Functional orthogonality of WRN inhibitor resistance enables alternating therapy and mutation-tolerant inhibitor design in MSI-H cancers

Abstract

Werner syndrome helicase (WRN) is a synthetic-lethal vulnerability in microsatellite instability-high (MSI-H)/mismatch repair-deficient (dMMR) cancers1-5, and non-covalent and covalent WRN inhibitors are now entering clinical development6-9. A central unresolved question is whether resistance to one WRN inhibitor class inevitably compromises the target, or instead creates actionable vulnerabilities to an alternate modality. Here we generated ten stable acquired-resistance models across three MSI-H cell lines using the non-covalent inhibitor HRO761 and the covalent inhibitor VVD-214. Whole-exome sequencing, biochemical reconstitution and isogenic knock-in models identified recurrent on-target WRN missense mutations as dominant resistance drivers, but with sharply modality-specific spectra: HRO761 resistance clustered at G729/F730/I852, whereas VVD-214 resistance concentrated at E846. These mutations impaired inhibitor engagement and abolished the canonical WRN inhibitor (WRNi)-induced pharmacodynamic cascade, including WRN reduction, DNA damage response (DDR) activation and G2/M arrest. Crucially, most resistance mutations retained biochemical, cellular and in vivo sensitivity to the alternate inhibitor modality, revealing a functional orthogonality that enabled a 7-day cyclic alternating regimen to delay tumour regrowth in xenografts. We further identified F730L as an engineered cross-resistant bottleneck model and used structure-guided, artificial intelligence (AI)-enabled optimization to generate GBA-007, a proof-of-concept mutation-tolerant WRN inhibitor candidate with promising activity against F730L in vitro and in vivo. Thus, clinically relevant WRN inhibitor classes impose distinct on-target resistance trajectories that can be exploited through schedule design, while cross-resistant bottlenecks can be addressed by rapid mutation-aware inhibitor engineering.