition of bacterial Oral amikacin (MAT2501) Preclinical ·· Matinas BioPharma
protein synthesis
Inhibition of bacterial Tobramycin/Ca-EDTA Preclinical ·· Respirion Pharmaceuticals
protein synthesis
Inhibition of bacterial Oxazolidinone inhibitor Preclinical ·· TB Alliance
protein synthesis
Inhibition of bacterial and CSA-131 Preclinical ·· Kinnear Pharmaceuticals
fungal growth
Disruption of bacterial outer Inhaled murepavadin Preclinical ·· Spexis
membrane
The pipeline includes new therapies that are being funded by the Cystic Fibrosis Foundation (CFF), tested in clinical trials in the Cystic Fibrosis Foundation Therapeutic
Development Network (TDN) and the European Cystic Fibrosis Society Clinical Trial Network (ECFS-CTN), or were identified by the literature search for this Series paper.
CFTR=cystic fibrosis transmembrane conductance regulator. ENaC=epithelial sodium channel. NA=not available. TMEM16A=transmembrane member 16A.
Table: The cystic fibrosis drug development pipeline
class I mutations that cause premature termination being tested in a phase 2 trial in patients with cystic
codons (PTCs), which prevent translation of a full-length fibrosis and at least one G542X mutation (table).85 Parallel
protein.2 The development of effective readthrough strategies to identify more efficacious or less toxic
therapies that restore CFTR function by suppressing readthrough agents include the screening and preclinical
translation termination at PTCs is, therefore, an attractive investigation of approved drug libraries with the potential
approach to reduce the remaining group of patients who for rapid translation of promising candidates to clinical
are not eligible for pharmacological restoration of CFTR. trials, and the large high-throughput screening of novel
Early proof-of-concept studies showed that PTCs in chemical entities. The latter approach led to the
CFTR can be suppressed by aminoglycoside antibiotics, identification of SRI-41315, a compound that reduces the
such as gentamycin.83 However, their poor efficacy and abundance of the termination factor eRF1 leading to an
toxicity impeded clinical development and led to the extended pause at stop codons and suppression of PTCs,
search for more efficacious and well tolerated resulting in the restoration of CFTR expression and
aminoglycoside analogues. The currently most advanced function in airway epithelial cells in people with cystic
investigational readthrough agent, ELX-02, which fibrosis.86 Furthermore, SRI-41315 was also shown to
showed a dose-dependent improvement of readthrough augment aminoglycoside-mediated readthrough,
of PTCs resulting in functional restoration of full-length suggesting combination therapies with readthrough
CFTR in cystic fibrosis models in vitro and in vivo, was agents that target distinct components of the translation
well tolerated in a clinical phase 1 trial84 and is currently machinery might be a promising treatment strategy for
www.thelancet.com Vol 402 September 30, 2023

cystic fibrosis and potentially other diseases caused by
PTCs. As PTCs also trigger nonsense-mediated mRNA
decay (NMD), limiting the amount of mRNA available
for translational readthrough, NMD inhibition provides
an additional strategy to augment the efficacy of
readthrough agents. Once full-length CFTR protein is
formed, its activity can be further augmented by CFTR
modulators. Indeed studies in intestinal organoids from
patients with cystic fibrosis and various PTC mutations
showed synergistic effects of combination therapy with
the readthrough agent ELX-02, the NMD inhibitor
SMG1i, and CFTR modulation with ETI with levels of
functional correction of CFTR that exceeded those
observed with lumacaftor–ivacaftor in organoids from
F508del-homozygous patients.87 The results of these in
vitro studies in patient-derived organoids are promising
as they suggest that, reminiscent to the rescue of F508del
with CFTR correctors, there might be an opportunity to
overcome the ceiling effect of a single readthrough agent
with combination therapy that targets several molecular
mechanisms and provides clinical efficacy for patients
with a spectrum of PTC mutations (figure 2).
Alternative ion channel targets to circumvent
CFTR dysfunction in the airway epithelium
Pharmacological targeting of alternative ion channels is
an attractive mutation-agnostic approach to circumvent
the consequences of CFTR dysfunction in the airways
that, in the era of highly effective modulator therapies,
holds promise for patients who are genetically ineligible
for CFTR modulators (figure 2). Given the role of ENaC
in the pathogenesis of airway surface liquid depletion in
cystic fibrosis, its inhibition has been the focus of
approaches aiming to improve mucus hydration and
clearance. Several small molecule ENaC inhibitors were
developed that are more potent and more durable than
amiloride and show improved airway surface hydration
and mucociliary clearance in human airway epithelial
cultures and sheep. However, successful translation of
ENaC-directed approaches to patients is still pending and
most clinical development programmes have been
terminated.6,88 The inability of ENaC inhibitors to progress
through clinical development has been attributed to
limitations in dosing to avoid unwanted systemic side-
effects, such as hyperkalaemia caused by ENaC inhibition
in the kidney or insufficient airway deposition by
inhalation as a route of delivery in patients with cystic
fibrosis and chronic lung disease, which is characterised
by heterogeneous airway mucus plugging that is not a
feature of the preclinical sheep model. A novel, highly
potent ENaC inhibitor, ETD001, was safe and well
tolerated in a phase 1 trial in healthy volunteers (NCT
04926701), so dosing issues with earlier compounds
might be overcome and clinical testing in patients with
cystic fibrosis might be informative as to whether
improving airway hydration alone is sufficient to improve
clinical outcomes.
www.thelancet.com Vol 402 September 30, 2023
Series
Previous attempts to stimulate the alternative calcium-
activated chloride channel TMEM16A with denufosol,
an inhaled uridine-5ʹ-triphosphate analogue designed to
increase intracellular calcium in airway epithelial cells
via activation of P2Y2 receptors, did not show clinical
efficacy, probably due to the rapid inactivation of
denufosol by exonucleotidases present in inflamed cystic
fibrosis airways.89–91 In 2020, the first small molecule
potentiator of TMEM16A (ETX001) was reported and
shown to activate calcium-activated anion and fluid
secretion in bronchial epithelial cells from patients with
cystic fibrosis, and inhaled ETX001 improved mucociliary
clearance in sheep.92 Because TMEM16A conducts both
chloride and bicarbonate, its activation provides
an approach to compensate for CFTR dysfunction more
completely, including abnormalities in mucus function
and host defence that are related to deficient CFTR-
mediated bicarbonate transport. A related investigational
compound (GDC-6988) has entered early clinical
development (table). Another promising preclinical
strategy to enhance the activity of TMEM16A is blocking
the binding of microRNA-9 to its 3’ untranslated region,
which is involved in the downregulation of TMEM16A
expression.93 If successful in the clinical arena, this new
class of ion channel modulator would be an attractive
approach to improve mucus clearance in patients with
cystic fibrosis and potentially other muco-obstructive
lung diseases.
The promise of genetic therapies and gene
editing approaches
To address the current disparity in treatment options for
the approximately 10% of patients with cystic fibrosis
who are genetically ineligible for or intolerant of CFTR
modulator therapy, and given the remaining challenges
with pharmacological solutions for this patient
population (including patients with large CFTR deletions
that include the promoter and intronic regions of the
gene), enormous efforts are being put into gene
replacement and gene editing strategies based on nucleic
acid-based therapies to restore CFTR function in the
lungs.94–96 This revival of genetic therapies for cystic
fibrosis is underpinned by important advances in gene
delivery and gene editing technologies, and a robust
pipeline including several distinct approaches has been
established and is currently undergoing preclinical and
early clinical development (figure 2; table).
First, inhalation of stable CFTR mRNA packaged in
lipid nanoparticles designed to penetrate mucus for the
optimised targeting of airway epithelial cells is being
pursued to restore expression of wild-type CFTR in
a mutation-agnostic fashion.94,95 This approach is expected
to result in less immunogenicity than viral delivery
systems, but relies on frequent redosing as the inhaled
mRNA is degraded intracellularly. Interim results of the
first randomised, double-blind, placebo-controlled
phase 1/2 clinical study of MRT5005 in adult patients
1193
 Series
with cystic fibrosis and two severe class I or II CFTR
mutations showed that treatment was generally safe and
well tolerated through 28 days of follow-up, although
some febrile and hypersensitivity reactions were noted
that mostly resolved within 1–2 days allowing continued
treatment. Lung function remained stable after
treatment, but no beneficial effects on forced expiratory
volume in 1 sec were observed in this small first-in-
human trial.97 Other early phase studies testing the safety
and tolerability of mRNA replacement therapy are
currently under way (NCT05668741 and NCT05712538).
Second, adeno-associated virus (AAV) gene therapy with
improved AAV capsids optimised for lung gene transfer
and reduced immunogenicity has been developed for
cystic fibrosis gene therapy, with clinical trials underway.94
The AAV-based gene therapy 4D-710 (comprising an AAV
capsid carrying a transgene cassette encoding human
CFTR with a deletion in the regulatory domain
[CFTRΔR]) has been developed for more durable vector-
based expression of CFTR in airway epithelial cells and is
currently being tested in a first phase 1/2, single dose,
open-label trial in adult patients with cystic fibrosis who
are ineligible for or unable to tolerate CFTR modulator
therapy (NCT05248230). The deletion of part of the CFTR
transgene is necessary due to the poor packaging capacity
of AAV, and the consequences of this truncation on
CFTR function are currently unknown. Similar to
adenovirus, AAV vectors induce immunogenicity, which
hampers repeated dosing without losing efficacy.96 Third,
optimised lentiviral vectors hold promise for efficient
gene therapy for cystic fibrosis. Pseudotyped lentiviral
vectors containing envelope proteins from other viruses
have enhanced transduction efficiency in the lung, their
larger packaging capacity allows expression of full-length
human CFTR, their integration into the host genome
facilitates durable gene expression after a single dose,
and repeated administration was shown to be possible
without loss of efficacy.98 In preclinical studies, lentivirus-
based gene therapy was shown to provide efficient and
durable gene transfer to the mouse lung, efficient
restoration of CFTR function in cystic fibrosis intestinal
organoids from patients with class I mutations, and
a first-in-man trial of BI 3720931 as a long-lasting
therapeutic option for patients with cystic fibrosis is
currently in preparation.94,99 The results of these pilot
trials, including safety and tolerability data, and initial
data on the efficacy and durability of CFTR restoration
will probably be decisive for future directions with
mutation-agnostic gene replacement therapy for cystic
fibrosis.
In addition to these mutation-agnostic approaches,
several strategies for mutation-specific nucleic acid-based
therapies are being developed. First, preclinical studies
with antisense oligonucleotides that can bind to their
target RNA and modulate its splicing, as were shown in
2016 for other genetic diseases such as spinal muscular
atrophy and Duchenne muscular dystrophy,100,101 support
1194
the potential of this approach to treat patients with cystic
fibrosis and specific CFTR splicing and nonsense
mutations.94 These studies showed that targeted antisense
oligonucleotide-based splicing modulation is highly
effective in producing correctly spliced mRNA in patients
with the 3849+10 kb C→T splicing mutation,102 and can
induce skipping of CFTR exon 23, which harbours the
W1282X nonsense mutation,103 thereby restoring CFTR
function to airway epithelial cells. Lead antisense
oligonucleotide candidates for this approach are currently
being advanced to a proof-of-concept trial in patients
carrying these specific mutations.94 Second, engineered
transfer RNAs for the suppression of nonsense mutations
in the CFTR gene were shown to re-establish CFTR
expression and function in cell systems and patient-
derived epithelia and provide another promising
approach for patients with PTCs.94–106 Finally, important
advances in gene editing have been made.107 With
CRISPR-based adenine base editing and prime editing
(and without the need for double-strand breaks that are
required for conventional CRISPR/Cas9-mediated
genome engineering), several CFTR nonsense mutations
and F508del were successfully repaired in the genome of
intestinal organoids from patients with cystic fibrosis,
leading to effective restoration of CFTR function with no
detectable off-target effects during repair.108,109 These
preclinical results support the notion that gene editing
might be safely applied in human cells to correct
individual CFTR mutations in the genome for complete
and life-long restoration of CFTR function as a potential
cure of cystic fibrosis.
Despite these recent advances, substantial obstacles
remain that still have to be overcome to translate these
nucleic acid-based therapy approaches into effective
therapies for patients. These include effective delivery to
the right cell types in chronically inflamed and mucus-
obstructed cystic fibrosis airways without off-target
effects, including immunogenicity. To achieve this goal,
innate defence mechanisms need to be overcome and a
better understanding of where CFTR function needs to
be restored in the lung is needed, particularly in view of
the poorly defined role of the high levels of CFTR
expression in ionocytes in the pathogenesis of cystic
fibrosis lung disease.29 Furthermore, to what extent
repeated dosing is necessary and feasible for all nucleic
acid-based therapy approaches is currently unknown,
and the potential risk of oncogenicity (especially for viral
vectors that integrate into the host genome) will require
long-term safety monitoring. Finally, all current strategies
focus on inhaled delivery of nucleic acid-based therapies
to the lungs and how CFTR function might be restored
in other affected organs to improve the health of patients
with cystic fibrosis who are ineligible for modulator
therapy remains unclear. These obstacles also contribute
to the challenges around clinical trial designs in the
small population of patients with CF who are ineligible
for or intolerant of modulator therapy.110
www.thelancet.com Vol 402 September 30, 2023

Novel strategies for symptomatic therapies to
improve mucociliary clearance and reduce
airway inflammation and infection
For a long time, symptomatic therapies targeting
mucociliary dysfunction, chronic airway infection, and
inflammation were the backbone of substantial
improvements in the life expectancy and quality of life of
patients with cystic fibrosis.1,2 With the emergence of
highly effective CFTR modulators, these symptomatic
therapies will remain important both for genetically
ineligible and intolerant patients, and for eligible patients
with chronic lung disease and irreversible structural lung
damage, such as bronchiectasis and residual inflam­
mation, and infection, on modulator therapy.2 A robust
pipeline of symptomatic therapies with enhanced
efficacy, therefore, remains important to overcome the
remaining challenges related to airway mucus
obstruction, chronic inflammation, and infection in
multimodal cystic fibrosis care (table).
Insights into the role of excess crosslinking of mucins
via disulfide bonds in the pathogenesis of the atypical
viscoelasticity of cystic fibrosis mucus led to the
development of novel small molecule reducing agents as
mucolytics in 2015 that are more potent than
N-acetylcysteine, the only FDA-approved drug in this
class that did not improve mucus clearance and lung
function in patients.36 In preclinical studies, two novel
mucin-reducing agents, P3001 and the thiol-saccharide
mucolytic MUC-031, were shown to improve the
viscoelastic properties of cystic fibrosis sputum ex vivo
and reduce airway mucus plugging and inflammation
in a mouse model of cystic fibrosis lung disease.111,112
These encouraging results obtained with two distinct
compounds in preclinical models provide a rationale for
clinical testing in patients with cystic fibrosis and other
muco-obstructive lung diseases.
In the area of anti-inflammatory therapies, progress has
been made in the development of strategies designed to
target free neutrophil elastase activity in the airways,
which constitutes a key risk factor for lung disease
progression in children and adults with cystic fibrosis.53,54
Lonodelestat, a highly potent and selective inhibitor
of human neutrophil elastase, is in early clinical
development as an inhaled anti-inflammatory therapy for
cystic fibrosis. In a 4-week, phase 1 trial in patients with
cystic fibrosis, short-term inhalation of lonodelestat was
well tolerated and resulted in the inhibition of neutrophil
elastase activity in sputum.113 As an alternative approach,
brensocatib, an oral reversible inhibitor of cathepsin C
(also known as dipeptidyl peptidase 1), has been developed
as a systemic anti-inflammatory strategy. Cathepsin C is
responsible for the activation of all neutrophil serine
proteases, including cathepsin G and proteinase 3, in
addition to neutrophil elastase, and its inhibition
therefore provides the potential for broader antiproteolytic
effects. In a 24-week, phase 2 trial in patients with non-
cystic fibrosis bronchiectasis, brensocatib led to a
www.thelancet.com Vol 402 September 30, 2023
Series
reduction of free neutrophil elastase activity in sputum,
which was associated with improvements in clinical
outcomes.114 Whether this promising antiprotease strategy
can sufficiently reduce the protease burden in the lungs
and improve clinical outcomes of patients with cystic
fibrosis remains to be seen in ongoing clinical trials (eg,
NCT05090904).
Finally, novel anti-infective approaches to fight chronic
infection with P aeruginosa and other proinflammatory
pathogens more effectively remain a high priority.115
Several novel antibiotic approaches, including systemic
or inhaled administration of gallium (which was shown
to disrupt iron-dependent biological processes and lead
to the killing of antibiotic-resistant P aeruginosa strains in
vitro), are being actively studied in early phase clinical
trials in the Cystic Fibrosis Foundation Therapeutic
Development Network (CFF-TDN) and European Cystic
Fibrosis Society Clinical Trial Network (ECFS-CTN;
table). In addition to pharmacological approaches,
inhaled phage therapies,116 such as AP-PA02 and
BX004-A, that use a cocktails of bacteriophages to attack
and lyse chronically adapted and antibiotic-resistant
P aeruginosa strains in the lungs of patients with cystic
fibrosis provide a promising strategy to tackle the
remaining problem of chronic Pseudomonas infection as
a key trigger for chronic inflammation and mucus
hypersecretion (eg, NCT04596319, NCT05010577). For
more detailed information on new developments and
approaches and unmet clinical needs related to novel
anti-infective therapies, we refer the reader to reviews
from the past 2 years.117–120
Given the increasingly recognised roles of airway
mucus obstruction, chronic inflammation, and infection
in a range of other lung diseases including bronchiectasis
and COPD,31,121–123 innovative symptomatic therapies that
have been developed for cystic fibrosis might also provide
benefits to patients with high unmet needs in these
common lung diseases.
Conclusion
Improving our understanding of underlying disease
mechanisms in conjunction with a robust drug
development pipeline has enabled the development of
highly effective CFTR modulator therapy that provides
unprecedented improvement in clinical outcomes for
approximately 90% of patients with cystic fibrosis who are
genetically eligible for treatment. Despite this
breakthrough, an iterative process of fundamental and
clinical research remains instrumental to solving the
remaining challenges, with a current focus on the genetic
or pharmacological restoration of CFTR function in the
small patient population who are ineligible for modulator
therapy and have the highest unmet medical need, and
further functional improvement in the large, eligible
population towards full restoration of CFTR function.
With gene editing approaches that enable the correction of
individual CFTR mutations in the genome of patient cells,
1195
 Series
effective treatment for all patients with cystic fibrosis is
now on the horizon. Further improvement of symptomatic
therapies remains important for multimodal manage­
ment, especially for patients with chronic lung disease,
and might be applicable for tackling airway mucus
plugging, chronic inflammation, and infection in
common lung diseases such as bronchiectasis and COPD.
Contributors
SYG and MAM jointly performed the literature search and conceptualised
the content and figures of this Series paper. SYG designed the original draft
of the figures and reviewed and edited the manuscript. MAM wrote the
original draft of the manuscript and reviewed and edited the figures. Both
authors approved the final version of this Series paper for submission.
Declaration of interests
No funding was provided specifically for this Series paper. SYG reports
grants from the Christiane Herzog Foundation, the German Cystic
Fibrosis Association (Mukoviszidose), Vertex Pharmaceuticals,
and a fellowship from the Berlin Institute of Health Charité Clinician
Scientist Program; lecture honoraria from Chiesi and Vertex
Pharmaceuticals; and advisory board participation for Chiesi and Vertex
Pharmaceuticals outside the submitted work. MAM reports grants from
the German Research Foundation (DFG; grant numbers SFB-TR 84 and
SFB 1449; project numbers 431232613 and 450557679), the German
Federal Ministry of Education and Research (BMBF; grant number
82DZL009B1), the German Innovation Fund (grant number
01NVF19008), and Vertex Pharmaceuticals; consulting fees from AbbVie,
Antabio, Arrowhead Pharmaceuticals, Boehringer Ingelheim, Enterprise
Therapeutics, Kither Biotech, Prieris, Recode, Santhera, Splisense, and
Vertex Pharmaceuticals; lecture honoraria from Vertex Pharmaceuticals;
travel support from Boehringer Ingelheim and Vertex Pharmaceuticals;
a patent on the Scnn1b-transgenic mouse as an animal model for chronic
obstructive pulmonary disease and cystic fibrosis, a patent on the medical
uses of thiol-functionalised polyglycerol derivatives, and a patent on
receptor for advanced glycation endproducts (RAGE) proteins for the
treatment of fibrosis and DNA damage-mediated diseases; and advisory
board participation with AbbVie, Antabio, Arrowhead Pharmaceuticals,
Boehringer Ingelheim, Enterprise Therapeutics, Kither Biotech, Pari,
and Vertex Pharmaceuticals outside the submitted work. MAM is
a Fellow of the European Respiratory Society (FERS).
References
1 Shteinberg M, Haq IJ, Polineni D, Davies JC. Cystic fibrosis. Lancet
2021; 397: 2195–211.
2 Bell SC, Mall MA, Gutierrez H, et al. The future of cystic fibrosis
care: a global perspective. Lancet Respir Med 2020; 8: 65–124.
3 Taylor-Cousar JL, Robinson PD, Shteinberg M, Downey D. CFTR
modulator therapy: transforming the landscape of clinical care in
cystic fibrosis. Lancet 2023; published online Sept 9. https://doi.
org/10.1016/S0140-6736(23)01609-4.
4 Hisert KB, Birket S, Clancy JP, et al. Understanding and addressing
the needs of people with cystic fibrosis in the era of CFTR
modulator therapy. Lancet Respir Med 2023; published online Sept 9.
https://doi.org/10.1016/S2213-2600(23)00324-7.
5 McGarry ME, McColley SA. Cystic fibrosis patients of minority race
and ethnicity less likely eligible for CFTR modulators based on
CFTR genotype. Pediatr Pulmonol 2021; 56: 1496–503.
6 Mall MA, Mayer-Hamblett N, Rowe SM. Cystic fibrosis:
emergence of highly effective targeted therapeutics and potential
clinical implications. Am J Respir Crit Care Med 2020;
201: 1193–208.
7 Stoltz DA, Meyerholz DK, Welsh MJ. Origins of cystic fibrosis
lung disease. N Engl J Med 2015; 372: 1574–75.
8 Riordan JR. CFTR function and prospects for therapy.
Annu Rev Biochem 2008; 77: 701–26.
9 Boucher RC. Airway surface dehydration in cystic fibrosis:
pathogenesis and therapy. Annu Rev Med 2007; 58: 157–70.
10 Sheppard DN, Welsh MJ. Structure and function of the CFTR
chloride channel. Physiol Rev 1999; 79 (suppl): S23–45.
11 Welsh MJ, Smith AE. Molecular mechanisms of CFTR chloride
channel dysfunction in cystic fibrosis. Cell 1993; 73: 1251–54.
1196
12 Mendoza JL, Schmidt A, Li Q, et al. Requirements for efficient
correction of ΔF508 CFTR revealed by analyses of evolved
sequences. Cell 2012; 148: 164–74.
13 Rabeh WM, Bossard F, Xu H, et al. Correction of both NBD1
energetics and domain interface is required to restore ΔF508 CFTR
folding and function. Cell 2012; 148: 150–63.
14 Veit G, Avramescu RG, Chiang AN, et al. From CFTR biology
toward combinatorial pharmacotherapy: expanded classification of
cystic fibrosis mutations. Mol Biol Cell 2016; 27: 424–33.
15 Graeber SY, Vitzthum C, Pallenberg ST, et al. Effects of elexacaftor/
tezacaftor/ivacaftor therapy on CFTR function in patients with
cystic fibrosis and one or two F508del alleles.
Am J Respir Crit Care Med 2022; 205: 540–49.
16 Dekkers JF, Wiegerinck CL, de Jonge HR, et al. A functional CFTR
assay using primary cystic fibrosis intestinal organoids. Nat Med
2013; 19: 939–45.
17 Clancy JP, Cotton CU, Donaldson SH, et al. CFTR modulator
theratyping: current status, gaps and future directions. J Cyst Fibros
2019; 18: 22–34.
18 Ramalho AS, Amato F, Gentzsch M. Patient-derived cell models for
personalized medicine approaches in cystic fibrosis. J Cyst Fibros
2023; 22 (suppl): S32-8.
19 Fiedorczuk K, Chen J. Molecular structures reveal synergistic rescue
of Δ508 CFTR by Trikafta modulators. Science 2022; 378: 284–90.
20 Boucher RC, Stutts MJ, Knowles MR, Cantley L, Gatzy JT.
Na+ transport in cystic fibrosis respiratory epithelia. Abnormal
basal rate and response to adenylate cyclase activation. J Clin Invest
1986; 78: 1245–52.
21 Mall M, Grubb BR, Harkema JR, O’Neal WK, Boucher RC.
Increased airway epithelial Na+ absorption produces cystic fibrosis-
like lung disease in mice. Nat Med 2004; 10: 487–93.
22 Caputo A, Caci E, Ferrera L, et al. TMEM16A, a membrane protein
associated with calcium-dependent chloride channel activity. Science
2008; 322: 590–94.
23 Pedemonte N, Galietta LJ. Structure and function of TMEM16
proteins (anoctamins). Physiol Rev 2014; 94: 419–59.
24 Salomon JJ, Albrecht T, Graeber SY, et al. Chronic rhinosinusitis
with nasal polyps is associated with impaired TMEM16A-mediated
epithelial chloride secretion. J Allergy Clin Immunol 2021;
147: 2191–201.
25 Balázs A, Mall MA. Role of the SLC26A9 chloride channel as
disease modifier and potential therapeutic target in cystic fibrosis.
Front Pharmacol 2018; 9: 1112.
26 Gong J, He G, Wang C, et al. Genetic evidence supports the
development of SLC26A9 targeting therapies for the treatment of
lung disease. NPJ Genom Med 2022; 7: 28.
27 Galietta LJV. TMEM16A (ANO1) as a therapeutic target in cystic
fibrosis. Curr Opin Pharmacol 2022; 64: 102206.
28 Gorrieri G, Zara F, Scudieri P. SLC26A9 as a potential modifier and
therapeutic target in cystic fibrosis lung disease. Biomolecules 2022;
12: 202.
29 Okuda K, Dang H, Kobayashi Y, et al. Secretory cells dominate
airway CFTR expression and function in human airway superficial
epithelia. Am J Respir Crit Care Med 2021; 203: 1275–89.
30 Boucher RC. Muco-obstructive lung diseases. N Engl J Med 2019;
380: 1941–53.
31 Fahy JV, Dickey BF. Airway mucus function and dysfunction.
N Engl J Med 2010; 363: 2233–47.
32 Henderson AG, Ehre C, Button B, et al. Cystic fibrosis airway
secretions exhibit mucin hyperconcentration and increased osmotic
pressure. J Clin Invest 2014; 124: 3047–60.
33 Matsui H, Grubb BR, Tarran R, et al. Evidence for periciliary liquid
layer depletion, not abnormal ion composition, in the pathogenesis
of cystic fibrosis airways disease. Cell 1998; 95: 1005–15.
34 Hill DB, Button B, Rubinstein M, Boucher RC. Physiology and
pathophysiology of human airway mucus. Physiol Rev 2022;
102: 1757–836.
35 Button B, Cai LH, Ehre C, et al. A periciliary brush promotes the
lung health by separating the mucus layer from airway epithelia.
Science 2012; 337: 937–41.
36 Yuan S, Hollinger M, Lachowicz-Scroggins ME, et al. Oxidation
increases mucin polymer cross-links to stiffen airway mucus gels.
Sci Transl Med 2015; 7: 276ra27.
www.thelancet.com Vol 402 September 30, 2023

37 Pino-Argumedo MI, Fischer AJ, Hilkin BM, et al. Elastic mucus
strands impair mucociliary clearance in cystic fibrosis pigs.
Proc Natl Acad Sci USA 2022; 119: e2121731119.
38 Hughes GW, Ridley C, Collins R, Roseman A, Ford R, Thornton DJ.
The MUC5B mucin polymer is dominated by repeating structural
motifs and its topology is regulated by calcium and pH. Sci Rep
2019; 9: 17350.
39 Quinton PM. Cystic fibrosis: impaired bicarbonate secretion and
mucoviscidosis. Lancet 2008; 372: 415–17.
40 Quinton PM. Role of epithelial HCO3– transport in mucin secretion:
lessons from cystic fibrosis. Am J Physiol Cell Physiol 2010;
299: C1222–33.
41 Shah VS, Meyerholz DK, Tang XX, et al. Airway acidification
initiates host defense abnormalities in cystic fibrosis mice. Science
2016; 351: 503–07.
42 Pezzulo AA, Tang XX, Hoegger MJ, et al. Reduced airway surface
pH impairs bacterial killing in the porcine cystic fibrosis lung.
Nature 2012; 487: 109–13.
43 Schultz A, Puvvadi R, Borisov SM, et al. Airway surface liquid pH is
not acidic in children with cystic fibrosis. Nat Commun 2017;
8: 1409.
44 Cavinato L, Luly FR, Pastore V, et al. Elexacaftor/tezacaftor/ivacaftor
corrects monocyte microbicidal deficiency in cystic fibrosis.
Eur Respir J 2023; 61: 2200725.
45 Zhang S, Shrestha CL, Robledo-Avila F, et al. Cystic fibrosis
macrophage function and clinical outcomes after elexacaftor/
tezacaftor/ivacaftor. Eur Respir J 2023; 61: 2102861.
46 Brinkert K, Hedtfeld S, Burhop A, et al. Rescue from
Pseudomonas aeruginosa airway infection via stem cell
transplantation. Mol Ther 2021; 29: 1324–34.
47 Di A, Brown ME, Deriy LV, et al. CFTR regulates phagosome
acidification in macrophages and alters bactericidal activity.
Nat Cell Biol 2006; 8: 933–44.
48 Blanchard AC, Waters VJ. Microbiology of cystic fibrosis airway
disease. Semin Respir Crit Care Med 2019; 40: 727–36.
49 Caverly LJ, LiPuma JJ. Cystic fibrosis respiratory microbiota:
unraveling complexity to inform clinical practice.
Expert Rev Respir Med 2018; 12: 857–65.
50 Marsland BJ, Gollwitzer ES. Host-microorganism interactions in
lung diseases. Nat Rev Immunol 2014; 14: 827–35.
51 Muhlebach MS, Zorn BT, Esther CR, et al. Initial acquisition and
succession of the cystic fibrosis lung microbiome is associated with
disease progression in infants and preschool children. PLoS Pathog
2018; 14: e1006798.
52 McKelvey MC, Weldon S, McAuley DF, Mall MA, Taggart CC.
Targeting proteases in cystic fibrosis lung disease. paradigms,
progress, and potential. Am J Respir Crit Care Med 2020; 201: 141–47.
53 Sly PD, Gangell CL, Chen L, et al. Risk factors for bronchiectasis in
children with cystic fibrosis. N Engl J Med 2013; 368: 1963–70.
54 Mayer-Hamblett N, Aitken ML, Accurso FJ, et al. Association
between pulmonary function and sputum biomarkers in cystic
fibrosis. Am J Respir Crit Care Med 2007; 175: 822–28.
55 Rosen BH, Evans TIA, Moll SR, et al. Infection is not required for
mucoinflammatory lung disease in CFTR-knockout ferrets.
Am J Respir Crit Care Med 2018; 197: 1308–18.
56 Fritzsching B, Zhou-Suckow Z, Trojanek JB, et al. Hypoxic
epithelial necrosis triggers neutrophilic inflammation via IL-1
receptor signaling in cystic fibrosis lung disease.
Am J Respir Crit Care Med 2015; 191: 902–13.
57 Livraghi-Butrico A, Kelly EJ, Klem ER, et al. Mucus clearance,
MyD88-dependent and MyD88-independent immunity modulate
lung susceptibility to spontaneous bacterial infection and
inflammation. Mucosal Immunol 2012; 5: 397–408.
58 Le Gars M, Descamps D, Roussel D, et al. Neutrophil elastase
degrades cystic fibrosis transmembrane conductance regulator via
calpains and disables channel function in vitro and in vivo.
Am J Respir Crit Care Med 2013; 187: 170–79.
59 Ribeiro CMP, Gentzsch M. Impact of airway inflammation on the
efficacy of CFTR modulators. Cells 2021; 10: 3260.
60 Nichols DP, Morgan SJ, Skalland M, et al. Pharmacologic
improvement of CFTR function rapidly decreases sputum pathogen
density, but lung infections generally persist. J Clin Invest 2023;
133: e167957.
www.thelancet.com Vol 402 September 30, 2023
Series
61 Schaupp L, Addante A, Völler M, et al. Longitudinal effects of
elexacaftor/tezacaftor/ivacaftor on sputum viscoelastic properties,
airway infection and inflammation in patients with cystic fibrosis.
Eur Respir J 2023; 62: 2202153.
62 López-Otín C, Kroemer G. Hallmarks of health. Cell 2021;
184: 33–63.
63 Rajewsky N, Almouzni G, Gorski SA, et al. LifeTime and improving
European healthcare through cell-based interceptive medicine.
Nature 2020; 587: 377–86.
64 Goralski JL, Hoppe JE, Mall MA, et al. Phase 3 open-label clinical
trial of elexacaftor/tezacaftor/ivacaftor in children aged 2–5 years
with cystic fibrosis and at least one F508del allele.
Am J Respir Crit Care Med 2023; 208: 59–67.
65 Sutharsan S, McKone EF, Downey DG, et al. Efficacy and safety of
elexacaftor plus tezacaftor plus ivacaftor versus tezacaftor plus
ivacaftor in people with cystic fibrosis homozygous for F508del-
CFTR: a 24-week, multicentre, randomised, double-blind, active-
controlled, phase 3b trial. Lancet Respir Med 2022; 10: 267–77.
66 Mall MA, Brugha R, Gartner S, et al. Efficacy and safety of
elexacaftor/tezacaftor/ivacaftor in children 6 through 11 years of age
with cystic fibrosis heterozygous for F508del and a minimal
function mutation: a phase 3b, randomized, placebo-controlled
study. Am J Respir Crit Care Med 2022; 206: 1361–69.
67 Zemanick ET, Taylor-Cousar JL, Davies J, et al. A phase 3 open-label
study of elexacaftor/tezacaftor/ivacaftor in children 6 through
11 years of age with cystic fibrosis and at least one F508del allele.
Am J Respir Crit Care Med 2021; 203: 1522–32.
68 Griese M, Costa S, Linnemann RW, et al. Safety and efficacy of
elexacaftor/tezacaftor/ivacaftor for 24 weeks or longer in people
with cystic fibrosis and one or more F508del alleles: interim results
of an open-label phase 3 clinical trial. Am J Respir Crit Care Med
2021; 203: 381–85.
69 Heijerman HGM, McKone EF, Downey DG, et al. Efficacy and
safety of the elexacaftor plus tezacaftor plus ivacaftor combination
regimen in people with cystic fibrosis homozygous for the F508del
mutation: a double-blind, randomised, phase 3 trial. Lancet 2019;
394: 1940–48.
70 Middleton PG, Mall MA, Dřevínek P, et al. Elexacaftor-tezacaftor-
ivacaftor for cystic fibrosis with a single Phe508del allele.
N Engl J Med 2019; 381: 1809–19.
71 Taylor-Cousar JL, Mall MA, Ramsey BW, et al. Clinical development
of triple-combination CFTR modulators for cystic fibrosis patients
with one or two F508del alleles. ERJ Open Res 2019; 5: 00082-2019.
72 Graeber SY, Dopfer C, Naehrlich L, et al. Effects of lumacaftor-
ivacaftor therapy on cystic fibrosis transmembrane conductance
regulator function in Phe508del homozygous patients with cystic
fibrosis. Am J Respir Crit Care Med 2018; 197: 1433–42.
73 Barry PJ, Mall MA, Álvarez A, et al. Triple therapy for cystic fibrosis
Phe508del-gating and -residual function genotypes. N Engl J Med
2021; 385: 815–25.
74 Choi JY, Muallem D, Kiselyov K, Lee MG, Thomas PJ, Muallem S.
Aberrant CFTR-dependent HCO3- transport in mutations associated
with cystic fibrosis. Nature 2001; 410: 94–97.
75 Ramalho AS, Fürstová E, Vonk AM, et al. Correction of CFTR
function in intestinal organoids to guide treatment of cystic fibrosis.
Eur Respir J 2021; 57: 1902426.
76 Burgel PR, Sermet-Gaudelus I, Durieu I, et al. The French
Compassionate Program of elexacaftor–tezacaftor–ivacaftor in
people with cystic fibrosis with advanced lung disease and no
F508del CFTR variant. Eur Respir J 2023; 2202437.
77 Sun X, Yi Y, Yan Z, et al. In utero and postnatal VX-770
administration rescues multiorgan disease in a ferret model of
cystic fibrosis. Sci Transl Med 2019; 11: eaau7531.
78 McCague AF, Raraigh KS, Pellicore MJ, et al. Correlating cystic
fibrosis transmembrane conductance regulator function with
clinical features to inform precision treatment of cystic fibrosis.
Am J Respir Crit Care Med 2019; 199: 1116–26.
79 McKone EF, Emerson SS, Edwards KL, Aitken ML. Effect of
genotype on phenotype and mortality in cystic fibrosis:
a retrospective cohort study. Lancet 2003; 361: 1671–76.
80 Uluer AZ, MacGregor G, Azevedo P, et al. Safety and efficacy of
vanzacaftor–tezacaftor–deutivacaftor in adults with cystic fibrosis:
randomised, double-blind, controlled, phase 2 trials.
Lancet Respir Med 2023; 11: 550–62.
1197
 Series
81 Veit G, Xu H, Dreano E, et al. Structure-guided combination
therapy to potently improve the function of mutant CFTRs. Nat Med
2018; 24: 1732–42.
82 Ghigo A, Murabito A, Sala V, et al. A PI3Kγ mimetic peptide
triggers CFTR gating, bronchodilation, and reduced inflammation
in obstructive airway diseases. Sci Transl Med 2022; 14: eabl6328.
83 Wilschanski M, Yahav Y, Yaacov Y, et al. Gentamicin-induced
correction of CFTR function in patients with cystic fibrosis and
CFTR stop mutations. N Engl J Med 2003; 349: 1433–41.
84 Leubitz A, Vanhoutte F, Hu MY, et al. A randomized, double-blind,
placebo-controlled, multiple dose escalation study to evaluate the
safety and pharmacokinetics of ELX-02 in healthy subjects.
Clin Pharmacol Drug Dev 2021; 10: 859–69.
85 Kerem E. ELX-02: an investigational read-through agent for the
treatment of nonsense mutation-related genetic disease.
Expert Opin Investig Drugs 2020; 29: 1347–54.
86 Sharma J, Du M, Wong E, et al. A small molecule that induces
translational readthrough of CFTR nonsense mutations by eRF1
depletion. Nat Commun 2021; 12: 4358.
87 de Poel E, Spelier S, Suen SWF, et al. Functional restoration of
CFTR nonsense mutations in intestinal organoids. J Cyst Fibros
2022; 21: 246–53.
88 Mall MA. ENaC inhibition in cystic fibrosis: potential role in the
new era of CFTR modulator therapies. Eur Respir J 2020;
56: 2000946.
89 Ratjen F, Durham T, Navratil T, et al. Long term effects of denufosol
tetrasodium in patients with cystic fibrosis. J Cyst Fibros 2012;
11: 539–49.
90 Moss RB. Pitfalls of drug development: lessons learned from trials
of denufosol in cystic fibrosis. J Pediatr 2013; 162: 676–80.
91 Gentzsch M, Mall MA. Ion channel modulators in cystic fibrosis.
Chest 2018; 154: 383–93.
92 Danahay HL, Lilley S, Fox R, et al. TMEM16A potentiation: a novel
therapeutic approach for the treatment of cystic fibrosis.
Am J Respir Crit Care Med 2020; 201: 946–54.
93 Sonneville F, Ruffin M, Coraux C, et al. MicroRNA-9 downregulates
the ANO1 chloride channel and contributes to cystic fibrosis lung
pathology. Nat Commun 2017; 8: 710.
94 Allaire NE, Griesenbach U, Kerem B, Lueck JD, Stanleigh N,
Oren YS. Gene, RNA, and ASO-based therapeutic approaches in
Cystic Fibrosis. J Cyst Fibros 2023; 22 (suppl 1): S39–44.
95 Harrison PT. CFTR RNA- and DNA-based therapies.
Curr Opin Pharmacol 2022; 65: 102247.
96 McLachlan G, Alton EWFW, Boyd AC, et al. Progress in respiratory
gene therapy. Hum Gene Ther 2022; 33: 893–912.
97 Rowe SM, Zuckerman JB, Dorgan D, et al. Inhaled mRNA therapy
for treatment of cystic fibrosis: Interim results of a randomized,
double-blind, placebo-controlled phase 1/2 clinical study.
J Cyst Fibros 2023; published online April 29. https://doi.
org/10.1016/j.jcf.2023.04.008.
98 Mitomo K, Griesenbach U, Inoue M, et al. Toward gene therapy for
cystic fibrosis using a lentivirus pseudotyped with Sendai virus
envelopes. Mol Ther 2010; 18: 1173–82.
99 Alton EW, Beekman JM, Boyd AC, et al. Preparation for a first-in-
man lentivirus trial in patients with cystic fibrosis. Thorax 2017;
72: 137–47.
100 Finkel RS, Chiriboga CA, Vajsar J, et al. Treatment of infantile-onset
spinal muscular atrophy with nusinersen: a phase 2, open-label,
dose-escalation study. Lancet 2016; 388: 3017–26.
101 Mendell JR, Goemans N, Lowes LP, et al. Longitudinal effect of
eteplirsen versus historical control on ambulation in Duchenne
muscular dystrophy. Ann Neurol 2016; 79: 257–71.
102 Oren YS, Irony-Tur Sinai M, Golec A, et al. Antisense
oligonucleotide-based drug development for cystic fibrosis patients
carrying the 3849+10 kb C-to-T splicing mutation. J Cyst Fibros 2021;
20: 865–75.
103 Oren YS, Avizur-Barchad O, Ozeri-Galai E, et al. Antisense
oligonucleotide splicing modulation as a novel cystic fibrosis
therapeutic approach for the W1282X nonsense mutation.
J Cyst Fibros 2022; 21: 630–36.
1198
104 Albers S, Allen EC, Bharti N, et al. Engineered tRNAs suppress
nonsense mutations in cells and in vivo. Nature 2023; 618: 842–48.
105 Ko W, Porter JJ, Sipple MT, Edwards KM, Lueck JD. Efficient
suppression of endogenous CFTR nonsense mutations using
anticodon-engineered transfer RNAs. Mol Ther Nucleic Acids 2022;
28: 685–701.
106 Lueck JD, Yoon JS, Perales-Puchalt A, et al. Engineered transfer
RNAs for suppression of premature termination codons.
Nat Commun 2019; 10: 822.
107 Amaral MD, Harrison PT. Development of novel therapeutics for all
individuals with CF (the future goes on). J Cyst Fibros 2023;
22 (suppl 1): S45–49.
108 Geurts MH, de Poel E, Pleguezuelos-Manzano C, et al. Evaluating
CRISPR-based prime editing for cancer modeling and CFTR repair
in organoids. Life Sci Alliance 2021; 4: e202000940.
109 Geurts MH, de Poel E, Amatngalim GD, et al. CRISPR-based
adenine editors correct nonsense mutations in a cystic fibrosis
organoid biobank. Cell Stem Cell 2020; 26: 503–10.
110 Mayer-Hamblett N, Clancy JP, Jain R, et al. NAdvancing the
pipeline of cystic fibrosis clinical trials: a new roadmap with a global
trial network perspective. Lancet Respir Med 2023; published online
Sept 9. https://doi.org/10.1016/S2213-2600(23)00297-7.
111 Addante A, Raymond W, Gitlin I, et al. A novel thiol-saccharide
mucolytic for the treatment of muco-obstructive lung diseases.
Eur Respir J 2023; 61: 2202022.
112 Ehre C, Rushton ZL, Wang B, et al. An improved inhaled mucolytic
to treat airway muco-obstructive diseases. Am J Respir Crit Care Med
2019; 199: 171–80.
113 Barth P, Bruijnzeel P, Wach A, et al. Single dose escalation studies
with inhaled POL6014, a potent novel selective reversible inhibitor
of human neutrophil elastase, in healthy volunteers and subjects
with cystic fibrosis. J Cyst Fibros 2020; 19: 299–304.
114 Chalmers JD, Haworth CS, Metersky ML, et al. Phase 2 trial of the
DPP-1 inhibitor brensocatib in bronchiectasis. N Engl J Med 2020;
383: 2127–37.
115 Murray TS, Stanley G, Koff JL. Novel approaches to multidrug-
resistant infections in cystic fibrosis. Clin Chest Med 2022;
43: 667–76.
116 Trend S, Fonceca AM, Ditcham WG, Kicic A, Cf A. The potential of
phage therapy in cystic fibrosis: essential human-bacterial-phage
interactions and delivery considerations for use in Pseudomonas
aeruginosa-infected airways. J Cyst Fibros 2017; 16: 663–70.
117 Sanya DRA, Onésime D, Vizzarro G, Jacquier N. Recent advances
in therapeutic targets identification and development of treatment
strategies towards Pseudomonas aeruginosa infections.
BMC Microbiol 2023; 23: 86.
118 Ong T, Ramsey BW. Cystic fibrosis: a review. JAMA 2023;
329: 1859–71.
119 Elborn JS, Blasi F, Burgel PR, Peckham D. Role of inhaled
antibiotics in the era of highly effective CFTR modulators.
Eur Respir Rev 2023; 32: 220154.
120 Barton TE, Frost F, Fothergill JL, Neill DR. Challenges and
opportunities in the development of novel antimicrobial
therapeutics for cystic fibrosis. J Med Microbiol 2022; published
online Dec 21. https://doi.org/10.1099/jmm.0.001643.
121 Mall MA, Criner GJ, Miravitlles M, et al. Cystic fibrosis
transmembrane conductance regulator in COPD: a role in
respiratory epithelium and beyond. Eur Respir J 2023; 61: 2201307.
122 Dunican EM, Elicker BM, Henry T, et al. Mucus plugs and
emphysema in the pathophysiology of airflow obstruction and
hypoxemia in smokers. Am J Respir Crit Care Med 2021; 203: 957–68.
123 Chalmers JD, Chang AB, Chotirmall SH, Dhar R, McShane PJ.
Bronchiectasis. Nat Rev Dis Primers 2018; 4: 45.
Copyright © 2023 Elsevier Ltd. All rights reserved.
www.thelancet.com Vol 402 September 30, 2023