Methods of improving skeletal muscle function

Abstract

The present invention relates to a method of improving muscle function in a subject suffering from a disease or condition of impaired muscle function, the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist.

Description

Technical Field

[0001] The present invention relates to methods for improving muscle function in a subject in need thereof, in particular for therapeutic use in conditions associated with muscle strength loss, muscle disorders and / or muscle pain. Background of the Invention

[0003] Achondroplasia is the most common form of non-lethal skeletal dysplasia, affecting more than 250,000 people worldwide. Achondroplasia is caused by a pathogenic variant in the gene encoding fibroblast growth factor receptor 3 (FGFR3) and is inherited as an autosomal dominant trait. FGFR3 is a negative regulator of long bone development and is highly expressed in growth plate chondrocytes.

[0004] Infants with achondroplasia typically have hypotonia (hypotonicity), which leads to delayed motor skill development and skeletal muscle weakness, and causes spinal deformities such as kyphosis (Takken et al., Journal of Pediatrics 2017, Vol 150, pp26 - 30; Achondroplasia Patient Guide, Department of Orthopaedic Surgery, Johns Hopkins University, 2003). Muscle weakness is also characteristic of adult achondroplasia (Sims et al., J Appl Physiol (1985) Mar 1, 2018; 124(3):696 - 703; de Vries Am J Med Genet. 2021; 185A:1023 - 1032).

[0005] Spinal deformities in achondroplasia patients require treatment in infancy, childhood and adulthood. Infants may require the use of braces or body casts, and corrective surgery may be required in childhood. In adulthood, kyphosis causes spinal stenosis and usually requires surgery to straighten the spine and fuse the bones of the spine together.

[0006] Inhibiting FGFR3 signal transduction has been the focus of developing therapeutic interventions for achondroplasia. FGFR3 inhibitors may act on the receptor itself or its downstream signaling pathways to inhibit FGFR3 signal transduction. Accordingly, suitable examples of FGFR3 inhibitors include tyrosine kinase inhibitors (such as infigratinib, pemigatinib, futibatinib, erdafitinib or TYRA - 300), C - type natriuretic peptide (CNP), FGFR3 siRNA and FGFR3 antisense oligonucleotides.

[0007] Infigratinib is an FGFR-selective tyrosine kinase inhibitor that has been approved for the treatment of certain cancers (Truseltiq) and is in clinical development for height growth in children with achondroplasia (Savarirayan et al., Ther Adv Musculoskelet Dis. March 21, 2022; 14).

[0008] TYRA-300 is an orally active, potent FGFR3-selective tyrosine kinase inhibitor that is active in the presence of mutations, including the FGFR3 V555 mutation, and is more selective for FGFR3 than FGF1 and other FGFR subtypes. TYRA-300 is being developed by Tyra Biosciences.

[0009] FGFR3 signals through multiple intracellular pathways, including signal transducer and activator of transcription (STAT) and mitogen-activated protein kinase (MAPK), and constitutive activation of FGFR3 is associated with the achondroplasia phenotype. Activation of FGFR3 is associated with increased phosphorylation of the STAT and MAPK pathways. The MAPK pathway can be regulated by C-type natriuretic peptide (CNP). Binding of CNP to its receptor, natriuretic peptide receptor B (NPR-B), causes the production of cGMP, which activates different signal transduction mediators, including cyclic nucleotide phosphodiesterases (PDEs), cGMP-regulated ion channels (cGIC), and cGMP-dependent protein kinases (cGKI and cGKII). The effect of CNP / NPR-B on FGFR3 is mediated by the activation of cGKII, which inhibits the activation of RAF-1, thereby inhibiting the activation of MEK1 / 2 and ERK1 / 2 in the MAPK pathway. Examples of FGFR3 inhibitors acting downstream of FGFR3 include molecules that activate the NPR-B receptor, as activation of this receptor inhibits FGFR3 downstream signaling by inhibiting the mitogen-activated protein kinase (MAPK) pathway.

[0010] Vosoritide is a C-type natriuretic peptide (CNP) variant that has been approved for the treatment of achondroplasia in pediatric patients with growing bones and acts directly on the growth plates of the bones to promote new bone growth (https: / / www.ema.europa.eu / en / medicines / human / EPAR / voxzogo).

[0011] TransCon TMCNP is a investigational long-acting CNP prodrug that is currently in clinical development for the treatment of achondroplasia in pediatric patients with open epiphyses (Breinholt et al., Br J Clin Pharmacol. November 2022, 88(11):4763-4772). In a Phase 2 clinical trial (ACcomplisH), TransCon TM CNP demonstrated an advantage in the change in annualized ACH-specific height SDS compared to placebo, and a reduction in achondroplasia-related adverse events was reported.

[0012] CNP is a potent regulator of growth plate chondrogenesis. The binding of CNP to natriuretic peptide-binding receptor-2 (NPR-B) on the surface of chondrocytes induces the intracellular synthesis of cyclic guanosine monophosphate (cGMP) and activates cGMP-dependent signal transduction (Potter et al., Handb Exp Pharmacol. 2009;(191):341-366). CNP is applicable to cardiac remodeling and acute myocardial infarction, smooth muscle relaxation, and the treatment of hypertension (Nakagawa and Saito, Biology 2022, 11, 1017). Perez-Temero et al., PNAS 2022, vol 119 / 13 e2116470119 reported that C-type natriuretic peptide is a key regulator of metabolic homeostasis. CNP exerts these metabolic regulatory effects by inhibiting sympathetic thermogenic programming and reducing the expression of peroxisome proliferator-activated receptor-γ coactivator-1α via Gi-coupled natriuretic peptide receptor (NPR)-C, accompanied by adipogenesis driven by NPR-B / protein kinase-G. Perez-Temero et al., Front. Mol. Neurosci. 15:991112. doi:10.3389 / fnmol.2022.991112 reported that, according to CNP-deficient mice, CNP plays a role in regulating the blood-brain barrier and modulating the motor reactivity to a new environment. In particular, the absence of CNP in gbCNP- / - mice led to weight loss, but muscle mass remained unchanged.

[0013] Another example of an FGFR3 inhibitor that acts downstream of the FGFR3 itself pathway is the molecule meclizine, which attenuates the MAPK signaling pathway at the level of ERK phosphorylation (see, for example, Kitoh et al., 2020. PLoS ONE 15(4):e0229639. https: / / doi.org / 10.1371 / joumal.pone.0229639).

[0014] Mackler et al. (Arch. Biochem and Biophys 159, 885 - 888, 1973) reported a decrease in oxidative energy production in adult achondroplasia (ACH). Domondon et al. (Am J Physiol Renal Physiol 2019 317: F1164–F1168) reviewed the regulation of mitochondrial function by natriuretic peptides, highlighting the role of ANP and BNP / NPR-A activation in mitochondria. Miyashita et al. (Diabetes 2009 58, 2880 - 2892) reported that the BNP / cGK cascade can promote muscle mitochondrial biogenesis and fat oxidation and prevent obesity in BNP-TG mice.

[0015] In contrast, Perez-Temero et al., PNAS 2022 Vol. 119 No. 13 e2116470119 reported that CNP plays a protective role in coordinating metabolic homeostasis by inhibiting sympathetic thermogenesis programming through NPR-C, while driving adipogenesis through NPR-B / protein kinase-G, indicating an opposing role of CNP to NPR-A ANP / BNP activation. PGC-1α is a key regulator of mitochondrial biogenesis, and as reported by Domondon 2018, PGC-1α is positively regulated by ANP and BNP. Summary of the Invention

[0016] The treatment of achondroplasia has been focused on promoting endochondral bone growth, and these therapies have been selected because of their ability to improve the annualized growth / height velocity in children with achondroplasia. The inventors of the present invention surprisingly found that treating children with achondroplasia with the CNP drug Trans Con CNP resulted in improved physical function and a reduction in adverse events associated with the achondroplasia disease. According to the studies reported below, these improvements in physical function are thought to be caused by improved muscle function and are not related to bone growth. Children taking the placebo showed a deterioration in physical function and a higher incidence of adverse events associated with the achondroplasia disease. In addition, in an achondroplasia mouse model, it was shown that Trans Con CNP treatment increased the survival rate of pups within 15 days after birth. This finding was associated with a reduction in the incidence of maternal infanticide, a phenomenon related to pup muscle weakness and occurring within a time range inconsistent with the effects involving bone growth. The FGFR3 signal transduction inhibitor CNP (as described above, CNP inhibits FGFR3-mediated signal transduction) effectively enhances physical function and muscle function without enhancing endochondral bone growth, and these findings suggest that CNP and other FGFR3 inhibition strategies are suitable therapies for improving muscle function, such as treating hypotonia and related diseases in children and adults. The binding of CNP to the NPR-B receptor may contribute to the mechanism of action, and thus NPR-B receptor agonists are also considered for this use. The binding of CNP to the NPR-C receptor may contribute to the mechanism of action, and thus NPR-C receptor agonists are also considered for this use.

[0017] The present invention provides a method for improving muscle function in a subject having a disease or disorder characterized by impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor.

[0018] The present invention provides a method for improving muscle function in a subject having a disease or disorder characterized by impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of an NPR-B agonist.

[0019] The present invention provides a method for improving muscle function in a subject having a disease or disorder characterized by impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of an NPR-C agonist.

[0020] The present invention provides a method for improving muscle function in a subject having a disease or disorder characterized by impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor, an NPR-B agonist, or an NPR-C agonist.

[0021] The present invention provides a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP). In some embodiments, the NPR-B agonist or CNP is vosoritide (SEQ ID NO:30).

[0022] The present invention provides a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP), wherein the CNP is administered as a CNP conjugate and / or a prodrug of CNP or a pharmaceutically acceptable salt thereof.

[0023] The present invention provides a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP), wherein the CNP is administered as a CNP conjugate and / or a prodrug of CNP or a pharmaceutically acceptable salt thereof; wherein the method comprises administering to the subject successive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, wherein between successive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, the amount of free CNP continuously exposed in the patient's plasma is at least about 1 pmol / L. In some embodiments, for example, successive doses are administered daily or weekly or bi-weekly or monthly. In some embodiments, the time interval between successive doses is at least about 24 hours, such as at least about one week. In some embodiments, the CNP conjugate or the prodrug of CNP is a compound of formula (IIf’), a compound of formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

[0024] The present invention provides a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP), wherein the CNP is administered as a CNP conjugate and / or a prodrug of CNP or a pharmaceutically acceptable salt thereof, wherein the CNP conjugate or the prodrug of CNP is a compound of formula (IIf’), a compound of formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

[0025] In some embodiments, the subject is a human subject. In some embodiments, the subject is a human subject less than 18 years of age. In some embodiments, the subject is a human subject at least 18 years of age. In some embodiments, the subject has closed epiphyses.

[0026] The present invention provides a method for improving muscle function in a subject suffering from a disease or disorder associated with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP), wherein the method comprises infusing CNP into the subject, such as by intravenous infusion or subcutaneous infusion, wherein the infusion results in a sustained exposure of CNP (free CNP) in the patient's plasma of at least 1 pmol / L for a period of at least about 1 hour. In some embodiments, CNP (free CNP) is continuously exposed in the patient's plasma for a period of at least about 2 hours (such as at least about 4 hours, such as at least about 6 hours).

[0027] The present invention provides a method for improving muscle function in a subject suffering from a disease or disorder associated with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor, wherein the FGFR3 signal transduction inhibitor (FGFR3 antagonist) is an FGFR3 tyrosine kinase inhibitor, such as the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of: infigratinib, pemigatinib, futibatinib, erdafitinib, and TYRA-300.

[0028] The present invention provides a method for improving muscle function in a subject (such as a therapeutic method).

[0029] The present invention provides a method for improving skeletal muscle function in a subject (such as a therapeutic method).

[0030] The present invention provides a method (such as a therapeutic method) for improving muscle strength in a subject and / or improving muscle endurance (such as skeletal muscle strength and / or skeletal muscle endurance).

[0031] The present invention provides a method (such as a therapeutic method) for improving muscle tone in a subject (such as skeletal muscle tone).

[0032] In each case, the method comprises administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-C agonist or an effective amount of an NPR-B agonist. In some embodiments, the method comprises administering an effective amount of an NPR-B / NPR-C agonist (such as CNP).

[0033] The subject may suffer from a disease or disorder that results in impaired muscle function (such as muscle strength, endurance, and / or tone). The disease or disorder may be a disease or disorder that results in impaired skeletal muscle function.

[0034] Optionally, an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist or CNP, such as a CNP conjugate or a prodrug of CNP or a pharmaceutically acceptable salt thereof, can be used in combination with a growth hormone (such as human growth hormone).

[0035] The present invention provides the use of an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist in a method for improving muscle function in a subject, optionally, wherein the subject has a disease or disorder that causes impaired muscle function.

[0036] The present invention provides the use of an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist in a method for improving skeletal muscle function in a subject, optionally, wherein the subject has a disease or disorder that causes impaired skeletal muscle function.

[0037] In some embodiments, the subject has a chondrodysplasia disease, such as a disease selected from the group consisting of achondroplasia, hypochondroplasia, and thanatophoric dysplasia. The subject is preferably a human subject. The subject can be less than 18 years old or at least 18 years old. The subject can have closed epiphyses.

[0038] In some embodiments, the FGFR3 signal transduction inhibitor is an FGFR3 antagonist or an NPR-B agonist.

[0039] In some embodiments, an NPR-C agonist can be used in the methods or uses described in the present invention.

[0040] FGFR3 antagonists can include fibroblast growth factor receptor (FGFR) 3 tyrosine kinase inhibitors, anti-FGFR3 antibodies, anti-FGFR3 antisense oligonucleotides, or anti-FGFR3 siRNAs. Suitable NPR-B agonists are C-type natriuretic peptides, or conjugates or prodrugs thereof. Suitable NPR-C agonists are C-type natriuretic peptides, or conjugates or prodrugs thereof.

[0041] Examples of FGFR3 antagonists include fibroblast growth factor receptor (FGFR) 3 tyrosine kinase inhibitors, such as infigratinib, pemigatinib, futibatinib, erdafitinib, or TYRA-300. WO2022147246A1 discloses such FGFR3 antagonists, which are incorporated herein by reference in their entirety.

[0042] The present invention provides a method for improving muscle function (such as skeletal muscle function) in a subject having a disease or disorder with impaired muscle function (such as skeletal muscle function), the method comprising administering a therapeutically effective amount of CNP.

[0043] The present invention provides a method for improving muscle function (such as skeletal muscle function) in a subject suffering from a disease or disorder with impaired muscle function (such as skeletal muscle function), the method comprising administering a therapeutically effective amount of vosoritide.

[0044] In some embodiments, CNP comprises SEQ ID NO:24 or consists of SEQ ID NO:24. In some embodiments, CNP comprises a peptide selected from the group consisting of: SEQ ID NO:30, SEQ ID NO:98, SEQ ID NO:99, SEQ ID NO:100, SEQ ID NO:101, SEQ ID NO:102, SEQ ID NO:103, SEQ ID NO:104, SEQ ID NO:105, and SEQ ID NO:90 or consists of a peptide selected from the group consisting of: SEQ ID NO:30, SEQ ID NO:98, SEQ ID NO:99, SEQ ID NO:100, SEQ ID NO:101, SEQ ID NO:102, SEQ ID NO:103, SEQ ID NO:104, SEQ ID NO:105, and SEQ ID NO:90. In some embodiments, CNP is a CNP conjugate or a pharmaceutically acceptable salt thereof, comprising a CNP selected from the group consisting of: SEQ ID NO:30, SEQ ID NO:98, SEQ ID NO:99, SEQ ID NO:100, SEQ ID NO:101, SEQ ID NO:102, SEQ ID NO:103, SEQ ID NO:104, SEQ ID NO:105, or SEQ ID NO:90 and SEQ ID NO:90.

[0045] Improvement of muscle function can be, for example, a) increasing muscle (such as skeletal muscle) strength, b) increasing muscle (such as skeletal muscle) tone, c) increasing muscle (such as skeletal muscle) endurance, d) increasing muscle (such as skeletal muscle) mass, e) reducing muscle (such as skeletal muscle) fatigue, f) increasing cardiovascular endurance, g) improving cardiovascular fitness, h) reducing exercise intolerance, i) enhancing exercise ability, j) reducing exercise-induced fatigue, or k) exacerbating muscle hypertonia.

[0046] Administration of an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist can result in an increase in muscle (such as skeletal muscle) mass and / or skeletal muscle / fat ratio in a subject.

[0047] Administering an effective amount of an FGFR3 signaling inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist can result in the treatment or prevention of musculoskeletal pain in a subject, improvement in posture or reduction of abnormal curvature of the spine, improvement of kyphosis, lordosis, spinal stenosis or scoliosis, improvement of sleep apnea, obstructive sleep apnea, otitis media, or reduction of obesity. These improvements may be due to improvement in muscle function (such as skeletal muscle function). Thus, it is preferred to treat, prevent or improve any of the above conditions by improving muscle function (such as skeletal muscle function).

[0048] In some embodiments, CNP is administered as a prodrug. In some embodiments, the CNP prodrug provides sustained exposure to the active CNP peptide after administration to a subject.

[0049] The prodrug may optionally be a compound of formula (IIf’) or formula (IIf) or compound (1), or a pharmaceutically acceptable salt thereof.

[0050] In some embodiments, where the subject is an adult (i.e., at least 18 years old), the subject may have been treated with an FGFR3 signaling inhibitor or an NPR-B agonist (i.e., CNP) or an NPR-C agonist before the age of 18. Thus, the present invention provides a method of treatment that begins before the age of 18 and continues beyond the age of 18.

[0051] Administering an FGFR3 signaling inhibitor or an NPR-B agonist or an NPR-C agonist can cause one or more improvements in muscle function selected from the group consisting of:

[0052] a) increasing skeletal muscle strength,

[0053] b) increasing skeletal muscle tone,

[0054] c) increasing skeletal muscle endurance,

[0055] d) increasing skeletal muscle mass,

[0056] e) reducing skeletal muscle fatigue,

[0057] f) increasing cardiovascular endurance,

[0058] g) improving cardiovascular fitness,

[0059] h) reducing exercise intolerance,

[0060] i) enhancing exercise ability, or

[0061] j) reducing exercise-induced fatigue, and

[0062] k) reducing muscle hypotonia.

[0063] Accordingly, the method can alternatively be described as a method of increasing the skeletal muscle strength of a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0064] The method can also be described as a method of increasing the skeletal muscle tone of a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0065] The method can also be described as a method of increasing the skeletal muscle endurance of a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0066] The method can also be described as a method of increasing the skeletal muscle mass of a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0067] The method can also be described as a method of reducing skeletal muscle fatigue in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0068] The method can also be described as a method of increasing the cardiovascular endurance of a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0069] The method can also be described as a method of improving the cardiovascular fitness of a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0070] The method can also be described as a method of reducing exercise intolerance in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0071] The method can also be described as a method of enhancing exercise capacity in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0072] The method can also be described as a method of reducing exercise-induced fatigue in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0073] The method can also be described as a method of reducing muscle hypotonia in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0074] Administration of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or NPR-C agonist can result in an increase in the skeletal muscle / fat ratio in a subject, and the method can alternatively be expressed as a method of increasing the skeletal muscle / fat ratio in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0075] Administration of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or NPR-C agonist can result in a reduction in muscle hypotonia, and the method can thus be expressed as a method of reducing muscle hypotonia in a subject (optionally, where the subject has a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist. Thus, the method can be described as a method of treating muscle hypotonia in a subject.

[0076] Administration of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an NPR-C agonist can result in a reduction in musculoskeletal pain in a subject, and the method can thus be formulated as a method of treating, preventing or alleviating musculoskeletal pain in a subject (optionally, wherein the subject suffers from a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0077] The method also causes an improvement in posture and an improvement in spinal curvature abnormalities, and thus the method can be formulated as a method of improving the posture of a subject or treating spinal curvature abnormalities in a subject (optionally, wherein the subject suffers from a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist. The method also results in an improvement in kyphosis, lordosis or scoliosis, and thus the method can be defined as a method of treating one or more of these conditions in a subject (optionally, wherein the subject suffers from a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0078] The method can cause an improvement in sleep apnea, snoring, obstructive sleep apnea, otitis media, and thus the method can be defined as a method of treating one or more of these conditions in a subject (optionally, wherein the subject suffers from a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist. It can lead to a reduction in the frequency, incidence and / or severity of sleep apnea, snoring, obstructive sleep apnea, otitis media.

[0079] The method can cause a reduction in obesity, and thus the method can be defined as a method of reducing obesity in a subject (optionally, wherein the subject suffers from a disease or disorder with impaired muscle (such as skeletal muscle) function), the method comprising administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0080] The present invention also provides a method for treating kyphosis in a patient in need of such treatment, the method comprising administering to the patient an effective amount of CNP, a CNP conjugate or a pharmaceutically acceptable salt or unit dosage form thereof, thereby treating kyphosis.

[0081] In some embodiments, the patient has been diagnosed with a skeletal dysplasia or skeletal disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, short stature, Noonan syndrome, and SHOX deficiency.

[0082] The present invention also provides a method for treating patients in need of such treatment for foramen magnum stenosis, the method comprising administering to the patient an effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, thereby treating foramen magnum stenosis. In some embodiments, the patient has achondroplasia.

[0083] The present invention also provides a method for treating otitis media or ear infections in a patient or reducing the incidence of ear infections in a patient in need of such treatment, the method comprising administering to the patient a therapeutically effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, thereby treating otitis media or ear infections or reducing the incidence of ear infections. In some embodiments, the patient has achondroplasia.

[0084] The present invention also provides a method for treating sleep apnea syndrome in a patient in need of such treatment, the method comprising administering to the patient a therapeutically effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, for example, the treatment can reduce the incidence of sleep apnea or alleviate the severity of sleep apnea. In some embodiments, the patient has achondroplasia.

[0085] The present invention also provides a method for reducing the frequency of achondroplasia-related adverse events in patients diagnosed with achondroplasia, the method comprising administering a therapeutically effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, wherein optionally, the patient can be a pediatric patient and / or a patient with open epiphyses.

[0086] In any of the above methods, the subject may have a chondrodysplasia disease, such as a disease selected from the group consisting of achondroplasia, hypochondroplasia, and lethal dysplasia.

[0087] In the above method, the subject may have achondroplasia. In some embodiments, the subject does not have achondroplasia.

[0088] In any of the above methods, the subject may have achondroplasia, wherein the subject is a human subject at least 18 years of age or a human subject with closed epiphyses.

[0089] In terms of the methods mentioned herein, the present invention also provides an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist for the methods, and the use of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist in the manufacture of a medicament for the methods.

[0090] In some embodiments, CNP is in the form of a unit dosage form comprising a CNP conjugate or a pharmaceutically acceptable salt thereof.

[0091] In some embodiments, the unit dosage form of CNP comprises a therapeutically effective amount of a CNP conjugate or a pharmaceutically acceptable salt thereof, wherein the CNP moiety is reversibly conjugated to a polymeric moiety. BRIEF DESCRIPTION OF THE DRAWINGS

[0092] Figure 1 : Survival rate of Fgfr3Y367C / + pups during the study period, with the comparison group treated with compound (1) at 5.6 mg / kg / day (solid line), with compound (1) at 1.2 mg / kg every three days (dashed line), or treated with vehicle only (dotted line).

[0093] Figure 2 : Change in pedicle width after 52 weeks of treatment compared to the placebo group (groups 3 and 4), as detailed in Example 14. The data show that the treated pedicle width tended to increase compared to the placebo.

[0094] Figure 3 : Change in average hand length after 52 weeks of treatment compared to the placebo (groups 3 and 4), as detailed in Example 15. The results show that the hand length after treatment tended to increase significantly in a dose-dependent manner.

[0095] DEFINITIONS

[0096] As used herein, the term "about" is used in connection with a numerical value to denote a range that is the numerical value plus or minus not more than 10% of the numerical value and includes the two endpoints, in some embodiments not more than 8% of the numerical value, in some embodiments not more than 5% of the numerical value, and in some embodiments not more than 2% of the numerical value. For example, the phrase "about 200" is used to denote a range of 200 + / - 10% and includes the two endpoints, i.e., a range from 180 to 220 and including 180 and 220; in some embodiments, 200 + / - 8%, i.e., a range from 184 to 216 and including 184 and 216; in some embodiments, a range of 200 + / - 5% and includes the two endpoints, i.e., a range from 190 to 210 and including 190 and 210; in some embodiments, 200 + / - 2%, i.e., a range from 196 to 204 and including 196 and 204. It should be understood that the percentage "about 20%" does not mean "20% + / - 10%", i.e., a range from 10% - 30% and including 10% and 30%, but "about 20%" means a range from 18% - 22% and including 18% and 22%, i.e., plus or minus 10% of the numerical value 20.

[0097] As used herein, the term "antimicrobial agent" refers to a chemical substance, such as a chemical substance that kills or inhibits the growth of microorganisms (such as bacteria, fungi, yeasts, protozoa, molds) and / or destroys viruses.

[0098] As used herein, the term "buffer" or "buffering agent" refers to a chemical compound that maintains the pH value within a desired range. Physiologically tolerated buffers are, for example, sodium phosphate, succinate, histidine, bicarbonate, citrate, acetate, sulfate, nitrate, chloride, and pyruvate. Antacids such as Mg(OH)2 or ZnCO3 can also be used.

[0099] As used herein, the term "CNP" refers to all CNP polypeptides, which in some embodiments are from mammalian species, such as from human and mammalian species, particularly from human and murine species, and their variants, analogs, orthologs, homologs, and derivatives and fragments thereof, characterized by regulating the growth, proliferation, and differentiation of chondrocytes in the growth plate of cartilage. The human CNP precursor, which consists of 126 amino acids, is further cleaved to produce CNP-53 and CNP-22. The term "CNP" also includes all CNP variants, analogs, orthologs, homologs, derivatives, and fragments thereof. All CNP variants, analogs, orthologs, homologs, derivatives, and fragments thereof disclosed in WO2009 / 067639A2 and WO2010 / 135541A2 are hereby incorporated by reference. CNP peptides and pharmaceutical compositions containing CNP peptides are disclosed in WO2009 / 067639, WO2010 / 135541, WO2017 / 020034, WO2017 / 100400, WO2021055497, WO2021 / 030411, WO2023 / 283657, WO2022 / 115563, all of which are hereby incorporated by reference into this text. Exemplary CNP peptides are provided herein, including vosoritide.

[0100] The term "C 1-4 alkyl", used alone or in combination herein, denotes a straight-chain or branched-chain alkyl moiety having 1-4 carbon atoms. If present at the end of a molecule, examples of straight-chain or branched-chain C 1-4 alkyl are methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl, and tert-butyl. When two moieties of a molecule are linked by C 1-4 alkyl, examples of such C 1-4 alkyl are -CH2-, -CH2-CH2-, -CH(CH3)-, -CH2-CH2-CH2-, -CH(C2H5)-, -C(CH3)2-. Each hydrogen atom of the C 1-4 alkyl carbon may optionally be substituted with a substituent as defined above. Optionally, the C 1-4 alkyl may be interrupted by one or more moieties as defined below.

[0101] The term "C 1-6 alkyl", used alone or in combination herein, refers to a straight-chain or branched-chain alkyl moiety having 1-6 carbon atoms. If present at the end of a molecule, the straight-chain and branched-chain C 1-6Examples of alkyl groups are methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl, tert-butyl, n-pentyl, 2-methylbutyl, 2,2-dimethylpropyl, n-hexyl, 2-methylpentyl, 3-methylpentyl, 2,2-dimethylbutyl, 2,3-dimethylbutyl, and 3,3-dimethylpropyl. When two moieties of a molecule are linked by a C 1-6 alkyl group, examples of such C 1-6 alkyl groups are -CH2-, -CH2-CH2-, -CH(CH3)-, -CH2-CH2-CH2-, -CH(C2H5)-, and -C(CH3)2-. Each hydrogen atom of the C 1-6 alkyl carbon may optionally be substituted with a substituent as defined above. Optionally, the C 1-6 alkyl group may be interrupted by one or more moieties as defined below.

[0102] Accordingly, "C 1-10 alkyl", "C 1-20 alkyl", or "C 1-50 alkyl" each represent an alkyl chain having 1-10, 1-20, or 1-50 carbon atoms, respectively, where each hydrogen atom of the C 1-10 , C 1-20 , or C 1-50 carbon may optionally be substituted with a substituent as defined above. Optionally, the C 1-10 , C 1-20 alkyl, or C 1-50 alkyl may be interrupted by one or more moieties as defined below.

[0103] The term "C 2-6 alkenyl", used herein alone or in combination, represents a straight-chain or branched-chain hydrocarbon moiety having 2-6 carbon atoms and containing at least one carbon-carbon double bond. If present at the end of a molecule, examples are -CH=CH2, -CH=CH-CH3, -CH2-CH=CH2, -CH=CHCH2-CH3, and -CH=CH-CH=CH2. When two moieties of a molecule are linked by a C 2-6 alkenyl group, an example of such C 2-6 alkenyl is -CH=CH-. Each hydrogen atom of the C 2-6 alkenyl moiety may optionally be substituted with a substituent as defined above. Optionally, the C 2-6 alkenyl may be interrupted by one or more moieties as defined below.

[0104] Accordingly, the terms "C 2-10 alkenyl", "C 2-20 alkenyl", or "C 2-50 alkenyl", alone or in combination, represent a straight-chain or branched-chain hydrocarbon moiety having 2-10, 2-20, or 2-50 carbon atoms and containing at least one carbon-carbon double bond. The C 2-10Alkenyl, C 2-20 alkenyl or C 2-50 Each hydrogen atom of the alkenyl group is optionally substituted with a substituent as defined above. Optionally, C 2-10 alkenyl, C 2-20 alkenyl or C 2-50 alkenyl may be interrupted by one or more moieties as defined below.

[0105] The term "C 2-6 alkynyl" as used herein alone or in combination refers to a straight or branched chain hydrocarbon moiety having 2 - 6 carbon atoms and containing at least one carbon-carbon triple bond. If present at the end of a molecule, examples are -C≡CH, -CH2-C≡CH, -CH2CH2-C≡CH, and -CH2-C≡C-CH3. When two moieties of a molecule are joined by C 2-6 alkynyl, then an example is -C≡C-. C 2-6 Each hydrogen atom of the alkynyl group is optionally substituted with a substituent as defined above. Optionally, one or more double bonds may be present. Optionally, C 2-6 alkynyl may be interrupted by one or more moieties as defined below.

[0106] Accordingly, the term "C 2-10 alkynyl", "C 2-20 alkynyl" or "C 2-50 alkynyl" as used herein alone or in combination respectively denote a straight or branched chain hydrocarbon moiety having 2 - 10, 2 - 20 or 2 - 50 carbon atoms and containing at least one carbon-carbon triple bond. C 2-10 alkynyl, C 2-20 alkynyl or C 2-50 alkynyl group's each hydrogen atom is optionally substituted with a substituent as defined above. Optionally, one or more double bonds may be present. Optionally, C 2-10 alkynyl, C 2-20 alkynyl or C 2-50 alkynyl may be interrupted by one or more moieties as defined below.

[0107] As described above, C 1-4 alkyl, C 1-6 alkyl, C 1-10 alkyl, C 1-20 alkyl, C 1-50 alkyl, C 2-6 alkenyl, C 2-10 alkenyl, C 2-20 alkenyl, C 2-50 alkenyl, C 2-6 alkynyl, C 2-10 alkynyl, C 2-20 alkenyl or C 2-50The alkynyl group is optionally interrupted by one or more moieties, and in some embodiments, the one or more moieties are selected from the group consisting of:

[0108]

[0109] wherein

[0110] the dashed line represents attachment to the remainder of the moiety or reagent; and

[0111] -R and -R a are each independently selected from the group consisting of: -H, methyl, ethyl, propyl, butyl, pentyl, and hexyl.

[0112] As used herein, the term "C 3-10 cycloalkyl" refers to a cyclic alkyl chain having 3 to 10 carbon atoms, which may be saturated or unsaturated, such as cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cyclohexenyl, cycloheptyl, cyclooctyl, cyclononyl, or cyclodecyl. Each hydrogen atom of the C 3-10 cycloalkyl carbon may be substituted with a substituent as defined above. The term "C 3-10 cycloalkyl" also includes bridged bicyclics such as norbornane or norbornene.

[0113] As used herein, the term "8- to 30-membered carbocyclic polycycle" or "8- to 30-membered carbocyclic polycyclic" refers to a cyclic moiety of two or more rings having 8 to 30 ring atoms, wherein two adjacent rings share at least 1 ring atom and may contain no more than the maximum number of double bonds (fully, partially, or unsaturated aromatic or non-aromatic rings). In some embodiments, the 8- to 30-membered carbocyclic polycycle refers to a cyclic moiety of two, three, four, or five rings, and in some embodiments, two, three, or four rings.

[0114] As used herein, the term "3- to 10-membered heterocyclic group" or "3- to 10-membered heterocycle" refers to a ring having 3, 4, 5, 6, 7, 8, 9 or 10 ring atoms, which may contain no more than the maximum number of double bonds (fully, partially or unsaturated aromatic or non-aromatic rings), wherein at least 1 ring atom to 4 ring atoms are substituted with heteroatoms selected from the group consisting of sulfur (including -S(O)-, -S(O)2-), oxygen and nitrogen (including =N(O)-), and wherein the ring is attached to the remainder of the molecule through a carbon or nitrogen atom. Examples of 3- to 10-membered heterocycles include, but are not limited to, aziridine, ethylene oxide, thioethylene oxide, azirine, oxirene, thiirene ring, azetidine, oxetane, thietane, furan, thiophene, pyrrole, pyrroline, imidazole, imidazoline, pyrazole, pyrazoline, oxazole, oxazoline, isoxazole, isoxazoline, thiazole, thiazoline, isothiazole, isothiazoline, thiadiazole, thiadiazoline, tetrahydrofuran, tetrahydrothiophene, pyrrolidine, imidazolidine, pyrazolidine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, thiadiazolidine, sulfolane, pyran, dihydropyran, tetrahydropyran, imidazolidine, pyridine, pyridazine, pyrazine, pyrimidine, piperazine, piperidine, morpholine, tetrazole, triazole, triazolidine, tetrazolidine, diazepane, azepine and homopiperazine. Each hydrogen atom of the 3- to 10-membered heterocyclic group or 3- to 10-membered heterocyclic group may be substituted with a substituent as defined below.

[0115] As used herein, the term "8- to 11-membered heterobicyclic group" or "8- to 11-membered heterobicycle" refers to a heterocyclic moiety of two rings having 8-11 ring atoms, wherein the two rings share at least 1 ring atom and may contain no more than the maximum number of double bonds (fully, partially or unsaturated aromatic rings or non-aromatic rings), wherein at least 1 ring atom to 6 ring atoms are substituted with heteroatoms selected from the group consisting of sulfur (including -S(O)-, -S(O)2-), oxygen and nitrogen (including =N(O)-), and wherein the rings are attached to the remainder of the molecule through a carbon or nitrogen atom. Examples of 8- to 11-membered heterobicycles are indole, dihydroindole, benzofuran, benzothiophene, benzoxazole, benzisoxazole, benzothiazole, benzisothiazole, benzimidazole, benzimidazoline, quinoline, quinazoline, dihydroquinazoline, quinoline, dihydroquinoline, tetrahydroquinoline, decahydroquinoline, isoquinoline, decahydroisoquinoline, tetrahydroisoquinoline, dihydroisoquinoline, benzazepine, purine and pteridine. The term "8- to 11-membered heterobicycle" also includes a spiro ring structure of two rings such as 1,4-dioxa-8-azaspiro[4.5]decane or a bridged heterocycle such as 8-azabicyclo[3.2.1]octane. Each hydrogen atom of the 8- to 11-membered heterobicyclic group or 8- to 11-membered heterobicyclic carbon may be substituted with a substituent as defined below.

[0116] Similarly, the term "8- to 30-membered hetero polycyclic group" or "8- to 30-membered hetero polycycle" refers to a heterocyclic moiety of two or more rings (preferably three, four, or five rings) having 8 to 30 ring atoms, wherein two adjacent rings share at least 1 ring atom and may contain no more than the maximum number of double bonds (fully, partially, or unsaturated aromatic or non-aromatic rings), wherein at least 1 and up to 10 ring atoms are substituted with heteroatoms selected from the group consisting of sulfur (including -S(O)-, -S(O)2-), oxygen, and nitrogen (including =N(O)-), and wherein the ring is attached to the remainder of the molecule through a carbon or nitrogen atom.

[0117] It should be understood that, as part of the structure The related phrase "R x / R y Combined with the atoms to which they are attached to form a C 3-10 Cycloalkyl or 3- to 10-membered heterocyclic group" means that R x / R y Forms the following structure:

[0118]

[0119] Wherein R is a C 3-10 Cycloalkyl or 3- to 10-membered heterocyclic group.

[0120] It should also be understood that, as part of the structure The related phrase "R x / R y Combined with the atoms to which they are attached to form ring A" means that R x / R y Forms the following structure:

[0121]

[0122] As used herein, the term "CNP polypeptide variant" refers to a polypeptide from the same species that differs from a reference CNP polypeptide. Generally, the differences are limited such that the amino acid sequences of the reference polypeptide and the variant are overall very similar and are identical in many regions. In some embodiments, the CNP polypeptide variant is at least 70%, 80%, 90%, or 95% identical to the reference CNP polypeptide. A polypeptide having an amino acid sequence that is, for example, at least 95% "identical" to a query amino acid sequence means that the amino acid sequence of the subject polypeptide is identical to the query sequence, except that the subject polypeptide sequence may contain up to 5 amino acid alterations per 100 amino acids of the query amino acid sequence. These alterations of the reference sequence may occur at the amino (N-terminal) or carboxyl (C-terminal) positions of the reference amino acid sequence, or at any position between these terminal positions, singly between residues scattered throughout the reference sequence, or in one or more contiguous groups within the reference sequence. The query sequence may be the entire amino acid sequence of the reference sequence or any fragment specified as described herein. Such CNP polypeptide variants can be naturally occurring variants, e.g., naturally occurring allelic variants encoded by one of several alternative forms of CNP that occupy a given locus on a chromosome or in an organism, or isotypes encoded by naturally occurring splice variants derived from a single initial transcript. Alternatively, the CNP polypeptide variant can be a naturally occurring variant that is unknown and can be prepared by mutagenesis techniques known in the art. It is known in the art that one or more amino acids can be deleted from the N-terminus or C-terminus of a bioactive peptide or protein without significant loss of biological function. Such N-terminal and / or C-terminal deletions are also included within the term CNP polypeptide variant.

[0123] As used herein, the term "dose" or "unit dose" refers to a predetermined amount of a drug (such as CNP) administered in a single administration to produce a certain degree of biological response in a patient. The dose of a drug depends on its intrinsic potency, in which case it is a therapeutic dose or a therapeutic unit dose.

[0124] As used herein, the term "dosage form" refers to the physical form of an active pharmaceutical ingredient that contains a combination with selected additional ingredients or excipients and is intended to be delivered to the site of action in the body by various routes of administration. It also refers to the physical form that presents an exact mixture of the active pharmaceutical ingredient and excipients to facilitate administration and delivery to the site of action, achieve rapid onset of action, and improve biopharmaceutical efficiency. As used herein, the term "unit dosage form" refers to a dosage form that is formulated for single administration to a patient. For example, a unit dosage form can be a single vial or a container containing an amount of the drug suitable for single administration.

[0125] As used herein, the term "dosage regimen" is a combination of the dose and frequency of administration. The dosage regimen may also include the route of administration (e.g., subcutaneous) and / or the duration of administration (e.g., until the patient reaches 18 years of age or epiphyseal closure). Administration of the dosage regimen can maintain a steady-state serum concentration of CNP, wherein the peak, trough, and area under the curve within a defined time interval are maintained within a defined amplitude of fluctuation and / or the ratio of the peak to the trough does not exceed a defined threshold.

[0126] As used herein, the term "drug" refers to a substance used for treating, curing, preventing, or diagnosing a disease or for enhancing physical or mental health. If a drug (e.g., CNP) is conjugated to another moiety, the portion derived from the drug in the resulting product is referred to as the "drug moiety".

[0127] As used herein, the term "excipient" refers to a compound administered together with a drug or a drug conjugate, such as a buffer, an isotonicity regulator, a preservative, a stabilizer, an anti-adsorbent, an oxidation protector, or other adjuvants. However, in some cases, an excipient may have dual or triple functions. The term "excipient" may also refer to a diluent, an adjuvant, or a carrier administered together with a drug or a drug conjugate. Such pharmaceutical excipients may be sterile liquids, such as water and oils, including oils of petroleum, animal, vegetable, or synthetic origin, including but not limited to peanut oil, soybean oil, mineral oil, sesame oil, etc. When the pharmaceutical preparation is for oral administration, water is the preferred excipient. When the pharmaceutical preparation is for intravenous or subcutaneous administration, physiological saline and aqueous glucose solutions are the preferred excipients. In some embodiments, saline solutions, aqueous glucose solutions, and glycerol solutions are used as liquid excipients for injection solutions. Suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, mannitol, trehalose, gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glyceryl monostearate, talc, sodium chloride, skim milk powder, glycerol, propylene, ethylene glycol, water, ethanol, etc. The pharmaceutical preparation may also contain a small amount of a wetting agent or an emulsifier, a pH buffer (e.g., acetate, succinate, Tris (tris (hydroxymethyl) aminomethane), carbonate, phosphate, HEPES (4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid), MES (2-(N-morpholino) ethanesulfonic acid)), or may contain a surfactant (e.g., poloxamer, poloxamine, CHAPS, ), or an amino acid (such as glycine, lysine or histidine). The pharmaceutical preparation can be in the form of a solution, suspension, emulsion, tablet, pill, capsule, powder, sustained release agent, etc. The pharmaceutical preparation can be formulated into a suppository using traditional binders and excipients (such as triglycerides). Oral preparations can include standard excipients, such as pharmaceutical grade mannitol, lactose, starch, magnesium stearate, sodium saccharin, cellulose, magnesium carbonate, etc. Such preparations contain a therapeutically effective amount of the drug or drug moiety and a suitable amount of excipients to provide an appropriate dosage form for the patient. The preparation should be suitable for the mode of administration.

[0128] As used herein, the term "preparation" or "pharmaceutical preparation" refers to a preparation containing one or more CNP conjugates and one or more excipients, as well as any product directly or indirectly resulting from the combination, complexation or aggregation of any two or more components of the composition, or any product resulting from the dissociation of one or more components, or any product resulting from other types of reactions or interactions of one or more components. Thus, the pharmaceutical preparations described in the present invention encompass any preparation or composition made by mixing one or more CNP conjugates and pharmaceutically acceptable excipients (such as buffers and swelling agents).

[0129] As used herein, the term "drug in free form" refers to an unmodified, pharmaceutically fully active form, such as a drug after being released from a CNP conjugate or a pharmaceutically acceptable salt thereof.

[0130] As used herein, the term "functional group" refers to an atomic group that can react with other atomic groups. Functional groups include, but are not limited to, the following groups: carboxylic acid (-(C=O)OH), primary or secondary amine (-NH2, -NH-), maleimide, thiol (-SH), sulfonic acid (-(O=S=O)OH), carbonate, carbamate (-O(C=O)N<), hydroxyl (-OH), aldehyde (-(C=O)H), ketone (-(C=O)-), hydrazine (>N-N<), isocyanate, isothiocyanate, phosphoric acid (-O(P=O)OHOH), phosphonic acid (-O(P=O)OHH), haloacetyl, alkyl halide, acryloyl, aryl fluoride, hydroxylamine, disulfide, sulfonamide, sulfuric acid, vinyl sulfone, ketene, diazoalkane, ethylene oxide and aziridine.

[0131] As used herein, the term "halogen" refers to fluorine, chlorine, bromine or iodine. Usually, fluorine or chlorine is preferably the halogen.

[0132] As used herein, the term "interrupt" means inserting a moiety between two carbon atoms, or (if the insertion is at one end of the moiety) inserting between a carbon or heteroatom and a hydrogen atom, and in some embodiments inserting between a carbon and a hydrogen atom.

[0133] As used herein, the term "isotonic agent" refers to a compound that minimizes pain, irritation, and tissue damage caused by cell damage resulting from osmotic pressure differences between an injection solution and plasma.

[0134] As used herein, the term "moiety" refers to a portion of a molecule that is missing one or more atoms compared to the corresponding reagent. For example, if a reagent having the chemical formula "H-X-H" reacts with another reagent and becomes part of the reaction product, the corresponding moiety of the reaction product has the structure "H-X-" or "-X-", where each "-" represents attachment to another moiety. Thus, a drug moiety (e.g., a CNP moiety) is released from a conjugate as a drug (e.g., CNP).

[0135] It should be understood that if a sequence of atoms or a chemical structure is provided that attaches to two moieties or interrupts a moiety, unless otherwise expressly stated, the sequence or structure can attach to the two moieties in either direction. For example, the moiety "-C(O)N(R 1 )-" can attach to two moieties or interrupt a moiety as "-C(O)N(R 1 )-" or "-N(R 1 )C(O)-". Similarly, the moiety:

[0136]

[0137] can attach as:

[0138] or attach to two moieties or interrupt a moiety.

[0139] When the CNP moiety contains one or more acidic or basic groups, the unit dosage form also contains its corresponding pharmaceutically or toxicologically acceptable salts, especially its pharmaceutically available salts. Thus, a CNP moiety containing one or more acidic groups can be present and used, for example, as an alkali metal salt, an alkaline earth metal salt or an ammonium salt. More precise examples of such salts include sodium salts, potassium salts, calcium salts, magnesium salts or salts formed with ammonia or organic amines (such as ethylamine, ethanolamine, triethanolamine or amino acids), and other salts or amines known to those skilled in the art. A CNP moiety containing one or more basic groups (i.e., protonatable groups) can be present and used in the form of its addition salts with inorganic or organic acids. Examples of suitable acids include hydrogen chloride, hydrogen bromide, phosphoric acid, sulfuric acid, nitric acid, methanesulfonic acid, p-toluenesulfonic acid, naphthalenedisulfonic acid, oxalic acid, acetic acid, tartaric acid, lactic acid, salicylic acid, benzoic acid, formic acid, propionic acid, pivalic acid, diethylacetic acid, malonic acid, succinic acid, pimelic acid, fumaric acid, maleic acid, malic acid, aminosulfonic acid, phenylpropionic acid, gluconic acid, ascorbic acid, isonicotinic acid, citric acid, adipic acid and other acids known to those skilled in the art. For those skilled in the art, further methods for converting basic groups into cations are known, such as the alkylation of amino groups, resulting in positively charged ammonium groups and counterions of appropriate salts. If the CNP moiety contains both acidic and basic groups, the pharmaceutical preparations according to the present invention include, in addition to the above salt forms, internal salts or betaines (zwitterions). The corresponding salts can be obtained by conventional methods known to those skilled in the art, for example, by contacting these conjugates with organic or inorganic acids or bases in a solvent or dispersant, or by anion exchange or cation exchange with other salts. The unit dosage form according to the present invention also includes all salts of the CNP conjugate which are not suitable for direct use in medicine due to low physiological compatibility, but can be used, for example, as intermediates in chemical reactions or for the preparation of pharmaceutically acceptable salts.

[0140] As used herein, the term "patient" refers to a subject who is susceptible to a therapeutic or prophylactic treatment according to the present invention, particularly a human subject.

[0141] As used herein, the term "pharmaceutically acceptable" refers to a substance that does not cause harm when administered to a patient, and preferably refers to a substance approved by a regulatory agency (such as EMA (Europe) and / or FDA (USA) and / or any other national regulatory agency) for use in animals, preferably for use in humans.

[0142] As used herein, the term "physiological conditions" refers to an aqueous buffer having a pH of 7.4 and a temperature of 37°C.

[0143] As used herein, the term "polypeptide" refers to a chain of at least 2 and up to 50 (including 50) amino acid monomer moieties linked by peptide (amide) bonds. For simplicity, for CNP drugs and CNP moieties only, sequences having more than 50 amino acids are also referred to as "polypeptides".

[0144] As used herein, the term "preservative" refers to a chemical substance that has an antibacterial effect and prevents chemical deterioration.

[0145] As used herein, the term "protein" refers to a chain of more than 50 amino acid monomer moieties linked by peptide bonds, preferably not more than 12,000 amino acid monomers linked by peptide bonds, such as not more than 10,000 amino acid monomer moieties, not more than 8,000 amino acid monomer moieties, not more than 5,000 amino acid monomer moieties or not more than 2,000 amino acid monomer moieties.

[0146] As used herein, the term "polymer" denotes a molecule comprising repeating structural units (i.e., monomers), wherein the repeating structural units (i.e., monomers) are linked by chemical bonds in a linear, cyclic, branched, cross-linked or dendritic or a combination thereof manner, which can be of synthetic origin or biological origin, or a combination of both. It should be understood that the polymer can also contain one or more other chemical groups and / or moieties, e.g., one or more functional groups. In some embodiments, the soluble polymer has a molecular weight of at least 0.5 kDa, such as a molecular weight of at least 1 kDa, a molecular weight of at least 2 kDa, a molecular weight of at least 3 kDa or a molecular weight of at least 5 kDa. If the polymer is soluble, in some embodiments, its molecular weight is at most 1000 kDa, such as at most 750 kDa, such as at most 500 kDa, such as at most 300 kDa, such as at most 200 kDa, such as at most 100 kDa.

[0147] It should be understood that a protein or polypeptide is also a polymer with amino acids as repeating structural units, although the side chains of each amino acid may be different.

[0148] As used herein, the term "polymeric" or "polymeric moiety" refers to a reagent or moiety that contains one or more polymers or polymeric moieties. The polymeric reagent or moiety can also optionally contain one or more other moieties, which in some embodiments are selected from the group consisting of:

[0149] C 1-50 alkyl, C 2-50 alkenyl, C 2-50 alkynyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, phenyl, naphthyl, indenyl, indanyl and tetrahydronaphthyl; and

[0150] bonds selected from the group consisting of:

[0151]

[0152] wherein

[0153] the dashed line indicates attachment to the remainder of the moiety or reagent; and

[0154] -R and -R a are each independently selected from the group consisting of: -H, methyl, ethyl, propyl, butyl, pentyl, and hexyl.

[0155] Those skilled in the art understand that the polymeric products obtained by polymerization do not all have the same molecular weight, but exhibit a molecular weight distribution. Thus, the molecular weight ranges, molecular weights, monomer number ranges in the polymer, and monomer numbers used herein are number average molecular weights and average monomer numbers, that is, the arithmetic average of the molecular weights of the polymer or polymeric moiety and the arithmetic average of the monomer numbers of the polymer or polymeric moiety.

[0156] Thus, in a polymeric moiety containing "x" monomer units, any integer value of "x" given corresponds to the arithmetic average of the monomer numbers. Any integer range of "x" given provides the integer range in which the arithmetic average of the monomer numbers lies. An integer value of "x" given as "about x" means that the arithmetic average of the monomer numbers is within the integer range of x + / - 10%, in some embodiments within the integer range of x + / - 8%, in some embodiments within the integer range of x + / - 5%, and in some embodiments within the integer range of x + / - 2%.

[0157] As used herein, the term "PEG-based" in relation to a moiety or reagent means that the moiety or reagent contains PEG. In some embodiments, the PEG-based moiety or reagent contains at least 10% (w / w) PEG, such as at least 20% (w / w) PEG, such as at least 30% (w / w) PEG, such as at least 40% (w / w) PEG, such as at least 50% (w / w) PEG, such as at least 60% (w / w) PEG, such as at least 70% (w / w) PEG, such as at least 80% (w / w) PEG, such as at least 90% (w / w) PEG, such as at least 95% (w / w) PEG. The remaining weight percentage of the PEG-based moiety or reagent is the other moieties selected from the following moieties and bonds:

[0158] C 1-50 alkyl, C 2-50 alkenyl, C 2-50 alkynyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, phenyl, naphthyl, indenyl, indanyl, and tetrahydronaphthyl; and

[0159] Linkages selected from the following group:

[0160]

[0161] wherein

[0162] the dashed line indicates attachment to the remainder of the moiety or reagent; and

[0163] -R and -R a are each independently selected from the group: -H, methyl, ethyl, propyl, butyl, pentyl, and hexyl.

[0164] As used herein, the term "PEG-based moiety or reagent comprising at least X% PEG" means that the moiety or reagent comprises at least X% (w / w) ethylene glycol units (-CH2CH2O-), where the ethylene glycol units may be arranged in block form, in an alternating arrangement, or may be randomly distributed within the moiety or reagent. In some embodiments, all of the ethylene glycol units of the moiety or reagent are present in one block; in some embodiments, the remaining weight percentage of the moiety or reagent of the PEG-based moiety is selected from the following moieties and other moieties of the linkages:

[0165] C 1-50 alkyl, C 2-50 alkenyl, C 2-50 alkynyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, phenyl, naphthyl, indenyl, indanyl, and tetrahydronaphthyl; and

[0166] Linkages selected from the following group:

[0167]

[0168] wherein

[0169] the dashed line indicates attachment to the remainder of the moiety or reagent; and

[0170] -R and -R a are each independently selected from the group: -H, methyl, ethyl, propyl, butyl, pentyl, and hexyl.

[0171] As used herein, the term "hyaluronic acid-based moiety comprising at least X% hyaluronic acid" is used accordingly.

[0172] As used herein, the term "prodrug" refers to a drug moiety (such as a CNP moiety) that is reversibly and covalently conjugated to a polymeric moiety (such as -Z) via a reversible linker moiety. The prodrug releases the reversibly and covalently bound drug moiety in the form of the corresponding drug. In other words, a prodrug is a conjugate that contains a drug moiety (such as a CNP moiety) that is covalently and reversibly conjugated to a polymeric moiety via a reversible linker moiety, wherein the covalent and reversible conjugation of the polymeric moiety to the reversible linker moiety is direct or through a spacer. Such prodrugs or conjugates release the previously conjugated drug moiety in the form of the free drug.

[0173] As used herein, the term "random coil" refers to a peptide or protein that, in some embodiments, adopts / has / forms a conformation that is substantially lacking in a defined secondary and tertiary structure, as determined by circular dichroism spectroscopy performed in an aqueous buffer at ambient temperature and pH 7.4. In some embodiments, the ambient temperature is about 20 °C, i.e., between 18 °C and 22 °C, and in some embodiments, the ambient temperature is 20 °C.

[0174] As used herein, the term "reversible bond" is a bond that is cleavable in the absence of an enzyme under physiological conditions (aqueous buffer at pH 7.4, 37 °C) and has a half-life of from 1 hour to 6 months, such as from 1 hour to 4 months, such as from 1 hour to 3 months, from 1 hour to 2 months, or from 1 hour to 1 month. Thus, a stable bond is a bond that has a half-life of more than six months under physiological conditions (aqueous buffer at pH 7.4, 37 °C).

[0175] As used herein, the term "reagent" refers to a chemical compound that contains at least one functional group that is reactive with a functional group of another compound or drug. It should be understood that a drug that contains a functional group (such as a primary amine or a secondary amine or a hydroxyl functional group) is also a reagent.

[0176] As used herein, the term "reversible linker moiety" is a moiety that is covalently conjugated to a drug moiety (such as a CNP moiety) via a reversible bond and is also covalently conjugated to a polymeric moiety (such as -Z), wherein the covalent conjugation to the polymeric moiety is direct or through a spacer moiety (such as -L 2 -). In some embodiments, the linkage between -Z and -L 2 - is a stable linkage. A conjugate that contains a reversible linker moiety may be referred to as a reversible conjugate.

[0177] As used herein, the term "spacer" or "spacer moiety" refers to a moiety that is suitable for linking two moieties. Suitable spacers may be selected from the group consisting of C 1-50 alkyl, C 2-50 alkenyl, or C 2-50 alkynyl, wherein C 1-50Alkyl, C 2-50 Alkenyl or C 2-50 Alkynyl may optionally be interrupted by one or more groups selected from the group consisting of: -NH-, -N(C 1-4 Alkyl)-, -O-, -S-, -C(O)-, -C(O)NH-, -C(O)N(C 1-4 Alkyl)-, -O-C(O)-, -S(O)-, -S(O)2-, 4- to 7-membered heterocyclic group, phenyl and naphthyl.

[0178] As used herein, the term "substituted" means that one or more -H atoms of a molecule or moiety are replaced by different atoms or groups of atoms, which are referred to as "substituents".

[0179] In some embodiments, the one or more substituents are independently selected from the group consisting of: halogen, -CN, -COOR x1 , -OR x1 , -C(O)R x1 , -C(O)N(R x1 R x1a ), -S(O)2N(R x1 R x1a ), -S(O)N(R x1 R x1a ), -S(O)2R x1 , -S(O)R x1 , -N(R x1 )S(O)2N(R x1a R x1b ), -SR x1 , -N(R x1 R x1a ), -NO2, -OC(O)R x1 , -N(R x1 )C(O)R x1a , -N(R x1 )S(O)2R x1a , -N(R x1 )S(O)R x1a , -N(R x1 )C(O)OR x1a , -N(R x1 )C(O)N(R x1a R x1b ), -OC(O)N(R x1 R x1a ), -T 0 , C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl; where -T 0 , C 1-50 Alkyl, C2-50 The alkenyl and C 2-50 alkynyl are optionally substituted by one or more identical or different -R x2 groups, and wherein the C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 ), -, -S(O)2N(R x3 ), -, -S(O)N(R x3 ), -, -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a ), -, -S-, -N(R x3 ), -, -OC(OR x3 )(R x3a ), -, -N(R x3 )C(O)N(R x3a ), - and -OC(O)N(R x3 );

[0180] -R x1 , -R x1a , -R x1b are independently selected from the group consisting of: -H, -T 0 , C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl; wherein -T 0 , C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl are optionally substituted by one or more identical or different -R x2 groups, and wherein the C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 ), -, -S(O)2N(R x3 ), -, -S(O)N(R x3 ), -, -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a ), -, -S-, -N(R x3 ), -, -OC(OR x3 )(R x3a ), -, -N(R x3)C(O)N(R x3a )-, and -OC(O)N(R x3 )-;

[0181] Each T 0 is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, and 8- to 11-membered heterobicyclic group; wherein each T 0 is independently optionally substituted by one or more identical or different -R x2 substituents;

[0182] Each -R x2 is independently selected from the group consisting of: halogen, -CN, oxo(=O), -COOR x4 , -OR x4 , -C(O)R x4 , -C(O)N(R x4 R x4a ), -S(O)2N(R x4 R x4a ), -S(O)N(R x4 R x4a ), -S(O)2R x4 , -S(O)R x4 , -N(R x4 )S(O)2N(R x4a R x4b ), -SR x4 , -N(R x4 R x4a ), -NO2, -OC(O)R x4 , -N(R x4 )C(O)R x4a , -N(R x4 )S(O)2R x4a , -N(R x4 )S(O)R x4a , -N(R x4 )C(O)OR x4a , -N(R x4 )C(O)N(R x4a R x4b ), -OC(O)N(R x4 R x4a ), and C 1-6 alkyl; wherein the C 1-6 alkyl is optionally substituted by one or more identical or different halogens;

[0183] Each -R x3 , -R x3a , -R x4 , -R x4a, -R x4b independently selected from the group consisting of: -H and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted with one or more identical or different halogens.

[0184] In some embodiments, said one or more substituents are independently selected from the group consisting of: halogen, -CN, -COOR x1 , -OR x1 , -C(O)R x1 , -C(O)N(R x1 R x1a ), -S(O)2N(R x1 R x1a ), -S(O)N(R x1 R x1a ), -S(O)2R x1 , -S(O)R x1 , -N(R x1 ), S(O)2N(R x1a R x1b ), -SR x1 , -N(R x1 R x1a ), -NO2, -OC(O)R x1 , -N(R x1 ), C(O)R x1a , -N(R x1 ), S(O)2R x1a , -N(R x1 ), S(O)R x1a , -N(R x1 ), C(O)OR x1a , -N(R x1 ), C(O)N(R x1a R x1b ), -OC(O)N(R x1 R x1a ), -T 0 , C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl; wherein -T 0 , C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl is optionally substituted with one or more identical or different -R x2 substituents, and wherein C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl is optionally interrupted by one or more groups selected from the group consisting of: -T 0-, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 )-, -S(O)2N(R x3 )-, -S(O)N(R x3 )-, -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a )-, -S-, -N(R x3 )-, -OC(OR x3 )(R x3a )-, -N(R x3 )C(O)N(R x3a )- and -OC(O)N(R x3 )-;

[0185] Each -R x1 , -R x1a , -R x1b , -R x3 , -R x3a is independently selected from the group consisting of: -H, halogen, C 1-6 alkyl C 2-6 alkenyl and C 2-6 alkynyl;

[0186] Each T 0 is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, and 8- to 11-membered heterobicyclic group; wherein each T 0 is independently optionally substituted by one or more identical or different -R x2 substituents;

[0187] Each -R x2 is independently selected from the group consisting of: halogen, -CN, oxo(=O), -COOR x4 , -OR x4 , -C(O)R x4 , -C(O)N(R x4 R x4a ), -S(O)2N(R x4 R x4a ), -S(O)N(R x4 R x4a ), -S(O)2R x4 , -S(O)R x4 , -N(R x4 )S(O)2N(R x4a R x4b ), -SR x4 , -N(R x4 R x4a ), -NO2, -OC(O)Rx4 , -N(R x4 )C(O)R x4a , -N(R x4 )S(O)2R x4a , -N(R x4 )S(O)R x4a , -N(R x4 )C(O)OR x4a , -N(R x4 )C(O)N(R x4a R x4b ), -OC(O)N(R x4 R x4a ) and C 1-6 alkyl; wherein the C 1-6 alkyl is optionally substituted with one or more identical or different halogens;

[0188] Each -R x4 , -R x4a , -R x4b is independently selected from the group consisting of: -H, halogen, C 1-6 alkyl C 2-6 alkenyl and C 2-6 alkynyl.

[0189] In some embodiments, the one or more substituents are independently selected from the group consisting of: halogen, -CN, -COOR x1 , -OR x1 , -C(O)R x1 , -C(O)N(R x1 R x1a ), -S(O)2N(R x1 R x1a ), -S(O)N(R x1 R x1a ), -S(O)2R x1 , -S(O)R x1 , -N(R x1 )S(O)2N(R x1a R x1b ), -SR x1 , -N(R x1 R x1a ), -NO2, -OC(O)R x1 , -N(R x1 )C(O)R x1a , -N(R x1 )S(O)2R x1a , -N(R x1 )S(O)R x1a , -N(R x1 )C(O)OR x1a, -N(R x1 )C(O)N(R x1a R x1b ), -OC(O)N(R x1 R x1a ), -T 0 , C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl; wherein -T 0 , C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl are optionally substituted by one or more identical or different -R x2 ; and wherein C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 ), -S(O)2N(R x3 ), -S(O)N(R x3 ), -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a ), -S-, -N(R x3 ), -OC(OR x3 )(R x3a ), -N(R x3 )C(O)N(R x3a ), and -OC(O)N(R x3 );

[0190] Each -R x1 , -R x1a , -R x1b , -R x2 , -R x3 , -R x3a is independently selected from the group consisting of: -H, halogen, C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl;

[0191] Each T 0 is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, and 8- to 11-membered heterobicyclic group; wherein each T 0 is independently optionally substituted by one or more identical or different -R x2 .

[0192] In some embodiments, up to six -H atoms in the optionally substituted molecule are independently substituted by substituents, for example, five -H atoms are independently substituted by substituents, four -H atoms are independently substituted by substituents, three -H atoms are independently substituted by substituents, two -H atoms are independently substituted by substituents, or one -H atom is substituted by a substituent.

[0193] As used herein, the term "therapeutically effective amount" refers to an amount sufficient to cure, alleviate, or partially inhibit the clinical manifestations of a particular disease and its complications. The effective amount for each purpose depends on the severity of the disease or injury and the body weight and general condition of the subject. It should be understood that the determination of a suitable dose can be achieved by routine experimentation, by constructing a matrix of values and testing different points in the matrix, which are within the routine skills of a trained physician. Within the scope of the present invention, a therapeutically effective amount refers to a dose intended to achieve a therapeutic effect over a relatively long period of time, i.e., at least one day, such as two days, such as three days, such as four days, such as five days, such as six days, such as one week, or such as two weeks.

[0194] As used herein, the term "cleavable linker" refers to a reversible linker that releases the drug in free form upon cleavage.

[0195] As used herein, the term "water - soluble" with respect to a polymeric moiety means that when such a polymeric moiety is part of a CNP conjugate, at least 1 g of the CNP conjugate containing such a water - soluble polymeric moiety can be dissolved in 1 L of water at 20 °C to form a homogeneous solution.

[0196] Generally, the term "comprising" or "including" also encompasses "consisting of".

[0197] The amino acid sequence of the CNP polypeptide can vary without significantly affecting the structure or function of the peptide. Such mutants include deletions, insertions, inversions, duplications, and substitutions selected according to general rules known in the art that have little effect on activity. For example, Bowie et al. ((1990), Science 247:1306 - 1310) provide guidance on how to perform phenotypically silent amino acid substitutions, which is incorporated herein by reference in its entirety, where the authors indicate that there are mainly two ways to study the tolerance of amino acid sequences to changes.

[0198] As used herein, the term "CNP analogue" refers to CNP from different and unrelated organisms that perform the same function in each organism but do not derive from an ancestral structure common to the ancestors of these organisms. Instead, the analogous CNP appears independently and has later evolved to perform the same or similar functions. In other words, analogous CNP polypeptides are polypeptides with completely different amino acid sequences but exhibiting the same biological activity (i.e., regulating the growth, proliferation, and differentiation of chondrocytes in the cartilage growth plate).

[0199] As used herein, the term "CNP ortholog" refers to CNP in two different species whose sequences are related to each other through a common ancestral CNP in an ancestral species, but which have evolved to be different from each other.

[0200] As used herein, the term "CNP homolog" refers to CNP in different organisms that perform the same function in each organism and are derived from an ancestral structure common to the ancestors of that organism. In other words, homologous CNP polypeptides are polypeptides that have fairly similar amino acid sequences and exhibit the same biological activity (i.e., regulate the growth, proliferation, and differentiation of chondrocytes in the cartilage growth plate). In some embodiments, a CNP polypeptide homolog can be defined as a polypeptide that exhibits at least 40%, 50%, 60%, 70%, 80%, 90%, or 95% identity to a reference CNP polypeptide. Detailed Description

[0201] The present invention relates to a method of improving muscle function (such as skeletal muscle function) in a subject suffering from a disease or disorder with impaired muscle function, the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist.

[0202] FGFR3 signal transduction inhibitor

[0203] The FGFR3 signaling pathway is well understood and involves the MAPK pathway and the STET pathway. In a non-pathological state, the receptor is activated by ligand (e.g., FGF1, FGF2, or FGF9) binding and receptor dimerization, which brings the tyrosine kinase domains of each member of the receptor dimer close together, causing them to cross-phosphorylate each other on tyrosine in their activation loops. This activates the kinase, which then binds to adapter proteins and phosphorylates cytoplasmic substrates, triggering downstream signaling cascades that control cell growth and differentiation. Certain pathological states are associated with constitutive FGFR3 activation, in which receptor dimerization and phosphorylation may occur in the absence of ligand binding.

[0204] Inhibition of FGFR3 signal transduction can be achieved by reducing or preventing the activity of the signal cascade at any point in the cascade. For example, FGFR3 antagonists can bind to the receptor itself to reduce or prevent ligand binding activation, and such molecules can be defined as direct FGFR3 antagonists. Examples include anti-FGFR3 antibodies, such as FGFR3 monoclonal antibodies. Suitable examples are disclosed in WO2022 / 040560, which discloses anti-FGFR3 monoclonal antibodies and their use in the treatment of achondroplasia, and the entire content thereof is incorporated herein by reference. Similarly, WO2018 / 145120 and WO2020 / 180898 are both incorporated herein by reference in their entirety, which disclose anti-FGFR3 monoclonal antibodies and their use in treatment. Vofatamab (B-701) is a monoclonal antibody specific for fibroblast growth factor receptor 3 in clinical development.

[0205] FGFR3 signal transduction inhibitors can also prevent FGFR3 signal transduction by blocking or reducing ligand binding to FGFR3. Decoy molecules against FGFR3 ligands have been developed for this purpose. By providing alternative molecules to which the ligand can bind, signal transduction through FGFR3 molecules is reduced or inhibited. An example of a molecule that has been used to block excessive intracellular signal transduction through FGFR3 and alleviate the symptoms of achondroplasia is the soluble form of human FGFR3 (sFGFR3). It has been shown to act as a decoy receptor and prevent FGF from binding to FGFR3. FGFR3 soluble decoy / sFGFR3 polypeptides are disclosed in WO16110786, WO2022 / 106976, and WO2018 / 007597, which are all incorporated herein by reference in their entirety. Recifercept is an FGFR3 soluble decoy in clinical development for the treatment of pediatric achondroplasia (Goncalves et al., PLoS One. 2020;15(12):e0244368).

[0206] FGFR3 signal transduction inhibitors can also act by acting on the intracellular portion of the FGFR3 molecule itself (such as binding to or otherwise blocking its activity), for example by preventing or reducing phosphorylation of the FGFR3 molecule, to act to reduce or block FGFR3 signal transduction. Tyrosine kinase inhibitors (such as Infigratinib or TYR300), such as FGFR3-selective tyrosine kinase inhibitors, can be used for this purpose. WO2022 / 187443 discloses FGFR3-selective FGFR3 inhibitors (tyrosine kinase inhibitors) for the treatment of achondroplasia and other diseases, and the entire content thereof is incorporated herein by reference. LY3866288, also known as LOXO-435 (also known as LOX-24350), is an FGFR3 inhibitor in clinical development.

[0207] Alternatively, FGFR3 signal transduction inhibitors can achieve this function by acting on one or more molecules downstream of the receptor in one or more of its signaling pathways (such as binding to or otherwise blocking its activity). Such FGFR3 signaling pathway inhibitors can reduce or block the activity of the MAPK signaling pathway or the STAT signaling pathway downstream of FGFR3. Examples of targets of FGFR3 signal transduction inhibitors in the MAPK pathway are the proteins ras, raf, mek, and erk. CNP acts as an FGFR3 signaling pathway inhibitor in this way; activation of the CNP receptor NPR-B leads to the production of cGMP and the activation of PKG, which inhibits raf kinase. So CNP and other NPR-B agonists can also be FGFR3 signal transduction inhibitors. So FGFR3 signal transduction inhibitors may act directly or indirectly on one or more of FGFR3 itself, ras, raf, mek, and erk, or STAT.

[0208] Similarly, preventing or reducing the expression of the FGFR3 protein itself is another possible way to inhibit FGFR3 signal transduction. Thus, FGFR3 signal transduction inhibitors can reduce or lower the amount of FGFR3 protein in cells. Examples of suitable strategies include antisense molecules and siRNA, such as against the FGFR3 protein itself. In this case, in the absence of siRNA molecules or antisense molecules, or before the administration of siRNA molecules or antisense molecules, the amount of FGFR3 in the relevant cells may be less than 90%, 80%, 70%, 60%, 50%, 40%, 30%, 20%, 10% of the amount of FGFR3 in the cells.

[0209] Thus, suitable examples of FGFR3 signal transduction inhibitors include antibodies against FGFR3 (such as antagonistic antibodies against FGFR3), tyrosine kinase inhibitors (such as infigratinib, pemigatinib, futibatinib, erdafitinib or TYRA-300), molecules that block or reduce FGFR3-ligand binding, molecules that inhibit FGFR3 signal transduction through the activation of the NPR-B receptor (such as C-type natriuretic peptide (CNP) and its variants), FGFR3 siRNA and FGFR3 antisense oligonucleotides.

[0210] In some embodiments, the fibroblast growth factor receptor 3 (FGFR3) antagonist is infigratinib or a pharmaceutically acceptable salt thereof having the following structure:

[0211]

[0212] Infigratinib has been approved for the treatment of certain cancers and is currently in clinical development for the treatment of achondroplasia in children aged 3 - 11 years, who receive up to 0.25 mg / kg of infigratinib per day in tablet form (https: / / clinicaltrials.gov / ct2 / show / NCT04265651). High doses of infigratinib used for the treatment of cancer are associated with side effects including muscle weakness and muscle spasms. Therefore, in the context of the present invention, the daily dose may need to be limited to about 3 mg / kg or less, such as about 0.25 mg / kg or less.

[0213] Other FGFR3 signal transduction inhibitors include pemigatinib, futibatinib, erdafitinib or TYRA-300. FGFR3 signal transduction inhibitors (including TYRA-300) are disclosed in WO2023 / 279041, WO2021 / 138392, WO2022 / 147246 and WO2021 / 138391, which are hereby incorporated by reference in their entirety.

[0214] FGFR3 signal transduction inhibitors can be identified and characterized by standard methods, such as those described in WO2023 / 279041, WO2021 / 138392, WO2022 / 147246 and WO2021 / 138391.

[0215] CNP drugs

[0216] In a preferred embodiment, C-type natriuretic peptide (CNP) drugs are used. As described above, CNP in vivo binds to NPR-B to exert its effect on the FGFR3 signaling pathway and can therefore also be described as an NPR-B agonist. According to the present invention, other NPR-B agonists can also be used, including small molecule NPR-B receptor agonists.

[0217] CNP drugs are molecules that contain CNP peptides as defined above. The CNP drugs and CNP peptides are preferably administered in the form of an NPR-B agonist as defined above, or in a form that results in the production of an NPR-B agonist in vivo (such as the release of a CNP peptide that acts as an NPR-B agonist in vivo due to in vivo processing).

[0218] For example, the CNP drug can be administered in the form of a CNP peptide, a CNP peptide conjugate, or a CNP prodrug. The methods of the present invention can also employ NPR-C ligands; CNP is an example of an NPR-C ligand.

[0219] FGFR3 Inhibition Assay

[0220] Guagnana et al., J. Med. Chem. 2011, 54, 7066 - 7083 (incorporated herein by reference in its entirety) provide a radioactive kinase assay that can be used to identify FGFR3 tyrosine kinase inhibitors. In the presence of radiolabeled ATP, the kinase activity of the enzyme is measured by the phosphorylation of a synthetic substrate by the purified GST fusion FGFR3-K650E kinase domain. Guagnana also discloses a BaF3 cell line proliferation assay and an FGFR1-4 cell autophosphorylation assay, which can also be used to identify FGFR3 inhibitors.

[0221] NPR-B Activity Assay Can Be Used to Identify NPR-B Agonists

[0222] The NPR-B assay, such as the NPR-B assay reported by Breinholt et al., 2019 J Pharmacol Exp Ther 370:459 - 471 (which is incorporated herein by reference in its entirety), can be used to identify functional CNP peptides, free CNP released from CNP prodrugs, and other NPR-B agonists.

[0223] The activity of CNP to elicit an intracellular cyclic guanosine monophosphate (cGMP) response can be determined in NIH3T3 cells. These cells express NPR-B on the cell surface (Abbey and Potter, 2003 Endocrinology, Volume 144, Issue 1, January 1, 2003, pages 240–246), and stimulation of this receptor with CNP results in the production of the second messenger cGMP intracellularly. Briefly, NIH3T3 cells are cultured in Dulbecco's modified Eagle medium F-12 medium containing 5% FBS and 5 mM glutamine under conditions of 37 °C and 5% CO2. For each assay, the cells are suspended in stimulation buffer (Dulbecco's PBS containing 0.5 mM 3-isobutyl-1-methylxanthine) and seeded in a 96-well plate (5x l0 4 / well), and incubated in duplicate with different concentrations of CNP. After incubation at 37 °C and 5% CO2 for 30 minutes, the cells were lysed in the provided lysis buffer, and then the cGMP level was measured using a commercially available cGMP assay based on time-resolved fluorescence energy transfer (cGMP kit, catalog 62GM2PEB, Cisbio, Codolet, France). Activity was determined using four-parameter logistic curve fitting and by parallel line analysis of the samples and comparison with CNP-38 (SEQ ID NO:24 (CNP-38): LQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC, where the cysteines at positions 22 and 38 are linked by a disulfide bond) as a reference standard (PLA 2.0 software; Stegmann Systems, Rodgau, Germany).

[0224] In some embodiments, the NPR-B agonist (e.g., C-type natriuretic peptide) has at least about 25% of the NPR-B activity of the CNP-38 reference standard (the activity that elicits an intracellular cGMP response in the NIH3T3 cell assay), such as at least about 50%, 75%, 80%, 85%, 90% of the activity of the CNP-38 reference standard in the NPR-B activity assay described above.

[0225] It should be understood that for CNP prodrugs, the activity of the prodrug in the CNP assay needs to be evaluated based on the CNP (free CNP) released from the prodrug.

[0226] NPR-C affinity assay and agonist assay for identifying NPR-C agonists

[0227] An NPR-C affinity assay can be used to identify functional CNP peptides, free CNP released from CNP prodrugs, and other NPR-C ligands, such as the NPR-C affinity assay reported in Breinholt et al., 2019 J Pharmacol Exp Ther 370:459-471.

[0228] The NPR-C affinity assay uses a HEK293 cell line stably overexpressing human NPR-C. The NPR-C affinity assay can be used to evaluate the relative NPR-C affinity of CNP or another NPR-C ligand relative to the CNP-38 standard. In some embodiments, in the NPR-C affinity assay, C-type natriuretic peptide has at least about 25% of the NPR-C affinity of the CNP-38 reference standard, such as at least about 50% of the NPR-C affinity of the CNP-38 reference standard, such as at least about 75% of the NPR-C affinity of the CNP-38 reference standard.

[0229] Zhou and Murthy, Am J Physiol Cell Physiol 284:C1255-C1261, 2003 (which is incorporated herein by reference in its entirety) reported the G protein activation activity of NPRC and provided assays for identifying receptor-activated G proteins by [35S]GTPγS binding assay and for PLC-β activity, either of which can be used to identify NPR-C ligands with NPR-C agonist activity (NPR-C agonist: for example, the standard used when evaluating NPR-C agonists in the NPR-C activity assay method is cANP4-23). Zhou and Murthery further disclosed the [125I]ANP binding assay, which can be used to identify NPR-C ligands.

[0230] Exemplary CNP (including CNP peptides)

[0231] Naturally occurring human CNP-22 (SEQ ID NO:1) has the following sequence:

[0232] GLSKGCFGLKLDRIGSMSGLGC,

[0233] wherein the cysteines at positions 6 and 22 are linked by a disulfide bond.

[0234] In some embodiments, the term "CNP" also refers to the following peptide sequences:

[0235] SEQ ID NO:2 (CNP-53):

[0236] DLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0237] SEQ ID NO:3 (G-CNP-53):

[0238] GDLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0239] SEQ ID NO:4 (M-CNP-53):

[0240] MDLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0241] SEQ ID NO:5 (P-CNP-53):

[0242] PDLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0243] SEQ ID NO:6(CNP-53M48N):

[0244] DLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSNSGLGC;

[0245] SEQ ID NO:7(CNP-53Δ15-31):

[0246] DLRVDTKSRAAWARGLSKGCFGLKLDRIGSMSGLGC;

[0247] SEQ ID NO:8(CNP-52):

[0248] LRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0249] SEQ ID NO:9(CNP-51):

[0250] RVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0251] SEQ ID NO:10(CNP-50):

[0252] VDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0253] SEQ ID NO:11(CNP-49):

[0254] DTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0255] SEQ ID NO:12(CNP-48):

[0256] TKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0257] SEQ ID NO:13(CNP-47):

[0258] KSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0259] SEQ ID NO:14(CNP-46):

[0260] SRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0261] SEQ ID NO:15(CNP-45):

[0262] RAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0263] SEQ ID NO:16(CNP-44):

[0264] AAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0265] SEQ ID NO:17(CNP-44Δ14-22):

[0266] AAWARLLQEHPNAGLSKGCFGLKLDRIGSMSGLGC;

[0267] SEQ ID NO:18(CNP-44Δ15-22):

[0268] AAWARLLQEHPNARGLSKGCFGLKLDRIGSMSGLGC;

[0269] SEQ ID NO:19(CNP-43):

[0270] AWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0271] SEQ ID NO:20(CNP-42):

[0272] WARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0273] SEQ ID NO:21(CNP-41):

[0274] ARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0275] SEQ ID NO:22 (CNP-40):

[0276] RLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0277] SEQ ID NO:23 (CNP-39):

[0278] LLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0279] SEQ ID NO:24 (CNP-38):

[0280] LQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC,

[0281] in which the cysteines at positions 22 and 38 are linked by a disulfide bond;

[0282] SEQ ID NO:25 (CNP-37):

[0283] QEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0284] SEQ ID NO:26 (CNP-37Q1pQ, where pQ = pyroglutamic acid):

[0285] pQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0286] SEQ ID NO:27 (G-CNP-37):

[0287] GQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0288] SEQ ID NO:28 (P-CNP-37):

[0289] PQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0290] SEQ ID NO:29 (M-CNP-37):

[0291] MQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0292] SEQ ID NO:30 (PG-CNP-37) (Vesopressin peptide sequence):

[0293] PGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0294] SEQ ID NO:31 (MG-CNP-37):

[0295] MGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0296] SEQ ID NO:32 (CNP-37M32N):

[0297] QEHPNARKYKGANKKGLSKGCFGLKLDRIGSNSGLGC;

[0298] SEQ ID NO:33 (G-CNP-37M32N):

[0299] GQEHPNARKYKGANKKGLSKGCFGLKLDRIGSNSGLGC;

[0300] SEQ ID NO:34 (G-CNP-37K14Q):

[0301] GQEHPNARKYKGANQKGLSKGCFGLKLDRIGSMSGLGC;

[0302] SEQ ID NO:35 (G-CNP-37 K14P):

[0303] GQEHPNARKYKGANPKGLSKGCFGLKLDRIGSMSGLGC;

[0304] SEQ ID NO:36 (G-CNP-37 K14Q,Δ15):

[0305] GQEHPNARKYKGANQGLSKGCFGLKLDRIGSMSGLGC;

[0306] SEQ ID NO:37 (G-CNP-37 K14Q,K15Q):

[0307] GQEHPNARKYKGANQQGLSKGCFGLKLDRIGSMSGLGC;

[0308] SEQ ID NO:38 (CNP-36):

[0309] EHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0310] SEQ ID NO:39(CNP-35):

[0311] HPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0312] SEQ ID NO:40(CNP-34):

[0313] PNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0314] SEQ ID NO:41(CNP-33):

[0315] NARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0316] SEQ ID NO:42(CNP-32):

[0317] ARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0318] SEQ ID NO:43(CNP-31):

[0319] RKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0320] SEQ ID NO:44(CNP-30):

[0321] KYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0322] SEQ ID NO:45(CNP-29):

[0323] YKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0324] SEQ ID NO:46(CNP-28):

[0325] KGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0326] SEQ ID NO:47(GHKSEVAHRF-CNP-28):

[0327] GHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0328] SEQ ID NO:48(CNP-27):

[0329] GANKKGLSKGCFGLKLDRIGSMSGLGC;

[0330] SEQ ID NO:49(CNP-27 K4Q,K5Q):

[0331] GANQQGLSKGCFGLKLDRIGSMSGLGC;

[0332] SEQ ID NO:50(CNP-27 K4R,K5R):

[0333] GANRRGLSKGCFGLKLDRIGSMSGLGC;

[0334] SEQ ID NO:51(CNP-27K4P,K5R):

[0335] GANPRGLSKGCFGLKLDRIGSMSGLGC;

[0336] SEQ ID NO:52(CNP-27K4S,K5S):

[0337] GANSSGLSKGCFGLKLDRIGSMSGLGC;

[0338] SEQ ID NO:53(CNP-27K4P,K5R):

[0339] GANGANPRGLSRGCFGLKLDRIGSMSGLGC;

[0340] SEQ ID NO:54(CNP-27K4R,K5R,K9R):

[0341] GANRRGLSRGCFGLKLDRIGSMSGLGC;

[0342] SEQ ID NO:55(CNP-27K4R,K5R,K9R,M22N):

[0343] GANRRGLSRGCFGLKLDRIGSNSGLGC;

[0344] SEQ ID NO:56(P-CNP-27K4R,K5R,K9R):

[0345] PGANRRGLSRGCFGLKLDRIGSMSGLGC;

[0346] SEQ ID NO:57 (M-CNP-27K4R, K5R, K9R):

[0347] MGANRRGLSRGCFGLKLDRIGSMSGLGC;

[0348] SEQ ID NO:58 (HSA fragment-CNP-27):

[0349] GHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLG;

[0350] SEQ ID NO:59 (HSA fragment-CNP-27M22N):

[0351] GHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSNSGLGC;

[0352] SEQ ID NO:60 (M-HSA fragment-CNP-27):

[0353] MGHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0354] SEQ ID NO:61 (P-HSA fragment-CNP-27):

[0355] PGHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0356] SEQ ID NO:62 (CNP-26):

[0357] ANKKGLSKGCFGLKLDRIGSMSGLGC;

[0358] SEQ ID NO:63 (CNP-25):

[0359] NKKGLSKGCFGLKLDRIGSMSGLGC;

[0360] SEQ ID NO:64 (CNP-24):

[0361] KKGLSKGCFGLKLDRIGSMSGLGC;

[0362] SEQ ID NO:65 (CNP-23):

[0363] KGLSKGCFGLKLDRIGSMSGLGC;

[0364] SEQ ID NO:66 (R-CNP-22):

[0365] RGLSKGCFGLKLDRIGSMSGLGC;

[0366] SEQ ID NO:67 (ER-CNP-22):

[0367] ERGLSKGCFGLKLDRIGSMSGLGC;

[0368] SEQ ID NO:68 (R-CNP-22K4R):

[0369] RGLSRGCFGLKLDRIGSMSGLGC;

[0370] SEQ ID NO:69 (ER-CNP-22 4KR):

[0371] ERGLSRGCFGLKLDRIGSMSGLGC;

[0372] SEQ ID NO:70 (RR-CNP-22):

[0373] RRGLSRGCFGLKLDRIGSMSGLGC;

[0374] SEQ ID NO:71 (HRGP fragment-CNP-22):

[0375] GHHSHEQHPHGANQQGLSKGCFGLKLDRIGSMSGLGC;

[0376] SEQ ID NO:72 (HRGP fragment-CNP-22):

[0377] GAHHPHEHDTHGANQQGLSKGCFGLKLDRIGSMSGLGC;

[0378] SEQ ID NO:73 (HRGP fragment-CNP-22):

[0379] GHHSHEQHPHGANPRGLSKGCFGLKLDRIGSMSGLGC;

[0380] SEQ ID NO:74 (IgG1(Fc) fragment-CNP-22):

[0381] GQPREPQVYTLPPSGLSKGCFGLKLDRIGSMSGLGC;

[0382] SEQ ID NO:75 (HSA fragment - CNP - 22):

[0383] GQHKDDNPNLPRGANPRGLSKGCFGLKLDRIGSMSGLGC;

[0384] SEQ ID NO:76 (HSA fragment - CNP - 22):

[0385] GERAFKAWAVARLSQGLSKGCFGLKLDRIGSMSGLGC;

[0386] SEQ ID NO:77 (Osteonectin NPR C inhibitor fragment - CNP22):

[0387] FGIPMDRIGRNPRGLSKGCFGLKLDRIGSMSGLGC;

[0388] SEQ ID NO:78 (FGF2 heparin - binding domain fragment - CNP22):

[0389] GKRTGQYKLGSKTGPGPKGLSKGCFGLKLDRIGSMSGLGC;

[0390] SEQ ID NO:79 (IgG1 (Fc) fragment - CNP - 22K4R):

[0391] GQPREPQVYTGANQQGLSRGCFGLKLDRIGSMSGLGC;

[0392] SEQ ID NO:80 (HAS fragment - CNP - 22K4R):

[0393] GVPQVSTSTGANQQGLSRGCFGLKLDRIGSMSGLGC;

[0394] SEQ ID NO:81 (Fibronectin fragment - CNP - 22K4R):

[0395] GQPSSSSQSTGANQQGLSRGCFGLKLDRIGSMSGLGC;

[0396] SEQ ID NO:82 (Fibronectin fragment - CNP - 22K4R):

[0397] GQTHSSGTQSGANQQGLSRGCFGLKLDRIGSMSGLGC;

[0398] SEQ ID NO:83 (Fibronectin fragment - CNP - 22K4R):

[0399] GSTGQWHSESGANQQGLSRGCFGLKLDRIGSMSGLGC;

[0400] SEQ ID NO:84 (Zinc finger fragment - CNP - 22K4R):

[0401] GSSSSSSSSSGANQQGLSRGCFGLKLDRIGSMSGLGC;

[0402] SEQ ID NO:85 (CNP - 21):

[0403] LSKGCFGLKLDRIGSMSGLGC;

[0404] SEQ ID NO:86 (CNP - 20):

[0405] SKGCFGLKLDRIGSMSGLGC;

[0406] SEQ ID NO:87 (CNP - 19):

[0407] KGCFGLKLDRIGSMSGLGC;

[0408] SEQ ID NO:88 (CNP - 18):

[0409] GCFGLKLDRIGSMSGLGC;

[0410] SEQ ID NO:89 (CNP - 17):

[0411] CFGLKLDRIGSMSGLGC;

[0412] SEQ ID NO:90 (BNP fragment - CNP - 17 - BNP fragment):

[0413] SPKMVQGSGCFGLKLDRIGSMSGLGCKVLRRH;

[0414] SEQ ID NO:91 (CNP - 38L1G):

[0415] GQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0416] SEQ ID NO:92 (Ac-CNP-37; where Ac = acetyl):

[0417] Ac-QEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC;

[0418] SEQ ID NO:93:

[0419] QEHPNARX1YX2GANX3X4GLSX5GCFGLX6LDRIGSMSGLGC,

[0420] where X1, X2, X3, X4, X5, and X6 are each independently selected from the group consisting of K, R, P, S, and Q, provided that at least one of X1, X2, X3, X4, X5, and X6 is selected from the group consisting of R, P, S, and Q; in some embodiments, X1, X2, X3, X4, X5, and X6 are selected from the group consisting of K and R, provided that at least one of X1, X2, X3, X4, X5, and X6 is R;

[0421] SEQ ID NO:94:

[0422] QEHPNARKYKGANX1X2GLSX3GCFGLX4LDRIGSMSGLGC,

[0423] where X1, X2, X3, and X4 are each independently selected from the group consisting of K, R, P, S, and Q, provided that at least one of X1, X2, X3, and X4 is selected from the group consisting of R, P, S, and Q; in some embodiments, X1, X2, X3, and X4 are selected from K and R, provided that at least one of X1, X2, X3, and X4 is R;

[0424] SEQ ID NO:95:

[0425] QEHPNARKYKGANX1X2GLSKGCFGLKLDRIGSMSGLGC,

[0426] where X1X2 is selected from the group consisting of KR, RK, KP, PK, SS, RS, SR, QK, QR, KQ, RQ, RR, and QQ.

[0427] It should be understood that the equivalents of the cysteines at positions 22 and 38 in SEQ ID NO:24 are also linked by disulfide bonds in SEQ ID NOs:2 - SEQ ID NO:95.

[0428] One of ordinary skill in the art also recognizes that the conjugates described in the present invention can be prodrugs.

[0429] The unit dose contained in the unit dosage form of the present invention depends on the actual weight of the patient.

[0430] Vosoritide is approved for subcutaneous administration once daily at a dose of approximately 15 μg / kg, but the dose may be higher for infants (e.g., approximately 30 μg / kg). Vosoritide is currently available in vial sizes of 0.4 mg, 0.56 mg, and 1.2 mg, and the current recommended daily dose based on actual body weight (ABW) is as follows.

[0431] 10 - 11 kg: Subcutaneous injection of 0.24 mg once daily

[0432] 12 - 16 kg: Subcutaneous injection of 0.28 mg once daily

[0433] 17 - 21 kg: Subcutaneous injection of 0.32 mg once daily

[0434] 22 - 32 kg: Subcutaneous injection of 0.4 mg once daily

[0435] 33 - 43 kg: Subcutaneous injection of 0.5 mg once daily

[0436] 44 - 59 kg: Subcutaneous injection of 0.6 mg once daily

[0437] 60 - 89 kg: Subcutaneous injection of 0.7 mg once daily

[0438] ≥90 kg: Subcutaneous injection of 0.8 mg once daily

[0439] It has been reported that higher doses are more effective for younger children.

[0440] In some embodiments, the unit dose ranges from 50 μg - 7000 μg CNP. In some embodiments, the unit dose ranges from 100 μg - 5000 μg CNP. In some embodiments, the unit dose ranges from 100 μg - 3000 μg CNP. In some embodiments, the unit dose ranges from 100 μg - 2000 μg CNP. In some embodiments, the unit dose ranges from 100 μg - 1000 μg CNP. In some embodiments, the unit dose ranges from 150 μg - 750 μg CNP. In some embodiments, the unit dose ranges from 150 μg - 500 μg CNP. In some embodiments, the unit dose ranges from 150 μg - 350 μg CNP. In some embodiments, the unit dose is approximately 700 μg CNP. In some embodiments, the unit dose is approximately 600 μg CNP. In some embodiments, the unit dose is approximately 500 μg CNP. In some embodiments, the unit dose is approximately 400 μg CNP. In some embodiments, the unit dose is approximately 300 μg CNP.

[0441] In some embodiments, the unit dose is about 6 μg CNP / kg. In some embodiments, the unit dose is about 20 μg CNP / kg. In some embodiments, the unit dose is about 50 μg CNP / kg. In some embodiments, the unit dose is about 75 μg CNP / kg. In some embodiments, the unit dose is about 100 μg CNP / kg. In some embodiments, the unit dose is about 125 μg CNP / kg. In some embodiments, the unit dose is about 150 μg CNP / kg.

[0442] In some embodiments, the unit dose is 6 μg CNP / kg. In some embodiments, the unit dose is 20 μg CNP / kg. In some embodiments, the unit dose is 50 μg CNP / kg. In some embodiments, the unit dose is 75 μg CNP / kg. In some embodiments, the unit dose is 100 μg CNP / kg. In some embodiments, the unit dose is 125 μg CNP / kg. In some embodiments, the unit dose is 150 μg CNP / kg.

[0443] In some embodiments, the unit dosage form is liquid. In some embodiments, the unit dosage form is solid.

[0444] In some embodiments, for example, for the compound of formula (IIf') or formula (IIf) or compound (1), the unit dose ranges from about 12.3 nmol CNP / kg to at least about 37 nmol CNP / kg. In some embodiments, the unit dose ranges from 12.3 nmol CNP / kg to 36.9 nmol CNP / kg. In some embodiments, the unit dose ranges from at least 24.6 nmol CNP / kg. In some embodiments, the unit dose ranges from about 24.6 nmol CNP / kg. In some embodiments, the unit dose is 24.6 nmol CNP / kg.

[0445] In some embodiments, for example, for the compound of formula (IIf') or formula (IIf) or compound (1), the unit dose ranges from about 6 μg CNP / kg to at least about 100 μg CNP / kg. In some embodiments, the unit dose ranges from about 6 μg CNP / kg to about 150 μg CNP / kg.

[0446] In some embodiments, for example for a compound of formula (IIf’) or formula (IIf) or compound (1), the unit dose comprised in a unit dosage form of the present invention ranges from 6 μg CNP / kg to at least 100 μg CNP / kg. In some embodiments, the unit dose ranges from 6 μg CNP / kg to 150 μg CNP / kg.

[0447] The unit dose is preferably administered weekly.

[0448] For a CNP conjugate or CNP prodrug, for example for a compound of formula (IIf’) or formula (IIf) or compound (1), it should be understood that “x” μg CNP / kg means “x” μg CNP per kg of patient body weight (i.e., the CNP moiety comprised in the CNP conjugate). Similarly, it should be understood that “y” nmol CNP / kg means “y” nmol CNP per kg of patient body weight (i.e., the CNP moiety comprised in the CNP conjugate).

[0449] Subject / Patient

[0450] In some embodiments, the subject is an adult. Adults are 18 years of age and older. In some embodiments, the subject is at least 19 years of age, such as at least 20 or 25 years of age.

[0451] In some embodiments, the subject is a pediatric patient, i.e., less than 18 years of age, such as less than 16 years of age or less than 14 years of age, or 5 years of age. In some embodiments, the subject is an infant (e.g., less than 1 year old or less than 9 months or 6 months old).

[0452] The subject is also referred to as the patient.

[0453] In some embodiments, the weight of the patient ranges from about 2 kg to about 80 kg. In some embodiments, the weight of the patient ranges from about 4 kg to about 60 kg. In some embodiments, the weight of the patient is about 5 kg. In some embodiments, the weight of the patient is about 9 kg. In some embodiments, the weight of the patient is about 10 kg. In some embodiments, the weight of the patient is about 11 kg. In some embodiments, the weight of the patient is about 12 kg. In some embodiments, the weight of the patient is about 15 kg. In some embodiments, the weight of the patient is about 20 kg. In some embodiments, the weight of the patient is about (at least about) 30 kg. In some embodiments, the weight of the patient is about (at least about) 40 kg. In some embodiments, the weight of the patient is about (at least about) 50 kg. In some embodiments, the weight of the patient is about (at least about) 60 kg. In some embodiments, the weight of the patient is about (at least about) 70 kg. In some embodiments, the weight of the patient is about (at least about) 80 kg.

[0454] Diseases or disorders with impaired muscle function

[0455] In some embodiments, the subject has a disease or disorder characterized by impaired muscle function (such as skeletal muscle). This means that normal muscle function is reduced or absent. The reduction in muscle function can be evaluated relative to a threshold level or a reference individual without the disease or disorder. The loss or reduction of muscle function may be caused by a disease or disorder that directly affects the muscle (such as myopathy), or by a disease that affects the neuromuscular junction or the nervous system.

[0456] Diseases or disorders characterized by impaired muscle function (such as skeletal muscle) can include dyschondroplastic diseases, such as diseases selected from the group consisting of achondroplasia, hypochondroplasia, and lethal dysplasia. In some embodiments, the subject has achondroplasia.

[0457] In some embodiments, the subject has a RASopathy.

[0458] In some embodiments, the subject has a dyschondroplastic disease, such as diseases selected from the group consisting of achondroplasia, hypochondroplasia, and lethal dysplasia. In some embodiments, the subject has achondroplasia.

[0459] In some embodiments, the subject does not have a dyschondroplastic disease, such as diseases selected from the group consisting of achondroplasia, hypochondroplasia, and lethal dysplasia. In some embodiments, the subject does not have achondroplasia. In some embodiments, the subject does not have a dyschondroplastic disease.

[0460] Skeletal muscle is one of the three main muscle types in the body, the other two being cardiac muscle and smooth muscle. Skeletal muscle is the muscle attached to bones by tendons. Skeletal muscle can also be referred to as striated muscle. Administration of an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist has been shown to cause improvement in muscle function, particularly in skeletal muscle function.

[0461] In some embodiments, the subject has myopathy. Myopathy is a heterogeneous group of diseases that mainly affect skeletal muscle structure, metabolism, or channel function, usually resulting in muscle weakness, stiffness, cramps, and spasms, and may cause or exacerbate skeletal deformities, such as abnormal curvature of the spine. Myopathy usually presents as muscle weakness and affects activities of daily living. In some embodiments, the myopathy or impaired muscle function can be mitochondrial myopathy, i.e., a myopathy caused by defects in mitochondria. Myopathy can be genetic or acquired. Hereditary myopathy may be congenital myopathy, i.e., the symptoms of myopathy appear at birth or in early childhood.

[0462] In some embodiments, the subject has a disease or disorder associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

[0463] Thus, in some embodiments the method is performed on a subject having a disease or disorder associated with impaired neuromuscular function (such as a neuromuscular disease or a neurodegenerative disease).

[0464] The present invention also provides methods of treating or preventing a disease or disorder associated with impaired neuromuscular function (such as a neuromuscular disease or a neurodegenerative disease), the method comprising administering to a subject having a neuromuscular disease or a neurodegenerative disease a therapeutically effective amount of an FGFR3 signal transduction inhibitor, an NPR-B agonist, or an NPR-C agonist (such as an NPR-B agonist, such as C-type natriuretic peptide (such as a conjugate of C-type natriuretic peptide)). In some embodiments, the neuromuscular disease or neurodegenerative disease is a disease with mitochondrial dysfunction.

[0465] Administering to a subject having a disease or disorder associated with impaired neuromuscular function a therapeutically effective amount of an FGFR3 signal transduction inhibitor, an NPR-B agonist, or an NPR-C agonist (such as an NPR-B agonist) can improve the mitochondrial function of the subject. This can be observed (or monitored), for example, by improved muscle function (such as improved skeletal muscle function or improved neuromuscular function), or by slowing, delaying, or reducing disease progression (such as reducing the rate of loss or decline of muscle function), or by reducing the rate of loss or decline of neuromuscular function (such as, compared to a reference or compared to a subject before treatment or without treatment). In some embodiments, the treatment method can be initiated after a disease or disorder associated with impaired neuromuscular function is diagnosed, optionally before significant or substantial loss of muscle or neuromuscular function.

[0466] Mitochondrial function impairment or mitochondrial dysfunction has been shown in many neurodegenerative diseases, including Parkinson's disease (PD), Alzheimer's disease (AD), Huntington's disease (HD), ataxia (such as Friedreich's ataxia (FRDA)), and amyotrophic lateral sclerosis (ALS). Mitochondrial dysfunction can be identified by diagnosing a disease or disorder associated with mitochondrial dysfunction via genetic testing (i.e., identifying gene polymorphisms associated with or causing mitochondrial dysfunction), via biopsy biochemical analysis of affected tissues, or via biochemical markers in blood or urine (see, for example, Muraresku et al., Curr Genet Med Rep. June 2018;6(2):62-72).

[0467] Diseases or conditions associated with impaired neuromuscular function may include neuromuscular disorders / neuromuscular diseases (NMDs). Suitable NMD disorders and diseases may be associated with mitochondrial damage and dysfunction (see, for example, Marra et al., Biomolecules 2021, vol 11(11); 1633). Thus, the methods described herein can be used to improve mitochondrial function or slow the decline of mitochondrial function in a subject (e.g., compared to a reference or compared to a subject before treatment or without treatment) suffering from a disease or condition associated with impaired neuromuscular function (such as an NMD).

[0468] Accordingly, the methods described herein can be used to improve muscle function or slow the decline of muscle function in these diseases or conditions associated with impaired neuromuscular function. Examples of neuromuscular diseases include genetically acquired diseases, which include muscular dystrophies and myopathies as well as neuromuscular diseases. Neuromuscular diseases include neurodegenerative diseases and disorders associated with loss of mitochondrial function and can be selected, for example, from the group consisting of: motor neuron disease (MND, also known as amyotrophic lateral sclerosis, ALS), Parkinson's disease (PD), multiple sclerosis (MS, including progressive MS or relapsing-remitting MS), Alzheimer's disease (AD), ataxia (such as Friedreich's ataxia (FRDA)) and Huntington's disease (HD).

[0469] Parkinson's disease (PD) is associated with mitochondrial dysfunction, and the pathogenesis of PD leads to muscle weakness and muscle fatigue (Borsche et al., J Parkinsons Dis. 2021;11(1):45-60). Timmer et al., J Neurosci. 2007 Jan 17;27(3):459–471; pointed out abnormal FGFR3 / FGF-2 signal transduction in PD animal models. The central and systemic CNP (amino-terminal pro-CNP) levels are reduced in patients with Parkinson's disease and can be restored by treatment with monoamine oxidase inhibitors (Espiner et al., J Neural Transm (Vienna), April 2014;121(4):371-8; Woodward, Parkinsonism Relat Disord. October 2017;43:15-19). Patients with Parkinson's disease usually report muscle weakness and muscle fatigue, which may severely affect gait. Zheng et al., Sci Transl Med. October 6, 2010;2(52):52ra73 reported that PGC-lα is a therapeutic target for Parkinson's disease. Mitochondrial dysfunction is a core dysfunction in the pathology of Parkinson's disease (PD), and PD-related genes, including PGC-lα, are closely related to mitochondrial integrity (Piccinin, Int. J. Mol. Sci 2001 22(7)3487). Patients with Parkinson's disease show lower PGC-lα expression levels and require therapeutic agents that can increase PGC-lα expression in patients with Parkinson's disease and enhance mitochondrial function.

[0470] The muscle function of PD patients is routinely monitored using physical function tests (such as sit-to-stand tests and six-minute walk tests) (for example, see Clael et al., Neurosci J 2918 8507018). Suitable physical function tests for monitoring PD patients may include speech, facial expression, rising from a chair, gait, or postural stability (for example, see Brusse et al., Physical Therapy, Vol. 85, No. 2, February 1, 2005, pp. 134–141). Recently, the FDA approved a PD monitoring application (Rube Labs) for monitoring patients via smart devices (such as mobile phones or smartwatches), which can monitor physical activities (such as walking) and other PD symptoms (such as tremors and dyskinesia) throughout the day. Therefore, it is envisioned to use such smart device applications to monitor the effective treatment of the present invention.

[0471] Reduced PGC-lα expression leads to mitochondrial dysfunction and is associated with neuronal loss in multiple sclerosis (Witte et al., Acta Neuropathol. February 2013; 125(2):231-43; Peixoto de Barcelos Biology (Basel) 2019 8(2):37). Rosenkranz et al., eLife 2021; 10:e61798 reported that enhancing mitochondrial activity in neurons prevents neurodegeneration in a mouse model of multiple sclerosis (MS) and proposed that enhancing mitochondrial activity in neurons could be a therapeutic strategy for MS. Rajendran et al. (Cells 2021) reported that FGF / FGFR signaling and FGFR inhibition in MS are a therapeutic option for reducing inflammation and inducing myelin regeneration. Multiple sclerosis causes muscle fatigue, pain, imbalance, and reduced physical activity, which can further lead to muscle weakness. In fact, muscle fatigue is considered the most common MS symptom. Muscle function in multiple sclerosis can be monitored through self-report questionnaires or by using smart devices that can provide remote monitoring of fatigue and activity (e.g., Block Front. Neurol. 2022 13 https: / / doi.org / 10.3389 / fneur.2022.878313, Stuart et al., MultScler J Exp Transl Clin. December 7, 2020; 6(4):2055217320975185.). Witte et al. reported that reduced PGC-lα expression is associated with neuronal loss in MS.

[0472] Zhao et al. (Cells July 2002; 11(13)2049) reported that mitochondrial dysfunction is a key contributing factor in amyotrophic lateral sclerosis (ALS), and mitochondrial dysfunction is related to and involved in the pathogenesis of the disease. Zhao et al. (Molecular Neurodegeneration 6, Article number: 51 (2011)) reported that PGC-lα plays a protective role in ALS.

[0473] In Alzheimer's disease pathology, impairment of PGC-1α-mediated mitochondrial biogenesis is shown and precedes mitochondrial dysfunction associated with AD progression (Bhatia, Curr. Neuropharmacol. 2002 20(4):675-692). The physical functions of people with dementia such as Alzheimer's disease (AD) are affected, resulting in slow reactions, muscle weakness, poor coordination, and impaired balance, and together with cognitive impairment are major contributing factors to events such as falls and fractures. In the later stages of dementia, physical abilities may be severely impaired, severely restricting walking, gait, and movement (see, for example, Taraldsen et al., BMC Geriatrics Vol. 21, Article number: 670 (2021), which reported monitoring the daily physical activities of dementia patients using physical acceleration sensors).

[0474] As a result of administering an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist, various changes may occur in muscle function.

[0475] For example, muscle strength may be increased. Muscle strength is the maximum ability to exert force in a short period of time. It can be evaluated, for example, using the Oxford Scale, which involves testing the resistance of key muscles in the upper and lower limbs against the resistance of the tester and grading the strength of the patient accordingly on a scale of 0-5 (Naqvi U. Muscle strength grading. In Statpearls [Internet], May 29, 2019, Stat Pearls Publishing. Available from https: / / www.ncbi.nlm.nih.gov / books / NBK436008 / obtained):

[0476] ·0 No muscle activation

[0477] ·1 Muscle activation (such as twitching) is detected, but full-range movement is not achieved

[0478] ·2 Muscles are activated with gravity eliminated, achieving full-range movement

[0479] ·3 Muscles are activated against gravity, full-range movement

[0480] ·4 Muscles are activated against a certain resistance, full-range movement

[0481] ·5 Muscles are activated against the full resistance of the tester, full-range movement

[0482] Commonly tested muscles include the shoulder abductor, elbow flexor, elbow extensor, wrist extensor, finger flexor, intrinsic hand muscles, hip flexor, knee extensor, dorsiflexor, great toe extensor, and plantar flexor. These muscle groups are typically selected to systematically evaluate important spinal nerve roots. For example, testing the strength of the elbow flexor, elbow extensor, wrist extensor, finger flexor, and intrinsic hand muscles allows for an orderly assessment of the C5 - T1 nerve roots. Alternatively, or in addition, distal strength can be semi - quantitatively measured by recording grip strength using a hand - held dynamometer (or by having the patient squeeze an inflated blood pressure cuff); or by using myometry (which can more precisely measure the force that a muscle can exert and allows for recording of differences in strength over time). Thus, an increase in muscle strength can be manifested as an increase in the Oxford score, or as an increase in distal strength evaluated by recording grip strength using a hand - held dynamometer (or by having the patient squeeze an inflated blood pressure cuff) or by myometry.

[0483] For example, muscle tone may improve. Muscle tone, also known as residual muscle contraction or tension, is the continuous, passive partial contraction of a muscle at rest, or the resistance of a muscle to passive stretch. It helps maintain posture and decreases during REM sleep. It is different from muscle strength. Muscle tone is regulated by motor neuron activity and can be affected by various factors including age, disease, and neurogenic hypotonia. Hypotonia refers to a decrease in the resting tone of a muscle and a decrease in resistance to passive movement. Hypotonia rarely occurs alone without some degree of weakness. Hypotonia (low muscle tone) is manifested as a decrease in muscle hardness, an inability to effectively support an upright posture against gravity, or an inability to generate sufficient force during contraction. Thus, hypotonic muscles are usually more compliant rather than stiff. For example, hypotonia is observed in subjects with various conditions such as Down syndrome, muscular dystrophy, cerebral palsy, Prader - Willi syndrome, myotonic dystrophy, Marfan syndrome, Tay - Sachs disease, etc. Hypotonia is usually evaluated by medical observation, and improvement in hypotonia will result in an increase in resting tone and resistance to passive movement, as evaluated by medical professionals.

[0484] For example, muscle endurance (or muscular endurance) may increase. This is the ability of a muscle or muscle group to resist fatigue during repeated muscle contractions against an external force. This is typically evaluated by observation, such as by performing repeated exercises over a period of time, for example, by counting the number of push - ups a patient can complete within a given time (such as 60 seconds), or by determining how long it takes an individual to complete a certain number of repeated exercises. An increase in muscle endurance is manifested as an increase in the number of repeated exercises completed within a given time, or a decrease in the time required to complete a certain number of repeated exercises.

[0485] For example, muscle mass may increase. Muscle mass refers to the amount of muscle in a subject's body, including skeletal muscle, smooth muscle, and cardiac muscle. In a preferred embodiment, skeletal muscle mass increases. Muscle mass can be measured, for example, by dual-energy X-ray absorptiometry, CT scan, or MRI scan. Muscle mass can be increased by the methods described in the present invention, and the increase in muscle mass can also lead to an increase in the ratio of muscle to fat (such as the ratio of skeletal muscle to fat). Fat content can be measured using DEXA and bioelectrical impedance analysis (BIA). Additionally or alternatively, one or more of the subject's muscle volume, muscle density, and muscle length may also increase.

[0486] For example, muscle fatigue may decrease. Muscle fatigue is used to describe the decline in force generated by a muscle or muscle group during repeated contractions against an external force. An example of a test for measuring muscle fatigue is the Biering-Sorenson test, which is used to evaluate the fatigue of the trunk extensor muscles and can also be used in back pain tests. As described in Sorenson (Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 1984; 9: 106–119), in the test, "when the subject's hips and legs are fixed to a couch with three wide canvas straps and the subject lies prone with the arms crossed in front of the chest, for how many seconds can the subject hold the unsupported upper body (from the upper edge of the iliac crest) horizontal." A decrease in muscle fatigue will be manifested as an increase in the amount of time the subject can hold the required position.

[0487] For example, cardiovascular endurance may increase, that is, the ability of the subject's heart and lungs to supply oxygen to the body. This can also be defined as the ability to perform moderate to high-intensity exercise (as a percentage of maximal oxygen uptake) for a long time. Cardiovascular endurance can be measured by standard techniques, including measuring maximal oxygen uptake by indirect calorimetry. Maximal oxygen uptake is the maximum amount of oxygen that an individual can utilize during strenuous or maximal exercise and is usually measured by determining the amount and gas concentration of the air inhaled and exhaled by the individual during maximal, graded exercise on a treadmill or a stationary bicycle. Maximal oxygen uptake can be expressed in liters of oxygen consumed per minute (l / min), or the value can also be normalized according to body size differences and expressed as milliliters of oxygen consumed per kilogram of body weight per minute (ml / kg / min). Therefore, an increase in cardiovascular endurance can be observed as an increase in maximal oxygen uptake (l / min) or (ml / kg / min) using this detection method.

[0488] For example, cardiovascular fitness may be improved. Cardiovascular fitness is the body's maximum ability to absorb oxygen. This is also measured as maximal oxygen uptake (L O2 / Min). Therefore, an improvement in cardiovascular fitness can also be observed as an increase in maximal oxygen uptake (l / min) or (ml / kg / min).

[0489] For example, exercise intolerance may be reduced. Exercise intolerance refers to a decrease in the body's ability to perform activities involving strenuous exercise, which may lead to an inability or reduced ability to perform physical sports at a normal level or duration. Objective tests for exercise intolerance include moderate-intensity activities such as stair climbing, six-minute walk test, shuttle walk test, cardiac stress test, and cardiopulmonary exercise test (CPET). In the six-minute walk test, the aim is to see how far an individual can walk, and for an average person without exercise intolerance, around 600 meters is a reasonable result. Therefore, a reduction in exercise intolerance can be observed as an increase in the distance walked by an individual in the six-minute test.

[0490] For example, exercise capacity (i.e., the maximum physical exertion that a patient can tolerate) may be enhanced. This can be evaluated by maximal exercise tests (such as EST, i.e., a symptom-limited test using a 12-lead electrocardiogram for diagnosing exercise-induced myocardial ischemia, arrhythmia, or abnormal blood pressure response, or cardiopulmonary exercise test), submaximal exercise tests, six-minute walk test, and incremental shuttle walk test, and an appropriate test is selected according to the physical condition of the subject. Therefore, an improvement in exercise capacity can be observed as an increase in the score in any of these evaluations.

[0491] For example, exercise-induced fatigue (EF) may be reduced. Exercise-induced fatigue is a decrease in maximal voluntary muscle strength due to intense and prolonged exercise. Generally, this is determined by observing the fatigue state after prolonged intense exercise.

[0492] Many improvements in muscle function are based on the observations of medical professionals and cannot be quantified, but such an increase or improvement may be observed by medical professionals according to the standard tests for muscle function used in this field. Any such quantifiable increase or improvement can be, for example, an increase or improvement in performance determined by a score or value at least 1, 2, 3, 4, 5, 6, 12, 18, 24, 36 months after administration of an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist, and the score or value is improved (regardless of whether the actual value increases or decreases depending on the nature of the test) by at least 1, 2, 3, 5, 10, 15, 20, 25, 30, 35% transduction compared to the value before administration or compared to the value before administration of an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist. Optionally, muscle biopsy or biochemical analysis of muscle metabolites released into body fluids can be used in these methods and may produce quantitative results.

[0493] As described above, an improvement in muscle function can be defined as an improvement in muscle function relative to that before administration or non - administration of an FGFR3 signal transduction inhibitor, or an NPR - B agonist, or an NPR - C agonist. Thus, in some embodiments, a subject treated with an FGFR3 signal transduction inhibitor, or an NPR - B agonist, or an NPR - C agonist may still experience an overall decline in muscle function (e.g., over time), but in these embodiments, this decline in muscle function may be less than that which occurs in the absence of treatment. In such alternative embodiments, an improvement in muscle function can be manifested as a reduction in the decline of muscle function (e.g., compared to the decline of muscle function in the absence of treatment). This is especially true for diseases or disorders associated with impaired neuromuscular function described herein (e.g., neuromuscular diseases or neurodegenerative diseases). This may mean that, depending on the diagnosis of the subject, it takes longer than expected for the subject to reach a certain level of muscle function. Or, the progression of the disease (e.g., in terms of muscle function) slows down, such that it takes at least 1, 2, 3, 6 months or at least 1, 2, 3 years longer than without treatment to reach a given point in the progression of the disease.

[0494] The musculoskeletal pain of the subject may also be improved. Musculoskeletal pain is defined as acute or chronic pain that affects bones, muscles, ligaments, tendons, and even nerves. The pain may include a variety of different pain syndromes, ranging from local pain to neuropathic pain. Musculoskeletal pain is mainly somatic pain in nature. The most common forms of musculoskeletal pain are chronic low back pain and neck pain.

[0495] For example, musculoskeletal pain may be pain in the musculoskeletal system including joints, ligaments, muscles, nerves, or tendons. In some embodiments, musculoskeletal pain may be chronic pain, typically with a pain duration of more than 12 weeks. In some embodiments, musculoskeletal pain may be muscle pain, such as skeletal muscle pain (e.g., chronic skeletal muscle pain). In some embodiments, musculoskeletal pain may be pain associated with abnormal curvature of the spine. In some embodiments, the pain may be unrelated to arthritis (e.g., osteoarthritis). In some embodiments, musculoskeletal pain may be myalgia. In some embodiments, musculoskeletal pain may be related to or caused by muscle cramps or spasms. Musculoskeletal pain can be diagnosed or monitored by, for example, pain reported by the patient (e.g., see Nielsen and Arendt - Nielsen, Curr Pain Headache Rep, December 2003; 7(6):443 - 51), MRI or CT scans, electromyography (e.g., for measuring the electrical activity of nerves and muscles).

[0496] Posture may also be improved, or abnormal spinal curvatures reduced. Poor or incorrect posture, which can be defined as postural dysfunction, occurs when the curves of the subject's spine are more pronounced when the spine is in an unnatural position. Complications of poor posture include back pain, spinal dysfunction, joint degeneration, rounded shoulders, and a protruding abdomen. The improvements related to posture and spinal curvature following administration of an FGFR3 signal transduction inhibitor or an NPR-B agonist or an NPR-C agonist may be due to the improvement in muscle function described above. This is consistent with the observations in Example 1, that treatment with test compound (1) had an impact on survival after only 15 days of treatment, a time frame consistent with the impact on muscle historical survival, and in mouse models with muscle weakness as a primary phenotypic feature, an increase in the incidence of maternal infanticide has been described (e.g., Sullivan 2014).

[0497] Such improvements can be in kyphosis, lordosis, or scoliosis of the spine, or in spinal stenosis that may be caused by any of the aforementioned spinal deformities. Kyphosis refers to an excessive forward rounding of the upper part of the spine. Lordosis refers to an excessive inward curvature of the spine. Scoliosis refers to an abnormal lateral curvature of the spine. Spinal stenosis, which may be caused by any of the aforementioned spinal deformities, refers to a narrowing of the spinal canal within the spine. Optionally, the improvement in kyphosis, lordosis, spinal stenosis, or scoliosis is achieved by improving muscle function. These spinal abnormalities may occur in dyschondroplasia diseases, and preferably, subjects with kyphosis, lordosis, spinal stenosis, or scoliosis have a dyschondroplasia disease, such as a disease selected from the group consisting of achondroplasia, hypochondroplasia, and lethal dysplasia.

[0498] For example, abnormal spinal curvatures can be monitored by physical examination or imaging methods such as X-ray examination, spinal radiography, CT scan, or MRI scan. Signs of abnormal spinal curvatures may include, for example, uneven shoulders, the head not being centered above the pelvis, one or both hips being elevated or abnormally high, unevenness in the lumbar region, and tilting of the body. For example, the Cobb method can be used to measure the degree of spinal curvature. Further embodiments related to the treatment of abnormal spinal curvatures.

[0499] In some embodiments, the invention relates to treating spinal deformities in subjects having a dyschondroplasia disease (such as the dyschondroplasia diseases disclosed herein, such as achondroplasia). Spinal deformities in dyschondroplasia such as achondroplasia cause pain and disability. Congenital spinal stenosis is common in achondroplasia and is associated with neurological symptoms that worsen with age, can lead to premature or accidental death, and may require corrective surgery or repeated corrective surgeries throughout the patient's life.

[0500] Spinal deformities can include abnormal curvature of the spine, which can be corrected at least in part by strengthening the back muscles and appropriately by the therapeutic uses disclosed or claimed herein. Spinal deformities may be abnormal vertebral pedicle morphology or spinal canal stenosis, which is typical in achondroplasia and may be further exacerbated by abnormal spinal curvature. Abnormal vertebral pedicle morphology may be a decrease in the interpedicular distance or a decrease in the pedicle width. Interpedicular stenosis and thickened pedicles are common in achondroplasia, and the resulting spinal canal stenosis usually requires surgical intervention, such as correction of foramen magnum (FM) stenosis.

[0501] The present invention provides the use of an FGFR3 signal transduction inhibitor or an NPR-B agonist for use according to the present invention or according to any one of the claims, wherein said use results in an increase in spinal height, such as an increase in thoracic vertebral height, an increase in interpedicular distance or an increase in pedicle width.

[0502] The present invention provides the use of an NPR-B agonist for use according to the present invention or according to any one of the claims, wherein said use results in an increase in spinal height, such as an increase in thoracic vertebral height, an increase in interpedicular distance or an increase in pedicle width. The present invention provides a method for treating spinal pedicle deformities in a subject in need thereof, said method comprising administering to said subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor or an NPR-B agonist. Appropriately, the method may include the initial steps of: (i) diagnosing or measuring the spinal pedicle deformity of the subject, and then (ii) administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor, an NPR-B agonist. Appropriately, the measurement step may involve one or more X-ray examinations, such as anteroposterior (AP) X-ray examination and / or lateral X-ray examination. Lateral X-ray examination can be used to measure, for example, pedicle width, while anteroposterior X-ray examination can be used to measure, for example, interpedicular distance. X-ray examinations of the spine or spinal deformity before and after administration can be used to determine effective treatment. The diagnosis or measurement step may be to measure one or more of spinal height, thoracic vertebral height, interpedicular distance and pedicle width. The diagnostic measurement step may be or include the measurement of spinal pedicle morphology or spinal stenosis / spinal canal stenosis.

[0503] In some embodiments, administration results in improvement of sleep apnea, obstructive sleep apnea, or otitis media. Sleep apnea is a condition in which a subject's breathing stops and restarts multiple times during sleep. This prevents the subject's body from getting enough oxygen. Obstructive sleep apnea (OSA) is a form of sleep apnea that occurs when the muscles in the throat relax and block air from entering the lungs. Otitis media is an infection of the middle ear that causes inflammation (redness and swelling) and fluid buildup behind the eardrum, and is associated with midfacial hypoplasia. Otitis media can lead to hearing loss. Optionally, the improvement of sleep apnea, obstructive sleep apnea, or otitis media is achieved by improving muscle function. These conditions may occur in chondrodysplasia diseases. Preferably, an individual with sleep apnea, obstructive sleep apnea, or otitis media has a chondrodysplasia disease, such as a disease selected from the group consisting of achondroplasia, hypochondroplasia, and thanatophoric dysplasia. Given the association between sleep disordered breathing and weakness of the upper airway (e.g., larynx and pharynx) muscles, it is believed that improvement of muscle function will be beneficial for these conditions.

[0504] In some embodiments, the present invention relates to a method of treating obstructive sleep apnea. For example, sleep apnea (such as obstructive sleep apnea) can be monitored by nocturnal polysomnography / using a respiratory monitor.

[0505] Otitis media is defined as an infection of the middle ear space, which is usually diagnosed and monitored by physical examination, and various diagnostic tools can be used, such as a pneumatic otoscope, tympanometry, and acoustic reflexometry. Otitis media is often associated with ear pain, hearing loss, and fever, which can also be monitored. In some embodiments, otitis media is acute otitis media, and the present invention provides effective treatment that can reduce the frequency of acute otitis media events, reduce the severity of acute otitis media, or both. In some embodiments, the present invention relates to prophylactic treatment of otitis media. Thus, the monitoring of otitis media can be to evaluate the frequency or severity of acute otitis media events, or both.

[0506] In some embodiments, administration results in a reduction in obesity. If a subject has lower muscle function prior to treatment, this can make it more difficult for them to exercise and to exercise well and effectively to control weight and maintain overall physical health. By improving the muscle function of the subject, a reduction in obesity can also be achieved. This issue has been observed in patients with dyschondroplasia disorders, and obesity is considered a major health problem in achondroplasia, requiring early but complex clinical treatment (see Saint-Laurent, C., Garde-Etayo, L. & Gouze, E. Obesity in achondroplasia patients: from evidence to medical monitoring. Orphanet J Rare Dis 14, 253 (2019). https: / / doi.org / 10.1186 / s13023-019-1247-6 ), which states that children with achondroplasia are restricted in their psychomotor development and physical condition, and the early onset of overweight and obesity can lead to a worsening of a sedentary lifestyle and / or prevent these children from participating in sports activities carried out by children of the same age. Optionally, the reduction in obesity is achieved by improving muscle function. Obesity can occur in dyschondroplasia disorders, and preferably, subjects with obesity have a dyschondroplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and thanatophoric dysplasia.

[0507] Obesity is defined as a body mass index (BMI) of over 30. Thus, a reduction in obesity can be a reduction in BMI. A subject may have a BMI of over 30 at the start of administration, such as a pre-administration BMI of over 30, 32, 35, 38, 40. In some embodiments, the pre-administration BMI is 25 - 30, such as over 26, 27, 28, 29.

[0508] Embodiments related to hand length

[0509] Hand deformities are characteristic of achondroplasia and include short finger lengths, trident hand deformity, and an inability to fully extend the fingers.

[0510] The present invention provides an FGFR3 signal transduction inhibitor or an NPR-B agonist for promoting the growth of hand length or finger length in a human subject less than 18 years of age or with open epiphyses.

[0511] The present invention provides an FGFR3 signal transduction inhibitor or an NPR-B agonist for correcting hand deformities in a human subject less than 18 years of age or with open epiphyses.

[0512] The present invention provides a use of an FGFR3 signal transduction inhibitor or an NPR-B agonist according to the present invention or according to any one of the claims, wherein the use increases the growth of hand length or finger length in a human subject (such as a human subject less than 18 years old or a human subject whose epiphyses are not closed).

[0513] The present invention provides a method for increasing the rate of hand or finger length in a subject in need of treatment, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor or an NPR-B agonist.

[0514] Suitably, the method according to the present invention may comprise the steps of: (i) assessing the hand length or finger length of a subject in need of treatment, and (ii) administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor or an NPR-B agonist, and (iii) optionally measuring the increase in hand length or finger length after said administration.

[0515] The present invention provides a method for correcting a hand deformity in a subject in need of treatment, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor or an NPR-B agonist.

[0516] Suitably, the method according to the present invention may comprise the steps of: (i) assessing the hand deformity of a subject in need of treatment, and (ii) administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor or an NPR-B agonist, and (iii) optionally assessing the change in hand deformity of the subject after said administration.

[0517] Methods covering the evaluation steps

[0518] In some embodiments, the present invention provides a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function. The method comprises performing at least 1 assessment of the muscle function of a subject suffering from a disease or disorder with impaired muscle function, and administering to the subject a therapeutically effective amount or course of an FGFR3 signal transduction inhibitor, an NPR-B agonist or an NPR-C agonist.

[0519] This can be described as a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, the method comprising:

[0520] (i) performing at least 1 assessment of the muscle function of a subject suffering from a disease or disorder with impaired muscle function, and

[0521] (ii) administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor, an NPR-B agonist or an NPR-C agonist.

[0522] The assessment step can be performed before the administration step, such as to determine a baseline value or measured value of muscle function before the start of administration. This can be used, for example, to compare with subsequent values or measured values of muscle function (which can be evaluated after administration). For example, in such cases, the assessment step can be performed before the start of administration (such as up to one week, one month, or three months). The pre - administration assessment step can be used as a comparison, such as to determine the effectiveness of treatment. The administration step can be initiated in response to the assessment step.

[0523] The administration step generally includes multiple administrations of an FGFR3 signal transduction inhibitor, an NPR - B agonist, or an NPR - C agonist. The assessment of muscle function can also be performed at least twice or multiple times. Optionally, it is performed once or at least once (such as to determine a baseline) before the start of the administration step, and once or at least once after the start of the administration step. The assessment step can also be performed at least three times, once or at least once (such as to determine a baseline) before the start of the administration step, and twice or at least twice after the start of the administration step.

[0524] This can provide useful information to compare the muscle function determined before the start of the administration step with the muscle function determined after the start of the administration step, or to compare successive measured muscle functions, or to use regularly measured muscle functions to, for example, observe trends in muscle function (such as the response to treatment). This can be used to determine treatment outcomes or to provide information for the revision of treatment regimens.

[0525] The assessment of muscle function can also be performed before the start of administration (optionally in combination with other signs or symptoms of the subject) to diagnose that the subject has a disease or disorder with impaired muscle function. Thus, the methods mentioned herein can also additionally include diagnosing that the subject has impaired muscle function and / or a disease or disorder with impaired muscle function. The administration can be initiated in response to the assessment step and / or the diagnosis of the subject's disease or disorder. The administration can also be initiated in response to the assessment of impaired muscle function relative to a reference value (which can be obtained, for example, by evaluating a normal or control subject (such as a subject known not to have a disease or disorder with impaired muscle function)).

[0526] The assessment step can be additionally or alternatively performed after the start of administration (such as between successive drug doses). The assessment step performed after the start of administration can be performed once or multiple times. The assessment step can be performed, for example, at regular intervals (such as once a week, once a month, once a year) at least 4, 5, 6, 7, 8, 9, 10 times. The assessment step can be performed throughout the treatment period.

[0527] The assessment of muscle function can include any of the following: a) skeletal muscle strength, b) skeletal muscle tone, c) skeletal muscle endurance, d) skeletal muscle mass, e) skeletal muscle fatigue, f) cardiovascular endurance, g) cardiovascular fitness, h) exercise intolerance, i) exercise capacity, j) exercise-induced fatigue, k) hypotonia, l) skeletal muscle mass and / or muscle / fat ratio (e.g., skeletal muscle / fat ratio), m) musculoskeletal pain, n) spinal posture or curvature (optionally kyphosis, lordosis, spinal stenosis, or scoliosis), o) sleep apnea, obstructive sleep apnea, or otitis media, p) obesity.

[0528] Such assessments include those described elsewhere herein. Examples include measurements of muscle weight, muscle length, muscle density, muscle size, and / or volume. The assessment can include imaging the subject and observing the subject's performance. The assessment can have or not have quantitative metrics in physical tests (e.g., muscle fatigue and cardiovascular tests) or by biochemical analysis of muscle biopsies or biochemical analysis of muscle metabolites released into body fluids.

[0529] The assessment can include imaging, such as at least one imaging step (such as X-ray examination, spinal radiography, CT scan, or MRI scan).

[0530] The assessment can include determining a performance metric of the subject, for example, it can be a measurement or observation of the subject's ability to perform certain tasks, such as referring to the physical function tests described elsewhere herein (such as, determining muscle fatigue and endurance levels, such as the sit-to-stand test and the six-minute walk test).

[0531] If more than one assessment is performed, a composite index may be generated. In some embodiments, a composite index is generated for at least 2, 3, 4, 5, 6, 7 (or 1-6, 2-5, 3-4) of any of the assessments performed, for example, for at least 2, 3, 4, 5, 6, 7 (or 1-6, 2-5, 3-4) of the above assessments a)-p). If a composite index is generated, it can form the basis for any comparison mentioned elsewhere herein.

[0532] Improvement in muscle function can be any improvement in muscle function as defined elsewhere herein.

[0533] In some methods, at least 1 assessment step is performed before the start of the administration step, such as to determine the baseline value or measured value of muscle function, and 1, 2, or more assessment steps are performed after the start of the administration, such as to determine changes in muscle function responsive to the administration.

[0534] Comparison of muscle function values before and after administration can indicate an increase in muscle function, no change in muscle function, or a decrease in muscle function. An increase in muscle function that begins after administration and is responsive to the administration can be an indicator of a positive response to treatment (i.e., the treatment is successful).

[0535] In some embodiments, an increase or gradual increase in muscle function with further dosing, or an increase in muscle function when the subject had a decrease in muscle function prior to treatment or showed a decrease in muscle function in historical control subjects, is an indicator of a positive response to treatment.

[0536] The finding of no change or a decrease in muscle function may indicate a positive response to treatment or may indicate a need to modify the treatment regimen (such as increasing its dose and / or frequency), depending on the circumstances and the desired outcome. For example, if the subject's muscle function was impaired but stable prior to starting treatment, no change or a decrease in muscle function after dosing may be a negative indicator of response to treatment. However, if the subject's muscle function was impaired and decreasing prior to starting treatment, then no change in muscle function after dosing and responsive to the dosing may indicate a positive response to treatment. Similarly, even a decrease in muscle function after starting treatment that is less than expected (based on the decrease in the subject prior to starting treatment or in untreated historical control subjects) can indicate a positive response to treatment. A decrease in muscle function that exceeds any expectation based on the decrease in the subject prior to starting treatment or in untreated historical control subjects may indicate a negative response to the dosing. The expectation may depend on a comparison to a control value determined in the same subject prior to starting treatment, a reference subject, or normal and / or control subjects.

[0537] Assessment of changes in muscle function in response to administration can be used to guide treatment decisions: whether to continue administering the drug, modify the drug regimen (such as changing the dose or frequency), or stop administering the drug. For example, if the assessment shows a positive response to the administration, the same treatment can be continued, such as under the same regimen. Depending on the degree of response and any side effects experienced by the subject, an increase or decrease in dose and / or frequency can also be considered. For example, the dose and / or frequency of administration can be increased to increase the response, or decreased to reduce any side effects. If the assessment indicates a negative response to treatment (or no positive response to treatment), and the subject tolerates the administered drug without unacceptable side effects, a higher dose or frequency of the same drug can be administered to attempt to elicit a positive treatment response. If the assessment continues to indicate a negative response to treatment (or no positive response to treatment) or the subject cannot tolerate the higher dose or frequency due to side effects, the drug can be stopped.

[0538] The evaluation steps can follow any treatment method mentioned in this article. For example, the present invention provides a method according to any one of items 34-114.

[0539] Methods related to the treatment or prevention of diseases or disorders associated with impaired neuromuscular function in a subject (such as neurodegenerative diseases) can similarly include evaluation steps related to muscle assays (such as skeletal muscle function, such as as described above). Optionally or additionally, such methods can include evaluation steps related to measuring mitochondrial dysfunction and measuring neuromuscular function, such as to determine whether the treatment results in a slowdown, delay, or reduction in disease progression, for example, a reduced rate of muscle function loss or decline, or a reduced rate of neuromuscular function loss or decline.

[0540] In combination with growth hormone

[0541] Human growth hormone is approved in Japan for the treatment of children with achondroplasia, and its combination therapy with CNP is under clinical study. The combination therapy with growth hormone in the methods and uses described in the present invention is expected to be advantageous.

[0542] In some embodiments, the growth hormone is or comprises recombinant human growth hormone (Somatropin), or is a recombinant human growth hormone conjugate (such as polyethylene glycolated recombinant human growth hormone), or a fatty acid growth hormone conjugate.

[0543] In some embodiments, the growth hormone is a growth hormone conjugate, such as a human growth hormone conjugate. The conjugate moiety can, for example, include a PEG moiety, a fatty acid moiety, a serum albumin binding moiety, an antibody moiety, or an antibody fragment moiety.

[0544] In some embodiments, the growth hormone is a long-acting growth hormone, such as a growth hormone administered once a week. For example, the long-acting growth hormone can be administered once a week or at a frequency lower than once a week.

[0545] Suitably, the growth hormone can be a controlled-release hGH. Long-acting human growth hormone and controlled-release hGH are disclosed in WO 2018 / 060314 Al, the entire content of which is incorporated herein by reference.

[0546] In some embodiments, the growth hormone is lonapegsomatropin (lonapegsomatropin-tcgd). In some embodiments, the growth hormone conjugate (such as a human growth hormone conjugate, a long-acting human growth hormone, or a controlled-release hGH (such as lonapegsomatropin)) is administered to a subject at a dose ranging from about 0.021 mg / kg / week to about 0.7 mg / kg / week (such as 0.21 mg / kg / week or about 0.21 mg / kg / week) (mg / kg refers to the mass of the growth hormone polypeptide without the conjugated moiety administered per week).

[0547] In some embodiments, the growth hormone is selected from the group consisting of: somapacitan or somapacitan-beco, sold as by Novo Nordisk), somatrogon, sold as NGENLA TM by (Pfizer / OPKO), eftansomatropin alfa, also known as eftansomatropin, efpegsomatropin, albusomatropin, somavaratan, ibutamoren, and lonapegsomatropin-tcgd.

[0548] Exemplary administration regimens for CNP drugs (such as drugs comprising a CNP conjugate (such as (IIf’) or a CNP of formula (IIf) or compound (1))).

[0549] Before subcutaneous administration to a patient in need, the solid unit dosage form is reconstituted. The reconstitution of the solid unit dosage form into a reconstituted preparation is carried out by adding a predetermined amount of reconstitution solution to the solid unit dosage form. Accordingly, a further aspect of the present invention is a method of reconstituting the solid unit dosage form of the present invention, wherein the method comprises the steps of:

[0550] (a) contacting the solid unit dosage form of the present invention with the reconstitution solution.

[0551] Reconstitution can be carried out in a container that provides a solid unit dosage form, such as in a vial, a syringe (such as a dual-chamber syringe), an ampoule, a cartridge (such as a dual-chamber cartridge), or a different container into which the solid unit dosage form can be transferred and then reconstituted therein. In some embodiments, the container for reconstituting the solid unit dosage form is a vial. In some embodiments, the container for reconstituting the solid unit dosage form is a syringe. In some embodiments, the container for reconstituting the solid unit dosage form is a dual-chamber syringe. In some embodiments, the container for reconstituting the solid unit dosage form is a cartridge. In some embodiments, the container for reconstituting the solid unit dosage form is a dual-chamber cartridge.

[0552] In some embodiments, the solid unit dosage form of the present invention is placed in the first chamber of a dual-chamber syringe, and the reconstitution solution is placed in the second chamber of the dual-chamber syringe.

[0553] The reconstitution solution is a sterile liquid, such as water or a buffer solution, which may further contain additives, such as preservatives and / or antibacterial agents.

[0554] In some embodiments, the reconstitution solution contains one or more preservatives and / or antibacterial agents and / or antioxidants.

[0555] In some embodiments, the reconstitution solution contains one or more preservatives.

[0556] The preservatives can be selected from the group consisting of m-cresol, benzoic acid, phenol, methyl paraben, ethyl paraben, propyl paraben, butyl paraben, potassium sorbate, chlorobutanol, benzyl alcohol, phenylmercuric nitrate, thimerosal, sorbic acid, potassium sorbate, chlorocresol, benzalkonium chloride, 2-ethoxyethanol, chlorhexidine, chlorobutanol, phenethyl alcohol, phenylmercuric acetate, and mixtures thereof.

[0557] In some embodiments, the preservative is m-cresol. In some embodiments, the preservative is benzyl alcohol. In some embodiments, the preservative is benzoic acid. In some embodiments, the preservative is phenol. In some embodiments, the preservative is methyl p-hydroxybenzoate. In some embodiments, the preservative is ethyl p-hydroxybenzoate. In some embodiments, the preservative is propyl p-hydroxybenzoate. In some embodiments, the preservative is butyl p-hydroxybenzoate. In some embodiments, the preservative is potassium sorbate. In some embodiments, the preservative is benzyl alcohol. In some embodiments, the preservative is phenylmercuric nitrate. In some embodiments, the preservative is thimerosal. In some embodiments, the preservative is sorbic acid. In some embodiments, the preservative is potassium sorbate. In some embodiments, the preservative is chlorocresol. In some embodiments, the preservative is benzalkonium chloride. In some embodiments, the preservative is 2-ethoxyethanol. In some embodiments, the preservative is chlorhexidine. In some embodiments, the preservative is chlorobutanol. In some embodiments, the preservative is phenethyl alcohol. In some embodiments, the preservative is phenylmercuric acetate.

[0558] In some embodiments, the concentration range of the preservative is 1-10 mg / ml. In some embodiments, the concentration range of the preservative is 1.5-3.5 mg / ml. In some embodiments, the concentration range of the preservative is 2-3 mg / ml.

[0559] The antioxidant can be selected from the group consisting of methionine, butylated hydroxytoluene, butylated hydroxyanisole, tocopherol, propyl gallate, ascorbic acid, ethylenediaminetetraacetic acid (EDTA), polyethyleneimine, vitamin E, and mixtures thereof.

[0560] In some embodiments, the antioxidant is methionine. In some embodiments, the antioxidant is butylated hydroxytoluene. In some embodiments, the antioxidant is butylated hydroxyanisole. In some embodiments, the antioxidant is tocopherol. In some embodiments, the antioxidant is propyl gallate. In some embodiments, the antioxidant is ethylenediaminetetraacetic acid. In some embodiments, the antioxidant is polyethyleneimine. In some embodiments, the antioxidant is vitamin E.

[0561] As defined herein, the term "methionine" is intended to cover D-methionine and L-methionine and mixtures thereof. In some embodiments, the term "methionine" refers to L-methionine. In some embodiments, the term "methionine" refers to D-methionine. In some embodiments, the term "methionine" refers to a mixture of D-methionine or L-methionine. In some embodiments, the term "methionine" refers to L-methionine hydrochloride.

[0562] As defined herein, the term "EDTA" is intended to cover all forms of EDTA known in the art, such as EDTA salts, including EDTA metal salts, such as disodium EDTA, dipotassium EDTA, calcium EDTA, dimagnesium EDTA, or mixtures thereof. In some embodiments, EDTA refers to disodium EDTA. In some embodiments, the term "EDTA" refers to calcium disodium EDTA. In some embodiments, the term "EDTA" refers to anhydrous EDTA.

[0563] In some embodiments, the molar ratio of the antioxidant to the CNP moiety is from about 0.1:1 to about 100:1. In some embodiments, the molar ratio of the antioxidant to the CNP moiety is from about 0.1:1 to about 70:1. In some embodiments, the molar ratio of the antioxidant to the CNP moiety is from about 0.1:1 to about 15:1. In some embodiments, the molar ratio of the antioxidant to the CNP moiety is from about 1:1 to about 10:1. In some embodiments, the molar ratio of the antioxidant to the CNP moiety is from about 3:1 to about 7:1.

[0564] In some embodiments, the reconstitution solution does not contain an antibacterial agent. In some embodiments, the reconstitution solution contains one or more excipients.

[0565] In some embodiments, the reconstitution solution is sterile water. In some embodiments, the reconstitution solution is sterile water containing 0.7 - 1.1% benzyl alcohol. In some embodiments, the reconstitution solution is sterile water containing 0.9% benzyl alcohol.

[0566] In some embodiments, the reconstitution solution contains a pH regulator.

[0567] The term "pH regulator" as used herein refers to a chemical compound for adjusting the pH value of the reconstitution solution.

[0568] In some embodiments, the pH regulator can be an acid or its acidic salt. The acid can be selected from the group consisting of acetic acid, citric acid, succinic acid, hydrochloric acid, phosphoric acid, carbonic acid, nitric acid, and mixtures thereof.

[0569] In some embodiments, the pH regulator can be an alkali or its basic salt. The alkali can be selected from the group consisting of Tris (tris(hydroxymethyl)aminomethane), sodium hydroxide, potassium hydroxide, lysine, and mixtures thereof.

[0570] In some embodiments, the volume of the reconstitution solution ranges from about 0.1 ml to about 4 ml. In some embodiments, the volume of the reconstitution solution is about 1 ml, such as about 2 ml, such as about 3 ml, or such as about 4 ml.

[0571] In some embodiments, the volume of the reconstitution solution is about 0.79 ml. In some embodiments, the volume of the reconstitution solution is 0.79 ml. In some embodiments, the volume of the reconstitution solution is about 1 ml. In some embodiments, the volume of the reconstitution solution is 1 ml. In some embodiments, the volume of the reconstitution solution is about 1.1 ml. In some embodiments, the volume of the reconstitution solution is 1.1 ml. In some embodiments, the volume of the reconstitution solution is about 1.25 ml. In some embodiments, the volume of the reconstitution solution is 1.25 ml.

[0572] It can be understood that the volume of the unit dose or the injection volume is based on the actual body weight of the patient and the concentration of the reconstitution solution. In some embodiments, the concentration of CNP in the reconstitution solution does not exceed 7 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is not less than 0.5 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 0.75 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 1 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 2.2 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 3.6 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 4.6 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 5 mg / ml. In some embodiments, the concentration of CNP in the reconstitution solution is 5.5 mg / ml.

[0573] After reconstitution, the volume of the unit dose does not exceed 4 ml. In some embodiments, the range of the unit dose volume is from about 0.01 ml to about 1.1 ml. In some embodiments, the range of the unit dose volume is from 0.01 ml to 0.75 ml. In some embodiments, the range of the unit dose volume is from 0.01 ml to 0.50 ml.

[0574] In some embodiments, the volume of the unit dose is about 0.03 ml. In some embodiments, the volume of the unit dose is about 0.05 ml. In some embodiments, the volume of the unit dose is about 0.1 ml. In some embodiments, the volume of the unit dose is about 0.2 ml. In some embodiments, the volume of the unit dose is about 0.25 ml. In some embodiments, the volume of the unit dose is about 0.3 ml. In some embodiments, the volume of the unit dose is about 0.35 ml. In some embodiments, the volume of the unit dose is about 0.4 ml. In some embodiments, the volume of the unit dose is about 0.5 ml. In some embodiments, the volume of the unit dose is about 0.6 ml. In some embodiments, the volume of the unit dose is about 0.75 ml. In some embodiments, the volume of the unit dose is about 1 ml.

[0575] In some embodiments, the patient is an infant and the volume of the unit dose ranges from about 10 μl to 100 μl. In some embodiments, the patient is an infant and the volume of the unit dose ranges from about 10 μl to 50 μl. In some embodiments, the patient is an infant and the volume of the unit dose ranges from about 10 μl to 30 μl.

[0576] In some embodiments, the patient is an infant and the volume of the unit dose is about 10 μl. In some embodiments, the patient is an infant and the volume of the unit dose is about 15 μl. In some embodiments, the patient is an infant and the volume of the unit dose is about 20 μl.

[0577] In some embodiments, the patient is an infant and the volume of the unit dose is 10 μl. In some embodiments, the patient is an infant and the volume of the unit dose is 15 μl. In some embodiments, the patient is an infant and the volume of the unit dose is 20 μl.

[0578] In some embodiments, the patient is an infant, the unit dose is 20 μg CNP / kg and the volume of the unit dose is about 10 μl. In some embodiments, the patient is an infant, the unit dose is 20 μg CNP / kg and the volume of the unit dose is about 15 μl. In some embodiments, the patient is an infant, the unit dose is 20 μg CNP / kg and the volume of the unit dose is about 20 μl.

[0579] In some embodiments, the unit dose is 6 μg CNP / kg and the volume of the unit dose is 0.06 ml. In some embodiments, the unit dose is 20 μg CNP / kg and the volume of the unit dose is 0.3 ml. In some embodiments, the unit dose is 50 μg CNP / kg and the volume of the unit dose is 0.2 ml. In some embodiments, the unit dose is 75 μg CNP / kg and the volume of the unit dose is 0.4 ml. In some embodiments, the unit dose is 100 μg CNP / kg and the volume of the unit dose is 0.5 ml. In some embodiments, the unit dose is 150 μg CNP / kg and the volume of the unit dose is 0.5 ml.

[0580] In some embodiments, the pH of the liquid unit dosage form is from about 4 to about 6. In some embodiments, the pH of the liquid unit dosage form is from about 4.5 to about 5.5. In some embodiments, the pH value of the liquid unit dosage form is about 5. In some embodiments, the pH of the liquid unit dosage form is 5.

[0581] In some embodiments, the unit dosage form according to the present invention further comprises the buffer, the isotonic agent and the pH regulator.

[0582] In some embodiments, the concentration range of the buffer in the unit dosage form is 1.3 - 57.6 mM. In some embodiments, the concentration range of the buffer in the unit dosage form is 1.7 - 33 mM. In some embodiments, the concentration range of the buffer in the unit dosage form is 5.1 - 20.3 mM. In some embodiments, the concentration of the buffer in the unit dosage form is about 10 mM.

[0583] Exemplary buffers can be selected from the group consisting of: succinic acid, citric acid, lactic acid, acetic acid, glutamic acid, fumaric acid, aspartic acid, glutaric acid, phosphoric acid, histidine, gluconic acid, tartaric acid, malic acid and mixtures thereof. Those skilled in the art will appreciate that the corresponding conjugate bases or salts of the buffers can also be included, such as succinate, citrate, lactate, acetate, glutamate, fumarate, aspartate, glutarate, phosphate, gluconate, tartrate, malate and mixtures thereof.

[0584] In some embodiments, the buffering agent is succinic acid. In some embodiments, the buffering agent is citric acid. In some embodiments, the buffering agent is lactic acid. In some embodiments, the buffering agent is acetic acid. In some embodiments, the buffering agent is glutamic acid. In some embodiments, the buffering agent is fumaric acid. In some embodiments, the buffering agent is aspartic acid. In some embodiments, the buffering agent is glutaric acid. In some embodiments, the buffering agent is phosphoric acid. In some embodiments, the buffering agent is histidine. In some embodiments, the buffering agent is gluconic acid. In some embodiments, the buffering agent is tartaric acid. In some embodiments, the buffering agent is malic acid.

[0585] The isotonic agent can be selected from the group consisting of: trehalose, mannitol, sucrose, raffinose, gelatin, lactose, calcium hydrogen phosphate, sorbitol, xylitol, glycine, histidine, hydroxyethyl starch, glucose, dextran, propylene glycol, and mixtures thereof.

[0586] In some embodiments, the isotonic agent can be selected from the group consisting of: trehalose, mannitol, sucrose, raffinose, gelatin, lactose, calcium hydrogen phosphate, sorbitol, xylitol, glycine, histidine, hydroxyethyl starch, glucose, dextran, propylene glycol, and mixtures thereof.

[0587] In some embodiments, the isotonic agent is selected from the group consisting of: trehalose, sucrose, and glycine. In some embodiments, the isotonic agent is a non-reducing sugar, such as trehalose or sucrose.

[0588] In some embodiments, the isotonic agent is trehalose.

[0589] As defined herein, the term "trehalose" is intended to encompass all salts and hydrated forms of trehalose, such as trehalose anhydrous or trehalose dihydrate. In some embodiments, the term "trehalose" refers to trehalose anhydrous. In some embodiments, the term "trehalose" refers to trehalose dihydrate.

[0590] In some embodiments, the unit dosage form contains succinic acid and trehalose.

[0591] In some embodiments, the unit dosage form contains:

[0592] CNP conjugate 0.9 - 82.1 mg / ml

[0593] Succinic acid 1.3 - 57.6 mM

[0594] Trehalose dihydrate 67 - 111.6 mg / ml,

[0595] and the pH ranges from pH 4.0 to 6.0.

[0596] In some embodiments, the unit dosage form comprises:

[0597] CNP conjugate 19.8 - 73.6 mg / ml

[0598] Succinic acid 1.7 - 50 mM

[0599] Trehalose dihydrate 63 - 100 mg / ml

[0600] and has a pH in the range of pH 4.0 - 6.0.

[0601] In some embodiments, the unit dosage form comprises:

[0602] CNP conjugate 27.5 - 50.5 mg / ml

[0603] Succinic acid 5.1 - 20.3 mM

[0604] Trehalose dihydrate 67 - 95 mg / ml

[0605] and has a pH in the range of pH 4.0 - 6.0.

[0606] In some embodiments, the unit dosage form comprises about 8.2 mg / ml CNP conjugate, about 10 mM succinic acid, about 89 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0607] In some embodiments, the unit dosage form comprises 8.2 mg / ml CNP conjugate, 10 mM succinic acid, 89 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0608] In some embodiments, the unit dosage form comprises about 11 mg / ml CNP conjugate, about 10 mM succinic acid, about 88.5 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0609] In some embodiments, the unit dosage form comprises 11 mg / ml CNP conjugate, 10 mM succinic acid, 88.5 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0610] In some embodiments, the unit dosage form comprises about 24.2 mg / ml CNP conjugate, about 10 mM succinic acid, about 85 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0611] In some embodiments, the unit dosage form comprises 24.2 mg / ml of the CNP conjugate, 10 mM succinic acid, 85 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0612] In some embodiments, the unit dosage form comprises about 39.6 mg / ml of the CNP conjugate, about 10 mM succinic acid, about 80 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0613] In some embodiments, the unit dosage form comprises 39.6 mg / ml of the CNP conjugate, 10 mM succinic acid, 80 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0614] In some embodiments, the unit dosage form comprises about 50.5 mg / ml of the CNP conjugate, about 10 mM succinic acid, about 77 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0615] In some embodiments, the unit dosage form comprises 50.5 mg / ml of the CNP conjugate, 10 mM succinic acid, 77 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0616] In some embodiments, the unit dosage form comprises about 54.9 mg / ml of the CNP conjugate, about 10 mM succinic acid, about 75 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0617] In some embodiments, the unit dosage form comprises 54.9 mg / ml of the CNP conjugate, 10 mM succinic acid, 75 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0618] In some embodiments, the unit dosage form comprises about 60.4 mg / ml of the CNP conjugate, about 10 mM succinic acid, about 73 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0619] In some embodiments, the unit dosage form comprises 60.4 mg / ml of the CNP conjugate, 10 mM succinic acid, 73 mg / ml of trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0620] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises:

[0621] CNP conjugate 8.2 - 44.4% (w / w)

[0622] Succinic acid 0.9 - 1.2% (w / w)

[0623] Trehalose dihydrate 53.7 - 89.1% (w / w)

[0624] Tris 1.0 - 1.5% (w / w).

[0625] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 8.2% (w / w) of the CNP conjugate, about 1.2% (w / w) of succinic acid, about 89.1% (w / w) of trehalose dihydrate, and about 1.5% (w / w) of Tris.

[0626] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 8.2% (w / w) of the CNP conjugate, 1.2% (w / w) of succinic acid, 89.1% (w / w) of trehalose dihydrate, and 1.5% (w / w) of Tris.

[0627] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 10.7% (w / w) of the CNP conjugate, about 1.2% (w / w) of succinic acid, about 86.8% (w / w) of trehalose dihydrate, and about 1.3% (w / w) of Tris.

[0628] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 10.7% (w / w) of the CNP conjugate, 1.2% (w / w) of succinic acid, 86.8% (w / w) of trehalose dihydrate, and 1.3% (w / w) of Tris.

[0629] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 21.6% (w / w) of the CNP conjugate, about 1.1% (w / w) of succinic acid, about 76.1% (w / w) of trehalose dihydrate, and about 1.2% (w / w) of Tris.

[0630] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 21.6% (w / w) of the CNP conjugate, 1.1% (w / w) of succinic acid, 76.1% (w / w) of trehalose dihydrate, and 1.2% (w / w) of Tris.

[0631] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 32.4% (w / w) of the CNP conjugate, about 1.0% (w / w) of succinic acid, about 65.4% (w / w) of trehalose dihydrate, and about 1.2% (w / w) of Tris.

[0632] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 32.4% (w / w) of the CNP conjugate, 1.0% (w / w) of succinic acid, 65.4% (w / w) of trehalose dihydrate, and 1.2% (w / w) of Tris.

[0633] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 38.9% (w / w) of the CNP conjugate, about 0.9% (w / w) of succinic acid, about 59.2% (w / w) of trehalose dihydrate, and about 1% (w / w) of Tris.

[0634] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 38.9% (w / w) of the CNP conjugate, 0.9% (w / w) of succinic acid, 59.2% (w / w) of trehalose dihydrate, and 1% (w / w) of Tris.

[0635] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 41.5% (w / w) of the CNP conjugate, about 0.9% (w / w) of succinic acid, about 56.6% (w / w) of trehalose dihydrate, and about 1% (w / w) of Tris.

[0636] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 41.5% (w / w) of the CNP conjugate, 0.9% (w / w) of succinic acid, 56.6% (w / w) of trehalose dihydrate, and 1% (w / w) of Tris based on the total weight of the solid unit dosage form.

[0637] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises about 44.4% (w / w) of the CNP conjugate, about 0.9% (w / w) of succinic acid, about 53.7% (w / w) of trehalose dihydrate, and about 1% (w / w) of Tris.

[0638] In some embodiments, based on the total weight of the solid unit dosage form, the unit dosage form comprises 44.4% (w / w) of the CNP conjugate, 0.9% (w / w) of succinic acid, 53.7% (w / w) of trehalose dihydrate, and 1% (w / w) of Tris.

[0639] The Applicant surprisingly found that after administering a unit dosage form of a CNP conjugate, such as a compound of (IIf’) or formula (IIf) or compound (1), to a patient in need, the incidence of hypotension was less than 10%, preferably less than 8%, most preferably less than 5%, and even more preferably less than 3%. In some embodiments, after administering the unit dosage form of the present invention to a patient in need, the incidence of hypotension was less than 1%. In some embodiments, no hypotension occurred.

[0640] It was also surprisingly found that no treatment emergent anti-CNP antibodies were detected after treatment with a CNP conjugate (CNP conjugate such as a compound of (IIf’) or formula (IIf)). In some embodiments, no anti-CNP binding antibodies were detected after repeated weekly exposure to the conjugate of the present invention for 1 - 9 months. In some embodiments, no anti-CNP binding antibodies were detected after weekly repeated exposure to the conjugate of the present invention for 52 weeks.

[0641] In addition, it was surprisingly found that weekly administration of 100 μg CNP / kg (CNP conjugate, such as a compound of (IIf’) or formula (IIf) or a mixture) to pediatric patients aged 2 - 10 years (such as 2 - 5 years or such as 5 - 10 years) in need of CNP treatment elicited similar responses as measured by annualized growth rate.

[0642] In some embodiments, the CNP moiety of the CNP conjugate has the sequence of SEQ ID NO:9, SEQ ID NO:10, SEQ ID NO:11, SEQ ID NO:12, SEQ ID NO:13, SEQ ID NO:14, SEQ ID NO:15, SEQ ID NO:16, SEQ ID NO:17, SEQ ID NO:18, SEQ ID NO:19, SEQ ID NO:20, SEQ ID NO:21, SEQ ID NO:22, SEQ ID NO:23, SEQ ID NO:24, SEQ ID NO:25 or SEQ ID NO:30. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:20, SEQ ID NO:21, SEQ ID NO:22, SEQ ID NO:23, SEQ ID NO:24 or SEQ ID NO:25. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:20. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:21. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:22. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:23. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:24. In some embodiments, the CNP moiety has the sequence of SEQ ID NO:25.

[0643] Exemplary CNP Conjugates and CNP Prodrugs

[0644] In some embodiments, the CNP conjugate has formula (Ia) or (Ib):

[0645]

[0646] wherein

[0647] -D is the CNP moiety;

[0648] -L 1 - is a reversible linker moiety;

[0649] -L 2 - is a single chemical bond or a spacer moiety;

[0650] -Z is a polymeric moiety;

[0651] x is an integer selected from the group consisting of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16;

[0652] y is an integer selected from the group consisting of: 1, 2, 3, 4, and 5.

[0653] -D of formula (Ia) or (Ib) is covalently and reversibly conjugated to -L 1 -.

[0654] In some embodiments, x in formula (Ia) is an integer selected from the group consisting of: 1, 2, 3, 4, 6, and 8. In some embodiments, x in formula (Ia) is an integer selected from the group consisting of: 1, 2, 4, and 6. In some embodiments, x in formula (Ia) is an integer selected from the group consisting of: 1, 4, and 6, and in some embodiments, x in formula (Ia) is 1.

[0655] In some embodiments, y in formula (Ib) is an integer selected from the group consisting of: 2, 3, 4, and 5. In some embodiments, y in formula (Ib) is an integer selected from the group consisting of: 2, 3, and 4. In some embodiments, y in formula (Ib) is an integer selected from the group consisting of: 2 and 3. In some embodiments, y in formula (Ib) is an integer selected from the group consisting of: 1, 2, and 3. In some embodiments, y of formula (Ib) is 1. In some embodiments, y of formula (Ib) is 2.

[0656] In some embodiments, the CNP conjugate has formula (Ia) and x = 1.

[0657] In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:9, SEQ ID NO:10, SEQ ID NO:11, SEQ ID NO:12, SEQ ID NO:13, SEQ ID NO:14, SEQ ID NO:15, SEQ ID NO:16, SEQ ID NO:17, SEQ ID NO:18, SEQ ID NO:19, SEQ ID NO:20, SEQ ID NO:21, SEQ ID NO:22, SEQ ID NO:23, SEQ ID NO:24, SEQ ID NO:25, or SEQ ID NO:30. In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:20, SEQ ID NO:21, SEQ ID NO:22, SEQ ID NO:23, SEQ ID NO:24, or SEQ ID NO:25.

[0658] In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:20. In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:21. In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:22. In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:23. In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:24. In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:25.

[0659] In some embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:30, SEQ ID NO:98, SEQ ID NO:99 or SEQ ID NO:90.

[0660] The moiety -L in formula (Ia) or (Ib) 1 - is conjugated to a functional group on the side chain of an amino acid residue of -D, the N-terminal amine functional group or the C-terminal carboxyl functional group of -D or a nitrogen atom in the backbone polypeptide chain of -D. Attachment to the N-terminus or C-terminus can be direct through the respective amine or carboxyl functional group or indirect, where a spacer moiety is first conjugated to the spacer moiety -L 1 - conjugated amine or carboxyl functional group.

[0661] The moiety -L in formula (Ia) or (Ib) 1 - is a cleavable linker from which the drug (i.e., D-H) is released in free form, that is, -L 1 - is a cleavable linker. Suitable cleavable linkers are known in the art, such as the cleavable linker moieties disclosed in WO2005 / 099768 A2, WO 2006 / 136586 A2, WO 2011 / 089216 A1 and WO 2013 / 024053 A1, which are incorporated herein by reference.

[0662] In some embodiments, -L 1 - is a cleavable linker as described in WO 2011 / 012722 A1, WO 2011 / 089214 A1, WO 2011 / 089215 A1, WO 2013 / 024052 A1 and WO 2013 / 160340 A1, which are incorporated herein by reference.

[0663] The moiety -L 1- can be connected to -D by any type of bond as long as it is reversible. In some embodiments, -L 1 - is connected to -D by a bond selected from the group consisting of: amide, ester, carbamate, acetal, acetalamine, imine, oxime, hydrazone, disulfide, and acylguanidine. In some embodiments, -L 1 - is connected to -D by a bond selected from the group consisting of: amide, ester, carbamate, and acylguanidine. It should be understood that these bonds may not be reversible by themselves, but the ortho groups contained in -L 1 - may render the bond reversible.

[0664] In some embodiments, moiety -L 1 - is connected to -D by an amide bond.

[0665] Moiety -L 1 - is disclosed in WO 2009 / 095479 A2. Thus, in some embodiments, moiety -L 1 - has the formula (II):

[0666]

[0667] where the dashed line represents attachment to the nitrogen of -D as part of the CNP via formation of an amide bond;

[0668] -X- is -C(R 4 R 4a )-, -N(R 4 )-, -O-, -C(R 4 R 4a )-C(R 5 R 5a )-, -C(R 5 R 5a )-C(R 4 R 4a )-, -C(R 4 R 4a )-N(R 6 )-, -N(R 6 )-C(R 4 R 4a )-, -C(R 4 R 4a )-O-, -O-C(R 4 R 4a )- or -C(R 7 R 7a )-;

[0669] X 1 is C or S(O);

[0670] -X 2 is -C(R 8R 8a )- or -C(R 8 R 8a )-C(R 9 R 9a )-;

[0671] =X 3 is =O, =S or =N-CN;

[0672] -R 1 、-R 1a 、-R 2 、-R 2a 、-R 4 、-R 4a 、-R 5 、-R 5a 、-R 6 、-R 8 、-R 8a 、-R 9 、-R 9a are independently selected from the group: -H and C 1-6 alkyl;

[0673] -R 3 、-R 3a are independently selected from the group: -H and C 1-6 alkyl, provided that if --R 3 、-R 3a one or both of which is not -H, then they are attached to the N to which they are attached through sp 3 hybridized carbon atoms;

[0674] -R 7 is -N(R 10 R 10a ) or -NR 10 -(C=O)-R 11 ;

[0675] -R 7a 、-R 10 、-R 10a 、-R 11 are independently selected from the group: -H and C 1-6 alkyl;

[0676] Optionally, -R 1a / -R 4a 、-R 1a / -R 5a 、-R 1a / -R 7a 、-R 4a / -R 5a 、-R 8a / -R 9aOne or more of the pairs form a chemical bond;

[0677] Optionally, -R 1 / -R 1a 、-R 2 / -R 2a 、-R 4 / -R 4a 、-R 5 / -R 5a 、-R 8 / -R 8a 、-R 9 / -R 9a One or more of the pairs are attached to the atoms to which they are attached to form a C 3-10 cycloalkyl or 3- to 10-membered heterocyclic group;

[0678] Optionally, -R 1 / -R 4 、-R 1 / -R 5 、-R 1 / -R 6 、-R 1 / -R 7a 、-R 4 / -R 5 、-R 4 / -R 6 、-R 8 / -R 9 、-R 2 / -R 3 One or more of the pairs are attached to the atoms to which they are attached to form Ring A;

[0679] Optionally, -R 3 / -R 3a is attached to the nitrogen atom to which it is attached to form a 3- to 10-membered heterocycle;

[0680] A is selected from the group consisting of phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, and 8- to 11-membered heterobicyclic group; and

[0681] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - may optionally be further substituted, provided that the hydrogen atom marked with an asterisk in formula (II) is not replaced by -L 2 -Z or a substituent;

[0682] wherein

[0683] -L 2 - is a single chemical bond or a spacer; and

[0684] -Z is a water-soluble polymer moiety.

[0685] In some embodiments, -L in formula (II) 1 - is replaced by a moiety -L 2 -Z. In some embodiments, -L in formula (II) 1 - is not further substituted.

[0686] It should be understood that if -R 3 / -R 3a attached to the nitrogen atom to which they are attached forms a 3- to 10-membered heterocycle, then only a 3- to 10-membered heterocycle in which the atom directly attached to nitrogen is an sp 3 hybridized carbon atom can be formed. In other words, the 3- to 10-membered heterocycle formed by -R 3 / -R 3a together with the nitrogen atom to which they are attached has the following structure:

[0687]

[0688] where the dashed line represents attachment to the remainder of -L 1 -;

[0689] the ring contains 3 to 10 atoms including at least one nitrogen; and

[0690] R # and R ## represent sp 3 hybridized carbon atoms.

[0691] It should also be understood that the 3- to 10-membered heterocycle can be further substituted.

[0692] Exemplary instances of suitable 3- to 10-membered heterocycles formed by -R 3 / -R 3a in formula (II) together with the nitrogen atom to which they are attached are as follows:

[0693]

[0694] where the dashed line represents attachment to the remainder of the molecule; and

[0695] -R is selected from the group consisting of: -H and C 1-6 alkyl.

[0696] -L in formula (II) 1 - is optionally further substituted. Generally, any substituent can be used as long as it does not affect the cleavage principle, that is, the hydrogen marked with an asterisk in formula (II) is not substituted and

[0697]

[0698] The nitrogen in the moiety remains part of a primary, secondary, or tertiary amine, i.e., -R 3 and -R 3a are each independently -H or are attached to -N< via an sp 3 hybridized carbon atom.

[0699] In some embodiments, -R 1 or -R la in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 2 or -R 2a in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 3 or -R 3a in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 4 in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 5 or -R 5a in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 6 in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 7 or -R 7a in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 8 or -R 8a in formula (II) is replaced by -L 2 -Z. In some embodiments, -R 9 or -R 9a in formula (II) is replaced by -L 2 -Z.

[0700] In some embodiments, -R 4 in formula (II) is replaced by -L 2 -Z.

[0701] In some embodiments, -X- in formula (II) is -C(R 4 R 4a )- or -N(R 4 )-. In some embodiments, -X- in formula (II) is -C(R 4 R 4a )-.

[0702] In some embodiments, X of formula (II) 1 is C.

[0703] In some embodiments, ═X of formula (II) 3 is ═O.

[0704] In some embodiments, -X in formula (II) 2 - is -C(R 8 R 8a ).

[0705] In some embodiments, -R of formula (II) 8 and -R 8a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, at least one of -R 8 and -R 8a in formula (II) is -H. In some embodiments, both -R 8 and -R 8a in formula (II) are -H.

[0706] In some embodiments, -R of formula (II) 1 and -R 1a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, at least one of -R 1 and -R 1a in formula (II) is -H. In some embodiments, both -R 1 and -R 1a in formula (II) are -H.

[0707] In some embodiments, -R of formula (II) 2 and -R 2a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, at least one of -R 2 and -R 2a in formula (II) is -H. In some embodiments, both -R 2 and -R 2a in formula (II) are -H.

[0708] In some embodiments, -R of formula (II) 3 and -R 3a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, at least one of -R 3 and -R 3a in formula (II) is methyl. In some embodiments, at least one of -R 3 and -R 3aare both -H. In some embodiments, -R in formula (II) 3 and -R 3a are both methyl. In some embodiments, -R in formula (II) 3 is -H and -R in formula (II) 3a is methyl.

[0709] In some embodiments, -R of formula (II) 4 and -R 4a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, at least one of -R of formula (II) 4 and -R 4a is -H. In some embodiments, -R of formula (II) 4 and -R 4a are both -H.

[0710] In some embodiments, part of -L 1 - has formula (IIa):

[0711]

[0712] where the dashed line represents attachment to the nitrogen of -D as part of the CNP by forming an amide bond;

[0713] -R 1 、-R 1a 、-R 2 、-R 2a 、-R 3 、-R 3a 、-R 4 、-R 4a and -X 2 - are used as defined in formula (II); and where -L 1 - is replaced by -L 2 -Z, where -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIa) is not substituted by -L 2 -Z or a substituent.

[0714] In some embodiments, -L of formula (IIa) 1 - is replaced by a moiety -L 2 -Z. In some embodiments, the moiety -L of formula (IIa) 1 - is not further substituted.

[0715] In some embodiments, -R of formula (IIa) 1 and -R la are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIa)1 -R and la at least one of which is -H. In some embodiments, -R of formula (IIa) 1 and -R la are both -H.

[0716] In some embodiments, -R of formula (IIa) 4 and -R 4a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIa) 4 and -R 4a at least one of which is -H. In some embodiments, -R of formula (IIa) 4 and -R 4a are both -H.

[0717] In some embodiments, -X of formula (IIa) 2 - is -C(R 8 R 8a ).

[0718] In some embodiments, -R of formula (IIa) 8 and -R 8a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIa) 8 and -R 8a at least one of which is -H. In some embodiments, -R of formula (IIa) 8 and -R 8a are both -H.

[0719] In some embodiments, -R of formula (IIa) 2 and -R 2a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIa) 2 and -R 2a at least one of which is -H. In some embodiments, -R of formula (IIa) 2 and -R 2a are both -H.

[0720] In some embodiments, -R of formula (IIa) 3 and -R 3a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, -R in formula (IIa) 3 and -R 3a at least one of which is methyl. In some embodiments, -R in formula (IIa) 3 and -R 3a are both -H. In some embodiments, -R in formula (IIa)3 and -R 3a are both methyl. In some embodiments, -R in formula (IIa) 3 is -H and -R in formula (IIa) 3a is methyl.

[0721] In some embodiments, part of -L 1 - has formula (IIb):

[0722]

[0723] where the dashed line represents attachment to the nitrogen of -D which is part of the CNP via formation of an amide bond;

[0724] -R 2 、-R 2a 、-R 3 、-R 3a and -X 2 - are used as defined in formula (II); and

[0725] where -L 1 - is replaced by -L 2 -Z, where -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIb) is not substituted by -L 2 -Z or a substituent.

[0726] In some embodiments, -L of formula (IIb) 1 - is replaced by a moiety -L 2 -Z. In some embodiments, the moiety -L of formula (IIb) 1 - is not further substituted. In some embodiments, -X of formula (IIb) 2 - is -C(R 8 R 8a )-.

[0727] In some embodiments, -R of formula (IIb) 8 and -R 8a are independently selected from the group consisting of: -H, methyl and ethyl. In some embodiments, at least one of -R of formula (IIb) 8 and -R 8a is -H. In some embodiments, -R of formula (IIb) 8 and -R 8a are both -H.

[0728] In some embodiments, -R of formula (IIb) 2 and -R 2aIndependently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIb) 2 and -R 2a at least one of which is -H. In some embodiments, -R of formula (IIb) 2 and -R 2a are both -H.

[0729] In some embodiments, -R of formula (IIb) 3 and -R 3a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, -R in formula (IIb) 3 and -R 3a at least one of which is methyl. In some embodiments, -R in formula (IIb) 3 and -R 3a are both -H. In some embodiments, -R in formula (IIb) 3 and -R 3a are both methyl. In some embodiments, -R in formula (IIb) 3 is -H, and -R in formula (IIb) 3a is methyl.

[0730] In some embodiments, a portion of -L 1 - has formula (IIb’):

[0731]

[0732] wherein the dashed line represents attachment to the nitrogen of -D as part of the CNP by formation of an amide bond;

[0733] The dashed line marked with an asterisk represents attachment to -L 2 -;

[0734] -R 2 、-R 2a 、-R 3 、-R 3a and -X 2 - are used as defined in formula (II); and

[0735] wherein -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIb’) is not substituted by a substituent.

[0736] In some embodiments, the portion -L 1 - of formula (IIb’) is not further substituted.

[0737] In some embodiments, -X 2 - of formula (IIb’) is -C(R8 R 8a )-.

[0738] In some embodiments, -R of formula (IIb’) 8 and -R 8a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIb’) 8 and -R 8a at least one of which is -H. In some embodiments, -R of formula (IIb’) 8 and -R 8a are both -H.

[0739] In some embodiments, -R of formula (IIb’) 2 and -R 2a are independently selected from the group consisting of: -H, methyl, and ethyl. In some embodiments, -R of formula (IIb’) 2 and -R 2a at least one of which is -H. In some embodiments, -R of formula (IIb’) 2 and -R 2a are both -H.

[0740] In some embodiments, -R of formula (IIb’) 3 and -R 3a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, -R in formula (IIb’) 3 and -R 3a at least one of which is methyl. In some embodiments, -R in formula (IIb’) 3 and -R 3a are both -H. In some embodiments, -R in formula (IIb’) 3 and -R 3a are both methyl. In some embodiments, -R in formula (IIb’) 3 is -H, and -R in formula (IIb’) 3a is methyl.

[0741] In some embodiments, part of -L 1 - has formula (IIc):

[0742]

[0743] wherein the dashed line represents attachment to the nitrogen of -D as part of CNP by forming an amide bond; and

[0744] wherein -L 1 - is replaced by -L 2 -Z, wherein -L 1-Optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIc) is not substituted by -L 2 -Z or a substituent.

[0745] In some embodiments, -L of formula (IIc) 1 -is substituted by a moiety -L 2 -Z. In some embodiments, the moiety -L of formula (IIc) 1 -is not further substituted.

[0746] In some embodiments, the moiety -L 1 -is selected from the group consisting of formulae (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv) and (IIc-v):

[0747]

[0748]

[0749] wherein the unmarked dashed line represents attachment to the nitrogen of -D as the CNP moiety by formation of an amide bond; and

[0750] the dashed line marked with an asterisk represents attachment to -L 2 -Z; and

[0751] wherein -L 1 -is optionally further substituted, provided that the hydrogen marked with an asterisk in formulae (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv) and (IIc-v) is not substituted by a substituent.

[0752] In some embodiments, the moiety -L of (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv) and (IIc-v) 1 -is not further substituted.

[0753] In some embodiments, the moiety -L 1 -has the formula (IIc-ii):

[0754]

[0755] wherein the unmarked dashed line represents attachment to the nitrogen of -D as the CNP moiety by formation of an amide bond; and

[0756] the dashed line marked with an asterisk represents attachment to -L 2 -Z.

[0757] In some embodiments, -L of formula (IIc-ii) 1 -is substituted by a moiety -L2 -substituted with -Z.

[0758] -L of formula (II), (IIa), (IIb), (IIb’), (IIc), (IIc-a), (IIc-b), (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv), (IIc-v) 1 -Optional further substituents of - are in some of the embodiments described above.

[0759] Another part -L 1 -is disclosed in WO 2016 / 020373 A1. Thus, in some embodiments, part -L 1 -has formula (III):

[0760]

[0761] wherein

[0762] The dotted line represents attachment to a primary or secondary amine or hydroxyl group of -D as the CNP moiety through the formation of an amide bond or an ester bond, respectively;

[0763] -R 1 ,-R la ,-R 2 ,-R 2a ,-R 3 and -R 3a are each independently selected from the group consisting of: -H, -C(R 8 R 8a R 8b ), -C(=O)R 8 , -C≡N, -C(=NR 8 )R 8a , -CR 8 (=CR 8a R 8b ), -C≡CR 8 and -T;

[0764] -R 4 , -R 5 and -R 5a are each independently selected from the group consisting of: -H, -C(R 9 R 9a R 9b ) and -T;

[0765] al and a2 are each independently 0 or 1:

[0766] Each -R 6 , -R 6a , -R 7 , -R 7a , -R8 , -R 8a , -R 8b , -R 9 , -R 9a , -R 9b Each independently selected from the following group: -H, halogen, -CN, -COOR 10 , -OR 10 , -C(O)R 10 , -C(O)N(R 10 R 10a ), -S(O)2N(R 10 R 10a ), -S(O)N(R 10 R 10a ), -S(O)2R 10 , -S(O)R 10 , -N(R 10 ), S(O)2N(R 10a R 10b ), -SR 10 , -N(R 10 R 10a ), -NO2, -OC(O)R 10 , -N(R 10 ), C(O)R 10a , -N(R 10 ), S(O)2R 10a , -N(R 10 ), S(O)R 10a , -N(R 10 ), C(O)OR 10a , -N(R 10 ), C(O)N(R 10a R 10b ), -OC(O)N(R 10 R 10a ), -T, C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl; wherein -T, C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl may optionally be substituted by one or more identical or different -R 11 , and wherein C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl may optionally be interrupted by one or more groups selected from the following group: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 12 ), -S(O)2N(R 12 ), -S(O)N(R 12)-, -S(O)2-, -S(O)-, -N(R 12 )S(O)2N(R 12a )-, -S-, -N(R 12 )-, -OC(OR 12 )(R 12a )-, -N(R 12 )C(O)N(R 12a )- and -OC(O)N(R 12 )-;

[0767] Each -R 10 , -R 10a , -R 10b is independently selected from the group consisting of: -H, -T, C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl; wherein -T, C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl are optionally substituted by one or more identical or different -R 11 substituents, and wherein C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 12 )-, -S(O)2N(R 12 )-, -S(O)N(R 12 )-, -S(O)2-, -S(O)-, -N(R 12 )S(O)2N(R 12a )-, -S-, -N(R 12 )-, -OC(OR 12 )(R 12a )-, -N(R 12 )C(O)N(R 12a )- and -OC(O)N(R 12 )-;

[0768] Each T is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, and 8- to 11-membered heterobicyclic group; wherein each T is independently optionally substituted by one or more identical or different -R 11 substituents;

[0769] Each -R 11 is independently selected from: halogen, -CN, oxo (=O), -COOR 13 , -OR13 , -C(O)R 13 , -C(O)N(R 13 R 13a ), -S(O)2N(R 13 R 13a ), -S(O)N(R 13 R 13a ), -S(O)2R 13 , -S(O)R 13 , -N(R 13 )S(O)2N(R 13a R 13b ), -SR 13 , -N(R 13 R 13a ), -NO2, -OC(O)R 13 , -N(R 13 )C(O)R 13a , -N(R 13 )S(O)2R 13a , -N(R 13 )S(O)R 13a , -N(R 13 )C(O)OR 13a , -N(R 13 )C(O)N(R 13a R 13b ), -OC(O)N(R 13 R 13a ) and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted with one or more identical or different halogens;

[0770] Each -R 12 , -R 12a , -R 13 , -R 13a , -R 13b is independently selected from the group consisting of: -H and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted with one or more identical or different halogens;

[0771] Optionally, one or more of -R 1 / -R 1a , -R 2 / -R 2a , -R 3 / -R 3a , -R 6 / -R 6a , -R 7 / -R 7a pairs are attached to the atoms to which they are attached to form C3-10 a cycloalkyl group or a 3- to 10-membered heterocyclic group;

[0772] Optionally, -R 1 / -R 2 、-R 1 / -R 3 、-R 1 / -R 4 、-R 1 / -R 5 、-R 1 / -R 6 、-R 1 / -R 7 、-R 2 / -R 3 、-R 2 / -R 4 、-R 2 / -R 5 、-R 2 / -R 6 、-R 2 / -R 7 、-R 3 / -R 4 、-R 3 / -R 5 、-R 3 / -R 6 、-R 3 / -R 7 、-R 4 / -R 5 、-R 4 / -R 6 、-R 4 / -R 7 、-R 5 / -R 6 、-R 5 / -R 7 、-R 6 / -R 7 one or more pairs of which are attached to the atoms to which they are attached to form ring A;

[0773] A is selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, and 8- to 11-membered hetero-bicyclic group;

[0774] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - may be further substituted;

[0775] wherein

[0776] -L 2- is a single chemical bond or a spacer; and

[0777] - Z is a water-soluble polymer moiety.

[0778] - L of formula (III) 1 - Optional further substituents are in some embodiments as described above. In some embodiments, - L of formula (III) 1 - is substituted by a moiety - L 2 - Z. In some embodiments, - L of formula (III) 1 - is not further substituted.

[0779] - L 1 - Other examples are disclosed in EP1536334B1, WO2009 / 009712A1, WO2008 / 034122A1, WO2009 / 143412A2, WO2011 / 082368A2 and US8618124B2, which are incorporated herein by reference in their entirety.

[0780] Other examples of - L are disclosed in US8946405B2 and US8754190B2, which are incorporated herein by reference in their entirety. Thus, the moiety - L 1 - has formula (IV): 1 - has formula (IV):

[0781]

[0782] wherein

[0783] The dashed line represents attachment to - D as the CNP moiety, wherein the attachment is via a functional group of - D selected from the group consisting of: - OH, - SH and - NH2;

[0784] m is 0 or 1;

[0785] - R 1 and - R 2 at least one or both of which are independently selected from the group consisting of: - CN, - NO2, optionally substituted aryl, optionally substituted heteroaryl, optionally substituted alkenyl, optionally substituted alkynyl, - C(O)R 3 - S(O)R 3 - S(O)2R 3 and - SR 4 - R 1 and - R 2 One and only one of which is selected from the group consisting of: - H, optionally substituted alkyl, optionally substituted aralkyl and optionally substituted heteroaralkyl;

[0786] - R 3Selected from the group consisting of: -H, optionally substituted alkyl, optionally substituted aryl, optionally substituted aralkyl, optionally substituted heteroaryl, optionally substituted heteroaralkyl, -OR 9 and -N(R 9 )2;

[0787] -R 4 is selected from the group consisting of: optionally substituted alkyl, optionally substituted aryl, optionally substituted aralkyl, optionally substituted heteroaryl and optionally substituted heteroaralkyl;

[0788] Each -R 5 is independently selected from the group consisting of: -H, optionally substituted alkyl, optionally substituted alkenylalkyl, optionally substituted alkynylalkyl, optionally substituted aryl, optionally substituted aralkyl, optionally substituted heteroaryl and optionally substituted heteroaralkyl;

[0789] -R 9 is selected from the group consisting of: -H and optionally substituted alkyl;

[0790] -Y- is absent and -X- is -O- or -S-; or

[0791] -Y- is -N(Q)CH2- and -X- is -O-;

[0792] Q is selected from the group consisting of: optionally substituted alkyl, optionally substituted aryl, optionally substituted aralkyl, optionally substituted heteroaryl and optionally substituted heteroaralkyl;

[0793] Optionally, -R 1 and -R 2 can be joined together to form a 3- to 8-membered ring; and

[0794] Optionally, -R 9 and the nitrogen to which it is attached form a heterocycle;

[0795] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - is optionally further substituted;

[0796] wherein

[0797] -L 2 - is a single chemical bond or a spacer; and

[0798] -Z is a water-soluble polymeric moiety.

[0799] The optional further substituent of -L 1 - of formula (IV) is in some embodiments as described above. In some embodiments, -L 1 - of formula (IV) is replaced by a moiety -L 2-substituted with -Z. In some embodiments, -L of formula (IV) 1 - is not further substituted.

[0800] The terms used only in the context of formula (IV) have the following meanings:

[0801] As used herein, the term "alkyl" includes straight-chain, branched-chain, or cyclic saturated hydrocarbon groups having 1-8 carbon atoms, or in some embodiments, straight-chain, branched-chain, or cyclic saturated hydrocarbon groups having 1-6 or 1-4 carbon atoms.

[0802] The term "alkoxy" includes an alkyl group bonded to oxygen, including methoxy, ethoxy, isopropoxy, cyclopropoxy, cyclobutoxy, and similar groups.

[0803] The term "alkenyl" includes non-aromatic unsaturated hydrocarbons having a carbon-carbon double bond.

[0804] The term "alkynyl" includes non-aromatic unsaturated hydrocarbons having a carbon-carbon triple bond.

[0805] The term "aryl" includes aromatic hydrocarbon groups having 6-18 carbon atoms (in some embodiments, 6-10 carbon atoms), including groups such as phenyl, naphthyl, and anthracenyl. The term "heteroaryl" includes aromatic rings containing 3-15 carbon atoms and containing at least one N, O, or S atom (in some embodiments, aromatic rings containing 3-7 carbon atoms and containing at least one N, O, or S atom), including groups such as pyrrolyl, pyridyl, pyrimidinyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, quinolinyl, indolyl, indenyl, and similar groups.

[0806] In some embodiments, an alkenyl, alkynyl, aryl, or heteroaryl moiety may be coupled to the remainder of the molecule via an alkylene bond. In these cases, the substituent will be referred to as alkenylalkyl, alkynylalkyl, arylalkyl, or heteroarylalkyl, indicating that the alkylene moiety is located between the alkenyl, alkynyl, aryl, or heteroaryl moiety and the molecule to which the alkenyl, alkynyl, aryl, or heteroaryl is coupled.

[0807] The term "halogen" includes bromine, fluorine, chlorine, and iodine.

[0808] The term "heterocycle" refers to a 4-8 membered aromatic or non-aromatic ring containing 3-7 carbon atoms and at least one N, O, or S atom. Examples are piperidinyl, piperazinyl, tetrahydropyranyl, pyrrolidine, and tetrahydrofuranyl, as well as the exemplary groups provided above for the term "heteroaryl".

[0809] When the ring system is optionally substituted, suitable substituents are selected from the group consisting of: alkyl, alkenyl, alkynyl or another ring, each substituent being optionally further substituted. Optional substituents on any group (including the above groups) include halogen, nitro, cyano, -OR, -SR, -NR2, -OCOR, -NRCOR, -COOR, -CONR2, -SOR, -SO2R, -SONR2, -SO2NR2, where each R is independently alkyl, alkenyl, alkynyl, aryl or heteroaryl, or two R groups together with the atoms to which they are attached form a ring.

[0810] Additional examples of -L are disclosed in WO2013 / 036857A1 1 - and are incorporated herein by reference in their entirety. Thus, in some embodiments, the moiety -L 1 - has formula (V):

[0811]

[0812] wherein

[0813] the dashed line represents attachment to -D which is part of the CNP, wherein the attachment is through the amine functionality of -D:

[0814] -R 1 is selected from the group consisting of: optionally substituted C1-C6 straight-chain, branched-chain or cyclic alkyl, optionally substituted aryl, optionally substituted heteroaryl, alkoxy and -NR 5 2;

[0815] -R 2 is selected from the group consisting of: -H, optionally substituted C1-C6 alkyl, optionally substituted aryl and optionally substituted heteroaryl;

[0816] -R 3 is selected from the group consisting of: -H, optionally substituted C1-C6 alkyl, optionally substituted aryl and optionally substituted heteroaryl;

[0817] -R 4 is selected from the group consisting of: -H, optionally substituted C1-C6 alkyl, optionally substituted aryl and optionally substituted heteroaryl;

[0818] each -R 5 is independently selected from the group consisting of: -H, optionally substituted C1-C6 alkyl, optionally substituted aryl and optionally substituted heteroaryl; or when two -R 5 are taken together, can be cycloalkyl or cycloheteroalkyl;

[0819] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - is optionally further substituted;

[0820] wherein

[0821] -L 2 - is a single chemical bond or a spacer; and

[0822] -Z is a water-soluble polymeric moiety.

[0823] In some embodiments, -L of formula (V) 1 - optional further substituents are as described above.

[0824] In some embodiments, -L in formula (V) 1 - is replaced by a moiety -L 2 -Z.

[0825] In some embodiments, -L of formula (V) 1 - is not further substituted.

[0826] The terms used only in the case of formula (V) have the following meanings:

[0827] "Alkyl", "alkenyl" and "alkynyl" include straight-chain, branched-chain or cyclo-hydrocarbon groups having 1-8 carbons or 1-6 carbons or 1-4 carbons, wherein alkyl is a saturated hydrocarbon, alkenyl contains one or more carbon-carbon double bonds, and alkynyl contains one or more carbon-carbon triple bonds. Unless otherwise specified, these contain 1-6C.

[0828] "Aryl" includes aromatic hydrocarbon groups having 6-18 carbons (6-10 carbons in some embodiments), including groups such as phenyl, naphthyl and anthracene. "Heteroaryl" includes aromatic rings containing 3-15 carbons and containing at least one N, O or S atom (3-7 carbon atoms and containing at least one N, O or S atom in some embodiments), including groups such as pyrrolyl, pyridyl, pyrimidinyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, quinolinyl, indolyl, indenyl and the like.

[0829] The term "substituted" refers to an alkyl, alkenyl, alkynyl, aryl or heteroaryl group that contains one or more substituents in place of one or more hydrogen atoms. Substituents are typically selected from: halogens including F, Cl, Br and I, lower alkyls including straight-chain, branched-chain and cyclic alkyls, lower haloalkyls including fluoroalkyl, chloroalkyl, bromoalkyl and iodoalkyl, hydroxy, lower alkoxys including straight-chain, branched-chain and cyclic ones, SH, lower alkylthios including straight-chain, branched-chain and cyclic ones, amino, alkylamino, dialkylamino, silyls including alkylsilyl, alkoxysilyl and arylsilyl, nitro, cyano, carbonyl, carboxylic acid, carboxylic ester, carboxamide, carbamoyl, amido, carbamate, urea, thiocarbamate, thiourea, ketone, sulfone, sulfonamide, aryls including phenyl, naphthyl and anthracenyl, heteroaryls including 5-membered heteroaryls (including, for example, pyrrole, imidazole, furan, thiophene, oxazole, thiazole, isoxazole, isothiazole, thiadiazole, triazole, oxadiazole and tetrazole), 6-membered heteroaryl compounds (including pyridine, pyrimidine, pyrazine) and fused heteroaryls (including benzofuran, benzothiophene, benzoxazole, benzimidazole, indole, benzothiazole, benzisoxazole and benzisothiazole).

[0830] Another instance of -L is disclosed in WO 2022 / 115563 Al, which is hereby incorporated by reference in its entirety. Thus, in some embodiments, -L 1 - has the formula (Va): 1 - has the formula (Va):

[0831]

[0832] where the dotted line marked with an asterisk represents attachment to -L 2 -Z, and the unmarked dotted line represents attachment to -D.

[0833] In some embodiments, -L 1 - has the formula (Va), the dotted line marked with an asterisk represents attachment to -L 2 -Z, and the unmarked dotted line represents attachment to -D, where -D is the CNP portion of the following amino acid sequence:

[0834] SEQ ID NO:97 (CNP-38N6Q,N14Q):

[0835] LQEHPQARKYKGAQKKGLSKGCFGLKLDRIGSMSGLGC,

[0836] where the cysteines at positions 22 and 38 are linked by a disulfide bond; and

[0837] where the attachment to -L 1 - occurs at the N-terminus or on the loop of the peptide.

[0838] Another instance of -L is disclosed in US7585837B2, which is incorporated herein by reference in its entirety. Thus, in some embodiments, part of -L 1 - has the formula (VI): 1 - has the formula (VI):

[0839]

[0840] wherein the dashed line represents attachment to -D as part of the CNP, and wherein the attachment is through an amine functional group of -D;

[0841] R 1 and R 2 are independently selected from the group consisting of hydrogen, alkyl, alkoxy, alkoxyalkyl, aryl, alkaryl, aralkyl, halogen, nitro, -SO3H, -SO2NHR 5 , amino, ammonium, carboxyl, PO3H2, and OPO3H2;

[0842] R 3 , R 4 and R 5 are independently selected from the group consisting of hydrogen, alkyl, and aryl;

[0843] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - is optionally further substituted;

[0844] wherein

[0845] -L 2 - is a single chemical bond or a spacer; and

[0846] -Z is a water-soluble polymer moiety.

[0847] Suitable substituents for formula (VI) are alkyl (such as C 1-6 alkyl), alkenyl (such as C 2-6 alkenyl), alkynyl (such as C 2-6 alkynyl), aryl (such as phenyl), heteroalkyl, heteroalkenyl, heteroalkynyl, heteroaryl (such as an aromatic 4-7 membered heterocycle), or a halogen moiety.

[0848] In some embodiments, -L 1 - of formula (VI) is replaced by a moiety -L 2 -Z. The optional further substituents of -L 1 - of formula (VI) are in some embodiments as described above.

[0849] In some embodiments, -L 1 - of formula (VI) is not further substituted.

[0850] The terms used only in the case of formula (VI) have the following meanings:

[0851] The terms "alkyl", "alkoxy", "alkoxyalkyl", "aryl", "alkaryl" and "aralkyl" refer to alkyl groups having 1 - 8 carbon atoms (1 - 4 carbon atoms in some embodiments), such as methyl, ethyl, propyl, isopropyl and butyl, and aryl groups having 6 - 10 carbon atoms, such as phenyl and naphthyl. The term "halogen" includes bromine, fluorine, chlorine and iodine.

[0852] Another example of -L is disclosed in WO2002 / 089789A1, which is incorporated herein by reference in its entirety. Thus, the moiety -L 1 - has the formula (VII): 1 - has the formula (VII):

[0853]

[0854] wherein

[0855] the dashed line represents attachment to -D which is part of the CNP, and wherein the attachment is through the amine functionality of -D;

[0856] L1 is a bifunctional linking group;

[0857] Y1 and Y2 are independently O, S or NR 7 ;

[0858] R 2 、R 3 、R 4 、R 5 、R 6 and R 7 are independently selected from the group consisting of: hydrogen, C 1-6 alkyl, C 3-12 branched alkyl, C 3-8 cycloalkyl, C 1-6 substituted alkyl, C 3-8 substituted cycloalkyl, aryl, substituted aryl, aralkyl, C 1-6 heteroalkyl, substituted C 1-6 heteroalkyl, C 1-6 alkoxy, phenoxy and C 1-6 heteroalkoxy;

[0859] Ar is a moiety which forms a polysubstituted aromatic hydrocarbon or a polysubstituted heterocyclic group when incorporated in formula (VII);

[0860] X is a chemical bond or a moiety that is actively transported into the target cell, a hydrophobic moiety or a combination thereof,

[0861] Y is 0 or 1;

[0862] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - is optionally further substituted;

[0863] wherein

[0864] -L 2 - is a single chemical bond or a spacer; and

[0865] -Z is a water-soluble polymeric moiety.

[0866] In some embodiments, -L of formula (VII) 1 - is replaced by a moiety -L 2 -Z. The optional further substituents of -L of formula (VII) 1 - are in some embodiments as described above.

[0867] In some embodiments, -L of formula (VII) 1 - is not further substituted.

[0868] The terms used only in the context of formula (VII) have the following meanings:

[0869] The term "alkyl" should be understood to include, for example, straight-chain, branched-chain, substituted C 1-12 alkyl, including alkoxy, C 3-8 cycloalkyl or substituted cycloalkyl, etc.

[0870] The term "substituted" should be understood to include adding or replacing one or more atoms contained in a functional group or a compound with one or more different atoms.

[0871] Substituted alkyl includes carboxyalkyl, aminoalkyl, dialkylamino, hydroxyalkyl and mercaptoalkyl; substituted cycloalkyl includes moieties such as 4-chlorocyclohexyl; aryl includes moieties such as naphthyl; substituted aryl includes moieties such as 3-bromophenyl; aralkyl includes moieties such as toluoyl; heteroalkyl includes moieties such as ethylthiophene; substituted heteroalkyl includes moieties such as 3-methoxythiophene; alkoxy includes moieties such as methoxy; phenoxy includes moieties such as 3-nitrophenoxy. Halogen should be understood to include fluorine, chlorine, iodine and bromine.

[0872] In some embodiments, -L 1 - includes a substructure of formula (VIII):

[0873]

[0874] wherein

[0875] The dotted line marked with an asterisk indicates attachment to the nitrogen of -D as part of the CNP by formation of an amide bond; the unmarked dotted line indicates attachment to the remainder of -L 1 -; and

[0876] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - is optionally further substituted;

[0877] wherein

[0878] -L 2 - is a single chemical bond or a spacer; and

[0879] -Z is a water-soluble polymeric moiety.

[0880] In some embodiments, -L of formula (VIII) 1 - is replaced by a moiety -L 2 -Z. -L of formula (VIII) 1 - is optionally further substituted in some embodiments as described above.

[0881] In some embodiments, -L of formula (VIII) 1 - is not further substituted.

[0882] In some embodiments, -L1- comprises a substructure of formula (IX):

[0883]

[0884] wherein

[0885] The dotted line marked with an asterisk indicates attachment to the nitrogen of -D as part of the CNP by formation of a carbamate bond;

[0886] The unmarked dotted line indicates attachment to the remainder of -L 1 -; and

[0887] wherein -L 1 - is replaced by -L 2 -Z, and wherein -L 1 - is optionally further substituted;

[0888] wherein

[0889] -L 2 - is a single chemical bond or a spacer; and

[0890] -Z is a water-soluble polymeric moiety.

[0891] -L of formula (IX) 1-Optional further substituents are as described above. In some embodiments, -L of formula (IX) 1 -is replaced by a moiety -L 2 -Z. In some embodiments, -L of formula (IX) 1 -is not further substituted.

[0892] Moiety -D can be attached to -L 1 -through any functional group of D-H, and is attached to -L 1 -through the amine functional group of D-H. This can be the N-terminal amine functional group or the amine functional group provided by the lysine side chain, that is, if the CNP has the sequence of SEQ ID NO:24, it is provided by lysines at positions 9, 11, 15, 16, 20, and 26.

[0893] Attachment of -L 1 -to the ring of the CNP moiety significantly reduces the affinity of the CNP conjugate for NPR-B compared to attachment at the N-terminus or to the acyclic part of the CNP, and the reduction in the affinity for NPR-B in turn reduces the risk of cardiovascular side effects such as hypotension.

[0894] Thus, in some embodiments, -L 1 -is conjugated to the side chain of the amino acid residue of the ring moiety of said -D or to the backbone of the ring moiety of said -D. In some embodiments, -L 1 -is covalently and reversibly conjugated to the side chain of the amino acid residue of the ring moiety of said -D. If -D is the CNP moiety having the sequence of SEQ ID NO:24, then in some embodiments, -L 1 -is conjugated to the amine functional group provided by the lysine at position 26 of the corresponding drug D-H.

[0895] Moiety -L 2 -is a chemical bond or a spacer moiety. In some embodiments, -L 2 -is a chemical bond. In some embodiments, -L 2 -is a spacer moiety.

[0896] Moiety -L 2 -can be attached to -L 1 -by replacing any -H present, unless explicitly excluded.

[0897] When -L 2 -is not a single chemical bond, -L 2 -is selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y1 )-, -S(O)2N(R y1 )-, -S(O)N(Ry1 )-, -S(O)2-, -S(O)-, -N(R y1 )S(O)2N(R y1a )-, -S-, -N(R y1 )-, -OC(OR y1 )(R y1a )-, -N(R y1 )C(O)N(R y1a )-, -OC(O)N(R y1 )-, C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl; wherein -T-, C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally substituted by one or more identical or different -R y2 substituents, and wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y3 )-, -S(O)2N(R y3 )-, -S(O)N(R y3 )-, -S(O)2-, -S(O)-, -N(R y3 )S(O)2N(R y3a )-, -S-, -N(R y3 )-, -OC(OR y3 )(R y3a )-, -N(R y3 )C(O)N(R y3a )- and -OC(O)N(R y3 )-;

[0898] -R yl and -R yla are each independently selected from the group consisting of: -H, -T, C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl; wherein -T, C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally substituted by one or more identical or different -R y2 substituents, and wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50The alkynyl group is optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y4 ), -, -S(O)2N(R y4 ), -, -S(O)N(R y4 ), -, -S(O)2-, -S(O)-, -N(R y4 )S(O)2N(R y4a ), -, -S-, -N(R y4 ), -, -OC(OR y4 )(R y4a ), -, -N(R y4 )C(O)N(R y4a ), - and -OC(O)N(R y4 );

[0899] Each T is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, 8- to 30-membered carbopolycyclic group, and 8- to 30-membered heteropolycyclic group; wherein each T is independently optionally substituted by one or more identical or different -R y2 substituents;

[0900] Each -R y2 is independently selected from the group consisting of: halogen, -CN, oxo (=O), -COOR y5 , -OR y5 , -C(O)R y5 , -C(O)N(R y5 R y5a ), -S(O)2N(R y5 R y5a ), -S(O)N(R y5 R y5a ), -S(O)2R y5 , -S(O)R y5 , -N(R y5 )S(O)2N(R y5a R y5b ), -SR y5 , -N(R y5 R y5a ), -NO2, -OC(O)R y5 , -N(R y5 )C(O)R y5a , -N(R y5 )S(O)2R y5a , -N(R y5 )S(O)R y5a , -N(R y5 )C(O)ORy5a , -N(R y5 )C(O)N(R y5a R y5b ), -OC(O)N(R y5 R y5a ) and C 1-6 alkyl; wherein the C 1-6 alkyl is optionally substituted by one or more identical or different halogens; each -R y3 , -R y3a , -R y4 , -R y4a , -R y5 , -R y5a and -R y5b is independently selected from the group consisting of: -H and C 1-6 alkyl, wherein the C 1-6 alkyl is optionally substituted by one or more identical or different halogens.

[0901] When -L 2 - is not a single chemical bond, -L 2 - is selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y1 ), -S(O)2N(R y1 ), -S(O)N(R y1 ), -S(O)2-, -S(O)-, -N(R y1 )S(O)2N(R y1a ), -S-, -N(R y1 ), -OC(OR y1 )(R y1a ), -N(R y1 )C(O)N(R y1a ), -OC(O)N(R y1 ), C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl; wherein -T-, C 1-20 alkyl, C 2-20 alkenyl and C 2-20 alkynyl are optionally substituted by one or more identical or different -R y2 s, and wherein the C 1-20 alkyl, C 2-20 alkenyl and C 2-50 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y3 ), -S(O)2N(R y3 ), -S(O)N(R y3)-, -S(O)2-, -S(O)-, -N(R y3 )S(O)2N(R y3a )-, -S-, -N(R y3 )-, -OC(OR y3 )(R y3a )-, -N(R y3 )C(O)N(R y3a )- and -OC(O)N(R y3 )-;

[0902] -R yl and -R yla are each independently selected from the group consisting of: -H, -T, C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl; wherein -T, C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl are optionally substituted with one or more identical or different -R y2 substituents, and wherein C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y4 )-, -S(O)2N(R y4 )-, -S(O)N(R y4 )-, -S(O)2-, -S(O)-, -N(R y4 )S(O)2N(R y4a )-, -S-, -N(R y4 )-, -OC(OR y4 )(R y4a )-, -N(R y4 )C(O)N(R y4a )- and -OC(O)N(R y4 )-;

[0903] Each T is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, 8- to 30-membered carbopolycyclic group, and 8- to 30-membered heteropolycyclic group; wherein each T is independently optionally substituted with one or more identical or different -R y2 substituents;

[0904] -R y2 is independently selected from the group consisting of: halogen, -CN, oxo (=O), -COOR y5 -, -ORy5 、 -C(O)R y5 、 -C(O)N(R y5 R y5a ), -S(O)2N(R y5 R y5a ), -S(O)N(R y5 R y5a ), -S(O)2R y5 、 -S(O)R y5 、 -N(R y5 )S(O)2N(R y5a R y5b ), -SR y5 、 -N(R y5 R y5a ), -NO2, -OC(O)R y5 、 -N(R y5 )C(O)R y5a 、 -N(R y5 )S(O)2R y5a 、 -N(R y5 )S(O)R y5a 、 -N(R y5 )C(O)OR y5a 、 -N(R y5 )C(O)N(R y5a R y5b ), -OC(O)N(R y5 R y5a ) and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted by one or more identical or different halogens; and

[0905] each -R y3 、 -R y3a 、 -R y4 、 -R y4a 、 -R y5 、 -R y5a and -R y5b is independently selected from the group consisting of: -H and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted by one or more identical or different halogens.

[0906] When -L 2 - is not a single chemical bond, -L 2 - is selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y1 ), -S(O)2N(R y1 ), -S(O)N(R y1)-, -S(O)2-, -S(O)-, -N(R y1 )S(O)2N(R y1a )-, -S-, -N(R y1 )-, -OC(OR y1 )(R y1a )-, -N(R y1 )C(O)N(R y1a )-, -OC(O)N(R y1 )-, C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl; wherein -T-, C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally substituted by one or more identical or different -R y2 substituents, and wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y3 )-, -S(O)2N(R y3 )-, -S(O)N(R y3 )-, -S(O)2-, -S(O)-, -N(R y3 )S(O)2N(R y3a )-, -S-, -N(R y3 )-, -OC(OR y3 )(R y3a )-, -N(R y3 )C(O)N(R y3a )- and -OC(O)N(R y3 )-;

[0907] -R yl and -R yla are independently selected from the group consisting of: -H, -T, C 1-10 alkyl, C 2-10 alkenyl and C 2-10 alkynyl;

[0908] Each T is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3-10 membered heterocyclic group, 8-11 membered heterobicyclic group, 8-30 membered carbopolycyclic group and 8-30 membered heteropolycyclic group;

[0909] Each -R y2 is independently selected from the group consisting of: halogen and C 1-6 alkyl; and

[0910] Each -R y3 、-R y3a 、-R y4 、-R y4a 、-R y5 、-R y5a and -R y5b are independently selected from the group consisting of: -H and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted by one or more identical or different halogens.

[0911] In some embodiments, -L 2 - is a C 1-20 alkyl chain which is optionally interrupted by one or more groups independently selected from the group consisting of: -O-, -T- and -C(O)N(R y1 )-; and C 1-20 alkyl chain is optionally substituted by one or more groups independently selected from the group consisting of: -OH, -T and -C(O)N(R y6 R y6a );wherein, -R yl 、-R y6 、-R y6a are independently selected from the group consisting of: H and C 1-4 alkyl, and wherein T is selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, 8- to 30-membered carbopolycyclic group, and 8- to 30-membered heteropolycyclic group.

[0912] In some embodiments, the molecular weight of -L 2 - ranges from 14 g / mol to 750 g / mol.

[0913] In some embodiments, the chain length of -L 2 - is 1 to 20 atoms.

[0914] As used herein, the term "chain length" with respect to moiety -L 2 - refers to the number of atoms in -L 1 - present in the shortest connection between -L 2 - and -Z.

[0915] In some embodiments, -L 2 - has formula (i):

[0916]

[0917] wherein

[0918] The dotted line marked with an asterisk indicates attachment to -L 1 -.

[0919] An unmarked dashed line indicates attachment to -Z;

[0920] -R 1 Selected from the group consisting of: -H, C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl;

[0921] n is selected from the group consisting of: 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18; and

[0922] wherein the moiety of formula (i) is optionally further substituted.

[0923] In some embodiments, -R of formula (i) 1 is selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, -R of formula (i) 1 is selected from the group consisting of: -H, methyl, ethyl, and propyl. In some embodiments, -R of formula (i) 1 is selected from the group consisting of: -H and methyl. In some embodiments, -R of formula (i) 1 is methyl.

[0924] In some embodiments, n of formula (i) is selected from the group consisting of: 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. In some embodiments, n of formula (i) is selected from the group consisting of: 0, 1, 2, 3, 4, and 5. In some embodiments, n of formula (i) is selected from the group consisting of: 0, 1, 2, and 3. In some embodiments, n of formula (i) is selected from the group consisting of: 0 and 1. In some embodiments, n of formula (i) is 0.

[0925] In some embodiments, -L 2 - is a moiety selected from the group consisting of:

[0926]

[0927]

[0928] wherein

[0929] A dashed line marked with an asterisk indicates attachment to -L 1 -:

[0930] An unmarked dashed line indicates attachment to -Z, and

[0931] Part (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi) and (xvii) may optionally be further substituted.

[0932] In some embodiments, -L 2 - is selected from the group consisting of:

[0933]

[0934] wherein

[0935] the dotted line marked with an asterisk represents attachment to -L 1 - attachment:

[0936] The unmarked dotted line represents attachment to -Z.

[0937] In some embodiments, -L 2 - is selected from the group consisting of:

[0938]

[0939] wherein the dotted line marked with an asterisk represents attachment to -L 1 - attachment:

[0940] The unmarked dotted line represents attachment to -Z.

[0941] In some embodiments, -L 2 - has formula (xvi):

[0942]

[0943] wherein

[0944] the dotted line marked with an asterisk represents attachment to -L 1 - attachment:

[0945] The unmarked dotted line represents attachment to -Z.

[0946] In some embodiments, part -L 1 -L 2 - is selected from the group consisting of:

[0947]

[0948] wherein

[0949] the unmarked dotted line represents attachment to the nitrogen of -D as part of CNP by forming an amide bond; and

[0950] the dotted line marked with an asterisk represents attachment to -Z.

[0951] In some embodiments, moiety -L 1 -L 2 - has formula (IId-ii):

[0952]

[0953] wherein

[0954] The unlabeled dashed line represents attachment to the nitrogen of -D as the CNP moiety via formation of an amide bond; and

[0955] The dashed line marked with an asterisk represents attachment to -Z.

[0956] In some embodiments, moiety -L 1 -L 2 - has formula (IId-ii’):

[0957]

[0958] wherein

[0959] The unlabeled dashed line represents attachment to the nitrogen of -D as the CNP moiety via formation of an amide bond; and

[0960] The dashed line marked with an asterisk represents attachment to -Z.

[0961] In some embodiments, moiety -L 1 -L 2 - is selected from the group consisting of:

[0962]

[0963]

[0964] wherein

[0965] The unlabeled dashed line represents attachment to the nitrogen of -D as the CNP moiety via formation of an amide bond; and

[0966] The dashed line marked with an asterisk represents attachment to -Z.

[0967] In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) ranges from 5 to 200 kDa. In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) ranges from 8 to 100 kDa. In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) ranges from 10 to 80 kDa. In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) ranges from 12 to 60 kDa. In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) ranges from 15 to 40 kDa. In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) is about 20 kDa. In some embodiments, the molecular weight of -Z in formula (Ia) or (Ib) is about 40 kDa.

[0968] The polymeric moiety -Z of formula (Ia) or (Ib) comprises a polymer. In some embodiments, -Z in formula (Ia) or (Ib) comprises a polymer selected from the group consisting of 2-methacryloyloxyethyl phosphorylcholine, poly(acrylic acid), poly(acrylate), poly(acrylamide), poly(alkoxy) polymer, poly(amide), poly(amidoamine), poly(amino acid), poly(anhydride), poly(asparagine), poly(butyric acid), poly(glycolic acid), poly(butylene terephthalate), poly(caprolactone), poly(carbonate), poly(cyanoacrylate), poly(dimethylacrylamide), poly(ester), poly(ethylene), poly(ethylene glycol), poly(ethylene oxide), poly(ethyl phosphate), poly(ethyl oxazoline), poly(glycolic acid), poly(hydroxyethyl acrylate), poly(hydroxyethyl oxazoline), poly(hydroxymethyl acrylate), poly(hydroxypropyl methacrylamide), poly(hydroxypropyl acrylate), poly(hydroxypropyl oxazoline), poly(iminocarbonate), poly(lactic acid), poly(polylactic-co-glycolic acid), poly(methacrylamide), poly(methacrylate), poly(methyloxazoline), poly(organophosphazene), poly(orthoester), poly(oxazoline), poly(propylene glycol), poly(siloxane), poly(urethane), poly(vinyl alcohol), poly(vinylamine), poly(vinyl methyl ether), poly(vinyl pyrrolidone), polysiloxane, cellulose, carboxymethyl cellulose, hydroxypropyl methyl cellulose, chitin, chitosan, dextran, dextrin, gelatin, hyaluronic acid and derivatives, functionalized hyaluronic acid, mannan, pectin, rhamnogalacturonans, starch, hydroxyalkyl starch, hydroxyethyl starch and other carbohydrate-based polymers, xylan and its copolymers.

[0969] In some embodiments, -Z of formula (Ia) or (Ib) comprises a protein. Preferred proteins are selected from the group consisting of the carboxy-terminal peptide of chorionic gonadotropin as described in US2012 / 0035101 A1 (which is incorporated herein by reference), albumin, the XTEN sequence as described in WO 2011123813 A2 (which is incorporated herein by reference), the proline / alanine random coil sequence as described in WO2011 / 144756 A1 (which is incorporated herein by reference), the proline / alanine / serine random coil sequences as described in WO2008 / 155134A1 and WO2013 / 024049A1 (which are incorporated herein by reference), and Fc fusion proteins.

[0970] In some embodiments, -Z of formula (Ia) or (Ib) is poly(sarcosine). In some embodiments, -Z of formula (Ia) or (Ib) comprises poly(N-methylglycine). In some embodiments, -Z of formula (Ia) or (Ib) contains a random coil protein moiety. In some embodiments, -Z of formula (Ia) or (Ib) contains 1 random coil protein moiety. In some embodiments, -Z of formula (Ia) or (Ib) contains 2 random coil protein moieties. In some embodiments, -Z of formula (Ia) or (Ib) contains 3 random coil protein moieties. In some embodiments, -Z of formula (Ia) or (Ib) contains 4 random coil protein moieties. In some embodiments, -Z of formula (Ia) or (Ib) contains 5 random coil protein moieties. In some embodiments, -Z of formula (Ia) or (Ib) contains 6 random coil protein moieties. In some embodiments, -Z of formula (Ia) or (Ib) contains 7 random coil protein moieties. In some embodiments, -Z of formula (Ia) or (Ib) contains 8 random coil protein moieties.

[0971] In some embodiments, such random coil protein moiety contains at least 25 amino acid residues and at most 2000 amino acids. In some embodiments, such random coil protein moiety contains at least 30 amino acid residues and at most 1500 amino acid residues. In some embodiments, such random coil protein moiety contains at least 50 amino acid residues and at most 500 amino acid residues.

[0972] In some embodiments, -Z of formula (Ia) or (Ib) includes a fatty acid derivative. In some embodiments, -Z of formula (Ia) or (Ib) is a fatty acid derivative. In some embodiments, -Z of formula (Ia) is a fatty acid derivative and x is 1.

[0973] In some embodiments, -Z of formula (Ia) or (Ib) is a fatty acid derivative as disclosed in WO 2006 / 097537 A2, which is incorporated herein by reference.

[0974] In some embodiments, -Z of formula (Ia) or (Ib) comprises a fatty acid derivative as disclosed in WO 2021 / 055497 A1, which is incorporated herein by reference. Thus, in some embodiments, -Z of formula (Ia) or (Ib) has the following structure (w):

[0975]

[0976] where the dashed line represents attachment to -L or -L in formula (Ia) or (Ib). 2 - or -L 1 - attachment.

[0977] In some embodiments, -Z has formula (w) and -L 1 - has formula (V).

[0978] In some embodiments, -Z-L 2 -L 1 - has formula (w-a):

[0979]

[0980] where the dashed line represents attachment to -D in formula (Ia) or (Ib).

[0981] In some embodiments, CNP has a sequence selected from the group consisting of:

[0982] PGQEHPQARRYRGAQRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO:98);

[0983] PGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC (SEQ ID NO:30);

[0984] PGQEHPNARRYRGANRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO:99); and

[0985] PGQEHPQARKYKGAQKKGLSKGCFGLKLDRIGSMSGLGC (SEQ ID NO:100).

[0986] In some embodiments, the CNP has a sequence selected from the group consisting of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100, -Z has formula (w) and -L 1 - is a reversible linker moiety. In some embodiments, the CNP has a sequence selected from the group consisting of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100, -Z has formula (w) and -L 1 - has formula (V). In some embodiments, the CNP has a sequence selected from the group consisting of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100, -Z-L 2 -L 1 - has formula (w-a). The -L 1 - can be attached to the CNP via a lysine other than the lysine within the ring structure, or can be attached to the N-terminus.

[0987] In some embodiments, the CNP of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100 further comprises an acetyl group, such as an acetyl group located at the N-terminus of the peptide. In some embodiments, the CNP of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100 further comprises an -OH or -NH2 group at the C-terminus. In some embodiments, the CNP of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100 is attached to -L 1 - at a residue of the CNP ring portion or at a site outside the CNP portion.

[0988] In some embodiments, -L 1 - is attached to a lysine residue, such as the lysine residues shown in bold in SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100:

[0989] PGQEHPQARRYRGAQRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO:98);

[0990] PGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC (SEQ ID NO:30);

[0991] PGQEHPNARRYRGANRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO:99); and

[0992] PGQEHPQARKYKGAQKKGLSKGCFGLKLDRIGSMSGLGC (SEQ ID NO:100).

[0993] In some embodiments, the CNP is selected from the group consisting of:

[0994] Ac-PGQEHPQARRYRGAQRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO:101);

[0995] Ac-PGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC-NH2 (SEQ ID NO:102);

[0996] Ac-PGQEHPNARRYRGANRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO:103);

[0997] Ac-PGQEHPNARRYRGANRRGLSRGCFGLKLDRIGSMSGLGC-NH2 (SEQ ID NO:104); and

[0998] Ac-PGQEHPQARRYRGAQRRGLSRGCFGLKLDRIGSMSGLGC-NH2 (SEQ ID NO:105).

[0999] In some embodiments, -Z of formula (Ia) or (Ib) is a hyaluronic acid-based polymer.

[1000] In some embodiments, -Z of formula (Ia) or (Ib) is a polymeric moiety as disclosed in WO 2013 / 024047 Al (which is incorporated herein by reference).

[1001] In some embodiments, -Z of formula (Ia) or (Ib) is a polymeric moiety as disclosed in WO 2013 / 024048 Al (which is incorporated herein by reference).

[1002] In some embodiments, -Z of formula (Ia) or (Ib) is a PEG-based polymer. In some embodiments, -Z is a branched or multi-armed PEG-based polymer.

[1003] In some embodiments, -Z of formula (Ia) or (Ib) is a branched polymer. In some embodiments, -Z in formula (Ia) or (Ib) is a branched polymer having 1, 2, 3, 4, 5, or 6 branch points. In some embodiments, -Z of formula (Ia) or (Ib) is a branched polymer having 1, 2, or 3 branch points. In some embodiments, -Z of formula (Ia) or (Ib) is a branched polymer having 1 branch point. In some embodiments, -Z of formula (Ia) or (Ib) is a branched polymer having 2 branch points. In some embodiments, -Z of formula (Ia) or (Ib) is a branched polymer having 3 branch points.

[1004] In some embodiments, the branch points are selected from the group consisting of: -N<, -CH<, and >C<.

[1005] In some embodiments, such a branched moiety -Z of formula (Ia) or (Ib) is PEG-based.

[1006] In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) ranges from 5 kDa to 500 kDa (including 5 kDa and 500 kDa). In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) ranges from 10 kDa to 250 kDa (including 10 kDa and 250 kDa). In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) ranges from 10 kDa to 150 kDa (including 10 kDa and 150 kDa). In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) ranges from 12 kDa to 100 kDa (including 12 kDa and 100 kDa). In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) ranges from 15 kDa to 80 kDa (including 15 kDa and 80 kDa). In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) ranges from 10 kDa to 80 kDa (including 10 kDa and 80 kDa). In some embodiments, the molecular weight is about 10 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 20 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 30 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 40 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 50 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 60 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 70 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 80 kDa. In some embodiments, the molecular weight of such a branched moiety -Z of formula (Ia) or (Ib) is about 40 kDa.

[1007] In some embodiments, -Z comprises a moiety

[1008]

[1009] In some embodiments, -Z comprises an amide bond.

[1010] In some embodiments, -Z of formula (Ia) or (Ib) comprises a moiety of formula (a):

[1011]

[1012] wherein

[1013] the dashed line represents attachment to -L2 - or the remainder of Z is attached;

[1014] BP a is a branch point selected from the group: -N<, -CR<, and >C<;

[1015] -R is selected from the group: -H and C 1-6 alkyl;

[1016] If BP a is -N< or -CR<, then a is 0, if BP a is >C<, then a is 1;

[1017] -S a -, -S a’ -, -S a” -, -S a”’ - are each independently a chemical bond or selected from the group: C 1-50 alkyl, C 2-50 alkenyl, and C 2-50 alkynyl; wherein C 1-50 alkyl, C 2-50 alkenyl, and C 2-50 alkynyl are optionally substituted by one or more identical or different -R 1 substituents, wherein C 1-50 alkyl, C 2-50 alkenyl, and C 2-50 alkynyl are optionally interrupted by one or more groups selected from the group: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 ), -, -S(O)2N(R 2 ), -, -S(O)N(R 2 ), -, -S(O)2-, -S(O)-, -N(R 2 ),S(O)2N(R 2a ), -, -S-, -N(R 2 ), -, -OC(OR 2 )(R 2a ), -, -N(R 2 ),C(O)N(R 2a ), -, and -OC(O)N(R 2 );

[1018] Each -T- is independently selected from the group: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, 8- to 30-membered carbopolycyclic group, and 8- to 30-membered heteropolycyclic group; wherein each -T- is independently optionally substituted by one or more identical or different -R 1 substituents;

[1019] Each -R 1 is independently selected from the group consisting of: halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 , -S(O)R 3 , -N(R 3 ), -N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 ), -N(R 3a ), -N(R 3 ), -N(R 3a ), -N(R 3 ), -N(R 3a ), -N(R 3 ), -N(R 3a ), -N(R 3 ), -N(R 3a R 3b ), -OC(O)N(R 3 R 3a ) and C 1-6 alkyl; wherein the C 1-6 alkyl is optionally substituted with one or more identical or different halogens;

[1020] Each -R 2 , -R 2a , -R 3 , -R 3a and -R 3b is independently selected from the group consisting of: -H and C 1-6 alkyl, wherein the C 1-6 alkyl is optionally substituted with one or more identical or different halogens.

[1021] -P a’ , -P a” and -P a”’ are independently polymer moieties.

[1022] Optionally, the moiety of formula (a) is substituted with one or more substituents.

[1023] In some embodiments, the BP of formula (a) a is -N<. In some embodiments, the BP of formula (a) a is -CR<. In some embodiments, -R is -H.

[1024] Thus, in some embodiments, a of formula (a) is 0.

[1025] In some embodiments, the BP of formula (a) a is >C<.

[1026] In some embodiments, the -S a - of formula (a) is a chemical bond.

[1027] In some embodiments, the -S a - of formula (a) is selected from the group consisting of: C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl, wherein the C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 ), -, -S(O)2N(R 4 ), -, -S(O)N(R 4 ), -, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a ), -, -S-, -N(R 4 ), -, -OC(OR 4 )(R 4a ), -, -N(R 4 )C(O)N(R 4a ), - and -OC(O)N(R 4 ); wherein -R 4 and -R 4a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, the -S a - of formula (a) is selected from the group consisting of: methyl, ethyl, propyl, butyl, which are optionally interrupted by one or more chemical groups selected from the group consisting of: -O-, -C(O)-, and -C(O)N(R 4 ).

[1028] In some embodiments, the -S a’ - of formula (a) is a chemical bond.

[1029] In some embodiments, the -S a’- selected from the group: C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl, wherein the C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl are optionally interrupted by one or more chemical groups selected from the group: -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 ), -, -S(O)2N(R 4 ), -, -S(O)N(R 4 ), -, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a ), -, -S-, -N(R 4 ), -, -OC(OR 4 )(R 4a ), -, -N(R 4 )C(O)N(R 4a ), - and -OC(O)N(R 4 ); wherein -R 4 and -R 4a are independently selected from the group: -H, methyl, ethyl, propyl, and butyl. In some embodiments, the -S a’ - of formula (a) is selected from the group: methyl, ethyl, propyl, butyl, which is optionally interrupted by one or more chemical groups selected from the group: -O-, -C(O)-, and -C(O)N(R 4 ).

[1030] In some embodiments, the -S a” - of formula (a) is a chemical bond.

[1031] In some embodiments, the -S a” - of formula (a) is selected from the group: C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl, wherein the C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl are optionally interrupted by one or more chemical groups selected from the group: -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 ), -, -S(O)2N(R 4 ), -, -S(O)N(R 4 ), -, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a ), -, -S-, -N(R 4 ), -, -OC(OR4 )(R 4a )-, -N(R 4 )C(O)N(R 4a )- and -OC(O)N(R 4 )-; wherein -R 4 and -R 4a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, the -S a” - of formula (a) is selected from the group consisting of: methyl, ethyl, propyl, butyl, which may be optionally interrupted by one or more chemical groups selected from the group consisting of: -O-, -C(O)-, and -C(O)N(R 4 ).

[1032] In some embodiments, the -S a”’ - of formula (a) is a chemical bond.

[1033] In some embodiments, the -S a”’ - of formula (a) is selected from the group consisting of: C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl, wherein the C 1-10 alkyl, C 2-10 alkenyl, and C 2-10 alkynyl may be optionally interrupted by one or more chemical groups selected from the group consisting of: -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 ), -S(O)2N(R 4 ), -S(O)N(R 4 ), -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a ), -S-, -N(R 4 ), -OC(OR 4 )(R 4a ), -N(R 4 )C(O)N(R 4a ), and -OC(O)N(R 4 ); wherein -R 4 and -R 4a are independently selected from the group consisting of: -H, methyl, ethyl, propyl, and butyl. In some embodiments, the -S a”’ - of formula (a) is selected from the group consisting of: methyl, ethyl, propyl, butyl, which may be optionally interrupted by one or more chemical groups selected from the group consisting of: -O-, -C(O)-, and -C(O)N(R 4 ).

[1034] In some embodiments, the -P a’ , -Pa” -P a”’ independently comprises a polymer selected from the group consisting of: 2-methacryloyloxyethyl phosphorylcholine, poly(acrylic acid), poly(acrylate), poly(acrylamide), poly(alkoxy) polymer), poly(amide), poly(amidoamine), poly(amino acid), poly(anhydride), poly(asparagine), poly(butyric acid), poly(glycolic acid), poly(butylene terephthalate), poly(caprolactone), poly(carbonate), poly(cyanoacrylate), poly(dimethylacrylamide), poly(ester), poly(ethylene), poly(ethylene glycol), poly(ethylene oxide), poly(ethyl phosphate), poly(ethyl oxazoline), poly(glycolic acid), poly(2-hydroxyethyl acrylate), poly(2-hydroxyethyl oxazoline), poly(2-hydroxypropyl methacrylate), poly(2-hydroxypropyl methacrylamide), poly(2-hydroxypropyl methacrylate), poly(2-hydroxypropyl oxazoline), poly(iminocarbonate), poly(lactic acid), poly(lactic acid-co-glycolic acid), poly(methacrylamide), poly(methacrylate), poly(methyl oxazoline), poly(organophosphazene), poly(orthoester), poly(oxazoline), poly(propylene glycol), poly(siloxane), poly(urethane), poly(vinyl alcohol), poly(vinylamine), poly(vinyl methyl ether), poly(vinylpyrrolidone), polysiloxane, cellulose, carboxymethyl cellulose, hydroxypropyl methyl cellulose, chitin, chitosan, dextran, dextrin, gelatin, hyaluronic acid and its derivatives, functionalized hyaluronic acid, mannan, pectin, rhamnogalacturonan, starch, hydroxyalkyl starch, hydroxyethyl starch and other carbohydrate-based polymers, xylan and its copolymers.

[1035] In some embodiments, -P of formula (a) a’ -P a” and -P a”’ each has a molecular weight range of 5 kDa - 50 kDa (including 5 kDa and 50 kDa), in some embodiments in the range of 5 kDa - 40 kDa (including 5 kDa and 40 kDa), in some embodiments in the range of 7.5 kDa - 35 kDa (including 7.5 kDa and 35 kDa), in some embodiments in the range of 7.5 kDa - 30 kDa (including 7.5 kDa and 30 kDa), in some embodiments in the range of 10 kDa - 30 kDa (including 10 kDa and 30 kDa).

[1036] In some embodiments, -P of formula (a) a’ -P a” and -P a”’ has a molecular weight of about 5 kDa. In some embodiments, -P of formula (a) a’ -P a” and -P a”’has a molecular weight of about 7.5 kDa. In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ has a molecular weight of about 10 kDa. In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ has a molecular weight of about 12.5 kDa. In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ has a molecular weight of about 15 kDa. In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ has a molecular weight of about 20 kDa.

[1037] In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ each contain a PEG-based moiety. In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ each contain a PEG-based moiety containing at least 20% PEG, in some embodiments containing at least 30% PEG, in some embodiments containing at least 40% PEG, in some embodiments containing at least 50% PEG, in some embodiments containing at least 60% PEG, in some embodiments containing at least 70% PEG, in some embodiments containing at least 80% PEG, in some embodiments containing at least 90% PEG,

[1038] In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ each contain a protein moiety, in some embodiments containing a random coil protein moiety, in some embodiments containing a random coil protein moiety selected from the group consisting of: PA, PAS, PAG, PG, and XTEN moieties.

[1039] In some embodiments, -P of formula (a) a’ , -P a” and -P a”’ is a PA moiety. In some embodiments, -P of formula (a) a’ , -P a” and -Pa”’ is the PAS portion. In some embodiments, the -P of formula (a) a’ , -P a” and -P a”’ are the PAG portion. In some embodiments, the -P of formula (a) a’ , -P a” and -P a”’ are the PG portion. In some embodiments, the -P of formula (a) a’ , -P a” and -P a”’ are the XTEN portion.

[1040] In some embodiments, -Z comprises one portion of formula (a). In some embodiments, -Z comprises two portions of formula (a). In further embodiments, -Z comprises three portions of formula (a). In some embodiments, -Z comprises four portions of formula (a). In some embodiments, -Z comprises five portions of formula (a). In some embodiments, -Z comprises six portions of formula (a).

[1041] In some embodiments, -Z comprises a portion of formula (b):

[1042]

[1043] wherein

[1044] the dashed line indicates attachment to the remainder of -L 2 - or -Z;

[1045] b1 is selected from the group consisting of: 0, 1, 2, 3, 4, 5, 6, 7, and 8;

[1046] b2 is selected from the group consisting of: 1, 2, 3, 4, 5, 6, 7, and 8;

[1047] b3 is an integer in the range of 150 - 1000 and including 150 and 1000; in some embodiments, an integer in the range of 150 - 500 and including 150 and 500; in some embodiments, an integer in the range of 200 - 460 and including 200 and 460; and

[1048] b4 is an integer in the range of 150 - 1000 and including 150 and 1000; in some embodiments, an integer in the range of 150 - 500 and including 150 and 500; in some embodiments, an integer in the range of 200 - 460 and including 200 and 460.

[1049] Optionally, the portion of formula (b) is substituted with one or more substituents.

[1050] In some embodiments, b3 and b4 of formula (b) are the same integer. In some embodiments, b3 and b4 of formula (b) are each an integer in the range of 200 - 250. In some embodiments, b3 and b4 of formula (b) are about 225. In some embodiments, b3 and b4 of formula (b) are each an integer in the range of 400 - 500. In some embodiments, b3 and b4 of formula (b) are about 450.

[1051] In some embodiments, b1 of formula (b) is selected from the group consisting of: 0, 1, 2, 3, and 4. In some embodiments, b1 of formula (b) is selected from the group consisting of: 1, 2, and 3. In some embodiments, b1 of formula (b) is 2.

[1052] In some embodiments, b2 in formula (b) is selected from the group consisting of: 1, 2, 3, 4, and 5. In some embodiments, b2 in formula (b) is selected from the group consisting of: 2, 3, and 4. In some embodiments, b2 in formula (b) is 3.

[1053] In some embodiments, b1 of formula (b) is 2, b2 of formula (b) is 3, and b3 and b4 are each about 450. In some embodiments, b1 of formula (b) is 2, b2 of formula (b) is 3, and b3 and b4 are each about 225.

[1054] In some embodiments, -Z contains one moiety of formula (b). In some embodiments, -Z contains two moieties of formula (b). In some embodiments, -Z contains three moieties of formula (b). In some embodiments, -Z contains four moieties of formula (b). In some embodiments, -Z contains five moieties of formula (b). In some embodiments, -Z contains six moieties of formula (b).

[1055] In some embodiments, -Z contains a moiety of formula (c):

[1056]

[1057] where

[1058] the dashed line represents attachment to -L 2 - or the remainder of -Z;

[1059] c1 and c2 are each an integer ranging from 150 - 500 and including 150 and 500 (in some embodiments, ranging from 200 - 460 and including 200 and 460).

[1060] Optionally, the moiety of formula (c) is substituted with one or more substituents.

[1061] In some embodiments, c1 and c2 of formula (c) are the same integer.

[1062] In some embodiments, c1 and c2 of formula (c) range from 200 to 250 and include 200 and 250. In some embodiments, c1 and c2 of formula (c) are about 225. In some embodiments, c1 and c2 of formula (c) range from 400 to 500 and include 400 and 500. In some embodiments, c1 and c2 of formula (c) are about 450.

[1063] In some embodiments, moiety -Z is a branched PEG-based polymer containing at least 10% PEG, having one branching point and two PEG-based polymer arms with a molecular weight of about 40 kDa. Accordingly, each of the two PEG-based polymer arms has a molecular weight of about 20 kDa. In some embodiments, the branching point is -CH<.

[1064] In some embodiments, -Z contains one moiety of formula (c). In some embodiments, -Z contains two moieties of formula (c). In some embodiments, -Z contains three moieties of formula (c). In some embodiments, -Z contains four moieties of formula (c). In some embodiments, -Z contains five moieties of formula (c). In some embodiments, -Z contains six moieties of formula (c).

[1065] In some embodiments, moiety -Z has formula (d):

[1066]

[1067] wherein

[1068] the dashed line represents attachment to -L 2 -attached;

[1069] -Z b -is selected from the group consisting of: C 1-50 alkyl, C 2-50 alkenyl, and C 2-50 alkynyl; wherein C 1-50 alkyl, C 2-50 alkenyl, and C 2-50 alkynyl are optionally substituted with one or more identical or different -R 1 substituents, and wherein C 1-50 alkyl, C 2-50 alkenyl, and C 2-50 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 ), -, -S(O)2N(R 2 ), -, -S(O)N(R 2 ), -, -S(O)2-, -S(O)-, -N(R2 )S(O)2N(R 2a )-, -S-, -N(R 2 )-, -OC(OR 2 )(R 2a )-, -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2 )-;

[1070] Each -T- is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclic group, 8- to 11-membered heterobicyclic group, 8- to 30-membered carbopolycyclic group, and 8- to 30-membered heteropolycyclic group; wherein each -T- is independently optionally substituted with one or more identical or different -R 1 substituents;

[1071] Each -R 1 is independently selected from the group consisting of: halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 , -S(O)R 3 , -N(R 3 )(S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )(C(O)R 3a , -N(R 3 )(S(O)2R 3a , -N(R 3 )(S(O)R 3a , -N(R 3 )(C(O)OR 3a , -N(R 3 )(C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ) and C 1-6 alkyl; wherein C 1-6The alkyl group is optionally substituted by one or more identical or different halogen atoms;

[1072] Each -R 2 -, -R 2a -, -R 3 -, -R 3a and -R 3b is independently selected from the group consisting of: -H and C 1-6 alkyl, wherein the C 1-6 alkyl is optionally substituted by one or more identical or different halogen atoms.

[1073] And

[1074] -Z a is

[1075]

[1076] wherein

[1077] BP a -, -S a -, -S a’ -, -S a” -, -S a”’ -, -P a’ -, -P a” and -P a”’ and the usage of a is as defined for formula (a).

[1078] Optionally, the moiety of formula (d) is substituted by one or more substituents.

[1079] In some embodiments, the BP a -, -S a -, -S a’ -, -S a” -, -S a”’ -, -P a’ -, -P a” and -P a”’ is as defined above for formula (a).

[1080] In some embodiments, -Z a of formula (d) has formula (b). In some embodiments, b1, b2, b3 and b4 are as described in formula (b).

[1081] In some embodiments, -Z of formula (Ia) or (Ib) has formula (e):

[1082]

[1083] wherein

[1084] The dashed line represents a bond to -L 2- Attachment;

[1085] e is selected from the group consisting of: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15; and

[1086] -Z a is

[1087]

[1088] wherein

[1089] b1, b2, b3, and b4 are defined as in formula (b).

[1090] Optionally, the moiety of formula (e) is substituted with one or more substituents.

[1091] In some embodiments, for b1, b2, b3, and b4 of formula (e), they are defined as described above for formula (b).

[1092] In some embodiments, e of formula (e) is 1. In some embodiments, e of formula (e) is 2. In some embodiments, e of formula (e) is 3. In some embodiments, e of formula (e) is 4. In some embodiments, e of formula (e) is 5. In some embodiments, e of formula (e) is 6. In some embodiments, e of formula (e) is 7. In some embodiments, e of formula (e) is 8. In some embodiments, e of formula (e) is 9. In some embodiments, e of formula (e) is 10. In some embodiments, e of formula (e) is 11. In some embodiments, e of formula (e) is 12. In some embodiments, e of formula (e) is 13. In some embodiments, e of formula (e) is 14. In some embodiments, e of formula (e) is 15.

[1093] In some embodiments, e of formula (e) is selected from the group consisting of: 2, 3, 4, 5, 6, 7, 8, and 9. In some embodiments, e of formula (e) is selected from the group consisting of: 3, 4, 5, and 6. In some embodiments, e of formula (e) is 5.

[1094] In some embodiments, e of formula (e) is 5, b1 of formula (e) is 2, b2 of formula (e) is 3, and both b3 and b4 of formula (e) are about 450.

[1095] In some embodiments, the moiety -Z of formula (Ia) or (Ib) has formula (e-i) or (e-i'):

[1096]

[1097] wherein

[1098] The dashed line represents attachment to -L 2 - attached,

[1099] e is selected from the group consisting of: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15;

[1100] -Z a is

[1101]

[1102] wherein

[1103] b1, b2, b3, and b4 are defined as in formula (b).

[1104] In some embodiments, b1, b2, b3, and b4 of formulas (e-i) and (e-i') are defined as in formula (b) above. In some embodiments, e of formulas (e-i) and (e-i') is as described for formula (e). In some embodiments, b1 of formulas (e-i) and (e-i') is 2, b2 of formulas (e-i) and (e-i') is 3, and both b3 and b4 of formulas (e-i) and (e-i') are about 450.

[1105] In some embodiments, -Z of formula (Ia) or (Ib) has formula (e-i).

[1106] In some embodiments, part of -Z is a branched PEG-based polymer containing at least 10% PEG, which has three branch points and four PEG-based polymer arms, and a molecular weight of about 40 kDa. Thus, the molecular weight of each of the four PEG-based polymer arms is about 10 kDa. In some embodiments, the branch point is -CH<.

[1107] In some embodiments, part of -Z has formula (f):

[1108]

[1109] wherein

[1110] The dashed line represents attachment to -L 2 - attached;

[1111] BP f is a branch point selected from the group consisting of: -N<, -CR<, and >C<;

[1112] -R is selected from the group consisting of: -H and C 1-6 alkyl;

[1113] If BP f is -N< or -CR< then f is 0, if BP f is >C< then f is 1;

[1114] -S f - and -S f’ - and -S f” - and -S f”’ - and -S are independently a chemical bond or selected from the group consisting of: C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl; wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl are optionally substituted by one or more identical or different -R 1 ; wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl are optionally interrupted by one or more groups selected from the group consisting of: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 ), -S(O)2N(R 2 ), -S(O)N(R 2 ), -S(O)2-, -S(O)-, -N(R 2 )S(O)2N(R 2a ), -S-, -N(R 2 ), -OC(OR 2 )(R 2a ), -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2 );

[1115] Each -T- is independently selected from the group consisting of: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3 - 10 membered heterocyclic group, 8 - 11 membered heterobicyclic group, 8 - 30 membered carbopolycyclic group and 8 - 30 membered heteropolycyclic group; wherein each -T- is independently optionally substituted by one or more identical or different -R 1 ;

[1116] Each -R 1 is independently selected from the group consisting of: halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 ), -S(O)R3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ) and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted by one or more identical or different halogens;

[1117] Each -R 2 , -R 2a , -R 3 , -R 3a and -R 3b is independently selected from the group consisting of: -H and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted by one or more identical or different halogens.

[1118] And

[1119] -Z a’ -, -Z a” - and -Z a”’ - are independently

[1120]

[1121] wherein

[1122] BP a , -S a , -S a’ , -S a” , -S a”’ , -P a’ , -P a” and -P a”’ and the usage of a is defined as in formula (a).

[1123] Optionally, the moiety of formula (f) is substituted with one or more substituents.

[1124] In some embodiments, the BP of formula (f) a -, -S a -,-S a’ -,-S a” -,-S a”’ -,-P a’ -,-P a” and -P a”’ are as defined above for formula (a).

[1125] In some embodiments, the BP of formula (f) f is -CR< and r is 0. In some embodiments, -R is -H.

[1126] In some embodiments, the -S f - of formula (f) is a chemical bond.

[1127] In some embodiments, the -Z a’ -,-Z a” -,-Z a”’ - of formula (f) has the same structure. In some embodiments, the -Z a’ -,-Z a” -,-Z a”’ - of formula (f) has formula (b).

[1128] In some embodiments, b1, b2, b3 and b4 are as described in formula (b).

[1129] In some embodiments, the -S f - of formula (f) is a chemical bond, and the BP a of formula (f) is -CR<, where -R is -H. In some embodiments, the -S f - of formula (f) is a chemical bond, the BP a of formula (f) is -CR<, where -R is -H, and the -Z a’ -,-Z a” -,-Z a”’ - of formula (f) has formula (b).

[1130] In some embodiments, -Z has formula (g):

[1131]

[1132] where

[1133] the dashed line represents attachment to -L 2 -;

[1134] -S g-, -S g’ - and -S g” - is independently selected from the following group: C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl; wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally substituted by one or more identical or different -R 1 ; wherein C 1-50 alkyl, C 2-50 alkenyl and C 2-50 alkynyl is optionally interrupted by one or more groups selected from the following group: -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 ), -S(O)2N(R 2 ), -S(O)N(R 2 ), -S(O)2-, -S(O)-, -N(R 2 )S(O)2N(R 2a ), -S-, -N(R 2 ), -OC(OR 2 )(R 2a ), -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2 );

[1135] Each -T- is independently selected from the following group: phenyl, naphthyl, indenyl, indanyl, tetrahydronaphthyl, C 3-10 cycloalkyl, 3-10 membered heterocyclic group, 8-11 membered heterobicyclic group, 8-30 membered carbopolycyclic group and 8-30 membered heteropolycyclic group; wherein each -T- is independently optionally substituted by one or more identical or different -R 1 ;

[1136] Each -R 1 is independently selected from the following group: halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3aR 3b ),-SR 3 、-N(R 3 R 3a )、-NO2、-OC(O)R 3 、-N(R 3 )C(O)R 3a 、-N(R 3 )S(O)2R 3a 、-N(R 3 )S(O)R 3a 、-N(R 3 )C(O)OR 3a 、-N(R 3 )C(O)N(R 3a R 3b )、-OC(O)N(R 3 R 3a ) and C 1-6 Alkyl; among which C 1-6 The alkyl group is optionally substituted with one or more halogens which may be the same or different;

[1137] Each-R 2 , -R 2a , -R 3 , -R 3a and -R 3b Independently selected from the group consisting of: -H and C 1-6 Alkyl, where C 1-6 The alkyl group is optionally substituted with one or more same or different halogens.

[1138] and

[1139] -Z a -and-Z a’ - Independently

[1140]

[1141] in

[1142] BP a , -S a -、-S a’ -、-S a” -、-S a”’ -、-P a’ , -P a” and -P a”’ and a are used as defined for formula (a).

[1143] Optionally, the moiety of formula (g) is substituted with one or more substituents.

[1144] In some embodiments, BP of formula (g) a , -Sa -, -S a’ -, -S a” -, -S a”’ -, -P a’ , -P a” and -P a”’ as defined above for formula (a).

[1145] In some embodiments, the -S of formula (g) g - is selected from the group consisting of: C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl, which are optionally substituted with one or more identical or different -R 1 substituents,

[1146] wherein

[1147] -R 1 is selected from the group consisting of: halogen, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ) and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted with one or more identical or different halogens; and

[1148] -R 3 、-R 3a and -R 3b are independently selected from the group consisting of: -H, methyl, ethyl, propyl, butyl.

[1149] In some embodiments, the -S g - of formula (g) is selected from C 1-6 alkyl.

[1150] In some embodiments, the -S g’ - of formula (g) is selected from the group consisting of: C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl, which may optionally be substituted by one or more identical or different -R 1 substituents,

[1151] wherein

[1152] -R 1 is selected from the group consisting of: halogen, oxo (=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b , -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; wherein C1-6 The alkyl group is optionally substituted by one or more identical or different halogens; and

[1153] -R 3 ,-R 3a and -R 3b are independently selected from the group consisting of: -H, methyl, ethyl, propyl, butyl.

[1154] In some embodiments, the -S g’ - of formula (g) is C 1-6 alkyl.

[1155] In some embodiments, the -S g” - of formula (g) is selected from the group consisting of: C 1-6 alkyl, C 2-6 alkenyl, and C 2-6 alkynyl, which is optionally substituted by one or more identical or different -R 1 substituents,

[1156] wherein

[1157] -R 1 is selected from the group consisting of: halogen, oxo (=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)2R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3R 3a ) and C 1-6 alkyl; wherein C 1-6 alkyl is optionally substituted by one or more identical or different halogens; and

[1158] -R 3 , -R 3a and -R 3b are independently selected from the group consisting of: -H, methyl, ethyl, propyl, butyl.

[1159] In some embodiments, -S g” - of formula (g) is C 1-6 alkyl.

[1160] In some embodiments, -Z a and -Z a’ of formula (g) have the same structure. In some embodiments, -Z a and -Z a’ of formula (g) have formula (b).

[1161] In some embodiments, BP a , -S a , -S a’ , -S a” , -S a”’ , -P a’ , -P a” and -P a”’ are as defined above for formula (a).

[1162] In some embodiments, -S g , -S g’ and -S g” - of formula (g-i) are as defined for formula (g).

[1163] In some embodiments, -Z a and -Z a’ of formula (g-i) have the same structure. In some embodiments, Z a and -Z a’ of formula (g-i) have formula (b). In some embodiments, b1, b2, b3 and b4 are as described for formula (b).

[1164] In some embodiments, -Z has formula (h):

[1165]

[1166] wherein

[1167] the dashed line represents attachment to -L 2 -: and

[1168] each -Z c is a moiety

[1169]

[1170] wherein

[1171] each c1 is independently an integer in the range of about 200 - 250.

[1172] Optionally, the moiety of formula (h) is substituted with one or more substituents.

[1173] In some embodiments, the two c1s of formula (h) are the same. In some embodiments, the two c1s of formula (h) are both about 225.

[1174] In some embodiments, moiety -Z has formula (h-i):

[1175]

[1176] wherein

[1177] the dashed line represents attachment to -L 2 -attachment: and

[1178] each -Z c is a moiety

[1179]

[1180] each c1 is independently an integer in the range of 200 - 250.

[1181] Optionally, the moiety of formula (h-i) is substituted with one or more substituents.

[1182] In some embodiments, the two c1s of formula (h-i) are the same. In some embodiments, the two c1s of formula (h-i) are both about 225.

[1183] In some embodiments, the CNP conjugate has formula (IIf):

[1184]

[1185] wherein

[1186] the unlabeled dashed line represents attachment to the nitrogen of -D which is part of the CNP by forming an amide bond; and

[1187] the dashed line marked with an asterisk represents attachment to -Z having the following structure

[1188]

[1189] wherein

[1190] each -Z a is

[1191]

[1192] wherein

[1193] each c1 is independently an integer in the range of 200 - 250.

[1194] In some embodiments, each c1 of formula (IIf) is about 225.

[1195] In some embodiments, -D of formula (IIf) is a CNP moiety, i.e., the conjugate of formula (IIf) is a CNP conjugate. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:24, SEQ ID NO:25 or SEQ ID NO:30. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:24. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:20. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:21. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:22. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:23. In some embodiments, -D of formula (IIf) is a CNP moiety having the sequence of SEQ ID NO:30.

[1196] In some embodiments, -D of formula (IIf) is a CNP moiety that is attached to -L through the nitrogen of the N - terminal amine functional group of the CNP 1 -.

[1197] In some embodiments, -D of formula (IIf) is a CNP moiety that is attached to -L through the nitrogen provided by the amine functional group of a lysine side chain of the CNP moiety 1 -.

[1198] In some embodiments, if the CNP moiety has SEQ ID NO:24, then the lysine side chain is not part of a ring formed by a disulfide bond between the cysteine residues at positions 22 and 38.

[1199] Thus, in some embodiments, if the CNP has the sequence of SEQ ID NO:24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) through the amine functional group provided by the lysine side chain at position 9 1 - linked.

[1200] In some embodiments, if the CNP has the sequence of SEQ ID NO:24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) through the amine functional group provided by the lysine side chain at position 11 1 -linked.

[1201] In some embodiments, if the CNP has the sequence of SEQ ID NO:24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) through the amine functional group provided by the lysine side chain at position 15 1 -linked.

[1202] In some embodiments, if the CNP has the sequence of SEQ ID NO:24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) through the amine functional group provided by the lysine side chain at position 16 1 -linked.

[1203] In some embodiments, if the CNP has the sequence of SEQ ID NO:24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) through the amine functional group provided by the lysine side chain at position 20 1 -linked.

[1204] In some embodiments, if the CNP moiety has SEQ ID NO:24, the lysine side chain is part of a ring formed by a disulfide bond between cysteine residues at positions 22 and 38.

[1205] Thus, in some embodiments, if the CNP has the sequence of SEQ ID NO:24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) through the amine functional group provided by the lysine side chain at position 26 1 -linked.

[1206] In some embodiments, the CNP conjugate has formula (IIf), wherein c1 is about 225, -D is the CNP moiety having the sequence of SEQ ID NO:20 and is attached to -L through the amine functional group provided by the lysine side chain at position 30 1 -.

[1207] In some embodiments, the CNP conjugate has formula (IIf), wherein c1 is about 225, -D is the CNP moiety having the sequence of SEQ ID NO:21 and is attached to -L through the amine functional group provided by the lysine side chain at position 29 1 -.

[1208] In some embodiments, the CNP conjugate has formula (IIf), where c1 is about 225, -D is the CNP moiety having the sequence of SEQ ID NO: 22 and is attached to -L through the amine functionality provided by the lysine side chain at position 28 1 -.

[1209] In some embodiments, the CNP conjugate has formula (IIf), where cl is about 225, -D is the CNP moiety having the sequence of SEQ ID NO: 23 and is linked to -L through the amine functionality provided by the lysine side chain at position 27 1 -.

[1210] In some embodiments, the CNP conjugate has formula (IIf), where cl is about 225, -D is the CNP moiety having the sequence of SEQ ID NO: 30 and is linked to -L1- through the amine functionality provided by the lysine side chain at position 27

[1211] It should be understood that the positions of the above cysteine and lysine vary according to the length of the CNP moiety, and those skilled in the art will be able to identify the corresponding cysteine and lysine in longer or shorter versions of the CNP moiety without difficulty, and it is also understood that for example, some lysines may not be present in shorter CNP moieties. It can further be understood that, for example due to site-directed mutagenesis, there may be more lysine residues in the non-cyclic and / or cyclic portions of the CNP moiety

[1212] In some embodiments, the CNP conjugate has formula (IIf), where c1 is about 225, -D is the CNP moiety having the sequence of SEQ ID NO: 24 and is attached to -L through the amine functionality provided by the lysine side chain at position 26 1 -.

[1213] In some embodiments, the CNP conjugate has formula (IIf’):

[1214]

[1215] where

[1216] The unlabeled dashed line represents attachment through the nitrogen provided by the lysine side chain at position 26 of the CNP moiety having SEQ ID NO: 24 by formation of an amide bond; and

[1217] The dashed line marked with an asterisk represents attachment to -Z having the following structure

[1218]

[1219] where

[1220] each Za For

[1221]

[1222] Each c1 is independently an integer in the range of 200 - 250.

[1223] In some embodiments, each c1 of formula (IIf’) is about 225.

[1224] In some embodiments, the unit dosage form of the present invention comprises a CNP conjugate of formula (IIf) or a pharmaceutically acceptable salt thereof:

[1225] Wherein

[1226] The unmarked dashed line represents attachment through the nitrogen provided by the side chain of lysine at position 26 of the CNP moiety of SEQ ID NO:24 by forming an amide bond;

[1227] The dashed line marked with an asterisk represents attachment to -Z having the following structure

[1228]

[1229] Wherein

[1230] Each Z a Is

[1231]

[1232] Wherein

[1233] Each c1 is independently an integer in the range of 200 - 250,

[1234] And wherein the unit dose is about 50 μg CNP / kg.

[1235] In some embodiments, the unit dosage form of the present invention comprises a CNP conjugate of formula (IIf) or a pharmaceutically acceptable salt thereof:

[1236] Wherein

[1237] The unmarked dashed line represents attachment through the nitrogen provided by the side chain of lysine at position 26 of SEQ ID NO:24 of the CNP moiety by forming an amide bond;

[1238] The dashed line marked with an asterisk represents attachment to -Z having the following structure

[1239]

[1240] Wherein

[1241] Each Za For

[1242]

[1243] wherein

[1244] each c1 is independently an integer in the range of 200 - 250,

[1245] and wherein the unit dose is about 75 μg CNP / kg.

[1246] In some embodiments, the unit dosage form of the present invention comprises a CNP conjugate of formula (IIf) or a pharmaceutically acceptable salt thereof:

[1247] wherein

[1248] The unlabeled dashed line represents an attachment provided by forming an amide bond with the side chain of lysine at position 26 of the CNP moiety of SEQ ID NO:24;

[1249] The dashed line marked with an asterisk represents an attachment to -Z having the following structure

[1250]

[1251] wherein

[1252] each Z c is

[1253]

[1254] wherein

[1255] each c1 is independently an integer in the range of 200 - 250,

[1256] and wherein the unit dose is about 100 μg CNP / kg.

[1257] In some embodiments, the unit dosage form of the present invention comprises a CNP conjugate of formula (IIf’) or a pharmaceutically acceptable salt thereof:

[1258]

[1259] wherein

[1260] The unlabeled dashed line represents a nitrogen attachment provided by forming an amide bond with the side chain of lysine at position 26 of the CNP moiety of SEQ ID NO:24;

[1261] The dashed line marked with an asterisk represents an attachment to -Z having the following structure

[1262]

[1263] wherein

[1264] each Z c is

[1265]

[1266] wherein

[1267] each c1 is independently an integer in the range of 200 - 250,

[1268] and wherein the unit dose is about 50 μg CNP / kg.

[1269] In some embodiments, the unit dosage form of the present invention comprises a CNP conjugate of formula (IIf’) or a pharmaceutically acceptable salt thereof:

[1270]

[1271] wherein

[1272] The unlabeled dashed line represents attachment through the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO:24 by formation of an amide bond;

[1273] The dashed line marked with an asterisk represents attachment to -Z having the following structure

[1274]

[1275] wherein

[1276] each Z a is

[1277]

[1278] wherein

[1279] each c1 is independently an integer in the range of 200 - 250,

[1280] and wherein the unit dose is about 75 μg CNP / kg.

[1281] In some embodiments, the unit dosage form of the present invention comprises a CNP conjugate of formula (IIf’) or a pharmaceutically acceptable salt thereof:

[1282]

[1283] wherein

[1284] The unlabeled dashed line represents attachment through the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO:24 by formation of an amide bond;

[1285] The dashed line marked with an asterisk indicates attachment to -Z having the following structure

[1286]

[1287] wherein

[1288] each Z a is

[1289]

[1290] wherein

[1291] each c1 is independently an integer in the range of 200 - 250,

[1292] and wherein the unit dose is about 100 μg CNP / kg.

[1293] In some embodiments, with respect to -Z c or -Z a portion, such as -Z in the CNP conjugate of formula (IIf) or (IIf’) c or -Z a portion, c1 is independently an integer from about 100 to about 500, such as an integer from about 150 to about 300, such as an integer from about 200 to about 250.

[1294] In some embodiments, with respect to -Z c or -Z a portion, -Z c or -Z a is a branched PEG portion comprising 2 linear PEG arms (such as annotated herein as -[-O-CH2-CH2] c1 -O-CH3), which are independently at least about 5 kDa, such as about 5 kDa - about 20 kDa, such as about 7 kDa - about 15 kDa, such as about 8 kDa - about 12 kDa, such as about 10 kDa.

[1295] In some embodiments, with respect to -Z c or -Z a portion, such as -Z in the CNP conjugate of formula (IIf) or (IIf’) c or -Z a portion, the average of each c1 present in the CNP conjugate is about 100 - about 500, such as about 150 - about 300, such as about 200 - about 250.

[1296] In some embodiments, each PEG arm present in the CNP conjugate (such as annotated herein as -[-O-CH2-CH2] c1The average of (-O-CH3) is at least about 5 kDa, such as about 5 kDa - about 20 kDa, such as about 7 kDa - about 15 kDa, such as about 8 kDa - about 12 kDa, such as about 10 kDa.

[1297] Another aspect of the invention is a method for improving muscle function in a human patient suffering from a disease treatable by CNP, the method comprising the step of administering to the subject an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist, optionally, wherein the FGFR3 signal transduction inhibitor or NPR-B agonist and / or NPR-C agonist is a CNP conjugate or a pharmaceutically acceptable salt thereof, and the CNP conjugate or a pharmaceutically acceptable salt thereof is administered at a unit dose of about 6 μg CNP / kg - at least about 150 μg CNP / kg.

[1298] Another aspect of the invention is a method for improving skeletal muscle function in a human patient suffering from a disease treatable by CNP, the method comprising the step of administering to the subject an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist, optionally, wherein the FGFR3 signal transduction inhibitor or NPR-B agonist and / or NPR-C agonist is a CNP conjugate or a pharmaceutically acceptable salt thereof, and the CNP conjugate or a pharmaceutically acceptable salt thereof is administered at a unit dose of about 6 μg CNP / kg - at least about 150 μg CNP / kg.

[1299] In some embodiments, the invention is a method for improving muscle function in a human patient suffering from a disease treatable by CNP, the method comprising the step of administering to the subject an effective amount of an FGFR3 signal transduction inhibitor or an effective amount of an NPR-B agonist or an effective amount of an NPR-C agonist, optionally, wherein the FGFR3 signal transduction inhibitor or NPR-B agonist or NPR-C agonist is a CNP conjugate or a pharmaceutically acceptable salt thereof, and the unit dose is about 6 μg CNP / kg - at least about 100 μg CNP / kg.

[1300] In some embodiments, the subject suffers from a disease or disorder treatable by CNP, optionally, wherein the disease or disorder is selected from the group consisting of: bone-related disorders (such as skeletal dysplasia), cancer, autoimmune diseases, fibrotic diseases, inflammatory diseases, central nervous system diseases (such as neurodegenerative diseases), infectious diseases, pulmonary diseases, cardiovascular diseases, metabolic diseases, and ophthalmic diseases.

[1301] In some embodiments, the subject suffers from a signal pathway-related syndrome.

[1302] In some embodiments, the diseases treatable by the methods or uses of the present invention include signal pathway-related syndromes: Signal pathway-related syndromes are caused by genetic abnormalities in the Ras / MAPK pathway (including the pathway activated by FGFR3) (see review Rauen, Annu Rev Genomics Hum Genet. 2013;14:355-369, doi:10.1146 / annurev-genom-091212-153523), including neurofibromatosis type 1, Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardiofaciocutaneous syndrome, and Legius syndrome.

[1303] In some embodiments, the present invention relates to the use of CNP or NPR-B agonists and / or NPR-C agonists for treating RAS signal pathway-related syndromes.

[1304] In some embodiments, the diseases treatable by CNP are selected from the group consisting of: achondroplasia, hypochondroplasia, short stature, dwarfism, osteochondrodysplasia, lethal dysplasia, osteogenesis imperfecta, achondrogenesis, punctate chondrodysplasia, homozygous achondroplasia, campomelic dysplasia, congenital lethal hypophosphatasia, perinatal lethal osteogenesis imperfecta, short rib polydactyly syndrome, acroradial dysplasia, Jansen metaphyseal chondrodysplasia, spondyloepiphyseal dysplasia congenita, osteodysplasty, dysostosis multiplex, congenital femoral shortening, Langer mesomelic dysplasia, Nievergelt mesomelic dysplasia, Robinow syndrome, Reinhardt syndrome, acromelic dysplasia, peripheral dysostosis, Kniest dysplasia, fibrochondrogenesis, Roberts syndrome, acromesozeugodactyly, micromelia, Morquio syndrome, Knies ...

Claims

1. Use of an FGFR3 signal transduction inhibitor, an NPR-B agonist, or an NPR-C agonist in a method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, wherein a therapeutically effective amount of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist is administered to the subject.

2. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to claim 1, wherein the FGFR3 signal transduction inhibitor is an FGFR3 antagonist or an NPR-B agonist.

3. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to claim 1 or 2, wherein the NPR-B agonist is C-type natriuretic peptide or comprises C-type natriuretic peptide (CNP).

4. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of claims 1-3, wherein the NPR-C agonist is C-type natriuretic peptide or comprises C-type natriuretic peptide (CNP).

5. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of claims 1-4, wherein the NPR-B agonist or NPR-C agonist is administered as a CNP conjugate or a pharmaceutically acceptable salt thereof.

6. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of claims 1-5, wherein the NPR-B agonist or NPR-C agonist is a prodrug of CNP.

7. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to claim 5 or 6, wherein the CNP conjugate or the prodrug of CNP is a compound of formula (IIf’), formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

8. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of claims 5-7, wherein the method comprises administering to the subject successive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, wherein between successive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, the sustained exposure of free CNP in the patient's plasma is at least about 1 pmol / L, such as at least about 4 pmol / L, such as between about 4 pmol / L and about 30 pmol / L.

9. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to claim 8, wherein the method comprises administering to the subject successive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, wherein between successive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, the sustained exposure of free CNP in the patient's plasma is at least about 9 pmol / L.

10. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 8 or 9, wherein a therapeutically effective amount of the CNP conjugate and / or prodrug is administered daily or weekly.

11. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of claims 3-7, wherein the method comprises administering an infusion of CNP to the subject, such as an intravenous or subcutaneous infusion, wherein the infusion results in a sustained exposure of free CNP in the patient's plasma of at least 1 pmol / L for a period of at least 1 hour, such as at least about 4 pmol / L, such as at least about 9 pmol / L, or about 4 pmol / L - about 30 pmol / L.

12. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of claims 1-11, wherein the NPR-B agonist is vosoritide or comprises vosoritide (SEQ ID NO: 30).

13. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 2, wherein the FGFR3 antagonist is an FGFR3 tyrosine kinase inhibitor.

14. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 13, wherein the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of: infigratinib, pemigatinib, futibatinib, erdafitinib, and TYRA-300.

15. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of the preceding claims, wherein the subject is a human subject.

16. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 15, wherein the age of the subject is less than 18 years old.

17. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 15, wherein the age of the subject is at least 18 years old.

18. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of the preceding claims, wherein the subject has closed epiphyses.

19. Use of the FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of the preceding claims, wherein the improvement in muscle function is one or more of the following: a) increased skeletal muscle strength, b) increased skeletal muscle tone, c) increased skeletal muscle endurance, d) increased skeletal muscle mass, e) reduced skeletal muscle fatigue, f) increased cardiovascular endurance, g) improved cardiovascular fitness, h) reduced exercise intolerance, i) enhanced exercise capacity, j) reduced exercise-induced fatigue, and k) reduced muscle hypotonia.

20. An FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein said administration results in an increase in skeletal muscle mass and / or muscle / fat ratio (such as skeletal muscle / fat ratio) in a subject.

21. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein the subject has hypotonia.

22. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein said administration results in the treatment or prevention of musculoskeletal pain in a subject.

23. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein said administration results in an improvement in posture or a reduction in abnormal spinal curvature.

24. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein said administration results in an improvement in kyphosis, lordosis, spinal stenosis, or scoliosis.

25. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein said administration results in an improvement in sleep apnea, obstructive sleep apnea, or otitis media (such as acute otitis media).

26. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein said administration results in a reduction in obesity.

27. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of the preceding claims, wherein the subject has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and lethal dysplasia.

28. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of claims 1-27, wherein the subject has a RAS signaling pathway-related syndrome, such as a RAS signaling pathway-related syndrome selected from the group consisting of: neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardiofaciocutaneous syndrome, and Legius syndrome.

29. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist, or NPR-C agonist according to any one of claims 1-28, wherein the subject has a disease or disorder associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

30. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 29, wherein the neurodegenerative disease is selected from the group consisting of Parkinson's disease, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), ataxia such as Friedreich's ataxia (FRDA), and Huntington's disease (HD).

31. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to claim 29 or 30, wherein the disease or disorder associated with impaired neuromuscular function is a disease or disorder with mitochondrial dysfunction.

32. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of claims 29 to 31, wherein the treatment results in a reduction in muscle function decline.

33. Use of an FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist according to any one of the preceding claims, wherein the method further comprises administering a growth hormone such as human growth hormone, or a prodrug thereof.

34. A method for improving muscle function in a subject suffering from a disease or disorder with impaired muscle function, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signal transduction inhibitor, NPR-B agonist or NPR-C agonist.

35. The method according to claim 34, wherein the FGFR3 signal transduction inhibitor is an FGFR3 antagonist or an NPR-B agonist.

36. The method according to claim 34 or 35, wherein the NPR-B agonist is C-type natriuretic peptide or comprises C-type natriuretic peptide (CNP).

37. The method according to any one of claims 34 - 36, wherein the NPR-C agonist is C-type natriuretic peptide or comprises C-type natriuretic peptide (CNP).

38. The method according to any one of claims 34 - 37, wherein, The NPR-B agonist or NPR-C agonist is administered as a CNP conjugate or a pharmaceutically acceptable salt thereof.

39. The method according to any one of claims 34 - 38, wherein, The NPR-B agonist or NPR-C agonist is a prodrug of CNP.

40. The method according to any one of claims 38 or 39, wherein the CNP conjugate or the prodrug of CNP is a compound of formula (IIf’), formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

41. The method according to any one of claims 38 - 40, wherein the method comprises administering to the subject consecutive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, wherein between consecutive doses of a therapeutically effective amount of the CNP conjugate and / or the prodrug of CNP, the persistent exposure amount of free CNP in the patient's plasma is at least about 1 pmol / L, such as at least about 4 pmol / L, such as between about 4 pmol / L - about 30 pmol / L.

42. The method according to claim 41, wherein the method comprises administering to a subject successive doses of a therapeutically effective amount of the CNP conjugate and / or a prodrug of CNP, wherein between successive doses of a therapeutically effective amount of the CNP conjugate and / or a prodrug of CNP, the amount of free CNP continuously exposed in the patient's plasma is at least about 9 pmol / L.

43. The method according to claim 41 or 42, wherein a therapeutically effective amount of the CNP conjugate and / or prodrug is administered daily or weekly.

44. The method according to any one of claims 36 - 40, which comprises administering to a subject an infusion of CNP, such as an intravenous or subcutaneous infusion, wherein the infusion results in a continuous exposure of free CNP in the patient's plasma of at least 1 pmol / L for a period of at least 1 hour, such as at least about 4 pmol / L, such as at least about 9 pmol / L, or from about 4 pmol / L to about 30 pmol / L.

45. The method according to any one of claims 34 to 44, wherein the NPR - B agonist is vosoritide or comprises vosoritide (SEQ ID NO:30).

46. The method according to claim 35, wherein the FGFR3 antagonist is an FGFR3 tyrosine kinase inhibitor.

47. The method according to claim 46, wherein the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of infigratinib, pemigatinib, fotivda, erdafitinib, and TYRA - 300.

48. The method according to any one of claims 34 - 47, wherein the subject is a human subject.

49. The method according to claim 48, wherein the subject is less than 18 years of age.

50. The method according to claim 48, wherein the subject is at least 18 years of age.

51. The method according to any one of claims 34 - 50, wherein the subject has closed epiphyses.

52. The method according to any one of claims 34 - 51, wherein the improvement in muscle function is one or more of the following: a) increased skeletal muscle strength, b) increased skeletal muscle tone, c) increased skeletal muscle endurance, d) increased skeletal muscle mass, e) reduced skeletal muscle fatigue, f) increased cardiovascular endurance, g) improved cardiovascular fitness, h) reduced exercise intolerance, i) enhanced exercise ability, j) reduced exercise - induced fatigue, and k) reduced muscle hypotonia.

53. The method according to any one of claims 34 - 52, wherein the administration results in an increase in the skeletal muscle mass and / or the muscle / fat ratio (such as the skeletal muscle / fat ratio) of the subject.

54. The method according to any one of claims 34 - 53, wherein the subject has muscle hypotonia.

55. The method according to any one of claims 34 - 54, wherein the administration results in: a. treatment or prevention of the subject's musculoskeletal pain; and / or b. improvement of posture or reduction of spinal abnormal curvature; and / or c. improvement of kyphosis, lordosis, spinal stenosis, or scoliosis; and / or d. Improvement of sleep apnea, obstructive sleep apnea, or otitis media (such as acute otitis media); and / or e. Reduction of obesity.

56. The method according to any one of claims 34 - 56, wherein the subject has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and thanatophoric dysplasia.

57. The method according to any one of claims 34 - 57, wherein the subject has a RAS signaling pathway - related syndrome, such as a RAS signaling pathway - related syndrome selected from the group consisting of neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation - arteriovenous malformation syndrome, Costello syndrome, cardiofaciocutaneous syndrome, and Legius syndrome.

58. The method according to any one of claims 34 - 57, wherein the subject has a disease or disorder associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

59. The method according to claim 58, wherein the neurodegenerative disease is selected from the group consisting of Parkinson's disease, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), ataxia such as Friedreich's ataxia (FRDA), and Huntington's disease (HD).

60. The method according to any one of claims 58 or 59, wherein the disease or disorder associated with impaired neuromuscular function is a disease or disorder with mitochondrial dysfunction.

61. The method according to any one of claims 58 - 60, wherein the treatment results in a reduction in muscle function decline.

62. The method according to any one of claims 34 - 61, further comprising administering a growth hormone such as human growth hormone, or a prodrug thereof.

63. Use of an FGFR3 signal transduction inhibitor, an NPR - B agonist, or an NPR - C agonist in the manufacture of a medicament for improving muscle function in a subject having a disease or disorder with impaired muscle function.

64. The use according to claim 63, wherein the FGFR3 signal transduction inhibitor is an FGFR3 antagonist or an NPR - B agonist.

65. The use according to claim 63 or 64, wherein the NPR - B agonist is C - type natriuretic peptide or comprises C - type natriuretic peptide (CNP).

66. The use according to any one of claims 63 - 65, wherein the NPR - C agonist is C - type natriuretic peptide or comprises C - type natriuretic peptide (CNP).

67. The use according to any one of claims 63 - 66, wherein the NPR - B agonist or NPR - C agonist is administered as a CNP conjugate or a pharmaceutically acceptable salt thereof.

68. The use according to any one of claims 63 - 67, wherein the NPR - B agonist or NPR - C agonist is a prodrug of CNP.

69. The use according to claim 67 or 68, wherein the CNP conjugate or prodrug of CNP is a compound of formula (IIf’), formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

70. The use according to any one of claims 67 - 69, wherein the drug is administered by a method comprising administering to the subject successive doses of a therapeutically effective amount of the CNP conjugate and / or prodrug of CNP, wherein between successive doses of a therapeutically effective amount of the CNP conjugate and / or prodrug of CNP, the sustained exposure of free CNP in the patient plasma is at least about 1 pmol / L, such as at least about 4 pmol / L, such as between about 4 pmol / L - about 30 pmol / L.

71. The use according to claim 70, wherein the method comprises administering to the subject successive doses of a therapeutically effective amount of the CNP conjugate and / or prodrug of CNP, wherein between successive doses of a therapeutically effective amount of the CNP conjugate and / or prodrug of CNP, the sustained exposure of free CNP in the patient plasma is at least about 9 pmol / L.

72. The use according to claim 70 or 71, wherein the therapeutically effective amount of the CNP conjugate and / or prodrug is administered daily or weekly.

73. The use according to any one of claims 65 - 69, wherein the drug is administered by a method comprising administering to the subject an infusion of CNP such as an intravenous or subcutaneous infusion, wherein the infusion results in a sustained exposure of free CNP in the patient plasma of at least 1 pmol / L for a period of at least 1 hour, such as at least about 4 pmol / L, such as at least about 9 pmol / L, or between about 4 pmol / L - about 30 pmol / L.

74. The use according to any one of claims 63 - 73, wherein the NPR - B agonist is vosoritide or comprises vosoritide (SEQ ID NO:30).

75. The use according to claim 64, wherein the FGFR3 antagonist is an FGFR3 tyrosine kinase inhibitor.

76. The use according to claim 75, wherein the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of infigratinib, pemigatinib, futibatinib, erdafitinib, and TYRA - 300.

77. The use according to any one of claims 63 - 76, wherein the subject is a human subject.

78. The use according to claim 77, wherein the age of the subject is less than 18 years old.

79. The use according to claim 77, wherein the age of the subject is at least 18 years old.

80. The use according to any one of claims 63 - 79, wherein the subject has closed epiphyses.

81. The use according to any one of claims 63 - 80, wherein the improvement in muscle function is one or more of the following: a) increased skeletal muscle strength, b) increased skeletal muscle tone, c) increased skeletal muscle endurance, d) increased skeletal muscle mass, e) reduced skeletal muscle fatigue, f) increasing cardiovascular endurance, g) improving cardiovascular fitness, h) reducing exercise intolerance, i) enhancing exercise capacity, j) reducing exercise-induced fatigue, and k) reducing muscle hypotonia.

82. The use according to any one of claims 63 - 81, wherein administration of the drug results in an increase in the skeletal muscle mass and / or muscle / fat ratio (such as skeletal muscle / fat ratio) of the subject.

83. The use according to any one of claims 63 - 82, wherein the subject has muscle hypotonia.

84. The use according to any one of claims 63 - 83, wherein administration of the drug results in: a. treatment or prevention of musculoskeletal pain in the subject; and / or b. improvement of posture or reduction of abnormal spinal curvature; and / or c. improvement of kyphosis, lordosis, spinal stenosis or scoliosis; and / or d. improvement of sleep apnea, obstructive sleep apnea or otitis media (such as acute otitis media); and / or e. reduction of obesity.

85. The use according to any one of claims 63 - 84, wherein the subject has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia and thanatophoric dysplasia.

86. The use according to any one of claims 63 - 85, wherein the subject has a RAS signaling pathway-related syndrome, such as a RAS signaling pathway-related syndrome selected from the group consisting of neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardiofaciocutaneous syndrome and Legius syndrome.

87. The use according to any one of claims 63 - 86, wherein the subject has a disease or disorder associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

88. The use according to claim 87, wherein the neurodegenerative disease is selected from the group consisting of Parkinson's disease, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), ataxia such as Friedreich's ataxia (FRDA) and Huntington's disease (HD).

89. The use according to claim 87 or 88, wherein the disease or disorder associated with impaired neuromuscular function is a disease or disorder with mitochondrial dysfunction.

90. The use according to any one of claims 87 - 89, wherein the treatment results in a reduction in muscle function decline.

91. The use according to any one of the preceding claims, wherein the drug is for administration in a method that further comprises administration of a growth hormone such as human growth hormone or a prodrug thereof.

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