Highlights
The Phase 3 CIFFREO trial evaluated fordadistrogene movaparvovec, an investigational AAV9-based mini-dystrophin gene therapy, in 122 ambulatory boys with Duchenne muscular dystrophy (DMD).
The study failed to meet its primary endpoint, with no statistically significant difference in the North Star Ambulatory Assessment (NSAA) total score change from baseline to week 52 between the treatment and placebo groups (p=0.91).
Safety concerns were prominent, with serious adverse events occurring in 32% of the treatment group compared to 14% in the placebo group.
Following these results, the study sponsor (Pfizer) has discontinued further clinical development of fordadistrogene movaparvovec, marking a significant setback in the DMD gene therapy landscape.
The Evolving Landscape of Duchenne Muscular Dystrophy Treatment
Duchenne muscular dystrophy (DMD) is a devastating X-linked recessive neuromuscular disorder characterized by the absence of functional dystrophin, a critical protein for maintaining muscle fiber integrity. Affecting approximately 1 in 3,500 to 5,000 male births, the disease leads to progressive muscle wasting, loss of ambulation in the early teens, and premature death due to respiratory or cardiac failure. For decades, the standard of care was limited to corticosteroid therapy, which, while effective at slowing progression, carries a heavy burden of systemic side effects.
The advent of gene-based therapies represented a paradigm shift. Because DMD is caused by mutations in a single gene (DMD), it is a prime candidate for gene replacement. However, the size of the full-length dystrophin gene exceeds the packaging capacity of adeno-associated virus (AAV) vectors. This necessitates the use of ‘mini-dystrophin’—truncated but functional versions of the protein. Fordadistrogene movaparvovec was developed as an rAAV9-based vector designed to deliver such a transgene, aiming to convert the severe DMD phenotype into a milder, Becker-like muscular dystrophy phenotype.
CIFFREO Study Design: A Rigorous Phase 3 Evaluation
The CIFFREO trial was a multicenter, double-blind, randomized, placebo-controlled Phase 3 study conducted across 45 sites globally. The trial aimed to provide definitive evidence on the safety and efficacy of fordadistrogene movaparvovec following promising but early-stage data. The study enrolled 122 ambulatory male participants aged 4 to 7 years with a confirmed genetic diagnosis of DMD.
Participants were randomized 2:1 into two cohorts. Cohort 1 received an intravenous infusion of fordadistrogene movaparvovec (2 x 10^14 vector genomes [vg]/kg) on day 1, followed by a placebo at 12 months. Cohort 2 received a placebo on day 1 and was scheduled to receive the active gene therapy at 12 months. This cross-over design was intended to eventually provide the therapy to all participants while maintaining a rigorous placebo-controlled period for the primary analysis.
The primary efficacy endpoint was the change from baseline in the North Star Ambulatory Assessment (NSAA) total score at week 52. The NSAA is a 17-item scale used to evaluate functional motor abilities in ambulatory children with DMD, with higher scores indicating better function. Secondary endpoints included the timed 10-meter run/walk, the rise-from-floor time, and various safety parameters.
Efficacy Results: A Disappointing Lack of Separation
The primary analysis included 64 participants in the fordadistrogene movaparvovec group and 28 in the placebo group who completed the 52-week follow-up. At the start of the study, both groups were well-matched; the mean age was approximately 6.4 years, and the baseline NSAA scores were 22.5 and 23.5 for the treatment and placebo groups, respectively.
At the 52-week mark, the results were sobering. The least squares (LS) mean change from baseline in the NSAA total score was 1.46 (SE 0.43) for the fordadistrogene movaparvovec group and 1.37 (SE 0.65) for the placebo group. The treatment difference was a negligible 0.09 (95% CI -1.46 to 1.64), resulting in a p-value of 0.91. This indicated that the gene therapy provided no detectable functional benefit over the natural history of the disease modified by standard care (corticosteroids) within the one-year timeframe.
Secondary functional outcomes mirrored the primary result, failing to show a significant divergence between the treatment arm and the placebo arm. While gene expression data (mini-dystrophin levels) were not the primary focus of this specific report, the lack of clinical translation suggests either insufficient protein production, inadequate distribution, or a biological failure of the mini-dystrophin construct itself to stabilize muscle fibers in this patient population.
Safety Profile and Adverse Event Analysis
Safety remains a paramount concern in systemic AAV gene therapy, particularly at high doses. In CIFFREO, adverse events (AEs) were nearly universal in the treatment group, occurring in 99% of participants compared to 77% in the placebo group. Most common AEs included vomiting (76%), pyrexia (62%), and decreased appetite (33%).
Of greater clinical concern was the incidence of serious adverse events (SAEs). Thirty-two percent (25 of 79) of participants receiving the gene therapy experienced an SAE, compared to 14% in the placebo group. Notable SAEs associated with the therapy included immune-mediated reactions, such as myocarditis and acute kidney injury, which have been observed in other AAV9-based trials. While there were no deaths in this specific study, the high rate of SAEs, coupled with the lack of efficacy, created a negative benefit-risk profile.
Expert Commentary: Contextualizing the Failure
The failure of fordadistrogene movaparvovec in Phase 3 highlights the immense challenges of translating gene therapy from early-stage biological promise to clinical efficacy. Several factors may have contributed to these results. First, the ‘placebo’ group in DMD trials often performs better than historical natural history data suggest, likely due to optimized corticosteroid management and the ‘trial effect’ where participants receive intensive specialized care. This makes the threshold for showing superiority much higher.
Second, the specific mini-dystrophin construct used in this trial may not have possessed the necessary domains to fully replace the function of the missing full-length dystrophin. Unlike delandistrogene moxeparvovec (Elevidys), which received accelerated approval based on different clinical data, the fordadistrogene movaparvovec construct failed to demonstrate a meaningful impact on the NSAA scale in this larger, more diverse cohort.
Third, the timing of intervention is critical. While the study targeted boys aged 4 to 7, it is possible that by this age, significant muscle fibrosis has already occurred, limiting the potential for gene therapy to restore function. However, given that the placebo group also remained relatively stable, the lack of separation remains the primary issue.
Conclusion and Future Directions
The results of the CIFFREO trial are a significant blow to the DMD community. The determination by the sponsor to discontinue the development of fordadistrogene movaparvovec underscores the rigorous and often harsh reality of late-stage clinical trials. For clinicians, these findings serve as a reminder that biomarker success (protein expression) does not always equate to functional success.
Despite this setback, the search for effective DMD treatments continues. Other gene therapy products, exon-skipping agents, and next-generation anti-inflammatory drugs remain under investigation. The lessons learned from CIFFREO—regarding vector dosing, immune management, and endpoint selection—will be invaluable for the design of future trials. For now, the focus returns to optimizing existing therapies while awaiting the next generation of genetic interventions.
Funding and Clinical Trial Information
This study was funded by Pfizer. The trial is registered at ClinicalTrials.gov under the identifier NCT04281485. The study is currently listed as active but not recruiting, as the primary development program for the agent has been terminated.
References
1. Muntoni F, Nascimento A, Shin J, et al. Safety and efficacy of fordadistrogene movaparvovec in ambulatory participants with Duchenne muscular dystrophy (CIFFREO): a phase 3, double-blind, randomised, placebo-controlled study. Lancet Neurol. 2026;25(3):245-255. doi:10.1016/S1474-4422(26)00036-0.
2. Mendell JR, Campbell K, Rodino-Klapac L, et al. Gene therapy for Duchenne muscular dystrophy. Arch Neurol. 2010;67(2):202-207.
3. Birnkrant DJ, Bushby K, Bann CM, et al. Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and neuromuscular, rehabilitation, endocrine, and gastrointestinal and nutritional management. Lancet Neurol. 2018;17(3):251-267.
