Membrane iron transporter inhibitors for treatment of hereditary hemochromatosis (HH)

Abstract

The present invention relates to compounds of the formula as well as pharmaceutically acceptable salts, solvates, hydrates or polymorphs thereof for use in the treatment of hereditary hemochromatosis.

Description

[0001] Foreword

[0002] This invention relates to compounds of formula (I).

[0003]

[0004] Or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof, which is used as an inhibitor of membrane iron transporter for the treatment of hereditary hemochromatosis (HH) and its associated symptoms and pathological conditions.

[0005] Background and Existing Technology

[0006] Iron is an essential element for almost all organisms, its relevance stemming from its crucial role in erythropoiesis and oxygen transport. Iron metabolism is primarily regulated by the levels of iron reuptake from hemoglobin in aging red blood cells, iron stores in the liver, and dietary iron absorption in the duodenum. Elemental iron is absorbed by duodenal intestinal cells via specific transport systems (DMT-1, membrane iron transporters), translocated into the bloodstream, and then transported to appropriate tissues and organs bound to its carrier, transferrin. In the human body, iron is vital, particularly for oxygen transport, oxygen uptake, cellular functions (e.g., mitochondrial electron transport, cognitive function), and ultimately, for overall energy metabolism. Mammalian organisms cannot remove or secrete iron from their bodies through active systems. Iron homeostasis is controlled by the hepatic peptide hormone hepcidin, which regulates the activity of the only known iron exporter, the membrane iron transporter, and thus regulates iron release from macrophages, hepatocytes, and intestinal cells. Hepcidin controls iron absorption through the intestine and placenta, as well as the recirculation of iron from the reticuloendothelial system. Hepcidin production is directly regulated by iron levels; more hepcidin is produced when the body is supplied with sufficient or excessive iron and oxygen, and less is produced when iron and oxygen levels are low or when erythropoiesis is increased. In small intestinal mucosal cells and macrophages, hepcidin binds to membrane iron transporters, thereby blocking their export function and promoting their internalization and degradation. Through this mechanism, hepcidin reduces the outflow of iron from cells into the bloodstream. Membrane iron transporters are transmembrane proteins composed of 571 amino acids, expressed in the liver, spleen, kidneys, heart, intestine, and placenta. Specifically, membrane iron transporters are located in the basolateral membrane of intestinal epithelial cells. Therefore, membrane iron transporters play a role in exporting dietary iron into the bloodstream. If hepcidin binds to membrane iron transporters, the membrane iron transporters are transported into the cell interior, where they are broken down, thus blocking the release of iron from the cell. If membrane iron transporters are inactivated or inhibited by hepcidin, preventing them from exporting iron stored in mucosal cells, then iron absorption in the intestine is blocked. A decrease in hepcidin leads to an increase in active membrane iron transporters, thereby allowing enhanced absorption of dietary iron and release of stored iron, resulting in elevated serum iron levels. Katsarou et al. published a review article on hepcidin therapeutics [A. Katsarou and K. Pantopoulos, Hepcidin Therapeutics, Pharmaceuticals, Vol. 11, No. 4, p. 127; 2018].

[0007] In pathological conditions, increased iron levels lead to iron overload. For example, excessive iron uptake in organs such as the liver and heart leads to iron accumulation. Furthermore, iron accumulation in the brain has been observed in patients with neurodegenerative diseases such as Alzheimer's and Parkinson's. The major portion of circulating iron is associated with transferrin, a classic iron transport molecule that prevents the formation of free reactive iron. The portion of iron not bound to transferrin (or other conventional iron-binding molecules such as heme, deferoxin, hemosiderin, etc.) is collectively referred to as non-transferrin-bound iron (NTBI).

[0008] A key harmful aspect of this excess of free iron is the undesirable formation of free radicals. In particular, iron(II) ions catalyze the formation of reactive oxygen species (ROS) (especially via the Fenton reaction). ROS damage DNA, lipids, proteins, and carbohydrates, thus having profound effects on cells, tissues, and organs. ROS formation is well-known and described in the literature as causing so-called oxidative stress. NTBI is widely described as exhibiting a high propensity to induce ROS and has potential toxicity to cells and major organs, including the heart, liver, pancreas, kidneys, and bone marrow.

[0009] Hereditary hemochromatosis (HH) is a genetic iron overload disorder caused by mutations that reduce the level of the iron-regulating hormone hepcidin or the binding of hepcidin to membrane iron transporters. HH is a common iron overload disorder in Scandinavians [Kowdley KV et al., ACG clinical guideline: hereditary hemochromatosis. Am J Gastroenterol., 2019, Vol. 114: pp. 1202-1218]. HH is characterized by excessive dietary iron absorption and pathologically high iron deposition in organs such as the liver, pancreas, and heart, which can lead to the formation of reactive oxygen species and ultimately organ damage. The high iron levels are a result of abnormally low levels of the iron-regulating hormone hepcidin or reduced binding of hepcidin to membrane iron transporters (the only transporters of extracellular iron). Hepcidin regulates iron levels by binding to a membrane iron transporter on the membranes of intestinal cells, hepatocytes, and macrophages, leading to the internalization and subsequent degradation of the iron transporter, thereby reducing iron transport into the plasma [Brissot P. et al., Haemochromatosis. Nat Rev Dis Primers. 2018, Vol. 4: 18016; Ganz T. Cellular iron: ferroportin is the only way out. Cell Metab. 2005, Vol. 1: 155-157; Nemeth E. et al., Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization. Science. 2004, Vol. 306: 2090-2093].

[0010] Hemochromatosis is classified into four different types: hereditary (classical) hemochromatosis, also known as HFE-associated hemochromatosis; type 2 hemochromatosis (juvenile hemochromatosis); type 3 hemochromatosis, also known as TFR2-associated hemochromatosis; and type 4 hemochromatosis, also known as membrane iron transporter disease. The specific symptoms associated with these conditions vary depending on the location and extent of iron accumulation. Type 4 HH is further subdivided into types 4A and 4B.

[0011] The most common form of HH is type 1 (hereditary hemochromatosis; HH), which is usually caused by mutations in the HFE gene that encodes the hemochromatosis (HFE) protein involved in hepcidin regulation. Among these HFE gene mutations, the most common is the C282Y mutation, followed by the H63D mutation. More than 80% of HH patients are homozygous for the C282Y mutation [Feder JN et al., A novel MHC class I-like gene is mutated in patients with hereditary hemochromatosis. Nat Genet. 1996, Vol. 13: 399-408; European Association for the Study of the Liver. EASL clinicalpractice guidelines for HFE hemochromatosis. J Hepatol. 2010, Vol. 53: 3-22]. The C282Y mutation disrupts a key disulfide bond in the α3 domain of the HFE protein and prevents the mutant HFE from binding to β-2 microglobulin, leading to impaired intracellular transport and accelerated degradation of HFE [Waheed A et al., Hereditary hemochromatosis: effects of C282Y and H63D mutations on association with beta2-microglobulin, intracellular processing, and cell surface expression of the HFE protein in COS-7 cells. Proc Natl AcadSci US A., 1997, Vol. 94: pp. 12384-12389].

[0012] However, HH can also be caused by mutations in other genes involved in sensing systemic iron storage, such as hepcidin (HAMP), hemojuglin (HJV), transferrin receptor 2 (TFR2), and membrane iron transporter-1 (FPN1), which encode hepcidin, hemojuglin, transferrin receptor 2, and membrane iron transporter, respectively [D′Alessio F et al., The hemochromatosis proteins HFE, TfR2, and HJV form a membrane-associated protein complex for hepcidinregulation. J Hepatol., 2012, Vol. 57: pp. 1052-1060].

[0013] Both HFE mutations (including C282Y and H63D mutations) and HH-associated non-HFE mutations lead to inappropriately low levels of hepcidin relative to iron status and increased release of iron into the plasma [Bridle KR et al., Disrupted hepcidin regulation in HFE-associated haemochromatosis and the liver as aregulator of body iron homoeostasis. Lancet., 2003, Vol. 361: 669-673.]. This results in high transferrin saturation (TSAT) and the formation of non-transferrin-bound iron (NTBI), which may ultimately lead to iron overload in critical organs.

[0014] Symptoms of hemochromatosis include feeling tired or weak, including extreme tiredness (fatigue), joint pain (especially knee and hand pain), abdominal pain above the liver, weight loss, loss of libido, or erectile dysfunction. Affected individuals may develop arthritis, liver disease (cirrhosis) or liver cancer, diabetes, heart abnormalities, and / or skin discoloration (including darkening of the skin, which may appear gray, metallic, or bronze).

[0015] If left untreated, iron overload can lead to serious complications, including liver fibrosis, cirrhosis and cancer, cardiomyopathy and heart failure, arthritis and diabetes [Pietrangelo A. Hereditary hemochromatosis: pathogenesis, diagnosis, and treatment. Gastroenterology. 2010; Vol. 139: pp. 393-408, Vol. 408: pp. e391-392.].

[0016] To date, venipuncture (bloodletting) is the standard treatment for patients with hemochromatosis. Venipuncture aims to lower serum ferritin levels to approximately 50 ng / mL and improve TSAT by approximately 50% [Brissot P, Brissot E., What's important and new in hemochromatosis? Clin Hematol Int., 2020, Vol. 2: 143-148; Brissot P, Loréal O., Hemochromatoses. J Hepatol., 2021, Vol. 75: 723-724]. Newly diagnosed patients typically undergo frequent venipunctures over several months during the so-called "induction phase" of treatment. Venipuncture is currently the only treatment option for HH patients, as there are currently no approved oral medications for HH. Although venipuncture is effective, simple, and inexpensive, it is still an invasive procedure and is not without complications. Adverse events were found in 37% of patients receiving maintenance therapy and 52% of patients in the induction phase, “most of the time” or “all of the time.” Adverse events included fatigue, syncope, pain at the venous access site, and hematoma. Weekly venous cut-off during the induction phase can lead to anemia and is inconvenient or intolerable for patients, and in some cases, venous access may be difficult to obtain. Due to the high treatment burden associated with repetitive and frequent venous cut-off procedures, patient compliance with venous cut-off during the maintenance phase generally declines steadily over time, and 16% of patients will “definitely” or “likely” decide to discontinue venous cut-off if alternative treatment options are available [Hicken BL et al., Patient compliance with phlebotomy therapy for iron overload associated with hemochromatosis. Am J Gastroenterol., 2003, Vol. 98: pp. 2072-2077].

[0017] Therefore, there is a need for novel therapies that provide effective and safe treatment for HH, improve patient compliance and reduce the burden of treatment, and reduce the frequency of venous transection.

[0018] Within the aforementioned primary type 1 hepatitis B (HH) patient group, approximately 10% of the subgroups are completely unsuitable for conventional treatment, i.e., venous transection, for various reasons. In particular, for this specific patient group, a novel HH treatment that can completely avoid or replace venous transection is needed.

[0019] Furthermore, venipuncture only provides symptomatic treatment but cannot target the underlying pathophysiology of HH.

[0020] Conventional medications used to treat iron overload are typically iron chelating compounds, which are designed to continuously remove excess iron. Established medications commonly used in chelation therapy include deferoxamine (also known as deferoxamine B; or...). ), delaros (also known as ) and deferoxone (also known as However, in hepatitis B (HH), iron chelation is only a treatment option when patients are intolerant to or refractory to venotomy. Venotomy is the first-line treatment option in HH. If iron chelation is considered in the treatment of patients with HH, then... It is the only approved drug, and it is approved in only a limited number of countries. In any case, established drugs known for iron chelation therapy exhibit toxic potential, which becomes a potential problem with long-term administration due to the need for long-term treatment. The only approved HH drug It cannot be administered orally.

[0021] With the goal of providing a novel treatment method that offers improved patient compliance, greater comfort, and easier integration into patients' daily lives, oral medication is a preferred option compared to, for example, parenteral administration. Compared to parenteral administration, oral administration offers the following advantages: ease of administration to patients (especially elderly patients), high flexibility in dosage and formulation, cost-effectiveness, fewer aseptic restrictions and risks of infection, injection site reactions, and the development of anti-drug antibodies.

[0022] International applications WO2017 / 068089 and WO2017 / 068090 have described a class of novel low molecular weight compounds with activity as inhibitors of membrane iron transporters. Furthermore, international application WO2018 / 192973 relates to specific salts of selected membrane iron transporter inhibitors described in WO2017 / 068089 and WO2017 / 068090. International application WO2021 / 191202 further describes a route for preparing selected membrane iron transporter inhibitors and their specific salt forms and polymorphs. The mention of potential treatment for hemochromatosis is only generally given in a list of possible indications, without providing any data.

[0023] The novel membrane iron transporter inhibitors described in the aforementioned international applications have been successfully tested in the following methods: methods for treating transfusion-dependent thalassemia (TDT), as described in international application WO2021 / 013771; methods for treating renal ischemia-reperfusion injury (IRI) or ischemic injury and acute kidney injury (AKI), as described in international application WO2021 / 013772; methods for treating sickle cell disease (SCD), as described in international application WO2021 / 078889; or methods for treating myelodysplastic syndromes (MDS), as described in international application WO2022 / 157185. The use of the small molecule membrane iron transporter inhibitor compound vamifeport (formerly known as VIT-2763) for the treatment of β-thalassemia and sickle cell disease is further described in several scientific papers [V, Nyffenegger N, Flace A et al., Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of β-thalassemia. J Clin Invest., 2019, Vol. 130: 491-506; Porter J, Taher A, Viprakasit V et al., Oral ferroportin inhibitor vamifeport for improving iron homeostasis and erythropoiesis in β-thalassemia: current evidence and future clinical development. Expert Rev Hematol., 2021, Vol. 14: 633-644; Nyffenegger N, Flace A, Doucerain C, Dürrenberger F, Manolova V. The oral ferroportin inhibitor VIT-2763 improves erythropoiesis without interfering with iron chelation therapy in a mouse model of β-thalassemia. Int J Mol Sci., 2021, Vol. 22: p. 873; Nyffenegger N, Zennadi R, Kalleda N et al., The oral ferroportin inhibitor vamifeport improves hemodynamics in a mouse model of sickle cell disease. Blood., 2022, Vol. 140: pp. 769-781; Kalleda N, Flae A, Altermatt P et al., The ferroportin inhibitor vamifeport ameliorates ineffective erythropoiesis in a mouse model of beta-thalassemia with bloodtransfusions. Haematologica., 2023. Furthermore, the first human study of Vamifeport in a phase 1 trial using healthy volunteers has been described [F. Richard et al., Oral ferroportin inhibitor RIB-2763: First-in-human, phase 1 study in healthy volunteers. American Journal of Hematoloty, Vol. 95, No. 1, pp. 68-77, 2019].

[0024] The inventors of this invention have now discovered that the membrane iron transporter inhibitor compound vamifeport (formerly known as VIT-2763) shows promise as a pharmaceutical compound for the treatment of hepatic encephalopathy (HH). In particular, the inventors have demonstrated in experimental studies the efficacy of vamifeport, alone and in combination with venous incision, in reducing serum iron levels and / or preventing hepatic iron deposition in an Hfe C282Y mouse model of HH.

[0025] Purpose of the invention

[0026] The object of this invention is to provide a novel method for treating hereditary hemochromatosis (HH) and its associated symptoms and pathological conditions. A specific object of this invention is to provide novel pharmaceutical compounds for the effective treatment of HH and its associated symptoms and pathological conditions, allowing for relief of the burden associated with conventional HH treatments, such as frequent venous incisions. Further objects to be addressed in a further aspect of the invention include providing novel treatment options that offer one or a combination of two or more of the following aspects: providing an effective and safe treatment for HH; providing improved patient compliance; comfort and ease of implementation in the patient's daily life; oral administration; and allowing for a reduced treatment burden. In a further aspect, the invention should provide a novel treatment that allows for a reduction in the frequency of venous incisions or provides a completely alternative treatment method, particularly for HH patients who are unsuitable for conventional treatment (i.e., venous incisions), enabling the complete avoidance or replacement of venous incisions. A further object of the invention is to provide a novel HH treatment option that not only provides symptomatic treatment but also targets the underlying pathophysiology of HH. A further object of the present invention is to provide a novel combination therapy option that can be used in conjunction with conventional venotomy without interfering with the iron removal process of venotomy. Detailed Implementation

[0027] The inventors of this invention were able to demonstrate that the compound vamifeport having the following formula (I)

[0028]

[0029] Or pharmaceutically acceptable salts, solvates, hydrates or polymorphs thereof may be used in novel methods for the treatment of hereditary hemochromatosis.

[0030] In a preferred aspect of the invention, the compound of formula (I) is used in the form of an HCl salt, and more preferably, the compound (i) is used in the form of a triHCl salt having the following formula (I-3HCl):

[0031]

[0032] In the following text, the vamifeport compound (I), including its salts, solvates, hydrates and polymorphs, are collectively referred to as "vamifeport" as described anywhere in this document.

[0033] The experimental studies conducted by the inventors and presented in the experimental section below provide preclinical proof of concept for the efficacy of vamifeport in treating hemorrhagic encephalopathy (HH) with or without venous transection. Specifically, the inventors were able to demonstrate that a single oral dose of vamifeport reduced serum iron levels in Hfe C282Y mice with a delayed onset and shorter duration compared to that observed in wild-type mice. In wild-type mice, vamifeport induces transient hypoferremia by inhibiting membrane iron transporters and leads to feedback regulation of hepatic Hamp, a phenomenon absent in Hfe C282Y mice, reflecting systemic iron-sensing dysregulation in this HH model. Long-term administration of vamifeport resulted in a persistent decrease in serum and hepatic iron in Hfe C282Y mice, and a significant reduction in hepatic Hamp expression, indicating that hepatic Hamp expression is significantly modulated following acute or continuous iron restriction with vamifeport. Importantly, vamifeport retains its activity when used in conjunction with venotomy and does not interfere with hepatic iron removal via venotomy in HfeC282Y mice. Experimental data show that long-term vamifeport treatment significantly reduces serum iron levels and prevents hepatic iron overload in the HH Hfe C282Y mouse model, thus supporting the invention described herein in further detail.

[0034] patient group

[0035] In particular, the inventors discovered that vamifeport can be used to treat patients with type 1 hemochromatosis and related symptoms and pathological conditions.

[0036] In one aspect, the present invention relates to compounds of formula (I) or salts, solvates, hydrates and polymorphs thereof for treating patients with HH caused by homozygous C282Y or H63D mutations or complex heterozygous C282Y / H63D mutations in the HFE gene, preferably patients with HH caused by homozygous C282Y mutations in the HFE gene.

[0037] In principle, the subject to be treated in the use of this invention can be any mammal, such as rodents and primates, and in a preferred aspect, the medical use relates to the treatment of humans. A subject suffering from HH and to be treated by the methods of this invention is also referred to as a “patient” or “individual.”

[0038] Subjects to be treated can be of any age. Preferred aspects of the invention relate to the treatment of adults and the elderly. In a preferred aspect of the invention, subjects to be treated with the novel method described herein are older than 20 years of age. In a further aspect of the invention, subjects to be treated with the novel method described herein are older than 30 years of age, preferably older than 40 years of age, more preferably older than 50 years of age, or older than 60 years of age. In a preferred case of treating elderly patients, subjects to be treated with the novel method described herein are 50 years of age and older, primarily due to the fact that type 1 HH patients typically develop iron overload at a relatively late age (i.e., at 50 years of age and older).

[0039] Because the treatment offered by this invention provides significant advantages, it is particularly preferred for treating elderly patients. Vamifeport and its salts, solvates, hydrates, or polymorphs can be administered orally, with oral administration being preferable to parenteral administration. Furthermore, the orally bioavailable membrane iron transporter inhibitor vamifeport exhibits moderate bioavailability and a short half-life in vivo, thus being washed away relatively quickly. This results in fewer side effects and faster drug reversibility, which is particularly important in the treatment of elderly patients.

[0040] The patient group or population suffering from HH and to be treated with the method of the present invention is selected from the subjects (patients) characterized by the above definition. In a further aspect of the invention, the patient group or population suffering from HH to be treated with the method of the present invention is selected from subjects (patients) having one or more of the pathological parameters described above.

[0041] In a further aspect of the invention, patient groups or populations suffering from hemangioma (HH) and awaiting treatment with the methods of the invention require frequent / regular venous transection. However, further clinical symptoms and parameters also play an important role in identifying HH.

[0042] Regular venous transection further means repeating the venous transection treatment more than once at predetermined time intervals (set). During the induction phase, weekly intervals are determined, while during the maintenance phase, monthly to quarterly or semi-annual intervals can be determined. The intervals between repeated venous transection procedures can be of equal length or can vary depending on the individual patient, the course of the disease, its severity, and treatment response. In particular, when entering the maintenance phase, the intervals are extended after the induction phase.

[0043] In a further aspect of the invention, regular / frequent venous incision refers to a period of no venous incision lasting no more than 6 months, preferably no more than 4 months.

[0044] Indications and treatment parameters

[0045] In the context of the uses of this invention, the term "treatment" includes preventing and alleviating at least one symptom or pathological condition associated with HH, such as those described in particular anywhere herein and in the following embodiments.

[0046] In the context of this invention, the term "treatment" further includes prevention or avoidance, for example by administering the compounds of this invention before or simultaneously with venous transection in HH patients.

[0047] Non-limiting examples of symptoms or pathological conditions associated with HH include, for example, increased systemic iron levels, increased liver iron concentration, iron accumulation in organs such as the liver, pancreas, and heart, increased hemoglobin levels and the burden of venipuncture treatment, and feeling tired or weak, including extreme tiredness (fatigue), joint pain (especially knee and hand pain), abdominal pain above the liver, weight loss, loss of sexual interest or erectile dysfunction, development of arthritis, liver disease (cirrhosis) or liver cancer, diabetes, cardiac abnormalities and / or skin discoloration (including darkening of the skin, which may be gray, metallic, or bronze), and combinations of these symptoms or conditions.

[0048] The following parameters can be determined to evaluate the efficacy of the compounds of the present invention in the treatment of hemorrhage (HH): serum iron, NTBI level, LPI (unstable plasma iron) level, erythropoietin, TSAT (transferrin saturation), Hb (hemoglobin), Hct (hematocrit), MCV (mean corpuscular volume), MCH (mean corpuscular hemoglobin), RDW (red blood cell distribution width), reticulocyte count, complete blood count, and iron content in the liver, spleen, and kidneys. These parameters can be determined using conventional methods in the art, particularly by methods described in more detail below. The compound (I) of the present invention is adapted to improve at least one of these parameters.

[0049] In one specific aspect, the HH treatment of the present invention results in a reduction of serum iron levels in patients by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%, measured at any time point within a time period of up to 72 hours, up to 60 hours, up to 48 hours, up to 36 hours, up to 24 hours, or up to 12 hours, 8 hours, 6 hours, 5 hours, 4 hours, 3 hours, 2 hours, 1 hour, and 0.5 hours after administration, and compared with serum iron levels measured at any time point within 0.5 hours, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 8 hours, 12 hours, 24 hours, 36 hours, or 48 hours or up to <1 week prior to the start of treatment of the present invention. Serum iron levels can be determined according to the assay method described in the following examples.

[0050] In a further aspect, the HH treatment of the present invention can result in a reduction in liver iron concentration in patients of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%, measured at any time point within a period of up to one week, up to two weeks, up to three weeks, up to four weeks, or up to three months after the first administration, and compared with the level of liver iron concentration in patients measured at any time point within one, two, three, or four weeks prior to the initiation of treatment of the present invention. Liver iron concentration can be determined according to the assay method described in the following examples.

[0051] Therefore, in a further aspect, the HH treatment of the present invention can result in a reduction in pancreatic iron concentration in patients of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%, measured at any time point within a period of up to one week, up to two weeks, up to three weeks, up to four weeks, or up to three months after the first administration, and compared with the level of pancreatic iron concentration in patients measured at any time point within one, two, three, or four weeks prior to the start of treatment of the present invention. Pancreatic iron concentration can be determined according to the assay method described in the following examples.

[0052] In a further aspect, the HH treatment of the present invention can result in a reduction in myocardial (cardiac) iron concentration in patients of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%, measured at any time point within a period of up to one week, up to two weeks, up to three weeks, up to four weeks, or up to three months after the first administration, and compared with the level of myocardial iron concentration in subjects measured at any time point within one, two, three, or four weeks prior to the start of treatment of the present invention. Myocardial (cardiac) iron concentration can be measured according to the assay method described in the following examples.

[0053] In a further aspect, the HH treatment of the present invention can result in a reduction of serum ferritin levels in patients by at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%, measured at any time point within a period of up to one week, up to two weeks, up to three weeks, up to four weeks, or up to three months after the first administration, and compared with serum ferritin levels measured at any time point within one, two, three, or four weeks prior to the initiation of treatment of the present invention. Serum ferritin levels can be determined according to conventional assay methods.

[0054] In a further aspect, the HH treatment of the present invention can result in an improvement of at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% in at least one of the patient's parameters Hb, Hct, RBC count, MCV, MCH, RDW, and reticulocyte count, measured at any time point within a period of up to one week, up to two weeks, up to three weeks, up to four weeks, or up to three months after the first dose, and compared with the corresponding parameters of the subject measured at any time point within one, two, three, or four weeks prior to the start of treatment of the present invention. These parameters can be measured according to conventional methods.

[0055] A further aspect of the invention relates to the use of vamifeport and its salts, solvates, hydrates or polymorphs as described herein in the treatment of HH, wherein the treatment is controlled to reduce serum iron levels and / or organ iron levels and / or prevent iron accumulation in organs, compared to untreated or conventionally treated HH patients.

[0056] In a more specific sense, the treatment is controlled to reduce liver iron content and / or prevent iron from accumulating in the liver, pancreas, and / or heart, preferably in the liver.

[0057] In a further aspect, the HH treatment of the present invention can result in an increase in the time interval between a venous incision setting and a subsequent venous incision setting throughout the treatment period.

[0058] In a further aspect, the HH treatment of the present invention enables HH patients treated according to the method of the present invention to not require venotomy until they are independent of venotomy for at least 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 18 months, 24 months or even longer during or after treatment.

[0059] In a further aspect, the HH treatment of the present invention can lead to a reduction in symptoms associated with one or more clinical HH and / or venous transection complications. Non-limiting examples have been described above.

[0060] In a further aspect, the HH treatment of the present invention can lead to an improvement in the quality of life of patients compared to those measured within 1 week, 2 weeks, 3 weeks, or 4 weeks before the start of treatment according to the present invention. The improvement in quality of life is measured within 3 months, 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, or 24 months after the start of treatment. Quality of life can be measured according to the measurement methods described in the following examples.

[0061] The HH treatment method of the present invention can achieve one or more of the above-mentioned improvements.

[0062] Dosing regimen

[0063] Compounds of formula (I), including their salts, solvates, hydrates, and polymorphs, may be used for treatments as described anywhere herein, wherein the treatment is characterized by one of the following administration regimens:

[0064] In a preferred aspect, the Vamifeport of the present invention is administered to HH patients in need of it on a long-term (i.e., repeated) basis for a selected treatment period, which may be a limited treatment period depending on the patient's condition or may continue for life.

[0065] Long-term dosing includes repeated administration of vamifeport for periods of at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks, and / or up to at least 8 weeks. The amount of dose repeated during such time intervals may vary depending on the patient's age, weight, condition, severity of disease, type of administration, and the course of disease under treatment.

[0066] In the method of the present invention, the Vamifeport of the present invention can be administered at a dose of 0.001 mg to 500 mg, for example, once to four times daily. However, the dose may be increased or decreased depending on the patient's age, weight, condition, severity of disease or type of administration, and the progression of disease under treatment.

[0067] In a further aspect of the invention, vamifeport can be used in dosages of 0.1mg, 0.2mg, 0.3mg, 0.4mg, 0.5mg, 0.6mg, 0.7mg, 0.8mg, 0.9mg, 1mg, 1.5mg, 2mg, 2.5mg, 3mg, 3.5mg, 4mg, 4.5mg, 5mg, 6mg, 7mg, 8mg, 9mg, 10mg, 11mg, 12mg, 13mg, 14mg, 15mg, 16mg, 17mg, 18mg, 19mg, 20mg, 25mg, 30mg, 35mg, 40mg, 45mg, 50mg, 55mg, 60mg, 65mg, 70mg, 75mg, 80mg, 85mg, 90mg, 95mg, 100mg, 105mg, 110mg, etc. Dosages of 115mg, 120mg, 125mg, 130mg, 135mg, 140mg, 145mg, 150mg, 155mg, 160mg, 165mg, 170mg, 175mg, 180mg, 185mg, 190mg, 195mg, 200mg, 205mg, 210mg, 215mg, 220mg, 225mg, 230mg, 235mg, 240mg, 245mg, 250mg, 255mg, 260mg, 265mg, 270mg, 275mg, 280mg, 285mg, 290mg, 295mg, 300mg, 325mg, 350mg, 375mg, 400mg, 425mg, 450mg, 475mg, and 500mg are administered.

[0068] The preferred dosage is between 0.5 mg and 500 mg, more preferably between 5 mg and 400 mg. The most preferred dosages are 5 mg, 15 mg, 30 mg, 60 mg, 120 mg, 180 mg, 240 mg or 360 mg.

[0069] The dosage defined above refers to the total dose administered to the human body, preferably as a single dose or split into two or three doses / dosage days.

[0070] Preferably, vamifeport is administered daily at the above-defined dose.

[0071] Preferably, the treatment of the present invention includes administration of vamifeport in doses from 40 mg to 360 mg per day, including daily doses of 40 mg, 60 mg, 120 mg, 180 mg, 240 mg or 360 mg in a single dose or in doses of two or three times daily.

[0072] The above dose can be administered as a single daily dose or as a total daily dose divided into sub-dose administrations two, three, or even more times per day.

[0073] In further respects, doses may be administered from 0.001 mg / kg to 35 mg / kg body weight, 0.01 mg / kg to 35 mg / kg body weight, 0.1 mg / kg to 25 mg / kg body weight, or doses between 0.5 mg / kg, 1 mg / kg, 2 mg / kg, 3 mg / kg, 4 mg / kg, 5 mg / kg, 6 mg / kg, 7 mg / kg, 8 mg / kg, 9 mg / kg, 10 mg / kg up to a maximum of 20 mg / kg body weight. Particularly preferred doses are 120 mg (for patients weighing >50 kg) and 60 mg (for patients weighing <50 kg), once or twice daily in each case.

[0074] In a further aspect, one of the doses defined above may be selected as the initial dose, and the same or different doses defined above may be administered once or more at repeat intervals of 1 to 7 days, 1 to 5 days, preferably 1 to 3 days or every two days.

[0075] The initial and subsequent doses can be selected from the doses defined above and adjusted / changed within the provided range according to the needs of HH patients.

[0076] In particular, the amount of subsequent doses can be appropriately selected based on the individual patient, the course of the disease, and the treatment response. One, two, three, four, five, six, seven, or more subsequent doses can be administered.

[0077] It is possible that the initial dose is equal to or different from the one or more subsequent doses. It is further possible that the subsequent doses are equal or different.

[0078] The repetition interval can be of the same length, or it can vary depending on the individual patient, the course of the disease, and the treatment response.

[0079] Preferably, the amount of subsequent doses decreases as the number of subsequent administrations increases.

[0080] Preferably, during a treatment period of at least 3 days, at least 5 days, or at least 7 days, the dosage is 3 mg to 360 mg, more preferably 5 mg to 360 mg, and most preferably 5 mg, 15 mg, 30 mg, 60 mg, 120 mg, 180 mg, 240 mg, or 360 mg, administered once, twice, or three times daily. In a further preferred aspect, a dosage of 60 mg or 120 mg is administered once daily. In a further preferred aspect, a total daily dose of 120 mg is administered by administering a dose of 60 mg twice daily, or a total daily dose of 240 mg is administered by administering a dose of 120 mg twice daily or a dose of 60 mg three times daily. Further preferred dosing regimens include administering a total daily dose of 240 mg or 360 mg as a single dose or split into two or three subsets, for example, administering 240 mg / day as two 120 mg subsets, or administering 360 mg / day as two 180 mg subsets or three 120 mg subsets.

[0081] In a further preferred embodiment, a total daily dose of 240 mg is administered by taking 120 mg twice daily, or a total daily dose of 360 mg is administered by taking 120 mg three times daily. These doses have been shown to be safe and well-tolerated.

[0082] The preferred dosing regimen further exhibits rapid oral absorption, with levels detectable as early as 15 to 30 minutes after administration. Even with repeated dosing, absorption levels remain stable, and no significant accumulation has been observed.

[0083] The preferred dosing regimen further demonstrated an effective reduction in mean serum iron levels and mean calculated transferrin saturation, as well as a shift in the mean serum hepcidin peak, thus indicating its efficacy in treating HH.

[0084] In a further aspect of the invention, the initial and one or more subsequent drug administrations are adjusted according to the hemoglobin concentration of the patient being treated. The hemoglobin concentration is determined using conventional methods.

[0085] combination therapy

[0086] A further object of the present invention relates to the use of vamifeport (including its salts, solvates, hydrates and polymorphs) in combination with conventional venipuncture therapy for the treatment of HH.

[0087] Drug administration can be performed before or simultaneously with the venipuncture procedure.

[0088] A preferred aspect of the invention relates to treating HH as described anywhere herein in the form of a combination therapy, which includes long-term administration of vamifeport as described above and frequent venous transection.

[0089] As described above, this combination therapy specifically includes long-term administration of vamifeport (at the same or different doses and / or dosing intervals) and increases the time interval between one venipuncture setting and subsequent venipuncture settings throughout the treatment period.

[0090] In a further aspect, as described above, this combination therapy specifically includes long-term administration of vamifeport (at the same or different doses and / or dosing intervals), and increases the time interval between one venous cut-off setting and subsequent venous cut-off settings throughout the treatment period until venous cut-off treatment is completely discontinued and replaced by vamifeport administration.

[0091] In a further aspect of the invention, a medicament, pharmaceutical composition, or dosage form comprising vamifeport as defined herein may be present as a combination formulation containing one or more other pharmaceutically active compounds in addition to vamifeport (“combination therapy compounds” / “combination drugs”). Such other active compounds are preferably selected from those compounds that can be used to treat patients with HH. In particular, preferred combination therapy compounds are selected from compounds that are used to treat iron overload and related symptoms, or combination drugs that can be used to treat HH-related pathological conditions and symptoms as described above.

[0092] Combination therapies having one or more of the combination therapy compounds (combination drugs) defined above can be administered using a fixed dose or a free dose combination for sequential use. Such combination therapies may include co-administration of vamifeport as defined in this invention with at least one other pharmaceutically active compound (drug / combination therapy compound).

[0093] Combination therapy in fixed-dose combination therapy includes co-administration of vamifeport as defined herein with at least one other pharmaceutically active compound in a fixed-dose formulation.

[0094] Combination therapy in free-dose combination therapy includes co-administering, as defined herein, vamifeport with at least one other pharmaceutically active compound, either by simultaneous administration of a single compound or by sequential use of distributed single compounds over a period of time.

[0095] Vamifeport salts, solvates, hydrates, and polymorphs

[0096] This invention relates to novel medical uses of the compound vamifeport having the structure according to formula (I):

[0097]

[0098] In a further aspect, the present invention relates to uses and treatment methods as defined herein, wherein the compound of formula (I) is used in the form of its pharmaceutically acceptable salts or solvates, hydrates and polymorphs.

[0099] Examples of suitable pharmaceutically acceptable salts are described in international applications WO2017 / 068089, WO2017 / 068090 and WO2018 / 192973. Further examples of suitable salt forms and polymorphs are described in international application WO2021 / 191202, which is incorporated herein by reference.

[0100] In a preferred aspect, the HCl salt of Vamifeport is used in the treatment methods described anywhere herein, and more preferably the 3HCl salt of Vamifeport is used.

[0101] Other suitable pharmaceutically acceptable salts include salts formed with acids selected from benzoic acid, citric acid, fumaric acid, lactic acid, malic acid, maleic acid, methanesulfonic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid, and toluenesulfonic acid; preferably salts formed with acids selected from citric acid, maleic acid, phosphoric acid, and sulfuric acid.

[0102] Typically, pharmaceutically acceptable salts of vamifeport can be selected from single salts (1:1 salts), triple salts (1:3 salts), and salts characterized by a vamifeport to acid ratio of (1-2):(1-3); including their solvates, hydrates, and polymorphs.

[0103] The salt of vamifeport is characterized by the selected base:acid ratio, i.e., vamifeport:acid as defined above, in the range of 1.0 to 2.0 (molar base): 1.0 to 3.0 (molar acid). In a specific embodiment, the selected base:acid ratio is 1.0 to 2.0 (molar base): 1.0 to 2.0 (molar acid).

[0104] Specific examples include the following base:acid ratio, i.e., vamifeport:acid as defined above:

[0105] 1.0 (molar base): 1.0 (molar acid);

[0106] 1.0 (molar base): 1.25 (molar acid);

[0107] 1.0 (molar base): 1.35 (molar acid);

[0108] 1.0 (molar base): 1.5 (molar acid);

[0109] 1.0 (molar base): 1.75 (molar acid);

[0110] 1.0 (molar base): 2.0 (molar acid);

[0111] 1.0 (molar base): 3.0 (molar acid); and

[0112] 2.0 (molar base): 1.0 (molar acid).

[0113] Salts with a base-to-acid ratio of 1:1 are also called "single salts" or "1:1 salts". For example, a single HCl salt is also called 1HCl or 1HCl salt.

[0114] Salts with a base-to-acid ratio of 1:2 are also called "disalts" or "1:2 salts". For example, diHCl salts are also called 2HCl or 2HCl salts.

[0115] Salts with a base-to-acid ratio of 1:3 are also called "tri-salts," "tri-combination salts," or "1:3 salts." For example, triHCl salts are also called 3HCl or 3HCl salts.

[0116] A salt with a base-to-acid ratio of 1:1.25 is also called a "1:1.25 salt".

[0117] A salt with a base-to-acid ratio of 1:1.35 is also called a "1:1.35 salt".

[0118] A salt with a base-to-acid ratio of 1:1.5 is also called a "1:1.5 salt".

[0119] A salt with a base-to-acid ratio of 1:1.75 is also called a "1:1.75 salt".

[0120] A salt with a base-to-acid ratio of 2:1 is also called a "half-salt" or "2:1 salt".

[0121] Vamifeport salts can exist in amorphous, polymorphic, crystalline and / or semi-crystalline (partially crystalline) forms, as well as in the form of solvates of the salts. Preferably, Vamifeport salts exist in crystalline and / or semi-crystalline (partially crystalline) forms and / or in the form of solvates of the salts.

[0122] The crystallinity of preferred salts or salt solvates can be determined using conventional analytical methods, particularly by various X-ray methods, which makes the analysis of salt compounds clear and simple. In particular, the degree of crystallinity can be determined or confirmed by using powder X-ray diffraction (reflection) or by using powder X-ray diffraction (transmission) (PXRD). Different resulting crystal gratings for crystalline solids with the same chemical composition are summarized by the term "polymorphism." For reference on solvates, hydrates, and polymorphs, as well as salts with specific crystallinities, see international applications WO2018 / 192973 and WO2021 / 191202, which are incorporated herein by reference.

[0123] In a further aspect of the invention, the vamifeport compound (I) is selected from the following salts:

[0124] 1:1 sulfates with the following formula

[0125]

[0126] 1:1 phosphates with the following formula

[0127]

[0128] 2:1 phosphate (hemiphosphate)

[0129]

[0130] And their polymorphs.

[0131] As described in WO2017 / 068089, WO2017 / 068090 and WO2018 / 192973, compound (I) of vamifeport is an inhibitor of membrane iron transporters. Therefore, the membrane iron transporter inhibitory activity of vamifeport is described in the aforementioned international applications.

[0132] Dosage form

[0133] In a further aspect of the invention, treatment of HH includes oral administration to a patient in need of it of vamifeport, its salts, solvates, hydrates or polymorphs as described anywhere herein.

[0134] Therefore, vamifeport, including its salts, solvates, hydrates or polymorphs, is preferably provided in a pharmaceutical or pharmaceutical composition in an oral administration form, including, for example, pills, tablets (e.g., enteric-coated tablets, film tablets and layered tablets), sustained-release formulations for oral administration, reservoir formulations, sugar tablets, granules, emulsions, dispersants, microcapsules, microformulations, nanoformulations, liposome formulations, capsules (e.g., enteric-coated capsules), powders, microcrystalline formulations, powders, drops, ampoules, solutions and suspensions for oral administration.

[0135] In a preferred embodiment of the invention, vamifeport, including its salts, solvates, hydrates, or polymorphs, is administered in the form of tablets or capsules as defined above. These may be present, for example, in an acid-resistant form or with a pH-dependent coating.

[0136] Therefore, a further aspect of the present invention relates to the compound vamifeport, including its salts, solvates, hydrates or polymorphs, and pharmaceuticals, compositions and formulations comprising them for the treatment of HH in an oral administration form.

[0137] A drug, pharmaceutical composition, or dosage form containing vamifeport, its salts, solvates, hydrates, or polymorphs may further contain one or more compounds selected from drug carriers, excipients, solvents, and excipients.

[0138] Preferably, the drug carrier, adjuvant, solvent, and excipient are selected from suitable compounds used to prepare oral dosage forms.

[0139] The drug, pharmaceutical composition, or dosage form may contain, for example, up to 99% by weight, up to 90% by weight, up to 80% by weight, or up to 70% by weight of Vamifeport, including its salts, solvates, hydrates, or polymorphs, with the remainder formed by a drug carrier, adjuvants, solvents, and excipients, and optionally further contain a pharmaceutically active compound in the case of combination therapy dosage forms as described below.

[0140] Pharmaceutically acceptable carriers, excipients, or solvents are common drug carriers, excipients, and solvents, including a variety of organic or inorganic carriers and / or excipients, as they are commonly used for pharmaceutical purposes, particularly for solid drug formulations. Examples include: excipients such as sucrose, starch, mannitol, sorbitol, lactose, glucose, cellulose, talc, calcium phosphate, and calcium carbonate; binders such as cellulose, methylcellulose, hydroxypropylcellulose, polypropylene pyrrolidone, gelatin, gum arabic, polyethylene glycol, sucrose, and starch; disintegrants such as starch, hydrolyzed starch, carboxymethylcellulose, calcium carboxymethylcellulose, hydroxypropyl starch, sodium glycol starch, sodium bicarbonate, calcium phosphate, and calcium citrate; lubricants such as magnesium stearate, talc, and sodium lauryl sulfate; and flavor enhancers such as citric acid, menthol, and glycine. Orange powder; preservatives, such as sodium benzoate, sodium bisulfite, parabens (e.g., methylparaben, ethylparaben, propylparaben, butylparaben); stabilizers, such as citric acid, sodium citrate, acetic acid, and polycarboxylic acids from the titriplex series, such as diethylenetriaminepentaacetic acid (DTPA); suspending agents, such as methylcellulose, polyvinylpyrrolidone, aluminum stearate; dispersants; diluents, such as water, organic solvents; waxes, fats and oils, such as beeswax, cocoa butter; polyethylene glycol; white petrolatum, etc.

[0141] Liquid pharmaceutical formulations, such as solutions, suspensions, and gels, typically contain a liquid carrier, such as water, and / or a pharmaceutically acceptable organic solvent. In addition, such liquid formulations may also contain pH adjusters, emulsifiers or dispersants, buffers, preservatives, wetting agents, gelling agents (e.g., methylcellulose), dyes, and / or flavoring agents, as defined above. The compositions can be isotonic, i.e., they may have the same osmotic pressure as blood. The isotonicity of the composition can be adjusted by using sodium chloride and other pharmaceutically acceptable agents, such as glucose, maltose, boric acid, sodium tartrate, propylene glycol, and other inorganic or organic soluble substances. The viscosity of the liquid composition can be adjusted by a pharmaceutically acceptable thickener, such as methylcellulose. Other suitable thickeners include, for example, xanthan gum, carboxymethyl cellulose, hydroxypropyl cellulose, carbomer, etc. The preferred concentration of the thickener will depend on the agent chosen.

[0142] Pharmaceutically acceptable preservatives can be used to increase the shelf life of the liquid composition. Benzyl alcohol can be suitable, although a variety of preservatives can also be used, including, for example, parabens, thimerosal, chlorobutanol, and benzalkonium chloride. Attached Figure Description

[0143] Figure 1Pharmacokinetics of single oral doses of vamifeport in Hfe C282Y and 129S2 wild-type mice with hereditary hemochromatosis. Experimental design (A); serum iron concentration (B); hepatic Hamp expression in Hfe C282Y (left) and 129S2 wild-type (right) mice after solvent or vamifeport treatment (C). For all scatter plots, data are presented as individual values ​​and means (n ​​= 6 to 10 animals / time point / treatment). Significant differences compared to the solvent-treated group are represented as *p < 0.05, **p < 0.01, and ***p < 0.001.

[0144] Figure 2 Pharmacokinetics of vamifeport after long-term oral administration in an Hfe C282Y mouse model of hereditary hemochromatosis. Experimental design (A); serum iron concentration and hepatic Hamp expression (B); hemoglobin levels over time (C); total liver iron and 58 Liver iron concentration (D). Total spleen iron concentration and representative images of DAB-enhanced Perls staining of duodenal cross sections from solvent- or vamifeport-treated Hfe C282Y mice (E). Hemoglobin data are presented as mean with standard deviation. For all scatter plots, data are presented as individual values ​​and mean (n = 5 to 6 animals / time points / treatment). Significant differences compared to the solvent-treated groups are indicated in black: *p < 0.05, **p < 0.01, and ***p < 0.001; significant intra-treatment differences within the solvent groups are indicated in gray: week 1 vs. week 7. Week 1 compared to Week 8 Week 7 compared to week 8 § p < 0.05. Significant intra-treatment differences in the vamifeport group are indicated in blue: week 3 vs. week 7. Week 4 compared to Week 7 Week 7 compared to week 8 § p < 0.05 [LID, low-iron diet].

[0145] Figure 3: Hematologic kinetics of long-term oral administration of vamifeport in an Hfe C282Y mouse model of hereditary hemochromatosis. Red blood cell (RBC) count (A); reticulocyte count (B); white blood cell count (C); platelet count (D); hematocrit level (E); mean corpuscular hemoglobin (MCH) concentration (F); mean corpuscular volume (MCV) (G); reticulocyte hemoglobin (Hb) concentration (H). For all scatter plots, data are presented as individual values ​​and means (n ​​= 5 to 6 animals / time point / treatment). Significant differences compared to the solvent-treated group are represented as: *p < 0.05, **p < 0.01, and ***p < 0.001.

[0146] Figure 4 In the Hfe C282Y mouse model of hereditary hemochromatosis, Vamifeport did not interfere with hepatic iron removal via venous incision. Experimental design (A); serum iron concentration and hepatic Hamp expression (B); total hepatic iron and 58 Liver iron concentration (C); total spleen iron concentration (D). For all scatter plots, data are presented as individual values ​​and means (n ​​= 6 to 9 animals / time point / treatment). Significant differences between treatment groups are represented as *p < 0.05, **p < 0.01, and ***p < 0.001.

[0147] [LID, Low-Iron Diet; SD, Standard Diet; WT, Wild Type].

[0148] Figure 5 : The kinetics of hematologic effects of long-term oral administration of vamifeport and venous incision treatment in an Hfe C282Y mouse model of hereditary hemochromatosis. Hemoglobin levels (A); erythropoietin (B). Hemoglobin data are presented as mean and standard deviation. For scatter plots, data are presented as individual values ​​and mean (n = 5 to 6 animals / time point / treatment). Significant differences compared to the solvent-treated group are represented as: *p < 0.05, **p < 0.01 and ***p < 0.001 [OD, optical density; WT, wild type].

[0149] Example

[0150] The invention is illustrated in more detail by way of the following examples. These examples are merely illustrative, and those skilled in the art can extend the specific examples to other membrane iron transporter inhibitor compounds of the invention.

[0151] I. Vamifeport and its salts, solvates, hydrates or polymorphs

[0152] For the preparation of the compound vamifeport used in the method of the present invention, and the preparation of its pharmaceutically acceptable salts, solvates, hydrates or polymorphs, see international applications WO2017 / 068089, WO2017 / 068090, WO2018 / 192973 and WO2021 / 191202.

[0153] II. Preclinical studies of the membrane iron transporter inhibitor compound Vamifeport in pharmacological assays for hemochromatosis Evaluation in mouse models II.1 Materials and Methods

[0154] Test compounds

[0155] In the experiment described below, vamifeport was administered in the form of a 3HCl salt.

[0156] animal models

[0157] Mice were housed under pathogen-free conditions. Mice were fed and acclimatized in the facility for at least 5 days prior to the start of the study. Animals were grouped and housed under a 12-hour reverse dark / light cycle (2–5 mice per cage), with nesting material, enrichment material, and water / food provided for their free access. Both acute and long-term studies were conducted in the laboratory, with animals transferred to the housing after each procedure in the long-term studies. No blinding of treatments was performed in these studies.

[0158] A) Acute acute effects of a single oral dose of Vamifeport in HH HfeC282Y mouse models and 129S2 wild-type mice Sexual pharmacodynamics

[0159] To investigate the acute effects of vamifeport, cages of 8- to 9-week-old female (n=42) and male (n=39) Hfe C282Y mice [Levy JE et al., The C282Y mutation causing hereditary hemochromatosis does not produce a null allele. Blood., 1999; Vol. 94: pp. 9-11] (JAX stock#005063; Jackson Laboratory, Bar Harbor, ME) and strain- and age-matched wild-type female (n=45) and male (n=45) 129S2 / SvPasCRL mice (Charles River Laboratories, Sulzfeld, Germany) were randomly assigned to relevant treatment groups and time points. Mice received a single dose of the solvent (0.5% methylcellulose) or 60 mg / kg (10 mL / kg) of vamifeport via gavage. Following administration, animals had free access to a low-iron diet (LID; #2039, Fe = 13.4 mg / kg; Granovit SA, Kaiseraugst, Switzerland) and drinking water. Multiple groups of animals were euthanized by complete exsanguination at 0.5, 1, 3, 6, and 16 hours post-administration, after terminal anesthesia with isoflurane. Blood and liver samples were collected for analysis of serum iron and hepatocytin (Hamp) expression.

[0160] B) Long-term pharmacodynamic effects of Vamifeport administered via drinking water in the HH Hfe C282Y mouse model.

[0161] To investigate the long-term effects of vamifeport, Hfe C282Y mice were allocated to cages at weaning (3 weeks of age), and each cage was assigned to a treatment group / time point by stratified randomization. Mice had free access to LID (#2039, Fe = 10.4 mg / kg; Granovit SA, Kaiseraugst, Switzerland) and drinking water. Wild-type mice were not used in accordance with the 3R principle, as the primary objective was to evaluate the effects of vamifeport relative to solvent treatment in a long-term study. Vamifeport was administered in drinking water, rather than by gavage as in acute studies, to avoid direct manipulation of the animals and the potential stress associated with prolonged twice-daily gavage (i.e., over several weeks of treatment). Four-week-old female (n=15) and male (n=26) Hfe C282Y mice (129-Hfetm 1.1 Nca / J) were provided with autoclaved mineral water containing either solvent or 1.0 mg / mL vamifeport (based on the weight of vamifeport, corresponding to a daily oral dose of approximately 110 mg / kg) for free access for 8 weeks. Vamifeport formulation was prepared weekly in the drinking water, and water intake was measured in each cage every 3 or 4 days by weighing the water bottle. The average daily water intake was 2.7 ± 0.3 mL / mouse. The mineral water was supplemented with... 58 Fe(II)SO4 (0.5 mM), 1% glucose, and 10 mM ascorbic acid were administered based on the oral dose (120 mg / kg; 60 mg / kg twice daily by gavage) shown to be effective in other mouse models of long-term vamifeport treatment [Manolova V et al., Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of β-thalassemia. J Clin Invest., 2019, Vol. 130: 491-506.]. Small blood samples were collected weekly via a tail vein incision for hemoglobin level analysis. Animals were euthanized by complete exsanguination after cervical dislocation following terminal isoflurane anesthesia at predetermined time points (weeks 2, 4, 6, and 8). Blood and liver samples were collected to analyze the effects of vamifeport on serum and organ iron levels and hepatocytin (Hamp) expression.

[0162] C) In the HH Hfe C282Y mouse model, administration of Vamifeport via drinking water to the liver after venous transection... Long-term effects of iron removal

[0163] A preliminary study was conducted to investigate the potential of combining vamifeport with venipuncture in 9- to 10-week-old female (n=7) and male (n=6) Hfe C282Y mice, administered either a solvent in drinking water or 0.3 mg / mL (approximately 40 mg / kg) or 1 mg / mL (approximately 110 mg / kg) of vamifeport, as described above. Mice were given an ad libitum to a standard diet (#3432, Fe=170 mg / kg; Granovit SA, Kaiseraugst, Switzerland) for 9 to 10 weeks (iron-loaded), then switched to LID (Fe=13.4 mg / kg) at week 0 of the study. Mice were anesthetized with isoflurane and venipuncture was performed every 2 weeks via sublingual bloodletting (removing approximately 20% of their total blood volume). Hfe C282Y mice (4 males / 4 females) treated with solvent and not subjected to venotomy, and wild-type 129S2 mice (4 males / 5 females) served as controls. At the end of the study (week 4), mice were anesthetized pretermally with isoflurane, and blood was collected via retroorbital effusion. Mice were then euthanized by cervical dislocation, and their livers were harvested for analysis of the combined use of vamifeport and venotomy on organ iron accumulation.

[0164] Analysis of iron-related parameters

[0165] Serum iron levels were measured three times using the MULTIGENT iron assay (Abbott Diagnostics, Baar, Switzerland) at 0.5 hours, 1 hour, 3 hours, 6 hours, and 16 hours in the acute study and at 2 weeks, 4 weeks, 6 weeks, and 8 weeks in the long-term study.

[0166] According to the manufacturer's instructions, the relative expression of hepatic hepcidin (Hamp) was analyzed by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) using the TaqMan gene expression assay (#Mm04231240_s1; Thermo Fisher Scientific, Waltham, MA) on a LightCycler 480II instrument (Roche Diagnostics, Rotkreuz, Switzerland). Hamp transcription levels were calculated by comparison with the reference gene Gusb (TaqMan: #Mm01197698_m1; Thermo Scientific, Waltham, MA). Hamp expression levels were analyzed at 0.5 hours, 1 hour, 3 hours, 6 hours, and 16 hours in acute studies and at 2 weeks, 4 weeks, 6 weeks, and 8 weeks in long-term studies.

[0167] In long-term and venous transection studies, hemoglobin concentration (HemoCue AB) in tail vein blood was measured weekly. Sweden).

[0168] Complete blood cell counts were measured using a veterinary ProCyte blood analyzer (Idexx Bioresearch, Westbrook, ME).

[0169] Organs were flash-frozen in liquid nitrogen, and total iron and / or total iron were determined using inductively coupled plasma atomic emission spectrometry (ICP-AES) and inductively coupled plasma mass spectrometry (ICP-MS), respectively. 58 Fe concentration. Organ iron levels (total iron and...) were analyzed at 4 weeks in the venous transection study and at 2, 4, 6, and 8 weeks in the long-term study. 58 Fe).

[0170] The duodenum was fixed in 10% buffered formalin and embedded in paraffin. Deparaffinized tissue sections were stained for non-heme iron deposition using DAB-enhanced Perls staining. Serial sections were stained with hematoxylin and eosin (HE). Images were acquired using an Olympus VS120 virtual slide microscope with a 40× objective lens (NA 0.95).

[0171] Statistical analysis

[0172] As part of the animal license application (ZH108 / 2017) for a long-term study, prior sample size calculations were performed using estimated effect sizes with several parameters, targeting a power of 0.8 and α = 0.05. Analysis of hemoglobin data was performed using two-way ANOVA, with repeated measures for time-course effects. Bonferroni multiple comparison tests were performed in cases where statistically significant effects were observed. Serum iron, Hamp gene expression, and organ iron concentrations were analyzed using one-way ANOVA and Dunnett multiple comparison tests. Statistical analysis was performed using Prism software (GraphPad Prism version 9.4.1, San Diego, CA).

[0173] result

[0174] A) The effect of a single dose of Vaifeport on serum levels in the HH HfeC282Y mouse model compared to 129S2 wild-type mice. Effects of iron and decreased hepatic Hamp expression

[0175] Mice homozygous for the C282Y mutation (Hfe C282Y mice) exhibit limited Hfe expression and show characteristics consistent with those in HFE deficiency (Hfe... - / -The iron metabolism-related parameters observed in mice were similar. Both mouse models developed iron overload due to defects in the expression of iron-regulated Hamp, and reproduced well the pathology observed in human HH [Levy JE et al., The C282Y mutation causing hereditary hemochromatosis does not produce a null allele. Blood., 1999, Vol. 94: pp. 9-11; Zhou XY et al., HFE geneknockout produces mouse model of hereditary hemochromatosis. Proc Natl Acad Sci US A., 1998; Vol. 95: pp. 2492-2497].

[0176] To evaluate the pharmacodynamic effects of vamifeport on systemic iron levels in the HH model, a single oral dose of vamifeport (60 mg / kg) was administered to Hfe C282Y mice and the corresponding wild-type control (129S2 mice), and the kinetics of changes in serum iron and hepatic Hamp expression were assessed. Figure 1 Figure A presents a schematic diagram outlining the experimental design of a study assessing the acute effects of vamifeport treatment.

[0177] Consistent with data published by HH Levy JE et al., Blood., 1999; Vol. 94: pp. 9-11, at all time points, the steady-state serum iron levels in solvent-treated Hfe C282Y mice were slightly higher than their wild-type counterparts in 129S2 mice (51 μM ± 4 μM vs. 45 μM ± 5 μM, respectively). Figure 1 (B) In both Hfe C282Y and 129S2 wild-type mice, serum iron levels began to decrease 30 minutes after a single oral administration of vamifeport (60 mg / kg). However, compared to their corresponding wild-type mice, the response to vamifeport in Hfe C282Y mice was delayed, less pronounced, and shorter in duration. In vamifeport-treated Hfe C282Y mice, serum iron levels were significantly lower at 1 hour and 3 hours after administration than those observed after solvent treatment, while in 129S2 wild-type mice, serum iron levels were significantly lower at 30 minutes, 1 hour, 3 hours, and 6 hours after administration compared to solvent treatment. In Hfe C282Y or 129S2 mice, there was no difference in serum iron levels between the vamifeport-treated and solvent-treated groups at 16 hours after administration.

[0178] At all time points, hepatic Hamp expression in solvent-treated Hfe C282Y mice was lower than in their wild-type counterparts (expressed as mean ΔCt Gusb-Hamp 6.6 ± 0.1 vs. 8 ± 0.5). Figure 1 C).

[0179] Interestingly, in Hfe C282Y mice, a single oral administration of vamifeport (60 mg / kg) did not significantly alter hepatic Hamp expression, but in 129S2 wild-type mice, a significant decrease was observed at 3 and 6 hours post-vamifeport treatment. This clearly demonstrates that iron limitation-induced hepatic Hamp expression is regulated differently in Hfe C282Y and 129S2 wild-type mice.

[0180] B) In the HH HfeC282Y mouse model, long-term iron restriction by Vamifeport led to a decrease in serum and liver iron levels. Continue to decrease

[0181] To investigate the long-term effects of vamifeport treatment on serum iron, liver Hamp, hemoglobin, and organ iron concentrations, a cohort of Hfe C282Y mice received vamifeport at a daily dose of 1.0 mg / mL (corresponding to 110 mg / kg) in drinking water for up to 8 weeks. The experimental design of this study is as follows: Figure 2 As shown in Figure A.

[0182] In Hfe C282Y mice, serum iron levels began to decline at week 2 of vamifeport administration, but the difference at this time point was not significant compared to serum iron levels observed with solvent treatment. Figure 2 B). Long-term vamifeport intake led to a sustained decrease in serum iron levels in Hfe C282Y mice—serum iron concentrations continued to decline at weeks 4, 6, and 8 of vamifeport treatment, and were significantly lower than those observed at all of these time points when treated with the solvent.

[0183] Contrary to what was observed in acute studies (where Hamp expression was measured up to 16 hours after a single dose of vamifeport), hepatic Hamp expression in Hfe C282Y mice was significantly lower than in the solvent-treated group at weeks 2, 4, 6, and 8 after long-term vamifeport administration. Figure 2 B). These data suggest that the sustained iron restriction induced by long-term vamifeport treatment regulates Hamp expression differently than that induced by acute vamifeport treatment.

[0184] Except for week 7, from week 1 to the end of the study (week 8), significantly lower hemoglobin levels were observed in solvent-treated Hfe C282Y mice during long-term vamifeport administration. Figure 2 C) reflects vamifeport-induced iron-limiting erythropoiesis.

[0185] Mutations present in Hfe C282Y mice lead to inappropriate Hamp expression, resulting in low hepcidin levels and excessive iron uptake and storage. Following prolonged Vamifeport treatment, Hfe C282Y mice maintained significantly lower total liver iron concentrations (reflecting liver iron accumulation before and during the study) than those after solvent treatment. The difference in total liver iron concentration was observed from week 2, and the vamifeport-treated animals maintained lower levels throughout the study, reaching statistical significance from week 4 onwards. Figure 2 D).

[0186] Long-term intake of vamifeport through drinking water prevents 58 Fe accumulation in the liver of Hfe C282Y mice was observed after solvent administration. In mice treated with vamifeport, this was observed at weeks 2, 4, 6, and 8. 58 The liver iron concentration was significantly lower in mice treated with solvent than in mice treated with solvent. Figure 2 The concentration in D) indicates that Vamifeport's iron restriction effectively prevents de novo iron accumulation.

[0187] In both the solvent-treated and vamifeport-treated groups, total spleen iron concentration increased over time; however, at week 6, the level in mice receiving long-term vamifeport treatment was significantly higher than that in mice receiving solvent treatment, reflecting that iron retention in spleen cells is a result of inhibition of membrane iron transporters. Figure 2 E). DAB-enhanced Perls staining of duodenal cross-sections from Hfe C282Y mice revealed iron accumulation in duodenal intestinal cells after 8 weeks of vamifeport treatment; in mice treated with solvent, duodenal staining was not obvious. Figure 2 E). These data indicate that vamifeport inhibits iron export from spleen cells and dietary iron absorption.

[0188] Compared to the solvent, in Hfe C282Y mice treated with vamifeport, the number of red blood cells increased significantly at 6 weeks, and a significant increase in reticulocytes was observed at 2 and 4 weeks. Figure 3 A, Figure 3 B). White blood cell and platelet levels were similar in these treatment groups. Figure 3C Figure 3 D). At all time points, in solvent-treated Hfe C282Y mice, hematocrit, mean corpuscular hemoglobin, mean corpuscular volume, and reticulocyte hemoglobin levels were significantly higher, due to iron-limiting erythropoiesis induced during Vamifeport treatment. Figure 3 E to Figure 3 H).

[0189] C) In the HH Hfe C282Y mouse model, Vamifeport and liver iron removal via venous incision were compared. combination therapy

[0190] Venotomy is currently the standard of care in the clinical management of HH patients, and is usually performed weekly during the induction phase, decreasing to 3-4 times per year during the maintenance phase. To investigate the potential of combining vamifeport treatment with venotomy in HH, a preliminary study was conducted to evaluate the effect of combining vamifeport with bi-weekly venotomy compared to venotomy alone (i.e., with solvent treatment) in Hfe C282Y mice. The experimental design of this preliminary study included… Figure 4 In A.

[0191] Vamifeport was administered in drinking water at concentrations of 0.3 mg / mL and 1.0 mg / mL, which correspond to daily doses of Vamifeport of approximately 40 mg / kg and 110 mg / kg, respectively. In Hfe C282Y mice that underwent venous transection, water intake containing 0.3 mg / mL vamifeport was similar to that containing solvent (Table 1).

[0192] Table 1. Drinking water consumption and calculated vamifeport dose in the Hfe C282Y mouse venous transection study.

[0193] N / A, not applicable.

[0194] However, Hfe C282Y mice that underwent sublingual vein incision consumed 56% less water (relative to the solvent) containing a higher concentration of vamifeport. Surprisingly, the control group (Hfe C282Y mice that did not undergo sublingual vein incision and were treated with 1 mg / mL vamifeport) consumed only about 20% less water than the solvent-treated group that did not undergo sublingual vein incision, suggesting that water intake containing 1 mg / mL vamifeport was reduced in animals that underwent sublingual vein incision. Based on the measured water intake containing vamifeport, the daily dose of vamifeport in this study was approximately 40 mg / kg for 0.3 mg / mL and approximately 60 mg / kg for 1 mg / mL. Since the intake of vamifeport was disproportionately reduced in the 1 mg / mL dose group, the data obtained only from the 0.3 mg / mL group were considered reliable. Therefore, only the results for the 0.3 mg / mL vamifeport dose were reported.

[0195] Serum iron concentration and hepatic Hamp expression did not change when venipuncture was used alone; however, non-significant decreases were observed in both parameters after treatment with vamifeport plus venipuncture. Figure 4 B).

[0196] In the HH Hfe C282Y mouse model, compared with solvent-treated mice that did not undergo venotomy, venotomy alone significantly reduced total liver iron concentration, but did not affect... 58 Fe liver iron concentration ( Figure 4 C). Importantly, in Hfe C282Y mice that underwent venous incision plus vamifeport, vamifeport did not interfere with the hepatic iron removal effect of venous incision compared with Hfe C282Y mice that underwent venous incision alone (total hepatic iron levels were lower, but not statistically significant). Furthermore, the decrease in total iron levels observed with venous incision plus vamifeport compared to no venous incision (p < 0.001) was statistically significant compared to the decrease in total iron levels observed with venous incision alone compared to no venous incision (p < 0.05). Between Hfe C282Y mice that underwent venous incision alone and those that did not, 58 There was no significant difference in liver iron levels. In Hfe C282Y mice, the combined use of vamifeport and venous incision significantly reduced [iron levels] compared to venous incision alone. 58 Fe liver iron concentration indicates that vamifeport prevents 58Fe is absorbed from drinking water, thus preventing iron accumulation in the liver. Similar levels of hemoglobin, splenic iron, and erythropoietin were observed during venipuncture plus vamifeport treatment and venipuncture alone treatment. Figure 5 ).

[0197] discuss

[0198] This paper presents preclinical studies evaluating the efficacy of oral vamifeport, a membrane iron transporter inhibitor, alone and in combination with venipuncture in reducing serum iron levels and preventing hepatic iron deposition in a Hfe C282Y mouse model of hepatitis H (HH). In these studies, Hfe C282Y mice exhibited elevated serum iron levels compared to control 129S2 wild-type mice, consistent with lower hepatic expression of the iron-regulating peptide hepcidin in the former group. Both acute and long-term oral vamifeport treatment significantly reduced serum iron levels in this mouse model, suggesting that despite long-term reductions in hepcidin levels, vamifeport's inhibition of membrane iron transporters may still correct elevated systemic iron levels in HH.

[0199] In long-term studies, the decrease in serum iron levels induced by vamifeport treatment reduced iron accumulation in the liver.

[0200] Although Hamp expression was downregulated due to acute hypoferemia at 3 and 6 hours after vamifeport administration in 129S2 wild-type mice, hepatic Hamp expression levels were not significantly altered in Hfe C282Y mice in the acute study. These findings are consistent with the presence of a nonfunctional hepatocyte efflux (HFE) in Hfe C282Y mice, which prevents proper endogenous regulation of hepcidin levels in the presence of acute hypoferemia, leading to progressive organ iron overload. Another possible explanation for the lack of hepcidin downregulation in the acute study is that serum iron levels in Hfe C282Y mice may still remain above the threshold for hepcidin inhibition after acute vamifeport treatment. Although acute vamifeport treatment had no significant effect on hepatic Hamp levels in Hfe C282Y mice, long-term treatment did significantly reduce Hamp expression. The differences in Hamp regulation observed during acute (decreased serum iron and persistent hepatic iron overload) and long-term (decreased serum and hepatic iron concentrations) vamifeport treatment may reflect two hypothesized mechanisms of hepcidin regulation. The detection of changes in hepatic iron storage is primarily mediated by hepatic BMP6, which in turn interacts with BMPRI / II and a multi-protein complex on the hepatocyte membrane to regulate hepcidin expression. Conversely, changes in serum iron (which binds to transferrin) regulate hepcidin expression via HFE and TFR2 signaling.

[0201] During long-term vamifeport treatment, hemoglobin levels were significantly lower than those observed in solvent-treated Hfe C282Y mice, indicating that iron restriction in this HH model restored hemoglobin levels to normal levels similar to those observed in healthy mice in a shorter 3-week study (160 g / L, n = 5 males / 5 females). In Hfe C282Y mice, vamifeport also induced iron-limiting erythropoiesis (likely a function of the decrease in mean erythrocyte volume), as demonstrated by the reductions in mean erythrocyte hemoglobin content, mean erythrocyte volume, and hematocrit levels. Although mice treated with vamifeport had lower total blood hemoglobin levels, red blood cell counts were unaffected. Long-term oral administration of vamifeport also significantly reduced total liver iron concentration and 58 The results showed that vamifeport prevented hepatic iron overload in Hfe C282Y mice. Furthermore, vamifeport treatment led to increased iron retention in iron-exporting organs such as the spleen and duodenum.

[0202] Importantly, in preliminary preclinical studies, vamifeport did not interfere with the iron removal process following venotomy. However, the dose of vamifeport used (approximately 40 mg / kg) was lower than the optimal effective dose (120 mg / kg) demonstrated in other rodent studies. Although a dose of approximately 40 mg / kg of vamifeport did not significantly improve hepatic iron removal, it did prevent iron loss in the liver of Hfe C282Y mice that underwent venotomy. 58 Fe uptake suggests the potential of vamifeport in improving the effectiveness of venous transection in HH patients.

[0203] Therefore, vamifeport offers a new treatment approach that targets HH through fundamental pathophysiology, rather than merely treating the symptoms as currently used in venous transection.

[0204] The data presented in this article support the use of vamifeport in combination therapy with venous cutoff, such as during the induction phase, and have the potential to be an alternative to venous cutoff, such as during the maintenance phase of treatment or in patients unsuitable for venous cutoff.

[0205] To date, methods investigated in the literature include restoring hepcidin levels through administration of hepcidin mimics (e.g., rusfertide [PTG-300] and rusfertide analog PN23114), synthetic hepcidin (e.g., LJPC-401), and minihepcidin (e.g., PR65 and oral minihepcidin PN20076). TMPRSS6 is a protein that inhibits hepcidin transcription, and agents targeting TMPRSS6 (e.g., small interfering RNA [siRNA] formulated with lipid nanoparticles, GalNAc-siRNA conjugate SLN124, and antisense oligonucleotides [e.g., IONIS-TMPRSS6-LRx / sapablursen, all of which target TMPRSS6 expression) are also being evaluated. Most available data come from Hfe at HH. - / - Preclinical studies of subcutaneously administered drugs in knockout mouse models. In these models, almost all tested drugs resulted in decreased serum iron levels and / or TSAT and / or reduced hepatic iron accumulation. However, for the reasons discussed above, treatments requiring injection of drugs are not advantageous compared to orally administered drugs.

[0206] In Hfe2 - / - Mouse (hemojugol knockout [Hjv]) - / - In [ ], the orally available micro-hepcidin PN20076 was also described as significantly reducing hepatic iron accumulation. In contrast, in hepcidin knockout (Hamp) with iron overload, - / - Subcutaneous administration of PR65 to mice was described as not significantly reducing serum iron levels, but significantly reducing liver iron concentrations. However, since hemoglobin levels were also significantly reduced, there may have been uncaptured transient decreases in serum iron concentrations in this study. Interestingly, in HH's Hjv - / - In mouse models, the rus-nonpeptide analog PN23114 improved iron parameters when used in combination with venipuncture.

[0207] As observed in this study of vamifeport, none of the evaluated treatment strategies (PN23114 alone, venipuncture, or a combination of both) resulted in a significant decrease in total hepatic iron content, but all three treatments further reduced hepatic iron deposition. In the most recent 6-month study, subcutaneous administration of rusfetide reduced serum iron levels and hepatic iron concentrations in 16 HH patients receiving a stable venipuncture regimen. Furthermore, the venipuncture rate significantly improved from a mean of 0.27 per month at baseline to 0.03 per month during rusfetide treatment. Positive results were also reported in an interim analysis of a phase 2 study of subcutaneous LJPC-401 versus placebo in 26 HH patients. After 16 weeks of treatment, patients receiving LJPC-401 showed a significant decrease in TSAT compared to placebo, and a significantly reduced need for venipuncture (0.06 venipunctures per month versus 0.41 venipunctures per month, respectively).

[0208] However, as mentioned above, subcutaneous (parenteral) administration is not advantageous compared to oral administration (e.g., using vamifeport). Exemplary advantages include improved patient convenience and ease of administration, reduced medical visits leading to cost savings, dosage / formulation flexibility, avoidance of injection site reactions / infection risks, and generally easier storage and supply chain management compared to injectable agents. Although oral medications typically have slower absorption and onset of action, vamifeport is absorbed relatively quickly, with levels detectable within 15–30 minutes after administration, and serum iron levels drop to trough levels within 4–8 hours in healthy volunteers.

[0209] In summary, these preclinical proof-of-concept studies demonstrate that long-term administration of the membrane iron transporter inhibitor vamifeport significantly reduced serum iron levels and prevented hepatic iron overload in the Hfe C282Y mouse model of HH, thus supporting future clinical development for this indication. Vamifeport has also shown potential as a combination therapy with venipuncture in HH patients in the induction phase, and ultimately as a substitute for venipuncture in HH patients.

[0210] III. Burden of venioplasty

[0211] The venous transection burden of subjects treated according to the method of the present invention can be assessed by determining the patient’s venous transection needs, for example by determining the amount and / or frequency of the bloodletting procedure through routine and clinically recognized evaluation.

[0212] IV. Organ iron levels

[0213] Iron levels, such as those in the liver, kidneys, spleen, duodenum, or myocardium, can be determined using conventional methods. For example, iron levels (e.g., liver iron concentration, pancreatic iron concentration, kidney iron concentration, spleen iron concentration, duodenal iron concentration, or myocardial iron concentration) can be determined by inductively coupled plasma optical emission spectroscopy (ICP-OES) and inductively coupled plasma mass spectrometry (ICP-MS).

[0214] V. Serum ferritin level measurement

[0215] Serum ferritin levels can be measured using standard methods.

[0216] VI. Hemoglobin measurement

[0217] Hemoglobin levels can be measured using standard methods.

[0218] VII. Quality of life

[0219] Quality of life assessments can be evaluated using, for example, the short form (36) health survey (SF-26) described in WO2016 / 183280.

Claims

1. A compound according to formula (I) Or its pharmaceutically acceptable salts, solvates, hydrates or polymorphs, for the treatment of hereditary hemochromatosis.

2. The compound for the purpose according to claim 1, wherein the compound (I) is present in the form of an HCl salt.

3. The compound for the stated purpose according to claim 1 or 2, wherein the compound is a 3HCl salt having the following formula (I-3HCl).

4. The compound for the use according to any one of claims 1 to 3, for treating patients with hereditary hemochromatosis caused by homozygous C282Y and H63D mutations in the HFE gene.

5. The compound for the use according to any one of claims 1 to 4, wherein the treatment is a combination therapy comprising administration of the compound of formula (I) and venipuncture.

6. The compound for the purpose according to any one of claims 1 to 5, wherein the treatment comprises long-term administration of the compound (I) or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof.

7. The compound for the stated use according to claim 6, wherein the long-term administration comprises administering the compound (I) or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof daily for a period of at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks and / or up to at least 8 weeks.

8. The compound for the purpose according to any one of claims 1 to 7, wherein the treatment is a combination therapy comprising long-term administration of the compound of formula (I) and frequent venous incision.

9. The compound for the use according to claim 8, wherein the combination therapy comprises long-term administration of the compound of formula (I), and increases the time interval between a venipuncture setting and a subsequent venipuncture setting throughout the treatment period.

10. The compound for the use according to any one of claims 1 to 9, wherein the treatment is controlled to reduce serum iron content and organ iron content and prevent iron accumulation in organs; Preferably, the treatment is controlled to reduce liver iron content and prevent iron from accumulating in the liver, pancreas, and / or heart, more preferably in the liver.

11. The compound for the said use according to any one of claims 1 to 10, wherein the compound (I) or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof is administered orally in an oral dosage form.

12. The compound for the use according to any one of claims 1 to 11, wherein the treatment comprises administration of compound (I) or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof in amounts ranging from 40 mg to 360 mg per day, including 40 mg, 60 mg, 120 mg, 240 mg and 360 mg per day in a single dose or a subset thereof administered twice or three times daily.

13. The compound for the stated use according to any one of claims 1 to 12, wherein the compound is in the form of a pharmaceutically acceptable salt formed with an acid selected from benzoic acid, citric acid, fumaric acid, lactic acid, malic acid, maleic acid, methanesulfonic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid, and toluenesulfonic acid. Preferably, it is in the form of a pharmaceutically acceptable salt formed with an acid selected from citric acid, maleic acid, phosphoric acid, and sulfuric acid; More preferably, the compound is selected from salts of the group consisting of: 1:1 sulfates with the following formula 1:1 phosphates with the following formula 2:1 phosphate (hemiphosphate) And their polymorphs.

14. The compound for the use according to any one of claims 1 to 13, wherein the treatment comprises treating and / or relieving associated symptoms, including feeling tired or weak, fatigue; joint pain, particularly knee and hand pain; abdominal pain above the liver; weight loss and loss of sexual interest or erectile dysfunction; development of arthritis; liver disease, including cirrhosis and liver cancer; diabetes; cardiac abnormalities; and skin discoloration, including darkening of the skin color, which may be gray, metallic, or bronze.

15. The compound for the stated use according to any one of claims 1 to 14, wherein the compound is formulated into a pharmaceutical dosage form, the pharmaceutical dosage form further comprising one or more selected from drug carriers, excipients, solvents and / or excipients, and / or one or more other pharmaceutically active compounds.

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