Ferroportin-inhibitors for the use in the treatment of hereditary haemochromatosis (HH)

Abstract

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

Description

[0001] FERROPORTIN-INHIBITORS FOR THE USE IN THE TREATMENT OF HEREDITARY HAEMOCHROMATOSIS (HH)

[0002] DESCRIPTION

[0003] INTRODUCTION

[0004] The invention relates to the use of the compound of the formula (I), or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof, which acts as ferroportin inhibitor, for treating hereditary hemochromatosis (HH) and the symptoms and pathological conditions associated therewith.

[0005] BACKGROUND AND PRIOR ART

[0006] Iron is an essential element for almost all organisms and its relevance lies in its key role in erythropoiesis and oxygen transport. The balance of the iron metabolism is primarily regulated on the level of iron recovery from haemoglobin of ageing erythrocytes, from iron stores in the liver and the duodenal absorption of dietary iron. Elemental iron is taken up by duodenal enterocytes via specific transport systems (DMT-1, ferroportin), transferred into the blood circulation and thereby conveyed to the appropriate tissues and organs bound to its carrier transferrin. In the human body, iron is of great importance, inter alia for oxygen transport, oxygen uptake, cell functions such as mitochondrial electron transport, cognitive functions, etc. and ultimately for the entire energy metabolism. Mammalian organisms are unable to remove or excrete iron from the body through an active system. Iron homeostasis is controlled by the hepatic peptide hormone hepcidin, which regulates the activity of the only know iron exporter ferroportin and thus iron release from macrophages, hepatocytes and enterocytes. Hepcidin controls iron absorption via the intestine and placenta and iron recycling from the reticuloendothelial system. Hepcidin production is directly regulated by iron level, i.e. if the organism is supplied with sufficient or excess iron and oxygen, more hepcidin is produced; if iron and oxygen levels are low, or in case of increased erythropoiesis less hepcidin is produced. In the small intestinal mucosal cells and macrophages hepcidin binds to ferroportin, thus blocking its export function and promoting its internalization and degradation. Through this mechanism hepcidin reduces iron efflux from cells to the bloodstream. The transport protein ferroportin is a transmembrane protein consisting of 571 amino acids which is expressed in the liver, spleen, kidneys, heart, intestine and placenta. In particular, ferroportin is localized in the basolateral membrane of intestinal epithelial cells. Ferroportin thus acts to export dietary iron into the blood. If hepcidin binds to ferroportin, ferroportin is transported into the interior of the cell, where its breakdown takes place so that the release of iron from the cells is then blocked. If ferroportin is inactivated or inhibited, by hepcidin, so that it is unable to export the iron which is stored in the mucosal cells, the absorption of iron in the intestine is blocked. A decrease of of hepcidin results in an increase of active ferroportin, thus allowing an enhanced dietary iron absorption and release of stored iron, and leading to increased serum iron level. Katsarou et al. published a review article on hepcidin therapeutics [A. Katsarou and K. Pantopoulos, Hepcidin Therapeutics, Pharmaceuticals, Vol. 11, No. 4, page 127; 2018].

[0007] In pathological cases an increased iron level leads to iron overload. For example, excessive iron uptake in organs, such as liver and heart, leads to accumulation of iron. Further, iron accumulation in brain has been observed in patients suffering from neurodegenerative diseases such as for example Alzheimer’s disease and Parkinson’s disease. The major portion of circulating iron is associated with transferrin, a classical iron transporting molecule, which prevents the formation of free reactive iron. Iron fractions not bound to transferrin (or to the other traditional iron binding molecules like haem, apoferritin, hemosiderin etc.) are collectively referred to as non-transferrin bound iron (NTBI).

[0008] A key detrimental aspect of such excess of free iron is the undesired formation of radicals. In particular, iron (II) ions catalyze the formation (inter alia via Fenton reaction) of reactive oxygen species (ROS). ROS cause damage to DNA, lipids, proteins and carbohydrates which has far-reaching effects in cells, tissue and organs. The formation of ROS is well known and described in the literature to cause the so-called oxidative stress. NTBI is widely described to exhibit high propensity to induce ROS, having potential toxicity on cell and major organs, including heart, liver, pancreas, kidney and bone marrow.

[0009] Hereditary hemochromatosis (HH) is an inherited iron overload condition caused by mutations that reduce the levels of the iron-regulatory hormone hepcidin or its binding to ferroportin. HH is an iron overload disorder common in Northern Europeans [Kowdley KV et al., ACG clinical guideline: hereditary hemochromatosis. Am J Gastroenterol. 2019; 114: 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 to organ damage. The high iron levels occur either as a result of abnormally low levels of the iron regulatory hormone hepcidin, or due to decreased binding of hepcidin to ferroportin, which is the sole transporter of iron out of cells. Hepcidin regulates iron levels by binding to ferroportin on the membranes of intestinal cells, hepatocytes, and macrophages, causing its internalization and subsequent degradation, thereby reducing iron transport into the plasma [Brissot P. et al., Haemochromatosis. Nat Rev Dis Primers. 2018;4:18016; Ganz T. Cellular iron: ferroportin is the only way out. Cell Metab. 2005;1:155-157; Nemeth E. et al., Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization. Science. 2004;306:2090-2093],

[0010] Hemochromatosis has been separated into four distinct disorders - hereditary (classic) hemochromatosis, also known as HFE-related hemochromatosis; hemochromatosis type 2 (juvenile hemochromatosis); hemochromatosis type 3, also known as TFR2-related hemochromatosis; and hemochromatosis type 4, also known as ferroportin disease. The specific symptoms related to these disorders can vary depending upon the location and extent of iron accumulation. Among the type 4 HH a further distinction between type 4A and type 4B is made.

[0011] The most common form of HH is the type 1 form (hereditary hemochromatosis; HH), which is usually caused by mutations in the HFE gene encoding the hemochromatosis (HFE) protein, which is involved in the regulation of hepcidin. Among those HFE gene mutations the most common are C282Y mutations, followed by H63D mutations. More than 80% of patients with HH are homozygous for the C282Y mutation [Feder JN et al., A novel MHC class l-like gene is mutated in patients with hereditary haemochromatosis. Nat Genet. 1996;13:399-408; European Association for the Study of the Liver. EASL clinical practice guidelines for HFE hemochromatosis. J Hepatol. 2010;53:3-22], The C282Y mutation disrupts a key disulfide bond in the a3 domain of the HFE protein and prevents binding of mutant HFE to beta-2 microglobulin, leading to impaired intracellular trafficking 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 Acad Sci U S A. 1997;94:12384-12389].

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

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

[0014] Symptoms of hemochromatosis include feeling tired or weak, including extreme tiredness (fatigue), pain in the joints, particularly in the knees and hands, pain in the abdomen over the liver, weight loss, loss of interest in sex or erectile dysfunction. Affected individuals may develop arthritis, liver disease (cirrhosis) or liver cancer, diabetes, heart abnormalities and / or skin discoloration, including darkening of skin color, 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;139:393-408, 4O8.e391-392.].

[0016] Up to date phlebotomy (blood letting) is the standard of care for patients suffering from hemochromatosis. Phlebotomy, aims to reduce serum ferritin levels to ~50 ng / mL and to improve TSAT to -50% [Brissot P, Brissot E. What's important and new in hemochromatosis? Clin Hematol I nt. 2020;2:143-148; Brissot P, Loreal O. Hemochromatoses. J Hepatol. 2021;75:723-724], Newly diagnosed patients often undergo frequent phlebotomies for many months during the so-called ‘induction phase’ of therapy. Phlebotomy is currently the only treatment option for patients with HH, there are currently no approved oral drugs for patients with HH. While phlebotomy is effective, simple, and inexpensive, it remains an invasive treatment that is not without complications. Adverse effects were found to occur ‘most’ or ‘all of the time’ in 37% of patients receiving maintenance therapy and 52% of those in the induction phase. The adverse effects included fatigue, fainting, pain at the venous access site, and hematomas. Weekly phlebotomies received during the induction phase may lead to anemia, as well as being inconvenient or intolerable to patients, in some cases, it may be difficult to gain veinous access. Due to the high treatment burden connected with repeating and frequent phlebotomy sessions, patient compliance with phlebotomy in the maintenance phase generally steadily decreases over time, and 16% of patients would ‘definitely’ or ‘probably’ decide to stop phlebotomy if alternative treatment options became available [Hicken BL et al., Patient compliance with phlebotomy therapy for iron overload associated with hemochromatosis. Am J Gastroenterol. 2003;98:2072-2077],

[0017] Therefore, there is a need for novel therapies providing efficacious and safe treatment of HH with improved patient compliance and reduced treatment burden and which may reduce the frequency of phlebotomies.

[0018] Among the above mentioned major group of type 1 HH patients a subgroup of approximately 10 % is not at all eligible to conventional treatment, i.e. phlebotomy, for different reasons. In particular for such specific patient group a novel treatment of HH is required which can completely avoid or replace phlebotomy.

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

[0020] Conventional drugs for treating iron overload in general are iron chelating compounds which aim at the constant removal of excess iron. Established drugs generally used in chelation therapy include deferoxamine (also known as desferrioxamine B; or Desferal®), deferasirox (also known as Exjade®) and deferiprone (also known as Ferriprox®). However, in HH iron chelation is only a treatment option when patients are either intolerant or refractory to phlebotomy. In HH phlebotomy is the first line treatment option. If iron chelation is considered in the treatment of patients suffering from HH, then Desferal® is the only approved drug and approval has only been given in a limited number of countries. In any case, the established drugs for iron chelation therapy are known to exhibit a toxic potential, which becomes potentially problematic in prolonged administration due to long-term treatment need. The only HH approved drug Desferal® cannot be administered orally.

[0021] With the aim of providing a novel treatment method with improved patient compliance and being more comfortable and easier to implement into patients’ daily life, orally administered drugs are the preferred choice, compared e.g. to parenteral administration. Oral administration forms offer the advantages of the ease of administration by patients, in particular elderly patients, high degree of flexibility on dosages and formulation, costeffectiveness, less sterility constraints and risk of infection, injection site reaction and anti-drug antibodies generation compared to parenteral administration forms. A novel class of low molecular weight compounds having activity as ferroportin inhibitors has been described in the international applications WO2017 / 068089 and WO20 17 / 068090. Further, international application WO2018 / 192973 relates to specific salts of selected ferroportin inhibitors described in WO2017 / 068089 and WO2017 / 068090. The international application W02021 / 191202 further describes manufacturing routes for preparing selected ferroportin inhibitors and specific salt forms and polymorphs thereof. Therein references to the potential treatment of hemochromatosis is just generally mentioned in a list of possible indications without providing any data.

[0022] The novel ferroportin inhibitors described in the above mentioned international applications have successfully been tested in methods of treating transfusion dependent thalassemia (TDT), as described in the international application W02021 / 013771, in methods of treating renal ischemia-reperfusion injury (IRI) or ischemic injury and acute kidney injuries (AKI), as described in the international application WO2021 / 013772, in methods of treating sickle cell diseases (SCD), as described in the international application WO2021 / 078889 or in methods of treating myelodysplastic syndromes (MDS), as described in the international application WO2022 / 157185. The use of the small-molecule ferroportin inhibitor compound vamifeport (previously designated as VIT-2763) for treatment of beta-thalassemia and sickle cell disease has further been described in the sever scientific papers [V Nyffenegger N, Flace A, et al. Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of / 3- thalassemia. J Clin Invest. 2019;130:491-506; Porter J, Taher A, Viprakasit V, et al. Oral ferroportin inhibitor vamifeport for improving iron homeostasis and erythropoiesis in / 3- thalassemia: current evidence and future clinical development. Expert Rev Hematol. 2021;14:633-644; Nyffenegger N, Flace A, Doucerain C, Durrenberger F, Manolova V. The oral ferroportin inhibitor VIT-2763 improves erythropoiesis without interfering with iron chelation therapy in a mouse model of / 3-thalassemia. Int J Mol Sci. 2021;22:873; 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;140:769-781; Kalleda N, Flace A, Altermatt P, et al. The ferroportin inhibitor vamifeport ameliorates ineffective erythropoiesis in a mouse model of beta-thalassemia with blood transfusions. Haematologica. 2023]. Further, first-in-human investigations of Vamifeport in a phase 1 study with healthy volunteers have 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, pages 68-77; 2019].

[0023] The inventors of the present invention have now found, that the ferroportin inhibitor compound vamifeport (previously designated as VIT-2763) turned out as a promising drug compound for treating HH. In particular, the inventors of the present invention showed in experimental studies the efficacy of vamifeport in reducing serum iron levels and / or preventing liver iron deposition in a Hfe C282Y mouse model of HH, alone and in combination with phlebotomy. OBJECT OF THE INVENTION

[0024] The object of the present invention is to provide a new method for treating hereditary hemochromatosis (HH) and the symptoms and pathological conditions associated therewith. A particular object of the present invention can be seen in providing novel drug compounds for effectively treating HH and the symptoms and pathological conditions associated therewith allowing to ameliorate the burden connected with the conventional HH treatment methods such as frequent phlebotomy. Further objects to be solved in further aspects of the invention comprise providing novel therapy options offering one or a combination of two or more of the following aspects of providing efficacious and safe treatment of HH, offering improved patient compliance, being comfortable and easy to implement into patients’ daily life, being orally administrable and allowing to reduce treatment burden. In a further aspect the invention should offer a novel treatment allowing to reduce the frequency of phlebotomies or offering a completely alternative treatment method, in particular for HH patients not being eligible to conventional treatment, i.e. phlebotomy, for those allowing to completely avoid or replace phlebotomy. A further object of the invention aims at providing a novel therapy option for HH which is able to provide not only a symptomatic treatment but targets the underlying pathophysiology of HH. A further object of the invention aims at providing novel combination therapy options, which can be used in combination with conventional phlebotomy without interfering with the de-ironing process of phlebotomy.

[0025] DESCRIPTION OF THE INVENTION

[0026] The inventors of the present invention were able to show that the compound vamifeport, with the following formula (I) or pharmaceutically acceptable salts, solvates, hydrates or polymorphs thereof, can be used in novel methods for the treatment of hereditary hemochromatosis.

[0027] In a preferred aspect of the invention, the compounds of the formula (I) are used in the form of a HCI salt, more preferably, the compound (i) is used in the form of the triple HCI salt with the following formula (I-3HCI):

[0028] Hereinafter, the vamifeport compound (I) including its salts, solvates, hydrates and polymorphs, each as described anywhere herein, are also collectively designated as “vamifeport”.

[0029] The experimental studies carried out by the inventors and presented in the experimental part below provide a preclinical proof of concept for the efficacy of vamifeport in HH with or without phlebotomy. In particular, the inventors were able to show that a single oral dose of vamifeport was able to lower serum iron levels in Hfe C282Y mice, with delayed onset and shorter duration than observed in wild-type mice, vamifeport induced transient hypoferremia by inhibiting ferroportin and resulted in a feedback regulation of liver Hamp in wild-type mice, which was absent in Hfe C282Y mice, reflecting the dysregulated systemic iron sensing in this HH model. Chronic dosing with vamifeport led to a sustained serum and liver iron reduction in Hfe C282Y mice, as well as markedly reducing liver Hamp expression in Hfe C282Y mice, suggesting distinct regulation of liver Hamp expression following acute or continuous iron restriction via vamifeport. Importantly, vamifeport retained its activity when combined with phlebotomy and did not interfere with liver iron removal by phlebotomy in Hfe C282Y mice. The experimental data demonstrate that chronic vamifeport treatment significantly reduces serum iron levels and prevents liver iron loading in the Hfe C282Y mouse model of HH, thus supporting the present invention as described herein in more detail.

[0030] Patient Groups

[0031] In particular, the inventors found that vamifeport can be used for treating patients suffering from type 1 hemochromatosis and the symptoms and pathological conditions associated therewith.

[0032] In one aspect the present invention relates to the compounds of the formula (I), or its salts, solvates, hydrates and polymorphs, for the treatment of patients suffering from HH caused by homozygous C282Y or H63D mutations, or compound heterozygous C282Y / H63D mutations in the HFE gene, preferably patient suffering from HH caused by homozygous C282Y mutations in the HFE gene.

[0033] In principle, the subjects to be treated in the use according to the invention can be any mammals such as rodents and primates, and in a preferred aspect the medical use relates to the treatment of humans. The subjects suffering from HH and to be treated with the method according to the invention are also designated as “patients” or “individuals”.

[0034] The subjects to be treated can be of any age. A preferred aspect of the invention relates to the treatment of adults and elderly people. In a preferred aspect of the invention the subjects to be treated with the new methods described herein are more than 20 years old. In a further aspect of the invention the subjects to be treated with the new methods described herein are greater than 30 years old, preferably greater than 40 years old, more preferably 50 years and greater than 50 years old, or greater than 60 years old. In the preferred case of treating elderly patients the subjects to be treated with the new methods described herein are 50 years old and above, which mainly results from the fact that typically type 1 HH patients present with iron overload rather late, i.e. in the age of 50 and above.

[0035] The treatment of elderly patients is particularly preferred due to the significant advantages provided by the treatment according to the present invention. Vamifeport and its salts, solvates, hydrates or polymorphs can be administered orally, which is advantageous over parenteral administration. Further, the orally bioavailable ferroportin inhibitor vamifeport turned out to have a moderate bioavailability and half-life in the body and is thus relatively quickly washed out. This leads to less adverse effects and a faster reversibility of the drug, which is of particular importance in the treatment of elderly patients.

[0036] The patient group or population suffering from HH and to be treated with the method according to the invention are selected from subjects (patients) being characterized as defined above. In a further aspect of the invention the patient group or population suffering from HH to be treated with the method according to the invention are selected from subjects (patients) having one or more pathological parameter of those described above.

[0037] In a further aspect of the invention the patient group or population suffering from HH and to be treated with the method according to the invention requires frequent / regular phlebotomy. However, further clinical symptoms and parameters also play an important role in determining HH.

[0038] Regular phlebotomy further means more than one repeating phlebotomy treatment (setting) within predetermined time intervals. During the induction phase weekly time intervals are determined, during the maintenance phase monthly up to quarterly or half-a-year time intervals can be determined. The intervals between repeating phlebotomy sessions may be of equal length or may vary depending on the individual patient, the course of disease, its severity and the treatment response. In particular, the intervals are extended after the induction phase when entering the maintenance phase.

[0039] In a further aspect of the invention regular / frequent phlebotomy means phlebotomy- free periods of not more than 6 months, preferably of not more than 4 months.

[0040] Indication and Treatment Parameters

[0041] The term “treat”, “treatment” or “treating” in the context of the use of the present invention includes prevention and amelioration of at least one symptom or pathological condition associated with HH, such as in particular the symptoms and pathological conditions described anywhere herein and in the examples below.

[0042] The term “treat”, “treatment” or “treating” in the context of the present invention further includes prevention or prophylaxis, e.g. by administering the compounds of the present invention prior to or accompanying phlebotomy in HH patients.

[0043] Non-limiting examples of symptoms or pathological conditions associated with HH include for example increased systemic iron levels, increased liver iron concentrations, iron accumulation in organs like liver, pancreas and heart, increased hemoglobin levels, and phlebotomy treatment burden, as well as feeling tired or weak, including extreme tiredness (fatigue), pain in the joints, particularly in the knees and hands, pain in the abdomen over the liver, weight loss, loss of interest in sex or erectile dysfunction, the development of arthritis, liver disease (cirrhosis) or liver cancer, diabetes, heart abnormalities and / or skin discoloration, including darkening of skin color, which may appear gray, metallic, or bronze, and combinations of these symptoms or conditions.

[0044] The following parameters can be determined to evaluate the efficacy of the compounds of the present invention in the medical use of treating HH: serum iron, NTBI levels, LPI (Labile Plasma Iron) levels, erythropoietin, TSAT (transferrin saturation), Hb (hemoglobin), Het (haematocrit), MCV (Mean Cell Volume), MCH (Mean Cell Hemoglobin), RDW (Red Blood Cell Distribution Width) and reticulocyte numbers, complete blood counts, liver, spleen and kidney iron content. The determination can be carried out using conventional methods of the art, in particular by those described below in more detail. The compounds (I) of the present invention are suitable to improve at least one of these parameters.

[0045] In a particular aspect, the treatment of HH according to the present invention results in reduced serum iron levels in a patient 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%, determined 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, 8, 6, 5, 4, 3, 2, 1 and 0.5 hours following the administration and as compared to the serum iron levels in the patient determined at any time point within 0.5, 1, 2, 3, 4, 5, 6, 8, 12, 24, 36, or 48 hours, or up to < 1 week prior to the commencement of treatment of the invention. Serum iron levels can be determined according to assays described in the Examples below.

[0046] In a further aspect, the treatment of HH according to the present invention may result in a decrease in liver iron concentration in the patient 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%, determined at any time point within a time period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months following the first administration and as compared to the levels of liver iron concentration in the patient determined at any time point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment of the invention. Liver iron concentration can be determined according to an assay described in the Examples below.

[0047] Accordingly, in a further aspect, the treatment of HH according to the present invention may result in a decrease in pancreas iron concentration in the patient 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%, determined at any time point within a time period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months following the first administration and as compared to the levels of pancreas iron concentration in the patient determined at any time point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment of the invention. Pancreas iron concentration can be determined according to an assay described in the Examples below. In a further aspect, the treatment of HH according to the present invention may result in a decrease in myocardial (heart) iron concentration in the patient 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 %, determined at any time point within a time period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months following the first administration and as compared to myocardial iron concentration in the subject determined at any time point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment of the invention. Myocardial (heart) iron concentration can be determined according to an assay described in the Examples below.

[0048] In a further aspect, the treatment of HH according to the present invention may result in reduced serum ferritin levels in the patient 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 %, determined at any time point within a time period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months following the first administration and as compared to the serum ferritin levels in the patient determined at any time point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment of the invention. Serum ferritin levels can be determined according to conventional assays.

[0049] In a further aspect, the treatment of HH according to the present invention may result in an improvement of at least one of the parameters Hb, Het, RBC counts, MCV, MCH, RDW, and reticulocyte numbers in the patient 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 %, determined at any time point within a time period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months following the first administration and as compared to the respective parameter in the subject determined at any time point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment of the invention. Said parameters can be determined according to conventional methods.

[0050] A further aspect of the invention relates to the use of vamifeport and its salts, solvates, hydrates or polymorphs in the treatment of HH as described herein, wherein the treatment is controlled to reduce the serum iron content and / or the organ iron content and / or prevent accumulation of iron in organs compared to a HH patient not treated or treated only with conventional phlebotomy.

[0051] In a further, more specific aspect the treatment is controlled to reduce the liver iron content and / or to prevent accumulation of iron in the liver, pancreas and / or heart, preferably in the liver.

[0052] In a further aspect, the treatment of HH according to the invention may result in increasing the time intervals between one and the subsequent phlebotomy setting over the overall treatment time.

[0053] In a further aspect, the treatment of HH according to the present invention may achieve that the HH patient treated according to the method of the present invention does not require phlebotomy 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 up to independence from phlebotomy during or after treatment.

[0054] In a further aspect, the treatment of HH according to the present invention may result in a reduction of the symptoms associated with one or more clinical HH and / or phlebotomy complications. Non-limiting examples have been described above.

[0055] In a further aspect, the treatment of HH according to the present invention may result in an improvement in the quality of life in the patients as compared to the quality of life in the patients determined within the 1 , 2, 3, or 4 week(s) prior to the commencement of treatment of the invention. The improvement of Quality of life is determined within 3, 6, 9, 12, 15, 18, 21 or 24 months after the commencement of the treatment. Quality of life can be determined according to an assay described in the Examples below.

[0056] With the treatment of HH according to the present invention one or more of the aforesaid improvements can be achieved.

[0057] Dosing Regimen

[0058] The compounds of the formula (I), including its salts, solvates, hydrates and polymorphs, can be used in the treatment as described anywhere herein, wherein the treatment is characterized by one of the following dosing regimens:

[0059] In a preferred aspect vamifeport according to the invention is administered to a HH patient in need thereof as a chronic, i.e. repeating, dosing over a selected treatment time, which may be a limited treatment time depending on the patient’s conditions or which may last life-long.

[0060] Chronic dosing comprises repeatedly administering vamifeport over 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. The amount of dosage repetitions during such time interval may vary depending on the age, weight, condition of the patient, severity of the disease or type of administration and the course of development of the disease under the treatment.

[0061] Vamifeport according to the invention may be administered in the method according to the invention in a dose of 0.001 to 500 mg, for example 1 to 4 times a day. However, the dose can be increased or reduced depending on the age, weight, condition of the patient, severity of the disease or type of administration and the course of development of the disease under the treatment.

[0062] In a further aspect of the invention vamifeport can be administered as a dose of 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg, 0.6 mg, 0.7 mg, 0.8 mg, 0.9 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg, 3 mg, 3.5 mg, 4 mg, 4.5 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 45 mg, 50 mg, 55 mg, 60 mg, 65 mg, 70 mg, 75 mg, 80 mg, 85 mg, 90 mg, 95 mg, 100 mg, 105 mg, 110 mg, 115 mg, 120 mg, 125 mg, 130 mg, 135 mg, 140 mg, 145 mg, 150 mg, 155 mg, 160 mg,

[0063] 165 mg, 170 mg, 175 mg, 180 mg, 185 mg, 190 mg, 195 mg, 200 mg, 205 mg, 210 mg, 215 mg, 220 mg, 225 mg, 230 mg, 235 mg, 240 mg, 245 mg, 250 mg, 255 mg, 260 mg, 265 mg, 270 mg, 275 mg, 280 mg, 285 mg, 290 mg, 295 mg, 300 mg, 325 mg, 350 mg, 375 mg, 400 mg, 425 mg, 450 mg, 475 mg, 500 mg.

[0064] Preferred is a dose of between 0.5 to 500 mg, more preferred between 5 to 400 mg. Most preferred is a dose of 5 mg, 15 mg, 30 mg, 60 mg, 120 mg, 180 mg, 240 mg or 360 mg.

[0065] The dosage amounts defined above relate to total doses administered in humans, preferably as a single dose or split into two or three doses / administration day.

[0066] Preferably vamifeport is administered in the above defined dosages daily.

[0067] Preferably, the treatment according to the invention comprises dosing of vamifeport in an amount of between 40 to 360 mg daily dose, including 40, 60, 120 mg, 180 mg, 240 mg or 360 mg daily dose administered in a single dose or twice or three times daily.

[0068] It is possible to administer the above defined dosages as a total daily dose either in a single dose daily or divided into sub-doses for administration twice or three times or even more times daily.

[0069] In a further aspect a dose between 0.001 to 35 mg / kg body weight, between 0.01 to 35 mg / kg body weight, between 0.1 to 25 mg / kg body weight, or between 0.5, 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10 and up to 20 mg / kg body weight can be administered. Particularly preferred is a dose of 120 mg for patients with > 50 kg body weight and of 60 mg for patients with < 50 kg body weight, in each case once or twice daily.

[0070] In a further aspect it is possible to select one of the above defined dosages as an initial dose and subsequently administer 1 or more times the same or varying doses of those defined above in repeating intervals of 1 to 7 days, 1 to 5 days, preferably of 1 to 3 days, or every second day.

[0071] The initial dose and the subsequent doses can be selected among the above defined dosages and adjusted / varied in accordance with the need of the HH patient within the provided ranges.

[0072] In particular, the amount of subsequent doses can be appropriately selected depending on the individual patient, the course of disease and the treatment response. It is possible to administer 1, 2, 3, 4, 5, 6, 7, and more subsequent doses.

[0073] It is possible that the initial dose is equal or different to the one or more subsequent doses. It is further possible, that the subsequent doses are equal or different.

[0074] The repeating intervals can be of the same length or can be varied depending on the individual patient, the course of disease and the treatment response.

[0075] Preferably, the subsequent doses are of decreasing amount with increasing number of subsequent dosing.

[0076] Preferably a dose of between 3 mg and 360 mg, more preferred between 5 mg and 360 mg, most preferred of 5 mg, 15 mg, 30 mg, 60 mg, 120 mg, 180 mg, 240 mg or 360 mg is administered once or two- or three-times daily over a treatment period of at least 3 days, at least 5 days, at least 7 days. In a further preferred aspect a dose 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 twice daily a 60 mg dose or a total daily dose of 240 mg is administered by administering twice daily 120 mg or three times daily 60 mg. Further preferred dosage regimens comprise the administration of a total daily dose of 240 or 360 mg as a single dose or split in 2 or 3 subsets, e.g. by administering 240 mg I day in two 120 mg subsets or administering 360 mg / day in two 180 mg subsets or in three 120 mg subsets.

[0077] In a further preferred aspect a total daily dose of 240 mg is administered by administering twice daily a 120 mg dose or a total daily dose of 360 mg is administered by administering three times daily 120 mg. Said doses turned out to be safe and well tolerated.

[0078] The preferred dosing regimen further showed fast oral absorption with detectable levels as early as 15 to 30 minutes post-dose. The absorption level can be maintained stable even upon repeated dosing and no critical accumulation is observed.

[0079] The preferred dosing regimen further turned out to efficiently decrease mean serum iron levels and mean calculated transferrin saturation and to shift the mean serum hepcidin peak, indicating its efficiency for treating HH.

[0080] In a further aspect of the invention, the initial and one or more subsequent dosing is adjusted depending on the hemoglobin concentration of the treated patient. The hemoglobin concentration is determined with conventional methods.

[0081] Combination Therapy

[0082] A further object of the present invention relates to the treatment of HH using vamifeport, including its salts, solvates, hydrates and polymorphs, in combination with conventional phlebotomy therapy.

[0083] Therein, the drug administration can occur prior to or concomitant with the phlebotomy therapy.

[0084] A preferred aspect of the invention relates to the treatment of HH as described anywhere herein in the form of a combination therapy comprising chronic dosing of vamifeport, as described above, and frequent phlebotomy.

[0085] Such combination therapy particularly comprises chronic dosing (with same or varying dosage amounts and / or dosing intervals) of vamifeport, as described above, and increasing the time intervals between one and the subsequent phlebotomy setting over the overall treatment time.

[0086] In a further aspect, such combination therapy comprises chronic dosing (with same or varying dosage amounts and / or dosing intervals) of vamifeport, as described above, and increasing the time intervals between one and the subsequent phlebotomy setting over the overall treatment time until phlebotomy treatment is completely stopped and replaced by vamifeport administration.

[0087] A further aspect of the invention medicaments, pharmaceutical compositions or dosage forms comprising vamifeport as defined herein may be present as combined preparations containing one or more additional pharmaceutically active compound (“combination therapy compound” / “co-drug”) besides vamifeport. Such additional active compounds are preferably selected among those being useful in the treatment of HH patients. Preferred combination therapy compounds are in particular compounds selected from medicaments for treating iron overload and the associated symptoms or co-drugs useful in treating the pathological conditions and disorders associated with HH and described above. A combination therapy with one or more of the combination therapy compounds (codrugs) defined above can be carried out using a fixed dose or free dose combination for sequential use. Such a combination therapy can comprise co-administration of vamifeport as defined in the present invention with the at least one additional pharmaceutically active compound (drug / combination therapy compound).

[0088] Combination therapy in a fixed dose combination therapy comprises co-administration of vamifeport as defined herein with the at least one additional pharmaceutically active compound in a fixed-dose formulation.

[0089] Combination therapy in a free dose combination therapy comprises co-administration of vamifeport as defined herein and the at least one additional pharmaceutically active compound in free doses of the respective compounds, either by simultaneous administration of the individual compounds or by sequential use of the individual compounds distributed over a time period.

[0090] Vamifeport Salts, Solvates, Hydrates and Polymorphs

[0091] The present invention relates to the new medical use of the compound vamifeport with the structure according to the formula (I):

[0092] In a further aspect, the present invention relates to the use and method of treatment as defined herein, wherein the compound according to formula (I) are used in the form of its pharmaceutically acceptable salts, or solvates, hydrates and polymorphs.

[0093] Examples of suitable pharmaceutically acceptable salts are described in the international applications WO2017 / 068089, WO2017 / 068090 and WO2018 / 192973. Further examples of suitable salt forms and of polymorphs are described in the international application WO2021 / 191202, which are herein incorporated by reference in this respect.

[0094] In a preferred aspect, HCI salts of vamifeport are used, more preferably a 3HCI salt of vamifeport is used in the treatment method as described anywhere herein.

[0095] Other suitable pharmaceutically acceptable salts comprise salts with acids from the group consisting of 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 with acids from the group consisting of citric acid, maleic acid, phosphoric acid and sulfuric acid.

[0096] Generally, the pharmaceutically acceptable salts of vamifeport can be selected from mono-salts (1:1 salts), triple salts (1:3 salts) and salts being characterized by a ratio of vamifeport to acid of 1-2 : 1-3; including solvates, hydrates and polymorphs thereof. Therein, the salts of vamifeport may be characterized by a selected ratio of base : acid, i.e. vamifeport : the acids as defined above, in the range of 1.0 to 2.0 (mol base) : 1.0 to 3.0 (mol acid). In a particular embodiment the selected ratio of base : acid is 1.0 to 2.0 (mol base) : 1.0 to 2.0 (mol acid).

[0097] Particular examples comprise the following ratios of base : acid, i.e. vamifeport : the acids as defined above:

[0098] 1.0 (mol base) : 1.0 (mol acid);

[0099] 1.0 (mol base) 1.25 (mol acid):

[0100] 1.0 (mol base) 1.35 (mol acid);

[0101] 1.0 (mol base) 1.5 (mol acid);

[0102] 1.0 (mol base) 1.75 (mol acid);

[0103] 1.0 (mol base) 2.0 (mol acid);

[0104] 1.0 (mol base) 3.0 (mol acid); and

[0105] 2.0 (mol base) 1.0 (mol acid).

[0106] Therein, a salt having a ratio of base : acid of 1 : 1 is also called “mono-salt(s)” or “1 : 1 salt(s)”. For example, a mono-HCI salt is also designated as 1HCI or 1 HCI salt.

[0107] Therein, a salt having a ratio of base : acid of 1 : 2 is also called “di-salt(s)” or “1 : 2 salt(s)”. For example, a di-HCI salt is also designated as 2HCI or 2HCI salt.

[0108] Therein, a salt having a ratio of base : acid of 1 : 3 is also called “tri-salt(s)”, “triple salts(s)” or “1 : 3 salt(s)”. For example, a tri-HCI salt is also designated as 3HCI or 3HCI salt.

[0109] A salt having a ratio of base : acid of 1 1.25 is also called “1 : 1.25 salt(s)”.

[0110] A salt having a ratio of base : acid of 1 1.35 is also called “1 : 1.35 salt(s)”.

[0111] A salt having a ratio of base : acid of 1 1.5 is also called “1 : 1.5 salt(s)”.

[0112] A salt having a ratio of base : acid of 1 1.75 is also called “1 : 1.75 salt(s)”.

[0113] A salt having a ratio of base : acid of 2 1 is also called “hemi-salt(s)“ or “2 : 1 salt(s)”.

[0114] The salts of vamifeport may be present in amorphous, polymorphous, crystalline and / or semi-crystalline (partly crystalline) form as well as in the form of a solvate of the salt. Preferably salts of the vamifeport are present in crystalline and / or semi-crystalline (partly crystalline) form and / or in the form of solvates thereof.

[0115] The preferable crystallinity of the salts or salt solvates can be determined by using conventional analytical methods, such as especially by using the various X-ray methods, which permit a clear and simple analysis of the salt compounds. In particular, the grade of crystallinity can be determined or confirmed by using Powder X-ray diffraction (reflection) methods or by using Powder X-ray diffraction (transmission) methods (PXRD). For crystalline solids having identical chemical composition, the different resulting crystal gratings are summarized by the term polymorphism. Regarding solvates, hydrates and polymorphs and salts with particular crystallinity reference is made to the international applications WO2018 / 192973 and W02021 / 191202, which in this respect are included herein by reference.

[0116] In a further aspect of the invention the vamifeport compound (I) is selected from the group consisting of the following salts: a 1:1 sulfate salt having the formula a 1 :1 phosphate salt having the formula and polymorphs thereof.

[0117] As described in WO2017 / 068089, WO2017 / 068090 and WO2018 / 192973 the vamifeport compound (I) acts as a ferroportin inhibitor. Regarding the ferroportin inhibitor activity of vamifeport reference is thus made to said international applications.

[0118] Administration Forms

[0119] In a further aspect of the invention the treatment of HH comprises the oral administration of vamifeport, its salts, solvates, hydrates or polymorphs, as described anywhere herein, to a patient in need thereof.

[0120] For this purpose, vamifeport, including its salts, solvates, hydrates or polymorphs, is preferably provided in medicaments or pharmaceutical compositions in the form of oral administration forms, including e.g. pills, tablets, such as enteric-coated tablets, film tablets and layer tablets, sustained release formulations for oral administration, depot formulations, dragees, granulates, emulsions, dispersions, microcapsules, microformulations, nanoformulations, liposomal formulations, capsules, such as enteric-coated capsules, powders, microcrystalline formulations, epipastics, drops, ampoules, solutions and suspensions for oral administration.

[0121] In a preferred embodiment of the invention vamifeport, including its salts, solvates, hydrates or polymorphs, is administered in the form of a tablet or capsule, as defined above. These may be present, for example, as acid resistant forms or with pH dependent coatings.

[0122] Accordingly, a further aspect of the present invention relates to the compound vamifeport, including its salts, solvates, hydrates or polymorphs, and medicaments, compositions and combined preparations comprising the same, for the use in the treatment of HH in the form of oral administration forms.

[0123] Medicaments, pharmaceutical compositions or dosage forms containing vamifeport, its salts, solvates, hydrates or polymorphs may further contain one or more compounds selected from the groups comprising pharmaceutical carriers, auxiliaries, solvents and excipients.

[0124] Preferably the pharmaceutical carriers, auxiliaries, solvents and excipients are selected among suitable compounds for preparing oral dosage forms.

[0125] The said medicaments, pharmaceutical compositions or dosage forms may contain, for example up to 99 weight-% or up to 90 weight-% or up to 80 weight-% or or up to 70 weight-% of vamifeport, including its salts, solvates, hydrates or polymorphs, the remainder being formed by the pharmaceutical carriers, auxiliaries, solvents and excipients, and - in the case of combination therapy dosage forms as described below, optionally further pharmaceutically active compounds.

[0126] Therein, the pharmaceutically acceptable carriers, auxiliary substances or solvents are common pharmaceutical carriers, auxiliary substances, excipients or solvents, including various organic or inorganic carrier and / or auxiliary materials as they are customarily used for pharmaceutical purposes, in particular for solid medicament formulations. Examples include excipients, such as saccharose, starch, mannitol, sorbitol, lactose, glucose, cellulose, talcum, calcium phosphate, calcium carbonate; binding agents, such as cellulose, methylcellulose, hydroxypropylcellulose, polypropyl pyrrolidone, gelatine, gum arabic, polyethylene glycol, saccharose, starch; disintegrating agents, such as starch, hydrolyzed starch, carboxymethylcellulose, calcium salt of carboxymethylcellulose, hydroxypropyl starch, sodium glycol starch, sodium bicarbonate, calcium phosphate, calcium citrate; lubricants, such as magnesium stearate, talcum, sodium laurylsulfate; flavorants, such as citric acid, menthol, glycin, orange powder; preserving agents, such as sodium benzoate, sodium bisulfite, paraben (for example methylparaben, ethylparaben, propylparaben, butylparaben); stabilizers, such as citric acid, sodium citrate, acetic acid and multicarboxylic acids from the titriplex series, such as, for example, diethylenetriaminepentaacetic acid (DTPA); suspending agents, such as methycellulose, polyvinyl pyrrolidone, aluminum stearate; dispersing agents; diluting agents, such as water, organic solvents; waxes, fats and oils, such as beeswax, cocoa butter; polyethylene glycol; white petrolatum; etc.

[0127] Liquid medicament formulations, such as solutions, suspensions and gels usually contain liquid carrier, such as water and / or pharmaceutically acceptable organic solvents. Furthermore, such liquid formulations can also contain pH-adjusting agents, emulsifiers or dispersing agents, buffering agents, preserving agents, wetting agents, gelatinizing agents (for example methylcellulose), dyes and / or flavouring agents, for example as defined above. The compositions may be isotonic, that is, they can 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, for example, dextrose, maltose, boric acid, sodium tartrate, propylene glycol and other inorganic or organic soluble substances. The viscosity of the liquid compositions can be adjusted by means of a pharmaceutically acceptable thickening agent, such as methylcellulose. Other suitable thickening agents include, for example, xanthan gum, carboxymethylcellulose, hydroxypropylcellulose, carbomer and the like. The preferred concentration of the thickening agent will depend on the agent selected.

[0128] Pharmaceutically acceptable preserving agents can be used in order to increase the storage life of the liquid composition. Benzyl alcohol can be suitable, even though a plurality of preserving agents including, for example, paraben, thimerosal, chlorobutanol and benzalkonium chloride can also be used.

[0129] DESCRIPTION OF THE FIGURES

[0130] Figure 1 : Kinetics of pharmacodynamic changes following a single oral dose of vamifeport in the Hfe C282Y mouse model of hereditary hemochromatosis and 129S2 wild-type mice. Experimental design (A); Serum iron concentration (B); Liver Hamp expression in Hfe C282Y (left) and 129S2 wild-type (right) mice after treatment with vehicle or vamifeport (C). For all scatter plots, data are presented as individual values with means (n=6-10 animals per timepoint / treatment). Significant differences compared with the vehicle treated group are indicated as: *p<0.05, **p<0.01, and ***p<0.001.

[0131] Figure 2: Kinetics of pharmacodynamic effects following chronic oral dosing of vamifeport in the Hfe C282Y mouse model of hereditary hemochromatosis. Experimental design (A); Serum iron concentration and liver Hamp expression (B); Hemoglobin levels over time (C); Total liver iron and58Fe liver iron concentrations (D). Total spleen iron concentration and representative images from DAB-enhanced Peris staining of duodenal cross-sections from vehicle- or vamifeport-treated Hfe C282Y mice (E). Hemoglobin data are presented as mean values with standard deviations. For all scatter plots, data are presented as individual values with means (n=5-6 animals per timepoint / treatment). Significant differences compared with the vehicle-treated group are indicated in black as: *p<0.05, **p<0.01, and ***p<0.001; Significant within-treatment differences in the vehicle group are indicated in grey as:tp<0.01 week 1 versus week 7; ^<0.01 week 1 versus week 8;§p<0.05 week 7 versus week 8. Significant within-treatment differences in the vamifeport group are indicated in blue as:tp<0.05 week 3 versus week 7; ^<0.05 week 4 versus week 7; §p<0.05 week 7 versus week 8 [LID, low iron diet]. Figure 3: Kinetics of hematological effects following chronic oral dosing of vamifeport in the Hfe C282Y mouse model of hereditary hemochromatosis. Red blood cell (RBC) count (A); Reticulocyte count (B); Leukocyte 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 with means (n=5-6 animals per timepoint / treatment). Significant differences compared with the vehicle-treated group are indicated as: *p<0.05, **p<0.01, and ***p<0.001.

[0132] Figure 4: Vamifeport does not interfere with liver iron removal by phlebotomy in the Hfe

[0133] C282Y mouse model of hereditary hemochromatosis. Experimental design (A); Serum iron concentration and liver Hamp expression (B); Total liver iron and 58Fe liver iron concentrations (C); Total spleen iron concentration (D). For all scatter plots, data are presented as individual values with means (n=6-9 animals per timepoint / treatment). Significant differences between treatment groups are indicated as: *p<0.05, **p<0.01, and ***p<0.001.

[0134] [LID, low iron diet; SD, standard diet; WT, wild type].

[0135] Figure 5: Kinetics of hematological effects following chronic oral dosing of vamifeport and phlebotomy treatment in the Hfe C282Y mouse model of hereditary hemochromatosis. Levels of hemoglobin (A); Erythropoietin (B). Hemoglobin data are presented as mean values with standard deviations. For the scatter plot, data are presented as individual values with means (n=5-6 animals per timepoint / treatment). Significant differences compared with the vehicle-treated group are indicated as: *p<0.05, **p<0.01, and ***p<0.001 [OD, optical density; WT, wild type],

[0136] EXAMPLES

[0137] The invention is illustrated in more detail by the following examples. The examples are merely explanatory, and the person skilled in the art can extend the specific examples to further ferroportin inhibitor compounds according to the present invention.

[0138] I. Vamifeport and its Salts, Solvates, Hydrates or Polymorphs

[0139] Regarding the preparation of the compound vamifeport used in the method of the present invention, and the preparation of pharmaceutically acceptable salts, solvates, hydrates or polymorphs thereof, reference is made to the international applications WO2017 / 068089, WO20 17 / 068090, WO2018 / 192973 and W02021 / 191202.

[0140] II. Evaluation of the Ferroportin Inhibitor Compound Vamifeport in a Preclinical

[0141] Mouse Model of Hemochromatosis Pharmacological Assays

[0142] 11.1 Materials and Methods Tested

[0143] In the experiments described hereafter, vamifeport has been administered in the form of the 3HCI salt.

[0144] Animal models

[0145] Mice were housed under pathogen-free conditions. Mice were bred in the facility and acclimatized for at least 5 days before study start. Animals were group-housed (2-5 mice per cage) under a 12-hour reverse dark / light cycle and provided with nesting material, enrichment materials, and water / food ad libitum. Both acute and chronic studies were conducted in the experimental room, with animals taken to the holding room after each procedure in the chronic studies. There was no treatment blinding in these studies.

[0146] To study the acute effects of vamifeport, cages of 8-9-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;94:9-11] (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 the relevant treatment groups and timepoints. Mice received a single dose of either vehicle (0.5% methylcellulose) or vamifeport 60 mg / kg (10 mL / kg) by oral gavage. After dosing, the animals had access to a low-iron diet (LID; #2039, Fe = 13.4 mg / kg; Granovit SA, Kaiseraugst, Switzerland) and drinking water ad libitum. Groups of animals were euthanized by complete exsanguination after terminal anesthesia with isoflurane at 0.5, 1, 3, 6, and 16 hours after dosing. Blood and livers were collected for analysis of serum iron and liver hepcidin (Hamp) expression.

[0147] To study the chronic effects of vamifeport, Hfe C282Y mice were distributed to cages at weaning (3 weeks of age), and each cage was allocated to a treatment group / timepoint according to a stratified randomization. Mice were fed a LID (#2039, Fe = 10.4 mg / kg; Granovit SA, Kaiseraugst, Switzerland) and had access to drinking water ad libitum. As the primary aim was to assess the treatment effects of vamifeport versus vehicle in the chronic studies, no wild-type mice were used, in line with the principles of the 3Rs. Vamifeport was administered in drinking water rather than by oral gavage as in the acute study, to avoid animal manipulation and potential stress related to longer-term twice-daily oral gavage (i.e. over several weeks of treatment). Four-week-old female (n=15) and male (n=26) Hfe C282Y mice (129-Hfetm1.1Nca / J) were provided with ad libitum access to autoclaved mineral water containing vehicle or vamifeport 1.0 mg / mL (base weight of vamifeport, corresponding to -110 mg / kg daily oral dose) for up to 8 weeks. The formulation of vamifeport in drinking water was freshly prepared weekly, and water intake per cage was measured at 3- or 4-day intervals by weighing the water bottles. The average daily intake of water was 2.7 ± 0.3 mL / mouse. The mineral water was supplemented with 0.5 mM Fe(ll)SC>4 containing58Fe (12% of total iron content; Vifor Pharma, batch no. ROR 3171), 1% glucose, and 10 mM ascorbic acid. The vamifeport dose was selected based on the oral dose that was shown to be efficacious in other mouse models of chronic vamifeport treatment (120 mg / kg; 60 mg / kg given by oral gavage twice daily) [Manolova V, et al. Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of / 3-thalassemia. J Clin Invest. 2019;130:491-506.]. Weekly smallvolume blood samples were taken by tail vein incision for the analysis of hemoglobin levels. At the predefined timepoints (2, 4, 6, and 8 weeks), animals were euthanized by complete exsanguination after terminal anesthesia with isoflurane followed by cervical dislocation. Blood and livers were collected to analyze the effect of vamifeport on the serum and organ iron levels and liver hepcidin (Hamp) expression.

[0148] A pilot study was performed to investigate the potential of combining vamifeport with phlebotomy, in which 9-10-week-old female (n=7) and male (n=6) Hfe C282Y mice received vehicle or 0.3 mg / mL (~40 mg / kg) or 1 mg / mL (-110 mg / kg) vamifeport in the drinking water, as described above. Mice were fed a standard diet ad libitum (#3432, Fe = 170 mg / kg; Granovit SA, Kaiseraugst, Switzerland) for 9-10 weeks (iron loading), then switched to a LID (Fe = 13.4 mg / kg) at study week 0. Mice were anesthetized with isoflurane and phlebotomized (removing -20% of their total blood volume) by sublingual bleeding every 2 weeks. Nonphlebotomized Hfe C282Y mice (4 males / 4 females) and wild-type 129S2 mice (4 males / 5 females) treated with vehicle served as controls. At the end of the study (week 4), mice were pre-terminally anesthetized with isoflurane, and blood collected by retro-orbital bleeding. Mice were then sacrificed by cervical dislocation, and their livers harvested and used to analyze the effect of vamifeport combined with phlebotomy on organ iron accumulation.

[0149] Analysis of Iron-Related Parameters

[0150] Serum iron levels were determined in triplicate using a MULTIGENT Iron assay (Abbott Diagnostics, Baar, Switzerland) at 0.5, 1 , 3, 6, and 16 hours in the acute study and at 2, 4, 6, and 8 weeks in the chronic study.

[0151] Relative liver hepcidin (Hamp) expression was analyzed by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) using TaqMan Gene Expression Assays (#Mm04231240_s1; Thermo Fisher Scientific, Waltham, MA) on a LightCycler 480 II instrument (Roche Diagnostics, Rotkreuz, Switzerland), according to manufacturer’s instructions. Hamp transcript levels were calculated by comparison with a reference gene Gusb (TaqMan: #MmO1197698_m1; Thermo Scientific, Waltham, MA). Hamp expression levels were analyzed at 0.5, 1 , 3, 6, and 16 hours in the acute study and at 2, 4, 6, and 8 weeks in the chronic study. In the chronic and phlebotomy studies, hemoglobin concentrations were determined weekly in tail vein blood (HemoCue AB, Angelholm, Sweden).

[0152] Complete blood counts were measured using the veterinary ProCyte blood analyzer (Idexx Bioresearch, Westbrook, ME).

[0153] Organs were snap frozen in liquid nitrogen, and total iron and / or58Fe concentrations were determined using inductively coupled plasma-optical emission spectrometry and inductively coupled plasma-mass spectrometry, respectively. Organ iron levels (total and58Fe) were analyzed at 4 weeks in the phlebotomy study and at 2, 4, 6, and 8 weeks in the chronic study.

[0154] Duodena were fixed in 10% buffered formalin and embedded in paraffin. Deparaffinized tissue sections were stained for non-heme ferric iron deposition with diaminobenzidine (DAB)-enhanced Peris stain. Consecutive sections were stained with hematoxylin and eosin (HE). Images were acquired with 40x objective (NA 0.95) using an Olympus VS120 Virtual Slide Microscope.

[0155] Statistical analysis

[0156] As part of the animal license application (ZH 108 / 2017) for the chronic studies, a priori sample size calculations were performed with an estimated effect size for several parameters, target power of 0.8, and a = 0.05. Analysis of hemoglobin data used two-way analysis of variance (ANOVA) with repeated measures for time-course effects. Where statistically significant effects were observed, Bonferroni multiple comparison test was performed. Analysis of serum iron, Hamp gene expression, and organ iron concentrations utilized oneway ANOVA with Dunnett multiple comparison test. Statistical analyses were conducted using Prism software (GraphPad Prism version 9.4.1 , San Diego, CA).

[0157] Results

[0158] A) Effects of Vamif eport Single Dose on Serum Iron and Liver Hamp Expression Attenuated in the Hfe C282Y Mouse Model ofHH versus 129S2 Wild-Type Mice

[0159] Mice homozygous for the C282Y mutation (Hfe C282Y mice) have limited Hfe expression and show similar iron metabolism-related parameters to those seen in HFE- deficient (Hfe'1') mice. Both mouse models develop iron overload due to defects in iron- regulated Hamp expression and recapitulate well the pathologies observed in human HH [Levy JE, et al., The C282Y mutation causing hereditary hemochromatosis does not produce a null allele. Blood. 1999;94:9-11; Zhou XY, et al., HFE gene knockout produces mouse model of hereditary hemochromatosis. Proc Natl Acad Sci U S A. 1998;95:2492-2497].

[0160] To assess 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 to corresponding wild-type controls (129S2 mice) and the kinetics of serum iron and liver Hamp expression changes assessed. A schema overviewing the experimental design of the studies assessing the acute effects of vamifeport treatment is presented in Figure 1A. In agreement with data published by HH Levy JE, et al., Blood. 1999;94:9-11, vehicle-treated Hfe C282Y mice had slightly higher steady-state serum iron levels than their wild-type 129S2 counterparts (51 ± 4 pM vs 45 ± 5 pM, respectively) at all timepoints (Figure 1 B). In both Hfe C282Y and 129S2 wild-type mice, serum iron levels started to reduce 30 minutes after a single oral dose of vamifeport (60 mg / kg). However, response to vamifeport was delayed, less pronounced, and shorter lasting in Hfe C282Y mice than in their wild-type counterparts. In vamifeport-treated Hfe C282Y mice, serum iron levels were significantly lower than those seen after vehicle treatment at 1 and 3 hours post dose, whereas in 129S2 wild-type mice, serum iron levels were significantly reduced following vamifeport treatment at 30 minutes, 1, 3, and 6 hours post dose, compared with vehicle. At 16 hours post dose, serum iron levels did not differ between vamifeport-treated and vehicle-treated groups in either Hfe C282Y or 129S2 mice.

[0161] Vehicle-treated Hfe C282Y mice had lower liver Hamp expression than their wild-type counterparts (expressed as average ACt Gusb-Hamp 6.6 ± 0.1 vs 8 ± 0.5) at all timepoints (Figure 1C).

[0162] Interestingly, there were no significant changes in liver Hamp expression following a single oral dose of vamifeport (60 mg / kg) in Hfe C282Y mice, but significant reductions were observed at 3 and 6 hours after vamifeport treatment in 129S2 wild-type mice. This clearly demonstrates that liver Hamp expression induced by iron restriction is differentially regulated in Hfe C282Y and 129S2 wild-type mice.

[0163] B) Chronic Iron Restriction by Vamifeport Results in Sustained Reductions in Serum and Liver Iron in the Hfe C282Y Mouse Model of HH

[0164] To study the longer-term effects of chronic vamifeport treatment on serum iron, liver Hamp, hemoglobin, and organ iron concentrations, cohorts of Hfe C282Y mice received vamifeport 1.0 mg / mL (corresponding to a daily dose of 110 mg / kg) in the drinking water for up to 8 weeks. The experimental design of this study is depicted in Figure 2A.

[0165] Serum iron levels started to decline at week 2 of vamifeport administration in Hfe C282Y mice but were not significantly different to those seen with vehicle treatment at this timepoint (Figure 2B). Chronic vamifeport intake led to a sustained reduction 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 the levels observed with vehicle treatment at all of these timepoints.

[0166] In contrast to observations in the acute study (in which Hamp expression was measured up to 16 hours after a single vamifeport dose), liver Hamp expression was significantly lower in Hfe C282Y mice at weeks 2, 4, 6, and 8 of chronic vamifeport administration than in the vehicle-treated group (Figure 2B). These data suggest that sustained iron restriction due to chronic vamifeport treatment regulates Hamp expression differently to that resulting from acute vamifeport treatment.

[0167] With the exception of week 7, from week 1 until study end (week 8), hemoglobin levels were significantly lower during chronic vamifeport dosing observed in vehicle-treated Hfe C282Y mice (Figure 2C), reflecting the iron- restricted erythropoiesis induced by vamifeport. The mutation present in Hfe C282Y mice results in inappropriate Hamp expression, leading to low hepcidin levels and excessive iron absorption and storage. Total liver iron concentration (reflecting the liver iron accumulated before and during the study) remained significantly lower in Hfe C282Y mice following chronic vamifeport treatment than following vehicle treatment. Differences in total liver iron concentration were observed from week 2, and the levels remained lower in the vamifeport-treated animals over the study period, reaching statistical significance from week 4 (Figure 2D).

[0168] Chronic vamifeport intake via drinking water prevented the accumulation of58Fe in the livers of Hfe C282Y mice that was seen following vehicle administration. At 2, 4, 6, and 8 weeks,58Fe liver iron concentrations were significantly lower in vamifeport-treated mice than in vehicle-treated mice (Figure 2D), demonstrating that iron restriction by vamifeport efficiently prevented de novo iron accumulation.

[0169] Total spleen iron concentration increased over time in both the vehicle- and vamifeport-treated groups, but levels at week 6 were significantly higher in mice receiving chronic vamifeport treatment than in those receiving vehicle treatment, reflecting the retention of iron in spleen cells as a result of ferroportin inhibition (Figure 2E). DAB-enhanced Peris staining of duodenal cross-sections from Hfe C282Y mice showed iron accumulation in duodenal enterocytes after 8 weeks of vamifeport treatment; no duodenal staining was apparent in mice receiving vehicle treatment (Figure 2E). These data demonstrated that vamifeport inhibits iron export from spleen cells and dietary iron absorption.

[0170] Red blood cell numbers were significantly increased at 6 weeks and significant increases in reticulocytes were observed at 2 and 4 weeks in Hfe C282Y mice treated with vamifeport compared with vehicle (Figures 3A, 3B). Leukocyte and platelet levels were similar in these treatment groups (Figures 3C, 3D). Levels of hematocrit, mean corpuscular hemoglobin, mean corpuscular volume, and reticulocyte hemoglobin were significantly higher in Hfe C282Y mice treated with vehicle at all time points, due to the induction of iron-restricted erythropoiesis during vamifeport treatment (Figures 3E-H).

[0171] C) Combination Therapy of Vamifeport with Liver Iron Removal by Phlebotomy in the Hfe C282Y Mouse Model of HH

[0172] Phlebotomy is the current standard of care for the clinical management of patients with HH and usually occurs weekly during the induction phase, decreasing to 3-4 times a year during the maintenance phase. To investigate the possibility of combining vamifeport treatment with phlebotomy in HH, a pilot study was performed to assess the effects of vamifeport in combination with bi-weekly phlebotomy versus phlebotomy alone (i.e. alongside vehicle treatment) in Hfe C282Y mice. The experimental design of this pilot study is included in Figure 4A.

[0173] Vamifeport was provided in the drinking water at concentrations of 0.3 mg / mL and 1.0 mg / mL, which should have corresponded to daily vamifeport doses of ~40 mg / kg and -110 mg / kg, respectively. The intake of water containing vamifeport at 0.3 mg / mL was similar to that of vehicle-containing water in phlebotomized Hfe C282Y mice (Table 1) Table 1. Drinking water consumption and the calculated vamifeport dose in the phlebotomy study in Hfe C282Y mice.

[0174] N / A, not applicable.

[0175] However, phlebotomized Hfe C282Y mice drank 56% less of the water containing the higher concentration of vamifeport (versus vehicle). Surprisingly, control, non-phlebotomized Hfe C282Y mice treated with 1 mg / mL vamifeport consumed only about 20% less water than the non-phlebotomized vehicle-treated group, suggesting that the intake of water containing 1 mg / mL vamifeport is reduced in sublingually phlebotomized animals. Based on the measured intake of vamifeport-containing water, daily doses of vamifeport in this study were ~40 mg / kg for 0.3 mg / mL and ~60 mg / kg for 1 mg / mL. Due to the disproportionally reduced intake of vamifeport in the 1 mg / mL dose group, only the data obtained for the 0.3 mg / mL group were considered reliable. Therefore, results are reported for the 0.3 mg / mL vamifeport dose only.

[0176] Serum iron concentration and liver Hamp expression were unchanged with phlebotomy alone; non-significant reductions were seen in both parameters with vamifeport plus phlebotomy treatment (Figure 4B).

[0177] Phlebotomy alone significantly reduced the total liver iron concentration in the Hfe C282Y mouse model of HH but did not affect58Fe liver iron concentration compared with that in vehicle-treated, non-phlebotomized mice (Figure 4C). Importantly, vamifeport did not interfere with the liver de-ironing effect of phlebotomy (total liver iron levels were lower, but not statistically significantly) in Hfe C282Y mice receiving phlebotomy plus vamifeport than in Hfe C282Y mice receiving phlebotomy alone. Furthermore, the reduction in total iron levels observed with phlebotomy plus vamifeport versus no phlebotomy (p<0.001) had a higher level of statistical significance than that seen with phlebotomy alone versus no phlebotomy (p<0.05). There was no significant difference in58Fe liver iron levels between Hfe C282Y mice receiving phlebotomy alone and those not receiving phlebotomy. Combining vamifeport with phlebotomy significantly decreased58Fe liver iron concentration in Hfe C282Y mice compared with phlebotomy alone, showing that vamifeport prevented the absorption of58Fe from drinking water and thereby prevented iron accumulation in the liver. Similar hemoglobin, spleen iron, and erythropoietin levels were observed during phlebotomy plus vamifeport treatment and treatment with phlebotomy alone (Figure 5). Discussion

[0178] The preclinical studies presented herein evaluated the efficacy of the oral ferroportin inhibitor vamifeport in reducing serum iron levels and preventing liver iron deposition in the Hfe C282Y mouse model of HH, alone and in combination with phlebotomy. In these studies, Hfe C282Y mice showed elevated serum iron levels compared with control 129S2 wild-type mice, which is consistent with lower liver expression of the iron regulatory peptide hepcidin in the former group. Both acute and chronic oral vamifeport treatment significantly reduced serum iron levels in this mouse model, demonstrating the potential of ferroportin inhibition by vamifeport to correct the elevated systemic iron levels in HH, despite chronically reduced hepcidin levels.

[0179] In the chronic studies, the lowered serum iron levels resulting from vamifeport treatment attenuated iron accumulation in the liver.

[0180] While Hamp expression was downregulated in response to acute hypoferremia at 3 and 6 hours after vamifeport administration in 129S2 wild-type mice, liver Hamp expression levels did not significantly change in Hfe C282Y mice in the acute study. These findings are consistent with the presence of non-functional HFE in Hfe C282Y mice, which prevents an appropriate endogenous regulation of hepcidin levels in the presence of acute hypoferremia, leading to progressive organ iron overload. Another possible explanation for the lack of hepcidin downregulation in the acute study is that serum iron levels may still have been above the threshold where hepcidin is inhibited following acute vamifeport treatment in Hfe C282Y mice. Although acute vamifeport treatment did not significantly affect hepatic Hamp levels in Hfe C282Y mice, chronic treatment did markedly reduce Hamp expression. The differential regulation of Hamp observed during acute (reduced serum iron and persisting liver iron overload) and chronic (reduced serum and liver iron concentrations) vamifeport treatment may reflect the two postulated mechanisms of hepcidin regulation. The detection of changes in liver iron stores is mediated mostly by hepatic BMP6, which in turn interacts with BMPRI / I I and a multiprotein complex on the hepatocyte membrane to regulate hepcidin expression. In contrast, changes in serum iron (which is bound to transferrin) regulate hepcidin expression via HFE and TFR2 signaling.

[0181] Hemoglobin levels during chronic vamifeport treatment were significantly lower than those observed in vehicle-treated Hfe C282Y mice, suggesting that iron restriction in this HH model normalizes hemoglobin levels to levels similar to those observed in healthy mice in a shorter 3-week study (160 g / L, n=5 males / 5 females). Vamifeport also induced iron- restricted erythropoiesis in Hfe C282Y mice, as evidenced by the reductions in mean corpuscular hemoglobin content, mean corpuscular volume, and hematocrit levels (likely as a function of lowered mean corpuscular volume). Although vamifeport-treated mice had lower total blood hemoglobin levels, red blood cell counts were unaffected. Chronic oral dosing of vamifeport also significantly reduced both total and58Fe liver iron concentrations, suggesting that vamifeport prevents liver iron loading in Hfe C282Y mice. Furthermore, vamifeport treatment resulted in an increase in iron entrapment in iron exporting organs such as the spleen and duodenum. Importantly, vamifeport did not interfere with the de-ironing process of phlebotomy in the pilot preclinical study. However, the dose of vamifeport used (~40 mg / kg) was lower than that shown to be optimally effective in other rodent studies (120 mg / kg). Although, vamifeport at a dose of ~40 mg / kg did not significantly improve liver iron removal, it did prevent the uptake of58Fe in the livers of Hfe C282Y mice receiving phlebotomy, indicating the potential of vamifeport for improving the effectiveness of venesection in patients with HH.

[0182] Therewith, vamifeport further offers a new therapeutic approach of targeting HH by the underlying pathophysiology instead of a merely symptomatic treatment approach as currently applied with phlebotomy.

[0183] The data shown herein support the use of vamifeport in a combination therapy alongside phlebotomy, e.g. in the induction phase, and having the potential to replace phlebotomy, e.g. in the maintenance phase of treatment or in patients not being eligible to phlebotomy.

[0184] Approaches that have been investigated in the literature so far include restoring hepcidin levels with the administration of hepcidin mimetics (e.g. rusfertide [PTG-300] and the rusfertide analog PN23114), synthetic hepcidins (e.g. LJPC-401), and minihepcidins (e.g. PR65 and the oral minihepcidin PN20076). Agents are also being evaluated that target TMPRSS6, a protein that inhibits hepcidin transcription (e.g. lipid nanoparticle-formulated small interfering RNAs [siRNAs], the GalNAc-siRNA conjugate SLN124, and antisense oligonucleotides [e.g. IONIS-TMPRSS6-LRx / sapablursen], all of which target Tmprss6 expression). Most of the available data come from preclinical studies of subcutaneously administered agents in the Hfe'1' knockout mouse model of HH. In such model, nearly all of the drugs tested led to reductions in serum iron levels and / or TSAT and / or decreased liver iron accumulation. However, therapeutic approaches requiring injection routes for administering the drugs are disadvantageous over orally administerable drugs for the reasons discussed above.

[0185] The orally available minihepcidin PN20076 has also been described to significantly reduce liver iron accumulation in Hfe?'1' mice (hemojuvelin knockout [Hjv1']). In contrast, subcutaneous administration of PR65 in hepcidin knockout (Hamp'1') mice with iron overload was described to not significantly decrease serum iron levels, but to significantly reduce liver iron concentration. However, as there was also a significant decrease in hemoglobin levels, there may have been a transient decrease in serum iron concentration that was not captured in this study. Interestingly, the rusfertide analog PN23114 improved iron parameters when combined with phlebotomy in a Hjv1' mouse model of HH.

[0186] As was observed for vamifeport in the present study, none of the assessed treatment strategies (PN23114 or phlebotomy alone or combined) led to a significant reduction in total liver iron content, but all three treatments reduced further liver iron deposition. In a recent 6-month study, subcutaneously administered rusfertide reduced serum iron levels and liver iron concentration in 16 patients with HH on a stable phlebotomy regimen. Furthermore, the phlebotomy rate significantly improved from a mean of 0.27 per month at baseline to 0.03 per month during rusfertide treatment. Positive results have also been reported in an interim analysis of a phase 2 study of subcutaneous LJPC-401 vs placebo in 26 patients with HH. After 16 weeks of treatment, TSAT was significantly reduced in patients receiving LJPC-401 vs placebo, as was the requirement for phlebotomy (0.06 vs 0.41 phlebotomies per month, respectively).

[0187] However, as mentioned above, subcutaneous (parenteral) administration is disadvantageous compared to orally administered treatments such as with vamifeport. Exemplary advantages include improved convenience and ease of administration for patients, cost savings owing to a reduced need for hospital visits, dosage / formulation flexibility, obviation of the risk of injection-site reactions / infection, and, in general, easier storage and supply chain management compared with injectable agents. Although absorption and onset of action are generally slower for oral drugs, vamifeport is absorbed relatively quickly, with levels detectable 15-30 minutes post dose and serum iron levels reducing to trough levels 4-8 hours after administration in healthy volunteers.

[0188] In summary, these preclinical proof-of-concept studies demonstrate that the ferroportin inhibitor vamifeport significantly reduces serum iron levels and prevents liver iron loading following chronic dosing in the Hfe C282Y mouse model of HH, thus supporting future clinical development in this indication, vamifeport has been shown to have the potential in a combination therapy alongside phlebotomy in patients with HH who are in the induction phase and to ultimately even replace phlebotomy in HH patients.

[0189] III. Phlebotomy Burden

[0190] Phlebotomy burden in a subject treated according to the methods of the present invention can be evaluated by determining the phlebotomy requirement of the patient, e.g. via the required amount and / or frequency of blood letting sessions by conventional and clinically acknowledged assessment.

[0191] IV. Organ Iron Levels

[0192] Iron levels, such as, e.g., liver, kidney, spleen, duodenum or myocardial iron levels can be determined using conventional assay(s). For example, iron levels (e.g., liver iron concentration, pancreas iron concentration, kidney iron concentration, spleen iron concentration, duodenum iron concentration or myocardial iron concentration) can be determined by inductively coupled optical emission spectroscopy (ICP-OES) and inductively coupled plasma mass spectrometry (ICP-MS).

[0193] V. Serum Ferritin Level Determination

[0194] Serum ferritin levels can be determined using conventional assay(s).

[0195] VI. Hemoglobin Determination

[0196] Hemoglobin levels can be determined using conventional assay(s).

[0197] VI I .Quality of Life The assessment of quality of life can be evaluated using the Short Form (36) Health Survey (SF-26) as described e.g. in WO2016 / 183280 can be used.

Claims

CLAIMS1. A compound according to the following formula (I)or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof for the use in the treatment of hereditary hemochromatosis.

2. The compound for the use according to claim 1, wherein the compound (I) is present in the form of a HCI salt.

3. The compound for the use according to claim 1 or 2, which is a 3HCI salt having the following formula (I-3HCI)(I-3HCI).

4. The compound for the use according to any one of claims 1 to 3, for the treatment of patients suffering from 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 a compound of the formula (I) and phlebotomy.

6. The compound for the use according to any one of claims 1 to 5, wherein the treatment comprises chronic dosing of the compound (I), or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof.

7. The compound for the use according to claim 6, wherein the chronic dosing comprises administering the compound (I), or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof, daily over 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 use according to any one of claims 1 to 7, wherein the treatment is a combination therapy comprising chronic dosing of a compound of the formula (I) and frequent phlebotomy.

9. The compound for the use according to claim 8, wherein the combination therapy comprises chronic dosing of the compound of the formula (I) and increasing the time intervals between one and the subsequent phlebotomy setting over the overall treatment time.

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

11. The compound for the 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 the form of oral dosage forms.

12. The compound for the use according to any one of claims 1 to 11, wherein the treatment comprises dosing of the compound (I), or a pharmaceutically acceptable salt, solvate, hydrate or polymorph thereof, in an amount of between 40 to 360 mg daily dose, including 40, 60, 120, 240 and 360 mg daily dose administered in a single dose or in two or three-times daily administered subsets.

13. The compounds for the use according to any one of the claims 1 or 4 to 12, which are in the form of a pharmaceutically acceptable salt with acids from the group consisting ofbenzoic 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 with acids from the group consisting of citric acid, maleic acid, phosphoric acid and sulfuric acid, more preferably the compounds are selected from the following group of salts: a 1 :1 sulfate salt having the formulaa 1 :1 phosphate salt having the formulaa 2 : 1 phosphate salt (hemiphosphate)and polymorphs thereof.

14. The compounds for the use according to any one of the claims 1 to 13, wherein the treatment comprises treatment and / or amelioration of associated symptoms, including feeling tired or weak, fatigue, pain in the joints, particularly in the knees and hands, pain in the abdomen over the liver, weight loss and loss of interest in sex or erectiledysfunction, development of arthritis, liver disease, including cirrhosis and liver cancer, diabetes, heart abnormalities and skin discoloration, including darkening of skin color, which may appear gray, metallic, or bronze.

15. The compounds for the use according to any one of the claims 1 to 14, which are formulated in a pharmaceutical dosage form, which further contains one or more selected from the group of pharmaceutical carriers, auxiliaries, solvents, and / or excipients and / or one or more additional pharmaceutically active compounds.

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