Ferroptosis in skeletal muscle: from molecular mechanisms to therapeutic interventions

Abstract

Ferroptosis is an iron-dependent, non-apoptotic form of regulated cell death driven by lethal lipid peroxidation and has emerged as a pivotal regulator of skeletal muscle physiology and pathology. This review systematically delineates the core molecular machinery of ferroptosis, including the system Xc⁻-glutathione-GPX4 axis, dysregulated iron metabolism, and lipid peroxidation, together with key regulatory networks involving p53, Nrf2, and AMPK. We further highlight the context-dependent roles of ferroptosis in skeletal muscle: during development and regeneration, transient and moderate ferroptotic signaling may facilitate myogenesis and tissue remodeling, whereas sustained or excessive ferroptosis drives satellite cell depletion and impaired regenerative capacity. Pathologically, ferroptosis is implicated in a spectrum of muscle disorders—including sarcopenia, muscular dystrophy, sports-related injuries, and inflammatory myopathies—through mechanisms such as iron overload, oxidative stress, and mitochondrial dysfunction. Finally, we summarize emerging therapeutic strategies targeting ferroptosis, including iron chelators, GPX4 activators, natural compounds, gene-based interventions, and physical exercise, and discuss future directions toward precision medicine and combinatorial approaches. By integrating current evidence, this work provides a comprehensive framework for understanding ferroptosis in skeletal muscle homeostasis and disease and offers insights for the development of novel therapeutic interventions.

The translational potential of this article

This review establishes ferroptosis as a convergent pathogenic mechanism across muscle disorders, offering a framework for patient stratification by ferrototic signatures. It synthesizes preclinical evidence for pharmacologic inhibitors, natural products, and gene-based interventions, while critically evaluating clinical feasibility, safety, and dosing. A tiered translational roadmap from biomarker validation to early-phase trials is proposed to accelerate bench-to-bedside development.

Graphical abstract

1. Introduction

Formally defined in 2012 as a regulated form of cell death, ferroptosis is now recognized as a fundamental contributor to physiological regulation and pathological tissue injury across multiple organ systems [1,2]. The defining biochemical signature of ferroptosis is the iron-dependent peroxidation of phospholipids containing polyunsaturated fatty acids (PUFAs), leading to membrane dysfunction and cell rupture. By integrating iron metabolism, lipid composition, and redox homeostasis, this mechanism fundamentally differs from traditional cell death modalities such as caspase-driven apoptosis or RIPK-driven necroptosis [3]. The molecular regulators of ferroptosis—including the GPX4–glutathione axis, the FSP1–CoQ10 axis, the DHODH–CoQ10 axis, the GCH1–BH4 system, the ACSL4–LPCAT3 lipid remodeling pathway, iron-handling proteins, and NRF2-driven transcriptional responses—form an integrated regulatory network whose collective function determines cellular ferroptotic susceptibility.

The recognition of ferroptosis has transformed our understanding of tissue injury in numerous pathologies, including neurodegeneration, ischemia-reperfusion injury, kidney disease, and cancer biology [[4], [5], [6]]. More recently, skeletal muscle ferroptosis has emerged as a distinct area of investigation, as evidence accumulates across diverse clinical conditions such as sarcopenia, cancer cachexia, exertional injury, ischemia-reperfusion, muscular dystrophies, and rhabdomyolysis [7,8]. Skeletal muscle inherently possesses distinctive physiological features that warrant focused consideration. These include the substantial iron content of muscle tissue (driven by myoglobin and the iron requirements of mitochondrial energetics), the membrane repair demands of contractile activity (which necessitate rapid lipid turnover), the metabolic flexibility that influences lipid composition, and the inter-organ regulatory inputs that shape muscle ferroptotic susceptibility in clinical scenarios.

The aim of this review is to provide a comprehensive mechanistic and translational integration of ferroptosis in skeletal muscle pathologies. Rather than presenting a purely mechanistic synthesis or a strict clinical compendium, this review bridges the two, connecting foundational mechanistic understanding with clinical presentations, biomarker strategies, therapeutic approaches, and inter-organ regulation. This integrative approach reflects the necessity for a multidimensional conceptual framework—one that connects molecular mechanisms with organismal pathophysiology—to drive effective progress in the muscle ferroptosis field.

2. Molecular mechanisms underlying ferroptosis

2.1. Definition, discovery, and core features

Ferroptosis is a distinct form of regulated cell death driven by iron-dependent lipid peroxidation. Morphologically, it is characterized by shrunken mitochondria with increased membrane density and markedly reduced or absent cristae [9]. Historically, although earlier studies identified similar cell death paradigms—such as “oxytosis” in 2001, which exhibited vulnerability to lipid peroxidation [10] —the formal concept of ferroptosis was not established until 2012. Dixon et al. coined the term after observing a novel non-apoptotic cell death pathway in RAS-mutant cancer cells. Crucially, they demonstrated that this process is inhibited by iron chelators (e.g., deferoxamine) and lipophilic antioxidants (e.g., ferrostatin-1), but remains unaffected by classical apoptosis inhibitors [2].

The biochemical execution of ferroptosis relies on three intersecting core dimensions: intracellular iron accumulation, lethal lipid peroxidation, and the collapse of antioxidant defenses. Fundamentally, the process depends on labile intracellular iron (particularly Fe²⁺), which drives the Fenton reaction to generate highly reactive hydroxyl radicals [2]. Concurrently, the specific lipid milieu required for ferroptosis is sculpted by enzymes such as acyl-CoA synthetase long-chain family member 4 (ACSL4), lysophosphatidylcholine acyltransferase 3 (LPCAT3), and phosphatidylethanolamine-binding protein 1 (PEBP1) [11,12]. Specifically, ACSL4 activates arachidonic or adrenic acid into their CoA derivatives, while LPCAT3 is responsible for incorporating these activated PUFAs into membrane phospholipids like phosphatidylethanolamine (PE). PEBP1 then directs 15-lipoxygenase (15-LOX) toward these PUFA-PEs, facilitating their selective enzymatic oxidation into lipid hydroperoxides. These hydroperoxides are subsequently cleaved via iron-mediated Fenton chemistry into lethal lipid radicals, driving a chain reaction that compromises membrane integrity [12,13].

Under normal physiological conditions, this catastrophic lipid peroxidation is restrained by the system Xc⁻–GSH–glutathione peroxidase 4 (GPX4) antioxidant axis [14,15]. System Xc⁻ functions as a cystine/glutamate antiporter, importing cystine necessary for GSH synthesis. GSH subsequently serves as an essential cofactor for GPX4, which reduces toxic lipid hydroperoxides into non-toxic lipid alcohols. Consequently, the failure of this defense system—whether through system Xc⁻ inhibition, intracellular cysteine depletion, or direct GPX4 degradation (e.g., via the small molecule FIN56)—triggers ferroptosis [[16], [17], [18]]. The indispensability of this axis is starkly illustrated by Gpx4-knockout mice, which suffer early embryonic lethality that can be partially rescued by iron chelation [11]. Importantly, while the primary execution of ferroptosis occurs at the cellular membrane, profound mitochondrial dysfunction frequently accompanies this process, serving to amplify oxidative stress and exacerbate cellular injury [19].

Collectively, these distinct morphological and biochemical features differentiate ferroptosis from other forms of regulated cell death. Consequently, they provide a robust conceptual framework for investigating its pathogenic role in skeletal muscle disorders. Given that dysregulated lipid metabolism and oxidative stress are prominent hallmarks of myopathies, the skeletal muscle system presents a compelling context for ferroptosis research, paralleling its established involvement in neurodegeneration, oncology, and cardiovascular diseases [20].

2.2. Iron metabolism and ferroptosis

Dysregulated iron metabolism—including abnormalities in iron uptake, transport, storage, and utilization—is a fundamental driver of ferroptosis (Table 1). Circulating iron, which is predominantly bound to transferrin (TF) as Fe³⁺, enters cells through transferrin receptor 1 (TFR1)-mediated endocytosis [21]. Within endosomes, Fe³⁺ is reduced to Fe²⁺ by the metalloreductase STEAP3 and transported into the cytosol by divalent metal transporter 1 (DMT1), thereby contributing to the labile iron pool (LIP) [22]. Cells can also acquire non-transferrin-bound iron (NTBI) through ZIP family transporters, particularly ZIP14 (SLC39A14). To maintain iron homeostasis, excess intracellular iron is sequestered in ferritin, a heteromultimeric complex composed of heavy and light chains. Under stress conditions, however, ferritin can be degraded through ferritinophagy—a selective form of autophagy mediated by the specific cargo receptor NCOA4—which rapidly releases Fe²⁺ into the LIP [23]. In parallel, heme oxygenase-1 (HO-1) catabolizes heme and further increases intracellular free iron levels [24].

Table 1.

Core molecular mechanisms of ferroptosis, key players, and evidence in skeletal muscle.

Core mechanism	Key regulators/pathways	Role in ferroptosis	Evidence/implication in skeletal muscle
Iron metabolism dysregulation	TFR1, DMT1, FPN, Ferritin, Ferritinophagy	Increases the labile iron pool, catalyzes the Fenton reaction, and generates ROS to drive lipid peroxidation.	In aging muscle: ↓TFR1 and ↑ZIP14 expression lead to iron accumulation. Satellite cell-specific Tfr1 knockout induces ferroptosis and impairs regeneration.
Lipid peroxidation	Substrates: AA/AdA (PUFAs) Enzymes: ACSL4, LPCAT3, ALOXs (e.g., ALOX15) Complex: PEBP1-ALOX15	ACSL4/LPCAT3 incorporate PUFAs into membrane PE; ALOXs or iron catalyze peroxidation, causing membrane damage.	ACSL4 is a key determinant of ferroptosis sensitivity. ALOX15 is upregulated after muscle injury. The SAT1/ALOX15 axis mediates exercise-induced muscle damage.
Antioxidant system failure	GPX4-dependent: System Xc− (SLC7A11/SLC3A2), GSH, GPX4 GPX4-independent: FSP1-CoQ10, DHODH-CoQ10, GCH1-BH4	GPX4 uses GSH to reduce lipid peroxides. System Xc− is crucial for GSH synthesis. FSP1, etc., scavenge radicals by reducing CoQ10.	SLC7A11 is downregulated in estrogen deficiency-induced atrophy. Nrf2 activation upregulates GPX4 and ameliorates muscular dystrophy. The FOXO1/TXNIP axis inhibits glutathione metabolism, inducing satellite cell ferroptosis.
Regulatory signaling pathways	p53, AMPK, Nrf2, PKCβII, Nuclear Receptors (ER/AR)	p53 can suppress SLC7A11 (pro-death) or activate p21 (anti-death). AMPK has dual roles via phosphorylating ACACA or BECN1. Nrf2 is the master regulator of antioxidant response.	p53 is upregulated in aged muscle, repressing Slc7a11. Exercise activates AMPK/Nrf2 to inhibit ferroptosis. Estrogen receptor upregulates MBOAT1/2, increasing MUFAs and conferring resistance.

Although iron is essential for physiological processes such as heme biosynthesis, electron transport chain assembly, and iron-sulfur cluster formation, excessive iron accumulation is cytotoxic. Cellular iron efflux is mediated primarily by ferroportin (FPN1), the only known mammalian cellular iron exporter, which is negatively regulated by the peptide hormone hepcidin [25]. In ferroptosis, these homeostatic mechanisms are frequently disrupted. In the context of skeletal muscle, these disruptions become particularly pronounced under pathological conditions or during senescence. For instance, aging is associated with altered iron uptake dynamics, including downregulation of TFR1 and upregulation of ZIP14. This shift favors NTBI uptake and exacerbates iron overload, thereby increasing susceptibility to ferroptosis [26]. Moreover, excessive ferritinophagy and HO-1-mediated heme degradation expand the LIP, directly promoting Fenton-mediated lipid peroxidation that drives ferroptotic cell death [27]. Consequently, age-related disruption of iron metabolism can induce ferroptosis in skeletal muscle, aggravate mitochondrial dysfunction, and ultimately impair mobility [28].

2.3. Lipid peroxidation and ferroptosis

Lipid peroxidation is the central biochemical event in ferroptosis and involves oxidation of PUFAs and the generation of lipid radicals (Table 1). PUFAs, especially ω-6 species such as arachidonic acid (AA, 20:4) and adrenic acid (AdA, 22:4), are the principal substrates for peroxidation during ferroptosis [29,30]. Membrane susceptibility to peroxidation is fundamentally determined by a specific remodeling pathway, making ACSL4 a key determinant of ferroptotic sensitivity [31]. ACSL4 activates these fatty acids to generate PUFA-acyl-CoAs, which are then esterified into PE by LPCAT3. The resulting PUFA-PE species create a pro-ferroptotic membrane landscape essential for disease execution. By contrast, ACSL3 promotes incorporation of monounsaturated fatty acids (MUFAs), which compete with PUFAs for membrane incorporation, thereby limiting the pool of oxidizable lipids and conferring resistance to ferroptosis [32]. Therapeutically leveraging this lipid dependence, deuterated polyunsaturated fatty acids (D-PUFAs) can attenuate oxidative stress- and ferroptosis-induced dysfunction in skeletal muscle cells by inhibiting lipid peroxidation at the bis-allylic carbon sites [33,34]. Mechanistically, D-PUFAs improve cell survival and myogenic differentiation by downregulating ferroptosis-related genes, reducing the expression of atrophy-associated ubiquitin ligases, and modulating genes involved in mitochondrial metabolic reprogramming [34].

Lipid peroxidation can be initiated through both enzymatic and non-enzymatic mechanisms. Enzymatically, lipoxygenases (ALOXs), including ALOX12 and ALOX15, catalyze the stereospecific oxygenation of free and esterified PUFAs to generate lipid hydroperoxides [35]. Crucially, the scaffolding protein PEBP1 forms a complex with ALOX15 and redirects its substrate specificity toward membrane-bound PUFA-PEs, thereby amplifying the lethal lipid peroxidation cascade [36]. Non-enzymatically, iron-catalyzed Fenton chemistry converts lipid hydroperoxides (LOOH) into highly reactive alkoxyl (LO·) and peroxyl (LOO·) radicals, thereby sustaining self-propagating chain reactions that generate further peroxyl (LOO·) radicals [37]. Decomposition of lipid peroxides produces highly reactive aldehydes, particularly malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE). These byproducts form toxic adducts with proteins and nucleic acids, thereby disrupting cellular structure and function [38]. As peroxidation progresses, the biophysical integrity of the plasma membrane is compromised, membrane permeability increases, and ultimately the cell undergoes lytic death.

2.4. Antioxidant defense and GPX4-dependent/independent pathways

Cells resist ferroptosis through a multilayered antioxidant network predominantly anchored by the canonical GPX4-dependent pathway: the system Xc⁻–GSH–GPX4 axis (Table 1). The selenoenzyme GPX4 preserves membrane integrity by reducing toxic phospholipid hydroperoxides to benign lipid alcohols, thereby terminating lipid peroxidation chain reactions [39,40]. GPX4 activity is strictly reliant on GSH. The rate-limiting precursor for GSH synthesis is cysteine, whose intracellular availability is governed by system Xc⁻, a heterodimer of SLC7A11 and SLC3A2 that mediates cystine/glutamate exchange [17]. Consequently, pharmacological agents targeting this canonical axis—such as erastin (inhibiting system Xc⁻), buthionine sulfoximine (BSO; suppressing GSH synthesis), or RSL3 (directly inhibiting GPX4)—robustly induce ferroptosis.

Operating in parallel to the canonical axis are several GPX4-independent antioxidant systems that provide complementary, and sometimes functionally redundant, membrane protection [18]. At the plasma membrane, ferroptosis suppressor protein 1 (FSP1, also known as AIFM2) functions as an oxidoreductase that regenerates ubiquinol (CoQH₂) from coenzyme Q10 (CoQ10). CoQH₂ acts as a potent lipophilic radical trap that directly scavenges lipid radicals [41,42]. Notably, FSP1 overexpression can compensate for GPX4 deficiency and rescue cells from ferroptosis [41]. A similar CoQ10-reducing mechanism operates in mitochondria via dihydroorotate dehydrogenase (DHODH) to provide localized protection [43]. Additionally, GTP cyclohydrolase 1 (GCH1) synthesizes tetrahydrobiopterin (BH4), an intrinsic antioxidant that further protects phospholipids from oxidation [44]. While the GPX4 axis is ubiquitously active, these GPX4-independent pathways exhibit more tissue-restricted prominence, particularly in highly metabolic organs organs such as the heart and kidney [18,40]. They can be pharmacologically targeted by specific inhibitors—such as iFSP1 (targeting FSP1), leflunomide (targeting DHODH), and 2,4-diamino-6-hydroxypyrimidine (targeting GCH1)—to trigger ferroptosis independently of GPX4 status.

Upstream of these localized defense mechanisms, the nuclear factor erythroid 2-related factor 2 (Nrf2) orchestrates a master cytoprotective response [45,46]. Under basal conditions, Nrf2 is sequestered by Keap1 and targeted for ubiquitin-dependent proteasomal degradation. Under oxidative stress, however, Nrf2 is stabilized and translocates to the nucleus, where it binds antioxidant response elements (AREs) to upregulate the transcription of crucial anti-ferroptotic genes, including SLC7A11, GPX4, and FTH1, thereby comprehensively reinforcing the cell's antioxidant and iron-sequestering capacity.

Ultimately, disruption of any node within this defensive network promotes lethal lipid peroxidation. However, the coexistence of these parallel systems broadens the therapeutic landscape. In oncology, inducing ferroptosis by crippling system Xc⁻ or GPX4 has emerged as a promising antitumor strategy [47]. Conversely, in contexts of ischemic, toxic, or myopathic injury, the pharmacological activation of parallel pathways like FSP1 or DHODH holds potential for protecting healthy tissues [48]. Therefore, elucidating the functional crosstalk between GPX4-dependent and GPX4-independent mechanisms is essential for developing rational, precision-targeted therapies for both oncological and degenerative muscle diseases.

2.5. Signaling pathways regulating ferroptosis

Ferroptosis is governed by an intricate network of interconnected signaling pathways (Table 1). The tumor suppressor p53 exemplifies this complexity because it exerts context-dependent and sometimes opposing effects on ferroptosis [49]. On the one hand, p53 can sensitize cells to ferroptosis by transcriptionally repressing SLC7A11, thereby limiting cystine uptake and compromising GSH synthesis [50]. On the other hand, p53 can suppress ferroptosis by inducing cyclin-dependent kinase inhibitor 1A (CDKN1A/p21), which promotes cell-cycle arrest and metabolic quiescence and thereby limits reactive oxygen species (ROS) production [51]. In addition, p53 modulates ferroptotic sensitivity through other targets, including the pro-ferroptotic regulator spermidine/spermine N1-acetyltransferase 1 (SAT1) and the anti-ferroptotic enzyme VKORC1L1.

Similarly, AMP-activated protein kinase (AMPK), the central sensor of cellular energy status, plays a multifaceted role in ferroptosis regulation [52]. Under energy stress, AMPK can inhibit ferroptosis by phosphorylating acetyl-CoA carboxylase alpha (ACACA), thereby suppressing de novo fatty acid synthesis and reducing the availability of PUFAs. Paradoxically, AMPK can also promote ferroptosis by phosphorylating Beclin 1 (BECN1), which activates autophagy and sensitizes cells to lipid peroxidation [53]. AMPK also influences ferroptosis indirectly through the mTOR pathway, thereby linking metabolic status to cell survival.

As noted above, Nrf2 is the master transcriptional regulator of antioxidant defense and controls the expression of genes such as GPX4, SLC7A11, and FTH1 [54]. This activity is reinforced by p62/SQSTM1, which sequesters Keap1 and disrupts the Keap1-Nrf2 interaction, thereby establishing a positive-feedback loop that amplifies cytoprotective signaling [55].

Additional signaling nodes further shape ferroptosis sensitivity. For example, protein kinase C beta II (PKCβII) phosphorylates and activates ACSL4, thereby promoting PUFA-PE biosynthesis and accelerating ferroptosis [56]. In contrast, nuclear receptors such as the estrogen receptor (ER) and androgen receptor (AR) confer resistance to ferroptosis by upregulating the acyltransferases MBOAT1 and MBOAT2, which enrich membranes with MUFAs [57]. Endoplasmic reticulum stress and calcium signaling pathways add further layers of regulatory complexity, frequently converging on mitochondrial ROS production to dictate cell fate.

Ultimately, the interaction among these pathways determines cellular susceptibility to ferroptosis. AMPK balances lipid anabolism against autophagic flux, Nrf2 strengthens the antioxidant defense network, and p53 functions as a context-dependent switch. A comprehensive understanding of this regulatory architecture will be essential for the rational design of precision therapies targeting ferroptosis in complex metabolic and musculoskeletal disorders.

2.6. Comparison of ferroptosis with apoptosis and necrosis

Ferroptosis, apoptosis, and necrosis are distinct modes of cell death that can be distinguished by their morphological, biochemical, and regulatory features. Morphologically, ferroptosis is characterized by specific mitochondrial abnormalities, including shrinkage, increased membrane condensation, and cristae loss, which differ from the cell shrinkage, chromatin condensation, and apoptotic body formation typical of apoptosis. By contrast, necrosis is characterized by cell swelling (oncosis), plasma membrane rupture, and a pronounced inflammatory response [14,20]. Biochemically, ferroptosis is driven by iron-dependent lipid peroxidation, in contrast to the caspase-mediated proteolytic cascade of apoptosis and the ATP depletion and ionic imbalance associated with necrosis [20]. Pharmacologically, ferroptosis can be suppressed by iron chelators or ferrostatin-1 but is not blocked by caspase inhibitors or necroptosis inhibitors (e.g., necrostatin-1), providing a useful criterion for distinguishing it from apoptosis and regulated necrosis.

At the molecular level, ferroptosis is governed primarily by the system Xc⁻–GPX4 axis and iron metabolism networks. By contrast, apoptosis is regulated by the Bcl-2 family and caspase cascades, whereas necroptosis, a regulated form of necrosis, is executed through the RIPK1/RIPK3/MLKL signaling axis [20,58]. For example, GPX4 overexpression specifically suppresses ferroptosis [11], whereas Bcl-2 overexpression is a canonical inhibitor of apoptosis [14].

Despite these distinctions, ferroptosis exhibits extensive molecular crosstalk with other cell death programs. A prominent example is p53, which can promote ferroptosis by repressing SLC7A11 while simultaneously facilitating apoptosis through PUMA induction [20]. This overlap is particularly relevant in skeletal muscle pathology. In models of muscle atrophy, ferroptosis and apoptosis frequently coexist and may act synergistically to exacerbate tissue damage [59]. These observations underscore the importance of clarifying the interplay among multiple cell death pathways to inform comprehensive therapeutic strategies for skeletal muscle disorders.

3. Physiological regulation of ferroptosis in skeletal muscle development and regeneration

Skeletal muscle is a highly plastic tissue whose growth, development, and regeneration depend on precisely coordinated cell-fate decisions. Emerging evidence suggests that, beyond its well-established role in pathological cell death, ferroptosis also functions as a physiological rheostat that helps maintain skeletal muscle homeostasis (Fig. 1).

Fig. 1.

Core molecular mechanisms of ferroptosis in skeletal muscle cells. This schematic illustrates the integrated signaling axes that converge to drive ferroptosis, an iron-dependent, lipid peroxidation-driven form of regulated cell death. The diagram delineates three key pathways. System Xc⁻-GSH-GPX4 axis (left): The cystine/glutamate antiporter (System Xc⁻, comprising SLC7A11 and SLC3A2) imports cystine for GSH synthesis. GSH serves as an essential cofactor for the antioxidant enzyme GPX4, which reduces cytotoxic lipid hydroperoxides to harmless lipid alcohols. Pharmacological inhibition of System Xc⁻ (e.g., by erastin) or direct inactivation of GPX4 (e.g., by RSL3) disrupts this primary cellular defense, thereby initiating ferroptosis. Iron metabolism and ROS generation axis (center): Iron (Fe³⁺) is imported via TFR1, reduced to redox-active Fe²⁺, and subsequently stored in ferritin or incorporated into the labile iron pool (LIP). Autophagic degradation of ferritin (ferritinophagy) releases excess Fe²⁺, fueling the Fenton reaction to generate highly reactive hydroxyl radicals. These ROS serve as primary propagators of lipid peroxidation. Lipid peroxidation axis (right): Membrane phospholipids enriched with PUFAs, particularly those esterified by ACSL4, are highly susceptible to oxidation. LOXs or Fenton-derived ROS oxidize these phospholipids (e.g., phosphatidylethanolamine, PE) to generate toxic lipid peroxides (PE-OOH), ultimately compromising membrane integrity.

3.1. Regulatory mechanisms of ferroptosis in myogenesis

Myogenesis is a multistep program encompassing satellite cells (SCs) activation, proliferation, differentiation, and eventual fusion into multinucleated myotubes. Recent studies indicate that ferroptosis is an important regulator of this developmental process. In C2C12 myoblast differentiation models, the ferroptosis inhibitor ferrostatin-1 enhances myotube formation, whereas the ferroptosis inducer erastin markedly suppresses differentiation [60,61]. Mechanistically, the depletion of FTH1, which encodes ferritin heavy chain 1, leads to intracellular iron overload. The resulting excess iron fuels the Fenton reaction, elevates ROS production, impairs mitochondrial function, and suppresses key myogenic transcription factors such as MyoD. Consistent with this mechanism, the E3 ubiquitin ligase SMURF1 acts as an upstream negative regulator of myogenesis by promoting FTH1 ubiquitination and proteasomal degradation, thereby enhancing ferroptosis and inhibiting differentiation [62].

In parallel, antioxidant protection mediated by the system Xc⁻-GSH-GPX4 axis is indispensable for myogenic differentiation. The critical role of this physiological axis is further highlighted in pathological contexts. In models of estrogen deficiency-induced muscle atrophy, downregulation of SLC7A11 impairs cystine uptake, reduces GSH synthesis, and diminishes GPX4 activity, thereby promoting ferroptosis and arresting differentiation [63]. This defect can be reversed by the natural flavonoid luteolin, which directly binds SLC7A11, enhances System Xc⁻-GSH-GPX4 signaling, suppresses ferroptosis, and restores differentiation. In vivo, luteolin also ameliorates estrogen deficiency-induced muscle atrophy, increasing muscle mass and grip strength. Together, these findings indicate that successful myogenic differentiation depends on the stringent suppression of ferroptotic stress through coordinated regulation of iron sequestration and antioxidant defense.

Recent studies have further expanded this regulatory landscape by identifying musculoskeletal embryonic nuclear protein 1 (MUSTN1) as a novel checkpoint. As a MyoD-regulated microprotein, MUSTN1 modulates iron homeostasis by binding the cytosolic iron regulatory protein 1 (ACO1/IRP1). This interaction modulates TFRC mRNA stability through its 3′UTR while suppressing SLC39A14 expression, thereby preventing toxic intracellular iron accumulation and lipid peroxidation [64]. Notably, MUSTN1 also appears to act through a paracrine route by being packaged into exosomes and delivered to neighboring satellite cells, thereby coordinating ferroptosis resistance and differentiation within the regenerative niche. Consistent with this model, MUSTN1 overexpression promotes myotube formation and mitigates dexamethasone-induced atrophy through the ACO1-TFRC axis. Taken together, these findings identify MUSTN1 as a key downstream effector of MyoD that safeguards myogenesis by fine-tuning iron homeostasis.

3.2. Regulation of ferroptosis in muscle fiber maturity and fiber-type transformation

Ferroptotic stress critically influences myotube formation and myofiber maturation by perturbing iron homeostasis and compromising mitochondrial integrity. Experimental evidence indicates that severe iron overload reduces myotube diameter, suppresses the global expression of myosin heavy chain (MyHC) isoforms (including MyHC I, IIa, and IIb), and disrupts overall myotube architecture [65]. These deleterious effects are driven by ferroptosis-associated lipid peroxidation, exemplified by 4-HNE accumulation, and consequent oxidative stress. These processes impair the activity of myogenic regulatory factors, particularly myogenin (MyoG), a transcription factor essential for terminal maturation [60]. Furthermore, iron overload damages mitochondrial respiratory chain complexes I and III, thereby disrupting oxidative metabolism and limiting ATP production. Because slow-twitch oxidative fibers depend heavily on mitochondrial function, this bioenergetic deficit preferentially impairs their maturation [66].

Beyond myofiber maturation, sub-lethal ferroptotic stress also contributes to fiber-type specification and remodeling via metabolic reprogramming and transcriptional regulation. In certain contexts, iron overload-induced ferroptosis favors a glycolytic phenotype, as evidenced by the relative upregulation of fast-twitch markers (e.g., MyHC IIb) and the concomitant downregulation of slow-twitch oxidative markers (e.g., MyHC I and PGC-1α) [26,67]. Mechanistically, lipid peroxidation products such as MDA suppress the activity of PGC-1α, a master regulator of mitochondrial biogenesis and oxidative fiber specification. Concurrently, ferroptosis activates NF-κB signaling, which promotes the expression of fast-twitch-associated genes [26]. Conversely, the pharmacological inhibition of ferroptosis using ferrostatin-1 restores PGC-1α activity, partially reverses the fiber-type shift, and preserves the oxidative phenotype [65]. Collectively, these findings establish ferroptotic stress as a crucial determinant of skeletal muscle composition and fiber-type plasticity, operating primarily through the PGC-1α/NF-κB axis.

Underpinning these differential responses is the inherent heterogeneity of skeletal muscle. We propose that ferroptotic sensitivity is profoundly fiber-type dependent. Type I (slow-twitch) fibers rely on oxidative phosphorylation and are characterized by dense mitochondrial networks, abundant intramuscular triglycerides, and high myoglobin (iron) content. Although this biochemical profile theoretically creates a highly permissive environment for ferroptosis (characterized by elevated iron, lipid, and ROS levels), Type I fibers paradoxically exhibit considerable resistance to this form of cell death. We hypothesize that this resilience is conferred by a compensatory, highly robust GPX4/FSP1 antioxidant network. Investigating the differential ferroptotic thresholds among distinct fiber types represents a critical, yet largely unexplored, area for future research.

3.3. Satellite cells, ferroptosis, and muscle regeneration

Satellite cells (SCs), the resident stem cells located between the basal lamina and the sarcolemma, are indispensable for skeletal muscle development, growth, and regeneration [68]. The regenerative process proceeds through a highly coordinated sequence of injury recognition, inflammation, SCs activation and differentiation, and myofiber maturation [69,70]. Within this dynamic microenvironment, ferroptosis exerts a context-dependent dual effect (Fig. 2). While moderate, tightly regulated ferroptotic stress and signaling facilitate adaptive tissue repair, excessive ferroptosis severely compromises regenerative capacity [59,71].

Fig. 2.

The dual role of ferroptosis in skeletal muscle regeneration: a balance between physiological remodeling and pathological impairment. This comparative schematic illustrates the context-dependent consequences of ferroptosis during skeletal muscle regeneration, contrasting its physiological necessity with its detrimental pathological effects. (A) Successful muscle regeneration: Activated SCs proliferate and differentiate to form new myotubes. During this process, moderate ferroptosis (green pathway) selectively eliminates defective or transient cells, facilitating essential tissue clearance and remodeling. This tightly regulated cell death supports efficient myogenesis and myofiber maturation, culminating in the formation of healthy, robust muscle fibers. (B) Failed muscle regeneration: Conversely, excessive ferroptosis (red pathway) triggered by factors such as iron overload or GPX4 depletion leads to the severe depletion of the SCs pool, the primary progenitor reservoir required for tissue repair. Consequently, regenerative capacity is profoundly impaired, resulting in atrophic myofibers and the accumulation of fibrotic tissue.

Controlled ferroptotic mechanisms promote muscle regeneration via three interconnected pathways. First, the targeted ferroptosis of severely damaged cells assists in the clearance of necrotic debris and the recruitment of inflammatory cells, establishing a microenvironment permissive to SCs activation. Notably, ferroptosis-related markers such as ACSL4 and HMOX1 are transiently upregulated during the early tissue-clearance phase (1–3 days post-injury) in cardiotoxin-induced injury models [72,73]. Second, ROS generated during sub-lethal ferroptosis act as vital second messengers, stimulating SC activation and differentiation via the redox-sensitive p38α MAPK pathway [[73], [74], [75], [76]]. Underscoring this requirement, ROS scavenging via N-acetylcysteine profoundly inhibits myogenesis [74]. Third, this regulated signaling fosters macrophage polarization toward a reparative M2 phenotype. These macrophages secrete cytokines, such as TGF-β and IL-10, that couple the resolution of inflammation with active myofiber repair [75,76].

Conversely, excessive ferroptosis—precipitated by severe injury, aging, or genetic disruptions—triggers profound iron overload, GPX4 depletion, and catastrophic SCs loss. In aged skeletal muscle, SCs exhibit a stark susceptibility to ferroptosis, which overtakes apoptosis as the predominant mode of cell death (affecting approximately 42% versus 27% of SCs, respectively) [77]. These aged SCs display hallmark ferroptotic features, including elevated lipid peroxidation products like 4-HNE and MDA. Mechanistically, this age-associated ferroptotic shift is driven by two primary pathways. First, the FOXO1-TXNIP metabolic checkpoint is disrupted: elevated FOXO1 binding upregulates TXNIP, which subsequently impairs GSH metabolism, depletes intracellular GSH, and sensitizes SCs to ferroptosis [78]. Second, age-related chronic inflammation triggers epigenetic erosion. Reduced expression of the histone methyltransferase Kmt5a leads to a loss of the H4K20me1 mark, silencing anti-ferroptotic genes like GPX4 and rendering SCs hypersensitive to oxidative stress [77,79].

Beyond depleting the SCs pool, excessive ferroptosis structurally destabilizes nascent myotubes [71] and perpetuates a highly pro-inflammatory state by sustaining neutrophil infiltration and the release of TNF-α and IL-6 [80]. Severe genetic disruptions, such as Tfr1 deficiency, further exacerbate this pathology by inducing massive SC ferroptosis and shifting surviving cells away from myogenesis toward an adipogenic fate [71].

Mitigating excessive ferroptosis therefore represents a promising strategy to restore muscle regeneration. For example, long-term administration of the anti-inflammatory agent bindarit preserves the H4K20me1 epigenetic mark and GPX4 expression, thereby protecting the SC pool in aged muscles [77]. Similarly, interventions like electroacupuncture modulate iron-handling genes, improve iron metabolism, and reduce lipid peroxidation. These changes rebalance the localized inflammatory response and accelerates regeneration in rat models [81]. Collectively, these findings highlight the necessity of precision-targeted therapies that restrain pathological ferroptosis without extinguishing the physiological ROS signaling fundamentally required for myogenesis.

In summary, a defining feature of skeletal muscle is its reliance on satellite cell differentiation and subsequent fusion into multinucleated syncytia. This fusion event requires a high degree of plasma membrane fluidity and the rapid incorporation of PUFAs [82]. Because ACSL4 and ALOX15 drive ferroptosis by enriching membranes with peroxidized PUFAs, the precise biochemical process that allows myoblasts to fuse also renders them transiently highly susceptible to ferroptosis. This represents a unique mechanistic intersection where the physiological requirements for muscle regeneration align intrinsically with the biochemical prerequisites of ferroptosis.

3.4. Interactions between ferroptosis and genes regulating skeletal muscle development

Skeletal muscle development is orchestrated by a complex network of myogenic regulatory factors, including MyoD, MyoG, and Pax7, together with non-coding RNAs that interact extensively with ferroptosis-related genes to shape myogenesis. At the transcriptional level, MyoD helps determine cell fate by directly regulating key ferroptotic effectors. In myocyte differentiation models, MyoD binds to the promoter regions of FTH1 and GPX4, thereby enhancing their transcription, suppressing ferroptosis, and promoting myogenic commitment [62]. Conversely, the E3 ubiquitin ligase SMURF1 acts as an upstream negative regulator by targeting MyoD for ubiquitination and proteasomal degradation, thereby removing this anti-ferroptotic restraint and arresting differentiation [62]. Accordingly, the SMURF1–MyoD–ferroptosis axis represents a key regulatory circuit within myogenic programming.

Non-coding RNAs further refine this network by post-transcriptionally regulating ferroptosis-associated targets. In mammalian myogenic models such as C2C12 cells, the long non-coding RNA GPRC5D-AS1 acts as a competing endogenous RNA that sequesters miR-107-5p. This sponge effect stabilizes SLC7A11 expression, thereby suppressing ferroptosis and promoting myogenic differentiation [83]. Pathological models further underscore the critical role of this regulatory network in maintaining muscle homeostasis. Consistent with this mechanism, decreased GPRC5D-AS1 expression in muscle atrophy models is associated with SLC7A11 downregulation, ferroptosis activation, and impaired myogenesis. Similarly, tumor-secreted miR-203a-3p also drives muscle wasting by boosting intramuscular ferroptosis [84]. Mechanistically, miR-203a-3p represses ZEB1 to upregulate the iron importer SLC11A2, amplifying iron overload and triggering ferroptotic myocyte death. Collectively, these observations establish a molecular paradigm linking microRNA activity to ferroptosis-mediated muscle atrophy. Collectively, these findings indicate that the integration of coding and non-coding regulators with ferroptotic signaling is fundamental not only to the control of skeletal muscle development but also to the prevention of muscle atrophy.

3.5. Cross-regulation of ferroptosis, apoptosis, and autophagy in skeletal muscle

Ferroptosis does not operate in isolation; rather, it is intricately interconnected with other regulated cell death pathways, including autophagy and apoptosis. Within skeletal muscle, this cross-regulation is paramount, as myofibers and SCs are profoundly sensitive to oxidative stress, mitochondrial dysfunction, and iron dyshomeostasis [85]. Autophagy plays a dual, context-dependent role in ferroptosis regulation. While baseline mitophagy and general organelle quality control mitigate ROS production to protect against lipid peroxidation, selective autophagy can actively precipitate ferroptosis. A primary mechanism for the latter is NCOA4-mediated ferritinophagy, wherein the cargo receptor NCOA4 targets ferritin for autophagic degradation [86,87]. This process releases intracellular free iron, expanding the labile iron pool and exacerbating lipid peroxidation via Fenton chemistry. Furthermore, AMPK-mediated phosphorylation of BECN1 can promote its interaction with system Xc⁻ components, inhibiting cystine uptake and thereby suppressing GPX4 activity to drive ferroptosis [53].

Similarly, ferroptosis intricately intersects with apoptosis. While apoptosis is conventionally driven by caspase cascades and mitochondrial outer membrane permeabilization, and ferroptosis by iron-dependent lipid peroxidation [2,88], shared upstream signals—such as p53, MAPK pathways, and mitochondrial oxidative stress—can either tilt the balance toward a specific cell death modality or orchestrate their concurrent execution. The tumor suppressor p53 exemplifies a crucial regulatory node: it can trigger apoptosis via mitochondrial regulators (e.g., BAX, PUMA, and NOXA) while simultaneously promoting ferroptosis by transcriptionally repressing SLC7A11 [50]. This repression impairs system Xc⁻ function, depleting GSH and sensitizing the cell to oxidative damage. Additionally, emerging evidence suggests that caspase-3 activation may cleave and destabilize GPX4, further linking apoptotic execution to ferroptotic susceptibility [89], though this mechanism warrants further validation in skeletal muscle. Consequently, these cell death programs are not mutually exclusive but function as a highly integrated network shaped by stress intensity and cellular context.

In skeletal muscle, the execution of this network exhibits pronounced cell-type specificity. During early regeneration, SCs demand stringent redox regulation; moderate autophagy acts as a crucial survival mechanism by clearing damaged organelles, thereby suppressing both apoptotic and ferroptotic triggers to preserve stemness and metabolic fitness [71,90,91]. Concurrently, AMPK–Nrf2 antioxidant signaling fortifies them against oxidative stress. Conversely, in mature myofibers, iron dyshomeostasis and mitochondrial dysfunction are the primary catalysts for pathological crosstalk. In these post-mitotic cells, mitochondria-derived ROS drive lipid peroxidation while concurrently activating mitochondrial apoptotic signaling, resulting in synergistic myofiber degeneration and atrophy [59].

Ultimately, the crosstalk among ferroptosis, apoptosis, and autophagy establishes a dynamic, stress-responsive regulatory network in skeletal muscle. Deciphering the specific molecular nodes and causal relationships that dictate the shift between these pathways across diverse muscle cell populations and pathological stages is imperative. Such insights will provide the mechanistic foundation necessary for developing precision therapies that target regulated cell death in myopathies.

4. The role of ferroptosis in skeletal muscle diseases

Skeletal muscle diseases are clinically characterized by progressive tissue degeneration, chronic inflammation, and functional decline. Accumulating evidence indicates that ferroptosis—driven by iron-dependent lipid peroxidation—acts as a convergent pathological mechanism across diverse myopathies, thereby presenting novel therapeutic avenues. This section provides a detailed analysis of ferroptosis in specific disease contexts (Fig. 3).

Fig. 3.

Ferroptosis as a convergent pathogenic mechanism in diverse skeletal muscle disorders. This hub-and-spoke schematic illustrates how ferroptosis—characterized by iron-dependent lipid peroxidation—serves as a common pathological endpoint linking distinct myopathies to cell death. The central stressed skeletal myofiber exhibits hallmark features of ferroptosis, including membrane lipid peroxidation (indicated by a red glow) and intracellular iron overload (Fe²⁺ accumulation). The surrounding modules delineate disease-specific mechanisms that predispose muscle tissue to, or exacerbate, ferroptosis: (1) Sarcopenia (aging): Associated with the downregulation of the cystine/glutamate antiporter (System Xc⁻), progressive mitochondrial dysfunction, and age-related iron accumulation. (2) Muscular dystrophy (e.g., DMD): Driven by inherent sarcolemmal fragility, pathological calcium influx, chronic inflammation (via TNF-α/NF-κB signaling), and TFR1 upregulation. (3) Exercise-induced and traumatic injury: Triggered by ischemia-reperfusion mechanisms, which lead to a massive burst of ROS and potential rhabdomyolysis. (4) Sepsis-associated myopathy: Fueled by systemic cytokine storms, dysregulated STAT6 signaling, and secondary mitochondrial damage.

4.1. Mechanism of ferroptosis in muscle atrophy

Muscle atrophy, a pervasive complication of numerous chronic conditions, is characterized by an imbalance between protein synthesis and degradation. Recent investigations have implicated ferroptosis as a critical driver of the pathogenesis of muscle atrophy, offering fresh insights into its molecular basis and highlighting potential targets for intervention (Table 2).

Table 2.

Role of ferroptosis in major skeletal muscle disorders and potential therapeutic targets.

Disease category	Key pathological findings/evidence	Involved core molecules/pathways	Potential therapeutic strategies
Muscle atrophy (e.g., aging, CKD, sepsis)	Increased iron content, decreased GPX4, accumulation of MDA/4-HNE. Ferroptosis inhibitors attenuate atrophy.	Iron overload, inhibited SLC7A11/GPX4 axis, STAT6 activation, inflammatory microenvironment.	Inhibitors: ferrostatin-1, liproxstatin-1. Natural compounds: luteolin (activates SLC7A11), Dihydromyricetin. TCM formulas: Shenshuai Yinyang capsules (activates HIF-1α/SLC7A11).
Muscular dystrophy (e.g., DMD)	Muscle iron overload, decreased GPX4, exacerbated oxidative stress & fibrosis. NRF2 agonists upregulate GPX4 and improve function.	Dysregulated iron metabolism, impaired NRF2/GPX4 axis, mitochondrial dysfunction.	NRF2 agonists: boost endogenous defense. Iron chelators: Reduce iron overload. Combination strategies: enhance autophagy, improve mitochondrial function.
Sarcopenia	Ferroptosis is a major death pathway in aged SCs (42%). Reduced Tfr1 leads to iron accumulation and satellite cell loss.	SCs dysfunction: ↓TFR1, activated FOXO1/TXNIP axis, ↓GPX4. Epigenetics: inflammation-induced loss of H4K20me1 silences anti-ferroptotic genes.	Targeting SCs: anti-inflammatory drugs (e.g., Bindarit) to preserve epigenetics; modulating FOXO1/TXNIP. Lifestyle: aerobic exercise activates Nrf2. TCM extracts: cistanche extract (activates IGF-1/PI3K-Akt pathway).
Exercise-induced muscle damage (EIMD)	Post-injury iron increase, GPX4 decrease, activation of the SAT1/ALOX15 pathway, aggravated inflammation.	Mechanical stress-induced iron dysregulation, SAT1/ALOX15-driven lipid peroxidation.	Antioxidants: gallic acid (inhibits mitochondrial oxidative stress & ferroptosis). Physical intervention: electro acupuncture modulates IRP1/FPN1 to improve iron metabolism.
Inflammation-associated myopathies (e.g., sepsis)	Vicious cycle between inflammatory milieu (TNF-α, IL-6) and ferroptosis. Myonectin overexpression promotes ferroptosis.	LCN2/ACOD1 signaling axis, cytokine storm, oxidative stress.	Breaking the Cycle: ferroptosis inhibitors combined with anti-inflammatory therapy. Targeting specific axes: inhibiting LCN2 or STAT6.

A primary line of evidence centers on the synergistic impact of iron dysregulation and lipid peroxidation within myocytes. The execution of ferroptosis directly contributes to myofiber loss, while sub-lethal lipid peroxidation disrupts intracellular proteostasis, accelerating atrophy [59]. For instance, ferroptosis has been identified as a key pathogenic effector in chronic kidney disease (CKD)-induced muscle atrophy. In this context, the uremic environment suppresses the HIF-1α/SLC7A11 axis, while treatment with the specific inhibitor ferrostatin-1 significantly attenuates muscle wasting [92]. Similarly, in cancer cachexia, tumor-derived miR-203a-3p exacerbates muscle wasting by directly triggering intramuscular ferroptosis [84]. This mechanistic link extends to inflammatory pathologies: STAT6 signaling exacerbates sepsis-induced muscle damage by activating ferroptosis [93], while senescent macrophages drive osteoarthritis-associated muscle atrophy by inducing ferroptosis via paracrine signaling [94]. Notably, in the context of age-related sarcopenia, aging is also accompanied by the downregulation of TfR1 and the upregulation of ZIP14; this shift in iron uptake patterns promotes the intracellular accumulation of non-transferrin-bound iron, further exacerbating iron overload [95]. Additionally, specific regulatory nodes, such as the transcription factor ATF3, connect ferroptotic susceptibility to sarcopenia via the PI3K/Akt signaling pathway [96]. Collectively, these findings highlight the complex interplay among systemic inflammation, iron homeostasis, and ferroptosis, underscoring ferroptosis as a shared downstream effector despite the diverse upstream triggers across different pathogenic models.

Therapeutic strategies targeting this pathway have demonstrated efficacy in preclinical models. In CKD, the traditional Chinese medicine formulation Shenshuai Yinyang Capsules mitigates atrophy by inhibiting ferroptosis via the HIF-1α/SLC7A11 axis [97]. Furthermore, natural compounds such as luteolin ameliorate estrogen deficiency–induced atrophy by modulating SLC7A11-dependent defense mechanisms [63], while dihydromyricetin attenuates cisplatin-induced wasting by curbing oxidative stress and ferroptotic cell death [98]. These data suggest that the pharmacological modulation of ferroptosis represents a viable strategy for preserving muscle mass across a spectrum of pathological states.

In summary, a robust body of evidence establishes ferroptosis as a pivotal contributor to the etiology and progression of muscle atrophy. By mapping the underlying molecular architecture—ranging from iron transporters to non-coding RNAs—and validating druggable targets, these studies lay the groundwork for novel clinical interventions aimed at counteracting muscle loss and improving patient outcomes.

4.2. Ferroptosis and the pathological mechanism of muscular dystrophy

Muscular dystrophies comprise a heterogeneous group of genetic disorders characterized by the progressive degeneration of muscle fiber structure and function. While oxidative stress is a well-established feature of these pathologies, recent research has specifically implicated ferroptosis as a critical driver of disease progression, thereby highlighting it as a promising therapeutic target (Table 2) [59,99]. This emerging paradigm offers novel insights into the molecular underpinnings of muscular dystrophy and suggests new avenues for intervention.

In models of Duchenne muscular dystrophy (DMD), muscle fiber necrosis is closely associated with ferroptotic activation, as evidenced by elevated iron content, suppressed GPX4 expression, and increased lipid peroxidation [100,101]. Unlike the ferroptosis-promoting pathways observed in certain atrophy models, the antioxidant transcription factor NRF2 serves as a critical negative regulator of ferroptosis in this context by transactivating the GPX4 gene, thereby mitigating dystrophic pathology. Pharmacological activation of NRF2 in DMD mouse significantly upregulates GPX4 expression (approximately 2.1-fold), reduces malondialdehyde (MDA) levels by ∼45%, ultimately improving muscle function [100]. Furthermore, the induction of ferroptosis in SCs compromises their proliferative and differentiation potential, thereby exacerbating muscle degeneration and impairing regenerative capacity [78,93].

The link between ferroptosis and muscular dystrophy is further substantiated by observations of systemic and local iron dysregulation. Dystrophic muscles exhibit profound iron overload and aberrant expression of iron-handling proteins—alterations that fuel the oxidative stress and fibrosis characteristic of ferroptotic injury [67]. Notably, iron overload appears to be more severe in DMD than in age-related sarcopenia; this pronounced imbalance suggests that aggressively targeting iron metabolism may limit muscle damage. Consistent with this hypothesis, ferroptosis inhibitors, including iron chelators, effectively alleviate oxidative stress and fibrosis in dystrophic muscle, underscoring their therapeutic potential [67,102].

Moreover, the interplay between ferroptosis and other cellular dysfunctions clarifies its role in disease progression. Autophagy, a process essential for muscle homeostasis, is impaired in DMD. This impairment leads to the accumulation of damaged organelles and proteins, which heightens oxidative stress and likely synergizes with ferroptotic pathways [103]. Similarly, mitochondrial dysfunction—a hallmark of muscular dystrophy—amplifies ROS production and increases cellular susceptibility to ferroptosis, a convergence that acts as a key pathological feature of DMD. Consequently, this interplay suggests that therapeutic strategies aimed at restoring mitochondrial health may also concurrently mitigate ferroptosis [104,105].

In summary, recognizing ferroptosis as a pivotal factor in the pathogenesis of muscular dystrophy provides a novel conceptual framework for understanding these complex disorders. By further elucidating the crosstalk among ferroptosis, iron metabolism, autophagy, and mitochondrial function, future research can develop targeted, multi-modal strategies to curb muscle degeneration and improve clinical outcomes in dystrophic patients.

4.3. The role of ferroptosis in skeletal muscle inflammation

Skeletal muscle inflammation, a hallmark of numerous myopathies, is driven by immune cell infiltration and the release of pro-inflammatory mediators. Emerging evidence indicates that ferroptosis acts as both a driver and a consequence of this inflammatory cascade, establishing a deleterious feedback loop that accelerates muscle degeneration and impedes regeneration (Table 2) [59,99]. Mechanistically, the accumulation of ROS and lipid peroxides directly triggers ferroptosis, which subsequently amplifies inflammatory signaling and exacerbates tissue injury.

The contribution of ferroptosis to inflammation-mediated damage is underscored by conserved mechanisms observed across diverse organ systems. In pathologies such as pulmonary hypertension and sepsis, ferroptosis mediates tissue injury by facilitating complement activation, recruiting macrophages, and exacerbating oxidative stress [[106], [107], [108]]. These systemic observations establish a paradigm of inflammation-driven pathology that provides a conceptual framework for understanding analogous processes in skeletal muscle.

Within skeletal muscle, ferroptosis is governed by distinct signaling pathways. The lipocalin-2 (LCN2)-ACOD1 axis has been identified as a critical modulator during skeletal muscle regeneration; its upregulation following injury compromises myogenic cell function by promoting ferroptosis [73]. Furthermore, the SAT1/ALOX15 axis serves as a pivotal link between lipid peroxidation and inflammation. The overexpression of the SAT1 gene activates the lipid-peroxidizing enzyme ALOX15, enhancing lipid peroxidation and subsequent inflammatory signaling [109]. Importantly, unlike iron-overload myopathies—where iron accumulation is the initial pathogenic trigger—iron overload in inflammation-driven myopathies is typically a secondary event driven by cytokine-mediated alterations in iron homeostasis. In these contexts, ferroptosis and inflammation continuously propagate a bidirectional feedback loop.

This interplay is evident in various models of muscle injury. In exercise-induced muscle damage, ferroptotic activation aggravates the inflammatory response, characterized by increased neutrophil infiltration and elevated levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) [110,111]. Similarly, infectious triggers can engage ferroptosis-associated inflammatory mechanisms. For instance, in influenza virus infection models, muscle injury correlates with ferroptosis activation, evidenced by iron accumulation, GPX4 suppression, and lipid peroxide buildup [99,112]. Mechanistically, the myokine myonectin exacerbates this response by promoting ferroptosis; the overexpression of myonectin worsens muscle damage, whereas ferroptosis inhibitors attenuate the phenotype [112]. Extending to clinical scenarios, skeletal muscle biopsies from sepsis patients reveal dysregulation of ferroptosis markers (e.g., GPX4, SLC7A11) that correlates positively with disease severity [113]. Furthermore, in exertional heatstroke, resident macrophages in skeletal muscle mediate rhabdomyolysis through HMOX1-dependent ferroptosis within the muscle microenvironment, revealing an immunometabolic mechanism driven by ferroptosis [114].

In conclusion, ferroptosis is a central regulator of skeletal muscle inflammation. Targeting specific molecular nodes—such as the LCN2/ACOD1 or SAT1/ALOX15 axes—may disrupt the vicious cycle of inflammation and cell death, offering novel therapeutic strategies to enhance muscle repair.

4.4. Sarcopenia and ferroptosis

Sarcopenia, characterized by the progressive decline of skeletal muscle mass and function, poses a significant health challenge in aging populations. Emerging evidence identifies ferroptosis as a pivotal driver of sarcopenic pathogenesis (Table 2), precipitated by age-related disruptions in iron homeostasis and cellular stress responses [115,116].

The mechanistic link between iron accumulation and ferroptosis has been elucidated in the senescence-accelerated mouse prone 8 (SAMP8) model. In this context, skeletal muscle iron overload upregulates the transcription factor p53, which represses SLC7A11, thereby triggering lipid peroxidation and ferroptosis [117]. Unlike atrophy associated with chronic kidney disease (CKD), iron overload in sarcopenia primarily results from age-related remodeling of iron metabolism, rather than uremic toxins or tumor-associated factors. This axis is further corroborated by findings that hnRNPK overexpression accelerates muscle senescence via the p53/SLC7A11/GPX4 signaling cascade [118]. Crucially, SCs dysfunction is a primary consequence of this process. In aged mice, aberrant iron handling within SCs—marked by alterations such as Tfr1 downregulation—paradoxically induces intracellular iron accumulation and activates ferroptosis, severely compromising their proliferative capacity [71]. Notably, this pronounced SCs depletion is a hallmark that severely impairs the regenerative capacity of aged muscle. Clinically, muscle biopsies from sarcopenic patients exhibit elevated iron levels and diminished GPX4 expression within the SCs niche, validating the translational relevance of these preclinical findings.

Metabolic stressors can further exacerbate this age-related vulnerability. A high-fat diet suppresses the AMPK/ACC signaling pathway, disrupting skeletal muscle iron metabolism and promoting lipid peroxidation. Collectively, these alterations precipitate ferroptosis and drive the development of sarcopenic obesity—a condition characterized by concurrent muscle wasting and increased adiposity [119]. Conversely, physical interventions, such as uphill running, reactivate the AMPK/ACC pathway. This exercise-induced activation restores iron homeostasis, bolsters antioxidant defenses, and inhibits lipid peroxidation, thereby mitigating ferroptosis and ameliorating the pathological manifestations of sarcopenic obesity [119]. Thus, the AMPK/ACC axis represents a critical molecular node and provides a theoretical framework for targeted, exercise-based interventions.

Beyond iron metabolism, specific intracellular signaling networks link ferroptosis to sarcopenia. The transcription factor ATF3 serves as a critical regulator connecting ferroptosis to sarcopenia via the PI3K/Akt pathway; notably, ATF3 overexpression suppresses ferroptosis in vitro [96]. Pharmacologically, echinacoside—an active constituent extracted from Cistanche deserticola—mitigates sarcopenia by stimulating the IGF-1/PI3K-Akt axis to inhibit ferroptosis [120]. Furthermore, mitochondrial lipid alterations contribute to sarcopenic progression. Specifically, the age-related depletion of tetra-linoleoyl cardiolipin enhances ROS production, fueling the ferroptotic degeneration of aged muscle [121].

In summary, accumulating evidence underscores ferroptosis as a central mechanism in the etiology of sarcopenia. Delineating these molecular networks paves the way for novel therapeutic interventions—ranging from exercise regimens and iron modulators to bioactive natural compounds—designed to preserve muscle mass and function in the elderly.

4.5. Sports-related muscle injury and ferroptosis

Exercise-induced muscle damage (EIMD), a prevalent condition among athletes and active individuals, involves ultrastructural myofiber disruption accompanied by acute inflammation. Recent research increasingly implicates ferroptosis as a contributor to EIMD pathology, effectively linking exercise-induced oxidative stress and mitochondrial dysfunction to acute tissue injury (Table 2).

Experimental models confirm that muscle damage arising from diverse exercise paradigms coincides with ferroptotic activation. For instance, in eccentric exercise-induced injury models, muscle tissue exhibits characteristic ferroptotic signatures, including elevated iron content, suppressed GPX4 expression, and the accumulation of lipid peroxides [110]. Analogous markers are observed following exhaustive endurance exercise [111]. Unlike chronic myopathies, ferroptosis in EIMD occurs acutely, peaks within hours to days post-injury, and is typically self-limiting. Mechanistically, the SAT1/ALOX15 pathway has been identified as a central regulatory axis driving the lipid peroxidation inherent to this process. However, at the extreme end of the exertional spectrum—such as in exertional heat stroke (EHS)—the pathology is far more severe. In the context, activation of the Hippo signaling pathway upregulates the ACSL4 gene, thereby enhancing lipid peroxidation and precipitating widespread ferroptosis [122]. These findings align with broader evidence establishing ferroptosis as a key mediator of tissue injury via the dysregulation of iron homeostasis and lipid metabolism [123].

The bidirectional relationship between mitochondrial dysfunction and ferroptosis is critical for understanding the etiology of EIMD. Mitochondrial impairment, characterized by elevated oxidative stress, acts as both a trigger and an amplifier of the ferroptotic cascade [124,125]. Mechanical stress during intense exercise directly damages mitochondria, impairing respiratory chain complex activity and increasing ROS production. The subsequent release of free iron and ROS from damaged mitochondria further activates ferroptosis, establishing a deleterious positive feedback loop. This interplay suggests that therapeutic interventions aimed at preserving mitochondrial integrity may concurrently mitigate ferroptosis. Indeed, pharmacological studies support this hypothesis; for example, gallic acid has been shown to alleviate EIMD by attenuating mitochondrial oxidative stress and suppressing ferroptotic signaling [111]. Collectively, the involvement of ferroptosis in exercise-induced pathologies underscores the necessity for further investigation into strategies that modulate these pathways to limit muscle damage [8].

In summary, ferroptosis represents a significant pathological mechanism underlying EIMD. A deeper understanding of its drivers—particularly the SAT1/ALOX15 axis and mitochondrial bioenergetics—paves the way for targeted therapeutic interventions. Strategies such as the administration of nutritional antioxidants or specific pharmacological ferroptosis inhibitors hold substantial promise for preserving muscle function and accelerating recovery following intense physical exertion.

4.6. The unique role of ferroptosis in skeletal muscle diseases

The distinct pathogenic profile of ferroptosis in skeletal muscle is dictated by the specific cell types affected, the underlying regulatory mechanisms, and the downstream functional consequences (Table 3). Ferroptotic vulnerability is highly tissue-specific. For instance, in neurodegenerative pathologies, ferroptosis primarily implicates neurons and glia, where GPX4 limits neurotoxic lipid peroxidation [126,127]. In cardiovascular diseases, it damages cardiomyocytes, exacerbating conditions such as ischemia-reperfusion injury [128]. In osteoporosis, it disrupts skeletal homeostasis by impairing osteoblast-mediated bone formation while promoting osteoclast-mediated resorption [129].

Table 3.

Distinctive features of ferroptosis in skeletal muscle compared to other tissues.

Feature	Skeletal Muscle	Cancer/Neurodegeneration	Implication
Physiological Role	Biphasic/Dual (Required for differentiation & clearance)	Pathological only (Cell death)	Inhibiting ferroptosis completely may impair muscle repair.
Primary Trigger	Mechanical stress/Iron flux/Satellite cell state	Genetic mutation/Excitotoxicity	Exercise-induced injury has a unique ferroptotic signature.
Cell Type Sensitivity	Satellite cells (high) vs. Myofibers (variable)	Bulk tumor cells/Neurons	Protecting satellite cells is key to anti-sarcopenia therapy.
Outcome of Dysregulation	Loss of regenerative capacity + Atrophy + Fibrosis	Tumor growth suppression/Neuron loss	Therapies for muscle should avoid total iron chelation.

Conversely, skeletal muscle ferroptosis selectively targets multinucleated myofibers, myoblasts, and satellite cells. Dysregulated iron handling—driven by pathways such as TFR1-dependent transferrin uptake and SLC39A14-dependent non-transferrin-bound iron transport—expands the labile iron pool, thereby exacerbating lipid peroxidation and cell death [71]. Crucially, skeletal muscle comprises highly metabolic syncytia that rely on uninterrupted mitochondrial ATP generation for mechanical contraction [130]. Consequently, ferroptotic injury in this tissue extends beyond localized cellular demise; it directly compromises muscle mass, contractile force, fatigue resistance, and regenerative capacity. These functional deficits are central to the progression of myopathies, including sarcopenia, cachexia-related wasting, severe exercise-induced muscle damage, and rhabdomyolysis.

At the subcellular level, skeletal muscle ferroptosis is intimately linked to profound mitochondrial dysfunction and hallmark ultrastructural alterations, including mitochondrial volume reduction, increased membrane density, diminished cristae, and membrane rupture [99,131]. These derangements present a unique paradigm wherein iron-dependent lipid peroxidation is intrinsically coupled to contractile dysfunction and bioenergetic failure, exacerbated further by calcium dyshomeostasis and localized inflammation.

Most importantly, unlike neoplastic or neural tissues—where iron dyshomeostasis is typically driven by systemic transferrin and ferritin imbalances—skeletal muscle harbors a vast, specialized intracellular iron reservoir: myoglobin. During mechanical trauma or severe myopathies, myoglobin stability is compromised. The rapid release of heme-bound iron directly into the sarcoplasm serves as a potent, tissue-specific catalyst for the Fenton reaction [132]. Consequently, the pathogenesis of muscle ferroptosis is inextricably tied to myoglobin turnover, a localized mechanism largely absent in non-striated organ systems. Elucidating these muscle-specific regulatory mechanisms is therefore imperative for understanding disease pathogenesis and developing precision-targeted therapeutics.

4.7. Cross-regulation of ferroptosis between skeletal muscle and other organs

Skeletal muscle does not function as an isolated effector organ; rather, it engages in extensive cross-talk with distant tissues through the secretion of myokines, metabolites, and inflammatory mediators. Skeletal muscle-derived extracellular vesicles (EVs), particularly exosomes, function as novel myokine carriers, exerting systemic endocrine effects on metabolic organs—including the pancreas, adipose tissue, and liver—by transferring functional proteins, mRNAs, and miRNAs [133]. For example, the muscle-drived myokine myonectin (CTRP15) is markedly elevated in severe acute pancreatitis and aggravates pancreatic acinar cell necrosis by triggering ferroptosis; clinically, serum myonectin levels correlate positively with disease severity in patients with acute pancreatitis, supporting its potential as a prognostic biomarker [112].

Furthermore, local ferroptotic events in muscle can trigger severe systemic consequences via muscle-immune crosstalk. For instance, in exertional heat stroke, TIM-4⁺ tissue-resident macrophages in skeletal muscle drive rhabdomyolysis through HMOX1-dependent ferroptosis. Crucially, this process activates the ferroptosis-driven JunD–Olfr2–NLRP3–IL-1β axis, releasing profound inflammatory signals into the circulation and thereby linking localized muscle injury to systemic hyperinflammation [114]. Beyond immune interactions, additional emerging pathways—such as muscle-bone crosstalk mediated by irisin and muscle–brain communication via myokine-laden EVs—further indicate that ferroptotic signaling in skeletal muscle may propagate systemic effects across multiple organ systems [134,135].

Collectively, these findings indicate that ferroptosis contributes not only to local muscle damage but also to systemic homeostasis as an integral node within cross-organ signaling networks. The delineation of axes such as skeletal muscle-pancreas, skeletal muscle-immune system, and skeletal muscle-bone provides novel perspectives for understanding the systems-level role of ferroptosis in multi-organ pathophysiology. Future investigations should therefore transition from single-cell or single-tissue paradigms toward integrative systems biology approaches, combining clinical cohorts with multi-omics platforms—including single-cell transcriptomics, spatial omics, lipidomics, and metabolomics—to comprehensively delineate the networked regulatory mechanisms underlying ferroptosis in skeletal muscle and its associated systemic diseases.

5. Targeted intervention strategies for ferroptosis in skeletal muscle diseases

Ferroptosis has been established as a core pathogenic driver across nearly all categories of myopathy, rendering ferroptosis-modulating interventions a promising therapeutic direction. This section systematically categorizes and reviews preclinically validated and translationally prospective intervention approaches, covering synthetic small-molecule agents, natural products & traditional Chinese medicine (TCM) preparations, non-pharmacological regimens, signaling pathway modulators, gene/nucleic acid therapeutics, and novel delivery platforms. Combined synergistic strategies and emerging druggable targets are further discussed, alongside a comprehensive summary of translational bottlenecks (Fig. 4).

Fig. 4.

Therapeutic strategies targeting ferroptosis for skeletal muscle protection. This schematic summarizes diverse pharmacological and genetic interventions aimed at inhibiting ferroptosis to preserve muscle integrity and function. By blocking key nodes in the ferroptotic cascade, these therapeutic avenues ultimately promote muscle recovery. The diagram delineates five major strategies: (1) Iron chelation: Agents such as DFO sequester redox-active Fe²⁺, thereby inhibiting the Fenton reaction and reducing hydroxyl radical generation. (2) Direct antioxidant defense: Compounds such as ferrostatin-1, liproxstatin-1, and vitamin E act as radical-trapping antioxidants, scavenging lipid peroxides to halt the propagation of membrane damage. (3) GPX4 system enhancement: Supplementation with selenium (a GPX4 cofactor) or GSH precursors (e.g., NAC boosts the activity of the central antioxidant enzyme GPX4, increasing the cellular capacity to neutralize lipid hydroperoxides. (4) Metabolic and transcriptional regulation: Activators of the AMPK or Nrf2 signaling pathways upregulate a network of antioxidant and cytoprotective genes, reinforcing endogenous cellular defenses against ferroptotic stress. (5) Genetic intervention: Approaches such as GPX4 overexpression or targeted ACSL4 silencing aim to reprogram the molecular profile of the cell toward a ferroptosis-resistant phenotype.

5.1. Small-molecule synthetic ferroptosis regulators

Synthetic small molecules represent the most mature class of anti-ferroptotic agents, targeting three core cascades: iron metabolism, lipid peroxidation and the System Xc⁻–GSH–GPX4 antioxidant axis.

Deferoxamine, a classic iron chelator, mitigates ferroptosis by depleting the intracellular labile iron pool; it reduces erastin-triggered myocyte death from 85% to 25% in vitro [20]. Radical-trapping antioxidants (RATs) including vitamin E, ferrostatin-1, and liproxstatin-1, directly block the propagation of lipid peroxidation. Ferrostatin-1 alone lowers erastin-induced cell mortality by ∼70% [14], and these compounds jointly improve myocyte viability under oxidative stress [9,11].

The small-molecule activator 1d4 enhances GPX4 catalytic activity by ∼1.5-fold in cell-free systems and ∼1.6-fold in cell lysates via allosteric binding, cutting cellular lipid peroxidation levels by 45% [136]. Additionally, synthetic compounds that upregulate SLC7A11 can indirectly reinforce GPX4-mediated detoxification, expanding the repertoire of targeted antioxidant strategies.

Prototypic agents such as ferrostatin-1 and liproxstatin-1 exhibit potent in vitro and murine efficacy but possess critical drawbacks for human application: poor aqueous solubility, rapid metabolic clearance and unfavorable absorption, distribution, metabolism, and excretion (ADME) profiles. Systemic administration is prone triggering hepatotoxicity and off-target organ injury. Next-generation derivatives and muscle-specific nanocarriers are urgently required to resolve these pharmacokinetic defects [137].

5.2. Natural bioactive compounds and TCM

Natural extracts and multi-component TCM formulas exert multi-target anti-ferroptotic effects with low systemic toxicity, serving as complementary candidates to synthetic drugs.

In the realm of natural bioactive extracts, lobetyolin alleviates CKD-associated muscle atrophy by activating the Hedgehog–GLI1 cascade; it upregulates SLC7A11 and GPX4, cuts intramuscular iron content by ∼45% and boosts muscle mass [92]. L-theanine relieves oxidative muscle damage by strengthening intrinsic antioxidant capacity and suppressing ferroptotic signaling [138]. Similarly, the natural flavonoid luteolin elevates SLC7A11 and GPX4 expression in estrogen-deficiency atrophy models, effectively restoring muscle contractile function [63].

Furthermore, TCM compound formulas regulate multiple redox axes simultaneously. Shenshuai Yinyang Capsules ameliorate CKD atrophy through the HIF-1α/SLC7A11 pathway, increasing muscle mass by ∼1.5-fold [97]. The Yiqi Qutan Formula reduces MDA by 40% and upregulates GPX4 to counter cisplatin-induced myotoxicity [139]. Remarkly, Qiangji Jianli Decoction alleviates experimental autoimmune myasthenia gravis by inhibiting ERS-ferroptosis crosstalk via the GRP78/IRE1α/GPX4 module, providing a modern molecular interpretation of the TCM theory “the spleen governs muscles” [140,141].

While natural products feature multi-target activity and favorable safety profiles, most suffer from low bioavailability and unclear tissue distribution, limiting their standalone clinical efficacy. Consequently, combining these agents with targeted delivery vehicles can significantly optimize their therapeutic performance.

5.3. Non-pharmacological therapeutic regimens

Exercise and nutritional supplementation act as safe, long-term modulators of muscle iron and lipid homeostasis, serving as essential strategies for chronic myopathy prevention and adjuvant treatment.

Physical exercise interventions have been shown to directly counteract ferroptotic signaling. For instance, exercise reshapes the expression profile of ferroptosis-related miRNAs, forming an exercise-miRNA-antioxidant regulatory circuit to restrain lipid peroxidation. Furthermore, when combined with pharmacological agents like ferrostatin-1, aerobic exercise synergistically represses ferroptosis and enhances endogenous antioxidant defenses, highlighting its value as a potent adjuvant therapy [142].

In terms of nutritional interventions, Coenzyme Q10 (CoQ10) supplementation reverses macrophage-driven mTORC1-HMGCR axis damage, restores endogenous antioxidant synthesis, and relieves osteoarthritis-linked muscle wasting [94]. Additionally, essential trace elements and targeted dietary lipids—such as selenium, deuterated PUFAs, and vitamin E—also serve as daily nutritional adjuvants to stabilize GPX4 activity and reduce ferroptotic susceptibility.

5.4. Targeted signaling pathway modulators

Beyond direct inhibition of core ferroptotic machinery, the precise modulation of upstream signaling cascades enables refined, disease-specific ferroptosis regulation.

In sepsis-induced myopathy, pharmacological STAT6 inhibition downregulates pro-ferroptotic CHI3L1, lowers intramuscular iron by 40% and rescues muscle weight loss [93]. During skeletal muscle ischemia-reperfusion injury, HIF1A transcriptionally activates the ferroptosis-promoting target CDKN1A; blocking this axis via LW6 or UC2288 alleviates mitochondrial damage and lipid peroxidation [143]. Targeting lipid metabolic cascades also offers therapeutic potential; for instance, the activation of ACOT7 (as demonstrated by vitamin E intervention) balances fatty acid metabolism and iron turnover to block ferroptotic cascades, a mechanism translatable to a broad spectrum of skeletal muscle lesions [144]. Notably, facioscapulohumeral muscular dystrophy (FSHD) models expressing DUX4 reveal highly unconventional, bidirectional iron regulatory effects: paradoxical moderate iron supplementation partially alleviates ferroptosis. This distinct phenomenon suggests that context-dependent, bidirectional iron-modulating strategies warrant further exploration in specific genetic myopathies [145].

5.5. Gene, RNA, and targeted delivery platforms

Gene delivery, RNA therapeutics, and tissue-specific carriers constitute cutting-edge intervention platforms designed to overcome the pharmacokinetic limitations and off-target defects of systemic small-molecule administration.

5.5.1. AAV-mediated gene delivery

Adeno-associated virus (AAV) vectors constitute a clinically tractable platform for delivering anti-ferroptotic transgenes to skeletal muscle [146]. AAV9 and AAVrh74 are the most widely used serotypes due to their efficient transduction of skeletal and cardiac muscle following systemic administration [147]. Muscle-restricted promoters (MHCK7, SPc5-12, desmin) confine transgene expression to myofibers, minimizing off-target effects. Engineered capsids, such as MyoAAV, achieve up to 10-fold higher muscle transduction than wild-type AAV9, improving the therapeutic window for muscle-targeted gene therapy [148]. For instance, a single intravenous AAV9-GPX4 injection elevates muscular GPX4 by ∼2.5-fold and reduces MDA by 45% in CKD atrophy models, with stable expression lasting over six months [92]. However, major translational barriers include pre-existing anti-AAV antibodies (30–50% population prevalence), high-dose hepatotoxicity, and risks from persistent GPX4 overexpression [149,150]; encouragingly, Tet-On inducible systems partially resolve such drawbacks by allowing temporal control of transgene expression [151].

5.5.2. Aptamer-based ferroptosis modulation

Aptamers are single-stranded oligonucleotides (20–80 nt) that fold into defined structures and bind targets with high affinity and specificity [152]. Compared with antibodies, aptamers offer minimal batch-to-batch variation, low immunogenicity, ease of conjugation, and rapid tissue penetration. Currently, he DNA aptamer AS1411 (targeting nucleolin) delivers ferroptosis inducers to cancer cells [153], while the peptide aptamer sP10 (targeting NPM1) modulates ferroptosis and autophagy in liver fibrosis [154].

For skeletal muscle, two strategies are promising. First, muscle-homing aptamer–drug conjugates (ApDCs) could be developed against sarcolemmal or SCs markers (e.g., DGC components or TFR1) to deliver ferrostatin-1 or GPX4 activators selectively. However, markers like TFR1 are not muscle-specific, requiring rigorous selectivity validation. Second, functional aptamers could directly inhibit pro-ferroptotic proteins (ACSL4, ALOX15) or stabilize GPX4 activity, administered locally for acute injury or systemically for chronic disorders. Although no aptamer targeting ferroptosis regulators has entered clinical trials for muscle disease yet, chemical modifications (e.g., 2′-fluoro, LNA) that enhance nuclease resistance provide a strong foundation for future translation [155].

5.5.3. Nanoparticle- and exosome-based delivery systems

Efficient and selective delivery to skeletal muscle is essential for gene-, RNA-, and small-molecule-based anti-ferroptotic intervention [156]. As noted previously, current prototypical inhibitors lack tissue specificity; for example, ferrostatin-1 distributes broadly to the liver, kidney, and brain with limited muscle exposure, making muscle-targeted delivery a critical priority.

Muscle-homing peptide-conjugated nanoparticles offer a promising strategy. The ASSLNIA peptide, identified by phage display, enhances skeletal muscle targeting [157]; ASSLNIA-conjugated PLGA nanoparticles loaded with ferrostatin-1 increased muscle accumulation by ∼3-fold versus untargeted controls in mice [158]. Alternative ligands include aptamers or peptides against muscle- or satellite-cell markers (e.g., TFR1). Optimal particle sizes (50–100 nm) balance distribution, retention, and uptake [159].

Exosomes—naturally secreted nanovesicles (30–150 nm) from mesenchymal stem cells (MSCs) or other cells—exhibit low immunogenicity, the capacity to cross biological barriers, and intrinsic tropism for injured tissues. MSC-derived exosomes loaded with GPX4 mRNA or anti-ferroptotic miRNAs (e.g., miR-23a-3p targeting ACSL4) show protective effects in muscle injury and atrophy models [160]. Notably, exosomes enriched in the microprotein MUSTN1 are internalized by satellite cells, suppressing ferroptosis and promoting myogenic differentiation [64]. Nonetheless, loading efficiency, batch consistency, cargo heterogeneity, and scalable manufacturing remain challenges, though GMP-compliant production is under development.

Finally, liposomal formulations also improve delivery. Liposomes encapsulating ferrostatin-1 or GPX4 activators enhance solubility and bioavailability; PEGylation prolongs circulation and facilitates passive accumulation in inflamed muscle. Active targeting can be achieved with muscle-enriched ligands (anti-TFR1 antibodies, ASSLNIA peptide). Building on the recent clinical success of mRNA therapeutics, lipid nanoparticles (LNPs) represent an emerging vehicle for GPX4 mRNA or ferroptosis-modulating siRNAs directly to dystrophic muscles [161].

5.6. Paths and challenges in clinical translation

Despite encouraging preclinical results, translating ferroptosis-targeted therapies into clinical practice for skeletal muscle diseases faces major hurdles across four key domains: patient heterogeneity, long-term safety, targeted delivery, and clinical trial design.

Patient Stratification and Heterogeneity. The etiological and pathophysiological diversity of muscle diseases—ranging from sarcopenia and muscular dystrophies to cachexia and inflammatory myopathies—demands rigorous patient stratification. Even within a single condition like sarcopenia, the contribution of ferroptosis likely fluctuates with age, nutritional status, systemic inflammation, and genetic background. A precision medicine framework must integrate multi-omics profiling of muscle or liquid biopsies to define distinct “ferroptosis-driven” subtypes. Furthermore, validating predictive circulating biomarkers (e.g., 4-HNE adducts, GSSG/GSH ratio, GPX4 activity) is essential to guide trial enrollment and monitor target engagement.

Safety and Dosing Regimens. The safety profiles and optimal dosing regimens for ferroptosis inhibitors remain largely undefined in humans. Because iron metabolism and baseline lipid peroxidation are crucial for normal physiological processes (such as erythropoiesis, immune cell activation, and mitochondrial respiration), systemic, long-term ferroptosis inhibition may induce off-target toxicities. Critical open questions include determining the safe duration of inhibition, evaluating the efficacy of intermittent (pulsatile) dosing, and exploring the synergistic potential of low-dose combinations (e.g., NAC plus vitamin E). Rigorous dose-finding studies in chronic wasting models are urgently needed to establish therapeutic windows.

Translational Bottlenecks in Targeted Delivery. Overcoming the pharmacokinetic limitations of current ferroptosis inhibitors is a paramount translational priority. As previously discussed, while advanced delivery platforms—such as muscle-homing nanoparticles, exosomes, and aptamer–drug conjugates—demonstrate high preclinical efficacy, scaling these nanotechnologies for GMP-compliant manufacturing and proving their systemic safety in humans remain formidable clinical bottlenecks.

Complexities in Clinical Trial Design. Designing robust clinical trials for anti-ferroptotic therapies presents unique complexities. Investigators must carefully select context-specific clinical endpoints (balancing morphological measures like muscle mass with functional outcomes like strength, physical performance, or patient-reported metrics) and define appropriate trial durations (ranging from weeks for acute reperfusion injuries to years for slow-progressing sarcopenia). Additionally, since ferroptosis often co-occurs with apoptosis or necroptosis, evaluating ferroptosis inhibitors within combination regimens targeting multiple cell death pathways will be crucial. This, in turn, will demand proactive engagement with regulatory agencies to establish clear protocols for testing novel combinatorial therapies.

6. Conclusion and prospect

Ferroptosis exerts dual regulatory effects on skeletal muscle homeostasis, balancing physiological adaptive remodeling and pathological degenerative damage. Despite substantial advances in mechanistic research, multiple unresolved scientific controversies and technical bottlenecks hinder the clinical translation of ferroptosis-targeted interventions. This section summarizes core academic debates, identifies prevailing translational obstacles, and proposes a tiered research roadmap to accelerate bench-to-bedside transformation.

6.1. Controversial points in skeletal muscle ferroptosis

Current discourse centers on the context-dependent nature of ferroptosis and its intricate crosstalk with other cell death programs. A primary controversy lies in distinguishing its physiological necessity from its pathological lethality. While substantial evidence implicates aberrant ferroptosis as a driver of muscle atrophy and dystrophy, emerging data suggest that transient, tightly regulated ferroptosis is a prerequisite for effective myogenesis and regeneration. Resolving this physiological versus pathological dichotomy—specifically, defining the molecular thresholds that shift the balance from adaptive remodeling to degeneration—is critical for determining when to therapeutically inhibit or induce ferroptosis.

The molecular regulation of ferroptosis and its interplay with other cell death pathways remain equally contentious. Ferroptosis often coexists with apoptosis in atrophic muscle, potentially acting as a precursor or partner in cell death execution [14,59], underscoring the need to clarify their mechanistic crosstalk. The identity of the principal enzymes driving lipid peroxidation is also debated: although PEBP1–15-LOX interaction promotes phosphatidylethanolamine peroxidation, genetic ablation of ACSL4 can completely abrogate ferroptosis, suggesting that LOX enzymes may not be universally essential [12]. Similarly, autophagy exhibits a paradoxical relationship with ferroptosis, capable of either promoting it via ferritinophagy (increasing labile iron) or suppressing it by removing ROS-generating organelles [14,20]. Elucidating these context-dependent interactions is essential for identifying precise therapeutic nodes.

6.2. Technical challenges in monitoring and validation

Translating ferroptosis research into clinical applications faces several technical hurdles, primarily regarding biomarker specificity, in vivo monitoring limitations, and drug safety. First, conventional markers such as MDA and tissue iron accumulation lack specificity, as they are elevated in numerous stress conditions [117]. The field is increasingly shifting toward more specific molecular signatures, such as ferroptosis-associated non-coding RNAs (e.g., lncRNA GPRC5D-AS1), which demonstrate a tighter correlation with the ferroptotic activity [83]. Second, advanced imaging tools are required to dynamically assess ferroptosis. The development of positron emission tomography (PET) probes targeting GPX4 offers a promising method for the non-invasive visualization and quantification of ferroptosis in living tissues, enabling more accurate preclinical assessments [162]. Third, systemic pharmacological inhibition of ferroptosis risks disrupting essential physiological iron metabolism. Strategies to enhance safety include: (i) tissue-targeted delivery, such as muscle-specific nanocarriers for ferrostatin-1, which can increase local concentrations tenfold while reducing off-target effects [163]; and (ii) rational combination therapies, such as co-administering low-dose iron chelators with vitamin E, which maintain efficacy while minimizing systemic side effects [11].

6.3. Prospects for precision therapeutics in muscle disorders

Ferroptosis has emerged as a core pathogenic mechanism across a broad spectrum of myopathies, yet realizing its therapeutic potential requires a paradigm shift from broad-spectrum inhibitors to precision-guided, multi-modal regimens. Future research should prioritize following three translational trajectories.

First, multi-omics subtyping and clinical Validation. Significant interpatient and inter-disease heterogeneity necessitates robust subtyping frameworks. Currently, human evidence linking ferroptosis to muscle disease relies largely on small biopsy cohorts (e.g., altered GPRC5D-AS1/SLC7A11 in sarcopenia [83], or abnormal iron/lipid profiles in DMD [164]). Moving forward, the field must leverage single-cell RNA sequencing, spatial transcriptomics, and lipidomics to stratify patients based on distinct ferroptotic molecular profiles (Fig. 5). Expanding these small cohorts into large, longitudinal clinical trials is a critical next step to validate ferroptosis as a clinically actionable target.

Fig. 5.

Conceptual framework for precision medicine targeting ferroptosis in sarcopenia and the muscle–bone crosstalk. The schematic integrates a personalized therapeutic workflow with the physiological interplay between skeletal muscle and bone. Left panel: precision medicine workflow. A diagnostic screening step (e.g., genomic or blood-based profiling) stratifies patients into distinct molecular subtypes, such as those with iron overload versus those with GPX4 deficiency. This stratification directs targeted therapeutic interventions: patients with iron overload may receive iron chelators, while those with GPX4 deficiency may be treated with GPX4 activators or Nrf2 signaling agonists. Right panel: muscle–bone crosstalk. The diagram illustrates the bidirectional signaling at the muscle–bone interface. Muscle-derived factors influence bone metabolism, while bone-derived factors (osteokines) modulate muscle iron handling and redox homeostasis. This reciprocal communication contributes to the maintenance of integrated musculoskeletal homeostasis.

Second, combinatorial and multi-modal interventions. Because single-target monotherapies often fail to resolve multifactorial myopathic lesions, future therapeutic regimens must be customized to individual profiles and combined synergistically. For instance, pairing ferrostatin-1 with aerobic exercise, or combining low-dose iron chelators with epigenetic modulators or metabolic supplements (e.g., CoQ10), can suppress ferroptosis while boosting endogenous antioxidant capacity [94,142]. Furthermore, utilizing advanced tissue-specific delivery systems (such as MSC-derived exosomes and machine-learning-optimized LNPs) will be essential to simultaneously modulate multiple ferroptotic pathways without disrupting systemic iron homeostasis.

Third, expanding the druggable target space. Conventional drug candidates targeting canonical proteins (SLC7A11, GPX4, ACSL4) face limits in druggability and tissue specificity. Future drug discovery should pivot toward novel, muscle-enriched targets. Promising avenues include targeting upstream epigenetic regulators (e.g., H4K20me1 to protect SCs pools [77]), exploring post-translational modifications (e.g., zDHHC8-mediated GPX4 palmitoylation [165]), or modulating GPX4-independent antioxidant axes (FSP1, DHODH, and GCH1), which warrant rigorous muscle-specific preclinical validation.

6.4. Concluding remarks

Extensive preclinical evidence has firmly established ferroptosis as a core driver of skeletal muscle atrophy and dystrophy, providing a unifying framework for understanding the molecular basis of diverse myopathies. Beyond direct therapeutic development, further dissecting ferroptosis functions in satellite cell homeostasis and muscle-bone interorgan signaling may uncover previously unrecognized musculoskeletal regulatory networks. Ultimately, unlocking the full therapeutic potential of ferroptosis-modulating agents will require cross-disciplinary collaborative frameworks—spanning mechanistic exploration, novel drug design, precision delivery platforms, and standardized clinical trials—to translate these fundamental discoveries into transformative therapies for muscle diseases.

Author contributions

Yongjie Xu, Kejin Ren and Yijia An: Conceptualization. Kaili Zhou, Yijia An and Xiaofang Cheng: Software. Kejin Ren, Tiantian Meng, and Cencen Li: Data curation. Yongjie Xu, Kejin Ren and Yijia An: Writing—original draft preparation; Yongjie Xu, Haixia Xu and Pengpeng Zhang: Writing—review and editing; Yongjie Xu: Funding acquisition. All authors have read and approved the final manuscript.

Declaration of generative AI in scientific writing

In the course of preparing this manuscript, the authors employed DeepSeek and Gemini for linguistic refinement to enhance the precision and clarity of expression. Subsequently, the authors conducted a thorough review and made necessary edits to the content, thereby assuming full responsibility for the final published version of the article.

Funding

This research was funded by the National Natural Science Foundation of China (31972537), the Department of Science and Technology in Henan Province (242102111015), the Natural Science Foundation of Henan Province (252300423642), the Key Research Projects of Higher Education Institutions in Henan Province (24A230015), the Postgraduate Education Reform and Quality Improvement Project of Henan Province (YJS2025KC33), and the Nanhu Scholars Program of Xinyang Normal University.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.