Methods for improving skeletal muscle function

Abstract

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

Description

[Technical Field]

[0001] The present invention relates to a method for improving muscle function in a subject in need thereof, particularly for therapeutic use in conditions involving muscle weakness, muscle conditions, and / or muscle pain. [Background technology]

[0002] Achondroplasia is the most common form of non-lethal skeletal dysplasia, affecting more than 250,000 people worldwide. Achondroplasia is caused by pathogenic variants in the gene encoding fibroblast growth factor receptor 3 (FGFR3) and is transmitted as an autosomal dominant form. FGFR3 is a negative regulator of long bone development and is highly expressed in chondrocytes of the growth plate.

[0003] Infants with achondroplasia typically have poor muscle tone (hypotonia), which can lead to delayed motor skill development and weak skeletal muscles, contributing to spinal deformities such as kyphosis (Takken et al., Journal of Pediatrics 2017, Vol 150, pp26-30; Patient Guide to Achondroplasia, John Hopkins Dept. Orthopaedic Surgery, 2003). Muscle weakness is also a hallmark of adult achondroplasia (Sims et al., J Appl Physiol (1985) 2018 Mar 1;124(3):696-703; de Vries Am J Med Genet. 2021;185A:1023-1032).

[0004] Spinal deformities in humans with achondroplasia require treatment during infancy, childhood, and adulthood. Infants require braces or casts, and children may require corrective surgery. In adulthood, the kyphosis can lead to spinal stenosis, often requiring surgery to straighten the spine and allow the bones of the spine to grow together.

[0005] Inhibition of FGFR3 signal transduction is attracting attention in the development of therapeutic intervention methods for treating achondroplasia.FGFR3 inhibitors may act on the receptor itself or on its downstream signal transduction pathway to inhibit FGFR3 signal transduction.Therefore, suitable examples of FGFR3 inhibitors include tyrosine kinase inhibitors (such as infigratinib, pemigatinib, futovatinib, erdafitinib or TYRA-300), C-type natriuretic peptide (CNP), FGFR3 siRNA and FGFR3 antisense oligonucleotide.

[0006] Infigratinib is an FGFR-selective tyrosine kinase inhibitor approved for the treatment of certain cancers (Truseltiq) but is in clinical development to increase height in children with achondroplasia (Savarirayan et al., Ther Adv Musculoskelet Dis 2022 Mar 21;14).

[0007] TYRA-300 is an oral, potent, FGFR3-selective tyrosine kinase inhibitor with activity in the presence of mutations, including the FGFR3 V555 mutation, and selectivity for FGFR3 over FGF1 and other FGFR isoforms. TYRA-300 was developed by Tyra Biosciences.

[0008] FGFR3 signals through several intracellular pathways, including signal transducers and activators of transcription (STATs) and mitogen-activated protein kinases (MAPKs), and constitutive activation of FGFR3 is associated with the achondroplasia phenotype. FGFR3 activation is associated with increased phosphorylation of the STAT and MAPK pathways. The MAPK pathway can be regulated by C-type natriuretic peptide (CNP). Binding of CNP to its receptor, natriuretic peptide receptor B (NPR-B), results in cGMP production and activates various signaling mediators, including cyclic nucleotide phosphodiesterases (PDEs), cGMP-regulated ion channels (cGICs), and cGMP-dependent protein kinases (cGKI and cGKII). The effects of CNP / NPR-B on FGFR3 are mediated by activation of RAF-1, which in turn activates cGKII, which inhibits activation of MEK1 / 2 and ERK1 / 2 in the MAPK pathway. Examples of FGFR3 inhibitors that act downstream of FGFR3 include molecules that activate the NPR-B receptor, which inhibits the mitogen-activated protein kinase (MAPK) pathway, thereby inhibiting downstream signaling of FGFR3.

[0009] Vosoritide is a C-type natriuretic peptide (CNP) variant approved for the treatment of achondroplasia in pediatric patients whose bones are still growing, acting directly on the bone growth plate to promote new bone growth ( https: / / www.ema.europa.eu / en / medicines / human / EPAR / voxzogo ).

[0010] TransCon™ CNP is an investigational, long-acting CNP prodrug in clinical development for the treatment of achondroplasia in pediatric patients with open epiphysis (Breinholt et al., Br J Clin Pharmacol. 2022 Nov;88(11):4763-4772). In a Phase 2 clinical trial (ACcomplisH), TransCon™ CNP demonstrated superiority over placebo in annualized change in ACH-specific height SDS and reported a reduction in achondroplasia-related adverse events.

[0011] CNP is a potent regulator of growth plate chondrogenesis, and its binding to natriuretic peptide-binding receptor-2 (NPR-B) on the surface of chondrocytes induces intracellular synthesis of cyclic guanosine monophosphate (cGMP) and activates cGMP-dependent signaling (Potter et al., Handb Exp Pharmacol. 2009;(191):341-366). CNP is indicated for the treatment of cardiac remodeling, acute myocardial infarction, smooth muscle relaxation, and hypertension (Nakagawa and Saito, Biology 2022, 11, 1017). Perez-Ternero et al., PNAS 2022, vol 119 / 13 e2116470119, reported that C-type natriuretic peptide is a crucial regulator of metabolic homeostasis. CNP exerts these metabolic regulatory effects by inhibiting sympathetic thermogenic programming via Gi-coupled natriuretic peptide receptor (NPR)-C and reducing the expression of peroxisome proliferator-activated receptor-γ coactivator-1α, while simultaneously driving adipogenesis via NPR-B / protein kinase-G. Perez-Ternero et al., Front. Mol. Neurosci. 15:991112. doi:10.3389 / fnmol.2022.991112, reported from CNP-deficient mice that CNP plays a role in regulating the blood-brain barrier and locomotor responsiveness to novel environments. In particular, CNP deletion in gbCNP- / - mice results in reduced body weight but not altered muscle mass.

[0012] Another example of an FGFR3 inhibitor acting on pathways downstream of FGFR3 itself is the molecule meclizine, which attenuates the MAPK signaling pathway at the level of ERK phosphorylation (see, for example, Kitoh et al. 2020. PLoS ONE 15(4):e0229639. https: / / doi.org / 10.1371 / journal.pone.0229639).

[0013] Mackler et al., 1973 (Arch. Biochem and Biophys 159, 885-888) reported that oxidative energy production is reduced in adult achondroplasia (ACH). Domondon et al., Am J Physiol Renal Physiol 2019 317:F1164-F1168, reviewed the regulation of mitochondrial function by natriuretic peptides and emphasized the role of ANP and BNP / NPR-A activation in mitochondria. Miyashita et al., Diabetes 2009 58, 2880-2892, reported that the BNP / cGK cascade promotes muscle mitochondrial biogenesis and fat oxidation and may prevent obesity in BNP-TG mice. In contrast, Perez-Ternero et al., PNAS 2022 Vol. 119 No. 13 e2116470119, reported that CNP has a conservative function in regulating metabolic homeostasis, suppressing sympathetic thermogenesis programming via NPR-C while simultaneously driving adipogenesis via NPR-B / protein kinase-G, indicating that CNP has an opposite effect to NPR-A ANP / BNP activation. PGC-1alpha is a key regulator of mitochondrial biogenesis, and as reported in Domondon 2018, PGC-1alpha is positively regulated via ANP and BNP. [Prior art documents] [Non-patent literature]

[0014] [Non-licensed document 1] Takken et al., Journal of Pediatrics 2017, Vol 150, pp26-30 [Non-licensed document 2] Patient Guide to Achondroplasia, John Hopkins Dept. Orthapaedic Surgery, 2003 [Non-licensed document 3] Sims et al., J Appl Physiol (1985) 2018 Mar 1;124(3):696-703

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[0015] Description of the Invention Treatments for achondroplasia have focused on promoting endochondral bone growth, and therapeutic agents have been selected for their ability to improve annular growth / height velocity in children with achondroplasia. The present inventors surprisingly found that treatment of children with achondroplasia with the CNP drug TransCon CNP resulted in improved physical function and a reduction in achondroplasia-related adverse events. Based on the study reported below, these improvements in physical function appear to result from improved muscle function, independent of bone growth. Children administered a placebo demonstrated reduced physical performance and a significantly increased incidence of achondroplasia-related adverse events. Furthermore, in a mouse model of achondroplasia, treatment with TransCon CNP was shown to increase pup survival within 15 days of birth. This finding correlated with a reduced incidence of maternal infanticide, a phenomenon associated with muscle weakness in pups, and occurred within a time frame inconsistent with the effects on bone growth. These findings that the FGFR3 signaling inhibitor CNP (as described above, CNP inhibits signaling through FGFR3) is effective in enhancing physical performance and muscle function independently of enhanced endochondral bone growth indicate that CNP and other FGFR3 inhibition strategies are suitable therapies for improving muscle function in both children and adults, for example, in the treatment of hypotonia and related disorders. Binding of CNP to the NPR-B receptor may contribute to its mechanism of action, and such NPR-B receptor agonists are also contemplated for this use. Binding of CNP to the NPR-C receptor may contribute to its mechanism of action, and such NPR-C receptor agonists are also contemplated for this use. [Means for solving the problem]

[0016] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering to the subject a therapeutically effective amount of an FGFR3 signaling inhibitor.

[0017] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising administering to the subject a therapeutically effective amount of an NPR-B agonist.

[0018] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering to the subject a therapeutically effective amount of an NPR-C agonist.

[0019] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering to the subject a therapeutically effective amount of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist.

[0020] The present invention provides a method of improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP). In certain embodiments, the NPR-B agonist or CNP is vosoritide (SEQ ID NO: 30).

[0021] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP) (CNP administered as a CNP conjugate and / or as a prodrug of CNP); or a pharmaceutically acceptable salt thereof.

[0022] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition that impairs muscle function, comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP) (CNP is administered as a CNP conjugate and / or a CNP prodrug); or a pharmaceutically acceptable salt thereof, wherein the method comprises administering to the subject successive doses of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug, wherein the sustained exposure of free CNP in the patient's plasma between successive doses of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug is at least about 1 pmol / L. In certain embodiments, the successive doses are administered, for example, daily, weekly, biweekly, or monthly. In certain embodiments, the time interval between successive doses is at least about 24 hours, for example, at least about one week. In certain embodiments, the CNP conjugate or prodrug is a compound of formula (IIf'), a compound of formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

[0023] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP) (CNP is administered as a CNP conjugate and / or as a CNP prodrug); or a pharmaceutically acceptable salt thereof, wherein the CNP conjugate or CNP prodrug is a compound of formula (IIf'), a compound of formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

[0024] In certain embodiments, the subject is a human subject. In certain embodiments, the subject is a human subject under the age of 18. In certain embodiments, the subject is a human subject at least 18 years of age. In certain embodiments, the subject has a closed epiphysis.

[0025] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, comprising administering to the subject a therapeutically effective amount of C-type natriuretic peptide (CNP), the method comprising infusion of CNP into the subject, e.g., iv or sc infusion, wherein the infusion results in a sustained exposure of CNP (free CNP) in the patient's plasma of at least 1 pmol / L for a period of at least about 1 hour. In certain embodiments, the sustained exposure of CNP (free CNP) in the patient's plasma for at least about 2 hours, e.g., at least about 4 hours, e.g., at least about 6 hours.

[0026] The present invention provides a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering a therapeutically effective amount of an FGFR3 signaling inhibitor to the subject, wherein the FGFR3 signaling inhibitor (FGFR3 antagonist) is an FGFR3 tyrosine kinase inhibitor, for example, the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of infigratinib, pemigatinib, futovatinib, erdafitinib, and TYRA-300.

[0027] The present invention provides methods (eg, therapeutic methods) for improving muscle function in a subject.

[0028] The present invention provides methods (eg, therapeutic methods) for improving skeletal muscle function in a subject.

[0029] The present invention provides methods (eg, treatment methods) for improving muscle strength and / or muscle stamina (eg, skeletal muscle strength and / or skeletal muscle stamina) in a subject.

[0030] The present invention provides methods (eg, therapeutic methods) for improving muscle stiffness (eg, skeletal muscle stiffness) in a subject.

[0031] In each case, the method includes administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-C agonist, or an effective amount of an NPR-B agonist. In certain embodiments, the method includes administering an effective amount of an NPR-B / NPR-C agonist (e.g., CNP).

[0032] The subject may be suffering from a disease or disorder that causes impairment of muscle function (e.g., muscle strength, stamina, and / or rigidity). The disease or disorder may be one that causes impairment of skeletal muscle function.

[0033] Optionally, the FGFR3 signaling inhibitor, or NPR-B agonist, or NPR-C agonist, or CNP, e.g., a CNP conjugate or a prodrug of CNP or a pharmaceutically acceptable salt thereof, can be used in combination with a growth hormone, e.g., human growth hormone.

[0034] The present invention provides an FGFR3 signaling inhibitor, or an NPR-B agonist, or an NPR-C agonist for use in a method for improving muscle function in a subject, optionally wherein the subject is suffering from a disease or disorder that causes impairment of muscle function.

[0035] The present invention provides an FGFR3 signaling inhibitor, or an NPR-B agonist, or an NPR-C agonist for use in a method for improving skeletal muscle function in a subject, optionally wherein the subject is suffering from a disease or disorder that causes impairment of skeletal muscle function.

[0036] In certain embodiments, the subject has an achondroplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and lethal skeletal dysplasia. The subject is preferably a human subject. The subject may be under 18 years of age or at least 18 years of age. The subject may have closed epiphyses.

[0037] In certain embodiments, the FGFR3 signaling inhibitor is an FGFR3 antagonist or an NPR-B agonist.

[0038] In certain embodiments, NPR-C agonists may be used in the methods or uses of the present invention.

[0039] The FGFR3 antagonist may include a fibroblast growth factor receptor (FGFR) 3 tyrosine kinase inhibitor, an anti-FGFR3 antibody, an anti-FGFR3 antisense oligonucleotide, or an anti-FGFR3 siRNA. A suitable NPR-B agonist is C-type natriuretic peptide or a conjugate or prodrug thereof. A suitable NPR-C agonist is C-type natriuretic peptide or a conjugate or prodrug thereof.

[0040] Examples of FGFR3 antagonists include fibroblast growth factor receptor (FGFR) 3 tyrosine kinase inhibitors, such as infigratinib, pemigatinib, futovatinib, erdafitinib, or TYRA-300. WO2022147246A1 discloses such FGFR3 antagonists and is incorporated herein by reference in its entirety.

[0041] The present invention provides a method for improving muscle function (e.g., skeletal muscle function) in a subject suffering from a disease or condition in which muscle function (e.g., skeletal muscle function) is impaired, the method comprising administering a therapeutically effective amount of CNP.

[0042] The present invention relates to a method of improving muscle function (e.g., skeletal muscle function) in a subject suffering from a disease or condition in which muscle function (e.g., skeletal muscle function) is impaired, said method comprising the step of administering a therapeutically effective amount of vosoritide.

[0043] In certain embodiments, the CNP comprises or consists of SEQ ID NO: 24. In certain embodiments, the CNP comprises or consists of a peptide selected from the group consisting of SEQ ID NO: 30, SEQ ID NO: 98, SEQ ID NO: 99, SEQ ID NO: 100, SEQ ID NO: 101, SEQ ID NO: 102, SEQ ID NO: 103, SEQ ID NO: 104, SEQ ID NO: 105, and SEQ ID NO: 90. In some embodiments, the CNP is a CNP conjugate or a pharmaceutically acceptable salt thereof comprising a CNP selected from the group consisting of SEQ ID NO: 30, SEQ ID NO: 98, SEQ ID NO: 99, SEQ ID NO: 100, SEQ ID NO: 101, SEQ ID NO: 102, SEQ ID NO: 103, SEQ ID NO: 104, or SEQ ID NO: 105 and SEQ ID NO: 90.

[0044] Improved muscle function can be, for example, a) increased muscle (e.g., skeletal muscle) strength, b) increased muscle (e.g., skeletal muscle) tone, c) increased muscle (e.g., skeletal muscle) stamina, d) increased muscle (e.g., skeletal muscle) mass, e) decreased muscle (e.g., skeletal muscle) fatigue, f) increased cardiovascular endurance, g) increased cardiovascular fitness, h) decreased exercise intolerance, i) increased exercise capacity, j) decreased exercise-induced fatigue, or k) increased muscle hypertonia.

[0045] Administration of an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist can result in an increase in muscle (e.g., skeletal muscle) mass and / or skeletal muscle / fat ratio in a subject.

[0046] The administration of an effective amount of FGFR3 signal transduction inhibitor, or an effective amount of NPR-B agonist, or an effective amount of NPR-C agonist can cause the treatment or prevention of musculoskeletal pain in subjects, improve posture or reduce abnormal curvature of the spine, improve kyphosis, lordosis, spinal stenosis or scoliosis, improve sleep apnea, obstructive sleep apnea, otitis media, or reduce obesity.These improvements can be caused by improving muscle function (for example, skeletal muscle function).Therefore, the treatment, prevention or improvement of any condition mentioned above is preferably due to the improvement of muscle function (for example, skeletal muscle function).

[0047] In certain embodiments, CNP is administered as a prodrug. In certain embodiments, a CNP prodrug provides sustained exposure of the active CNP peptide after administration to a subject.

[0048] The prodrug is optionally a compound of formula (IIf') or formula (IIf) or compound (1), or a pharmaceutically acceptable salt thereof.

[0049] In some embodiments, where the subject is an adult human (i.e., at least 18 years of age), the subject may have been treated with an FGFR3 signaling inhibitor, or an NPR-B agonist (e.g., CNP), or an NPR-C agonist before the age of 18. Thus, the present invention provides therapeutic treatments that begin before the age of 18 and continue beyond the age of 18.

[0050] Administration of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist a) Increased skeletal muscle strength, b) increased skeletal muscle tone; c) Increased skeletal muscle stamina, d) Increased skeletal muscle mass; e) reduced skeletal muscle fatigue; f) Increased cardiovascular endurance, g) Increased cardiovascular health, h) reduced exercise intolerance; i) Increased athletic performance, j) reduction of exercise-induced fatigue, and k) hypotonia The present invention can result in an improvement in one or more muscle functions selected from the group consisting of:

[0051] Thus, the method can alternatively be described as a method for increasing skeletal muscle strength in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0052] The method may also be described as a method for increasing skeletal muscle tone in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0053] The method may also be described as a method for increasing skeletal muscle stamina in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0054] The method may also be described as a method for increasing skeletal muscle mass in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0055] The method can also be described as a method of reducing skeletal muscle fatigue in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0056] The method may also be described as a method for increasing cardiovascular endurance in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0057] The method may also be described as a method for increasing cardiovascular health in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0058] The method may also be described as a method for reducing exercise intolerance in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0059] The method may also be described as a method for increasing exercise capacity in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0060] The method may also be described as a method for reducing exercise-induced fatigue in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0061] The method may also be described as a method for reducing hypotonia in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0062] Administration of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist or an NPR-C agonist may result in an increase in the skeletal muscle / fat ratio in a subject, and the method may alternatively be framed as a method for increasing the skeletal muscle / fat ratio in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising the step of administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0063] Administration of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist or an NPR-C agonist can cause hypotonia in a subject, and therefore this method can be described as a method for reducing hypotonia in a subject (optionally, the subject suffers from a disease or condition that impairs muscle, for example, skeletal muscle function), comprising administering an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist to the subject.Therefore, this method can be described as a method for treating hypotonia in a subject.

[0064] Administration of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist or an NPR-C agonist can result in a reduction in musculoskeletal pain in a subject, and therefore the method can be framed as a method for treating, preventing, or reducing musculoskeletal pain in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising the step of administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0065] The method also results in improved posture and improvement of abnormal spinal curvature, and therefore may be framed as a method for improving posture or treating abnormal spinal curvature in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist. The method can result in improvement of kyphosis, lordosis, or scoliosis, and therefore may be defined as a method for treating one or more of these conditions in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0066] The method may result in improvement of sleep apnea, snoring, obstructive sleep apnea, and otitis media, and as such may be defined as a method of treating one or more of these conditions in a subject (optionally, the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist. A reduction in the frequency, incidence, and / or severity of sleep apnea, snoring, obstructive sleep apnea, and otitis media may occur.

[0067] The method may result in a reduction in obesity, and as such may be defined as a method of reducing obesity in a subject (optionally wherein the subject is suffering from a disease or condition that impairs muscle, e.g., skeletal muscle function), the method comprising the step of administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0068] The present invention also provides a method for treating kyphosis in a patient in need thereof, said method comprising administering to the patient an effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, thereby treating the kyphosis.

[0069] In certain embodiments, the patient has been diagnosed with a bone dysplasia or bone disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, dwarfism, Noonan syndrome, and SHOX deficiency.

[0070] The present invention also provides a method for treating ostial stenosis in a patient in need thereof, the method comprising administering to the patient an effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, thereby treating the ostial stenosis. In some embodiments, the patient has achondroplasia.

[0071] The present invention also provides methods for treating otitis media or ear infections in a patient or reducing the incidence of ear infections in a patient in need of said treatment, said method comprising administering to the patient a therapeutically effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, thereby treating the otitis media or ear infection or reducing the incidence of ear infections. In some embodiments, the patient has achondroplasia.

[0072] The present invention also provides a method for treating sleep apnea syndrome in a patient in need thereof, the method comprising administering to the patient a therapeutically effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof. By way of example, the treatment can reduce the incidence of sleep apnea or reduce the severity of sleep apnea. In some embodiments, the patient has achondroplasia.

[0073] The present invention also provides a method for reducing the frequency of adverse events associated with achondroplasia in a patient diagnosed with achondroplasia, said method comprising the step of administering a therapeutically effective amount of CNP, a CNP conjugate, or a pharmaceutically acceptable salt or unit dosage form thereof, wherein optionally the patient may be a pediatric patient and / or a patient with an open epiphysis.

[0074] In any of the above methods, the subject can have a chondrodysplastic disorder, for example, a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and tothotopic skeletal dysplasia.

[0075] In the above methods, the subject may have achondroplasia. In some embodiments, the subject does not have achondroplasia.

[0076] In any of the above methods, the subject may have achondroplasia, and the subject is a human subject who is at least 18 years of age or who has closed epiphyses.

[0077] Insofar as methods are referred to herein, the present invention also provides an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist for use in the method, and the use of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist in the manufacture of a medicament for use in the method.

[0078] In certain embodiments, the CNP is in the form of a unit dosage form comprising a CNP conjugate or a pharmaceutically acceptable salt thereof.

[0079] In certain embodiments, a unit dosage form of CNP comprises a therapeutically effective amount of a CNP conjugate, or a pharmaceutically acceptable salt thereof, in which a CNP moiety is reversibly conjugated to a polymer moiety. [Brief explanation of the drawings]

[0080] [Figure 1] FIG. 1 shows the survival rate of Fgfr3Y367C / + pups during the study period compared to groups treated with 5.6 mg / kg / day of Compound (1) (solid line), 1.2 mg / kg / every 3 days of Compound (1) (dashed line), or vehicle alone (dotted line). [Figure 2] Figure 1 shows the change in pedicle width after 52 weeks with treatment compared to placebo (Cohorts 3 and 4), as detailed in Example 14. The data show a trend toward increased pedicle width with treatment compared to placebo. [Figure 3] Figure 1 shows the change in mean hand length after 52 weeks with treatment compared to placebo (Cohorts 3 and 4), as detailed in Example 15. The results show a clear trend toward a dose-dependent increase in hand length with treatment. DETAILED DESCRIPTION OF THE INVENTION

[0081] definition The term "about" used in conjunction with a numerical value herein refers to a range of the numerical value plus or minus 10% of the numerical value, in certain embodiments, 8% of the numerical value, in certain embodiments, 5% of the numerical value, and in certain embodiments, 2% of the numerical value. For example, the phrase "about 200" refers to a range of 200 + / - 10%, i.e., 180 to 220; in certain embodiments, a range of 200 + / - 8%, i.e., 184 to 216; in certain embodiments, a range of 200 + / - 5%, i.e., 190 to 210; and in certain embodiments, a range of 200 + / - 2%, i.e., 196 to 204. It is understood that a percentage indicated as "about 20%" does not mean "20% + / - 10%," i.e., a range of 10 to 30%, but rather means 18 to 22%, i.e., a range of plus or minus 10% of the numerical value 20.

[0082] As used herein, the term "antimicrobial agent" refers to chemicals, such as chemicals that kill or inhibit the growth of microorganisms, such as bacteria, fungi, yeasts, protozoa, molds, and / or destroy viruses.

[0083] As used herein, the term "buffer" or "buffering agent" refers to a compound that maintains pH within a desired range. Physiologically tolerated buffers include, for example, sodium phosphate, succinate, histidine, bicarbonate, citrate, acetate, sulfate, nitrate, chloride, and pyruvate. Antacids such as Mg(OH) or ZnCO may also be used.

[0084] As used herein, the term "CNP" refers, in certain embodiments, to all CNP polypeptides derived from mammalian species, e.g., humans and mammalian species, particularly humans and mice, as well as their variants, analogs, orthologs, homologs, derivatives, and fragments thereof, which are characterized by regulating the growth, proliferation, and differentiation of cartilage growth plate chondrocytes. Human prepro-CNP, which contains 126 amino acids, is further cleaved to yield CNP-53 and CNP-22. The term "CNP" also includes all CNP variants, analogs, orthologs, homologs, derivatives, and fragments thereof. The CNP variants, analogs, orthologs, homologs, derivatives, and fragments thereof disclosed in WO 2009 / 067639 A2 and WO 2010 / 135541 A2 are incorporated herein by reference. CNP peptides and pharmaceutical compositions comprising CNP peptides are disclosed in WO2009 / 067639, WO2010 / 135541, WO2017 / 020034, WO2017 / 100400, WO2021055497, WO2021 / 030411, WO2023 / 283657, and WO2022 / 115563, all of which are incorporated by reference herein. Exemplary CNP peptides are provided herein and include vosoritide.

[0085] As used herein, "C 1-4 The term "alkyl," alone or in combination, means a straight or branched chain alkyl moiety having 1 to 4 carbon atoms. When present at the terminal end of a molecule, the straight or branched chain C 1-4 Examples of alkyl are methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl, and tert-butyl. 1-4 When bonded by alkyl, such C 1-4 Examples of alkyl groups are -CH2-, -CH2-CH2-, -CH(CH3)-, -CH2-CH2-CH2-, -CH(C2H5)-, and -C(CH3)2-. 1-4 Each hydrogen of an alkyl carbon may be optionally replaced by a substituent as defined above.1-4 The alkyl may be interrupted by one or more moieties as defined below.

[0086] As used herein, "C 1-6 The term "alkyl," alone or in combination, means a straight or branched chain alkyl moiety having 1 to 6 carbon atoms. When present at the terminal end of a molecule, straight and branched chain C 1-6 Examples of alkyl groups are methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl, tert-butyl, n-pentyl, 2-methylbutyl, 2,2-dimethylpropyl, n-hexyl, 2-methylpentyl, 3-methylpentyl, 2,2-dimethylbutyl, 2,3-dimethylbutyl, and 3,3-dimethylpropyl. 1-6 When bonded by an alkyl group, such as C 1-6 Examples of alkyl groups are -CH2-, -CH2-CH2-, -CH(CH3)-, -CH2-CH2-CH2-, -CH(C2H5)- and -C(CH3)2-. 1-6 Each hydrogen atom of the carbon may be optionally replaced by a substituent as defined above. 1-6 The alkyl may be interrupted by one or more moieties as defined below.

[0087] Therefore, "C 1-10 Alkyl," "C 1-20 Alkyl" or "C 1-50 "Alkyl" means an alkyl chain having 1 to 10, 1 to 20, or 1 to 50 carbon atoms, respectively, where C 1-10 , C 1-20 or C 1-50 Each hydrogen atom of the carbon may be optionally replaced by a substituent as defined above. 1-10 , C 1-20 Alkyl or C 1-50 The alkyl may be interrupted by one or more moieties as defined below.

[0088] As used herein, "C 2-6The term "alkenyl," alone or in combination, means a straight or branched chain hydrocarbon moiety containing at least one carbon-carbon double bond, having 2 to 6 carbon atoms. When present at the end of the molecule, examples are -CH=CH2, -CH=CH-CH3, -CH2-CH=CH2, -CH=CHCH2-CH3 and -CH=CH-CH=CH2. When two parts of the molecule are C 2-6 When bonded by an alkenyl group, such C 2-6 An example of an alkenyl is -CH=CH-. 2-6 Each hydrogen atom of the alkenyl moiety may be optionally replaced by a substituent as defined above. 2-6 The alkenyl may be interrupted by one or more moieties as defined below.

[0089] Therefore, "C 2-10 alkenyl," "C 2-20 alkenyl" or "C 2-50 The term "alkenyl," alone or in combination, means a straight-chain or branched-chain hydrocarbon moiety containing at least one carbon-carbon double bond, having 2 to 10, 2 to 20, or 2 to 50 carbon atoms. 2-10 Alkenyl, C 2-20 Alkenyl or C 2-50 Each hydrogen atom of the alkenyl group may be optionally replaced by a substituent as defined above. 2-10 Alkenyl, C 2-20 Alkenyl or C 2-50 The alkenyl may be interrupted by one or more moieties as defined below.

[0090] As used herein, "C 2-6 The term "alkynyl," alone or in combination, means a straight or branched chain hydrocarbon moiety containing at least one carbon-carbon triple bond, having 2 to 6 carbon atoms. When present at the end of the molecule, examples are -C≡CH, -CH2-C≡CH, CH2-CH2-C≡CH, and CH2-C≡C-CH3. When two parts of the molecule are joined by an alkynyl group, an example is -C≡C-. C2-6 Each hydrogen atom of the alkynyl group may be optionally replaced by a substituent as defined above. Optionally, one or more double bond(s) may be present. Optionally, C 2-6 The alkynyl may be interrupted by one or more moieties as defined below.

[0091] Therefore, as used herein, "C 2-10 alkynyl", "C 2-20 alkynyl" and "C 2-50 The term "alkynyl," alone or in combination, means a straight-chain or branched-chain hydrocarbon moiety containing at least one carbon-carbon triple bond, having 2 to 10, 2 to 20, or 2 to 50 carbon atoms, respectively. 2-10 Alkynyl, C 2-20 Alkynyl or C 2-50 Each hydrogen atom of the alkynyl group may be optionally replaced by a substituent as defined above. Optionally, one or more double bond(s) may be present. Optionally, C 2-10 Alkynyl, C 2-20 Alkynyl or C 2-50 The alkynyl may be interrupted by one or more moieties as defined below.

[0092] As mentioned above, C 1-4 Alkyl, C 1-6 Alkyl, C 1-10 Alkyl, C 1-20 Alkyl, C 1-50 Alkyl, C 2-6 Alkenyl, C 2-10 Alkenyl, C 2-20 Alkenyl, C 2-50 Alkenyl, C 2-6 Alkynyl, C 2-10 Alkynyl, C 2-20 Alkenyl or C 2-50 The alkynyl may optionally be interrupted by one or more moieties, which in certain embodiments are [ka] (In the formula, The dashed line indicates the attachment of the moiety or reagent to the remainder of the -R and -R a are independently selected from the group consisting of -H, methyl, ethyl, propyl, butyl, pentyl, and hexyl. is selected from the group consisting of:

[0093] As used herein, "C 3-10 The term "cycloalkyl" means a cyclic alkyl chain having 3 to 10 carbon atoms, which may be saturated or unsaturated, for example, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cyclohexenyl, cycloheptyl, cyclooctyl, cyclononyl or cyclodecyl. 3-10 Each hydrogen atom of a cycloalkyl carbon may be optionally substituted by a substituent as defined above. 3-10 "Cycloalkyl" also includes bridged bicycles such as norbornane or norbornene.

[0094] As used herein, the term "8- to 30-membered carbopolycyclyl" or "8- to 30-membered carbopolycycle" refers to a cyclic moiety of two or more rings having 8 to 30 ring atoms, where two adjacent rings share at least one ring atom, and may contain up to a maximum number of double bonds (fully saturated, partially saturated, or unsaturated, aromatic or non-aromatic rings). In certain embodiments, 8- to 30-membered carbopolycyclyl refers to a cyclic moiety of 2, 3, 4, or 5 rings, and in certain embodiments, 2, 3, or 4 rings.

[0095] As used herein, the term "3- to 10-membered heterocyclyl" or "3- to 10-membered heterocycle" refers to a ring having 3, 4, 5, 6, 7, 8, 9, or 10 ring atoms, which may contain up to a maximum number of double bonds (fully saturated, partially saturated, or unsaturated, aromatic or non-aromatic ring), in which at least one ring atom, and up to four ring atoms, is replaced by a heteroatom selected from the group consisting of sulfur (including -S(O)-, -S(O)-), oxygen, and nitrogen (including =N(O)-), and which is bonded to the remainder of the molecule through a carbon or nitrogen atom. Examples of 3-10 membered heterocycles include, but are not limited to, aziridine, oxirane, thiirane, azirine, oxirene, thiylene, azetidine, oxetane, thietane, furan, thiophene, pyrrole, pyrroline, imidazole, imidazoline, pyrazole, pyrazoline, oxazole, oxazoline, isoxazole, isoxazoline, thiazole, thiazoline, isothiazole, isothiazol, thiazoline, thiadiazole, thiadiazoline, tetrahydrofuran, Examples thereof include tetrahydrothiophene, pyrrolidine, imidazolidine, pyrazolidine, oxazolidine, isoxazolidine, thiazolidine, isothiazolidine, thiadiazolidine, sulfolane, pyran, dihydropyran, tetrahydropyran, imidazolidine, pyridine, pyridazine, pyrazine, pyrimidine, piperazine, piperidine, morpholine, tetrazole, triazole, triazolidine, tetrazolidine, diazepane, azepine, and homopiperazine. Each hydrogen atom of the 3- to 10-membered heterocyclyl or the 3- to 10-membered heterocyclic group may be substituted by a substituent defined below.

[0096] As used herein, the term "8- to 11-membered heterobicyclyl" or "8- to 11-membered heterobicycle" refers to a two-ring heterocyclic moiety having 8 to 11 ring atoms, where at least one ring atom is shared by both rings and may contain up to a maximum number of double bonds (fully saturated, partially saturated, or unsaturated aromatic or non-aromatic rings), where at least one ring atom, and up to six ring atoms, is replaced by a heteroatom selected from the group consisting of sulfur (including -S(O)-, -S(O)-), oxygen, and nitrogen (including =N(O)-), and where the ring is bonded to the remainder of the molecule via a carbon or nitrogen atom. Examples of 8- to 11-membered heterobicycles include indole, indoline, benzofuran, benzothiophene, benzoxazole, benzisoxazole, benzothiazole, benzisothiazole, benzimidazole, benzimidazoline, quinoline, quinazoline, dihydroquinazoline, quinoline, dihydroquinoline, tetrahydroquinoline, decahydroquinoline, isoquinoline, decahydroisoquinoline, tetrahydroisoquinoline, dihydroisoquinoline, benzazepine, purine, and pteridine. The term 8- to 11-membered heterobicycle also includes two-ring spiro structures such as 1,4-dioxa-8-azaspiro[4.5]decane, or bridged heterocycles such as 8-aza-bicyclo[3.2.1]octane. Each hydrogen atom of an 8- to 11-membered heterobicyclyl or an 8- to 11-membered heterobicycle carbon may be substituted by a substituent as defined below.

[0097] Similarly, the terms "8-30 membered heteropolycyclyl" or "8-30 membered heteropolycycle" refer to a heterocyclic moiety having 3 or more rings, in particular 3, 4, or 5 rings, having 8 to 30 ring atoms, in which two adjacent rings share at least one ring atom and may contain up to a maximum number of double bonds (fully saturated, partially saturated, or unsaturated, aromatic or non-aromatic rings), in which at least one ring atom, and up to 10 ring atoms, is replaced by a heteroatom selected from the group of sulfur (including -S(O)-, -S(O)-), oxygen, and nitrogen (including =N(O)-), and in which the ring is bonded to the remainder of the molecule via a carbon or nitrogen atom.

[0098] The following structure: [ka] Regarding the part, "Pair R x / R y together with the atoms to which they are attached, C 3-10 The phrase "forms a cycloalkyl or 3- to 10-membered heterocyclyl" refers to R x and R y But the following structure: [ka] (Wherein R is C 3-10 cycloalkyl or 3-10 membered heterocyclyl It is understood to mean forming

[0099] The following structure: [ka] Regarding the part, "Pair R x / R y together with the atoms to which they are attached form a ring A" is x and R y But the following structure: [ka] It is also understood to mean forming

[0100] As used herein, the term "CNP polypeptide variant" refers to a polypeptide derived from the same species that differs from a reference CNP polypeptide. Generally, differences are limited so that the amino acid sequences of the reference and variant are closely similar overall and, in many regions, identical. In certain embodiments, a CNP polypeptide variant is at least 70%, 80%, 90%, or 95% identical to a reference CNP polypeptide. A polypeptide having an amino acid sequence that is, for example, at least 95% "identical" to a query amino acid sequence is intended to be identical to the query sequence, except that the amino acid sequence of the subject polypeptide may contain no more than five amino acid changes per 100 amino acids of the query amino acid sequence. These reference sequence changes may occur at the amino-terminal (N-terminal) or carboxy-terminal (C-terminal) positions of the reference amino acid sequence, or anywhere between these terminal positions, interspersed individually among residues in the reference sequence, or interspersed in one or more adjacent groups within the reference sequence. The query sequence may be the entire amino acid sequence of the reference sequence, or any fragment identified as described herein. Such CNP polypeptide variants may be natural variants, such as natural allelic variants encoded by one of several alternative forms of CNP occupying a given locus of a chromosome or organism, or isoforms encoded by natural splice variants derived from a single primary transcript. Alternatively, CNP polypeptide variants may be variants that are not known to occur naturally and can be produced by mutagenesis techniques known in the art. It is known in the art that one or more amino acids can be deleted from the N-terminus or C-terminus of a biologically active peptide or protein without significant loss of biological function. Such N-terminus and / or C-terminus deletions are also encompassed by the term CNP polypeptide variant.

[0101] As used herein, the term "dose" or "unit dose" refers to a predetermined amount of a drug, such as CNP, administered at one time to produce some biological response in a patient. The dose of a drug is determined by its inherent potency, in which case the amount is a therapeutic dose or a therapeutic unit dose.

[0102] The term "dosage form" as used herein refers to a physical form that contains an active pharmaceutical ingredient in combination with selected additional ingredients or excipients and is intended to be delivered to an active site in the body by various routes of drug administration. This term also refers to a physical form that provides a precise mixture of active pharmaceutical ingredients and excipients to assist in administration and delivery to the active site, achieve rapid onset of action, and improve bioavailability. The term "unit dosage form" as used herein refers to a dosage form configured for a single administration to a patient. For example, a unit dosage form may be a single vial or container containing a certain amount of drug suitable for a single administration.

[0103] As used herein, the term "dosing regimen" refers to the combination of the dose and frequency at which a drug is administered. The dosing regimen may also include the route of administration (e.g., subcutaneous) and / or the duration of administration (e.g., until the patient reaches 18 years of age or physeal closure). Administration of the dosing regimen may maintain a steady-state serum concentration of CNP in which the peak, trough, and area under the curve over a specified interval maintain a specified range of fluctuation and / or the peak-to-trough ratio does not exceed a specified threshold.

[0104] As used herein, the term "drug" refers to a substance used in the treatment, cure, prevention, or diagnosis of disease, or otherwise used to enhance physical or mental well-being. When a drug, such as CNP, is conjugated to another moiety, the portion of the resulting product derived from the drug is called a "drug moiety."

[0105] As used herein, the term "excipient" refers to a compound administered with a drug or drug conjugate, such as a buffer, isotonicity adjuster, preservative, stabilizer, anti-adsorption agent, oxidation protectant, or other auxiliary agent. However, in some cases, a single excipient may have dual or triple functions. The term "excipient" may also refer to a diluent, adjuvant, or vehicle with which a drug or drug conjugate is administered. Such pharmaceutical excipients may be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable, or synthetic origin, including, but not limited to, peanut oil, soybean oil, mineral oil, sesame oil, and the like. When the pharmaceutical formulation is administered orally, water is the preferred excipient. When the pharmaceutical formulation is administered intravenously or subcutaneously, saline and aqueous dextrose are preferred excipients. In certain embodiments, saline, aqueous dextrose, and glycerol solutions are used as liquid excipients for injectable solutions. Suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, mannitol, trehalose, gelatin, malt, rice, wheat flour, chalk, silica gel, sodium stearate, glycerol monostearate, talc, sodium chloride, nonfat dry milk, glycerol, propylene, glycol, water, ethanol, etc. Pharmaceutical formulations may also contain minor amounts of wetting or emulsifying agents, pH buffers such as acetates, succinates, Tris (tris(hydroxymethyl)aminomethane), carbonates, phosphates, HEPES (4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid), MES (2-(N-morpholino)ethanesulfonic acid), or surfactants such as Tween®, poloxamer, poloxamine, CHAPS, Igepal®, or amino acids such as glycine, lysine, or histidine. These pharmaceutical formulations can take the form of solutions, suspensions, emulsion, tablets, pills, capsules, powders, sustained-release formulations, etc. The pharmaceutical formulation can be formulated as a suppository, with traditional binders and excipients such as triglycerides.Oral formulations may contain standard excipients, such as pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharin, cellulose, magnesium carbonate, etc. Such formulations contain a therapeutically effective amount of the drug or drug moiety, together with a suitable amount of excipient to provide the form for proper administration to the patient. The formulation should suit the mode of administration.

[0106] As used herein, the term "formulation" or "pharmaceutical formulation" refers to a formulation comprising one or more CNP conjugates and one or more excipients, as well as any product that results directly or indirectly from the combination, complexation, or aggregation of any two or more of the components of the composition, or from the dissociation of one or more of the components, or from other types of reaction or interaction of one or more of the components. Thus, pharmaceutical formulations of the present invention encompass any formulation or composition made by mixing one or more CNP conjugates with pharmaceutically acceptable excipients, such as buffers and bulking agents.

[0107] As used herein, the term "free form" of a drug refers to the drug in its unmodified, pharmacologically fully active form, e.g., after release from a CNP conjugate or a pharmaceutically acceptable salt thereof.

[0108] As used herein, the term "functional group" refers to an atomic group capable of reacting with another atomic group. Functional groups include, but are not limited to, the following groups: carboxylic acid (-(C=O)OH), primary or secondary amine (-NH, -NH-), maleimide, thiol (-SH), sulfonic acid (-(O=S=O)OH), carbonate, carbamate (-O(C=O)N<), hydroxyl (-OH), aldehyde (-(C=O)H), ketone (-(C=O)-), hydrazine (>NN<), isocyanate, isothiocyanate, phosphate (-O(P=O)OHOH), phosphonate (-O(P=O)OHH), haloacetyl, alkyl halide, acryloyl, aryl fluoride, hydroxylamine, disulfide, sulfonamide, sulfate, vinyl sulfone, vinyl ketone, diazoalkane, oxirane, and azirizine.

[0109] As used herein, the term "halogen" means fluoro, chloro, bromo, or iodo. It is generally preferred that the halogen is fluoro or chloro.

[0110] As used herein, the term "interrupted" means that a moiety is inserted between two carbon atoms, or, if the insertion is at one of the ends of the moiety, between a carbon atom or heteroatom and a hydrogen atom, and in certain embodiments, between a carbon atom and a hydrogen atom.

[0111] As used herein, the term "isotonicity agent" refers to a compound that minimizes pain, irritation, and tissue trauma that can result from cell damage caused by the osmotic pressure difference between the injected solution and plasma.

[0112] As used herein, the term "moiety" refers to a portion of a molecule that lacks one or more atoms (one or more) compared to the corresponding reagent. For example, when a reagent of the formula "HXH" reacts with another reagent and becomes part of a reaction product, the corresponding moiety in the reaction product has the structure "HX-" or "-X-", where each "-" indicates a bond to another moiety. Thus, a drug moiety, e.g., a CNP moiety, is released from the conjugate as a drug, e.g., CNP.

[0113] When a sequence or chemical structure of atoms connecting two moieties or interrupting one moiety is provided, it is understood that the sequence or chemical structure may be attached to the two moieties in either orientation, unless expressly stated otherwise. For example, the moiety "-C(O)N(R 1 )-" is "-C(O)N(R 1 )-" or "-N(R 1 )C(O)—” or can be interrupted in one moiety. Similarly, the moiety: [ka] teeth, [ka] as, or [ka] As such, it can be joined into two parts or broken into one part.

[0114] If the CNP moiety contains one or more acidic or basic groups, the unit dosage form also includes their corresponding pharmaceutically or toxicologically acceptable salts, particularly their pharmaceutically acceptable salts. Thus, CNP moieties containing one or more acidic groups may exist and can be used, for example, as alkali metal salts, alkaline earth metal salts, or ammonium salts. More specific examples of such salts include sodium salts, potassium salts, calcium salts, magnesium salts, or salts with ammonia or organic amines (e.g., ethylamine, ethanolamine, triethanolamine, etc.) or amino acids, as well as other salts or amines known to those skilled in the art. CNP moieties containing one or more basic groups, i.e., groups that can be protonated, may exist and can be used in the form of their addition salts with inorganic or organic acids. Examples of suitable acids include hydrogen chloride, hydrogen bromide, phosphoric acid, sulfuric acid, nitric acid, methanesulfonic acid, p-toluenesulfonic acid, naphthalenedisulfonic acid, oxalic acid, acetic acid, tartaric acid, lactic acid, salicylic acid, benzoic acid, formic acid, propionic acid, pivalic acid, diethylacetic acid, malonic acid, succinic acid, pimelic acid, fumaric acid, maleic acid, malic acid, sulfamic acid, phenylpropionic acid, gluconic acid, ascorbic acid, isonicotinic acid, citric acid, adipic acid, and other acids known to those skilled in the art. Further methods for converting basic groups to cations are known to those skilled in the art, such as alkylation of amine groups to provide a positively charged ammonium group and a suitable counterion for its salt. When the CNP moiety contains both an acidic and a basic group, the pharmaceutical formulations according to the present invention also include internal salts or betaines (zwitterions) in addition to the salt forms mentioned above. The respective salts can be obtained by conventional methods known to those skilled in the art, for example, by contacting these conjugates with an organic or inorganic acid or base in a solvent or dispersant, or by anion or cation exchange with other salts. The unit dosage form according to the present invention also includes all salts of CNP conjugates that are not directly suitable for use in pharmaceuticals due to their low physiological compatibility, but can be used, for example, as intermediates for chemical reactions or for preparing pharmaceutically acceptable salts.

[0115] The term "patient" as used herein refers to a subject, particularly a human subject, suitable for treatment or prevention according to the present invention.

[0116] As used herein, the term "pharmaceutically acceptable" means a substance that is not harmful when administered to a patient, and preferably means approved by a regulatory authority, e.g., the EMA (Europe) and / or the FDA (USA) and / or any other country's regulatory authority, for use in animals, preferably for use in humans.

[0117] As used herein, the term "physiological conditions" refers to an aqueous buffer at pH 7.4 and 37°C.

[0118] As used herein, the term "polypeptide" refers to a chain of two to fifty amino acid monomer moieties linked by peptide (amide) bonds. For CNP drugs and CNP moieties only, sequences having more than 50 amino acids are also referred to as "polypeptides" for simplicity.

[0119] As used herein, the term "preservative" refers to a chemical substance that has antimicrobial activity and prevents chemical degradation.

[0120] The term "protein" as used herein refers to a chain of more than 50 amino acid monomer moieties linked by peptide bonds, preferably having 12,000 or fewer amino acid monomers, such as 10,000 or fewer amino acid monomer moieties, 8,000 or fewer amino acid monomer moieties, 5,000 or fewer amino acid monomer moieties or 2,000 or fewer amino acid monomer moieties linked by peptide bonds.

[0121] As used herein, the term "polymer" refers to a molecule comprising repeating structural units, i.e., monomers, linked by chemical bonds, which may be linear, cyclic, branched, cross-linked, dendrimer-like, or a combination thereof, and which may be of synthetic origin, biological origin, or a combination of both. It is understood that a polymer may also comprise one or more other chemical groups and / or moieties, such as, for example, one or more functional groups. In certain embodiments, a soluble polymer has a molecular weight of at least 0.5 kDa, e.g., at least 1 kDa, at least 2 kDa, at least 3 kDa, or at least 5 kDa. When a polymer is soluble, in certain embodiments, it has a molecular weight of at most 1000 kDa, e.g., at most 750 kDa, e.g., at most 500 kDa, e.g., at most 300 kDa, e.g., at most 200 kDa, e.g., at most 100 kDa.

[0122] A protein or polypeptide is also understood to be a polymer in which amino acids are repeating structural units, even though the side chain of each amino acid may be different.

[0123] As used herein, the term "polymeric" or "polymeric moiety" refers to a reagent or moiety that comprises one or more polymers or polymer moieties. A polymeric reagent or moiety may also optionally comprise one or more other moieties, which in certain embodiments are selected from the group consisting of: - C 1-50 Alkyl, C 2-50 Alkenyl, C 2-50 Alkynyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, phenyl, naphthyl, indenyl, indanyl, and tetralinyl; and - Groups including: [ka] (In the formula, The dashed line indicates the bond to the remainder of the moiety or reagent; -R and -R a are each independently selected from the group consisting of -H, methyl, ethyl, propyl, butyl, pentyl and hexyl. A bond selected from:

[0124] Those skilled in the art will understand that not all polymerization products resulting from a polymerization reaction have the same molecular weight, but rather exhibit a distribution of molecular weights. Consequently, as used herein, molecular weight range, molecular weight, range of the number of monomers in a polymer, and number of monomers in a polymer refer to the number average molecular weight and the monomer number average, i.e., the arithmetic mean of the molecular weight of the polymer or polymer portion, and the arithmetic mean of the number of monomers in the polymer or polymer portion.

[0125] Thus, in a polymer segment comprising "x" monomer units, any integer designated as "x" corresponds to the arithmetic average number of monomers. Any range of integers designated as "x" provides a range of integers within which the arithmetic average number of monomers lies. An integer "x" designated as "about x" means that the arithmetic average number of monomers lies within the integer range of x + / - 10%, in certain embodiments within the integer range of x + / - 8%, in certain embodiments within the integer range of x + / - 5%, and in certain embodiments within the integer range of x + / - 2%.

[0126] As used herein, the term "PEG-based" in reference to a moiety or reagent means that the moiety or reagent comprises PEG. In certain embodiments, the PEG-based moiety or reagent comprises at least 10% (w / w) PEG, such as at least 20% (w / w) PEG, such as at least 30% (w / w) PEG, such as at least 40% (w / w) PEG, such as at least 50% (w / w), such as at least 60% (w / w) PEG, such as at least 70% (w / w) PEG, such as at least 80% (w / w) PEG, such as at least 90% (w / w) PEG, such as at least 95% (w / w) PEG. The remaining weight percentage of the PEG-based moiety or reagent is other moieties selected from the following moieties and linkages: - C 1-50 Alkyl, C 2-50 Alkenyl, C 2-50 Alkynyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, phenyl, naphthyl, indenyl, indanyl, and tetralinyl; and - Groups including: [ka] (In the formula, The dashed line indicates the bond to the remainder of the moiety or reagent; -R and -R a are each independently selected from the group consisting of -H, methyl, ethyl, propyl, butyl, pentyl and hexyl. A bond selected from:

[0127] As used herein, the term "PEG-based comprising at least X% PEG" in reference to a moiety or reagent means that the moiety or reagent comprises at least X% (w / w) ethylene glycol units (-CHCHO-), where the ethylene glycol units may be arranged in alternating blocks within the moiety or reagent or may be randomly distributed, and in certain embodiments, all the ethylene glycol units of the moiety or reagent are present in one block, and the remaining weight percent of the PEG-based moiety or reagent is, in certain embodiments, other moieties selected from the following moieties and bonds: - C 1-50 Alkyl, C 2-50 Alkenyl, C 2-50 Alkynyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, phenyl, naphthyl, indenyl, indanyl and tetralinyl, and - Groups including: [ka] (In the formula, The dashed line indicates the bond to the remainder of the moiety or reagent; -R and -R a are each independently selected from the group consisting of -H, methyl, ethyl, propyl, butyl, pentyl and hexyl. A bond selected from:

[0128] As used herein, the term "a hyaluronic acid system containing at least X% hyaluronic acid" is used arbitrarily.

[0129] The term "prodrug" as used herein refers to a drug moiety, such as a CNP moiety, that is reversibly and covalently conjugated to a polymer moiety such as -Z via a reversible linker moiety. A prodrug releases the reversibly and covalently bound drug moiety in the form of its corresponding drug. In other words, a prodrug is a conjugate that includes a drug moiety, such as a CNP moiety, that is covalently and reversibly conjugated to a polymer moiety via a reversible linker moiety, and the covalent and reversible conjugation of the polymer moiety to the reversible linker moiety is direct or via a spacer. Such a prodrug or conjugate releases the previously conjugated drug moiety in the form of a free drug.

[0130] As used herein, the term "random coil" refers to a peptide or protein that adopts / has / forms, in certain embodiments, a conformation substantially devoid of defined secondary and tertiary structure as determined by circular dichroism spectroscopy performed in aqueous buffer at ambient temperature and pH 7.4. In certain embodiments, ambient temperature is about 20°C, i.e., 18°C ​​to 22°C, while in certain embodiments, ambient temperature is 20°C.

[0131] As used herein, the term "reversible bond" refers to a bond that is cleavable in the absence of enzymes under physiological conditions (aqueous buffer at pH 7.4 and 37°C) with a half-life of 1 hour to 6 months, e.g., 1 hour to 4 months, e.g., 1 hour to 3 months, 1 hour to 2 months, or 1 hour to 1 month. Thus, a stable bond is one that has a half-life of greater than 6 months under physiological conditions (aqueous buffer at pH 7.4 and 37°C).

[0132] As used herein, the term "reagent" means a compound that contains at least one functional group for reaction with a functional group of another compound or drug. It is understood that drugs that contain a functional group (e.g., a primary or secondary amine or hydroxyl functional group) are also reagents.

[0133] As used herein, the term "reversible linker moiety" refers to a moiety that is covalently conjugated to a drug moiety, such as a CNP moiety, via a reversible bond and is also covalently conjugated to a polymer moiety, such as -Z, where the covalent conjugation to the polymer moiety is direct or via a linker such as -L. 2 In certain embodiments, -Z and -L 2 - is a stable bond. A conjugate that includes a reversible linker moiety can be referred to as a reversible conjugate.

[0134] As used herein, the term "spacer" or "spacer moiety" refers to a moiety suitable for linking two moieties. Suitable spacers include C 1-50 Alkyl, C 2-50 Alkenyl or C 2-50 alkynyl, wherein C 1-50 Alkyl, C 2-50 Alkenyl or C 2-50 Alkynyl optionally includes -NH-, -N(C 1-4 alkyl)-, -O-, -S-, -C(O)-, -C(O)NH-, -C(O)N(C 1-4and is interrupted by one or more groups selected from alkyl)-, -OC(O)-, -S(O)-, -S(O)2-, 4- to 7-membered heterocyclyl, phenyl, and naphthyl.

[0135] As used herein, the term "substituted" means that one or more -H atom(s) of a molecule or moiety is replaced by a different atom or group of atoms, called a "substituent."

[0136] In certain embodiments, such one or more substituents are, independently of each other, halogen, —CN, —COOR x1 , -OR x1 , -C(O)R x1 , -C(O)N(R x1 R x1a ), -S(O)2N(R x1 R x1a ), -S(O)N(R x1 R x1a ), -S(O)R x1 , -S(O)R x1 , -N(R x1 )S(O)2N(R x1a R x1b ), -SR x1 , -N(R x1 R x1a ), -NO2, -OC(O)R x1 , -N(R x1 )C(O)R x1a , -N(R x1 )S(O)2R x1a , -N(R x1 )S(O)R x1a , -N(R x1 )C(O)OR x1a , -N(R x1 )C(O)N(R x1a R x1b ), -OC(O)N(R x1 R x1a ), -T 0 , C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; 0 , C 1-50 Alkyl, C2-50 Alkenyl and C 2-50 Alkynyl may be one or more -R x2 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl has -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 )-, -S(O)2N(R x3 )-, -S(O)N(R x3 )-, -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a )-, -S-, -N(R x3 )-, -OC(OR x3 )(R x3a )-, -N(R x3 )C(O)N(R x3a )- and -OC(O)N(R x3 )-, optionally interrupted by one or more groups selected from the group consisting of; -R x1 , -R x1a , -R x1b are independent of each other, -H, -T 0 , C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; 0 , C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl may be one or more -R x2 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl has -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 )-, -S(O)2N(R x3 )-, -S(O)N(R x3 )-;-S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a )-, -S-, -N(Rx3 )-, -OC(OR x3 )(R x3a )-, -N(R x3 )C(O)N(R x3a )- and -OC(O)N(R x3 )-, optionally interrupted by one or more groups selected from the group consisting of; Each T 0 is phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 is independently selected from the group consisting of cycloalkyl, 3- to 10-membered heterocyclyl, and 8- to 11-membered heterobicyclyl; 0 may independently be one or more of the same or different -R x2 optionally substituted with; Each-R x2 are independently halogen, -CN, oxo(=O), -COOR x4 , -OR x4 , -C(O)R x4 , -C(O)N(R x4 R x4a ), -S(O)2N(R x4 R x4a ), -S(O)N(R x4 R x4a ), -S(O)R x4 , -S(O)R x4 , -N(R x4 )S(O)2N(R x4a R x4b ), -SR x4 , -N(R x4 R x4a ), -NO2, -OC(O)R x4 , -N(R x4 )C(O)R x4a , -N(R x4 )S(O)2R x4a , -N(R x4 )S(O)R x4a , -N(R x4 )C(O)OR x4a , -N(R x4 )C(O)N(R x4a R x4b ), -OC(O)N(R x4 R x4a ), and C 1-6alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R x3 , -R x3a , -R x4 , -R x4a , -R x4b are independently -H and C 1-6 alkyl; 1-6 The alkyl is optionally substituted with one or more halogens which may be the same or different.

[0137] In certain embodiments, the one or more substituents are, independently of each other, halogen, —CN, —COOR x1 , -OR x1 , -C(O)R x1 , -C(O)N(R x1 R x1a ), -S(O)2N(R x1 R x1a ), -S(O)N(R x1 R x1a ), -S(O)R x1 , -S(O)R x1 , -N(R x1 )S(O)2N(R x1a R x1b ), -SR x1 , -N(R x1 R x1a ), -NO2, -OC(O)R x1 , -N(R x1 )C(O)R x1a , -N(R x1 )S(O)2R x1a , -N(R x1 )S(O)R x1a , -N(R x1 )C(O)OR x1a , -N(R x1 )C(O)N(R x1a R x1b ), -OC(O)N(R x1 R x1a ), -T 0 , C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10alkynyl; 0 , C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10 Alkynyl may be one or more -R x2 optionally substituted with C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10 Alkynyl has -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 )-, -S(O)2N(R x3 )-, -S(O)N(R x3 )-, -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a )-, -S-, -N(R x3 )-, -OC(OR x3 )(R x3a )-, -N(R x3 )C(O)N(R x3a )- and -OC(O)N(R x3 )-, optionally interrupted by one or more groups selected from the group consisting of; Each-R x1 , -R x1a , -R x1b , -R x3 , -R x3a are independently -H, halogen, C 1-6 Alkyl, C 2-6 Alkenyl, and C 2-6 alkynyl; Each T 0 are independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, and 8- to 11-membered heterobicyclyl; 0 may independently be one or more of the same or different -R x2 optionally substituted with; Each-R x2 are independently halogen, -CN, oxo(=O), -COOR x4 , -OR x4 , -C(O)Rx4 , -C(O)N(R x4 R x4a ), -S(O)2N(R x4 R x4a ), -S(O)N(R x4 R x4a ), -S(O)R x4 , -S(O)R x4 , -N(R x4 )S(O)2N(R x4a R x4b ), -SR x4 , -N(R x4 R x4a ), -NO2, -OC(O)R x4 , -N(R x4 )C(O)R x4a , -N(R x4 )S(O)2R x4a , -N(R x4 )S(O)R x4a , -N(R x4 )C(O)OR x4a , -N(R x4 )C(O)N(R x4a R x4b ), -OC(O)N(R x4 R x4a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R x4 , -R x4a , -R x4b are independently -H, halogen, C 1-6 Alkyl, C 2-6 Alkenyl, and C 2-6 alkynyl.

[0138] In certain embodiments, the one or more substituents are, independently of each other, halogen, —CN, —COOR x1 , -OR x1 , -C(O)R x1 , -C(O)N(R x1 R x1a ), -S(O)2N(R x1 R x1a ), -S(O)N(Rx1 R x1a ), -S(O)R x1 , -S(O)R x1 , -N(R x1 )S(O)2N(R x1a R x1b ), -SR x1 , -N(R x1 R x1a ), -NO2, -OC(O)R x1 , -N(R x1 )C(O)R x1a , -N(R x1 )S(O)2R x1a , -N(R x1 )S(O)R x1a , -N(R x1 )C(O)OR x1a , -N(R x1 )C(O)N(R x1a R x1b ), -OC(O)N(R x1 R x1a ), -T 0 , C 1-6 Alkyl, C 2-6 Alkenyl, and C 2-6 alkynyl; 0 , C 1-6 Alkyl, C 2-6 Alkenyl, and C 2-6 Alkynyl may be one or more -R x2 optionally substituted with C 1-6 Alkyl, C 2-6 Alkenyl, and C 2-6 Alkynyl has -T 0 -, -C(O)O-, -O-, -C(O)-, -C(O)N(R x3 )-, -S(O)2N(R x3 )-, -S(O)N(R x3 )-, -S(O)2-, -S(O)-, -N(R x3 )S(O)2N(R x3a )-, -S-, -N(R x3 )-, -OC(OR x3 )(R x3a )-, -N(R x3 )C(O)N(R x3a )- and -OC(O)N(Rx3 )-, optionally interrupted by one or more groups selected from the group consisting of; Each-R x1 , -R x1a , -R x1b , -R x2 , -R x3 , -R x3a are independently -H, halogen, C 1-6 Alkyl, C 2-6 Alkenyl, and C 2-6 alkynyl; Each T 0 are independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, and 8- to 11-membered heterobicyclyl; 0 may independently be one or more of the same or different -R x2 is optionally replaced by

[0139] In certain embodiments, up to six -H atoms of an optionally substituted molecule are independently substituted by substituents, e.g., five -H atoms are independently substituted by substituents, four -H atoms are independently substituted by substituents, three -H atoms are independently substituted by substituents, two -H atoms are independently substituted by substituents, or one -H atom is substituted by a substituent.

[0140] As used herein, the term "therapeutically effective amount" refers to an amount sufficient to cure, alleviate, or partially arrest the clinical symptoms of a given disease and its complications. The effective amount for each purpose will depend on the severity of the disease or injury as well as the weight and general condition of the subject. It will be understood that determining the appropriate dosage can be achieved using routine experimentation by constructing a matrix of values ​​and testing different points in the matrix, all of which is within the ordinary skill of a skilled physician. Within the scope of the present invention, a therapeutically effective amount relates to a dosage that aims to achieve a therapeutic effect over a long period of time, i.e., for at least 1 day, e.g., 2 days, e.g., 3 days, e.g., 4 days, e.g., 5 days, e.g., 6 days, e.g., 1 week, or e.g., 2 weeks.

[0141] As used herein, the term "traceless linker" means a reversible linker that, when cleaved, releases the drug in its free form.

[0142] As used herein, the term "water-soluble" with respect to a polymer moiety means that when such a polymer moiety is part of a CNP conjugate, at least 1 g of a CNP conjugate containing such a water-soluble polymer moiety can be dissolved in 1 liter of water at 20°C to form a homogeneous solution.

[0143] In general, the terms "comprise" or "comprising" also encompass "consist of" or "consisting of."

[0144] The amino acid sequence of a CNP polypeptide can be altered without significantly affecting the structure or function of the peptide. Such variants include deletions, insertions, inversions, repeats, and substitutions selected according to principles known in the art so as to have minimal effect on activity. For example, guidance on how to make phenotypically silent amino acid substitutions is provided in Bowie et al. (1990), Science 247:1306-1310, which is incorporated herein by reference in its entirety, in which the authors demonstrate that there are two main approaches to determining the tolerance of an amino acid sequence to change.

[0145] As used herein, the term "CNP analog" refers to a CNP from another, unrelated organism that performs the same function in the respective organism but does not originate from an ancestral structure shared by the ancestors of the organisms. Instead, analog CNPs arose separately and subsequently evolved to perform the same or similar function. In other words, analog CNP polypeptides are polypeptides with significantly different amino acid sequences that achieve the same biological activity, i.e., regulating the growth, proliferation, and differentiation of chondrocytes in the cartilage growth plate.

[0146] As used herein, the term "CNP ortholog" refers to a CNP present in two different species whose sequences are related to each other through a common homologous CNP in an ancestral species, but which have evolved to be distinct from each other.

[0147] As used herein, the term "CNP homolog" refers to CNPs from different organisms that perform the same function in each organism and that originate from an ancestral structure shared by the ancestors of those organisms. In other words, homologous CNP polypeptides are polypeptides with closely related amino acid sequences that achieve the same biological activity, i.e., regulating the growth, proliferation, and differentiation of chondrocytes in the cartilage growth plate. In certain embodiments, a CNP polypeptide homolog can be defined as a polypeptide that exhibits at least 40%, 50%, 60%, 70%, 80%, 90%, or 95% identity to a reference CNP polypeptide.

[0148] Detailed Description of the Invention The present invention relates to a method for improving muscle function, e.g., skeletal muscle function, in a subject suffering from a disease or condition in which muscle function is impaired, the method comprising the step of administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist.

[0149] FGFR3 signaling inhibitors The FGFR3 signaling pathway is well understood and involves the MAPK and STET pathways. In non-pathological conditions, receptors are activated by ligand (e.g., FGF1, FGF2, or FGF9) binding and receptor dimerization, resulting in the tyrosine kinase domains of each member of the receptor dimer pair coming into close proximity and cross-phosphorylating each other on tyrosines in the activation loop. This activates the kinase, which then binds to adaptor proteins, phosphorylates cytosolic substrates, and triggers downstream signaling cascades that regulate cell proliferation and differentiation. Certain pathological conditions are associated with constitutive FGFR3 activation; in these conditions, receptor dimerization and phosphorylation can occur even in the absence of ligand binding.

[0150] Inhibition of FGFR3 signaling can occur at any point in the signaling cascade by reducing or preventing the activity of the cascade. For example, an FGFR3 antagonist can bind to the receptor itself, reducing or preventing binding of an activating ligand; such a molecule is defined as a direct FGFR3 antagonist. Examples include anti-FGFR3 antibodies, such as FGFR3 monoclonal antibodies. Suitable examples are disclosed in WO2022 / 040560, which discloses anti-FGFR3 monoclonal antibodies and their use in the treatment of achondroplasia and is incorporated herein by reference in its entirety. Similarly, WO2018 / 145120 and WO2020 / 180898 disclose anti-FGFR3 monoclonal antibodies and their use in treatment and is incorporated herein by reference in their entirety. Vofatamab (B-701) is a monoclonal antibody specific for fibroblast growth factor receptor 3 currently in clinical development.

[0151] FGFR3 signaling inhibitors can also act to prevent FGFR3 signaling by preventing or reducing ligand binding to FGFR3. For this purpose, decoy molecules of FGFR3 ligands have been developed. By providing a surrogate molecule to which the ligand can bind, signaling through the FGFR3 molecule is reduced or inhibited. By providing a surrogate molecule to which the ligand can bind, signaling through the FGFR3 molecule is reduced or inhibited. One example of a molecule that has been used to prevent excessive intracellular signaling through FGFR3 and rescue the symptoms of achondroplasia is a soluble form of human FGFR3 (sFGFR3). This has been shown to act as a decoy receptor and prevent FGF from binding to FGFR3. FGFR3 soluble decoy / sFGFR3 polypeptides are disclosed in WO16110786, WO2022 / 106976, and WO2018 / 007597, all of which are incorporated herein by reference in their entireties. Recifercept is an FGFR3 soluble decoy in clinical development for the treatment of pediatric achondroplasia (Goncalves et al., PLoS One. 2020;15(12):e0244368).

[0152] FGFR3 signaling inhibitors can also act to reduce or prevent FGFR3 signaling by acting on the intracellular portion of the FGFR3 molecule itself (e.g., binding to or otherwise preventing its activity), for example, by preventing or reducing phosphorylation of the FGFR3 molecule. Tyrosine kinase inhibitors, such as infigratinib or TYR300, e.g., FGFR3-selective tyrosine kinase inhibitors, can be used for this purpose. WO2022 / 187443 discloses FGFR3-selective FGFR3 inhibitors (tyrosine kinase inhibitors) for use in the treatment of achondroplasia and other disorders, and is incorporated herein by reference in its entirety. LY3866288, also known as LOXO-435 (also known as LOX-24350), is an FGFR3 inhibitor in clinical development.

[0153] Alternatively, FGFR3 signaling inhibitors may perform this function by acting on molecules downstream of the receptor in one or more of its signaling pathways (e.g., by binding to or otherwise preventing the activity of such molecules). Such FGFR3 signaling pathway inhibitors can act to reduce or prevent the activity of the MAPK signaling pathway or STAT signaling pathway downstream of FGFR3. Examples of targets of FGFR3 signaling inhibitors in the MAPK pathway include the proteins ras, raf, mek, and erk. CNP thus acts as an inhibitor of the FGFR3 signaling pathway. Activation of the CNP receptor NPR-B leads to cGMP production and activation of PKG, inhibiting raf kinase. Therefore, CNP and other NPR-B agonists can also be FGFR3 signaling inhibitors. Therefore, FGFR3 signaling inhibitors can act directly or indirectly on one or more of FGFR3 itself, ras, raf, mek, and erk, or STAT.

[0154] Similarly, preventing or reducing the expression of FGFR3 protein itself is another possible method of inhibiting FGFR3 signal transduction.Therefore, FGFR3 signal transduction inhibitors can act to reduce or lower the amount of FGFR3 protein in cells.Examples of suitable strategies include, for example, antisense molecules and siRNA directed to FGFR3 protein itself.In this case, the amount of FGFR3 in relevant cells can be less than 90, 80, 70, 60, 50, 40, 30, 20, 10% of the amount of FGFR3 in cells in the absence of siRNA molecules or antisense molecules, or before siRNA molecules or antisense molecules are administered.

[0155] Therefore, suitable examples of FGFR3 signaling inhibitors include antibodies against FGFR3 (e.g., antagonist antibodies against FGFR3), tyrosine kinase inhibitors (e.g., infigratinib, pemigatinib, futovatinib, erdafitinib, or TYRA-300), molecules that prevent or reduce FGFR3-ligand binding, molecules that inhibit FGFR3 signaling via activation of the NPR-B receptor (e.g., C-type natriuretic peptide (CNP) and its variants), FGFR3 siRNA, and FGFR3 antisense oligonucleotides.

[0156] In certain embodiments, the fibroblast growth factor receptor 3 (FGFR3) antagonist is infigatinib, which has the following structure, or a pharmaceutically acceptable salt thereof: [ka]

[0157] Infigratinib is approved for the treatment of certain cancers and is currently in clinical development for the treatment of achondroplasia in children aged 3 to 11 years, with up to 0.25 mg / kg of infigratinib administered daily in tablet form (https: / / clinicaltrials.gov / ct2 / show / NCT04265651). Because high doses of infigratinib used to treat cancer can be associated with side effects that may include muscle weakness and muscle spasms, in the context of the present invention, it may be desirable to limit the daily dose to about 3 mg / kg or less, e.g., about 0.25 mg / kg or less.

[0158] Other FGFR3 signaling inhibitors include pemigatinib, futibatinib, erdafitinib, or TYRA-300. FGFR3 signaling inhibitors, including TYRA-300, are disclosed in WO2023 / 279041, WO2021 / 138392, WO2022 / 147246, and WO2021 / 138391, all of which are incorporated herein by reference in their entireties.

[0159] FGFR3 signaling inhibitors can be identified and characterized by standard methods, such as those described in WO2023 / 279041, WO2021 / 138392, WO2022 / 147246 and WO2021 / 138391.

[0160] CNP drugs In an advantageous embodiment, C-type natriuretic peptide (CNP) drug is used.As discussed above, in vivo, CNP binds to NPR-B and exerts its effect on FGFR3 signaling pathway, and therefore can also be described as NPR-B agonist.Other NPR-B agonists, including small molecule NPR-B receptor agonists, can also be used according to the present invention.

[0161] CNP drugs are molecules that contain the CNP peptide as defined above. CNP drugs and CNP peptides are preferably administered in a form that is an NPR-B agonist as defined above or that results in the production of an NPR-B agonist in vivo (e.g., as a result of in vivo processing that releases a CNP peptide that is an NPR-B agonist in vivo).

[0162] By way of example, the CNP drug can be administered in the form of a CNP peptide, or a CNP peptide conjugate or a CNP prodrug. The methods of the invention can also employ NPR-C ligands; CNP is one example of an NPR-C ligand.

[0163] FGFR3 inhibition assay Guagnana et al., J. Med. Chem. 2011, 54, 7066-7083, the entire contents of which are incorporated herein by reference, provides a radioactive kinase assay that can be used to identify FGFR3 tyrosine kinase inhibitors: enzyme kinase activity is measured by phosphorylation of a synthetic substrate by purified GST-fused FGFR3-K650E kinase domain in the presence of radiolabeled ATP. Also disclosed in Guagnana are a BaF3 cell line proliferation assay and an FGFR1-4 cell autophosphorylation assay, which can also be used to identify FGFR3 inhibitors.

[0164] NPR-B activity assays can be used to identify NPR-B agonists Functional CNP peptides and free CNP released from CNP prodrugs, as well as other NPR-B agonists, are identified using an NPR-B assay, such as that reported in Breinholt et al., 2019 J Pharmacol Exp Ther 370:459-471, which is incorporated herein by reference in its entirety.

[0165] The activity of CNP in eliciting intracellular cyclic guanosine monophosphate (cGMP) responses can be determined in NIH3T3 cells. These cells express NPR-B on the cell surface (Abbey and Potter, 2003 Endocrinology, Volume 144, Issue 1, 1 January 2003, Pages 240-246). Stimulation of this receptor with CNP results in the intracellular production of the second messenger cGMP. Briefly, NIH3T3 cells are cultured in Dulbecco's modified Eagle's medium F-12 supplemented with 5% FBS and 5 mM glutamine at 37°C and 5% CO2. For each assay, cells are resuspended in stimulation buffer (Dulbecco's PBS containing 0.5 mM 3-isobutyl-1-methylxanthine) and seeded (5 x 10) into 96-well plates. 4Cells were incubated in duplicate with different concentrations of CNP (per well). After 30 minutes of incubation at 37°C and 5% CO2, the cells were lysed with the provided lysis buffer, and cGMP levels were measured using a commercially available cGMP assay based on time-resolved fluorescence energy transfer (cGMP kit, catalog 62GM2PEB; Cisbio, Codolet, France). Activity was determined by parallel line analysis of the samples using a four-parameter logistic curve fit compared to CNP-38 (SEQ ID NO: 24 (CNP-38): LQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC, where cysteines at positions 22 and 38 are linked by a disulfide bridge) as a reference standard (PLA 2.0 software; Stegmann Systems, Rodgau, Germany).

[0166] In certain embodiments, the NPR-B agonist (e.g., C-type natriuretic peptide) has at least about 25% of the NPR-B activity (activity in eliciting an intracellular cGMP response in an NIH3T3 cell assay) of the CNP-38 reference standard in an NPR-B activity assay such as those described above, e.g., at least about 50%, 75%, 80%, 85%, or 90% of the activity of the CNP-38 reference standard.

[0167] In the case of CNP prodrugs, it is understood that the activity of the prodrug in the CNP assay should be assessed on the CNP released from the prodrug (free CNP).

[0168] NPR-C affinity and agonist assays that can be used to identify NPR-C agonists Functional CNP peptides, free CNP released from CNP prodrugs, and other NPR-C ligands can be identified using an NPR-C affinity assay, such as the NPR-C affinity assay reported in Breinholt et al., 2019 J Pharmacol Exp Ther 370:459-471.

[0169] This NPR-C affinity assay uses a HEK293 cell line stably overexpressing human NPR-C. This NPR-C affinity assay can be used to assess the relative NPR-C affinity of CNP or another NPR-C ligand relative to a CNP-38 standard. In certain embodiments, the C-type natriuretic peptide has at least about 25% of the NPR-C affinity of the CNP-38 reference standard, e.g., at least about 50% of the affinity for NPR-C of the CNP-38 reference standard, e.g., at least about 75% of the affinity for NPR-C of the CNP-38 reference standard, in the NPR-C affinity assay.

[0170] Zhou and Murthy, Am J Physiol Cell Physiol 284:C1255-C1261, 2003, the entire contents of which are incorporated herein by reference, report on the G protein-activating activity of NPRC and provide an assay for identifying receptor-activated G proteins using a [35S]GTPγS binding assay, and an assay for PLC-beta activity, both of which can be used to identify NPR-C ligands with NPR-C agonist activity (NPR-C agonists: for example, the standard used to evaluate NPR-C agonists in NPR-C activity assays is cANP4-23). ​​Zhou and Murthy further disclose a [125I]ANP binding assay that can be used to identify NPR-C ligands.

[0171] Exemplary CNPs (including CNP peptides) Naturally occurring human CNP-22 (SEQ ID NO: 1) has the following sequence: GLSKGCFGLKLDRIGSMSGLGC Here, the cysteines at positions 6 and 22 are linked by a disulfide bridge.

[0172] In certain embodiments, the term "CNP" also refers to the following peptide sequence: SEQ ID NO:2 (CNP-53): DLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 3 (G-CNP-53): GDLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 4 (M-CNP-53): MDLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 5 (P-CNP-53): PDLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 6 (CNP-53 M48N): DLRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSNSGLGC; SEQ ID NO: 7 (CNP-53 Δ15-31): DLRVDTKSRAAWARGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO:8 (CNP-52): LRVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 9 (CNP-51): RVDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 10 (CNP-50): VDTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 11 (CNP-49): DTKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 12 (CNP-48): TKSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 13 (CNP-47): KSRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 14 (CNP-46): SRAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 15 (CNP-45): RAAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 16 (CNP-44): AAWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 17 (CNP-44 Δ14-22): AAWARLLQEHPNAGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 18 (CNP-44 Δ15-22): AAWARLLQEHPNARGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 19 (CNP-43): AWARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 20 (CNP-42): WARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 21 (CNP-41): ARLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 22 (CNP-40): RLLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 23 (CNP-39): LLQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 24 (CNP-38): LQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC, Here, the cysteines at positions 22 and 38 are linked by a disulfide bridge. SEQ ID NO: 25 (CNP-37): QEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 26 (CNP-37 Q1pQ, where pQ = pyroglutamic acid): pQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 27 (G-CNP-37): GQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 28 (P-CNP-37): PQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 29 (M-CNP-37): MQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 30 (PG-CNP-37) (vosoritide peptide sequence): PGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 31 (MG-CNP-37): MGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 32 (CNP-37 M32N): QEHPNARKYKGANKKGLSKGCFGLKLDRIGSNSGLGC; SEQ ID NO: 33 (G-CNP-37 M32N): GQEHPNARKYKGANKKGLSKGCFGLKLDRIGSNSGLGC; SEQ ID NO: 34 (G-CNP-37 K14Q): GQEHPNARKYKGANQKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 35 (G-CNP-37 K14P): GQEHPNARKYKGANPKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 36 (G-CNP-37 K14Q, Δ15): GQEHPNARKYKGANQGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 37 (G-CNP-37 K14Q, K15Q): GQEHPNARKYKGANQQGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 38 (CNP-36): EHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 39 (CNP-35): HPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 40 (CNP-34): PNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 41 (CNP-33): NARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 42 (CNP-32): ARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 43 (CNP-31): RKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 44 (CNP-30): KYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 45 (CNP-29): YKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 46 (CNP-28): KGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 47 (GHKSEVAHRF-CNP-28): GHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 48 (CNP-27): GANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 49 (CNP-27 K4Q, K5Q): GANQQGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 50 (CNP-27 K4R, K5R): GANRRGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 51 (CNP-27 K4P, K5R): GANPRGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 52 (CNP-27 K4S, K5S): GANSSGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 53 (CNP-27 K4P, K5R): GANGANPRGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 54 (CNP-27 K4R, K5R, K9R): GANRRGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 55 (CNP-27 K4R, K5R, K9R, M22N): GANRRGLSRGCFGLKLDRIGSNSGLGC; SEQ ID NO: 56 (P-CNP-27 K4R, K5R, K9R): PGANRRGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 57 (M-CNP-27 K4R, K5R, K9R): MGANRRGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 58 (HSA fragment-CNP-27): GHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLG; SEQ ID NO: 59 (HSA fragment-CNP-27 M22N): GHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSNSGLGC; SEQ ID NO: 60 (M-HSA fragment-CNP-27): MGHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 61 (P-HSA fragment-CNP-27): PGHKSEVAHRFKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 62 (CNP-26): ANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 63 (CNP-25): NKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 64 (CNP-24): KKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 65 (CNP-23): KGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 66 (R-CNP-22): RGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 67 (ER-CNP-22): ERGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 68 (R-CNP-22 K4R): RGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 69 (ER-CNP-22 4KR): ERGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 70 (RR-CNP-22): RRGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 71 (HRGP fragment-CNP-22): GHHSHEQHPHGANQQGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 72 (HRGP fragment-CNP-22): GAHHPHEHDTHGANQQGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 73 (HRGP fragment-CNP-22): GHHSHEQHPHGANPRGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 74 (IgG1(F c ) fragment-CNP-22): GQPREPQVYTLPSGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 75 (HSA fragment-CNP-22): GQHKDDNPNLPRGANPRGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 76 (HSA fragment-CNP-22): GERAFKAWAVARLSQGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 77 (Osteocrine NPR C inhibitor fragment-CNP22): FGIPMDRIGRNPRGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 78 (FGF2 heparin binding domain fragment-CNP22): GKRTGQYKLGSKTGPGPKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 79 (IgG1(F c )Fragment-CNP-22 K4R): GQPREPQVYTGANQQGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 80 (HSA fragment-CNP-22 K4R): GVPQVSTSTGANQQGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 81 (Fibronectin fragment-CNP-22 K4R): GQPSSSSQSTGANQQGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 82 (Fibronectin fragment-CNP-22 K4R): GQTHSSGTQSGANQQGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 83 (Fibronectin fragment-CNP-22 K4R): GSTGQWHSESGANQQGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 84 (Zinc finger fragment-CNP-22 K4R): GSSSSSSSSSGANQQGLSRGCFGLKLDRIGSMSGLGC; SEQ ID NO: 85 (CNP-21): LSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 86 (CNP-20): SKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 87 (CNP-19): KGCFGLKLDRIGSMSGLGC; SEQ ID NO: 88 (CNP-18): GCFGLKLDRIGSMSGLGC; SEQ ID NO: 89 (CNP-17): CFGLKLDRIGSMSGLGC; SEQ ID NO: 90 (BNP fragment-CNP-17-BNP fragment): SPKMVQGSGCFGLKLDRIGSMSGLGCKVLRRH; SEQ ID NO: 91 (CNP-38 L1G): GQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO: 92 (Ac-CNP-37; where Ac = acetyl): Ac-QEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC; SEQ ID NO:93: QEHPNARX1YX2GANX3X4GLSX5GCFGLX6LDRIGSMSGLGC, wherein X1, X2, X3, X4, X5, and X6 are independently selected from the group consisting of K, R, P, S, and Q, with the proviso that at least one of X1, X2, X3, X4, X5, and X6 is selected from the group consisting of R, P, S, and Q; in certain embodiments, X1, X2, X3, X4, X5, and X6 are selected from the group consisting of K and R, with the proviso that at least one of X1, X2, X3, X4, X5, and X6 is R; SEQ ID NO:94: QEHPNARKYKGANX1X2GLSX3GCFGLX4LDRIGSMSGLGC, wherein X1, X2, X3, and X4 are independently selected from the group consisting of K, R, P, S, and Q, with the proviso that at least one of X1, X2, X3, and X4 is selected from the group consisting of R, P, S, and Q; in certain embodiments, X1, X2, X3, and X4 are selected from K and R, with the proviso that at least one of X1, X2, X3, and X4 is R; SEQ ID NO:95: QEHPNARKYKGANX1X2GLSKGCFGLKLDRIGSMSGLGC, wherein X1X2 is selected from the group consisting of KR, RK, KP, PK, SS, RS, SR, QK, QR, KQ, RQ, RR and QQ.

[0173] It is understood that in SEQ ID NOs: 2 to 95, the equivalents of cysteines at positions 22 and 38 of SEQ ID NO: 24 are also linked by disulfide bridges.

[0174] It will also be appreciated by those skilled in the art that the conjugates of the present invention may be prodrugs.

[0175] The unit dose contained in the unit dosage form of the present invention is determined by the actual body weight of the patient.

[0176] Vosoritide is approved for once-daily subcutaneous administration at or about 15 μg / kg, although higher doses (e.g., about 30 μg / kg) can be administered to infants. Vosoritide is currently available in 0.4 mg, 0.56 mg, and 1.2 mg vials, and the current recommended daily doses based on actual body weight (ABW) are as follows: 10-11 kg: 0.24 mg SC qDay 12-16 kg: 0.28 mg SC qDay 17-21 kg: 0.32 mg SC qDay 22-32 kg: 0.4 mg SC qDay 33-43 kg: 0.5 mg SC qDay 44-59 kg: 0.6 mg SC qDay 60-89 kg: 0.7 mg SC qDay ≧90kg or more: 0.8mg SC qDay Higher doses have been reported to be more effective in younger children.

[0177] In certain embodiments, the unit dose is 50 μg to 7000 μg of CNP. In certain embodiments, the unit dose is 100 μg to 5000 μg of CNP. In certain embodiments, the unit dose is 100 μg to 3000 μg of CNP. In certain embodiments, the unit dose is 100 μg to 2000 μg of CNP. In certain embodiments, the unit dose is 100 μg to 1000 μg of CNP. In certain embodiments, the unit dose is 150 μg to 750 μg of CNP. In certain embodiments, the unit dose is 150 μg to 500 μg of CNP. In certain embodiments, the unit dose is 150 μg to 350 μg of CNP. In certain embodiments, the unit dose is about 700 μg of CNP. In certain embodiments, the unit dose is about 600 μg of CNP. In certain embodiments, the unit dose is about 500 μg of CNP. In certain embodiments, the unit dose is about 400 μg CNP. In certain embodiments, the unit dose is about 300 μg CNP.

[0178] In certain embodiments, the unit dose is about 6 μg CNP / kg. In certain embodiments, the unit dose is about 20 μg CNP / kg. In certain embodiments, the unit dose is about 50 μg CNP / kg. In certain embodiments, the unit dose is about 75 μg CNP / kg. In certain embodiments, the unit dose is about 100 μg CNP / kg. In certain embodiments, the unit dose is about 125 μg CNP / kg. In certain embodiments, the unit dose is about 150 μg CNP / kg.

[0179] In certain embodiments, the unit dose is 6 μg CNP / kg. In certain embodiments, the unit dose is 20 μg CNP / kg. In certain embodiments, the unit dose is 50 μg CNP / kg. In certain embodiments, the unit dose is 75 μg CNP / kg. In certain embodiments, the unit dose is 100 μg CNP / kg. In certain embodiments, the unit dose is 125 μg CNP / kg. In certain embodiments, the unit dose is 150 μg CNP / kg.

[0180] In certain embodiments, the unit dosage form is a liquid. In certain embodiments, the unit dosage form is a solid.

[0181] In certain embodiments, for example, for a compound of Formula (IIf') or Formula (IIf), or Compound (1), the unit dose ranges from about 12.3 nmol CNP / kg to at least about 37 nmol CNP / kg. In certain embodiments, the unit dose is 12.3 nmol CNP / kg to 36.9 nmol CNP / kg. In certain embodiments, the unit dose is at least 24.6 nmol CNP / kg. In certain embodiments, the unit dose is about 24.6 nmol CNP / kg. In certain embodiments, the unit dose is 24.6 nmol CNP / kg.

[0182] In certain embodiments, for example, for a compound of Formula (IIf') or Formula (IIf), or Compound (1), the unit dose ranges from about 6 μg CNP / kg to at least about 100 μg CNP / kg. In certain embodiments, the unit dose ranges from about 6 μg CNP / kg to about 150 μg CNP / kg.

[0183] In certain embodiments, for example, of Formula (IIf') or Formula (IIf) or Compound (1), the unit dose contained in the unit dosage form of the invention is from 6 μg CNP / kg to at least 100 μg CNP / kg. In certain embodiments, the unit dose is from 6 μg CNP / kg to 150 μg CNP / kg.

[0184] The unit dose is preferably administered once a week.

[0185] In the case of a CNP conjugate or CNP prodrug, such as a compound of Formula (IIf') or Formula (IIf), or Compound (1), "x" μg CNP / kg is understood to mean "x" μg of CNP per kg of patient body weight, i.e., the CNP moiety contained within the CNP conjugate. Similarly, "y" nmol CNP / kg is understood to refer to "y" nmol of CNP per kilogram of patient body weight, i.e., "y" nmol of the CNP moiety contained in the CNP conjugate.

[0186] Subjects / patients In certain embodiments, the subject is an adult. An adult human is at least 18 years old. In certain embodiments, the subject is at least 19 years old, such as at least 20 or 25 years old.

[0187] In certain embodiments, the subject is a pediatric patient, i.e., under the age of 18, e.g., under the age of 16 or under the age of 14, or under the age of 5. In certain embodiments, the subject is an infant (e.g., under the age of 1, or under the age of 9 or 6 months).

[0188] The subject is also called a patient.

[0189] In certain embodiments, the patient weighs between about 2 kg and about 80 kg. In certain embodiments, the patient weighs between about 4 kg and about 60 kg. In certain embodiments, the patient weighs about 5 kg. In certain embodiments, the patient weighs about 9 kg. In certain embodiments, the patient weighs about 10 kg. In certain embodiments, the patient weighs about 11 kg. In certain embodiments, the patient weighs about 12 kg. In certain embodiments, the patient weighs about 15 kg. In certain embodiments, the patient weighs about 20 kg. In certain embodiments, the patient weighs (at least about) 30 kg. In certain embodiments, the patient weighs (at least about) 40 kg. In certain embodiments, the patient weighs (at least about) 50 kg. In certain embodiments, the patient weighs (at least about) 60 kg. In certain embodiments, the patient weighs (at least about) 70 kg. In certain embodiments, the patient weighs (at least about) 80 kg.

[0190] Diseases or conditions that impair muscle function In certain embodiments, the subject suffers from a disease or condition that impairs muscle function (e.g., skeletal muscle). This means that normal muscle function is reduced or absent. The reduction in muscle function can be assessed relative to a threshold level or relative to individuals without the disease or condition. The loss or reduction in muscle function can result from a disease or condition that directly affects the muscle (e.g., myopathy), or can be a disease that affects the neuromuscular junction or a disease that affects the nervous system.

[0191] The disease or condition in which muscle function (e.g., skeletal muscle) is impaired can include a chondrodysplasia disease, such as a disease selected from the group consisting of achondroplasia, hypochondroplasia, and tothostatic dysplasia. In certain embodiments, the subject has achondroplasia.

[0192] In certain embodiments, the subject has a RASopathy.

[0193] In certain embodiments, the subject has a chondrodysplasia disorder, e.g., a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and tothostatic dysplasia. In certain embodiments, the subject has achondroplasia.

[0194] In certain embodiments, the subject does not have a chondrodysplasia disorder, e.g., a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and lethal osteodysplasia. In certain embodiments, the subject does not have achondroplasia. In certain embodiments, the subject does not have a chondrodysplasia disorder.

[0195] Skeletal muscle is one of the three main types of muscle in the body, the others being cardiac muscle and smooth muscle. Skeletal muscle is attached to bone via tendons. Skeletal muscle is also sometimes called striated muscle. Administration of FGFR3 signaling inhibitors, NPR-B agonists, or NPR-C agonists has been shown to improve muscle function, particularly skeletal muscle function.

[0196] In certain embodiments, the subject has myopathy. Myopathy is a heterogeneous group of disorders that primarily affect the structure, metabolism, or channel function of skeletal muscle, typically resulting in muscle weakness, stiffness, cramps, and spasms, and may result in or contribute to skeletal deformities, such as abnormal curvature of the spine. Myopathy usually presents with muscle weakness that interferes with daily living activities. In some embodiments, the myopathy or muscle dysfunction may be mitochondrial myopathy, i.e., myopathy caused by mitochondrial defects. Myopathy may be hereditary or acquired. Hereditary myopathy may be congenital, i.e., myopathic symptoms may begin at birth or in early childhood.

[0197] In certain embodiments, the subject has a disease or condition associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

[0198] Thus, in some embodiments, the method is performed in a subject with a disease or condition associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

[0199] The present invention also provides a method for treating or preventing a disease or condition associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease, comprising administering a therapeutically effective amount of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist (e.g., an NPR-B agonist, such as a C-type natriuretic peptide (e.g., a conjugate of CNP)) to a subject suffering from the neuromuscular disease or neurodegenerative disease. In some embodiments, the neuromuscular disease or neurodegenerative disease is a disease in which mitochondrial dysfunction is present.

[0200] The administration of an effective amount of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist (e.g., an NPR-B agonist) to a subject with a disease or condition associated with impaired neuromuscular function can result in an improvement in mitochondrial function in the subject. This can be observed (or monitored), for example, through improved muscle function, such as improved skeletal muscle function or improved neuromuscular function; or through a delay, slowing, or reduction in disease progression (e.g., compared to a reference, or a subject before or without treatment), such as a reduction in the rate of loss or decline of muscle function, or a reduction in the rate of loss or decline of neuromuscular function. In some embodiments, the treatment method can be initiated after the diagnosis of a disease or condition associated with impaired neuromuscular function, and optionally before significant or noticeable loss of muscle or neuromuscular function.

[0201] Mitochondrial dysfunction, or mitochondrial dysfunction, has been identified in many neurodegenerative diseases, including Parkinson's disease (PD), Alzheimer's disease (AD), Huntington's disease (HD), ataxias such as Friedreich's ataxia (FRDA), and amyotrophic lateral sclerosis (ALS). Mitochondrial dysfunction can be identified by diagnosing a disease or disorder associated with mitochondrial dysfunction through genetic testing, i.e., identifying genetic polymorphisms associated with or causing mitochondrial dysfunction, through biochemical analysis of biopsies of affected tissue, or through biochemical markers in blood or urine (see, for example, Muraresku et al., Curr Genet Med Rep. 2018 Jun;6(2):62-72).

[0202] Diseases or conditions associated with impaired neuromuscular function may include neuromuscular disorders / neuromuscular diseases (NMD). Suitable NMD disorders and diseases may be associated with mitochondrial impairment and dysfunction (see, for example, Marra et al., Biomolecules 2021, vol. 11 (11); 1633). Thus, the methods of the present invention can be used to improve mitochondrial function or slow the decline of mitochondrial function in subjects with diseases or conditions associated with impaired neuromuscular function (e.g., NMD) (e.g., compared to a reference, or a pre-treatment or untreated subject).

[0203] Therefore, the method of the present invention can be used to improve muscle function or slow the decline of muscle function in these diseases or conditions associated with impaired neuromuscular function. Examples of neuromuscular diseases include muscular dystrophies and myopathies, as well as genetically acquired diseases including neuromuscular diseases. Neuromuscular diseases include neurodegenerative diseases and disorders associated with the loss of mitochondrial function, and can be selected from the group consisting of motor neuron disease (MND, also known as amyotrophic lateral sclerosis (ALS)); Parkinson's disease (PD); multiple sclerosis (MS, including progressive MS or relapsing-remitting MS); Alzheimer's disease (AD); ataxias, such as Friedreich's ataxia (FRDA), and Huntington's disease (HD).

[0204] Parkinson's disease (PD) is associated with mitochondrial dysfunction, and PD pathology results in muscle weakness and fatigue (Borsche et al., J Parkinsons Dis. 2021;11(1):45-60). Timmer et al., J Neurosci. 2007 Jan 17;27(3):459-471, demonstrated abnormalities in FGFR3 / FGF-2 signaling in an animal model of PD. Central and systemic CNP (amino-terminal proCNP) levels are both reduced in Parkinson's disease and can be restored by treatment with monoamine oxidase inhibitors (Espiner et al., J Neural Transm (Vienna). 2014 Apr;121(4):371-8; Woodward, Parkinsonism Relat Disord. 2017 Oct;43:15-19). Muscle weakness and fatigue, which can significantly impact gait, are commonly reported by PD patients. Zheng et al., Sci Transl Med. 2010 Oct 6;2(52):52ra73, reported PGC-1α as a therapeutic target for Parkinson's disease. Mitochondrial dysfunction is a central dysfunction in the pathology of Parkinson's disease (PD), and PD-related genes, including PGC-1α, are strictly related to mitochondrial integrity (Piccinin, Int. J. Mol. Sci 2001 22(7) 3487). Low expression of PGC-1α has been reported in PD, and therapeutic agents that increase PGC-1α expression and enhance mitochondrial function in PD patients are needed.

[0205] In PD patients, muscle function can be routinely monitored using physical function tests, such as the sit-to-stand test and the 6-minute walk test (see, e.g., Clael et al., Neurosci J 2918 8507018). Suitable physical function tests used to monitor PD patients include speech, facial expression, chair rise, gait, or postural stability (see, e.g., Brusse et al., Physical Therapy, Volume 85, Issue 2, February 1, 2005, Pages 134-141). Recently, the FDA approved a PD monitoring app (Rube Labs) for patient monitoring via a smart device (e.g., a mobile phone or smartwatch), which can provide day-long monitoring of physical activity, such as gait, and other PD symptoms, such as tremor and dyskinesia. Therefore, it is envisioned that such smart device apps can be used to monitor effective treatment according to the present invention.

[0206] Decreased expression of PGC-1α contributes to mitochondrial dysfunction and correlates with neuronal loss in multiple sclerosis (Witte et al., Acta Neuropathol. 2013 Feb;125(2):231-43; Peixoto de Barcelos Biology (Basel) 2019 8(2):37). Rosenkranz et al., eLife 2021;10:e61798, reported that increasing mitochondrial activity in neurons prevented neurodegeneration in a mouse model of multiple sclerosis (MS), suggesting that increasing mitochondrial activity in neurons could be a therapeutic strategy for MS. Rajendran et al., Cells 2021, reported on FGF / FGFR signaling in MS and FGFR inhibition as a therapeutic option to reduce inflammation and induce remyelination. Multiple sclerosis causes muscle fatigue, pain, imbalance, and decreased physical activity, further contributing to muscle weakness. In fact, muscle fatigue is considered to be the most common symptom of MS. Monitoring muscle function in MS can be achieved using self-report questionnaires or smart devices, which can provide remote monitoring of fatigue and activity (e.g., Block Front. Neurol. 2022 13 https: / / doi.org / 10.3389 / fneur.2022.878313, Stuart et al., Mult Scler J Exp Transl Clin. 2020 Dec 7;6(4):2055217320975185). Witte et al. reported that decreased expression of PGC-1α correlates with neuronal loss in MS.

[0207] Zhao et al., Cells 2002 Jul;11(13) 2049, reported that mitochondrial dysfunction is an important factor in amyotrophic lateral sclerosis (ALS) and that mitochondrial dysfunction is related to and involved in the pathology of the disease. Zhao et al., Molecular Neurodegeneration 6, Article number:51 (2011), reported that PGC-1α plays a protective role in ALS.

[0208] Impairment of PGC-1α-mediated mitochondrial biogenesis has been implicated in the pathology of Alzheimer's disease and precedes mitochondrial dysfunction associated with the progression of AD (Bhatia, Curr. Neuropharmacol. 2002 20(4):675-692). In patients surviving dementia, such as Alzheimer's disease (AD), physical function is affected, resulting in slower reaction time, muscle weakness, poor coordination, and impaired balance. These, along with cognitive impairment, are major causes of falls and fractures. In the later stages of dementia, physical ability declines significantly, resulting in significant limitations in walking, gait, and movement (see, for example, Taraldsen et al., BMC Geriatrics volume 21, Article number:670 (2021) for a report on the use of body accelerometer sensors to monitor daily physical activity in patients with dementia).

[0209] Administration of FGFR3 signaling inhibitors or NPR-B or NPR-C agonists may result in various changes in muscle function.

[0210] For example, muscle strength may improve. Muscle strength is the maximal ability to exert force for a short period of time. This can be assessed, for example, using the Oxford Scale, which tests the major muscles of the upper and lower limbs against the examiner's resistance and rates the patient's muscle strength accordingly on a scale of 0 to 5 (Naqvi U. Muscle strength grading. InStatpearls [Internet] 2019 May 29. StatPearls Publishing. Available from: https: / / www.ncbi.nlm.nih.gov / books / NBK436008 / ): 0 No muscle activity · 1 Track muscle activity, such as spasms, without achieving full range of motion 2. Activate muscles without gravity for a full range of motion 3. Activation of muscles against gravity, full range of motion 4 Muscle activation against some resistance, full range of motion 5. Muscle activation against full range of motion, with full resistance from the examiner

[0211] Muscles typically tested include shoulder abductors, elbow flexors, elbow extensors, wrist extensors, finger flexors, wrist invertors, hip flexors, knee extensors, dorsiflexors, hallucis extensors, and plantar flexors. These muscle groups are generally selected to allow for systematic assessment of important spinal nerve roots. For example, testing the strength of elbow flexors, elbow extensors, wrist extensors, finger flexors, and intrinsic muscles of the hand can systematically assess nerve roots C5 through T1. Alternatively or additionally, distal muscle strength can be semiquantitatively measured using a handgrip ergometer (or by having the patient grasp an inflated BP cuff) to record grip strength, or dynamometry can be performed to more accurately measure the force a muscle can exert and record changes in muscle strength over time. Thus, an increase in muscle strength is observed as an increase in Oxford score or an increase in distal muscle strength assessed by a handgrip ergometer (or the patient gripping an inflated BP cuff) to record grip strength, or by dynamometry.

[0212] For example, muscle tone may improve. Muscle tone, also known as residual muscle tone or tonus, refers to the sustained, passive partial contraction of a muscle at rest, or the muscle's resistance to passive stretching. Muscle tone helps maintain posture and is reduced during REM sleep. Muscle tone is distinct from muscle strength. Muscle tone is regulated by motor neuron activity and can be affected by various factors, including age, disease, and nerve injury. Hypotonia refers to decreased resting muscle tone and decreased resistance to passive movement. Hypotonia rarely occurs alone without some degree of muscle weakness. Hypotonia (low muscle tone) refers to decreased muscle stiffness, resulting in an inability to effectively maintain an upright posture against gravity or to exert adequate force during contraction; as a result, hypotonic muscles tend to be more flexible than stiff. Hypotonia is observed, for example, in subjects with a variety of conditions, such as Down syndrome, muscular dystrophy, cerebral palsy, Prader-Willi syndrome, myotonic dystrophy, Marfan syndrome, and Tay-Sachs disease. Hypotonia is typically assessed by medical observation, and improvement of hypotonia is evidenced by increased resting tone and resistance to passive movement, as assessed by a medical professional.

[0213] For example, there may be an improvement in muscle endurance (or muscle stamina), which is the resistance of a muscle or muscle group to fatigue during repeated muscle contractions against an external force. This is usually assessed by observation, for example, performing repetitive exercises over a period of time, such as counting the number of push-ups a patient can perform within a period of time, e.g., 60 seconds, or measuring the time it takes an individual to perform a certain number of repetitions. Improvement in muscle endurance is manifested as an increase in the number of repetitions within a period of time, or a decrease in the time required to perform a certain number of repetitions.

[0214] For example, there may be an improvement in muscle mass. Muscle mass refers to the amount of muscle in a subject's body, including skeletal muscle, smooth muscle, and cardiac muscle. In a preferred embodiment, there is an improvement in skeletal muscle mass. Muscle mass can be measured, for example, by performing dual-energy X-ray absorptiometry, a CT scan, or an MRI scan. Muscle mass can be increased by the methods of the present invention, and an increase in muscle mass can also result in an increase in the muscle-to-fat ratio (e.g., the ratio of skeletal muscle to fat). Fat mass can be measured using DEXA and bioelectrical impedance analysis (BIA). Additionally or alternatively, one or more of the subject's muscle volume, muscle density, and muscle length may be increased.

[0215] For example, there may be a decrease in muscle fatigue. Muscle fatigue is used to describe the decrease in force generated by a muscle or muscle group during repeated contractions against an external force. One example of a test to measure muscle fatigue is the Biering-Sorenson test, which has been used to assess fatigue in the trunk extensor muscles and is also used as a test for low back pain. The test described by Sorenson (Biering-Sorenson F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine. 1984;9:106-119) "measures the number of seconds a subject can maintain a horizontal, unsupported upper body (from the upper border of the iliac crest) while lying face down with their hips and legs secured to a sofa with three wide canvas straps and their arms folded across their chest." A decrease in muscle fatigue is manifested as an improvement in the amount of time a subject can maintain a required position.

[0216] For example, cardiovascular endurance may be increased, which is the ability of a subject's heart and lungs to deliver oxygen to the body. This can also be defined as the ability to perform moderate- to high-intensity exercise for extended periods (as a percentage of VO2max). Cardiovascular endurance can be measured by standard techniques, including measuring VO2max by indirect calorimetry. VO2max is the maximum amount of oxygen an individual can utilize during strenuous or maximal exercise and is typically measured by determining the inhaled and exhaled volumes and gas concentrations while a person performs maximal graded exercise on a treadmill or cycle ergometer. VO2max can be expressed as liters of oxygen consumed per minute (l / min) or, normalized for differences in body size, as milliliters of oxygen consumed per kilogram of body weight per minute (ml / kg / min). Thus, using this assay, increases in cardiovascular endurance can be observed as increases in VO2max (l / min) or (ml / kg / min).

[0217] For example, there may be an increase in cardiovascular fitness. Cardiovascular fitness is the body's maximum ability to take in oxygen. This is also measured as VO2max (L O2 / min). Thus, an increase in cardiovascular fitness may be observed as an increase in VO2max (l / min) or (ml / kg / min).

[0218] For example, there may be a decrease in exercise intolerance. Exercise intolerance is a decrease in the body's ability to perform strenuous activities, which may result in an inability or reduced ability to perform physical exercise at a normal level or for a normal duration. Objective tests of exercise intolerance include moderate activities such as stair climbing, the 6-minute walk, the shuttle walk test, cardiac stress tests, and cardiopulmonary exercise testing (CPET). The 6-minute walk test aims to determine how far a person can walk, and for an average person without exercise intolerance, a reasonable result would be approximately 600 meters. Therefore, a decrease in exercise intolerance can be observed as an increase in the distance that can be walked in the 6-minute test.

[0219] For example, there may be an increase in exercise capacity, which is the maximum amount of physical work a patient can sustain. This can be assessed by a maximal exercise stress test (e.g., a symptom-limited test performed using a 12-lead electrocardiogram to diagnose exercise-induced myocardial ischemia, arrhythmia, or abnormal blood pressure response, or a cardiopulmonary exercise stress test), a submaximal exercise stress test, a 6-minute walk test, and an incremental shuttle walk test, with appropriate tests selected depending on the subject's physical condition. Therefore, an increase in exercise capacity can be observed as an increase in the score obtained in any of these assessments.

[0220] For example, there may be a decrease in exercise-induced fatigue (EF), which is the decrease in maximal voluntary muscle force that occurs with prolonged, intense exercise, typically measured by observing fatigue after prolonged, high-intensity exercise.

[0221] Although many improvements in muscle function are based on observation by medical professionals and are not quantified, increases or improvements can be observed by medical professionals based on standard tests of muscle function used in the art. Such quantifiable increases or improvements can be performance improvements, as determined by an improved score or value of at least 1, 2, 3, 4, 5, 6, 12, 18, 24, or 36 months after administration of an FGFR3 signaling inhibitor or an NPR-B agonist or an NPR-C agonist, compared to values ​​without or before administration of the FGFR3 signaling inhibitor or an NPR-B agonist or an NPR-C agonist (whether the actual value increases or decreases depends on the nature of the test). Optionally, biochemical assays on muscle biopsies or biochemical assays of muscle metabolites released into body fluids can be used in these methods and can provide quantitative results.

[0222] As described above, improvement in muscle function can be defined as an improvement compared to muscle function without or before administration of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist. Thus, in certain embodiments, a subject treated with an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist may still experience an overall decline in muscle function (e.g., over time), but in these embodiments, this decline in muscle function may be less than the decline that would occur in the absence of treatment. In any such embodiment, improvement in muscle function may manifest as a reduction in the decline in muscle function (e.g., compared to the decline in muscle function in the absence of treatment). This is particularly the case for conditions referred to herein as diseases or conditions associated with impaired neuromuscular function, such as neuromuscular or neurodegenerative diseases. This may mean that it takes a subject longer to reach a certain level of muscle function than would be expected based on the subject's diagnosis. In other words, the progression of the disease (e.g., in terms of muscle function) is slowed so that it takes at least 1, 2, 3, or 6 months, or at least 1, 2, or 3 years, to reach a given point in disease progression, compared to the absence of treatment.

[0223] Also, musculoskeletal pain in subjects may be improved.Musculoskeletal pain is defined as acute or chronic pain that affects bones, muscles, ligaments, tendons, and even nerves.This pain may include many different pain syndromes, from localized pain to neuropathic pain.Musculoskeletal pain is primarily physical in nature.The most common forms of musculoskeletal pain are chronic lower back pain and neck pain.

[0224] Musculoskeletal pain can be, for example, pain in the musculoskeletal system, including joints, ligaments, muscles, nerves, or tendons. In some embodiments, musculoskeletal pain can be chronic pain, typically pain lasting 12 weeks or more. In some embodiments, musculoskeletal pain can be muscle pain, such as chronic myoskeletal pain. In some embodiments, musculoskeletal pain can be pain associated with abnormal curvature of the spine. In some embodiments, the pain may not be associated with arthritis, such as osteoarthritis. In some embodiments, musculoskeletal pain can be myalgia. In some embodiments, musculoskeletal pain can be associated with or caused by muscle spasms or spasms. Musculoskeletal pain can be diagnosed or monitored, for example, via patient-reported pain (see, e.g., Nielsen and Arendt-Nielsen, Curr Pain Headache Rep. 2003 Dec;7(6):443-51); MRI or CT scan; or electromyography testing to measure electrical activity of nerves and muscles.

[0225] There may also be an improvement in posture or a reduction in abnormal spinal curvature. Poor posture refers to postural dysfunction and can be defined as a condition in which a subject's spine is placed in an unnatural position, exaggerating the curve. Complications of poor posture include back pain, spinal dysfunction, joint degeneration, hunched shoulders, and a protruding belly. The improvements in posture and spinal curvature following administration of an FGFR3 signaling inhibitor or an NPR-B or NPR-C agonist may result from improved muscle function, as described above. This is consistent with the observations in Example 1, where treatment with test compound (1) affected survival after just 15 days of treatment, a time frame consistent with the historical impact of muscle on survival, and an increased incidence of maternal infanticide was described in a mouse model with muscle weakness as a primary phenotypic trait (e.g., Sullivan 2014).

[0226] Kyphosis, lordosis, or scoliosis, or spinal stenosis, may be improved and may result from any of the spinal deformities listed above. Kyphosis is an exaggerated forward rounding of the upper part of the spine. Lordosis is a severe inward curvature of the spine. Scoliosis is an abnormal lateral curvature of the spine. Spinal stenosis, for example, may result from any of the spinal deformities listed above and is a narrowing of the spinal canal of the spine. In some cases, improvement in kyphosis, lordosis, spinal stenosis, or scoliosis is due to improved muscle function. These spinal abnormalities can occur in chondrodysplasia disorders, preferably the subject with kyphosis, lordosis, spinal stenosis or scoliosis has a chondrodysplasia, e.g., a disorder selected from the group consisting of achondroplasia, hypochondroplasia and tothostatic dysplasia.

[0227] Abnormal spinal curvature can be monitored, for example, by physical examination or imaging (e.g., X-ray, spinal radiography, CT scan, or MRI scan). Signs of abnormal spinal curvature can include, for example, misaligned shoulders, head not resting on pelvis, one or both hips elevated or abnormally high, misaligned hips, and body tilt. Spinal curvature can be measured, for example, using the Cobb method.

[0228] Further embodiments relate to the treatment of abnormal curvatures of the spine. In some embodiments, the present invention relates to the treatment of spinal deformities in subjects with chondrodysplasia disorders, such as those disclosed herein, e.g., achondroplasia. Spinal deformities in chondrodysplasias, e.g., achondroplasia, can result in pain and disability. Congenital narrowing of the spinal canal is common in achondroplasia and is associated with neurological symptoms that worsen with age, can cause premature or sudden death, and can require corrective or repeated corrective surgery during the patient's lifetime.

[0229] Spinal deformities can include abnormal curvature of the spine, which can be at least partially corrected by strengthening the back muscles, preferably through the therapeutic applications disclosed or claimed herein. Spinal deformities can be spinal pedicle malformations or spinal stenosis, which are typical of achondroplasia, and can be further exacerbated by abnormal curvature of the spine. Spinal pedicle malformations can be reduced pedicle distance or reduced pedicle width. Narrowed vertebral distance and thickened pedicles are common in achondroplasia, and the resulting spinal stenosis often requires surgical intervention, such as correcting narrowing of the foramen magnum (FM).

[0230] The present invention provides the use of an FGFR3 signaling inhibitor or an NPR-B agonist for the use according to the invention or for the use according to any one of the claims, wherein said use results in increased spinal height, such as increased thoracic spine height; increased pedicle distance or increased pedicle width.

[0231] The present invention provides a use of an NPR-B agonist for the use according to the present invention or any one of the claims, wherein the use results in increased spinal column height, for example, increased thoracic vertebral height, increased pedicle distance, or increased pedicle width. The present invention also provides a method for treating spinal pedicle malformation in a subject in need of treatment, the method comprising administering a therapeutically effective amount of an FGFR3 signaling inhibitor or an NPR-B agonist to the subject. Preferably, the method may include an initial step of (i) diagnosing or measuring spinal pedicle malformation in the subject, followed by (ii) administering a therapeutically effective amount of an FGFR3 signaling inhibitor or an NPR-B agonist to the subject. Preferably, the measuring step may include one or more x-rays, such as an anteroposterior (AP) x-ray or a lateral x-ray. Lateral x-rays are useful, for example, for measuring pedicle width, and AP x-rays are useful, for example, for measuring pedicle distance. X-rays of the spine or spinal deformity taken before and after administration can be used to determine effective treatment. The diagnostic or measuring step can be one or more measurements of spinal height, thoracic height, pedicle distance, and pedicle width. The diagnostic measuring step can be or include measurements of spinal pedicle morphology or spinal stenosis / stenosis.

[0232] In certain embodiments, administration results in improvement of sleep apnea, obstructive sleep apnea, or otitis media. Sleep apnea is a condition in which a subject's breathing stops and restarts repeatedly during sleep. This can result in insufficient oxygen distribution in the subject's body. Obstructive sleep apnea (OSA) is a form of sleep apnea that occurs when the throat muscles relax, obstructing airflow to the lungs. Otitis media is an infection of the middle ear that causes inflammation (redness and swelling) and fluid accumulation behind the eardrum and is accompanied by midface hypoplasia. Otitis media can also cause hearing loss. In some cases, improvement of sleep apnea, obstructive sleep apnea, or otitis media is due to improved muscle function. These conditions can occur in chondrodysplasia disorders, and preferably, the subject with sleep apnea, obstructive sleep apnea, or otitis media has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and lethal skeletal dysplasia. Due to the association between sleep-disordered breathing and upper airway (eg, laryngeal and pharyngeal) muscle weakness, improving muscle function is thought to produce benefit in these conditions.

[0233] In some embodiments, the present invention relates to methods of treating obstructive sleep apnea. Sleep apnea, e.g., obstructive sleep apnea, can be monitored, for example, via overnight polysomnography / using a respiratory monitor.

[0234] Otitis media is defined as an infection of the middle ear cavity and is typically diagnosed and monitored by physical examination, with several diagnostic tools available, including pneumatic otoscopes, tympanometry, and acoustic reflectometry. Otitis media is often accompanied by ear pain, hearing loss, and fever, which can also be monitored. In some embodiments, the otitis media is acute otitis media, and the present invention provides effective treatments that can reduce the frequency of acute otitis media events, reduce the severity of acute otitis media, or both. In some embodiments, the present invention relates to prophylactic treatment of otitis media. Thus, monitoring otitis media can be evaluating the frequency or severity of acute otitis media events, or both.

[0235] In certain embodiments, administration leads to a reduction in obesity.If the subject before treatment suffers from reduced muscle function, this makes it difficult for the subject to exercise, and makes it difficult for the subject to exercise effectively and effectively for weight control and general physical health.By improving the muscle function of the subject, obesity can also be reduced. This challenge has been observed in patients with achondroplasia disorders, and obesity has been identified as a major health problem in achondroplasia, requiring early and complex clinical management (see Saint-Laurent, C., Garde-Etayo, L. & Gouze, E. Obesity in achondroplasia patients: from evidence to medical monitoring Orphanet J Rare Dis 14, 253 (2019). https: / / doi.org / 10.1186 / s13023-019-1247-6), which notes that children with achondroplasia are limited in their psychomotor development and physical condition, and that the early onset of overweight and obesity exacerbates a sedentary lifestyle and / or contributes to the exclusion of these children from sports practiced by children of the same age. In some cases, the reduction in obesity is due to improved muscle function. Obesity can occur in chondrodysplasia disorders, and preferably the subject with obesity has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and tothostatic dysplasia.

[0236] Obesity is defined as a body mass index (BMI) greater than 30. Thus, a reduction in obesity can be a reduction in BMI. The subject can have a BMI greater than 30 at the start of administration, for example, a BMI greater than 30, 32, 35, 38, or 40 before administration. In certain embodiments, the subject has a BMI of 25 to 30 before administration, for example, a BMI greater than 26, 27, 28, or 29.

[0237] Hand Length Embodiment Hand deformities are characteristic of achondroplasia and include short finger length, tridentate hand deformity, and inability to fully extend the fingers.

[0238] The present invention provides an FGFR3 signaling inhibitor or an NPR-B agonist for use in promoting hand length or finger length growth in a human subject under the age of 18 or whose epiphyses have not yet closed.

[0239] The present invention provides an FGFR3 signaling inhibitor or an NPR-B agonist for use in correcting hand deformities in human subjects under the age of 18 or in whom the epiphyses have not yet closed.

[0240] The present invention provides an FGFR3 signaling inhibitor or an NPR-B agonist for use according to the invention or for use as defined in any one of the claims, wherein said use increases hand length growth or finger length growth in a human subject, such as a human subject under the age of 18 or whose epiphyses have not yet closed.

[0241] The present invention provides a method for increasing the percentage of hand or finger length in a subject in need of treatment, said method comprising the step of administering to said subject a therapeutically effective amount of an FGFR3 signaling inhibitor or an NPR-B agonist.

[0242] Suitably, the methods of the present invention comprise the steps of (i) assessing hand length or finger length(s) in a subject in need of treatment, and (ii) administering a therapeutically effective amount of an FGFR3 signalling inhibitor or an NPR-B agonist to the subject, and (iii) optionally measuring the increase in hand length or finger length after said administration.

[0243] The present invention provides a method for correcting a hand deformity in a subject in need thereof, the method comprising administering to the subject a therapeutically effective amount of an FGFR3 signaling inhibitor or an NPR-B agonist.

[0244] Preferably, the method of the present invention comprises the steps of (i) assessing a hand deformity in a subject in need of treatment, and (ii) administering a therapeutically effective amount of an FGFR3 signaling inhibitor or an NPR-B agonist to the subject, and (iii) optionally assessing a change in the hand deformity in the subject after said administration.

[0245] Methods that include an evaluation step In certain embodiments, the present invention provides a method for improving muscle function in a subject suffering from a disease or condition that impairs muscle function, the method comprising the steps of assessing muscle function at least once in a subject suffering from a disease or condition that impairs muscle function, and administering to the subject a therapeutically effective amount or regimen of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist.

[0246] This is a method of improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, said method comprising: (i) assessing muscle function at least once in a subject suffering from a disease or condition that impairs muscle function; and (ii) administering a therapeutically effective amount of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist to the subject. The method can be described as comprising:

[0247] The evaluation step can be performed before the administration step, e.g., to determine a baseline value or determination of muscle function before administration begins. This can be useful, for example, for comparison with subsequent muscle function values ​​or determinations that may be assessed after administration. For example, in such cases, the evaluation step can be performed, e.g., one week, one month, or three months before administration begins. The pre-administration evaluation step can be used, for example, as a comparison to determine the effectiveness of treatment. The administration step can be initiated in response to the evaluation step.

[0248] The administering step generally includes administering the FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist multiple times. The assessment of muscle function can be performed at least twice, or multiple times. Optionally, the assessment is performed once or at least once before the administering step begins (e.g., to determine a baseline) and once or at least once after the administering step begins. The assessment step can also be performed at least three times: once or at least once before the administering step begins (e.g., to determine a baseline), and twice or at least twice after the administering step begins.

[0249] It may be beneficial to compare muscle function determined before initiating the administration step with muscle function determined after initiating the administration step, or to compare successive determinations of muscle function, or to use periodic determinations of muscle function to observe trends in muscle function, e.g., in response to treatment, which can be used to determine treatment outcome or to inform modifications to the treatment protocol.

[0250] Assessment of muscle function before the start of administration, optionally in combination with other signs or symptoms of the subject, can also be used to diagnose the subject as suffering from a disease or condition in which muscle function is impaired. Thus, the methods referred to herein can further include a step of diagnosing the subject as suffering from impaired muscle function and / or as suffering from a disease or condition in which muscle function is impaired. Administration can be initiated in response to the assessment step and / or in response to a diagnosis of a disease or condition in the subject. Administration can also be initiated in response to an assessment of impaired muscle function relative to a reference value, for example, obtained by assessment performed on a normal subject or control subject (e.g., a subject known not to suffer from a disease or condition in which muscle function is impaired).

[0251] Additionally or alternatively, the evaluation step can be performed after administration has begun, for example, during continuous administration of the drug. The evaluation step performed after administration has begun can be performed once or multiple times. The evaluation step can be performed at least 4, 5, 6, 7, 8, 9, or 10 times, for example, weekly, monthly, or yearly, for example, periodically. The evaluation step can be performed during the treatment period.

[0252] Assessment of muscle function may include any of the following: a) skeletal muscle strength, b) skeletal muscle tone, c) skeletal muscle stamina, d) skeletal muscle mass, e) skeletal muscle fatigue, f) cardiovascular endurance, g) cardiovascular fitness, h) exercise intolerance, i) exercise capacity, j) exercise-induced fatigue, k) muscle hypotonia, l) skeletal muscle mass and / or muscle / fat ratio (e.g., skeletal muscle / fat ratio), m) musculoskeletal pain, n) spinal posture or curvature, optionally kyphosis, lordosis, spinal stenosis, or scoliosis, o) sleep apnea, obstructive sleep apnea, or otitis media, and p) obesity.

[0253] Such assessments include those described elsewhere herein. Examples include measuring muscle weight, muscle length, muscle density, muscle size, and / or muscle volume. Assessments may include imaging the subject to observe the subject's performance. Assessments may be by physical testing, such as the presence or absence of quantitative metrics in muscle fatigue and cardiovascular testing, or by biochemical assays in muscle biopsies, or muscle metabolites released into bodily fluids.

[0254] The evaluation may include imaging, for example, at least one imaging step (eg, an X-ray, a spinal radiograph, a CT scan, or an MRI scan).

[0255] The assessment may include determining a subject's performance metrics, which may be, for example, a measurement or observation of the subject's ability to perform a particular task, e.g., with reference to physical function tests, e.g., those described elsewhere herein (e.g., for determining muscle fatigue and endurance levels, e.g., the sit-to-stand test and the 6-minute walk test).

[0256] If more than one assessment is performed, a composite index may be generated. In certain embodiments, a composite index is generated for at least 2, 3, 4, 5, 6, or 7 (or 1-6, 2-5, 3-4) of any assessments performed, e.g., at least 2, 3, 4, 5, 6, or 7 (or 1-6, 2-5, 3-4) of assessments a) through p) above. If a composite index is generated, it can form the basis of any comparisons referred to elsewhere herein.

[0257] The improvement in muscle function can be any improvement in muscle function as defined elsewhere herein.

[0258] In some methods, the evaluation step is performed at least once before initiating the administering step, e.g., to determine a baseline value or determination of muscle function, and is performed one, two, or more times after initiating administration, e.g., so that changes in muscle function in response to administration can be determined.

[0259] A comparison of muscle function values ​​before and after treatment can indicate an increase in muscle function, no change in muscle function, or a decrease in muscle function. An increase in muscle function after and in response to the initiation of treatment can be an indicator of a positive response to treatment, i.e., that the treatment is successful.

[0260] In some embodiments, an increase in muscle function or a gradual increase with further administration, or an increase in muscle function if the subject had decreased muscle function prior to treatment, or a decrease in muscle function in historical control subjects, is indicative of a positive response to treatment.

[0261] A finding that muscle function remains unchanged or declines may indicate a positive response to treatment or may indicate the need for a change in the treatment protocol (e.g., an increase in dosage and / or frequency), depending on the specific condition and expected outcome. For example, in a subject whose muscle function was impaired but stable before drug administration began, unchanged or declined muscle function after drug administration may indicate a negative response to treatment. However, if muscle function was impaired and declined in the subject before drug administration began, unchanged muscle function after and in response to drug administration may indicate a positive response to treatment. Similarly, a decrease in muscle function after drug administration that is less than would be expected based on declines in the subject before administration began or in previous untreated control subjects may still indicate a positive response to treatment. A decline in muscle function that exceeds any expectation based on declines in the subject before administration began or in previous untreated control subjects may indicate a negative response to drug administration. Predictions may depend on comparison with control value(s) determined in the same subject, reference subject, or normal and / or control subject before drug administration began.

[0262] Assessment of changes in muscle function in response to administration can be used to guide treatment decisions, such as whether to continue administering the drug, change the drug regimen (e.g., change the dosage or frequency), or discontinue administration of the drug. For example, if the assessment indicates a positive response to administration, the same treatment can continue, e.g., with the same regimen. Also, depending on the magnitude of the response and any side effects the subject is experiencing, it may be considered to increase or decrease the dosage and / or frequency. For example, the dosage and / or frequency can be increased to enhance the response, or decreased to reduce any side effects. If the assessment indicates a negative response to the treatment (or no positive response to the treatment) and the subject is tolerating the administered drug without unacceptable side effects, a higher dose or frequency of the same drug can be administered to attempt to elicit a positive therapeutic response. If the assessment continues to indicate a negative response to the treatment (or no positive response to the treatment), or if the subject cannot tolerate a higher dosage or frequency due to side effects, administration of the drug can be discontinued.

[0263] The evaluation step can follow any of the methods of treatment mentioned herein. For example, the present invention provides the method of any one of items 34 to 114.

[0264] Methods for treating or preventing a disease or condition associated with neuromuscular dysfunction in a subject, such as a neurodegenerative disease, can also incorporate an evaluation step for determining muscle (e.g., skeletal muscle function, as noted above). Alternatively or additionally, such methods can incorporate an evaluation step for determining mitochondrial dysfunction, neuromuscular function, for example, to establish whether treatment results in a slowing, delay, or reduction in disease progression, e.g., a reduction in the rate of loss or decline of muscle function, or a reduction in the rate of loss or decline of neuromuscular function.

[0265] Combined use with growth hormone Human growth hormone has been approved in Japan for the treatment of pediatric achondroplasia, and combination therapy with CNP is currently under clinical investigation. Combination therapy with growth hormone in the methods and uses of the present invention is expected to be advantageous.

[0266] In some embodiments, the growth hormone is or comprises somatropin, or a somatropin conjugate, such as PEGylated somatropin or a fatty acid growth hormone conjugate. In some embodiments, the growth hormone is a growth hormone conjugate, such as a human growth hormone conjugate. The conjugate moiety can include, for example, a PEG moiety, a fatty acid moiety, a serum albumin binding moiety, an antibody moiety, or an antibody fragment moiety. In some embodiments, the growth hormone is a long-acting growth hormone, such as a growth hormone for once-weekly administration. For example, the long-acting growth hormone can be administered once a week or less frequently than weekly.

[0267] Suitably, the growth hormone may be controlled-release hGH. Long-acting human growth hormone and controlled-release hGH are disclosed in WO2018 / 060314A1, which is incorporated herein by reference in its entirety.

[0268] In some embodiments, the growth hormone is lonapegsomatropin (lonapegsomatropin-tcgd). In some embodiments, the growth hormone conjugate, e.g., human growth hormone conjugate, long-acting human growth hormone, or controlled-release hGH, e.g., lonapegsomatropin, is administered to a subject at a dose ranging from about 0.021 mg / kg / week to about 0.7 mg / kg / week, e.g., 0.21 mg / kg / week or about 0.21 mg / kg / week (mg / kg refers to the mass of growth hormone polypeptide, not including the conjugate moiety, administered per week).

[0269] In some embodiments, the growth hormone is selected from the group consisting of somapasitan or somapasitan-beko (sold as SOGROYA® Novo Nordisk), somatrogon (sold as NGENLA™ by (Pfizer / OPKO)), eftansomatropin alfa (also known as eftansomatopine), efpegsomatropin, albusomatropin, somabaratan, ibutamoren, and lonapegsomatropin-tcgd.

[0270] Exemplary administration protocols for CNP drugs, eg, drugs including CNP conjugates, eg, CNP of Formula (IIf') or Formula (IIf) or Compound (1). For example, prior to subcutaneous administration to a patient in need thereof, the solid unit dosage form is reconstituted. The reconstitution of the solid unit dosage form into a reconstituted formulation is carried out by adding a predetermined amount of reconstitution solution to the solid unit dosage form. Accordingly, a further aspect of the present invention is a method for reconstituting the solid unit dosage form of the present invention, said method comprising the following steps: (a) contacting a solid unit dosage form of the present invention with a reconstitution solution The method includes:

[0271] Reconstitution may be carried out in the container in which the solid unit dosage form is provided, such as a vial; a syringe, such as a dual-chamber syringe; an ampoule; a cartridge, such as a dual-chamber cartridge, or the solid unit dosage form may be transferred to a different container, where it is subsequently reconstituted.In certain embodiments, the container in which the reconstitution of the solid unit dosage form is carried out is a vial.In certain embodiments, the container in which the reconstitution of the solid unit dosage form is carried out is a syringe.In certain embodiments, the container in which the reconstitution of the solid unit dosage form is carried out is a dual-chamber syringe.In certain embodiments, the container in which the reconstitution of the solid unit dosage form is carried out is a cartridge.In certain embodiments, the container in which the reconstitution of the solid unit dosage form is carried out is a dual-chamber cartridge.

[0272] In certain embodiments, a solid unit dosage form according to the invention is provided in a first chamber of a dual chamber syringe and a reconstitution solution is provided in a second chamber of the dual chamber syringe.

[0273] The reconstitution solution is a sterile liquid such as water or a buffer, and may contain additional additives such as preservatives and / or antimicrobial agents.

[0274] In certain embodiments, the reconstituted solution comprises one or more preservatives and / or antimicrobial agents and / or antioxidants.

[0275] In certain embodiments, the reconstituted solution includes one or more preservatives.

[0276] The preservative may be selected from the group consisting of m-cresol, benzoic acid, phenol, methylparaben, ethylparaben, propylparaben, butylparaben, potassium sorbate, chlorobutanol, benzyl alcohol, phenylmercuric nitrate, thimerosal, sorbic acid, potassium sorbate, chlorocresol, benzalkonium chloride, 2-ethoxyethanol, chlorhexidine, chlorobutanol, phenylethyl alcohol, phenylmercuric acetate, and mixtures thereof.

[0277] In certain embodiments, the preservative is m-cresol. In certain embodiments, the preservative is benzyl alcohol. In certain embodiments, the preservative is benzoic acid. In certain embodiments, the preservative is phenol. In certain embodiments, the preservative is methylparaben. In certain embodiments, the preservative is ethylparaben. In certain embodiments, the preservative is propylparaben. In certain embodiments, the preservative is butylparaben. In certain embodiments, the preservative is potassium sorbate. In certain embodiments, the preservative is benzyl alcohol. In certain embodiments, the preservative is phenylmercuric nitrate. In certain embodiments, the preservative is thimerosal. In certain embodiments, the preservative is sorbic acid. In certain embodiments, the preservative is potassium sorbate. In certain embodiments, the preservative is chlorocresol. In certain embodiments, the preservative is benzalkonium chloride. In certain embodiments, the preservative is 2-ethoxyethanol. In certain embodiments, the preservative is chlorhexidine. In certain embodiments, the preservative is chlorobutanol. In certain embodiments, the preservative is phenylethyl alcohol. In certain embodiments, the preservative is phenylmercuric acetate.

[0278] In certain embodiments, the preservative has a concentration of 1 to 10 mg / ml, 1.5 to 3.5 mg / ml, or 2 to 3 mg / ml.

[0279] The antioxidant may be selected from the group consisting of methionine, butylhydroxytoluene, butylhydroxyanisole, tocopherol, propyl gallate, ascorbic acid, ethylenediaminetetraacetic acid (EDTA), poly(ethyleneimine), vitamin E, and mixtures thereof.

[0280] In certain embodiments, the preservative is methionine. In certain embodiments, the preservative is butylhydroxytoluene. In certain embodiments, the preservative is butylhydroxyanisole. In certain embodiments, the preservative is tocopherol. In certain embodiments, the preservative is propyl gallate. In certain embodiments, the preservative is ethylenediaminetetraacetic acid. In certain embodiments, the preservative is poly(ethyleneimine). In certain embodiments, the preservative is vitamin E.

[0281] The term "methionine," as defined herein, is intended to encompass both D-methionine and L-methionine, and mixtures thereof. In certain embodiments, the term "methionine" refers to L-methionine. In certain embodiments, the term "methionine" refers to D-methionine. In certain embodiments, the term "methionine" refers to a mixture of D-methionine or L-methionine. In certain embodiments, the term "methionine" refers to L-methionine hydrochloride.

[0282] The term "EDTA," as defined herein, is intended to encompass all forms of EDTA known in the art, e.g., EDTA salts, including, for example, EDTA metal salts, such as disodium EDTA, dipotassium EDTA, calcium EDTA, dimagnesium EDTA, or mixtures thereof. In certain embodiments, EDTA refers to disodium EDTA. In certain embodiments, the term "EDTA" refers to dicalcium EDTA. In certain embodiments, the term "EDTA" refers to EDTA (anhydrous).

[0283] In certain embodiments, the molar ratio of antioxidant to CNP moiety is about 0.1:1 to about 100:1. In certain embodiments, the molar ratio of antioxidant to CNP moiety is about 0.1:1 to about 70:1. In certain embodiments, the molar ratio of antioxidant to CNP moiety is about 0.1:1 to about 15:1. In certain embodiments, the molar ratio of antioxidant to CNP moiety is about 1:1 to about 10:1. In certain embodiments, the molar ratio of antioxidant to CNP moiety is about 3:1 to about 7:1.

[0284] In certain embodiments, the reconstituted solution does not include an antimicrobial agent. In certain embodiments, the reconstituted solution includes one or more excipients.

[0285] In certain embodiments, the reconstitution solution is sterile water. In certain embodiments, the reconstitution solution is sterile water containing 0.7 to 1.1% benzyl alcohol. In certain embodiments, the reconstitution solution is sterile water containing 0.9% benzyl alcohol.

[0286] In certain embodiments, the reconstituted solution comprises a pH modifying agent.

[0287] As used herein, the term "pH modifying agent" refers to a compound used to modify the pH of the reconstituted solution.

[0288] In certain embodiments, the pH modifier may be an acid or an acid salt thereof, which may be selected from the group consisting of acetic acid, citric acid, succinic acid, hydrochloric acid, phosphoric acid, carbonic acid, nitric acid, and mixtures thereof.

[0289] In certain embodiments, the pH modifier may be a base or a basic salt thereof, which may be selected from the group consisting of Tris (tris(hydroxymethyl)aminomethane), sodium hydroxide, potassium hydroxide, lysine, and mixtures thereof.

[0290] In certain embodiments, the volume of the reconstituted solution is about 0.1 ml to about 4 ml, hi certain embodiments, the volume of the reconstituted solution is about 1 ml, such as about 2 ml, such as about 3 ml, or such as about 4 ml.

[0291] In certain embodiments, the volume of the reconstituted solution is about 0.79 ml. In certain embodiments, the volume of the reconstituted solution is 0.79 ml. In certain embodiments, the volume of the reconstituted solution is about 1 ml. In certain embodiments, the volume of the reconstituted solution is 1 ml. In certain embodiments, the volume of the reconstituted solution is about 1.1 ml. In certain embodiments, the volume of the reconstituted solution is 1.1 ml. In certain embodiments, the volume of the reconstituted solution is about 1.25 ml. In certain embodiments, the volume of the reconstituted solution is 1.25 ml.

[0292] It is understood that the unit dose volume or injection volume is based on the patient's actual weight and the concentration of the reconstituted solution. In certain embodiments, the concentration of CNP in the reconstituted solution is 7 mg / ml or less. In certain embodiments, the concentration of CNP in the reconstituted solution is 0.5 mg / ml or more. In certain embodiments, the concentration of CNP in the reconstituted solution is 0.75 mg / ml. In certain embodiments, the concentration of CNP in the reconstituted solution is 1 mg / ml. In certain embodiments, the concentration of CNP in the reconstituted solution is 2.2 mg / ml. In certain embodiments, the concentration of CNP in the reconstituted solution is 3.6 mg / ml. In certain embodiments, the concentration of CNP in the reconstituted solution is 4.6 mg / ml. In certain embodiments, the concentration of CNP in the reconstituted solution is 5 mg / ml. In certain embodiments, the concentration of CNP in the reconstituted solution is 5.5 mg / ml.

[0293] After reconstitution, a unit dose has a volume of 4 ml or less. In certain embodiments, the volume of a unit dose is about 0.01 ml to about 1.1 ml. In certain embodiments, the volume of a unit dose is 0.01 ml to 0.75 ml. In certain embodiments, the volume of a unit dose is 0.01 ml to 0.50 ml.

[0294] In certain embodiments, the unit dose volume is about 0.03 ml. In certain embodiments, the unit dose volume is about 0.05 ml. In certain embodiments, the unit dose volume is about 0.1 ml. In certain embodiments, the unit dose volume is about 0.2 ml. In certain embodiments, the unit dose volume is about 0.25 ml. In certain embodiments, the unit dose volume is about 0.3 ml. In certain embodiments, the unit dose volume is about 0.35 ml. In certain embodiments, the unit dose volume is about 0.4 ml. In certain embodiments, the unit dose volume is about 0.5 ml. In certain embodiments, the unit dose volume is about 0.6 ml. In certain embodiments, the unit dose volume is about 0.75 ml. In certain embodiments, the unit dose volume is about 1 ml.

[0295] In certain embodiments, the patient is an infant and the unit dose volume is about 10 μl to 100 μl. In certain embodiments, the patient is an infant and the unit dose volume is about 10 μl to 50 μl. In certain embodiments, the patient is an infant and the unit dose volume is about 10 μl to 30 μl.

[0296] In certain embodiments, the patient is an infant and the unit dose volume is about 10 μl. In certain embodiments, the patient is an infant and the unit dose volume is about 15 μl. In certain embodiments, the patient is an infant and the unit dose volume is about 20 μl.

[0297] In certain embodiments, the patient is an infant and the unit dose volume is 10 μl. In certain embodiments, the patient is an infant and the unit dose volume is 15 μl. In certain embodiments, the patient is an infant and the unit dose volume is 20 μl.

[0298] In certain embodiments, the patient is an infant, the unit dose is 20 μg CNP / kg, and the unit dose volume is about 10 μl. In certain embodiments, the patient is an infant, the unit dose is 20 μg CNP / kg, and the unit dose volume is about 15 μl. In certain embodiments, the patient is an infant, the unit dose is 20 μg CNP / kg, and the unit dose volume is about 20 μl.

[0299] In certain embodiments, the unit dose is 6 μg CNP / kg and the unit dose volume is 0.06 ml. In certain embodiments, the unit dose is 20 μg CNP / kg and the unit dose volume is 0.3 ml. In certain embodiments, the unit dose is 50 μg CNP / kg and the unit dose volume is 0.2 ml. In certain embodiments, the unit dose is 75 μg CNP / kg and the unit dose volume is 0.4 ml. In certain embodiments, the unit dose is 100 μg CNP / kg and the unit dose volume is 0.5 ml. In certain embodiments, the unit dose is 150 μg CNP / kg and the unit dose volume is 0.5 ml.

[0300] In certain embodiments, the pH of the liquid unit dosage form is about pH 4 to about pH 6. In certain embodiments, the pH of the liquid unit dosage form is about pH 4.5 to about pH 5.5. In certain embodiments, the pH of the liquid unit dosage form is about 5. In certain embodiments, the pH of the liquid unit dosage form is 5.

[0301] In certain embodiments, the unit dosage forms of the present invention further comprise a buffering agent, an isotonicity agent, and a pH modifying agent.

[0302] In certain embodiments, the buffering agent has a concentration in the unit dosage form of 1.3 to 57.6 mM. In certain embodiments, the buffering agent has a concentration in the unit dosage form of 1.7 to 33 mM. In certain embodiments, the buffering agent has a concentration in the unit dosage form of 5.1 to 20.3 mM. In certain embodiments, the buffering agent has a concentration in the unit dosage form of about 10 mM.

[0303] Exemplary buffering agents can be selected from the group consisting of succinic acid, citric acid, lactic acid, acetic acid, glutamic acid, fumaric acid, aspartic acid, glutaric acid, phosphate, histidine, gluconic acid, tartaric acid, malic acid, and mixtures thereof. It will be apparent to those skilled in the art that the corresponding conjugate bases or salts of the above buffering agents can also be included, such as succinate, citrate, lactate, acetate, glutamate, fumarate, aspartate, glutarate, phosphate, gluconate, tartrate, malate, and mixtures thereof, respectively.

[0304] In certain embodiments, the buffering agent is succinic acid. In certain embodiments, the buffering agent is citric acid. In certain embodiments, the buffering agent is lactic acid. In certain embodiments, the buffering agent is acetic acid. In certain embodiments, the buffering agent is glutamic acid. In certain embodiments, the buffering agent is fumaric acid. In certain embodiments, the buffering agent is aspartic acid. In certain embodiments, the buffering agent is glutaric acid. In certain embodiments, the buffering agent is phosphate. In certain embodiments, the buffering agent is histidine. In certain embodiments, the buffering agent is gluconic acid. In certain embodiments, the buffering agent is tartaric acid. In certain embodiments, the buffering agent is malic acid.

[0305] The isotonicity agent may be selected from the group consisting of trehalose, mannitol, sucrose, raffinose, gelatin, lactose, calcium hydrogen phosphate, sorbitol, xylitol, glycine, histidine, hydroxyethyl starch, dextrose, dextran, Ficoll®, propylene glycol, and mixtures thereof.

[0306] In certain embodiments, the isotonicity agent may be selected from the group consisting of trehalose, mannitol, sucrose, raffinose, gelatin, lactose, calcium hydrogen phosphate, sorbitol, xylitol, glycine, histidine, hydroxyethyl starch, dextrose, dextran, propylene glycol, and mixtures thereof.

[0307] In certain embodiments, the isotonicity agent is selected from the group consisting of trehalose, sucrose, and glycine, hi certain embodiments, the isotonicity agent is a non-reducing sugar, such as trehalose or sucrose.

[0308] In certain embodiments, the isotonicity agent is trehalose.

[0309] The term "trehalose," as defined herein, is intended to encompass all salts and hydrated forms of trehalose, such as trehalose (anhydrous) or trehalose dihydrate. In certain embodiments, the term "trehalose" refers to trehalose (anhydrous). In certain embodiments, the term "trehalose" refers to trehalose dihydrate.

[0310] In certain embodiments, the unit dosage form comprises succinic acid and trehalose.

[0311] In certain embodiments, the unit dosage form comprises: CNP conjugate 0.9~82.1mg / ml Succinic acid 1.3~57.6 mM Trehalose dihydrate 67~111.6mg / ml and has a pH of 4.0 to 6.0.

[0312] In certain embodiments, the unit dosage form comprises: CNP conjugate 19.8~73.6mg / ml Succinic acid 1.7~50mM Trehalose dihydrate 63~100mg / ml and has a pH of 4.0 to 6.0.

[0313] In certain embodiments, the unit dosage form comprises: CNP conjugate 27.5~50.5mg / ml Succinic acid 5.1~20.3mM Trehalose dihydrate 67~95mg / ml and has a pH of 4.0 to 6.0.

[0314] In certain embodiments, the unit dosage form comprises about 8.2 mg / ml CNP conjugate, about 10 mM succinic acid, about 89 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0315] In certain embodiments, the unit dosage form comprises 8.2 mg / ml CNP conjugate, 10 mM succinic acid, 89 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0316] In certain embodiments, the unit dosage form comprises about 11 mg / ml CNP conjugate, about 10 mM succinic acid, about 88.5 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0317] In certain embodiments, the unit dosage form comprises 11 mg / ml CNP conjugate, 10 mM succinic acid, 88.5 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0318] In certain embodiments, the unit dosage form comprises about 24.2 mg / ml CNP conjugate, about 10 mM succinic acid, about 85 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0319] In certain embodiments, the unit dosage form comprises 24.2 mg / ml CNP conjugate, 10 mM succinic acid, 85 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0320] In certain embodiments, the unit dosage form comprises about 39.6 mg / ml CNP conjugate, about 10 mM succinic acid, about 80 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0321] In certain embodiments, the unit dosage form comprises 39.6 mg / ml CNP conjugate, 10 mM succinic acid, 80 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0322] In certain embodiments, the unit dosage form comprises about 50.5 mg / ml CNP conjugate, about 10 mM succinic acid, about 77 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0323] In certain embodiments, the unit dosage form comprises 50.5 mg / ml CNP conjugate, 10 mM succinic acid, 77 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0324] In certain embodiments, the unit dosage form comprises about 54.9 mg / ml CNP conjugate, about 10 mM succinic acid, about 75 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0325] In certain embodiments, the unit dosage form comprises 54.9 mg / ml CNP conjugate, 10 mM succinic acid, 75 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0326] In certain embodiments, the unit dosage form comprises about 60.4 mg / ml CNP conjugate, about 10 mM succinic acid, about 73 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of about 5.

[0327] In certain embodiments, the unit dosage form comprises 60.4 mg / ml CNP conjugate, 10 mM succinic acid, 73 mg / ml trehalose dihydrate, and optionally Tris and / or hydrochloric acid, and has a pH of 5.

[0328] In certain embodiments, the unit dosage form contains, by total weight of the solid unit dosage form, the following: CNP conjugate 8.2~44.4%(w / w) Succinic acid 0.9~1.2%(w / w) Trehalose dihydrate 53.7~89.1%(w / w) Tris 1.0-1.5% (w / w) Includes.

[0329] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, about 8.2% (w / w) CNP conjugate, about 1.2% (w / w) succinic acid, about 89.1% (w / w) trehalose dihydrate, and about 1.5% (w / w) Tris.

[0330] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 8.2% (w / w) CNP conjugate, 1.2% (w / w) succinic acid, 89.1% (w / w) trehalose dihydrate, and 1.5% (w / w) Tris.

[0331] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, about 10.7% (w / w) CNP conjugate, about 1.2% (w / w) succinic acid, about 86.8% (w / w) trehalose dihydrate, and about 1.3% (w / w) Tris.

[0332] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 10.7% (w / w) CNP conjugate, 1.2% (w / w) succinic acid, 86.8% (w / w) trehalose dihydrate, and 1.3% (w / w) Tris.

[0333] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, about 21.6% (w / w) CNP conjugate, about 1.1% (w / w) succinic acid, about 76.1% (w / w) trehalose dihydrate, and about 1.2% (w / w) Tris.

[0334] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 21.6% (w / w) CNP conjugate, 1.1% (w / w) succinic acid, 76.1% (w / w) trehalose dihydrate, and 1.2% (w / w) Tris.

[0335] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, about 32.4% (w / w) CNP conjugate, about 1.0% (w / w) succinic acid, about 65.4% (w / w) trehalose dihydrate, and about 1.2% (w / w) Tris.

[0336] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 32.4% (w / w) CNP conjugate, 1.0% (w / w) succinic acid, 65.4% (w / w) trehalose dihydrate, and 1.2% (w / w) Tris.

[0337] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, about 38.9% (w / w) CNP conjugate, about 0.9% (w / w) succinic acid, about 59.2% (w / w) trehalose dihydrate, and about 1% (w / w) Tris.

[0338] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 38.9% (w / w) CNP conjugate, 0.9% (w / w) succinic acid, 59.2% (w / w) trehalose dihydrate, and 1% (w / w) Tris.

[0339] In certain embodiments, the unit dosage form comprises, based on the total weight of the solid unit dosage form, about 41.5% (w / w) CNP conjugate, about 0.9% (w / w) succinic acid, about 56.6% (w / w) trehalose dihydrate, and about 1% (w / w) Tris.

[0340] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 41.5% (w / w) CNP conjugate, 0.9% (w / w) succinic acid, 56.6% (w / w) trehalose dihydrate, and 1% (w / w) Tris.

[0341] In certain embodiments, the unit dosage form comprises, based on the total weight of the solid unit dosage form, about 44.4% (w / w) CNP conjugate, about 0.9% (w / w) succinic acid, about 53.7% (w / w) trehalose dihydrate, and about 1% (w / w) Tris.

[0342] In certain embodiments, the unit dosage form comprises, by total weight of the solid unit dosage form, 44.4% (w / w) CNP conjugate, 0.9% (w / w) succinic acid, 53.7% (w / w) trehalose dihydrate, and 1% (w / w) Tris.

[0343] Applicant has surprisingly found that when a unit dosage form of a CNP conjugate, e.g., a compound of Formula (IIf') or Formula (IIf), or Compound (1), is administered to a patient in need thereof, the incidence of hypotension is less than 10%, preferably less than 8%, most preferably less than 5%, and even more preferably less than 3%. In certain embodiments, when a unit dosage form of the invention is administered to a patient in need thereof, the incidence of hypotension is less than 1%. In certain embodiments, the incidence of hypotension is nonexistent.

[0344] It has also been surprisingly found that therapeutically developed anti-CNP antibodies are not detectable upon treatment with a CNP conjugate (e.g., a compound or compounds of Formula (IIf') or Formula (IIf)). In certain embodiments, anti-CNP binding antibodies are not detectable upon repeated weekly exposure to a conjugate of the invention for 1 to 9 months. In certain embodiments, anti-CNP binding antibodies are not detectable upon repeated weekly exposure to a conjugate of the invention for 52 weeks.

[0345] Furthermore, it has surprisingly been found that administration of 100 μg CNP / kg per week (a CNP conjugate, e.g., a compound or compound of Formula (IIf') or Formula (IIf)) to pediatric patients in need of CNP treatment between the ages of 2 and 10 years, e.g., between 2 and 5 years, or e.g., between 5 and 10 years, resulted in similar responses, measured as annual growth velocity.

[0346] In certain embodiments, the CNP portion of the CNP conjugate has the sequence of SEQ ID NO:9, SEQ ID NO:10, SEQ ID NO:11, SEQ ID NO:12, SEQ ID NO:13, SEQ ID NO:14, SEQ ID NO:15, SEQ ID NO:16, SEQ ID NO:17, SEQ ID NO:18, SEQ ID NO:19, SEQ ID NO:20, SEQ ID NO:21, SEQ ID NO:22, SEQ ID NO:23, SEQ ID NO:24, SEQ ID NO:25, or SEQ ID NO:30. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:20, SEQ ID NO:21, SEQ ID NO:22, SEQ ID NO:23, SEQ ID NO:24, or SEQ ID NO:25. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:20. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:21. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:22. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:23. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:24. In certain embodiments, the CNP portion has the sequence of SEQ ID NO:25.

[0347] Exemplary CNP Conjugates and CNP Prodrugs In certain embodiments, the CNP conjugate has formula (Ia) or (Ib): [ka] (In the formula, -D is a CNP moiety; -L 1 - is a reversible linker moiety; -L 2 - is a single chemical bond or spacer moiety; -Z is a polymeric moiety; x is an integer selected from the group consisting of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16; y is an integer selected from the group consisting of 1, 2, 3, 4 and 5. It has.

[0348] -D in formula (Ia) or (Ib) is -L 1 - is covalently and reversibly conjugated to

[0349] In certain embodiments, x in Formula (Ia) is an integer selected from the group consisting of 1, 2, 3, 4, 6, and 8. In certain embodiments, x in Formula (Ia) is an integer selected from the group consisting of 1, 2, 4, and 6. In certain embodiments, x in Formula (Ia) is an integer selected from the group consisting of 1, 4, and 6, and in certain embodiments, x in Formula (Ia) is 1.

[0350] In certain embodiments, y in Formula (Ib) is an integer selected from the group consisting of 2, 3, 4, and 5. In certain embodiments, y in Formula (Ib) is an integer selected from the group consisting of 2, 3, and 4. In certain embodiments, y in Formula (Ib) is an integer selected from the group consisting of 2 and 3. In certain embodiments, y in Formula (Ib) is an integer selected from the group consisting of 1, 2, and 3. In certain embodiments, y in Formula (Ib) is 1. In certain embodiments, y in Formula (Ib) is 2.

[0351] In certain embodiments, the CNP conjugate has the formula (Ia) with x=1.

[0352] In certain embodiments, -D of Formula (Ia) or (Ib) has the sequence of SEQ ID NO: 9, SEQ ID NO: 10, SEQ ID NO: 11, SEQ ID NO: 12, SEQ ID NO: 13, SEQ ID NO: 14, SEQ ID NO: 15, SEQ ID NO: 16, SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19, SEQ ID NO: 20, SEQ ID NO: 21, SEQ ID NO: 22, SEQ ID NO: 23, SEQ ID NO: 24, SEQ ID NO: 25, or SEQ ID NO: 30. In certain embodiments, -D of Formula (Ia) or (Ib) has the sequence of SEQ ID NO: 20, SEQ ID NO: 21, SEQ ID NO: 22, SEQ ID NO: 23, SEQ ID NO: 24, or SEQ ID NO: 25.

[0353] In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO: 20. In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO: 21. In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO: 22. In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO: 23. In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO: 24. In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO: 25.

[0354] In certain embodiments, -D of formula (Ia) or (Ib) has the sequence of SEQ ID NO:30, SEQ ID NO:98, SEQ ID NO:99 or SEQ ID NO:90.

[0355] The moiety -L of formula (Ia) or (Ib) 1- is conjugated to a functional group in the side chain of an amino acid residue of -D, to the N-terminal amine functional group or the C-terminal carboxyl functional group of -D, or to a nitrogen atom in the backbone polypeptide chain of -D. Attachment to either the N- or C-terminus can be direct via the corresponding amine or carboxyl functional group, respectively, or a spacer moiety is first conjugated to the amine or carboxyl functional group to which the spacer moiety -L 1 - can be indirect, such as being conjugated.

[0356] The moiety -L of formula (Ia) or (Ib) 1 - is a reversible linker from which the drug, i.e., DH, is released in its free form, i.e., -L 1 - is a traceless linker. Suitable reversible linkers are known in the art, such as the reversible linker moieties disclosed in WO 2005 / 099768 A2, WO 2006 / 136586 A2, WO 2011 / 089216 A1 and WO 2013 / 024053 A1, which are incorporated herein by reference.

[0357] In certain embodiments, -L 1 - is a reversible linker as described in WO 2011 / 012722 A1, WO 2011 / 089214 A1, WO 2011 / 089215 A1, WO 2013 / 024052 A1 and WO 2013 / 160340 A1, which are incorporated herein by reference.

[0358] Part-L 1 - can be linked to -D through any type of bond, provided that the bond is reversible. 1 - is linked to -D through a bond selected from the group consisting of amide, ester, carbamate, acetal, aminal, imine, oxime, hydrazone, disulfide, and acylguanidine.1 - is linked to -D through a bond selected from the group consisting of amide, ester, carbamate and acylguanidine. These bonds may not be reversible themselves, but -L 1 It is understood that the adjacent groups contained within may make the bond reversible.

[0359] In certain embodiments, the moiety -L 1 - is attached to -D via an amide bond.

[0360] Part-L 1 - is disclosed in WO 2009 / 095479 A2. Thus, in certain embodiments, the moiety -L 1 - is a group represented by the formula (II): [ka] (In the formula, The dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond, and -X- is -C(R 4 R 4a )-, -N(R 4 )-, -O-, -C(R 4 R 4a )-C(R 5 R 5a )-, -C(R 5 R 5a )-C(R 4 R 4a )-, -C(R 4 R 4a )-N(R 6 )-, -N(R 6 )-C(R 4 R 4a )-, -C(R 4 R 4a )-O-, -OC(R 4 R 4a )- or -C(R 7 R 7a )- and X 1 is C or S(O), -X 2 - is -C(R 8 R 8a)- or -C(R 8 R 8a )-C(R 9 R 9a )- and =X 3 is =O, =S, or =N-CN, -R 1 , -R 1a , -R 2 , -R 2a , -R 4 , -R 4a , -R 5 , -R 5a , -R 6 , -R 8 , -R 8a , -R 9 , -R 9a -H and C 1-6 independently selected from the group consisting of alkyl, -R 3 , -R 3a -H and C 1-6 alkyl, with the proviso that -R 3 , -R 3a If one or both of are other than -H, they must not be attached to the N to which they are attached. 3 bonded through a hybridized carbon atom, -R 7 is -N(R 10 R 10a ), or -NR 10 -(C=O)-R 11 and -R 7a , -R 10 , -R 10a , -R 11 are, independently of each other, -H or C 1-6 is alkyl, In some cases, Pair-R 1a / -R 4a , -R 1a / -R 5a , -R 1a / -R 7a , -R 4a / -R 5a , -R 8a / -R 9a one or more of the following forms a chemical bond; In some cases, Pair-R 1 / -R 1a , -R 2 / -R 2a , -R 4 / -R 4a , -R 5 / -R 5a , -R 8 / -R 8a , -R 9 / -R 9a One or more of the following, together with the atoms to which they are attached, form a C 3-10 forming a cycloalkyl or a 3- to 10-membered heterocyclyl; In some cases, Pair-R 1 / -R 4 , -R 1 / -R 5 , -R 1 / -R 6 , -R 1 / -R 7a , -R 4 / -R 5 , -R 4 / -R 6 , -R 8 / -R 9 , -R 2 / -R 3 together with the atoms to which they are attached form ring A, In some cases, -R 3 / -R 3a together with the nitrogen atom to which they are attached form a 3- to 10-membered heterocyclic ring, A is phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, and 8- to 11-membered heterobicyclyl where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, provided that the hydrogen with an asterisk in formula (II) is -L 2 is not substituted by -Z or a substituent; -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0361] In certain embodiments, -L of formula (II) 1 - is one part - L 2 In certain embodiments, -L of formula (II) is substituted with -Z. 1 - is not further substituted.

[0362] -R in formula (II) 3 / -R 3a However, when they are combined with the nitrogen atom to form a 3- to 10-membered heterocycle, the atom directly bonded to the nitrogen atom is sp 3 It is understood that only 3-10 membered heterocyclic rings can be formed in which the carbon atoms are hybridized. 3 / -R 3a and the nitrogen atom to which they are attached, the 3- to 10-membered heterocycle has the following structure: [ka] (In the formula, The dashed line is -L 1 - indicates the bond to the remainder of the ring contains 3 to 10 atoms, including at least one nitrogen; R # and R ## sp 3 (representing a hybridized carbon atom) It has.

[0363] It is also understood that the 3- to 10-membered heterocycle may be further substituted.

[0364] -R in formula (II) 3 / -R 3a and the nitrogen atom to which they are attached are the following: [ka] (In the formula, The dashed line indicates the bond to the rest of the molecule; -R is -H and C 1-6 alkyl).

[0365] -L in formula (II) 1 - may be optionally further substituted. In general, any substituent may be used as long as it does not affect the principle of cleavage, i.e., the hydrogen with an asterisk in formula (II) is not substituted, and the moiety of formula (II) [ka] The nitrogen in remains part of a primary, secondary, or tertiary amine, i.e., -R 3 and -R 3a are each independently -H or sp 3 It is bonded to -N< by a hybridized carbon atom.

[0366] In certain embodiments, -R of formula (II) 1 or -R 1a -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 2 or -R 2a -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 3 or -R 3a -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 4 -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 5 or -R 5a -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 6 -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 7 or -R 7a -L 2 In certain embodiments, -R of formula (II) is substituted with -Z. 8 or -R 8a -L2 In certain embodiments, -R of formula (II) is substituted with -Z. 9 or -R 9a -L 2 Replaced with -Z.

[0367] In certain embodiments, -R of formula (II) 4 -L 2 Replaced with -Z.

[0368] In certain embodiments, -X- in formula (II) is -C(R 4 R 4a )- or -N(R 4 In certain embodiments, -X- in formula (II) is -C(R 4 R 4a )-.

[0369] In certain embodiments, X in formula (II) 1 is C.

[0370] In certain embodiments, the =X group of formula (II) 3 is =O.

[0371] In certain embodiments, -X in formula (II) 2 - is -C(R 8 R 8a )-.

[0372] In certain embodiments, -R of formula (II) 8 and -R 8a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (II) 8 and -R 8a In certain embodiments, at least one of -R in formula (II) is -H. 8 and -R 8a Both are -H.

[0373] In certain embodiments, -R of formula (II) 1 and -R 1ais independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (II) 1 and -R 1a In certain embodiments, at least one of -R in formula (II) is -H. 1 and -R 1a Both are -H.

[0374] In certain embodiments, -R of formula (II) 2 and -R 2a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (II) 2 and -R 2a In certain embodiments, at least one of -R in formula (II) is -H. 2 and -R 2a Both are H.

[0375] In certain embodiments, -R of formula (II) 3 and -R 3a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -R of formula (II) 3 and -R 3a In certain embodiments, at least one of -R in formula (II) is methyl. 3 and -R 3a are both H. In certain embodiments, -R in formula (II) 3 and -R 3a In certain embodiments, -R in formula (II) is methyl. 3 is -H, and -R in formula (II) 3a is methyl.

[0376] In certain embodiments, -R of formula (II) 4 and -R 4a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (II) 4 and -R 4a In certain embodiments, at least one of -R in formula (II) is -H.4 and -R 4a Both are -H.

[0377] In certain embodiments, the moiety -L 1 - is a group represented by the formula (IIa): [ka] (In the formula, The dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond, and -R 1 , -R 1a , -R 2 , -R 2a , -R 3 , -R 3a , -R 4 , -R 4a and -X 2 - is used as defined in formula (II) and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIa) is -L 2 -Z or is not substituted by a substituent.

[0378] In certain embodiments, -L of formula (IIa) 1 - is one part - L 2 In certain embodiments, the moiety -L of formula (IIa) is substituted with -Z. 1 - is not further substituted.

[0379] In certain embodiments, -R of formula (IIa) 1 and -R 1a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (IIa) 1 and -R 1a In certain embodiments, at least one of -R in formula (IIa) is -H. 1 and -R 1a Both are -H.

[0380] In certain embodiments, -R of formula (IIa) 4 and -R 4a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (IIa) 4 and -R 4a In certain embodiments, at least one of -R in formula (IIa) is -H. 4 and -R 4a Both are -H.

[0381] In certain embodiments, -X in formula (IIa) 2 - is -C(R 8 R 8a )-.

[0382] In certain embodiments, -R of formula (IIa) 8 and -R 8a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (IIa) 8 and -R 8a In certain embodiments, at least one of -R in formula (IIa) is -H. 8 and -R 8a Both are -H.

[0383] In certain embodiments, -R of formula (IIa) 2 and -R 2a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (IIa) 2 and -R 2a In certain embodiments, at least one of -R in formula (IIa) is -H. 2 and -R 2a Both are H.

[0384] In certain embodiments, -R of formula (IIa) 3 and -R 3a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -R of formula (IIa)3 and -R 3a In certain embodiments, at least one of -R in formula (IIa) is methyl. 3 and -R 3a In certain embodiments, -R in formula (IIa) 3 and -R 3a In certain embodiments, -R in formula (IIa) is methyl. 3 is -H, and -R in formula (IIa) 3a is methyl.

[0385] In certain embodiments, the moiety -L 1 - is a group represented by the formula (IIb): [ka] (In the formula, The dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond, and -R 2 , -R 2a , -R 3 , -R 3a and -X 2 - is used as defined in formula (II) and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIb) is -L 2 -Z or is not substituted by a substituent.

[0386] In certain embodiments, -L of formula (IIb) 1 - is one part - L 2 In certain embodiments, the moiety -L of formula (IIb) is substituted with -Z. 1 - is not further substituted.

[0387] In certain embodiments, -X in formula (IIb) 2 - is -C(R 8 R 8a )-.

[0388] In certain embodiments, -R of formula (IIb) 8 and -R 8a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (IIb) 8 and -R 8a In certain embodiments, at least one of -R in formula (IIb) is -H. 8 and -R 8a Both are -H.

[0389] In certain embodiments, -R of formula (IIb) 2 and -R 2a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R of formula (IIb) 2 and -R 2a In certain embodiments, at least one of -R in formula (IIb) is -H. 2 and -R 2a Both are H.

[0390] In certain embodiments, -R of formula (IIb) 3 and -R 3a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -R of formula (IIb) 3 and -R 3a In certain embodiments, at least one of -R in formula (IIb) is methyl. 3 and -R 3a In certain embodiments, -R in formula (IIb) 3 and -R 3a In certain embodiments, -R in formula (IIb) 3 is -H, and -R in formula (IIb) 3a is methyl.

[0391] In certain embodiments, the moiety -L 1 - is a group represented by the formula (IIb'): [ka] (In the formula, The dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond, and the dashed line with an asterisk indicates the attachment of -L 2 - indicates a bond to -R 2 , -R 2a , -R 3 , -R 3a , and -X 2 - is used as defined in formula (II), where -L 1 - is optionally further substituted, with the proviso that the hydrogen with an asterisk in formula (IIb') is not substituted by a substituent.

[0392] In certain embodiments, the moiety -L of formula (IIb') 1 - is not further substituted.

[0393] In certain embodiments, -X in formula (IIb') 2 - is -C(R 8 R 8a )-.

[0394] In certain embodiments, -R 8 and -R 8a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R 8 and -R 8a In certain embodiments, at least one of -R in formula (IIb') is -H. 8 and -R 8a Both are -H.

[0395] In certain embodiments, -R 2 and -R 2a is independently selected from the group consisting of -H, methyl, and ethyl. In certain embodiments, -R 2 and -R 2aIn certain embodiments, at least one of -R in formula (IIb') is -H. 2 and -R 2a Both are H.

[0396] In certain embodiments, -R 3 and -R 3a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -R 3 and -R 3a In certain embodiments, at least one of -R in formula (IIb') is methyl. 3 and -R 3a In certain embodiments, -R in formula (IIb') 3 and -R 3a In certain embodiments, -R in formula (IIb') 3 is —H, and —R in formula (IIb′) 3a is methyl.

[0397] In certain embodiments, the moiety -L 1 - is a group represented by the formula (IIc): [ka] where the dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond. and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formula (IIc) is -L 2 -Z or is not substituted by a substituent.

[0398] In certain embodiments, -L of formula (IIc) 1 - is one part - L 2 In certain embodiments, the moiety -L of formula (IIc) is substituted with -Z. 1 - is not further substituted.

[0399] In certain embodiments, the moiety -L 1 represents the formulae (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv) and (IIc-v): [ka] TIFF2025539088000023.tif56159 (in the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; A dashed line with an asterisk indicates -L 2 -Z) is selected from the group consisting of -L 1 - is optionally further substituted, provided that the hydrogen marked with an asterisk in formulas (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv) and (IIc-v) is not replaced by a substituent.

[0400] In certain embodiments, the moiety -L of formula (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv) and (IIc-v) 1 - is not further substituted.

[0401] In certain embodiments, the moiety -L 1 - is a group represented by the formula (IIc-ii): [ka] (In the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; A dashed line with an asterisk indicates -L 2 -Z) It has.

[0402] In certain embodiments, -L in formula (IIc-ii) 1 - is one part - L 2Replaced with -Z.

[0403] -L of formula (II), (IIa), (IIb), (IIb'), (IIc), (IIc-a), (IIc-b), (IIc-i), (IIc-ii), (IIc-iii), (IIc-iv), (IIc-v) 1 The optional further substituents of - are, in certain embodiments, as described above.

[0404] Another part - L 1 - is disclosed in WO2016 / 020373A1. Thus, in certain embodiments, the moiety -L 1 - is a group represented by the formula (III): [ka] (In the formula, The dashed lines indicate attachment by forming an amide or ester bond to a primary or secondary amine or hydroxyl of the CNP moiety, -D, respectively; -R 1 , -R 1a , -R 2 , -R 2a , -R 3 and -R 3a are, independently of each other, -H, -C(R 8 R 8a R 8b ), -C(=O)R 8 , -C≡N, -C(=NR 8 )R 8a , -CR 8 (=CR 8a R 8b ), -C≡CR 8 and -T, -R 4 , -R 5 and -R 5a are, independently of each other, -H, -C(R 9 R 9a R 9b ) and -T; a1 and a2 are independently 0 or 1; Each-R 6 , -R6a , -R 7 , -R 7a , -R 8 , -R 8a , -R 8b , -R 9 , -R 9a , -R 9b are, independently of each other, -H, halogen, -CN, -COOR 10 , -OR 10 , -C(O)R 10 , -C(O)N(R 10 R 10a ), -S(O)2N(R 10 R 10a ), -S(O)N(R 10 R 10a ), -S(O)R 10 , -S(O)R 10 , -N(R 10 )S(O)2N(R 10a R 10b ), -SR 10 , -N(R 10 R 10a ), -NO2, -OC(O)R 10 , -N(R 10 )C(O)R 10a , -N(R 10 )S(O)2R 10a , -N(R 10 )S(O)R 10a , -N(R 10 )C(O)OR 10a , -N(R 10 )C(O)N(R 10a R 10b ), -OC(O)N(R 10 R 10a ), -T, C 1-20 Alkyl, C 2-20 Alkenyl, and C 2-20 alkynyl, wherein -T, C 1-20 Alkyl, C 2-20 Alkenyl and C 2-20 Alkynyl may be one or more -R 11 optionally substituted with C 1-20 Alkyl, C 2-20 Alkenyl and C 2-20Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 12 )-, -S(O)2N(R 12 )-, -S(O)N(R 12 )-, -S(O)2-, -S(O)-, -N(R 12 )S(O)2N(R 12a )-, -S-, -N(R 12 )-, -OC(OR 12 )(R 12a )-, -N(R 12 )C(O)N(R 12a )- and -OC(O)N(R 12 )-, optionally interrupted by one or more groups selected from the group consisting of Each-R 10 , -R 10a , -R 10b are independently -H, -T, C 1-20 Alkyl, C 2-20 Alkenyl and C 2-20 alkynyl, wherein -T, C 1-20 Alkyl, C 2-20 Alkenyl and C 2-20 Alkynyl may be one or more -R 11 optionally substituted with C 1-20 Alkyl, C 2-20 Alkenyl and C 2-20 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 12 )-, -S(O)2N(R 12 )-, -S(O)N(R 12 )-, -S(O)2-, -S(O)-, -N(R 12 )S(O)2N(R 12a )-, -S-, -N(R 12 )-, -OC(OR 12 )(R 12a )-, -N(R 12 )C(O)N(R 12a )- and -OC(O)N(R 12 )-, optionally interrupted by one or more groups selected from the group consisting of Each T is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, and 8- to 11-membered heterobicyclyl, wherein each T is independently selected from the group consisting of one or more of the same or different -R 11 and optionally substituted with Each-R 11 are each independently a halogen, -CN, oxo (=O), -COOR 13 , -OR 13 , -C(O)R 13 , -C(O)N(R 13 R 13a ), -S(O)2N(R 13 R 13a ), -S(O)N(R 13 R 13a ), -S(O)R 13 , -S(O)R 13 , -N(R 13 )S(O)2N(R 13a R 13b ), -SR 13 , -N(R 13 R 13a ), -NO2, -OC(O)R 13 , -N(R 13 )C(O)R 13a , -N(R 13 )S(O)2R 13a , -N(R 13 )S(O)R 13a , -N(R 13 )C(O)OR 13a , -N(R 13 )C(O)N(R 13a R 13b ), -OC(O)N(R 13 R 13a ), and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R 12 , -R 12a , -R 13 , -R 13a , -R 13b are independently -H and C 1-6alkyl, wherein C 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; In some cases, Pair-R 1 / -R 1a , -R 2 / -R 2a , -R 3 / -R 3a , -R 6 / -R 6a , -R 7 / -R 7a One or more of the following, together with the atoms to which they are attached, form a C 3-10 forming a cycloalkyl or a 3- to 10-membered heterocyclyl; In some cases, Pair-R 1 / -R 2 , -R 1 / -R 3 , -R 1 / -R 4 , -R 1 / -R 5 , -R 1 / -R 6 , -R 1 / -R 7 , -R 2 / -R 3 , -R 2 / -R 4 , -R 2 / -R 5 , -R 2 / -R 6 , -R 2 / -R 7 , -R 3 / -R 4 , -R 3 / -R 5 , -R 3 / -R 6 , -R 3 / -R 7 , -R 4 / -R 5 , -R 4 / -R 6 , -R 4 / -R 7 , -R 5 / -R 6 , -R 5 / -R 7 , -R 6 / -R7 together with the atoms to which they are attached form ring A, A is phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, and 8- to 11-membered heterobicyclyl and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted; -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0405] -L in formula (III) 1 The optional further substituents of - are as described above in certain embodiments. 1 - is one part - L 2 In certain embodiments, -L of formula (III) is substituted with -Z. 1 - is not further substituted.

[0406] -L 1 Further embodiments of - are disclosed in EP 1536334 B1, WO 2009 / 009712 A1, WO 2008 / 034122 A1, WO 2009 / 143412 A2, WO 2011 / 082368 A2, and U.S. Pat. No. 8,618,124 B2, which are incorporated herein by reference in their entirety.

[0407] -L 1 Further embodiments of - are disclosed in U.S. Pat. No. 8,946,405 B2 and U.S. Pat. No. 8,754,190 B2, which are incorporated herein by reference in their entirety. Thus, the moiety -L 1 - is a group represented by the formula (IV): [ka] (In the formula, The dashed line indicates the bond to the CNP moiety, -D, where the bond is through a functional group of -D selected from the group consisting of -OH, -SH, and -NH; m is 0 or 1; -R 1 and -R 2 At least one or both of the following are, independently of each other, -CN, -NO2, optionally substituted aryl, optionally substituted heteroaryl, optionally substituted alkenyl, optionally substituted alkynyl, -C(O)R 3 , -S(O)R 3 , -S(O)2R 3 , and -SR 4 is selected from the group consisting of -R 1 and -R 2 is selected from the group consisting of: -H, optionally substituted alkyl, optionally substituted arylalkyl, and optionally substituted heteroarylalkyl; -R 3 is -H, optionally substituted alkyl, optionally substituted aryl, optionally substituted arylalkyl, optionally substituted heteroaryl, optionally substituted heteroarylalkyl, -OR 9 and -N(R 9 )2, -R 4 is selected from the group consisting of optionally substituted alkyl, optionally substituted aryl, optionally substituted arylalkyl, optionally substituted heteroaryl, and optionally substituted heteroarylalkyl; Each-R 5is independently selected from the group consisting of: -H, optionally substituted alkyl, optionally substituted alkenylalkyl, optionally substituted alkynylalkyl, optionally substituted aryl, optionally substituted arylalkyl, optionally substituted heteroaryl, and optionally substituted heteroarylalkyl; -R 9 is selected from the group consisting of —H and optionally substituted alkyl; -Y- is absent and -X- is -O- or -S-; or -Y- is -N(Q)CH2- and -X- is -O-; Q is selected from the group consisting of optionally substituted alkyl, optionally substituted aryl, optionally substituted arylalkyl, optionally substituted heteroaryl, and optionally substituted heteroarylalkyl; In some cases, -R 1 and -R 2 may be taken together to form a 3- to 8-membered ring, In some cases, both -R 9 together with the nitrogen to which they are attached form a heterocyclic ring) and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0408] -L in formula (IV) 1 In certain embodiments, the optional further substituents of - are as described above. 1 - is one part - L 2 In certain embodiments, -L of formula (IV) is substituted with -Z. 1 - is not further substituted.

[0409] The terms used exclusively in connection with formula (IV) have the following meanings:

[0410] As used herein, the term "alkyl" includes straight-chain, branched, or cyclic saturated hydrocarbon groups of 1 to 8 carbons, or in certain embodiments, 1 to 6 or 1 to 4 carbon atoms.

[0411] The term "alkoxy" includes an alkyl group attached to an oxygen, such as methoxy, ethoxy, isopropoxy, cyclopropoxy, cyclobutoxy, and the like.

[0412] The term "alkenyl" includes non-aromatic unsaturated hydrocarbons containing a carbon-carbon double bond.

[0413] The term "alkynyl" includes non-aromatic unsaturated hydrocarbons containing a carbon-carbon triple bond.

[0414] The term "aryl" includes aromatic hydrocarbon groups of 6 to 18 carbons, and in certain embodiments 6 to 10 carbons, such as groups such as phenyl, naphthyl, and anthracenyl. The term "heteroaryl" includes aromatic rings containing 3 to 15 carbons, and in certain embodiments 3 to 7 carbons, containing at least one N, O, or S atom, such as groups such as pyrrolyl, pyridyl, pyrimidinyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, quinolyl, indolyl, indenyl, and the like.

[0415] In certain embodiments, an alkenyl, alkynyl, aryl, or heteroaryl moiety may be attached to the remainder of the molecule via an alkylene bond. In such circumstances, the substituent is referred to as alkenylalkyl, alkynylalkyl, arylalkyl, or heteroarylalkyl, indicating that an alkylene moiety is located between the alkenyl, alkynyl, aryl, or heteroaryl moiety and the molecule to which the alkenyl, alkynyl, aryl, or heteroaryl is attached.

[0416] The term "halogen" includes bromo, fluoro, chloro and iodo.

[0417] The term "heterocyclic ring" refers to a 4-8 membered aromatic or non-aromatic ring containing 3 to 7 carbon atoms and at least one N, O, or S atom. Examples are piperidinyl, piperazinyl, tetrahydropyranyl, pyrrolidine, and tetrahydrofuranyl, as well as the exemplary groups provided above for the term "heteroaryl."

[0418] When a ring system is optionally substituted, suitable substituents are selected from the group consisting of alkyl, alkenyl, alkynyl, or additional rings, each of which is optionally further substituted. Optional substituents on any group, including those described above, include halo, nitro, cyano, -OR, -SR, -NR, -OCOR, -NRCOR, -COOR, -CONR, -SOR, -SOR, -SONR, -SONR, -SONR, where each R is independently alkyl, alkenyl, alkynyl, aryl, or heteroaryl, or two R groups, together with the atoms to which they are attached, form a ring.

[0419] -L 1 Further embodiments of - are disclosed in WO2013 / 036857A1, which is incorporated herein by reference in its entirety. Thus, in certain embodiments, the moiety -L 1 - is a compound of formula (V): [ka] (In the formula, The dashed line indicates the bond to the CNP moiety, -D, where the bond is through the amine functional group of -D; -R 1 is an optionally substituted C1-C6 straight, branched, or cyclic alkyl, an optionally substituted aryl, an optionally substituted heteroaryl, an alkoxy, and -NR 5 2, -R 2 is selected from the group consisting of -H, optionally substituted C1-C6 alkyl, optionally substituted aryl, and optionally substituted heteroaryl; -R 3 is selected from the group consisting of -H, optionally substituted C1-C6 alkyl, optionally substituted aryl, and optionally substituted heteroaryl; -R 4 is selected from the group consisting of -H, optionally substituted C1-C6 alkyl, optionally substituted aryl, and optionally substituted heteroaryl; Each-R 5 are each independently selected from the group consisting of: -H, optionally substituted C1-C6 alkyl, optionally substituted aryl, and optionally substituted heteroaryl, or when taken together, two -R 5 can be cycloalkyl or cycloheteroalkyl) and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0420] -L in formula (V) 1 The optional further substituents of - are, in certain embodiments, as described above.

[0421] In certain embodiments, -L in formula (V) 1 - is one part - L 2 Replaced with -Z.

[0422] In certain embodiments, -L in formula (V) 1 - is not further substituted.

[0423] The terms used exclusively in connection with formula (V) have the following meanings:

[0424] "Alkyl," "alkenyl," and "alkynyl" include straight-chain, branched, or cyclic hydrocarbon groups of 1 to 8 carbons, or 1 to 6 carbons, or 1 to 4 carbons, where alkyl is a saturated hydrocarbon, alkenyl contains one or more carbon-carbon double bonds, and alkynyl contains one or more carbon-carbon triple bonds. Unless otherwise specified, they contain 1 to 6 C.

[0425] "Aryl" includes aromatic hydrocarbon groups of 6 to 18 carbons, and in certain embodiments 6 to 10 carbons, such as, for example, phenyl, naphthyl, and anthracene. "Heteroaryl" includes aromatic rings of 3 to 15 carbons, and in certain embodiments 3 to 7 carbons, containing at least one N, O, or S atom, such as, for example, pyrrolyl, pyridyl, pyrimidinyl, imidazolyl, oxazolyl, isoxazolyl, thiazolyl, isothiazolyl, quinolyl, indolyl, indenyl, and the like.

[0426] The term "substituted" refers to an alkyl, alkenyl, alkynyl, aryl, or heteroaryl group containing one or more substituents in place of one or more hydrogen atoms. Substituents generally include halogen (e.g., F, Cl, Br, and I), lower alkyl (e.g., straight-chain, branched-chain, and cyclic), lower haloalkyl (e.g., fluoroalkyl, chloroalkyl, bromoalkyl, and iodoalkyl), OH, lower alkoxy (e.g., straight-chain, branched-chain, and cyclic), SH, lower alkylthio (e.g., straight-chain, branched-chain, and cyclic), amino, alkylamino, dialkylamino, silyl (e.g., alkylsilyl, alkoxysilyl, and arylsilyl), nitro, cyano, carbonyl, carboxylic acid, carboxylic acid ester, carboxylic acid amide, aminocarbonyl, aminoacyl, carbamate, urea, thiocarbamate, and the like. The heteroaryl may be selected from aryls such as phenyl, naphthyl, anthracenyl, thioureas, ketones, sulfones, sulfonamides, aryls (such as phenyl, naphthyl, and anthracenyl), heteroaryls (such as 5-membered heteroaryls such as pyrrole, imidazole, furan, thiophene, oxazole, thiazole, isoxazole, isothiazole, thiadiazole, triazole, oxadiazole, and tetrazole, 6-membered heteroaryls such as pyridine, pyrimidine, pyrazine, and fused heteroaryls such as benzofuran, benzothiophene, benzoxazole, benzimidazole, indole, benzothiazole, benzisoxazole, and benzisothiazole).

[0427] -L 1 Another embodiment of - is disclosed in WO 2022 / 115563 A1, which is incorporated herein by reference in its entirety. Thus, in certain embodiments, -L 1 - is the formula (Va): [ka] (In the formula, A dashed line with an asterisk indicates -L 2 The unmarked dashed line indicates the bond to -Z, and the unmarked dashed line indicates the bond to -D. It has.

[0428] In certain embodiments, -L 1 - has formula (Va), and the dashed line with an asterisk represents -L 2 The unmarked dashed line indicates the bond to -Z, and the unmarked dashed line indicates the bond to -D, where -D is the amino acid sequence: SEQ ID NO: 97 (CNP-38 N6Q, N14Q): LQEHPQARKYKGAQKKGLSKGCFGLKLDRIGSMSGLGC is the CNP part of where the cysteines at positions 22 and 38 are linked via a disulfide bridge; -L 1 The bond to - can be made either at the N-terminus or in the ring of the peptide.

[0429] -L 1 Another embodiment of - is disclosed in U.S. Patent No. 7,585,837 B2, which is incorporated herein by reference in its entirety. Thus, in certain embodiments, the moiety -L 1 - is a group represented by the formula (VI): [ka] (In the formula, The dashed line indicates the bond to the CNP moiety, -D, where the bond is through the amine functional group of -D; R 1 and R 2 are independently hydrogen, alkyl, alkoxy, alkoxyalkyl, aryl, alkaryl, aralkyl, halogen, nitro, -SO3H, -SO2NHR 5 , amino, ammonium, carboxyl, PO3H2, and OPO3H2; R 3 , R 4 and R 5 are independently selected from the group consisting of hydrogen, alkyl, and aryl; where -L 1 -L 2-Z is substituted, and -L 1 - is optionally further substituted, -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0430] Suitable substituents for formula (VI) are alkyl (e.g., C 1-6 alkyl), alkenyl (e.g., C 2-6 alkenyl), alkynyl (e.g., C 2-6 alkynyl), aryl (e.g., phenyl), heteroalkyl, heteroalkenyl, heteroalkynyl, heteroaryl (e.g., aromatic 4- to 7-membered heterocycle), or halogen moiety.

[0431] In certain embodiments, -L of formula (VI) 1 - is one part - L 2 -L in formula (VI) is substituted with -Z. 1 The optional further substituents of - are, in certain embodiments, as described above.

[0432] In certain embodiments, -L of formula (VI) 1 - is not further substituted.

[0433] The terms used exclusively in connection with formula (VI) have the following meanings:

[0434] The terms "alkyl," "alkoxy," "alkoxyalkyl," "aryl," "alkaryl," and "aralkyl" refer to alkyl groups of 1 to 8, and in certain embodiments 1 to 4, carbon atoms, e.g., methyl, ethyl, propyl, isopropyl, and butyl, and aryl groups of 6 to 10 carbon atoms, e.g., phenyl and naphthyl. The term "halogen" includes bromo, fluoro, chloro, and iodo.

[0435] -L 1Further embodiments of - are disclosed in WO2002 / 089789A1, which is incorporated herein by reference in its entirety. Thus, the moiety -L 1 is a group represented by the formula (VII): [ka] (In the formula, The dashed line indicates the bond to the CNP moiety, -D, where the bond is through the amine functional group of -D; L1 is a bifunctional linking group, Y1 and Y2 are independently O, S, or NR 7 and R 2 , R 3 , R 4 , R 5 , R 6 and R 7 are independently hydrogen, C 1-6 Alkyl, C 3-12 Branched alkyl, C 3-8 Cycloalkyl, C 1-6 Substituted alkyl, C 3-8 Substituted cycloalkyl, aryl, substituted aryl, aralkyl, C 1-6 Heteroalkyl, substituted C 1-6 Heteroalkyl, C 1-6 Alkoxy, phenoxy and C 1-6 heteroalkoxy; Ar is a moiety that, when included in formula (VII), forms a polysubstituted aromatic hydrocarbon or polysubstituted heterocyclic group; X is a chemical bond, a moiety that is actively transported into a target cell, a hydrophobic moiety, or a combination thereof; y is 0 or 1) and where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0436] In certain embodiments, -L of formula (VII) 1 - is one part - L 2 -L in formula (VII) is substituted with -Z. 1 The optional further substituents of - are, in certain embodiments, as described above.

[0437] In certain embodiments, -L of formula (VII) 1 - is not further substituted.

[0438] The terms used exclusively in connection with formula (VII) have the following meanings: The term "alkyl" includes, for example, straight-chain, branched-chain, substituted C 1-12 Alkyl, e.g., alkoxy, C 3-8 It is understood to include cycloalkyl or substituted cycloalkyl, and the like.

[0439] The term "substituted" shall be understood to include the addition or replacement of one or more atoms contained in a functional group or compound with one or more different atoms.

[0440] Substituted alkyls include carboxyalkyl, aminoalkyl, dialkylamino, hydroxyalkyl, and mercaptoalkyl, substituted cycloalkyls include moieties such as 4-chlorocyclohexyl, aryls include moieties such as naphthyl, substituted aryls include moieties such as 3-bromo-phenyl, aralkyls include moieties such as toluyl, heteroalkyls include moieties such as ethylthiophene, substituted heteroalkyls include moieties such as 3-methoxythiophone, alkoxys include moieties such as methoxy, and phenoxys include moieties such as 3-nitrophenoxy. Halo- shall be understood to include fluoro, chloro, iodo, and bromo.

[0441] In certain embodiments, -L 1 - is a substructure of formula (VIII) [ka] (In the formula, The dashed line with an asterisk indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; Unmarked dashed lines are -L 1 - indicates the bond to the rest of Including, where -L 1 -L 2 -Z is substituted, and -L 1 - is optionally further substituted, -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0442] In certain embodiments, -L of formula (VIII) 1 - is one part - L 2 -L in formula (VIII) is substituted with -Z. 1 The optional further substituents of - are as described above.

[0443] In certain embodiments, -L of formula (VIII) 1 - is not further substituted.

[0444] In certain embodiments, -L 1 - is a substructure of formula (IX) [ka] (In the formula, The dashed line with an asterisk indicates the attachment of the CNP moiety, -D, to the nitrogen by forming a carbamate bond; Unmarked dashed lines are -L 1 - indicates the bond to the rest of Including, where -L 1 -L 2-Z is substituted, and -L 1 - is optionally further substituted, -L 2 - is a single chemical bond or spacer, -Z is a water-soluble polymer moiety.

[0445] -L in formula (IX) 1 The optional further substituents of - are as described above. In certain embodiments, -L of formula (IX) 1 - is one part - L 2 In certain embodiments, -L of formula (IX) is substituted with -Z. 1 - is not further substituted.

[0446] The moiety -D can be linked to -L via any functional group of the DH. 1 - can be attached to -L through the amine functional group of D-H 1 -, which may be the N-terminal amine functionality or may be the amine functionality provided by lysine side chains, i.e., by lysines at positions 9, 11, 15, 16, 20, and 26 when CNP has the sequence of SEQ ID NO: 24.

[0447] -L to the ring of the CNP moiety 1 -binding significantly reduces the affinity of the CNP conjugate for NPR-B compared to binding at the N-terminus or to the non-cyclic portion of CNP, and this reduced affinity for NPR-B in turn reduces the risk of cardiovascular side effects such as hypotension.

[0448] Thus, in certain embodiments, -L 1 - is conjugated to the side chain of an amino acid residue of the cyclic moiety of -D or to the backbone of the cyclic moiety of -D. 1 - is covalently and reversibly conjugated to the side chain of an amino acid residue in the ring portion of -D. When -D is a CNP moiety having the sequence of SEQ ID NO: 24, -L 1- is, in certain embodiments, conjugated to the amine functionality provided by the lysine at position 26 of the corresponding drug DH.

[0449] Part-L 2 - is a chemical bond or a spacer moiety. In certain embodiments, -L 2 - is a chemical bond. In certain embodiments, -L 2 - is a spacer portion.

[0450] Part-L 2 - can be used to form -L by replacing any -H present, unless specifically excluded. 1 - can be bound to

[0451] -L 2 If - is other than a single chemical bond, -L 2 - stands for -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y1 )-, -S(O)2N(R y1 )-, -S(O)N(R y1 )-, -S(O)2-, -S(O)-, -N(R y1 )S(O)2N(R y1a )-, -S-, -N(R y1 )-, -OC(OR y1 )(R y1a )-, -N(R y1 )C(O)N(R y1a )-, -OC(O)N(R y1 )-, C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; wherein -T-, C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl may be one or more of the same or different -R y2 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y3 )-, -S(O)2N(Ry3 )-, -S(O)N(R y3 )-, -S(O)2-, -S(O)-, -N(R y3 )S(O)2N(R y3a )-, -S-, -N(R y3 )-, -OC(OR y3 )(R y3a )-, -N(R y3 )C(O)N(R y3a )- and -OC(O)N(R y3 )-, optionally interrupted by one or more groups selected from the group consisting of; -R y1 and -R y1a are, independently of each other, -H, -T, C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 alkynyl; wherein -T, C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl may be one or more -R y2 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y4 )-, -S(O)2N(R y4 )-, -S(O)N(R y4 )-, -S(O)2-, -S(O)-, -N(R y4 )S(O)2N(R y4a )-, -S-, -N(R y4 )-, -OC(OR y4 )(R y4a )-, -N(R y4 )C(O)N(R y4a )- and -OC(O)N(R y4 )-, optionally interrupted by one or more groups selected from the group consisting of; Each T is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; wherein each T is independently selected from the group consisting of one or more of the same or different -R y2 optionally substituted with; Each-R y2 are independently halogen, -CN, oxo(=O), -COOR y5 , -OR y5 , -C(O)R y5 , -C(O)N(R y5 R y5a ), -S(O)2N(R y5 R y5a ), -S(O)N(R y5 R y5a ), -S(O)R y5 , -S(O)R y5 , -N(R y5 )S(O)2N(R y5a R y5b ), -SR y5 , -N(R y5 R y5a ), -NO2, -OC(O)R y5 , -N(R y5 )C(O)R y5a , -N(R y5 )S(O)2R y5a , -N(R y5 )S(O)R y5a , -N(R y5 )C(O)OR y5a , -N(R y5 )C(O)N(R y5a R y5b ), -OC(O)N(R y5 R y5a ), and C 1-6 alkyl; 1-6 The alkyl is optionally substituted with one or more halogens which may be the same or different; each -R y3 , -R y3a , -R y4 , -R y4a , -R y5 , -R y5a and -R y5b are independently -H and C 1-6alkyl; C 1-6 The alkyl is optionally substituted with one or more halogens which may be the same or different.

[0452] -L 2 If - is other than a single chemical bond, -L 2 - stands for -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y1 )-, -S(O)2N(R y1 )-, -S(O)N(R y1 )-, -S(O)2-, -S(O)-, -N(R y1 )S(O)2N(R y1a )-, -S-, -N(R y1 )-, -OC(OR y1 )(R y1a )-, -N(R y1 )C(O)N(R y1a )-, -OC(O)N(R y1 )-, C 1-20 Alkyl, C 2-20 Alkenyl, and C 2-20 alkynyl; wherein -T-, C 1-20 Alkyl, C 2-20 Alkenyl, and C 2-20 Alkynyl may be one or more -R y2 optionally substituted with C 1-20 Alkyl, C 2-20 Alkenyl, and C 2-20 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y3 )-, -S(O)2N(R y3 )-, -S(O)N(R y3 )-, -S(O)2-, -S(O)-, -N(R y3 )S(O)2N(R y3a )-, -S-, -N(R y3 )-, -OC(OR y3 )(R y3a )-, -N(R y3 )C(O)N(R y3a )- and -OC(O)N(R y3 )-, optionally interrupted by one or more groups selected from the group consisting of; -R y1 and -R y1a are, independently of each other, -H, -T, C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10 alkynyl; wherein -T, C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10 Alkynyl may be one or more -R y2 optionally substituted with C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y4 )-, -S(O)2N(R y4 )-, -S(O)N(R y4 )-, -S(O)2-, -S(O)-, -N(R y4 )S(O)2N(R y4a )-, -S-, -N(R y4 )-, -OC(OR y4 )(R y4a )-, -N(R y4 )C(O)N(R y4a )- and -OC(O)N(R y4 )-, optionally interrupted by one or more groups selected from the group consisting of; Each T is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; wherein each T is independently selected from the group consisting of one or more of the same or different -R y2 optionally substituted with; -R y2 is halogen, -CN, oxo(=O), -COOR y5 , -OR y5 , -C(O)R y5 , -C(O)N(R y5 R y5a ), -S(O)2N(R y5 R y5a), -S(O)N(R y5 R y5a ), -S(O)R y5 , -S(O)R y5 , -N(R y5 )S(O)2N(R y5a R y5b ), -SR y5 , -N(R y5 R y5a ), -NO2, -OC(O)R y5 , -N(R y5 )C(O)R y5a , -N(R y5 )S(O)2R y5a , -N(R y5 )S(O)R y5a , -N(R y5 )C(O)OR y5a , -N(R y5 )C(O)N(R y5a R y5b ), -OC(O)N(R y5 R y5a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R y3 , -R y3a , -R y4 , -R y4a , -R y5 , -R y5a and -R y5b are, independently of each other, -H and C 1-6 alkyl; 1-6 The alkyl is optionally substituted with one or more halogens which may be the same or different.

[0453] -L 2 If - is other than a single chemical bond, -L 2 - stands for -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y1 )-, -S(O)2N(R y1 )-, -S(O)N(R y1 )-, -S(O)2-, -S(O)-, -N(R y1 )S(O)2N(R y1a)-, -S-, -N(R y1 )-, -OC(OR y1 )(R y1a )-, -N(R y1 )C(O)N(R y1a )-, -OC(O)N(R y1 )-, C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; wherein -T-, C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl may be one or more -R y2 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R y3 )-, -S(O)2N(R y3 )-, -S(O)N(R y3 )-, -S(O)2-, -S(O)-, -N(R y3 )S(O)2N(R y3a )-, -S-, -N(R y3 )-, -OC(OR y3 )(R y3a )-, -N(R y3 )C(O)N(R y3a )- and -OC(O)N(R y3 )-, optionally interrupted by one or more groups selected from the group consisting of; -R y1 and -R y1a are independently -H, -T, C 1-10 Alkyl, C 2-10 Alkenyl, and C 2-10 alkynyl; Each T is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 selected from the group consisting of cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; Each-R y2are independently halogen and C 1-6 selected from the group consisting of alkyl; Each-R y3 , -R y3a , -R y4 , -R y4a , -R y5 , -R y5a and -R y5b are, independently of each other, -H and C 1-6 alkyl; C 1-6 The alkyl is optionally substituted with one or more halogens which may be the same or different.

[0454] In certain embodiments, -L 2 - is C 1-20 Alkyl chains, including -O-, -T- and -C(O)N(R y1 )-, wherein C is optionally interrupted by one or more groups independently selected from 1-20 The alkyl chains are -OH, -T and -C(O)N(R y6 R y6a Optionally substituted with one or more groups independently selected from: y1 , -R y6 , -R y6a are independently H and C 1-4 alkyl, and T is selected from the group consisting of phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 It is selected from the group consisting of cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl.

[0455] In certain embodiments, -L 2 - has a molecular weight in the range of 14 g / mol to 750 g / mol.

[0456] In certain embodiments, -L 2 - has a chain length of 1 to 20 atoms.

[0457] As used herein, the moiety -L 2The term "chain length" in relation to -L 1 -L in the shortest bond between - and -Z 2 -Refers to the number of atoms.

[0458] In certain embodiments, -L 2 - is a compound of formula (i): [ka] (In the formula, A dashed line with an asterisk indicates -L 1 - indicates a bond to; The unmarked dashed line indicates the bond to -Z; -R 1 -H, C 1-6 Alkyl, C 2-6 Alkenyl and C 2-6 alkynyl; n is selected from the group consisting of 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18. and wherein the moiety of formula (i) is optionally further substituted.

[0459] In certain embodiments, -R of formula (i) 1 is selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -R in formula (i) 1 is selected from the group consisting of -H, methyl, ethyl, and propyl. In certain embodiments, -R in formula (i) 1 is selected from the group consisting of —H and methyl. In certain embodiments, —R 1 is methyl.

[0460] In certain embodiments, n in formula (i) is selected from the group consisting of 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10. In certain embodiments, n in formula (i) is selected from the group consisting of 0, 1, 2, 3, 4, and 5. In certain embodiments, n in formula (i) is selected from the group consisting of 0, 1, 2, and 3. In certain embodiments, n in formula (i) is selected from the group consisting of 0 and 1. In certain embodiments, n in formula (i) is 0.

[0461] In certain embodiments, -L 2 -teeth, [ka] TIFF2025539088000035.tif45159 (in the formula, A dashed line with an asterisk indicates -L 1 - indicates a bond to; The unmarked dashed line indicates the bond to -Z.) is a moiety selected from the group consisting of wherein moieties (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), (xiii), (xiv), (xv), (xvi) and (xvii) are optionally further substituted.

[0462] In certain embodiments, -L 2 -teeth, [ka] (In the formula, A dashed line with an asterisk indicates -L 1 - indicates a bond to; The unmarked dashed line indicates the bond to -Z.) is selected from the group consisting of:

[0463] In certain embodiments, -L 2 -teeth, [ka] (In the formula, A dashed line with an asterisk indicates -L 1 - indicates a bond to; The unmarked dashed line indicates the bond to -Z.) is selected from the group consisting of:

[0464] In certain embodiments, -L 2 - is a group represented by the formula (xvi): [ka] (In the formula, A dashed line with an asterisk indicates -L 1 - indicates a bond to; The unmarked dashed line indicates the bond to -Z.) It has.

[0465] In certain embodiments, the moiety -L 1 -L 2 -teeth, [ka] (In the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; The dashed line with an asterisk indicates the bond to -Z) is selected from the group consisting of:

[0466] In certain embodiments, the moiety -L 1 -L 2 - is a group represented by the formula (IId-ii): [ka] (In the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; The dashed line with an asterisk indicates the bond to -Z) It has.

[0467] In certain embodiments, the moiety -L 1 -L 2 - is a group represented by the formula (IId-ii'): [ka] (In the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; The dashed line with an asterisk indicates the bond to -Z) It has.

[0468] In certain embodiments, the moiety -L 1 -L 2 -teeth, [ka] (In the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; The dashed line with an asterisk indicates the bond to -Z) is selected from the group consisting of:

[0469] In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of 5 to 200 kDa. In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of 8 to 100 kDa. In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of 10 to 80 kDa. In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of 12 to 60 kDa. In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of 15 to 40 kDa. In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of about 20 kDa. In certain embodiments, -Z of Formula (Ia) or (Ib) has a molecular weight of about 40 kDa.

[0470] The polymer moiety -Z of Formula (Ia) or (Ib) comprises a polymer. In certain embodiments, -Z of Formula (Ia) or (Ib) comprises 2-methacryloyl-oxyethyl phosphorylcholines, poly(acrylic acids), poly(acrylates), poly(acrylamides), poly(alkyloxy)polymers, poly(amides), poly(amidoamines), poly(amino acids), poly(anhydrides), poly(aspartamides), poly(butyric acids), poly(glycolic acids), polybutylene terephthalates, poly(caprolactones), poly(carbonates), poly(siloxanes), poly(methylcellulose ... Poly(acrylates), poly(dimethylacrylamides), poly(esters), poly(ethylenes), poly(ethylene glycols), poly(ethylene oxides), poly(ethyl phosphates), poly(ethyl oxazolines), poly(glycolic acids), poly(hydroxyethyl acrylates), poly(hydroxyethyl-oxazolines), poly(hydroxymethacrylates), poly(hydroxypropyl methacrylamides), poly(hydroxypropyl methacrylates), poly Poly(hydroxypropyloxazolines), poly(iminocarbonates), poly(lactic acids), poly(lactic-co-glycolic acids), poly(methacrylamides), poly(methacrylates), poly(methyloxazolines), poly(organophosphazenes), poly(orthoesters), poly(oxazolines), poly(propylene glycols), poly(siloxanes), poly(urethanes), poly(vinyl alcohols), poly(vinylamines), poly(vinyl methyl ethers), poly(vinyl The polymers include polymers selected from the group consisting of hydroxypropyl methylcelluloses, ...

[0471] In certain embodiments, -Z in Formula (Ia) or (Ib) comprises a protein. Preferred proteins are selected from the group consisting of the carboxyl terminal peptide of chorionic gonadotropin described in US2012 / 0035101A1 (herein incorporated by reference); albumin; the XTEN sequence described in WO2011123813A2 (herein incorporated by reference); the proline / alanine random coil sequence described in WO2011 / 144756A1 (herein incorporated by reference); the proline / alanine / serine random coil sequence described in WO2008 / 155134A1 and WO2013 / 024049A1 (herein incorporated by reference); and Fc fusion proteins.

[0472] In certain embodiments, -Z of formula (Ia) or (Ib) is polysarcosine. In certain embodiments, -Z of formula (Ia) or (Ib) comprises poly(N-methylglycine). In certain embodiments, -Z of formula (Ia) or (Ib) comprises a random coil protein moiety. In certain embodiments, -Z of formula (Ia) or (Ib) comprises one random coil protein moiety. In certain embodiments, -Z of formula (Ia) or (Ib) comprises two random coil protein moieties. In certain embodiments, -Z of formula (Ia) or (Ib) comprises three random coil protein moieties. In certain embodiments, -Z of formula (Ia) or (Ib) comprises four random coil protein moieties. In certain embodiments, -Z of formula (Ia) or (Ib) comprises five random coil protein moieties. In certain embodiments, -Z of formula (Ia) or (Ib) comprises six random coil protein moieties. In certain embodiments, -Z of formula (Ia) or (Ib) comprises 7 random coil protein moieties. In certain embodiments, -Z of formula (Ia) or (Ib) comprises 8 random coil protein moieties.

[0473] In certain embodiments, such random coil protein portions comprise at least 25 amino acid residues and at most 2000 amino acids. In certain embodiments, such random coil protein portions comprise at least 30 amino acid residues and at most 1500 amino acid residues. In certain embodiments, such random coil protein portions comprise at least 50 amino acid residues and at most 500 amino acid residues.

[0474] In certain embodiments, -Z of Formula (Ia) or (Ib) comprises a fatty acid derivative. In certain embodiments, -Z of Formula (Ia) or (Ib) is a fatty acid derivative. In certain embodiments, -Z of Formula (Ia) is a fatty acid derivative and x is 1.

[0475] In certain embodiments, -Z of formula (Ia) or (Ib) is a fatty acid derivative as disclosed in WO 2006 / 097537 A2, which is incorporated herein by reference.

[0476] In certain embodiments, -Z of formula (Ia) or (Ib) comprises a fatty acid derivative disclosed in WO 2021 / 055497 A1, which is incorporated herein by reference. Thus, in certain embodiments, -Z of formula (Ia) or (Ib) has the following structure (w): [ka] (In the formula, the dashed line represents -L in formula (Ia) or (Ib). 2 -or-L 1 - indicates a bond to It has.

[0477] In certain embodiments, -Z has the formula (w) and -L 1 - has the formula (V).

[0478] In certain embodiments, -ZL 2 -L 1 - is the formula (wa): [ka] wherein the dashed line indicates the bond to -D in formula (Ia) or (Ib). It has.

[0479] In certain embodiments, the CNP is: PGQEHPQARRYRGAQRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO: 98); PGQEHPNARKYKGANKKGLSKGCFGLKLDRIGSMSGLGC (SEQ ID NO: 30); PGQEHPNARRYRGANRRGLSRGCFGLKLDRIGSMSGLGC (SEQ ID NO: 99); and PGQEHPQARKYKGAQKKGLSKGCFGLKLDRIGSMSGLGC (SEQ ID NO: 100) The nucleic acid sequence has a sequence selected from the group consisting of:

[0480] In certain embodiments, the CNP has a sequence selected from the group consisting of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100, -Z has the formula (w), and -L 1 - is a reversible linker moiety. In certain embodiments, CNP has a sequence selected from the group consisting of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100, -Z has the formula (w), and -L 1 - has formula (V). In certain embodiments, the CNP has a sequence selected from the group consisting of SEQ ID NO: 98, SEQ ID NO: 30, SEQ ID NO: 99, and SEQ ID NO: 100, and -ZL 2 -L 1 - has (wa). 1 - may be attached to the CNP via a lysine other than the lysine in the ring structure, or -L 1 - may be attached to the N-terminus.

[0481] In certain embodiments, the CNPs of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100 further comprise an acetyl group, e.g., an acetyl group at the N-terminus of the peptide. In certain embodiments, the CNPs of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100 further comprise an -OH or -NH2 group at the C-terminus. In certain embodiments, the CNPs of SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99, and SEQ ID NO:100 and -L 1 The - is attached to the remainder of the CNP ring moiety or to a site other than the CNP moiety.

[0482] In certain embodiments, -L 1 - is attached at lysine residues, such as the bolded lysine residues in SEQ ID NO:98, SEQ ID NO:30, SEQ ID NO:99 and SEQ ID NO:100.

[0483] [Table 1]

[0484] In certain embodiments, the CNP is:

[0485] [Table 2] is selected from the group consisting of:

[0486] In certain embodiments, -Z of formula (Ia) or (Ib) is a hyaluronic acid-based polymer.

[0487] In certain embodiments, -Z of formula (Ia) or (Ib) is a polymer moiety disclosed in WO 2013 / 024047 A1, which is incorporated herein by reference.

[0488] In certain embodiments, -Z of formula (Ia) or (Ib) is a polymer moiety disclosed in WO 2013 / 024048 A1, which is incorporated herein by reference.

[0489] In certain embodiments, -Z of formula (Ia) or (Ib) is a PEG-based polymer. In certain embodiments, -Z is a branched or multi-arm PEG-based polymer.

[0490] In certain embodiments, -Z in Formula (Ia) or (Ib) is a branched polymer. In certain embodiments, -Z in Formula (Ia) or (Ib) is a branched polymer having 1, 2, 3, 4, 5, or 6 branch points. In certain embodiments, -Z in Formula (Ia) or (Ib) is a branched polymer having 1, 2, or 3 branch points. In certain embodiments, -Z in Formula (Ia) or (Ib) is a branched polymer having 1 branch point. In certain embodiments, -Z in Formula (Ia) or (Ib) is a branched polymer having 2 branch points. In certain embodiments, -Z in Formula (Ia) or (Ib) is a branched polymer having 3 branch points.

[0491] In certain embodiments, the branch points are selected from the group consisting of -N<, -CH< and >C<.

[0492] In certain embodiments, such branched moieties -Z of formula (Ia) or (Ib) are PEG-based.

[0493] In certain embodiments, such branching moieties-Z of Formula (Ia) or (Ib) have a molecular weight of 5 kDa to 500 kDa. In certain embodiments, such branching moieties-Z of Formula (Ia) or (Ib) have a molecular weight of 10 kDa to 250 kDa. In certain embodiments, such branching moieties-Z of Formula (Ia) or (Ib) have a molecular weight of 10 kDa to 150 kDa. In certain embodiments, such branching moieties-Z of Formula (Ia) or (Ib) have a molecular weight of 12 kDa to 100 kDa. In certain embodiments, such branching moieties-Z of Formula (Ia) or (Ib) have a molecular weight of 15 kDa to 80 kDa. In certain embodiments, such branching moieties-Z of Formula (Ia) or (Ib) have a molecular weight of 10 kDa to 80 kDa. In certain embodiments, the molecular weight is about 10 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 20 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 30 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 40 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 50 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 60 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 70 kDa. In certain embodiments, the molecular weight of such branching moiety-Z of Formula (Ia) or (Ib) is about 80 kDa. In certain embodiments, such branched moiety -Z of formula (Ia) or (Ib) has a molecular weight of about 40 kDa.

[0494] In certain embodiments, -Z is the following moiety: [ka] Includes.

[0495] In certain embodiments, -Z comprises an amide bond.

[0496] In certain embodiments, -Z of formula (Ia) or (Ib) is a moiety of formula (a): [ka] (In the formula, The dashed line is -L 2 - or - represents the bond of Z to the remainder; BP a is a branch point selected from the group consisting of -N<, -CR< and >C<; -R is -H and C 1-6 selected from the group consisting of alkyl; a is BP a is 0 when -N< or -CR<, and a is BP a is 1 if >C<; -S a -, -S a' -, -S a'' -and-S a''' - are, independently of each other, a chemical bond or C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 alkynyl; C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl may be one or more -R 1 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 )-, -S(O)2N(R 2 )-, -S(O)N(R 2 )-, -S(O)2-, -S(O)-, -N(R 2 )S(O)2N(R 2a )-, -S-, -N(R 2 )-, -OC(OR 2 )(R 2a )-, -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2)-, optionally interrupted by one or more groups selected from the group consisting of; Each -T- is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; wherein each -T- is independently selected from the group consisting of one or more -R 1 optionally substituted with; Each-R 1 are independently halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R 2 , -R2a , -R 3 , -R 3a and -R 3b are independently -H and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -P a' , -P a" and -P a''' are independently polymer moieties) Includes.

[0497] Optionally, the moiety of formula (a) is substituted with one or more substituents.

[0498] In certain embodiments, BP of formula (a) a In certain embodiments, BP of formula (a) is -N<. a is -CR<. In certain embodiments, -R is -H.

[0499] Thus, in certain embodiments, a in formula (a) is 0.

[0500] In certain embodiments, BP of formula (a) a is >C<.

[0501] In certain embodiments, -S of formula (a) a - is a chemical bond.

[0502] In certain embodiments, -S of formula (a) a -C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 alkynyl, C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 Alkynyl includes -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 )-, -S(O)2N(R 4 )-, -S(O)N(R 4)-, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a )-, -S-, -N(R 4 )-, -OC(OR 4 )(R 4a )-, -N(R 4 )C(O)N(R 4a )- and -OC(O)N(R 4 )-, optionally interrupted by one or more chemical groups selected from the group consisting of -R 4 and -R 4a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -S in formula (a) a - is selected from the group consisting of methyl, ethyl, propyl, and butyl, including -O-, -C(O)-, and -C(O)N(R 4 )-.

[0503] In certain embodiments, -S of formula (a) a' is a chemical bond.

[0504] In certain embodiments, -S of formula (a) a' -C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 alkynyl, C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 Alkynyl includes -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 )-, -S(O)2N(R 4 )-, -S(O)N(R 4 )-, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a )-, -S-, -N(R 4 )-, -OC(OR 4 )(R 4a )-, -N(R 4 )C(O)N(R 4a )- and -OC(O)N(R 4)-, optionally interrupted by one or more chemical groups selected from the group consisting of -R 4 and -R 4a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -S in formula (a) a' - is selected from the group consisting of methyl, ethyl, propyl, and butyl, including -O-, -C(O)-, and -C(O)N(R 4 )-.

[0505] In certain embodiments, -S of formula (a) a'' - is a chemical bond.

[0506] In certain embodiments, -S of formula (a) a'' -C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 alkynyl, C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 Alkynyl includes -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 )-, -S(O)2N(R 4 )-, -S(O)N(R 4 )-, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a )-, -S-, -N(R 4 )-, -OC(OR 4 )(R 4a )-, -N(R 4 )C(O)N(R 4a )- and -OC(O)N(R 4 )-, optionally interrupted by one or more chemical groups selected from the group consisting of -R 4 and -R 4a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -S in formula (a) a"- is selected from the group consisting of methyl, ethyl, propyl, and butyl, including -O-, -C(O)-, and -C(O)N(R 4 )-.

[0507] In certain embodiments, -S of formula (a) a''' - is a chemical bond.

[0508] In certain embodiments, -S of formula (a) a''' -C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 alkynyl, C 1-10 Alkyl, C 2-10 Alkenyl and C 2-10 Alkynyl includes -C(O)O-, -O-, -C(O)-, -C(O)N(R 4 )-, -S(O)2N(R 4 )-, -S(O)N(R 4 )-, -S(O)2-, -S(O)-, -N(R 4 )S(O)2N(R 4a )-, -S-, -N(R 4 )-, -OC(OR 4 )(R 4a )-, -N(R 4 )C(O)N(R 4a )- and -OC(O)N(R 4 )-, optionally interrupted by one or more chemical groups selected from the group consisting of -R 4 and -R 4a is independently selected from the group consisting of -H, methyl, ethyl, propyl, and butyl. In certain embodiments, -S in formula (a) a''' - is selected from the group consisting of methyl, ethyl, propyl, and butyl, including -O-, -C(O)-, and -C(O)N(R 4 )-.

[0509] In certain embodiments, -P of formula (a) a' , -Pa'' and -P a''' are independently 2-methacryloyl-oxyethyl phosphorylcholines, poly(acrylic acids), poly(acrylates), poly(acrylamides), poly(alkyloxy)polymers, poly(amides), poly(amidoamines), poly(amino acids), poly(anhydrides), poly(aspartamides), poly(butyric acids), poly(glycolic acids), polybutylene terephthalates, poly(caprolactones), poly(carbonates), poly(cyanoacrylates), poly(dimethylsiloxane ... acrylamides), poly(esters), poly(ethylenes), poly(ethylene glycols), poly(ethylene oxides), poly(ethyl phosphates), poly(ethyl oxazolines), poly(glycolic acids), poly(hydroxyethyl acrylates), poly(hydroxyethyl-oxazolines), poly(hydroxy methacrylates), poly(hydroxypropyl methacrylamides), poly(hydroxypropyl methacrylates), poly(hydroxypropyl oxazolines), Poly(oxazolines), poly(iminocarbonates), poly(lactic acids), poly(lactic-co-glycolic acids), poly(methacrylamides), poly(methacrylates), poly(methyloxazolines), poly(organophosphazenes), poly(orthoesters), poly(oxazolines), poly(propylene glycols), poly(siloxanes), poly(urethanes), poly(vinyl alcohols), poly(vinylamines), poly(vinyl methyl ethers), poly(vinylpyrrolidone) The polymers include polymers selected from the group consisting of: celluloses, silicones, celluloses, carbomethylcelluloses, hydroxypropylmethylcelluloses, chitins, chitosans, dextrans, dextrins, gelatins, hyaluronic acids and derivatives, functionalized hyaluronic acids, mannans, pectins, rhamnogalacturonans, starches, hydroxyalkyl starches, hydroxyethyl starches and other hydrocarbon-based polymers, xylans, and copolymers thereof.

[0510] In certain embodiments, -P of formula (a) a' , -P a'' and -Pa''' independently have a molecular weight of 5 kDa to 50 kDa, in certain embodiments, 5 kDa to 40 kDa, in certain embodiments, 7.5 kDa to 35 kDa, in certain embodiments, 7.5 to 30 kDa, and in certain embodiments, 10 to 30 kDa.

[0511] In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' In certain embodiments, -P of formula (a) has a molecular weight of about 5 kDa. a' , -P a'' and -P a''' has a molecular weight of about 7.5 kDa. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' has a molecular weight of about 10 kDa. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' has a molecular weight of about 12.5 kDa. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' has a molecular weight of about 15 kDa. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' has a molecular weight of approximately 20 kDa.

[0512] In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' In certain embodiments, -P of formula (a) independently comprises a PEG-based moiety. a' , -P a'' and -P a'''independently comprise a PEG-based moiety that comprises at least 20% PEG, in certain embodiments, at least 30% PEG, in certain embodiments, at least 40% PEG, in certain embodiments, at least 50% PEG, in certain embodiments, at least 60% PEG, in certain embodiments, at least 70% PEG, in certain embodiments, at least 80% PEG, and in certain embodiments, at least 90% PEG.

[0513] In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' independently comprise a protein moiety, in certain embodiments a random coil protein moiety, in certain embodiments a random coil protein moiety selected from the group consisting of a PA, PAS, PAG, PG, and XTEN moiety.

[0514] In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' is a PA moiety. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' is a PAS moiety. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' is a PAG moiety. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' is a PG moiety. In certain embodiments, -P of formula (a) a' , -P a'' and -P a''' is the XTEN portion.

[0515] In certain embodiments, -Z comprises one moiety of formula (a). In certain embodiments, -Z comprises two moieties of formula (a). In other embodiments, -Z comprises three moieties of formula (a). In certain embodiments, -Z comprises four moieties of formula (a). In certain embodiments, -Z comprises five moieties of formula (a). In certain embodiments, -Z comprises six moieties of formula (a).

[0516] In certain embodiments, -Z is a moiety of formula (b): [ka] (In the formula, The dashed line is -L 2 - represents the bond to or to the remainder of -Z; b1 is selected from the group consisting of 0, 1, 2, 3, 4, 5, 6, 7 and 8; b2 is selected from the group consisting of 1, 2, 3, 4, 5, 6, 7 and 8; b3 is an integer from 150 to 1000; in certain embodiments, an integer from 150 to 500; in certain embodiments, an integer from 200 to 460; b4 is an integer of 150 to 1000; in certain embodiments, an integer of 150 to 500; in certain embodiments, an integer of 200 to 460. Includes.

[0517] Optionally, the moiety of formula (b) is substituted with one or more substituents.

[0518] In certain embodiments, b3 and b4 in formula (b) are the same integer. In certain embodiments, b3 and b4 in formula (b) are both integers from 200 to 250, and in certain embodiments, b3 and b4 in formula (b) are about 225. In certain embodiments, b3 and b4 in formula (b) are both integers from 400 to 500, and in certain embodiments, b3 and b4 in formula (b) are about 450.

[0519] In certain embodiments, b1 of formula (b) is selected from the group consisting of 0, 1, 2, 3, and 4. In certain embodiments, b1 of formula (b) is selected from the group consisting of 1, 2, and 3. In certain embodiments, b1 of formula (b) is 2.

[0520] In certain embodiments, b2 of formula (b) is selected from the group consisting of 1, 2, 3, 4, and 5. In certain embodiments, b2 of formula (b) is selected from the group consisting of 2, 3, and 4. In certain embodiments, b2 of formula (b) is 3.

[0521] In certain embodiments, b1 of Formula (b) is 2, b2 of Formula (b) is 3, and b3 and b4 are both about 450. In certain embodiments, b1 of Formula (b) is 2, b2 of Formula (b) is 3, and b3 and b4 are both about 225.

[0522] In certain embodiments, -Z comprises one moiety of formula (b). In certain embodiments, -Z comprises two moieties of formula (b). In certain embodiments, -Z comprises three moieties of formula (b). In certain embodiments, -Z comprises four moieties of formula (b). In certain embodiments, -Z comprises five moieties of formula (b). In certain embodiments, -Z comprises six moieties of formula (b).

[0523] In certain embodiments, -Z is a moiety of formula (c): [ka] (In the formula, The dashed line is -L 2 - represents the bond to or to the remainder of -Z; c1 and c2 are independently an integer between 150 and 500; in certain embodiments, an integer between 200 and 460. Includes.

[0524] Optionally, the moiety of formula (c) is substituted with one or more substituents. In certain embodiments, c1 and c2 of formula (c) are both the same integer.

[0525] In certain embodiments, c1 and c2 of formula (c) are 200 to 250, and in certain embodiments, about 225. In certain embodiments, c1 and c2 of formula (c) are 400 to 500, and in certain embodiments, c1 and c2 of formula (c) are about 450.

[0526] In certain embodiments, the moiety -Z is a branched PEG-based polymer containing at least 10% PEG, has one branch point, two PEG-based polymer arms, and has a molecular weight of about 40 kDa. Thus, each of the two PEG-based polymer arms has a molecular weight of about 20 kDa. In certain embodiments, the branch point is -CH<.

[0527] In certain embodiments, -Z comprises one moiety of formula (c). In certain embodiments, -Z comprises two moieties of formula (c). In certain embodiments, -Z comprises three moieties of formula (c). In certain embodiments, -Z comprises four moieties of formula (c). In certain embodiments, -Z comprises five moieties of formula (c). In certain embodiments, -Z comprises six moieties of formula (c).

[0528] In certain embodiments, the moiety -Z has the formula (d): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to; -Z b -C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50Alkynyl may be one or more -R 1 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 )-, -S(O)2N(R 2 )-, -S(O)N(R 2 )-, -S(O)2-, -S(O)-, -N(R 2 )S(O)2N(R 2a )-, -S-, -N(R 2 )-, -OC(OR 2 )(R 2a )-, -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2 )-, optionally interrupted by one or more groups selected from the group consisting of; Each -T- is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; wherein each -T- is independently selected from the group consisting of one or more -R 1 optionally substituted with; Each-R 1 are independently halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R 2 , -R 2a , -R 3 , -R 3a and -R 3b are independently -H and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -Z a teeth, [ka] [In the formula, BP a , -S a -, -S a' -, -S a'' -, -S a''' -, -P a' , -P a'' , -P a''' and a are used as defined for formula (a). is) It has.

[0529] Optionally, the moiety of formula (d) is substituted with one or more substituents.

[0530] In certain embodiments, BP of formula (d) a , -Sa -, -S a' -, -S a'' -, -S a''' -, -P a' , -P a'' , -P a''' is as defined above for formula (a).

[0531] In certain embodiments, -Z in formula (d) a has formula (b): In certain embodiments, b1, b2, b3, and b4 are as described for formula (b).

[0532] In certain embodiments, the moiety -Z of formula (Ia) or (Ib) has the formula (e): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to; e is selected from the group consisting of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15; -Z a teeth, [ka] [In the formula, b1, b2, b3 and b4 are used as defined for formula (b). is) It has.

[0533] Optionally, the moiety of formula (e) is substituted with one or more substituents.

[0534] In certain embodiments, b1, b2, b3, and b4 in formula (e) are as defined above for formula (b).

[0535] In certain embodiments, e in Formula (e) is 1. In certain embodiments, e in Formula (e) is 2. In certain embodiments, e in Formula (e) is 3. In certain embodiments, e in Formula (e) is 4. In certain embodiments, e in Formula (e) is 5. In certain embodiments, e in Formula (e) is 6. In certain embodiments, e in Formula (e) is 7. In certain embodiments, e in Formula (e) is 8. In certain embodiments, e in Formula (e) is 9. In certain embodiments, e in Formula (e) is 10. In certain embodiments, e in Formula (e) is 11. In certain embodiments, e in Formula (e) is 12. In certain embodiments, e in Formula (e) is 13. In certain embodiments, e in Formula (e) is 14. In certain embodiments, e in Formula (e) is 15.

[0536] In certain embodiments, e in formula (e) is selected from the group consisting of 2, 3, 4, 5, 6, 7, 8, and 9. In certain embodiments, e in formula (e) is selected from 3, 4, 5, and 6. In certain embodiments, e in formula (e) is 5.

[0537] In certain embodiments, e in formula (e) is 5, b1 in formula (e) is 2, b2 in formula (e) is 3, and b3 and b4 in formula (e) are both about 450.

[0538] In certain embodiments, the moiety -Z of formula (Ia) or (Ib) has the formula (ei) or (ei'): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to e is selected from the group consisting of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15; -Z a teeth, [ka] [In the formula, b1, b2, b3 and b4 are used as defined for formula (b). is) It has.

[0539] In certain embodiments, b1, b2, b3, and b4 of formulas (ei) and (e-i') are as defined above for formula (b). In certain embodiments, e of formulas (ei) and (e-i') is as described for formula (e). In certain embodiments, b1 of formulas (ei) and (e-i') is 2, b2 of formulas (ei) and (e-i') is 3, and b3 and b4 of formulas (ei) and (e-i') are both about 450.

[0540] In certain embodiments, -Z of formula (Ia) or (Ib) has the formula (ei):

[0541] In certain embodiments, the moiety -Z is a branched PEG-based polymer comprising at least 10% PEG, has three branch points and four PEG-based polymer arms, and has a molecular weight of about 40 kDa. Thus, each of the four PEG-based polymer arms has a molecular weight of about 10 kDa. In certain embodiments, each of the three branch points is -CH<.

[0542] In certain embodiments, the moiety -Z has the formula (f): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to; BP f is a branch point selected from the group consisting of -N<, -CR< and >C<; -R is -H and C 1-6 selected from the group consisting of alkyl; f is BP f is 0 if -N< or -CR<, and f is BP f is 1 if >C<; -S f-, -S f' -, -S f'' -and-S f''' - is independently a chemical bond or independently C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl may be one or more -R 1 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 )-, -S(O)2N(R 2 )-, -S(O)N(R 2 )-, -S(O)2-, -S(O)-, -N(R 2 )S(O)2N(R 2a )-, -S-, -N(R 2 )-, -OC(OR 2 )(R 2a )-, -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2 )-, optionally interrupted by one or more groups selected from the group consisting of; Each -T- is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10 cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; wherein each -T- is independently selected from the group consisting of one or more -R 1 optionally substituted with; Each R 1 are independently halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R 2 , -R 2a , -R 3 , -R 3a and -R 3b -H, and C 1-6 alkyl, wherein C 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -Z a' , -Z a'' and -Z a''' is, independently, [ka] [In the formula, BP a , -S a -, -S a' -, -S a'' -, -S a''' -, -Pa' , -P a'' , -P a''' and a are used as defined for formula (a). is) It has.

[0543] Optionally, the moiety of formula (f) is substituted with one or more substituents.

[0544] In certain embodiments, BP of formula (f) a , -S a -, -S a' -, -S a'' -, -S a''' -, -P a' , -P a'' and -P a''' is as defined above for formula (a).

[0545] In certain embodiments, BP of formula (f) f is -CR< and r is 0. In certain embodiments, -R is -H.

[0546] In certain embodiments, -S of formula (f) f - is a chemical bond.

[0547] In certain embodiments, -Z in formula (f) a' , -Z a'' and -Z a''' have the same structure. In certain embodiments, -Z of formula (f) a' , -Z a'' and -Z a''' has the formula (b).

[0548] In certain embodiments, b1, b2, b3, and b4 are as described for formula (b).

[0549] In certain embodiments, -S of formula (f) f - is a chemical bond, and BP in formula (f) a is -CR< and -R is -H. In certain embodiments, -S of formula (f) f- is a chemical bond, and BP in formula (f) a is -CR<, -R is -H, and -Z in formula (f) a' , -Z a'' and -Z a''' has formula (b).

[0550] In certain embodiments, -Z is a group of formula (g): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to; -S g -, -S g' -and-S g'' - is independently C 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 alkynyl; 1-50 Alkyl, C 2-50 Alkenyl, and C 2-50 Alkynyl may be one or more -R 1 optionally substituted with C 1-50 Alkyl, C 2-50 Alkenyl and C 2-50 Alkynyl includes -T-, -C(O)O-, -O-, -C(O)-, -C(O)N(R 2 )-, -S(O)2N(R 2 )-, -S(O)N(R 2 )-, -S(O)2-, -S(O)-, -N(R 2 )S(O)2N(R 2a )-, -S-, -N(R 2 )-, -OC(OR 2 )(R 2a )-, -N(R 2 )C(O)N(R 2a )- and -OC(O)N(R 2 )-, optionally interrupted by one or more groups selected from the group consisting of; Each -T- is independently phenyl, naphthyl, indenyl, indanyl, tetralinyl, C 3-10cycloalkyl, 3- to 10-membered heterocyclyl, 8- to 11-membered heterobicyclyl, 8- to 30-membered carbopolycyclyl, and 8- to 30-membered heteropolycyclyl; wherein each -T- is independently selected from the group consisting of one or more -R 1 optionally substituted with; Each R 1 are independently halogen, -CN, oxo(=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; Each-R 2 , -R 2a , -R 3 , -R 3a and -R 3b are independently -H and C 1-6 alkyl, wherein C1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -Z a and -Z a' is, independently, [ka] [In the formula, BP a , -S a -, -S a' -, -S a'' -, -S a''' -, -P a' , -P a'' , -P a''' and a are used as defined for formula (a). is) It has.

[0551] Optionally, the moiety of formula (g) is substituted with one or more substituents.

[0552] In certain embodiments, BP of formula (g) a , -S a -, -S a' -, -S a'' -, -S a''' -, -P a' , -P a'' and -P a''' is as defined above for formula (a).

[0553] In certain embodiments, -S in formula (g) g -C 1-6 Alkyl, C 2-6 Alkenyl and C 2-6 alkynyl, which may be the same or different, and which may be one or more -R 1 and optionally substituted with where -R 1 is halogen, oxo (=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -R 3 , -R 3a and -R 3b is independently selected from —H, methyl, ethyl, propyl, and butyl.

[0554] In certain embodiments, -S in formula (g) g -C 1-6 alkyl.

[0555] In certain embodiments, -S in formula (g) g' -C 1-6 Alkyl, C 2-6 Alkenyl and C 2-6 alkynyl, which may be the same or different, and which may be one or more -R 1 and optionally substituted with where -R1 is halogen, oxo (=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -R 3 , -R 3a and -R 3b is independently selected from —H, methyl, ethyl, propyl, and butyl.

[0556] In certain embodiments, -S in formula (g) g' -C 1-6 It is alkyl.

[0557] In certain embodiments, -S in formula (g) g'' -C 1-6 Alkyl, C 2-6 Alkenyl and C2-6 alkynyl, which may be the same or different, and which may be one or more -R 1 and optionally substituted with where -R 1 is halogen, oxo (=O), -COOR 3 , -OR 3 , -C(O)R 3 , -C(O)N(R 3 R 3a ), -S(O)2N(R 3 R 3a ), -S(O)N(R 3 R 3a ), -S(O)R 3 , -S(O)R 3 , -N(R 3 )S(O)2N(R 3a R 3b ), -SR 3 , -N(R 3 R 3a ), -NO2, -OC(O)R 3 , -N(R 3 )C(O)R 3a , -N(R 3 )S(O)2R 3a , -N(R 3 )S(O)R 3a , -N(R 3 )C(O)OR 3a , -N(R 3 )C(O)N(R 3a R 3b ), -OC(O)N(R 3 R 3a ), and C 1-6 alkyl; 1-6 alkyl is optionally substituted with one or more halogens which may be the same or different; -R 3 , -R 3a and -R 3b is independently selected from —H, methyl, ethyl, propyl, and butyl.

[0558] In certain embodiments, -S in formula (g) g'' -C 1-6 It is alkyl.

[0559] In certain embodiments, -Z in formula (g) a and -Z a' have the same structure. In certain embodiments, -Z in formula (g) a and -Z a' has the formula (b).

[0560] In certain embodiments, BP of formula (gi) a , -S a -, -S a' -, -S a'' -, -S a''' -, -P a' , -P a'' and -P a''' is as defined above for formula (a).

[0561] In certain embodiments, -S of formula (gi) g -, -S g' -and-S g'' - is as defined for formula (g).

[0562] In certain embodiments, -Z in formula (gi) a and -Z a' have the same structure. In certain embodiments, -Z of formula (gi) a and -Z a' has formula (b): In certain embodiments, b1, b2, b3, and b4 are as described for formula (b).

[0563] In certain embodiments, -Z is a group of formula (h): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to; Each-Z C The following part: [ka] [In the formula, each c1 is independently an integer of 200 to 250] is) It has.

[0564] Optionally, the moiety of formula (h) is substituted with one or more substituents.

[0565] In certain embodiments, both c1's of formula (h) are the same. In certain embodiments, both c1's of formula (h) are about 225.

[0566] In certain embodiments, the moiety -Z has the formula (hi): [ka] (In the formula, The dashed line is -L 2 - indicates a bond to; Each-Z C The following part: [ka] [Each c1 is independently an integer between 200 and 250] is) It has.

[0567] Optionally, the moiety of formula (hi) is substituted with one or more substituents.

[0568] In certain embodiments, both c1's of formula (hi) are the same. In certain embodiments, both c1's of formula (hi) are about 225.

[0569] In certain embodiments, the CNP conjugate has the formula (IIf): [ka] (In the formula, The unmarked dashed line indicates the attachment of the CNP moiety, -D, to the nitrogen by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, Each-Z a teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) It has.

[0570] In certain embodiments, each c1 of Formula (IIf) is about 225.

[0571] In certain embodiments, -D of Formula (IIf) is a CNP moiety, i.e., the conjugate of Formula (IIf) is a CNP conjugate. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 24, SEQ ID NO: 25, or SEQ ID NO: 30. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 24. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 20. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 21. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 22. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 23. In certain embodiments, -D of Formula (IIf) is a CNP moiety having the sequence of SEQ ID NO: 30.

[0572] In certain embodiments, -D in formula (IIf) is linked to -L through the nitrogen of the N-terminal amine functional group of CNP. 1 - is the CNP portion bound to

[0573] In certain embodiments, -D of formula (IIf) is linked to -L through a nitrogen provided by the amine functionality of the lysine side chain of the CNP moiety. 1 - is the CNP portion bound to

[0574] In certain embodiments, when the CNP moiety has SEQ ID NO: 24, the lysine side chain is not part of the ring formed by the disulfide bridge between the cysteine ​​residues at positions 22 and 38.

[0575] Thus, in certain embodiments, when CNP has the sequence of SEQ ID NO: 24, the CNP moiety is connected to -L in the CNP conjugate of formula (IIf) via the amine functionality provided by the side chain of the lysine at position 9. 1 - is bonded to.

[0576] In certain embodiments, when CNP has the sequence of SEQ ID NO: 24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) via the amine functionality provided by the side chain of lysine at position 11. 1 - is bonded to.

[0577] In certain embodiments, when CNP has the sequence of SEQ ID NO: 24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) via the amine functionality provided by the side chain of lysine at position 15. 1 - is bonded to.

[0578] In certain embodiments, when CNP has the sequence of SEQ ID NO: 24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) via the amine functionality provided by the side chain of lysine at position 16. 1 - is bonded to.

[0579] In certain embodiments, when CNP has the sequence of SEQ ID NO: 24, the CNP moiety is linked to -L in the CNP conjugate of formula (IIf) via the amine functionality provided by the side chain of the lysine at position 20. 1 - is bonded to.

[0580] In certain embodiments, when the CNP moiety has SEQ ID NO: 24, the lysine side chain is part of a ring formed by a disulfide bridge between the cysteine ​​residues at positions 22 and 38.

[0581] Thus, in certain embodiments, when the CNP has the sequence of SEQ ID NO: 24, the CNP moiety is attached to -L in the CNP conjugate of formula (IIf) via the amine functionality provided by the side chain of the lysine at position 26. 1 - is bonded to.

[0582] In certain embodiments, the CNP conjugate has the formula (IIf), where c1 is about 225, -D is a CNP moiety having the sequence of SEQ ID NO: 20, and -L is connected via the amine functionality provided by the side chain of the lysine at position 30. 1 - is bonded to.

[0583] In certain embodiments, the CNP conjugate has the formula (IIf), where c1 is about 225, -D is a CNP moiety having the sequence of SEQ ID NO: 21, and -L is connected via the amine functionality provided by the side chain of the lysine at position 29. 1 - is bonded to.

[0584] In certain embodiments, the CNP conjugate has the formula (IIf), where c1 is about 225, -D is a CNP moiety having the sequence of SEQ ID NO: 22, and -L is connected via the amine functionality provided by the side chain of the lysine at position 28. 1 - is bonded to.

[0585] In certain embodiments, the CNP conjugate has the formula (IIf), where c1 is about 225, -D is a CNP moiety having the sequence of SEQ ID NO: 23, and -L is connected via the amine functionality provided by the side chain of the lysine at position 27. 1 - is bonded to.

[0586] In certain embodiments, the CNP conjugate has the formula (IIf), where c1 is about 225, -D is a CNP moiety having the sequence of SEQ ID NO: 30, and -L is connected via the amine functionality provided by the side chain of the lysine at position 27. 1 - is bonded to.

[0587] It is understood that the positions of the cysteines and lysines described above vary depending on the length of the CNP moiety, and that a person skilled in the art would have no difficulty in identifying corresponding cysteines and lysines in longer or shorter versions of the CNP moiety, and would also understand, for example, that some lysines may not be present in a shorter CNP moiety. It is further understood that, for example, as a result of site-directed mutagenesis, more lysine residues may be present in the non-cyclization and / or cyclization portions of the CNP moiety.

[0588] In certain embodiments, the CNP conjugate has the formula (IIf), where c1 is about 225, -D is a CNP moiety having the sequence of SEQ ID NO: 24, and -L is connected via the amine functionality provided by the side chain of the lysine at position 26. 1 - is bonded to.

[0589] In certain embodiments, the CNP conjugate has the formula (IIf'): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP portion of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z a teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) It has.

[0590] In certain embodiments, each c1 in Formula (IIf') is about 225.

[0591] In certain embodiments, the unit dosage form of the present invention has the formula (IIf): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z a teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) or a pharmaceutically acceptable salt thereof, wherein the unit dose is about 50 μg CNP / kg.

[0592] In certain embodiments, the unit dosage form of the present invention has the formula (IIf): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z a teeth, [ka] (In the formula, Each c1 is independently an integer of 200 to 250. is] (showing the bond to -Z) or a pharmaceutically acceptable salt thereof, wherein the unit dose is about 75 μg CNP / kg.

[0593] In certain embodiments, the unit dosage form of the present invention has the formula (IIf): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z c teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) or a pharmaceutically acceptable salt thereof, wherein the unit dose is about 100 μg CNP / kg.

[0594] In certain embodiments, the unit dosage form of the present invention has the formula (IIf'): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z c teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) or a pharmaceutically acceptable salt thereof, wherein the unit dose is 50 μg CNP / kg.

[0595] In certain embodiments, the unit dosage form of the present invention has the formula (IIf'): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z a teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) or a pharmaceutically acceptable salt thereof, wherein the unit dose is 75 μg CNP / kg.

[0596] In certain embodiments, the unit dosage form of the present invention has the formula (IIf'): [ka] (In the formula, The unmarked dashed line indicates attachment to the nitrogen provided by the side chain of the lysine at position 26 of the CNP moiety of SEQ ID NO: 24 by forming an amide bond; The dashed lines with asterisks indicate the structure: [ka] [In the formula, each Z a teeth, [ka] (wherein each c1 is independently an integer of 200 to 250) is] (showing the bond to -Z) or a pharmaceutically acceptable salt thereof, wherein the unit dose is 100 μg CNP / kg.

[0597] In some embodiments, -Z c or -Z a For moieties, such as those in the CNP conjugates of formula (IIf) or (IIf′), c1 is independently an integer from about 100 to about 500, such as from about 150 to about 300, such as from about 200 to about 250.

[0598] In some embodiments, -Z c or -Z a For parts, -Z c or -Z a is a branched PEG moiety containing two linear PEG arms, e.g., as used herein, -[-O-CH-CH] c1 -O-CH3, which are independently at least about 5 kDa, such as from about 5 kDa to about 20 kDa, such as from about 7 kDa to about 15 kDa, such as from about 8 kDa to about 12 kDa, for example about 10 kDa.

[0599] In some embodiments, -Z c or -Z aWith respect to moieties, such as those in a CNP conjugate of formula (IIf) or (IIf′), each c1 present in the CNP conjugate is on average about 100 to about 500, such as about 150 to about 300, such as about 200 to about 250.

[0600] In some embodiments, each PEG arm present on the CNP conjugate is represented by, for example, —[—O—CH 2 —CH 2 ] c1 -O-CH3 and is on average at least about 5 kDa, such as from about 5 kDa to about 20 kDa, such as from about 7 kDa to about 15 kDa, such as from about 8 kDa to about 12 kDa, for example about 10 kDa.

[0601] A further aspect of the present invention is a method for improving muscle function in a human patient having a disease treatable by CNP, the method comprising the step of administering to the subject an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist, optionally wherein the FGFR3 signaling inhibitor or NPR-B agonist and / or NPR-C agonist is a CNP conjugate or a pharmaceutically acceptable salt thereof, and the CNP conjugate or pharmaceutically acceptable salt thereof is administered in a unit dose of from about 6 μg CNP / kg to at least about 150 μg CNP / kg.

[0602] A further aspect of the present invention is a method for improving skeletal muscle function in a human patient having a disease treatable by CNP, the method comprising the step of administering to the subject an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-C agonist, wherein optionally the FGFR3 signaling inhibitor or NPR-B agonist and / or NPR-C agonist is a CNP conjugate or a pharmaceutically acceptable salt thereof, and the CNP conjugate or the pharmaceutically acceptable salt thereof is administered in a unit dose of from about 6 μg CNP / kg to at least about 150 μg CNP / kg.

[0603] In certain embodiments, the present invention relates to a method for improving muscle function in a human patient having a disease treatable by CNP, the method comprising the step of administering to the subject an effective amount of an FGFR3 signaling inhibitor, or an effective amount of an NPR-B agonist, or an effective amount of an NPR-B agonist, wherein the FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist is a CNP conjugate or a pharmaceutically acceptable salt thereof at a unit dose of about 6 μg CNP / kg to at least about 100 μg CNP / kg.

[0604] In certain embodiments, the subject has a disease or condition treatable by CNP, optionally wherein the disease or condition is selected from the group consisting of bone-related diseases, e.g., skeletal dysplasia; cancer; autoimmune diseases; fibrotic diseases; inflammatory diseases; central nervous system diseases, e.g., neurodegenerative diseases; infectious diseases; pulmonary diseases; heart and vascular diseases; metabolic diseases, and ophthalmological diseases.

[0605] In certain embodiments, the subject has a RAS disease.

[0606] In certain embodiments, said diseases treatable by the methods or uses of the invention comprise RASopathies: RASopathies result from genetic abnormalities in the Ras / MAPK pathway (and including pathways activated by FGFR3) (for review see Rauen, Annu Rev Genomics Hum Genet. 2013;14:355-369. doi:10.1146 / annurev-genom-091212-153523) and include neurofibromatosis type 1, Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardio-facio-cutaneous syndrome and Legius syndrome.

[0607] In certain embodiments, the present invention relates to the treatment of RAS diseases with CNP, or NPR-B agonists and / or NPR-C agonists.

[0608] In certain embodiments, the disease treatable by the CNP is achondroplasia, hypochondroplasia, short stature, dwarfism, osteochondrodysplasia, lethal dysplasia, osteogenesis imperfecta, achondrogenesis imperfecta, chondrodysplasia punctata, homozygous achondroplasia, chiropterid dysplasia, congenital lethal hypophosphatasia, perinatal lethal osteogenesis imperfecta, short rib polydactyly syndrome, rhizometaphyseal chondrodysplasia punctata, Jansen metaphyseal dysplasia, congenital spondyloepiphyseal dysplasia, osteogenesis imperfecta, osseous dysplasia congenita ... Femoral brachyosteosis, Langer metametaphyseal dysplasia, Niebergerd metametaphyseal dysplasia, Robinow syndrome, Reinhardt syndrome, acrodysostosis, peripheral dysostosis, Kniest dysplasia, fibrochondrogenesis, Roberts syndrome, distal metametaphyseal dysplasia, micromelia, Morquio syndrome, Kniest syndrome, metamorphic dysplasia, spondyloepiphyseal dysplasia, neurofibromatosis, Legius syndrome, Leopard syndrome, Noonan syndrome, hereditary gingival fibromatosis, neurofibromatosis type 1, Legius syndrome, heart and face Skin syndrome, Costello syndrome, SHOX deficiency, idiopathic short stature, growth hormone deficiency, osteoarthritis, cleidocranial dysplasia, craniosynostosis (e.g., Muenke syndrome, Crouzon syndrome, Apert syndrome, Jackson-Weiss syndrome, Pfeiffer syndrome, or Crouzon exoskeletal syndrome), dactyly, brachydactyly, camptodactyly, polydactyly, syndactyly, segmental dysplasia, enchondromatosis, fibrous dysplasia, hereditary multiple exostoses, hypophosphatemic rickets, Yaffe syndrome The disease is selected from the group consisting of Ehrlichtenstein syndrome, Marfan syndrome, McCune-Albright syndrome, osteopetrosis, bone ecchymosis, hemorrhagic shock, hypertension, restenosis, arteriosclerosis, acute decompensated heart failure, congestive heart failure, cardiac edema, renal edema, hepatic edema, acute renal failure, chronic renal failure, glaucoma, ocular hypertension, multiple myeloma, myeloproliferative syndrome, leukemia, plasma cell leukemia, lymphoma, glioblastoma, prostate cancer, bladder cancer, breast cancer, growth retardation, cranial deformity, orthodontic defect, cervical spinal cord compression, spinal stenosis, hydrocephalus, hearing loss due to chronic otitis, cardiovascular disease, neurological disease, and obesity.

[0609] In certain embodiments, the disease treatable by the CNP is achondroplasia (e.g., homozygous achondroplasia), hypochondroplasia, short stature, dwarfism, osteochondrodysplasia, lethal skeletal dysplasia, osteogenesis imperfecta, achondrogenesis imperfecta, chondrodysplasia punctata, chiropterid dysplasia, congenital lethal hypophosphatasia, perinatal lethal osteogenesis imperfecta, short rib polydactyly syndrome, rhizometaphyseal chondrodysplasia punctata, Jansen metaphyseal dysplasia, congenital spondyloepiphyseal dysplasia, osteogenesis imperfecta, and skeletal dysplasia. , congenital femoral brachyosteosis, Langer mesomelic dysplasia, Niebergelt mesomelic dysplasia, Robinow syndrome, Reinhardt syndrome, acrodysostosis, peripheral dysostosis, Kniest dysplasia, fibrochondrogenesis, Roberts syndrome, distal mesomelic dysplasia, micromelia, Morquio syndrome, Kniest syndrome, metamorphic dysplasia, spondyloepiphyseal dysplasia, neurofibromatosis, Legius syndrome, Leopard syndrome, Noonan syndrome, hereditary gingival fibromatosis, neurofibromatosis type 1, Legius syndrome, cardiac Viscero-facio-cutaneous syndrome, Costello syndrome, SHOX deficiency, idiopathic short stature, growth hormone deficiency, osteoarthritis, cleidocranial dysplasia, craniosynostosis (e.g., Muenke syndrome, Crouzon syndrome, Apert syndrome, Jackson-Weiss syndrome, Pfeiffer syndrome, or Crouzon exoskeletal syndrome), dactyly, brachydactyly, camptodactyly, polydactyly, syndactyly, segmental dysplasia, enchondromatosis, fibrous dysplasia, hereditary multiple exostoses, hypophosphatemic rickets, ya Miffle-Richtenstein syndrome, Marfan syndrome, McCune-Albright syndrome, osteopetrosis, bone ecchymosis, hemorrhagic shock, hypertension, restenosis, arteriosclerosis, acute decompensated heart failure, congestive heart failure, cardiac edema, renal edema, hepatic edema, acute renal failure, chronic renal failure, glaucoma, ocular hypertension, multiple myeloma, myeloproliferative syndrome, leukemia, plasma cell leukemia, lymphoma, glioblastoma, prostate cancer, bladder cancer, breast cancer, growth retardation, cranial deformities, orthodontic defectsdefect), cervical spinal cord compression, spinal cord stenosis, hydrocephalus, hearing loss due to chronic otitis, obesity, disorders involving abnormal RAS-mitogen-activated protein kinase signaling, pulmonary hypertension, vascular disorders, endothelial dysfunction, cirrhosis, hepatic ascites, hepatic fibrosis, hepatorenal syndrome, asthma, pulmonary fibrosis, chronic kidney disease, cardiorenal syndrome, dyspnea and lysosomal storage diseases, such as mucopolysaccharidosis.

[0610] In certain embodiments, the disease treatable by the CNP is arrhythmia, e.g., cardiac arrhythmia or sinus arrhythmia; atrial fibrillation; atrial flutter; bradycardia; Brugada syndrome; premature beats; commotio cordis; heart block; long QT syndrome; parasystole; preexcitation syndrome; tachycardia; ventricular fibrillation; ventricular flutter; cardiac conduction disorders; low cardiac output; cardiac hypertrophy; dilated cardiomyopathy; hypertrophy, e.g., left ventricular hypertrophy or right ventricular hypertrophy; cardiomyopathies, e.g., alcoholic, dilated, hypertrophic, restrictive, diabetic, or Chagas cardiomyopathy; arrhythmogenic right ventricular dysplasia; endocardial fibroelastosis; endomyocardial fibrosis; glycogen storage disease type IIb; Kearns-Sayre syndrome; myocardial reperfusion injury; myocarditis; sarcoglycanopathies; endocarditis, e.g., bacterial or non-infective endocarditis; cardiac arrest; sudden cardiac death; out-of-hospital cardiac arrest arrest); cardiorenal syndrome; paroxysmal dyspnea; cardiac edema, heart failure, e.g., diastolic or systolic heart failure; valvular heart disease; aortic regurgitation; aortic stenosis; heart valve prolapse; mitral regurgitation; mitral stenosis; pulmonary atresia; pulmonary regurgitation; pulmonary stenosis; tricuspid atresia; tricuspid regurgitation; tricuspid stenosis; myocardial ischemia; acute coronary syndrome; angina pectoris; coronary disease; Kounis syndrome; myocardial infarction; pulmonary heart disease; ventricular dysfunction, e.g., left or right ventricular dysfunction; ventricular outflow tract obstruction; aortic stenosis, pulmonary stenosis; hypertension; atherosclerosis; restenosis; critical limb ischemia; peripheral arterial disease; ischemia, e.g., ischemia-reperfusion injury or ischemic injury; cardiac edema, and abnormal fluid retention in myocardial edema.

[0611] In certain embodiments, the disease treatable by CNP is selected from the group consisting of ischemic heart disease, eg, myocardial infarction; congestive heart failure; arrhythmias, and atherosclerosis.

[0612] In certain embodiments, the disease treatable by the CNP is one or more central nervous system diseases selected from the group consisting of cerebral ischemia, e.g., ischemic hypoxia; cerebral infarction; transient ischemic attack; vertebrobasilar insufficiency; cerebrovascular disease; stroke; intracranial hemorrhage; corneal neovascularization; corneal transplantation; graft-versus-host disease; graft rejection; glaucoma, e.g., angle-closure glaucoma, neovascular glaucoma, open-angle glaucoma, or low-tension glaucoma; ischemic optic neuropathy; central serous chorioretinopathy; retinopathy, e.g., diabetic or hypertensive retinopathy; retinal degeneration; macular degeneration; geographic atrophy; macular edema; Stargardt's disease; vitelliform macular degeneration; exudative macular degeneration; retinoschisis; retinal detachment; retinal perforation; retinal hemorrhage; retinal neovascularization; retinal vein occlusion; retinal artery occlusion; retinopathy of prematurity; and proliferative vitreoretinopat...

Claims

1. 1. An FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist for use in a method for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired, wherein a therapeutically effective amount of the FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist is administered to the subject.

2. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 1, wherein the FGFR3 signaling inhibitor is an FGFR3 antagonist or an NPR-B agonist.

3. 3. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 1 or 2, wherein the NPR-B agonist is or comprises C-type natriuretic peptide (CNP).

4. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 3, wherein the NPR-C agonist is or comprises C-type natriuretic peptide (CNP).

5. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 1 to 4, wherein the NPR-B agonist or NPR-C agonist is administered as a CNP conjugate or a pharmaceutically acceptable salt thereof.

6. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 1 to 5, wherein the NPR-B agonist or NPR-C agonist is a prodrug of CNP.

7. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 5 or 6, wherein the CNP conjugate or CNP prodrug is a compound of formula (IIf'), a compound of formula (IIf), compound (1) or a pharmaceutically acceptable salt thereof.

8. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 5 to 7, wherein the method comprises administering to a subject continuous administration of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug, and the sustained exposure of free CNP in the patient's plasma during the continuous administration of the therapeutically effective amount of the CNP conjugate and / or CNP prodrug is at least about 1 pmol / L, for example at least about 4 pmol / L, for example about 4 pmol / L to about 30 pmol / L.

9. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 8, wherein the method comprises administering to a subject continuous administration of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug, and the sustained exposure of free CNP in the patient's plasma during the continuous administration of the therapeutically effective amount of a CNP conjugate and / or a CNP prodrug is at least about 9 pmol / L.

10. 10. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 8 or 9, wherein a therapeutically effective amount of the CNP conjugate and / or prodrug is administered once daily or once weekly.

11. 8. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 3 to 7, wherein the method comprises administering to the subject an infusion, e.g., an iv or sc infusion, of CNP, wherein the infusion results in a sustained exposure of free CNP in the patient's plasma of at least 1 pmol / L, such as at least about 4 pmol / L, for example about 9 pmol / L or from about 4 pmol / L to about 30 pmol / L, for a period of at least 1 hour.

12. 12. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 11, wherein the NPR-B agonist is or comprises vosoritide (SEQ ID NO: 30).

13. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 2, wherein the FGFR3 antagonist is an FGFR3 tyrosine kinase inhibitor.

14. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 13, wherein the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of infigratinib, pemigatinib, futibatinib, erdafitinib and TYRA-300.

15. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 14, wherein the subject is a human subject.

16. 16. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 15, wherein the subject is under 18 years of age.

17. 16. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 15, wherein the subject is at least 18 years old.

18. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 17, wherein the subject has a closed epiphysis.

19. Improved muscle function a) Increased skeletal muscle strength, b) increased skeletal muscle tone; c) Increased skeletal muscle stamina, d) Increased skeletal muscle mass; e) reduced skeletal muscle fatigue; f) Increased cardiovascular endurance, g) Increased cardiovascular health, h) reduced exercise intolerance; i) Increased athletic performance, j) reduction of exercise-induced fatigue, and k) Decreased hypotonia 19. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 18, which is one or more of:

20. 20. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 19, wherein administration results in an increase in skeletal muscle mass and / or muscle / fat ratio (e.g., skeletal muscle / fat ratio) in a subject.

21. 21. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 20, wherein the subject has hypotonia.

22. 22. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 21, wherein said administration results in the treatment or prevention of musculoskeletal pain in a subject.

23. 23. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 22, wherein said administration results in an improvement in posture or a reduction in abnormal curvature of the spine.

24. 24. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 1 to 23, wherein said administration results in improvement of kyphosis, lordosis, spinal stenosis, or scoliosis.

25. 25. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 1 to 24, wherein the administration results in improvement of sleep apnea, obstructive sleep apnea, or otitis media (e.g., acute otitis media).

26. 26. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 25, wherein said administration results in a reduction in obesity.

27. 27. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 1 to 26, wherein the subject has a chondrodysplasia disease, such as a disease selected from the group consisting of achondroplasia, hypochondroplasia, and lethal osteodysplasia.

28. 28. The FGFR3 signaling inhibitor, NPR-B agonist, or NPR-C agonist for use according to any one of claims 1 to 27, wherein the subject has a RAS disease, for example a RAS disease selected from the group consisting of neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardio-facio-cutaneous syndrome, and Legius syndrome.

29. 29. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 28, wherein the subject has a disease or condition associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

30. 30. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 29, wherein the neurodegenerative disease is selected from the group consisting of Parkinson's disease, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), ataxia such as Friedreich's ataxia (FRDA), and Huntington's disease (HD).

31. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to claim 29 or 30, wherein the disease or condition associated with impaired neuromuscular function is a disease or condition in which mitochondrial dysfunction is present.

32. 32. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 29 to 31, wherein said treatment results in a reduction in the decline of muscle function.

33. 33. The FGFR3 signaling inhibitor, NPR-B agonist or NPR-C agonist for use according to any one of claims 1 to 32, wherein the method further comprises the administration of a growth hormone, such as human growth hormone or a prodrug thereof.

34. A method for improving muscle function in a subject suffering from a disease or condition that impairs muscle function, the method comprising the step of administering to the subject a therapeutically effective amount of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist.

35. The method according to claim 34, wherein the FGFR3 signaling inhibitor is an FGFR3 antagonist or an NPR-B agonist.

36. 36. The method of claim 34 or 35, wherein the NPR-B agonist is or comprises C-type natriuretic peptide (CNP).

37. 37. The method of any one of claims 34 to 36, wherein the NPR-C agonist is or comprises C-type natriuretic peptide (CNP).

38. The method of any one of claims 34 to 37, wherein the NPR-B agonist or NPR-C agonist is administered as a CNP conjugate or a pharmaceutically acceptable salt thereof.

39. The method according to any one of claims 34 to 38, wherein the NPR-B agonist or NPR-C agonist is a prodrug of CNP.

40. 40. The method of claim 38 or 39, wherein the CNP conjugate or CNP prodrug is a compound of formula (IIf'), a compound of formula (IIf), compound (1), or a pharmaceutically acceptable salt thereof.

41. 41. The method of any one of claims 38 to 40, wherein the method comprises administering to a subject continuous administrations of therapeutically effective amounts of a CNP conjugate and / or a prodrug of CNP, and wherein the sustained exposure of free CNP in the patient's plasma during the continuous administrations of the therapeutically effective amounts of the CNP conjugate and / or prodrug of CNP is at least about 1 pmol / L, e.g., at least about 4 pmol / L, e.g., from about 4 pmol / L to about 30 pmol / L.

42. The method of claim 41, wherein the method comprises administering to a subject continuous administration of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug, and wherein the sustained exposure of free CNP in the patient's plasma during the continuous administration of the therapeutically effective amount of a CNP conjugate and / or a CNP prodrug is at least about 9 pmol / L.

43. 43. The method of claim 41 or 42, wherein a therapeutically effective amount of the CNP conjugate and / or prodrug is administered once daily or once weekly.

44. 41. The method of any one of claims 36 to 40, comprising administering to a subject an infusion, e.g., an iv or sc infusion, of CNP, wherein the infusion results in a sustained exposure of free CNP in the patient's plasma of at least 1 pmol / L, e.g., at least about 4 pmol / L, e.g., about 9 pmol / L or about 4 pmol / L to about 30 pmol / L, for a period of at least 1 hour.

45. 45. The method of any one of claims 34 to 44, wherein the NPR-B agonist is or comprises vosoritide (SEQ ID NO: 30).

46. 36. The method of claim 35, wherein the FGFR3 antagonist is an FGFR3 tyrosine kinase inhibitor.

47. 47. The method of claim 46, wherein the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of infigratinib, pemigatinib, futibatinib, erdafitinib, and TYRA-300.

48. 48. The method of any one of claims 34 to 47, wherein the subject is a human subject.

49. 49. The method of claim 48, wherein the subject is under 18 years of age.

50. 49. The method of claim 48, wherein the subject is at least 18 years of age.

51. 51. The method of any one of claims 34 to 50, wherein the subject has a closed epiphysis.

52. Improved muscle function a) Increased skeletal muscle strength, b) increased skeletal muscle tone; c) Increased skeletal muscle stamina, d) Increased skeletal muscle mass; e) reduced skeletal muscle fatigue; f) Increased cardiovascular endurance, g) Increased cardiovascular health, h) reduced exercise intolerance; i) Increased athletic performance, j) reduction of exercise-induced fatigue, and k) Decreased hypotonia 52. The method of any one of claims 34 to 51, wherein the method is one or more of:

53. 53. The method of any one of claims 34 to 52, wherein the administration results in an increase in skeletal muscle mass and / or muscle / fat ratio (e.g., skeletal muscle / fat ratio) in the subject.

54. 54. The method of any one of claims 34 to 53, wherein the subject has hypotonia.

55. said administering a. treating or preventing musculoskeletal pain in a subject; and / or b. Improved posture or reduction of abnormal curvatures of the spine; and / or c. Improvement of kyphosis, lordosis, spinal stenosis, or scoliosis; and / or d. improvement of sleep apnea, obstructive sleep apnea, or otitis media (e.g., acute otitis media); and / or e. Reduction of obesity The method of any one of claims 34 to 54, wherein

56. 57. The method of any one of claims 34 to 56, wherein the subject has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia, and tothotopic skeletal dysplasia.

57. 58. The method of any one of claims 34 to 57, wherein the subject has a RAS disease, such as a RAS disease selected from the group consisting of neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardio-facio-cutaneous syndrome, and Legius syndrome.

58. 58. The method of any one of claims 34 to 57, wherein the subject has a disease or condition associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

59. 59. The method of claim 58, wherein the neurodegenerative disease is selected from the group consisting of Parkinson's disease, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), ataxia, such as Friedreich's ataxia (FRDA), and Huntington's disease (HD).

60. 60. The method of any one of claims 58 or 59, wherein the disease or condition associated with impaired neuromuscular function is a disease or condition in which mitochondrial dysfunction is present.

61. 61. The method of any one of claims 58 to 60, wherein said treatment results in a reduction in the decline of muscle function.

62. 62. The method of any one of claims 34 to 61, further comprising the administration of a growth hormone, such as human growth hormone or a prodrug thereof.

63. Use of an FGFR3 signaling inhibitor, an NPR-B agonist, or an NPR-C agonist in the manufacture of a medicament for improving muscle function in a subject suffering from a disease or condition in which muscle function is impaired.

64. 64. The use according to claim 63, wherein the FGFR3 signaling inhibitor is an FGFR3 antagonist or an NPR-B agonist.

65. 65. The use of claim 63 or 64, wherein the NPR-B agonist is or comprises C-type natriuretic peptide (CNP).

66. 66. The use of any one of claims 63 to 65, wherein the NPR-C agonist is or comprises C-type natriuretic peptide (CNP).

67. 67. The use of any one of claims 63 to 66, wherein the NPR-B agonist or NPR-C agonist is administered as a CNP conjugate or a pharmaceutically acceptable salt thereof.

68. The use according to any one of claims 63 to 67, wherein the NPR-B agonist or NPR-C agonist is a prodrug of CNP.

69. The use according to claim 67 or 68, wherein the CNP conjugate or CNP prodrug is a compound of formula (IIf'), a compound of formula (IIf), compound (1) or a pharmaceutically acceptable salt thereof.

70. The use of any one of claims 67 to 69, wherein the medicament is for administration by a method comprising the step of administering to a subject continuous administration of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug, and wherein the sustained exposure of free CNP in the patient's plasma during the continuous administration of the therapeutically effective amount of a CNP conjugate and / or a CNP prodrug is at least about 1 pmol / L, for example at least about 4 pmol / L, for example from about 4 pmol / L to about 30 pmol / L.

71. The use described in claim 70, wherein the method comprises administering to a subject continuous administration of a therapeutically effective amount of a CNP conjugate and / or a CNP prodrug, and wherein the sustained exposure of free CNP in the patient's plasma during the continuous administration of the therapeutically effective amount of a CNP conjugate and / or a CNP prodrug is at least about 9 pmol / L.

72. 72. The use of claim 70 or 71, wherein a therapeutically effective amount of the CNP conjugate and / or prodrug is administered once daily or once weekly.

73. 70. The use of any one of claims 65 to 69, wherein the medicament is for administration by a method comprising administering to a subject an infusion, e.g., an iv or sc infusion, of CNP, wherein the infusion results in a sustained exposure of free CNP in the patient's plasma of at least 1 pmol / L, e.g., at least about 4 pmol / L, e.g., about 9 pmol / L or from about 4 pmol / L to about 30 pmol / L, over a period of at least 1 hour.

74. 74. The use according to any one of claims 63 to 73, wherein the NPR-B agonist is or comprises vosoritide (SEQ ID NO: 30).

75. 65. The use of claim 64, wherein the FGFR3 antagonist is an FGFR3 tyrosine kinase inhibitor.

76. 76. The use according to claim 75, wherein the FGFR3 tyrosine kinase inhibitor is selected from the group consisting of infigratinib, pemigatinib, futibatinib, erdafitinib and TYRA-300.

77. 77. The use according to any one of claims 63 to 76, wherein the subject is a human subject.

78. 78. The use of claim 77, wherein the subject is under 18 years of age.

79. 78. The use of claim 77, wherein the subject is at least 18 years of age.

80. 80. The use of any one of claims 63 to 79, wherein the subject has a closed epiphysis.

81. Improved muscle function a) Increased skeletal muscle strength, b) increased skeletal muscle tone; c) Increased skeletal muscle stamina, d) Increased skeletal muscle mass; e) reduced skeletal muscle fatigue; f) Increased cardiorespiratory endurance; g) Increased cardiovascular health, h) reduced exercise intolerance; i) Increased athletic performance, j) reduction of exercise-induced fatigue, and k) Decreased hypotonia 81. The use according to any one of claims 63 to 80, wherein the use is one or more of:

82. 82. The use of any one of claims 63 to 81, wherein administration of the medicament results in an increase in skeletal muscle mass and / or muscle / fat ratio (e.g. skeletal muscle / fat ratio) in the subject.

83. The use of any one of claims 63 to 82, wherein the subject has hypotonia.

84. The administration of the medicine a. treating or preventing musculoskeletal pain in a subject; and / or b. Improved posture or reduction of abnormal curvatures of the spine; and / or c. Improvement of kyphosis, lordosis, spinal stenosis, or scoliosis; and / or d. improvement of sleep apnea, obstructive sleep apnea, or otitis media (e.g., acute otitis media); and / or e. Reduction of obesity Use according to any one of claims 63 to 83, resulting in

85. 85. The use of any one of claims 63 to 84, wherein the subject has a chondrodysplasia disorder, such as a disorder selected from the group consisting of achondroplasia, hypochondroplasia and tothotopic skeletal dysplasia.

86. 86. The use of any one of claims 63 to 85, wherein the subject has a RAS disease, such as a RAS disease selected from the group consisting of neurofibromatosis type 1 (NF1), Noonan syndrome, Noonan syndrome with multiple lentigines, capillary malformation-arteriovenous malformation syndrome, Costello syndrome, cardio-facio-cutaneous syndrome, and Legius syndrome.

87. 87. The use according to any one of claims 63 to 86, wherein the subject has a disease or condition associated with impaired neuromuscular function, such as a neuromuscular disease or a neurodegenerative disease.

88. 88. The use of claim 87, wherein the neurodegenerative disease is selected from the group consisting of Parkinson's disease, Alzheimer's disease, multiple sclerosis, amyotrophic lateral sclerosis (ALS), ataxias such as Friedreich's ataxia (FRDA), and Huntington's disease (HD).

89. 89. The use according to claim 87 or 88, wherein the disease or condition associated with impaired neuromuscular function is a disease or condition in which mitochondrial dysfunction is present.

90. 90. The use of any one of claims 87 to 89, wherein the treatment results in a reduction in the decline of muscle function.

91. 91. Use according to any one of claims 63 to 90, wherein the medicament is for administration in a method further comprising the administration of a growth hormone, such as human growth hormone or a prodrug thereof.

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