Potent transthyretin (TTR) stabilization in patients with TTR amyloidosis receiving acoramidis

Abstract

Described herein are methods for treating transthyretin (TTR) amyloidosis with Compound 1 in subjects with specific mutations in the TTR protein (Compound 1). The methods involve specific dosing regimens that are highly effective in treating the subjects and are well tolerated by the subjects. JPEG2026508526000012.jpg22128

Description

[Technical Field]

[0001] (CROSS-REFERENCE TO RELATED APPLICATIONS) This application claims the benefit of priority under 35 U.S.C. § 119 to U.S. Provisional Application Nos. 63 / 487,801, filed March 1, 2023, and 63 / 516,757, filed July 31, 2023, the entire disclosures of each of which are incorporated herein by reference.

[0002] STATEMENT OF RIGHTS TO INVENTIONS MADE UNDER FEDERALLY SPONSORED RESEARCH AND DEVELOPMENT Not applicable

[0003] Reference to a "Sequence Listing," table, or computer program listing appendix submitted on a compact disc This application incorporates by reference the entire 4,096 byte Sequence Listing entitled 051418-510001WO.xml, filed February 27, 2024, and submitted in computer readable form herewith. [Background technology]

[0004] Aberrant protein interactions and aggregation, either due to protein misfolding or overactivation of signaling pathways, are the underlying causes of many human degenerative diseases, and therefore targeting protein-protein interactions (PPIs) has attracted considerable interest.

[0005] One such example of abnormal protein aggregation is the soluble protein transthyretin (TTR or prealbumin). TTR is a 55 kDa homotetrameric protein present in blood and cerebrospinal fluid. Upon dissociation from its homotetrameric form, TTR dimers can misfold into amyloidogenic monomers. This has been observed in wild-type TTR as well as over 100 different mutated variants. Studies have shown that stabilizing the tetrameric form of TTR inhibits the misfolding of amyloidogenic monomers and subsequent TTR amyloid formation and deposition.

[0006] A benzoxazole derivative called tafamidis (2-(3,5-dichlorophenyl)-1,3-benzoxazole-6-carboxylic acid) has been described to inhibit abnormal TTR aggregation and fibrillation. Tafamidis was approved by the U.S. Food and Drug Administration (FDA) in May 2019 as the first approved medication for the treatment of cardiomyopathy in adults with wild-type or hereditary TTR-mediated amyloidosis to reduce cardiovascular mortality and cardiovascular-related hospitalizations.

[0007] Acoramidis (3-(3-(3,5-dimethyl-1H-pyrazol-4-yl)propoxy)-4-fluorobenzoic acid, also known as AG10) is another compound in development for the treatment of TTR amyloid-related diseases. This compound is a highly potent stabilizer of the TTR tetramer, but has not yet been approved by the FDA.

[0008] Thus, there is a need in the art to provide methods for treating abnormal TTR aggregation and fibrillation using Acoramidis. The present disclosure addresses these needs and provides related advantages as well. Summary of the Invention

[0009] In some embodiments, there is provided a method of treating transthyretin (TTR) amyloidosis in a subject in need thereof, comprising administering to a subject in need thereof a therapeutically effective amount of a compound of the formula: [ka] Compound 1 having the formula or a pharmaceutically acceptable salt thereof, wherein the therapeutically effective amount is a total daily dosage of about 10 milligrams (mg) to about 2,000 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

[0010] In some embodiments, the TTR amyloidosis in the subject is a glycine to serine mutation at position 6 (G6S), an alanine to serine mutation at position 25 (A25S); a valine to methionine mutation at position 30 (V30M); an alanine to aspartic acid mutation at position 36 (A36D); a glutamic acid to aspartic acid mutation at position 42 (E42D); a serine to arginine mutation at position 50 (S50R); a threonine-to-alanine mutation at position 60 (T60A); an isoleucine to leucine mutation at position 68 (I68L); a glutamic acid to glutamine mutation at position 89 (E89Q); a glutamic acid to glutamine mutation at position 92 (E92Q); a valine to leucine mutation at position 94 (V94L); a valine to isoleucine mutation at position 122 (V122I); an alanine to serine mutation at position 97 (A97S); an aspartic acid to alanine mutation at position 38 (D38A); a phenylalanine to leucine mutation at position 64 (F64L); a leucine to histidine mutation at position 58 (L58H); a proline to serine mutation at position 24 (P24S), and and a tyrosine to cysteine ​​mutation at position 114 (Y114C).

[0011] In some embodiments, the TTR amyloidosis in the subject is a glycine to serine mutation at position 6 (G6S), an alanine to serine mutation at position 25 (A25S); an alanine to aspartic acid mutation at position 36 (A36D); a glutamic acid to aspartic acid mutation at position 42 (E42D); a serine to arginine mutation at position 50 (S50R); an isoleucine to leucine mutation at position 68 (I68L); a glutamic acid to glutamine mutation at position 89 (E89Q); a glutamic acid to glutamine mutation at position 92 (E92Q); a valine to leucine mutation at position 94 (V94L), and and an alanine to serine mutation at position 97 (A97S).

[0012] In some embodiments, the total daily dose of Compound 1 or a pharmaceutically acceptable salt thereof is about 800 mg. In some embodiments, the total daily dose of Compound 1 or a pharmaceutically acceptable salt thereof is about 1,500 to about 1,700 mg. In some embodiments, the total daily dose of Compound 1 or a pharmaceutically acceptable salt thereof is about 1,600 mg. In some embodiments, the total daily dose of Compound 1 or a pharmaceutically acceptable salt thereof is about 1,100 to about 1,300 mg. In some embodiments, the total daily dose of Compound 1 or a pharmaceutically acceptable salt thereof is about 1,236 mg. In some embodiments, the HCl salt form of Compound 1 is administered.

[0013] In some embodiments, the total daily dose is about 800 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt form. In some embodiments, the total daily dose is about 1,500 to about 1,600 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt form. In some embodiments, the total daily dose is about 1,600 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt form. In some embodiments, the total daily dose is about 1,100 to about 1,300 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt form. In some embodiments, the total daily dose is about 1,236 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt form.

[0014] In some embodiments, Compound 1 is administered once daily. In some embodiments, Compound 1 is administered twice daily.

[0015] Other objects, features, and advantages of the present invention will become apparent to those skilled in the art from the following detailed description and drawings. [Brief explanation of the drawings]

[0016] [Figure 1]Percent Western blot stabilization for certain variants of TTR in the presence of Compound 1 (acoramidis, left column (10 μM)), or tafamidis (middle column (26 μM) and right column (16 μM)) is plotted. SD is shown only for conditions with more than one sample.

[0017] [Figure 2] A gel from a Western blot assay of an individual V112I patient sample is shown. All conditions were run in duplicate lanes. Brackets indicate bands corresponding to tetrameric TTR with or without retinol binding protein (RBP).

[0018] [Figure 3] 1 shows the time course of FPE in individuals with the V122I TTR mutation. The doses tested were acoramidis 10 μM, also referred to herein as Compound 1, tafamidis 26 μM (closed circles), tafamidis 16 μM (closed triangles), and DMSO (open circles).

[0019] [Figure 4] The percent stabilization of TTR FPE for each mutant is shown. For each mutant, the left column is 10 μM acoramidis, also referred to herein as Compound 1, the middle column is 26 μM tafamidis, and the right column is 16 μM tafamidis.

[0020] [Figure 5A] Stabilization of unique mutant patient samples as measured by (5A) Western blot (WB) and (5B) fluorescent probe exclusion (FPE) is shown, with wild-type (WT) results as a reference. For panel (5A), Acoramidis, also referred to herein as Compound 1, is the left column. DMSO is the right column. (5C) Overall stabilization across all mutant samples tested as measured by WB and (5D) FPE. [Figure 5B] Stabilization of unique mutant patient samples as measured by (5A) Western blot (WB) and (5B) fluorescent probe exclusion (FPE) is shown, with wild-type (WT) results as a reference. For panel (5A), Acoramidis, also referred to herein as Compound 1, is the left column. DMSO is the right column. (5C) Overall stabilization across all mutant samples tested as measured by WB and (5D) FPE. [Figure 5C] Stabilization of unique mutant patient samples as measured by (5A) Western blot (WB) and (5B) fluorescent probe exclusion (FPE) is shown, with wild-type (WT) results as a reference. For panel (5A), Acoramidis, also referred to herein as Compound 1, is the left column. DMSO is the right column. (5C) Overall stabilization across all mutant samples tested as measured by WB and (5D) FPE. [Figure 5D] Stabilization of unique mutant patient samples as measured by (5A) Western blot (WB) and (5B) fluorescent probe exclusion (FPE) is shown, with wild-type (WT) results as a reference. For panel (5A), Acoramidis, also referred to herein as Compound 1, is the left column. DMSO is the right column. (5C) Overall stabilization across all mutant samples tested as measured by WB and (5D) FPE.

[0021] [Figure 6A]Figure 6 shows Phase 3 ATTRibute-CM results in patients receiving Compound 1 (800 mg twice daily) at a total daily dose of 1,600 mg or placebo. Results demonstrate that ex vivo TTR stabilization correlates with in vivo measurements of serum TTR. (6A) shows the mean change from baseline in serum TTR at Month 30, (6B) shows the median % WB stabilization at Month 30, (6C) shows the median % FPE stabilization at Month 30, (6D) is a waterfall plot of % WB stabilization for mutant patients at Month 30, and (6E) is a waterfall plot of mutant patients' change from baseline in serum TTR at Month 30. Note: mutant = mutant TTR genotype. ATTRibute-CM participants had the option of receiving concomitant tafamidis in addition to blinded acoramidis or placebo in the study. For individuals receiving concomitant tafamidis, the average time on tafamidis in the study was 11 months. [Figure 6B] Figure 6 shows Phase 3 ATTRibute-CM results in patients receiving Compound 1 (800 mg twice daily) at a total daily dose of 1,600 mg or placebo. Results demonstrate that ex vivo TTR stabilization correlates with in vivo measurements of serum TTR. (6A) shows the mean change from baseline in serum TTR at Month 30, (6B) shows the median % WB stabilization at Month 30, (6C) shows the median % FPE stabilization at Month 30, (6D) is a waterfall plot of % WB stabilization for mutant patients at Month 30, and (6E) is a waterfall plot of mutant patients' change from baseline in serum TTR at Month 30. Note: mutant = mutant TTR genotype. ATTRibute-CM participants had the option of receiving concomitant tafamidis in addition to blinded acoramidis or placebo in the study. For individuals receiving concomitant tafamidis, the average time on tafamidis in the study was 11 months. [Figure 6C]Figure 6 shows Phase 3 ATTRibute-CM results in patients receiving Compound 1 (800 mg twice daily) at a total daily dose of 1,600 mg or placebo. Results demonstrate that ex vivo TTR stabilization correlates with in vivo measurements of serum TTR. (6A) shows the mean change from baseline in serum TTR at Month 30, (6B) shows the median % WB stabilization at Month 30, (6C) shows the median % FPE stabilization at Month 30, (6D) is a waterfall plot of % WB stabilization for mutant patients at Month 30, and (6E) is a waterfall plot of mutant patients' change from baseline in serum TTR at Month 30. Note: mutant = mutant TTR genotype. ATTRibute-CM participants had the option of receiving concomitant tafamidis in addition to blinded acoramidis or placebo in the study. For individuals receiving concomitant tafamidis, the average time on tafamidis in the study was 11 months. [Figure 6D] Figure 6 shows Phase 3 ATTRibute-CM results in patients receiving Compound 1 (800 mg twice daily) at a total daily dose of 1,600 mg or placebo. Results demonstrate that ex vivo TTR stabilization correlates with in vivo measurements of serum TTR. (6A) shows the mean change from baseline in serum TTR at Month 30, (6B) shows the median % WB stabilization at Month 30, (6C) shows the median % FPE stabilization at Month 30, (6D) is a waterfall plot of % WB stabilization for mutant patients at Month 30, and (6E) is a waterfall plot of mutant patients' change from baseline in serum TTR at Month 30. Note: mutant = mutant TTR genotype. ATTRibute-CM participants had the option of receiving concomitant tafamidis in addition to blinded acoramidis or placebo in the study. For individuals receiving concomitant tafamidis, the average time on tafamidis in the study was 11 months. [Figure 6E]Figure 6 shows Phase 3 ATTRibute-CM results in patients receiving Compound 1 (800 mg twice daily) at a total daily dose of 1,600 mg or placebo. Results demonstrate that ex vivo TTR stabilization correlates with in vivo measurements of serum TTR. (6A) shows the mean change from baseline in serum TTR at Month 30, (6B) shows the median % WB stabilization at Month 30, (6C) shows the median % FPE stabilization at Month 30, (6D) is a waterfall plot of % WB stabilization for mutant patients at Month 30, and (6E) is a waterfall plot of mutant patients' change from baseline in serum TTR at Month 30. Note: mutant = mutant TTR genotype. ATTRibute-CM participants had the option of receiving concomitant tafamidis in addition to blinded acoramidis or placebo in the study. For individuals receiving concomitant tafamidis, the average time on tafamidis in the study was 11 months. DETAILED DESCRIPTION OF THE INVENTION

[0022] I. General Described herein are methods for treating transthyretin (TTR) amyloidosis in a subject. Surprisingly, subjects with certain mutations in TTR responded surprisingly well to treatment.

[0023] II. Definition While various embodiments and aspects of the present invention have been shown and described herein, it will be apparent to those skilled in the art that such embodiments and aspects are provided by way of example only. Numerous variations, changes, and substitutions will immediately occur to those skilled in the art without departing from the invention. It will be understood that various alternatives to the embodiments of the invention described herein may be employed in practicing the invention.

[0024] The section headings used herein are for organizational purposes only and should not be construed as limiting the subject matter described. All documents or portions of documents cited in this application, including but not limited to patents, patent applications, papers, books, manuals, and treatises, are expressly incorporated herein by reference in their entirety for any purpose.

[0025] Unless otherwise defined, technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art. See, for example, SINGLETON ET AL., DICTIONARY OF MICROBIOLOGY AND MOLECULAR BIOLOGY, 2ND ED., J. WILEY & SONS (NEW YORK, NY 1994); SAMBROOK ET AL., MOLECULAR CLONING, A LABORATORY MANUAL, COLD SPRINGS HARBOR PRESS (COLD SPRINGS HARBOR, NY 1989). Any methods, devices, and materials similar or equivalent to those described herein can be used in the practice of the present invention. The following definitions are provided to facilitate understanding of certain terms used frequently herein and are not intended to limit the scope of the present disclosure.

[0026] "Compound 1" is a compound of the formula: [ka] the chemical 3-(3-(3,5-dimethyl-1H-pyrazol-4-yl)propoxy)-4-fluorobenzoic acid (AG10, Acoramidis), or a pharmaceutically acceptable salt thereof. When referring to a specific amount of Compound 1 administered to a patient, this application refers to the amount of the HCl salt of Compound 1 administered. One of ordinary skill in the art will recognize that administering the same amount of Compound 1 in the form of the free base or a different salt may require a small adjustment to the overall amount administered. Compound 1 is described in International Patent Application No. PCT / US2013 / 076213, filed December 18, 2013, which is incorporated herein by reference in its entirety. Crystalline and salt forms of Compound 1, as well as methods for making them, are described in International Patent Application No. PCT / US2018 / 000025, filed February 16, 2018, which is incorporated herein by reference in its entirety. Methods of treatment with Compound 1 are described in International Patent Application No. PCT / US2019 / 023555, filed March 22, 2019, which is incorporated herein by reference in its entirety.

[0027] As used herein, the terms "a" or "an" mean one or more.

[0028] The terms "comprise," "include," and "have," and their derivatives, are used interchangeably herein as inclusive, open-ended terms. For example, the use of "comprising," "including," or "having" means that whatever element is included in, has, or is contained within is not the only element encompassed by the subject of the clause containing the verb.

[0029] As used herein, the term "about" refers to a range of values ​​that includes the specified value and that one of ordinary skill in the art would consider reasonably equivalent to the specified value. In some embodiments, the term "about" refers to within a standard deviation using generally accepted measurements in the art. In some embodiments, about refers to a range covering + / - 10% of the particular value. In some embodiments, about refers to the particular value.

[0030] As used herein, "treatment" or "treating" or "alleviating" or "ameliorating" are used interchangeably herein. These terms refer to an approach to obtaining beneficial or desired results, including, but not limited to, therapeutic benefit. Therapeutic benefit refers to the eradication or amelioration of the underlying disease being treated. Therapeutic benefit is also achieved by the eradication or amelioration of one or more physiological symptoms associated with the underlying disease, such that an improvement is observed in a subject, even though the subject may still be afflicted with the underlying disease. Treatment includes slowing the progression of clinical symptoms of the disease by administering a composition; suppressing the disease, i.e., causing a reduction in clinical symptoms of the disease; inhibiting the disease, i.e., preventing the onset of clinical symptoms by administering a composition after the first appearance of symptoms; and / or relieving the disease, i.e., causing the resolution of clinical symptoms by administering a composition after the first appearance of symptoms. For example, certain methods described herein include treating transthyretin (TTR) amyloidosis by decreasing or reducing the occurrence or progression of TTR fibril formation, or treating TTR amyloidosis by reducing the symptoms of TTR amyloidosis.

[0031] An "effective amount" or "pharmaceutically effective amount" is an amount sufficient to achieve a stated purpose (e.g., achieve the effect of its administration, treat a disease, reduce enzyme activity, reduce one or more symptoms of a disease or condition). An example of an "effective amount" is an amount sufficient to contribute to the treatment or reduction of a symptom or symptoms of a disease, which may also be referred to as a "therapeutically effective amount." A "reduction" of a symptom or symptoms (and grammatical equivalents of this phrase) refers to a decrease in the severity or frequency of the symptom, or the elimination of the symptom. Efficacy can also be expressed as a "-fold" increase or a "-fold" reduction. For example, a therapeutically effective amount can have at least a 1.2-fold, 1.5-fold, 2-fold, 5-fold, or more effect relative to a control.

[0032] "Patient" or "subject" or "subject in need thereof" refers to an organism suffering from or susceptible to a disease or condition that can be treated by using the methods provided herein. The term does not necessarily indicate that the subject has been diagnosed with a specific disease, but typically refers to an individual under medical supervision. Non-limiting examples include humans, other mammals, bovine, rats, mice, dogs, monkeys, goats, sheep, cows, deer, and other non-mammals. In some embodiments, the patient, subject, or subject in need is a human.

[0033] III. MODE FOR CARRYING OUT THE INVENTION method In one aspect, provided herein is a method of treating transthyretin (TTR) amyloidosis, comprising administering to a subject in need of treatment for TTR amyloidosis a therapeutically effective amount of a compound of the formula: [ka] Compound 1 having the formula or a pharmaceutically acceptable salt thereof, wherein the therapeutically effective amount is a total daily dose of about 10 milligrams (mg) to 2,000 mg. In some embodiments, the total daily dose of Compound 1 is about 10 mg to about 50 mg, about 50 mg to about 300 mg, about 50 mg to about 150 mg, about 150 mg to about 800 mg, about 800 mg to about 1,600 mg, about 1,100 mg to about 1,300 mg, or about 800 mg to about 2,000 mg. In some embodiments, the total daily dose of Compound 1 is about 10 mg to about 50 mg. In some embodiments, the total daily dose of Compound 1 is about 50 mg to about 300 mg. In some embodiments, the total daily dose of Compound 1 is about 50 mg to about 150 mg. In some embodiments, the total daily dose of Compound 1 is about 150 mg to about 800 mg. In some embodiments, the total daily dose of Compound 1 is about 800 mg to about 1,600 mg. In some embodiments, the total daily dose of Compound 1 is about 1,200 mg to about 1,600 mg. In some embodiments, the total daily dose of Compound 1 is about 800 mg to 2,000 mg. In some embodiments, the total daily dose of Compound 1 is about 1,100 mg to about 1,300 mg. In some embodiments, the total daily dose of Compound 1 is about 800 mg. In some embodiments, the total daily dose of Compound 1 is about 1,600 mg. In some embodiments, the total daily dose of Compound 1 is about 1,236 mg. It is understood that the amounts of Compound 1 listed in this disclosure are the amount of the HCl salt of Compound 1 administered. One of skill in the art will recognize that administering the same amount of Compound 1 in the form of the free base or a different salt may require small adjustments to the overall amount administered.

[0034] In some embodiments, the total daily dose of Compound 1 is about 10 mg. In some embodiments, the total daily dose of Compound 1 is about 25 mg. In some embodiments, the total daily dose of Compound 1 is about 50 mg. In some embodiments, the total daily dose of Compound 1 is about 1000 mg. In some embodiments, the total daily dose of Compound 1 is about 150 mg. In some embodiments, the total daily dose of Compound 1 is about 200 mg. In some embodiments, the total daily dose of Compound 1 is about 300 mg. In some embodiments, the total daily dose of Compound 1 is about 600 mg. In some embodiments, the total daily dose of Compound 1 is about 800 mg. In some embodiments, the total daily dose of Compound 1 is about 1,600 mg. In some embodiments, the total daily dose of Compound 1 is about 1,236 mg.

[0035] Compound 1 can be administered once (SID or qd), twice (BID or q12h), three times (TID), or four times (QID) per day. In some embodiments, Compound 1 is administered once per day. In some embodiments, Compound 1 is administered twice per day. In some embodiments, Compound 1 is administered three times per day. In some embodiments, Compound 1 is administered four times per day.

[0036] In some embodiments, about 50 mg of Compound 1 is administered once daily. In some embodiments, about 150 mg of Compound 1 is administered once daily. In some embodiments, about 300 mg of Compound 1 is administered once daily. In some embodiments, about 800 mg of Compound 1 is administered once daily. In some embodiments, about 1,236 mg of Compound 1 is administered once daily.

[0037] In some embodiments, about 100 mg of Compound 1 is administered twice daily. In some embodiments, about 300 mg of Compound 1 is administered twice daily. In some embodiments, about 400 mg of Compound 1 is administered twice daily. In some embodiments, about 800 mg of Compound 1 is administered twice daily.

[0038] In another aspect, provided herein is a method of treating transthyretin (TTR) amyloidosis, comprising administering to a subject in need of treatment for TTR amyloidosis a therapeutically effective amount of a compound of the formula: [ka] Compound 1 having the formula or a pharmaceutically acceptable salt thereof, wherein a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of at least about 5 micromolar (μM). In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of at least about 6 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of at least about 6.5 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of at least about 7 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of at least about 7.5 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of at least about 8 μM.

[0039] In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of about 5 to about 30 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of about 5 to about 25 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of about 6 to about 20 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of about 7.5 to about 15 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of about 7.5 to about 10 μM. In some embodiments, a therapeutically effective amount of Compound 1 maintains a trough steady-state plasma concentration of Compound 1 of about 8 to about 10 μM.

[0040] In some embodiments, subjects receiving a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof experience an increase in serum concentrations of transthyretin (TTR) compared to baseline levels. In some embodiments, subjects receiving a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof experience an increase in serum concentrations of transthyretin (TTR) of at least about 10, 15, 20, 25, 30%, or more compared to baseline levels after 28 days of treatment. In some embodiments, subjects receiving a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof experience an increase in serum concentrations of transthyretin (TTR) of at least about 25%, or more compared to baseline levels after 28 days of treatment. In some embodiments, subjects have TTR serum levels below baseline serum TTR concentrations (20 mg / dL TTR) before treatment. In some embodiments, subjects receiving an effective amount of Compound 1 or a pharmaceutically acceptable salt thereof for 28 days experience an increase in serum TTR levels such that serum TTR levels are above baseline levels. In some embodiments, the subject experiencing increased TTR levels is a subject diagnosed with transthyretin amyloidosis (ATTR) cardiomyopathy.

[0041] In some embodiments, the TTR amyloidosis in the subject is a glycine to serine mutation at position 6 (G6S), an alanine to serine mutation at position 25 (A25S); a valine to methionine mutation at position 30 (V30M); an alanine to aspartic acid mutation at position 36 (A36D); a glutamic acid to aspartic acid mutation at position 42 (E42D); a serine to arginine mutation at position 50 (S50R); a threonine-to-alanine mutation at position 60 (T60A); an isoleucine to leucine mutation at position 68 (I68L); a glutamic acid to glutamine mutation at position 89 (E89Q); a glutamic acid to glutamine mutation at position 92 (E92Q); a valine to leucine mutation at position 94 (V94L); a valine to isoleucine mutation at position 122 (V122I); an alanine to serine mutation at position 97 (A97S); an aspartic acid to alanine mutation at position 38 (D38A); a phenylalanine to leucine mutation at position 64 (F64L); a leucine to histidine mutation at position 58 (L58H); a proline to serine mutation at position 24 (P24S), and and a tyrosine to cysteine ​​mutation at position 114 (Y114C). The wild-type transthyretin (TTR) protein is provided herein as SEQ ID NO: 1.

[0042] In some embodiments, the TTR amyloidosis in the subject is a glycine to serine mutation at position 6 (G6S), an alanine to serine mutation at position 25 (A25S); an alanine to aspartic acid mutation at position 36 (A36D); a glutamic acid to aspartic acid mutation at position 42 (E42D); a serine to arginine mutation at position 50 (S50R); an isoleucine to leucine mutation at position 68 (I68L); a glutamic acid to glutamine mutation at position 89 (E89Q); a glutamic acid to glutamine mutation at position 92 (E92Q); a valine to leucine mutation at position 94 (V94L), and and an alanine to serine mutation at position 97 (A97S). The wild-type transthyretin (TTR) protein is provided herein as SEQ ID NO: 1.

[0043] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a glycine to serine mutation at position 6 (G6S).

[0044] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing an alanine to serine mutation at position 25 (A25S).

[0045] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a valine to methionine mutation at position 30 (V30M).

[0046] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing an alanine to aspartic acid mutation at position 36 (A36D).

[0047] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a glutamic acid to aspartic acid mutation at position 42 (E42D).

[0048] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a serine to arginine mutation at position 50 (S50R).

[0049] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a threonine to alanine mutation at position 60 (T60A).

[0050] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing an isoleucine to leucine mutation at position 68 (I68L).

[0051] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a glutamic acid to glutamine mutation at position 89 (E89Q).

[0052] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a glutamic acid to glutamine mutation at position 92 (E92Q).

[0053] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a valine to leucine mutation at position 94 (V94L).

[0054] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a valine to isoleucine mutation at position 122 (V122I).

[0055] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing an alanine to serine mutation at position 97 (A97S).

[0056] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing an aspartic acid to alanine mutation at position 38 (D38A).

[0057] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a phenylalanine to leucine mutation at position 64 (F64L).

[0058] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a leucine to histidine mutation at position 58 (L58H).

[0059] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a proline to serine mutation at position 24 (P24S).

[0060] In some embodiments, the TTR amyloidosis in the subject is characterized by a TTR protein containing a tyrosine to cysteine ​​mutation at position 114 (Y114C).

[0061] There are a variety of diseases or disorders associated with transthyretin (TTR) amyloidosis, including, but not limited to, familial amyloid polyneuropathy, familial amyloid cardiomyopathy, senile systemic amyloidosis, cardiac amyloidosis, ocular amyloidosis, leptomeningeal amyloidosis, ocular-leptomeningeal amyloidosis, vitreous amyloidosis, gastrointestinal amyloidosis, neuropathic amyloidosis, non-neuropathic amyloidosis, non-hereditary amyloidosis, reactive / secondary amyloidosis, and cerebral amyloidosis.

[0062] In some embodiments, the transthyretin (TTR) amyloidosis disease is transthyretin amyloidosis (ATTR) cardiomyopathy. In some embodiments, the transthyretin (TTR) amyloidosis disease is transthyretin amyloidosis (ATTR) polyneuropathy.

[0063] ATTR cardiomyopathy includes wild-type ATTR cardiomyopathy (ATTRwt-CM) and genetic (familial) ATTR cardiomyopathy (ATTRm-CM). ATTRm-CM is caused by a mutation in the TTR protein, while ATTRwt-CM is not. Instead, ATTRwt-CM is generally an age-related process. In some embodiments, the ATTR cardiomyopathy is ATTRwt-CM. In some embodiments, the ATTR cardiomyopathy is ATTRm-CM.

[0064] ATTR polyneuropathy includes both wild-type ATTR polyneuropathy and genetic (familial) ATTR polyneuropathy. As mentioned for cardiomyopathy, ATTRm-PN is caused by mutations in the TTR protein, while ATTRwt-PN does not contain a genetic component. In some embodiments, ATTR-PN is ATTRwt-PN. In some embodiments, ATTR-PN is ATTRm-PN.

[0065] ATTR cardiomyopathy (both wild-type and familial) is a slowly progressive disease that causes heart failure and death in affected subjects. The disclosed methods provide clinical improvement in subjects with ATTR cardiomyopathy by halting or slowing the accumulation of TTR fibers in the myocardium. Through this process, the methods described herein provide clinical improvement in subjects with ATTR cardiomyopathy. Clinical improvement includes, but is not limited to, improvement in New York Heart Association (NYHA) functional class, Kansas City Cardiomyopathy Questionnaire response, improvement in EuroQoL-5 items (EQ-5D-5L), improvement in 6-minute walk test performance, improvement in markers related to heart health, such as troponin T, troponin I, B-type natriuretic peptide (BNP), and N-terminal pro-BNP, a reduction in the frequency of cardiovascular-related hospitalizations, and / or a reduction in mortality.

[0066] In some embodiments, the methods provided herein improve, stabilize, or delay the deterioration of a subject's New York Heart Association (NYHA) functional class. The NYHA functional class grades the severity of heart failure symptoms into one of four functional classes. The NYHA functional class is widely used in clinical practice and research because it provides a standard description of severity that can be used to assess response to treatment and guide management. The NYHA functional class is based on the severity of symptoms and physical activity limitations. Class I: No limitation of physical activity. Ordinary physical activity does not cause undue shortness of breath, fatigue, or palpitations. Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in excessive shortness of breath, fatigue, or palpitations. Class III: Severe limitation of physical activity. Comfortable at rest, but less than normal physical activity results in excessive shortness of breath, fatigue, or palpitations. Class IV: Inability to carry on any physical activity without discomfort. Rest symptoms may be present. Discomfort increases when any physical activity is undertaken.

[0067] In some embodiments, administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof reduces the subject's New York Heart Association (NYHA) functional class. In some embodiments, administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof in a subject with ATTR cardiomyopathy improves, stabilizes, or delays deterioration in the subject's New York Heart Association (NYHA) functional class. In some embodiments, administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof reduces the subject's NYHA functional class. In some embodiments, the NYHA functional class is reduced from Class IV to Class III, from Class IV to Class II, or from Class IV to Class I. In some embodiments, the NYHA functional class is reduced from Class IV to Class III. In some embodiments, the NYHA functional class is reduced from Class IV to Class II. In some embodiments, the NYHA functional class is reduced from Class III to Class II. In some embodiments, the NYHA functional class is reduced from Class III to Class II. In some embodiments, the NYHA functional class is reduced from Class III to Class I. In some embodiments, the NYHA functional class is reduced from Class II to Class I.

[0068] In some embodiments, the methods provided herein improve, stabilize, or delay deterioration in a subject's Kansas City Cardiomyopathy Questionnaire (KCCQ) classification. In some embodiments, the methods described herein provide an improved score on the Kansas City Cardiomyopathy Questionnaire (KCCQ) (Green CP, et al. (2000) Journal of the American College of Cardiology 35:1245-55), the contents of which are incorporated herein by reference for all purposes. The KCCQ includes specific questions related to cardiac health and provides a valid, reliable, and sensitive measure of disease-specific health-related quality of life.

[0069] The KCCQ questions ask subjects to rate how limited they are in carrying out usual aspects of their life (e.g., severely limited, very limited, moderately limited, slightly limited, or not limited at all). In some embodiments, the subject has a mean improvement of at least one level (e.g., from severely limited to very limited, from very limited to moderately limited, from moderately limited to slightly limited) for all questions on the questionnaire after treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0070] In some embodiments, the methods provided herein improve, stabilize, or delay the deterioration of a subject's EuroQoL-5 item (EQ-5D-5L) score. The EQ-5D-5L is a brief, self-administered, general-purpose health status assessment that takes approximately five minutes to complete. This assessment includes two parts. In the first part, respondents are asked to rate their current health status on five items (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression), with each item having five levels of functioning (1—no problem, 2—slight problem, 3—moderate problem, 4—severe problem, and 5—extreme problem). The second part is the respondent's self-assessment of their current health status on a visual analog scale (EQ VAS) with rating items labeled "best possible health state" (score 100) and "worst possible health state" (score 0). The scores from the five items can be used to calculate a single index value, also known as a utility score. The EQ-5D-5L questionnaire is in the public domain and can be obtained from EuroQoL.

[0071] In some embodiments, patients undergoing the treatment methods described herein have a mean improvement in EuroQoL-5 item (EQ-5D-5L) utility score of at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 points. In some embodiments, patients undergoing the treatment methods described herein have a mean improvement in EuroQoL-5 item (EQ-5D-5L) utility score of at least 5 points.

[0072] In some embodiments, administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy improves the subject's risk of mortality, morbidity, and quality of life.

[0073] In some embodiments, the methods described herein improve a subject's performance on a 6-minute walk test. The 6-minute walk test (6MWT) is a 6-minute, self-paced, timed walk designed to assess a subject's level of functional capacity. Subjects are allowed to stop and rest during the test if their level of exertion exceeds their comfort level. Pre-treatment, post-treatment, and intra-treatment assessments are relatively easy to assess and consist of measuring the distance a subject walks in 6 minutes. Thus, in some embodiments, a subject increases the total distance traveled in a 6-minute walk test after treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, a subject walks at least 25 meters more than the baseline distance measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, a subject walks at least 30 meters more than the baseline distance measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, a subject walks at least 50 meters more than the baseline distance measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the subject walks at least 75 meters more than the baseline distance measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the subject walks at least 100 meters more than the baseline distance measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, a subject receiving a treatment method described herein experiences a slower decline in 6-minute walk distance. For example, in some embodiments, the subject maintains approximately the same 6-minute walk distance as before treatment. In some embodiments, the subject travels 10 meters less in a 6-minute walk test. In some embodiments, the 6-minute walk test is used to compare a treated group to an untreated group. In some embodiments, the mean change from baseline between groups is at least 10 meters. In some embodiments, the mean change from baseline between groups is at least 20 meters. In some embodiments, the mean change from baseline between groups is at least 30 meters.In some embodiments, the methods of treatment provided herein reduced the decline in 6-minute walk test distance compared to individuals not receiving the treatment.

[0074] In some embodiments, administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy reduces mortality compared to a subject not receiving treatment.

[0075] In some embodiments, administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy reduces all-cause mortality compared to untreated subjects.

[0076] Troponin T, troponin I, brain natriuretic peptide (BNP), and N-terminal proBNP are polypeptides that are elevated in serum blood of subjects with poor myocardial health. In some embodiments, the levels of troponin T, troponin I, BNP, and / or N-terminal proBNP are decreased after treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the levels of troponin T, troponin I, BNP, and / or N-terminal proBNP are decreased by about 10% compared to the baseline levels of troponin T, troponin I, BNP, and / or N-terminal proBNP in the subject before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the levels of troponin T, troponin I, BNP, and / or N-terminal proBNP are decreased by about 15% compared to the baseline levels of troponin T, troponin I, BNP, and / or N-terminal proBNP in the subject before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0077] In some embodiments, administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy reduces serum blood levels of brain natriuretic peptide (BNP).

[0078] In some embodiments, administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof in a subject with ATTR cardiomyopathy reduces serum blood levels of N-terminal pro-brain natriuretic peptide (N-terminal pro-BNP).

[0079] As discussed above, the clinical improvement provided in some embodiments of the disclosed methods is a reduction in the rate of cardiovascular-related hospitalizations in subjects receiving the treatment compared to those not receiving the treatment, hi some embodiments, patients experience an average of at least 0.5, 1, 1.5, 2, 3, 4, or 5 fewer cardiovascular-related hospitalizations per year compared to those not receiving the treatment.

[0080] An additional clinical benefit provided in some embodiments of the methods disclosed herein is a reduction in mortality compared to individuals not receiving the treatment, ie, by about 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30 percent or more compared to subjects not receiving the treatment.

[0081] ATTR polyneuropathy is a disease in which TTR amyloid (ATTR) deposits weaken or otherwise impair normal nerve function. ATTR polyneuropathy is a progressive disease that causes cachexia and death in affected subjects. The disclosed methods provide clinical improvement in subjects with ATTR polyneuropathy by halting or slowing the accumulation of TTR fibers. Through this process, the methods described herein provide clinical improvement in subjects with ATTR polyneuropathy. Clinical improvement includes, but is not limited to, improvement in the Neuropathy Impairment Score (NIS) or modified Neuropathy Impairment Score+7 (mNIS+7), improvement in the Norfolk Quality of Life Diabetic Neuropathy Questionnaire, improvement in the Composite Autonomic Symptom Score (COMPASS-31) score, improvement in nutritional status as measured by modified body mass index (mBMI), and / or improvement in the subject's 10-meter walk test.

[0082] In some embodiments, the methods described herein provide an improved Neuropathy Score (NIS). NIS refers to a scoring system that measures weakness, sensation, and reflexes. The NIS score evaluates standard muscle groups for weakness (1 = 25% weakness, 2 = 50% weakness, 3 = 75% weakness, 3.25 = movement against gravity, 3.5 = movement with gravity removed, 3.75 = slight muscle contraction without movement, 4 = paralysis), standard muscle stretch reflex groups (0 = normal, 1 = decreased, 2 = absent), contact pressure, vibration, joint position and movement, and pinprick (all graded for the index finger and thumb: 0 = normal, 1 = decreased, 2 = absent). The evaluation is adjusted for age, sex, and physical strength.

[0083] In some embodiments, the methods described herein slow disease progression such that the rate of increase in NIS score is reduced compared to subjects not receiving Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein halt disease progression such that there is no change in NIS score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0084] In some embodiments, the methods described herein reduce the NIS score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the NIS score by at least 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, or 60% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the NIS score by at least 5% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the NIS score by at least 10% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the NIS score by at least 15% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0085] In some embodiments, the methods described herein provide an improved modified Neurological Impairment Score (mNIS+7). mNIS+7 refers to a clinical test-based assessment of neurological impairment (NIS) combined with electrophysiological measures of small and large nerve fiber function (NCS and QST) and autonomic function (postural blood pressure). The mNIS+7 score is a modification of the NIS+7 score (representing the NIS+7 tests). The NIS+7 analyzes the decrement and muscle stretch reflexes. Five of the seven tests include attributes of nerve conduction: peroneal nerve compound muscle action potential amplitude, motor nerve conduction velocity and motor nerve distal latency (MNDL), tibial MNDL, and sural sensory nerve action potential amplitude. These values ​​are corrected for age, sex, height, and weight variables. The remaining two of the seven tests include vibration detection threshold and heart rate reduction with deep breathing. The mNIS+7 score modifies the NIS+7 to take into account the use of smart somatosensory quantitative sensory testing, novel autonomic assessments, and the use of compound muscle action potentials of ulnar, peroneal, and tibial nerve amplitudes, and sensory nerve action potentials of the ulnar and sural nerves (Suanprasert, N. et al., Retrospective study of a TTR FAP cohort to modify NIS+7 for therapeutic trials, J. Neurol. Sci., 2014. 344(1-2):ppg. 121-128). Further details of the mNIS+7 test can be found in U.S. Patent Publication No. 2017 / 0307608, the contents of which are incorporated herein by reference for all purposes.

[0086] In some embodiments, the methods described herein slow disease progression such that the rate of increase in mNIS+7 score is reduced compared to subjects not receiving Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein halt disease progression such that there is no change in mNIS+7 score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0087] In some embodiments, the methods described herein reduce the mNIS+7 score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein improve the modified Neuropathy Score+7 (mNIS+7) in the subject. In some embodiments, the methods described herein reduce the mNIS+7 score by at least 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, or 60% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the mNIS+7 score by at least 5% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the mNIS+7 score by at least 10% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein reduce the mNIS+7 score by at least 15% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0088] In some embodiments, the methods described herein provide an improved score on the Norfolk Quality of Life Diabetic Neuropathy (QOL-DN) questionnaire. This questionnaire is well known to those skilled in the art and is a validated questionnaire that captures pain associated with large fiber, small fiber, and autonomic neuropathy. The questionnaire includes items related to symptoms experienced by the subject and questions related to the impact of neuropathy on the subject's daily activities.

[0089] In some embodiments, the methods described herein slow disease progression such that the rate of decline in Norfolk QOL-DN score is reduced compared to subjects not receiving Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein halt disease progression such that there is no change in Norfolk QOL-DN score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein slow disease progression such that there is no change in Norfolk QOL-DN score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

[0090] In some embodiments, the methods described herein improve the Norfolk QOL-DN score after treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein improve the Norfolk QOL-DN score by at least 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, or 60% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein improve the Norfolk QOL-DN score by at least 5% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein improve the Norfolk QOL-DN score by at least 10% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein improve the Norfolk QOL-DN score by at least 15% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof. In some embodiments, the methods described herein provide a change in the subject's Norfolk QOL-DN of about -1.5, -2.0, -2.5, -3.0, -3.5, -4.0, -4.5, -5.0, -5.5, -6.0, -6.7, -7.0, -7.5, -8.0, -8.5, -9.0, -9.5, or -10.0 as compared to the subject's baseline score.

[0091] In some embodiments, the methods disclosed herein provide an improved Composite Autonomic Symptom Score (COMPASS-31). The Composite Autonomic Symptom Score (COMPASS-31) is a patient questionnaire that assesses symptoms of autonomic neuropathy. In one embodiment, the methods of the present invention provide a subject with an improvement in their COMPASS-31 score relative to baseline. Such improvement can take the form of an increase in the subject's COMPASS-31 score of at least 0.1, e.g., at least 0.2, at least 0.3, at least 0.4, or at least 0.5, e.g., 0.1, 0.2, 0.3, 0.4, or 0.5, points. In some embodiments, the methods slow disease progression such that the COMPASS-31 score remains unchanged. In yet other embodiments, the methods of the present invention slow the rate at which the COMPASS-31 score declines, e.g., the rate at which the COMPASS-31 score declines in subjects treated with AG10 compared to the rate at which the COMPASS-31 score declines in subjects not treated with AG10.

[0092] In some embodiments, the methods disclosed herein provide improved nutritional status as measured by modified body mass index (mBMI), which is determined by multiplying an individual's BMI by the individual's serum albumin level. Calculating mBMI accounts for the contribution of edema to total body weight. In one embodiment, the methods of the present disclosure provide a subject with an improvement in mBMI relative to baseline. Such improvement can take the form of a reduction in mBMI score of about 2, 5, 7, 10, 12, 15, 20, or about 25. In other embodiments, the methods prevent an increase in mBMI index score, e.g., the methods result in a 0% increase in mBMI score. In yet other embodiments, the methods of the present invention slow the rate at which mBMI score increases, e.g., the rate at which mBMI score increases in subjects treated with AG10 compared to the rate at which mBMI score increases in subjects not treated with AG10.

[0093] In some embodiments, the methods disclosed herein provide an improvement in the 10-meter walk test (10MWT). This test measures an individual's walking speed over 10 meters. In one embodiment, the methods of the disclosure provide a subject with an increase from baseline in the 10-meter walk test. In some embodiments, the increase from baseline in the 10-meter walk test is about 0.025, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, or about 5.0 meters / second.

[0094] In some embodiments, the methods disclosed herein provide an improved Dyck / Rankin score. Dyck / Rankin scores are known in the art and are assigned by a physician after evaluating a patient's symptoms, neuropathy, and test results and determining the patient's ability to perform activities of daily living. Only impairments associated with peripheral neuropathy are graded. When determining whether a patient has difficulty or is unable to perform a particular task or activity of daily living, more than patient report should be used; physicians should use objective criteria. The scales (0-8) are outlined below. 0. No neuropathy Abnormal neuropathy with no symptoms (NSS<1), signs (NIS<2 points); or tests (e.g., 7 tests <97.5th percentile). 1. Minimal neurological impairment (only one of A, B, or C is abnormal) a) The test is the only abnormality (e.g., 7 tests >97.5th percentile); or b) Neuropathic signs are the only abnormality (e.g., NIS > 2 points); or c) Neuropathic symptoms are the only abnormality (e.g., NSS>1) 2. Minimal neurological impairment: 1a+1b. 3. Symptomatic neuropathy: 1a, 1a+1c; 1a+1c, or 1b+1c. Patients are able to carry on with normal activities of daily living, work, or recreational activities, and are able to fulfill normal family and social obligations. * Neuropathic symptoms: NSS ≥ 1 muscle weakness, atrophy, or spasms; negative or positive neuropathic sensory symptoms (N-NNS, P-NSS); or neuropathic autonomic symptoms. - Usual activities of daily living, work, recreation, and social and family activities. Despite neuropathic symptoms, patients are able to engage in normal activities, maintain normal patient household duties, and participate in recreational activities. Generally, patients are able to continue despite any motor, sensory, or autonomic symptoms. Patients may be unable to perform extraordinary activities, such as competitive sports, endurance activities, etc. 4. Symptomatic neurological impairment (as defined by a 3) interferes with and limits work, usual activities of daily living, recreational activities, or family and social obligations, but independent functioning is possible without the help of others. With this score, there is a clear limitation of usual* work, usual activities of daily living, recreational activities, family or social obligations* due to the neurological impairment. * The degree of motor, sensory, or autonomic symptoms or impairment is sufficient to limit the ability to work, perform usual activities of daily living, engage in recreational activities, or fulfill usual family and social responsibilities. Use of a cane or orthotic device would probably place the patient in this (or higher) category (then the patient would be in a lower category) unless the patient is able to perform "usual" activities of daily living, recreational activities, and fulfill social and family responsibilities. 5. Symptomatic neuropathy (defined as a 3) limits activities of daily living, work, and recreational activities. Assistance* from another caregiver (<2.5 hours / day) is required. Patients typically score this or higher (>5) if wheelchair use is essential for activities of daily living, recreational activities, or social and family responsibilities. * A family member or visiting nurse must provide daily management of activities of daily living (bathing, shaving, brushing teeth, eating, etc.), pain medications or sedatives, or help manage autonomic dysfunction that the patient is unable to do properly or safely on their own. 6 Symptomatic neurological impairment (as defined in 3) requiring caregiver assistance for more than 2.5 hours but less than 8 hours per day, as described in 5. 7. Symptomatic neurological impairment (defined as 3) requiring caregiver assistance for more than 8 hours per day, but not continuously as in stage 8. 8. Symptomatic neurological impairment (defined as 3) requiring full-time care in an intensive care unit.

[0095] The duration of administration depends on many factors, including the specific disease being treated. For example, particularly in transthyretin (TTR) amyloidosis diseases or conditions, there is a genetic component such that chronic (i.e., continuous, long-term) administration may be required. However, in some embodiments, administration of Compound 1 or a pharmaceutically acceptable salt thereof to a subject with a hereditary TTR amyloidosis disease is continued while the subject is exhibiting or experiencing symptoms associated with the TTR amyloidosis disease or condition, or for a set period of time after a specific endpoint has been met (e.g., reduction or complete elimination of symptoms). If the symptoms of the TTR amyloidosis disease return or begin to recur, administration of Compound 1 or a pharmaceutically acceptable salt thereof is resumed.

[0096] For subjects with non-genetically related TTR amyloidosis disease, several dosing options are available, depending on the severity of the disease and the clinical symptoms presented. In some embodiments, long-term administration of Compound 1 or a pharmaceutically acceptable salt thereof is required. In some embodiments, shorter-term or acute administration of Compound 1 or a pharmaceutically acceptable salt thereof is required. In some embodiments, administration of Compound 1 or a pharmaceutically acceptable salt thereof to a subject with non-genetically related TTR amyloidosis disease is continued while the subject is exhibiting or experiencing symptoms associated with the TTR amyloidosis disease or condition, or for a set period of time after a specific endpoint has been met (e.g., reduction or complete elimination of symptoms). If TTR amyloidosis disease symptoms return or begin to recur, administration of Compound 1 or a pharmaceutically acceptable salt thereof is resumed.

[0097] In some embodiments, Compound 1, or a pharmaceutically acceptable salt thereof, has at least 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100 or more days. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for at least 7, 14, 21, 28, 35, 42, 49, or 56 days. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 28 days. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 56 days. In some embodiments, Compound 1, or a pharmaceutically acceptable salt thereof, is administered for 84 days.

[0098] In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for at least 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, or 50 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for at least 10, 15, 20, 25, 30, 35, 40, 45, or 50 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 6 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 12 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 18 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 24 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 30 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 36 months. In some embodiments, Compound 1 or a pharmaceutically acceptable salt thereof is administered for 42 months.

[0099] Advantageously, the drugs used in diuretic therapy did not alter the exposure of AG10 during treatment. Thus, patients receiving diuretic therapy can be administered AG10 without a modified or specialized dosing regimen. Thus, in some embodiments, subjects receiving AG10 are also receiving an additional diuretic agent. Diuretic agents include, but are not limited to, ethacrynic acid, bumetanide, furosemide, and torsemide. In some embodiments, the diuretic is selected from the group consisting of furosemide or torsemide.

[0100] In some embodiments, the subject is also administered tafamidis.

[0101] Pharmaceutical Composition Compound 1 can be formulated into a variety of compositions suitable for delivery to a subject. Compositions suitable for administration to a subject typically include Compound 1 or a pharmaceutically acceptable salt and a pharmaceutically acceptable excipient.

[0102] Pharmaceutical compositions for administering Compound 1 or its pharmaceutically acceptable salts can be conveniently provided in unit dosage form and can be prepared by any of the methods known in the art of pharmacy and drug delivery. All methods include the step of combining the active ingredient with a carrier containing one or more accessory ingredients. In general, pharmaceutical compositions can be prepared by uniformly and / or intimately combining the active ingredient with a liquid carrier, a finely divided solid carrier, or both, and then, if necessary, shaping the product into the desired formulation.

[0103] Suitable formulations for use in the present invention can be found in Remington: THE SCIENCE AND PRACTICE OF PHARMACY, 21st Ed., Gennaro, Ed., Lippincott Williams & Wilkins (2003), which is incorporated herein by reference. The pharmaceutical compositions described herein can be manufactured in a manner known to those skilled in the art, i.e., by conventional mixing, dissolving, granulating, dragee-making, levigating, emulsifying, encapsulating, entrapping, or lyophilizing processes. The following methods and excipients are merely illustrative and are in no way limiting.

[0104] Compound 1 can be incorporated into various preparations for therapeutic administration. More specifically, Compound 1 can be formulated together or separately into pharmaceutical compositions by formulating with suitable pharmaceutically acceptable carriers or diluents, and can be formulated into preparations in the form of solid, semi-solid, liquid, or gaseous forms, such as tablets, capsules, pills, powders, granules, dragees, gels, slurries, ointments, solutions, suppositories, injections, inhalants, and aerosols. Thus, the administration of the compounds of the present invention can be achieved in various ways, including oral, buccal, parenteral, intravenous, intradermal (e.g., subcutaneous, intramuscular), transdermal, etc. Furthermore, Compound 1 can be administered in a local rather than systemic manner, for example, in a depot or sustained-release formulation.

[0105] Formulations for oral use can also be provided as hard gelatin capsules in which the active ingredient is mixed with an inert solid diluent, such as calcium carbonate, calcium phosphate, or kaolin, or as soft gelatin capsules in which the active ingredient is mixed with water or an oil medium, such as peanut oil, liquid paraffin, or olive oil. Additionally, emulsions can be prepared using water-immiscible ingredients such as oils and stabilized with surfactants such as mono-diglycerides, PEG esters, etc.

[0106] Aqueous suspensions contain the active material in admixture with excipients suitable for the manufacture of aqueous suspensions. Such excipients are suspending agents, for example, sodium carboxymethylcellulose, methylcellulose, hydroxypropylmethylcellulose, sodium alginate, polyvinylpyrrolidone, gum tragacanth, and gum acacia, and the dispersing or wetting agent may be a naturally occurring phosphatide, for example, lecithin, or a condensation product of an alkylene oxide with a fatty acid, for example, polyoxyethylene stearate, or a condensation product of ethylene oxide with a long-chain aliphatic alcohol, for example, heptadecaethyleneoxycetanol, or a condensation product of ethylene oxide with a fatty acid and a partial ester derived from a hexitol, such as polyoxyethylene sorbitol monooleate, or a condensation product of ethylene oxide with a fatty acid and a partial ester derived from a hexitol anhydride, for example, polyethylene sorbitan monooleate. The aqueous suspensions may also contain one or more preservatives, for example, ethyl or n-propyl p-hydroxybenzoate, one or more coloring agents, one or more flavoring agents, and one or more sweetening agents, such as sucrose or saccharin.

[0107] Dispersible powders and granules suitable for preparation of an aqueous suspension by the addition of water provide the active ingredient in admixture with a dispersing or wetting agent, a suspending agent, and one or more preservatives. Suitable dispersing or wetting agents and suspending agents are exemplified by those already mentioned above. Additional excipients, for example, sweeteners, flavorings, and coloring agents, may also be present.

[0108] Pharmaceutical dosage form The present disclosure includes pharmaceutical dosage forms of Compound 1 or its pharmaceutically acceptable forms. The dosage forms described herein are suitable for oral administration to a subject. The dosage form may be any form suitable for oral administration, including, but not limited to, capsules or tablets.

[0109] In some embodiments, the present disclosure provides 10 to 1,000 mg of a compound of the formula: [ka] The present invention provides a single unit dosage capsule or tablet form containing Compound 1 having the formula:

[0110] In some embodiments, the amount of Compound 1 is about 100-800 mg. In some embodiments, the amount of Compound 1 is about 150-600 mg. In some embodiments, the amount of Compound 1 is about 200-400 mg. In some embodiments, the amount of Compound 1 is about 200 mg. In some embodiments, the amount of Compound 1 is about 400 mg. In some embodiments, a single dose capsule or tablet comprises the HCl salt of Compound 1 or a pharmaceutically acceptable salt thereof.

[0111] In some embodiments, the single unit dosage form of Compound 1 is a tablet.

[0112] In some embodiments, the single unit dosage form of Compound 1 is a capsule.

[0113] In some embodiments, the single unit dosage form is a size 0, 1, 2, 3, 4, or 5 capsule. In some embodiments, the single unit dosage form is a size 0 capsule. In some embodiments, the single unit dosage form is a size 1 capsule. In some embodiments, the single unit dosage form is a size 2 capsule. In some embodiments, the single unit dosage form is a size 3 capsule. In some embodiments, the single unit dosage form is a size 4 capsule. In some embodiments, the single unit dosage form is a size 5 capsule.

[0114] kit The present disclosure also encompasses kits that include the pharmaceutical compositions and dosage forms of the present invention.

[0115] In some aspects, the present invention provides kits comprising Compound 1 or a pharmaceutically acceptable salt thereof. Some of the kits described herein include a label describing a method for administering Compound 1 or a pharmaceutically acceptable salt thereof. Some of the kits described herein include a label describing a method for treating transthyretin (TTR) amyloidosis. In some embodiments, the kits described herein include a label describing a method for treating wild-type transthyretin amyloid cardiomyopathy (ATTR-CM, also known as senile systemic amyloidosis). In some embodiments, the kits described herein include a label describing a method for treating familial amyloid cardiomyopathy (ATTR-mCM). In some embodiments, the kits described herein include a label describing a method for treating familial amyloid polyneuropathy (ATTR-PN, also known as FAP).

[0116] Compositions of the present disclosure include, but are not limited to, compositions comprising Compound 1 in a bottle, jar, vial, ampoule, tube, blister pack, or other container closure system approved by the Food and Drug Administration (FDA) or other regulatory agency, which may provide one or more unit dosages containing Compound 1 or a pharmaceutically acceptable salt thereof. The package or dispenser may also have a notice associated with the container in a format prescribed by a government agency regulating the manufacture, use, or sale of pharmaceuticals, the notice indicating approval by the agency. In certain embodiments, a kit may include a formulation or composition described herein, a container closure system containing the formulation or one or more dosage unit forms containing the formulation, and warnings or instructions describing the methods of use described herein.

[0117] Packaging systems such as blister packs include thermoformable hard film or PVC suitable for pharmaceutical packaging and a push-through lid. The lid can include a foil composed of a primer / aluminum / heat seal coating, or can be paper-based. Those skilled in the art will readily prepare blister packs containing Compound 1 or a pharmaceutically acceptable salt thereof. The bottle systems described herein can be made in various sizes (e.g., 75 cc, 100 cc, 200 cc, etc.) and generally include a child-resistant cap, which can be made from polypropylene. In some embodiments, a pharmaceutical dosage form of Compound 1 is packaged in a 75 cc bottle with a child-resistant cap. Those skilled in the art will readily prepare the bottle systems described herein.

[0118] In some embodiments, the present disclosure provides kits for twice-daily dosing, wherein the kits provide one or more unit doses containing Compound 1 for each administration.

[0119] In some embodiments, the total daily dose of Compound 1 is 800 mg, which means that 400 mg is administered in the first dose and 400 mg is administered in the second dose. In some embodiments, two unit doses containing 200 mg of Compound 1 are administered in the first dose, and two unit doses containing 200 mg of Compound 1 are administered in the second dose. In some embodiments, one unit dose containing 400 mg of Compound 1 is administered in the first dose, and one unit dose containing 400 mg of Compound 1 is administered in the second dose. In some embodiments, the HCl salt form of Compound 1 is administered.

[0120] In some embodiments, the total daily dose of Compound 1 is 1,600 mg, which means that 800 mg is administered in the first dose and 800 mg is administered in the second dose. In some embodiments, four unit doses containing 200 mg of Compound 1 are administered in the first dose, and four unit doses containing 200 mg of Compound 1 are administered in the second dose. In some embodiments, two unit doses containing 400 mg of Compound 1 are administered in the first dose, and two unit doses containing 400 mg of Compound 1 are administered in the second dose. In some embodiments, the HCl salt form of Compound 1 is administered.

[0121] IV. Working Examples The following examples are offered to illustrate, but not to limit, the claimed invention.

[0122] Materials and Methods Fluorescent probe exclusion assay (FPE) The occupancy of AG10 in the thyroxine-binding pocket of tetrameric TTR is determined by the ability of a fluorescent probe (probe) to covalently bind to the free tetrameric TTR binding site in serum over a 6-hour reaction period. The fluorescent probe emits fluorescence only when covalently bound to the ligand-binding site of TTR. The presence of acoramidis or tafamidis in the binding site suppresses the generation of a fluorescent signal.

[0123] An aliquot of each serum sample is plated in a 96-well plate. The change in fluorescence (λ) after addition of the probe is measured. ex = 328 nm and λ em = 384 nm) is monitored every 15 minutes for 6 hours at room temperature using a fluorescence-capable microplate.

number

[0124] Western blot to assess stabilization of tetrameric TTR Stabilization of TTR tetramers by AG10 is determined by comparing the amount of tetrameric TTR protein remaining after 72 hours of acid denaturation with the initial amount of tetrameric TTR protein, as determined by densitometric measurements of Western blot gels.

[0125] Plasma samples from subjects were diluted with acidified buffer (sodium acetate, KCl, EDTA, DTT, pH 4.0) for both the 0-hour and 72-hour time points. The 0-hour sample was directly cross-linked with glutaraldehyde and then quenched. The 72-hour sample was incubated at room temperature for 72 hours and then cross-linked and quenched using the same protocol. All samples were then denatured by adding SDS gel loading buffer and boiled prior to gel loading. Each sample was separated in an SDS-PAGE gel and analyzed by immunoblotting using anti-TTR antiserum (polyclonal rabbit anti-human prealbumin, DAKO catalog number A0002). The density of all TTR bands was quantified and reported using an infrared LICOR imaging system or a fluorescent imaging system.

number

[0126] Introduction: Transthyretin (TTR) amyloidosis (ATTR) is a progressive, fatal disease caused by destabilizing TTR variants (TTRv) and age-related factors. Dissociation of tetrameric TTR initiates protein misfolding, aggregation, and tissue deposition, which constitute the disease mechanism. More unstable variants drive a more severe clinical phenotype. TTR stabilizers have demonstrated clinical benefits on neurological and cardiovascular outcomes that correlate with the degree of TTR stabilization. Acoramidis (AG10) is a novel TTR stabilizer in development for the treatment of TTR amyloid cardiomyopathy.

[0127] Hypothesis: Acoramidis, when added to blood samples from ATTRv patients across a spectrum of destabilizing TTR mutants, achieves near-complete in vitro TTR stabilization, exceeding levels achieved with clinically relevant concentrations of tafamidis (a TTR stabilizer in clinical use).

[0128] Methods: Two established assays assessed TTR stabilization: fluorescent probe exclusion (FPE; measuring binding site occupancy), and Western blot (WB; quantifying the persistence of tetrameric TTR under accelerated dissociation conditions). Examples of each assay are provided above. Over 60 individual patient samples representing 18 unique TTRvs spanning the spectrum of intrinsic instability and clinical phenotypes were assayed. Acoramidis was added at 10 μM, with a target clinical steady-state trough concentration of 8-10 μM, compared to tafamidis added at its clinical peak (26 μM) and trough (16 μM) concentrations reported for its maximum approved dose.

[0129] Results: Acoramidis bound to serum TTR to a greater extent (103 ± 13%) than either the peak (87 ± 14%) or trough (71 ± 14%) concentrations of tafamidis. WB assays showed that addition of Acoramidis resulted in significantly greater and more durable TTR stabilization (93 ± 14%) than addition of tafamidis (peak: 49 ± 14%, trough: 36 ± 13%) in all paired individual patient plasma samples tested (Figure 1, p<0.0001). Rare variants (A97S, D38A, F64L, L58H, P24S, Y114C) also demonstrated near-complete stabilization upon in vitro addition of Acoramidis.

[0130] Figure 2 shows a gel from a Western blot assay of an individual V112I patient sample. All conditions were run in duplicate lanes. Brackets indicate bands corresponding to tetrameric TTR with or without retinol binding protein (RBP).

[0131] Figure 3 shows the time course of FPE in individuals with the V122I TTR mutation. The doses tested were acoramidis 10 μM (closed squares); tafamidis 26 μM (closed circles); tafamidis 16 μM (closed triangles); and DMSO (open circles).

[0132] Figure 4 shows the percent stabilization of TTR FPE for each mutant. For each mutant, the left column is 10 μM acoramidis, the middle column is 26 μM tafamidis, and the right column is 16 μM tafamidis.

[0133] Figure 5A-D shows the stabilization of specific mutant patient samples measured by (A) Western blot (WB) and (B) fluorescent probe exclusion (FPE), with wild-type (WT) results as a reference. (C) Overall stabilization across all tested mutant samples measured by WB and (D) FPE.

[0134] Figures 6A-E show Phase 3 ATTRibute-CM results in patients receiving Compound 1 (800 mg twice daily) or placebo for a total daily dose of 1,600 mg. Results demonstrate that ex vivo TTR stabilization correlates with in vivo measurements of serum TTR. (A) shows the mean change from baseline in serum TTR at 30 months, (B) shows the median % WB stabilization at 30 months, (C) shows the median % FPE stabilization at 30 months, (D) is a waterfall plot of % WB stabilization for mutant patients at 30 months, and (E) is a waterfall plot of % WB stabilization for mutant patients at 30 months. Note: Mutant = mutant TTR genotype. The columns for Acoramidis + Tafamidis represent data from patients receiving both compounds. This indicates that in patients receiving acoramidis, the addition of tafamidis does not increase TTR stabilization, while it also indicates that in patients receiving tafamidis, the addition of acoramidis increases TTR stabilization.

[0135] Tables 1 and 2 below summarize the WB and FPE results. [Table 1] Note: SD is shown only for conditions with more than one sample. The overall mean % WB stabilization with 10 μM Acoramidis is significantly higher than with 26 μM Tafamidis (p<0.0001). [Table 2] Note: SD is shown only for conditions with more than one sample. The overall mean % FPE stabilization with 10 μM acoramidis is significantly higher than with 26 μM tafamidis (p<0.0001). * Healthy pooled sera were tested using six replicates per assay condition.

[0136] Conclusions: At its target therapeutic trough concentration, Acoramidis achieved near-complete TTR stabilization across 18 unique genotypes, and in a subset of paired samples, stabilization was significantly greater with Acoramidis than with tafamidis, even at its peak clinical concentration. This observation held true across a range of destabilizing mutations, including approximately two-fold greater stabilization than with tafamidis for the common cardiomyopathy V122I variant. Based on the disease mechanism and the association between the degree of TTR destabilization and clinical outcome, these data suggest that Acoramidis has the potential to be a clinically differentiated and effective treatment option for patients with ATTRv, regardless of mutant genotype.

[0137] Results from the successful randomized, controlled, Phase 3 ATTRibute-CM study are consistent with in vitro findings. Acoramidis achieved near-complete stabilization in wild-type and ATTRv patients at 30 months, as measured by ex vivo WB and FPE assays. Acoramidis achieved a higher degree of TTR stabilization compared with tafamidis at clinically relevant concentrations, regardless of TTR genotype. In vitro and in vivo assessment of TTR stabilization demonstrated Acoramidis activity across 18 unique TTR mutations encountered.

[0138] Although the foregoing invention has been described in some detail by way of illustration and example for purposes of clarity of understanding, those skilled in the art will recognize that certain changes and modifications can be practiced that are within the scope of the appended claims. Furthermore, each reference provided herein is incorporated by reference in its entirety to the same extent as if each reference were individually incorporated by reference. In the event of a conflict between this application and a reference provided herein, this application shall control. array <210> SEQ ID NO:1 <211> Length: 127 <212> Type:PRT <213> Living organism: Homo sapiens Yoshikazu et al.J.Biol.Chem.(1974)249(21):6796-805 <400> Array: 1 GPTGTGESKCPLMVKVLDAVRGSPA 25 INVAVHVFRKAADDTWEPFASGKTS 50 ESGELHGLTTEEEFVEGIYKVEIDT 75 KSYWKALGISPFHEHAEVVFTANDS 100 GPRRYTIAALLSPYSYSTTAVVTNP 125 KE 127

Claims

1. 1. A method of treating transthyretin (TTR) amyloidosis in a subject in need thereof, comprising administering to a subject in need thereof a therapeutically effective amount of a compound of the formula: 【Chemistry 1】 Compound 1 having the formula or a pharmaceutically acceptable salt thereof, wherein the therapeutically effective amount is a total daily dose of about 10 milligrams (mg) to about 2,000 mg of Compound 1 in the form of its HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt; the TTR amyloidosis in the subject is a glycine to serine mutation at position 6 (G6S), an alanine to serine mutation at position 25 (A25S); alanine to aspartic acid mutation at position 36 (A36D), a glutamic acid to aspartic acid mutation at position 42 (E42D); a serine to arginine mutation at position 50 (S50R), an isoleucine to leucine mutation at position 68 (I68L); a glutamic acid to glutamine mutation at position 89 (E89Q); a glutamic acid to glutamine mutation at position 92 (E92Q); a valine to leucine mutation at position 94 (V94L), and and an alanine to serine mutation at position 97 (A97S).

2. 10. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 10 mg to about 50 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

3. 10. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 50 mg to about 300 mg of Compound 1 in the form of its HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

4. 10. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 50 mg to about 150 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

5. 10. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 150 mg to about 800 mg of Compound 1 in the form of its HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

6. 10. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 800 mg to about 1,600 mg of Compound 1 in the form of its HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

7. 2. The method of claim 1, wherein the therapeutically effective amount is a total daily dose of about 800 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

8. 2. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 1,600 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

9. 10. The method of claim 1, wherein the therapeutically effective amount is a total daily dosage of about 1,100 mg to about 1,300 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

10. 2. The method of claim 1, wherein the therapeutically effective amount is a total daily dose of about 1,236 mg of Compound 1 in the form of the HCl salt, or an equivalent amount of Compound 1 in the form of the free base or a different salt.

11. The method of any one of claims 1 to 10, wherein compound 1 is in the form of an HCl salt.

12. The method of any one of claims 1 to 11, wherein compound 1 is administered orally.

13. 13. The method of any one of claims 1 to 12, wherein compound 1 is administered once daily.

14. 13. The method of any one of claims 1 to 12, wherein compound 1 is administered twice daily.

15. 13. The method of any one of claims 1 to 12, wherein compound 1 is administered three times daily.

16. 13. The method of any one of claims 1 to 12, wherein compound 1 is administered four times daily.

17. 17. The method of any one of claims 1 to 16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing a glycine to serine mutation at position 6 (G6S).

18. 17. The method of any one of claims 1-16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing an alanine to serine mutation at position 25 (A25S).

19. 17. The method of any one of claims 1-16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing an alanine to aspartic acid mutation at position 36 (A36D).

20. 17. The method of any one of claims 1-16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing a glutamic acid to aspartic acid mutation at position 42 (E42D).

21. 17. The method of any one of claims 1 to 16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing a serine to arginine mutation at position 50 (S50R).

22. 17. The method of any one of claims 1-16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing an isoleucine to leucine mutation at position 68 (I68L).

23. 17. The method of any one of claims 1 to 16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing a glutamic acid to glutamine mutation at position 89 (E89Q).

24. 17. The method of any one of claims 1 to 16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing a glutamic acid to glutamine mutation at position 92 (E92Q).

25. 17. The method of any one of claims 1-16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing a valine to leucine mutation at position 94 (V94L).

26. 17. The method of any one of claims 1 to 16, wherein the FTR amyloidosis in the subject is characterized by a FTR protein containing an alanine to serine mutation at position 97 (A97S).

27. The method of any one of claims 1 to 26, wherein the TTR amyloidosis is a disease or condition selected from the group consisting of familial amyloid polyneuropathy, familial amyloid cardiomyopathy, senile systemic amyloidosis, cardiac amyloidosis, ocular amyloidosis, leptomeningeal amyloidosis, ocular-leptomeningeal amyloidosis, vitreous amyloidosis, gastrointestinal amyloidosis, neuropathic amyloidosis, non-neuropathic amyloidosis, non-hereditary amyloidosis, reactive / secondary amyloidosis, and cerebral amyloidosis.

28. The method of any one of claims 1 to 26, wherein the TTR amyloidosis is transthyretin amyloidosis (ATTR) cardiomyopathy or transthyretin amyloidosis (ATTR) polyneuropathy.

29. 27. The method of any one of claims 1 to 26, wherein the TTR amyloidosis is transthyretin amyloidosis (ATTR) cardiomyopathy.

30. 30. The method of claim 29, wherein the ATTR cardiomyopathy is familial ATTR cardiomyopathy (ATTRm-CM).

31. 31. The method of claim 29 or 30, wherein administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof in a subject with ATTR cardiomyopathy improves the risk of mortality, morbidity, and quality of life of the subject.

32. 32. The method of any one of claims 29-31, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy improves the subject's performance in a 6-minute walk test (6MWT).

33. 33. The method of claim 32, wherein the subject walks at least 25 meters (m) more than the baseline distance measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

34. 34. The method of any one of claims 29-33, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy reduces mortality compared to a subject not receiving treatment.

35. 35. The method of claim 34, wherein administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof in a subject with ATTR cardiomyopathy reduces all-cause mortality compared to untreated subjects.

36. 36. The method of any one of claims 29-35, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy ameliorates, stabilizes, or delays deterioration in the subject's New York Heart Association (NYHA) functional class.

37. 37. The method of claim 36, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, reduces the NYHA functional class of the subject.

38. 38. The method of claim 37, wherein the NYHA functional class is reduced from Class IV to Class III, from Class IV to Class II, or from Class IV to Class I.

39. 38. The method of claim 37, wherein the NYHA functional class is reduced from Class III to Class II.

40. 38. The method of claim 37, wherein the NYHA functional class is reduced from Class III to Class I.

41. 38. The method of claim 37, wherein the NYHA functional class is reduced from Class II to Class I.

42. 42. The method of any one of claims 29-41, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy ameliorates, stabilizes, or delays deterioration in the subject's Kansas City Cardiomyopathy Questionnaire (KCCQ) classification.

43. 43. The method of claim 42, wherein the subject has a mean improvement of at least one level in the subject's KCCQ classification.

44. 44. The method of any one of claims 29-43, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy ameliorates, stabilizes, or delays deterioration in the subject's EuroQoL-5 item (EQ-5D-5L) classification.

45. 45. The method of claim 44, wherein the subject has a mean improvement of at least a 5 point in the EQ-5D-5L utility score.

46. 46. ​​The method of any one of claims 29 to 45, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy reduces serum blood levels of brain natriuretic peptide (BNP).

47. 47. The method of claim 46, wherein the subject's serum blood level of BNP is reduced by at least 10% compared to the baseline level of BNP in the subject prior to treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

48. 48. The method of any one of claims 29-47, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR cardiomyopathy reduces serum blood levels of N-terminal pro-brain natriuretic peptide (N-terminal pro-BNP).

49. 49. The method of claim 48, wherein the subject's serum blood level of N-terminal proBNP is reduced by at least 10% compared to the baseline level of N-terminal proBNP in the subject prior to treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

50. 50. The method of any one of claims 29-49, wherein administration of a therapeutically effective amount of Compound 1 in a subject with ATTR cardiomyopathy reduces the frequency of cardiovascular-related hospitalizations compared to untreated subjects.

51. 27. The method of any one of claims 1 to 26, wherein the TTR amyloidosis is transthyretin amyloidosis (ATTR) polyneuropathy.

52. 52. The method of claim 51, wherein the ATTR polyneuropathy is familial ATTR polyneuropathy (ATTRm-PN).

53. 53. The method of claim 51 or 52, wherein administration of a therapeutically effective amount of Compound 1 or a pharmaceutically acceptable salt thereof in a subject with ATTR polyneuropathy improves the Neuropathy Score (NIS) in the subject.

54. 54. The method of claim 53, wherein the NIS score is reduced by at least 10% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

55. 55. The method of any one of claims 51 to 54, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR polyneuropathy improves modified Neuropathy Score+7 (mNIS+7) in the subject.

56. 56. The method of claim 55, wherein the mNIS+7 score is reduced by at least 10% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

57. 57. The method of any one of claims 51 to 56, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR polyneuropathy improves the subject's Norfolk Quality of Life Diabetic Neuropathy (QOL-DN) questionnaire score.

58. 58. The method of claim 57, wherein the Norfolk QOL-DN score is improved by at least 10% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

59. 59. The method of any one of claims 51-58, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR polyneuropathy improves the subject's Composite Autonomic Symptom Score (COMPASS-31) score.

60. 60. The method of claim 59, wherein the COMPASS-31 score is improved by at least 0.5% compared to the baseline level measured before treatment with Compound 1 or a pharmaceutically acceptable salt thereof.

61. 61. The method of any one of claims 51-60, wherein administration of a therapeutically effective amount of Compound 1 in a subject with ATTR polyneuropathy improves the subject's modified BMI (mBMI).

62. 62. The method of any one of claims 51-61, wherein administration of a therapeutically effective amount of Compound 1, or a pharmaceutically acceptable salt thereof, in a subject with ATTR polyneuropathy improves 10-meter walk test (10MWT) speed in said subject.

63. 63. The method of any one of claims 1 to 62, wherein Compound 1 or a pharmaceutically acceptable salt thereof is administered chronically.

64. 64. The method of any one of claims 1 to 63, wherein Compound 1, or a pharmaceutically acceptable salt thereof, is administered for at least 28 days.

65. 65. The method of any one of claims 1 to 64, wherein Compound 1, or a pharmaceutically acceptable salt thereof, is administered for at least 56 days.

66. 66. The method of any one of claims 1 to 65, wherein Compound 1, or a pharmaceutically acceptable salt thereof, is administered for at least 84 days.

67. 67. The method of any one of claims 1 to 66, wherein Compound 1, or a pharmaceutically acceptable salt thereof, is administered for at least 18 months.

68. 68. The method of any one of claims 1 to 67, wherein Compound 1, or a pharmaceutically acceptable salt thereof, is administered for at least 30 months.

69. 69. The method of any one of claims 1 to 68, wherein the subject is receiving diuretic therapy.

70. 70. The method of claim 69, wherein the diuretic therapy agent is furosemide or torsemide.

71. 71. The method of any one of claims 1 to 70, wherein the subject is also administered tafamidis.

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