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

Abstract

The present invention relates to compounds of the formula and their pharmaceutically acceptable salts, solvates, hydrates, or polymorphs for use in the treatment of hereditary hemochromatosis. [Formula 1] TIFF2026522008000015.tif27159

Description

[Technical Field]

[0001] The present invention relates to a compound of formula (I) that acts as a ferroportin inhibitor for treating hereditary hemochromatosis (HH) and related symptoms and pathological conditions. [ka]

[0002] or relating to the use of pharmaceutically acceptable salts, solvates, hydrates, or polymorphs thereof. [Background technology]

[0003] Iron is an essential element for almost all living organisms, and its relevance lies in its crucial role in red blood cell production and oxygen transport. The balance of iron metabolism is regulated primarily at the levels of iron recovery from hemoglobin in aging red blood cells, from iron stores in the liver, and from duodenal absorption of dietary iron. Elemental iron is taken up by duodenal intestinal cells via specific transport systems (DMT-1, ferroportin), transferred to the bloodstream, and thereby delivered to the appropriate tissues and organs bound to its carrier, transferrin. In the human body, iron is critically important for cellular functions such as oxygen transport, oxygen uptake, mitochondrial electron transport, cognitive functions, and ultimately overall energy metabolism. Mammalian organisms cannot remove or excrete iron from their bodies via active systems. Iron homeostasis is regulated by the hepatic peptide hormone hepcidin, which regulates the activity of ferroportin, the only known iron transporter, and therefore iron release from macrophages, hepatocytes, and intestinal cells. Hepcidin regulates iron absorption via the intestine and placenta, as well as iron recycling from the reticuloendothelial system. Hepcidin production is directly regulated by iron levels; that is, when an organism is supplied with sufficient or excess iron and oxygen, more hepcidin is produced. When iron and oxygen levels are low, or when erythrocyte production is increased, hepcidin production decreases. In small intestinal mucosal cells and macrophages, hepcidin binds to ferroportin, thus blocking its transport function and promoting its internalization and degradation. Through this mechanism, hepcidin reduces the outflow of iron from cells into the bloodstream. The transport protein ferroportin is a transmembrane protein consisting of 571 amino acids that is expressed in the liver, spleen, kidneys, heart, intestine, and placenta. In particular, ferroportin is localized to the basolateral membrane of intestinal epithelial cells. Therefore, ferroportin acts to transport dietary iron into the bloodstream. When hepcidin binds to ferroportin, ferroportin is transported into the cell, where it is broken down, resulting in the blockage of iron release from the cell. If ferroportin is inactivated or inhibited by hepcidin, and as a result cannot transport iron stored in mucosal cells, iron absorption in the intestines is blocked.A decrease in hepcidin leads to an increase in active ferroportin, thus enabling enhanced dietary iron absorption and release of stored iron, resulting in elevated serum iron levels. Katsarou et al. published a review article on hepcidin therapy [A. Katsarou and K. Pantopoulos, Hepcidin Therapeutics, Pharmaceuticals, Vol.11, No.4, page 127; 2018].

[0004] In pathological cases, elevated iron levels lead to iron overload. For example, excessive iron uptake in organs such as the liver and heart results in iron accumulation. Furthermore, iron accumulation in the brain has been observed in patients with neurodegenerative diseases such as Alzheimer's disease and Parkinson's disease. The majority of circulating iron is associated with transferrin, a classic iron transport molecule, which prevents the formation of free reactive iron. Iron fractions not bound to transferrin (or other conventional iron-binding molecules such as heme, apoferritin, and hemosiderin) are collectively called untransferrin-bound iron (NTBI).

[0005] A significant harmful aspect of such excess free iron is the undesirable formation of radicals. In particular, iron(II) ions catalyze the formation of reactive oxygen species (ROS) (particularly via the Fenton reaction). ROS cause damage to DNA, lipids, proteins, and carbohydrates, with widespread effects in cells, tissues, and organs. ROS formation is well known and has been described in the literature as causing so-called oxidative stress. NTBI has been widely described as showing a high tendency to induce ROS and has potential toxicity to cells, as well as to major organs including the heart, liver, pancreas, kidneys, and bone marrow.

[0006] Hereditary hemochromatosis (HH) is a hereditary iron overload condition caused by mutations that reduce the level of its binding to the iron-regulating hormones hepcidin or ferroportin. HH is a common iron overload disorder in Northern Europe [Kowdley KV et al., ACG clinical guideline:hereditary hemochromatosis. Am J Gastroenterol. 2019;114:1202-1218]. HH is characterized by excessive dietary iron absorption, as well as pathologically high iron deposition in organs such as the liver, pancreas, and heart, which can lead to the formation of reactive oxygen species and ultimately organ damage. High iron levels result from abnormally low levels of the iron-regulating hormone hepcidin, or from reduced binding of hepcidin to ferroportin, the sole transporter of iron to the extracellular space. Hepcidin regulates iron levels by binding to ferroportin on the membranes of intestinal cells, hepatocytes, and macrophages, inducing its internalization and subsequent degradation, thereby reducing iron transport into the plasma [Brissot P. et al., Haemochromatosis. Nat Rev Dis Primers. 2018; 4: 18016; Ganz T. Cellular iron: ferroportin is the only way out. Cell Metab. 2005; 1: 155-157; Nemeth E. et al., Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization. Science. 2004; 306: 2090-2093].

[0007] Hemochromatosis is divided into four distinct disorders: hereditary (classical) hemochromatosis, also known as HFE-associated hemochromatosis; hemochromatosis type 2 (juvenile hemochromatosis); hemochromatosis type 3, also known as TFR2-associated hemochromatosis; and hemochromatosis type 4, also known as ferroportin disease. Specific symptoms associated with these disorders can vary depending on the location and extent of iron accumulation. Within type 4 HH, further distinctions are made between type 4A and type 4B.

[0008] The most common form of HH is type 1 (hereditary hemochromatosis, HH), which is usually caused by a mutation in the HFE gene, which codes for the hemochromatosis (HFE) protein involved in the regulation of hepcidin. The most common of these HFE gene mutations is the C282Y mutation, followed by the H63D mutation. More than 80% of HH patients are homozygous for the C282Y mutation [Feder JN et al., A novel MHC class I-like gene is mutated in patients with hereditary hemochromatosis. Nat Genet. 1996;13:399-408; European Association for the Study of the Liver. EASL clinical practice guidelines for HFE hemochromatosis. J Hepatol. 2010;53:3-22]. The C282Y mutation disrupts a critical disulfide bond in the α3 domain of the HFE protein, preventing the binding of the mutant HFE to β-2 microglobulin, leading to impaired intracellular transport and accelerated HFE degradation [Waheed A et al., Hereditary hemochromatosis: effects of C282Y and H63D mutations on association with beta2-microglobulin, intracellular processing, and cell surface expression of the HFE protein in COS-7 cells. Proc Natl Acad Sci US A. 1997;94:12384-12389].

[0009] However, HH can also be caused by mutations in other genes involved in sensing systemic iron storage, such as hepcidin (HAMP), hemoduvelin (HJV), transferrin receptor 2 (TFR2), and ferroportin-1 (FPN1), which encode hepcidin, hemoduvelin, transferrin receptor 2, and ferroportin, respectively [D'Alessio F et al., The hemochromatosis proteins HFE, TfR2, and HJV form a membrane-associated protein complex for hepcidin regulation. J Hepatol. 2012;57:1052-1060.].

[0010] Both HFE mutations, including the C282Y and H63D mutations, and non-HFE mutations associated with HH, result in inappropriately low levels of hepcidin and increased iron release into plasma compared to iron status [Bridle KR et al., Disrupted hepcidin regulation in HFE-associated haemochromatosis and the liver as a regulator of body iron homoeostasis. Lancet. 2003;361:669-673.]. This leads to the formation of high transferrin-saturated (TSAT) and non-transferrin-bound iron (NTBI), which can ultimately result in iron overload in vital organs.

[0011] Symptoms of hemochromatosis include fatigue or weakness (including extreme tiredness), joint pain, especially in the knees and hands, abdominal pain over the liver, weight loss, loss of sexual interest, or erectile dysfunction. Affected individuals may develop arthritis, liver disease (cirrhosis) or liver cancer, diabetes, heart abnormalities, and / or skin discoloration (including darkening of the skin color, which may appear gray, metallic, or bronze).

[0012] If left untreated, iron overload can lead to serious complications including hepatic fibrosis, cirrhosis and cancer, cardiomyopathy and heart failure, arthritis, and diabetes [Pietrangelo A. Hereditary hemochromatosis: pathogenesis, diagnosis, and treatment. Gastroenterology. 2010;139:393-408,408.e391-392.].

[0013] To date, venotomy (bloodletting) is the standard care for patients with hemochromatosis. Venotomy aims to reduce serum ferritin levels to approximately 50 ng / mL and improve TSAT by approximately 50% [Brissot P, Brissot E. What's important and new in hemochromatosis? Clin Hematol Int. 2020;2:143-148; Brissot P, Loreal O. Hemochromatoses. J Hepatol. 2021;75:723-724]. Newly diagnosed patients often undergo frequent venotomy for several months during the so-called "induction phase" of treatment. Currently, venotomy is the only treatment option for HH patients, and there are currently no approved oral medications for HH patients. Venotomy is effective, simple, and inexpensive, but it remains an invasive procedure that is not without complications. Adverse effects were found to occur “almost always” or “constantly” in 37% of patients receiving maintenance therapy and 52% of patients in the induction phase. Adverse effects included fatigue, loss of consciousness, pain at the venous access site, and hematoma. Weekly venotomy in the induction phase can lead to anemia, may be inconvenient or untolerable for patients, and in some cases may make it difficult to obtain venous access. Due to the high procedural burden associated with repeated, frequent venotomy sessions, patient compliance with venotomy in the maintenance phase generally declines steadily over time, with 16% of patients “certainly” or “probably” deciding to discontinue venotomy if alternative treatment options become available [Hicken BL et al., Patient compliance with phlebotomy therapy for iron overload associated with hemochromatosis. Am J Gastroenterol. 2003;98:2072-2077].

[0014] Therefore, there is a need for novel treatments that provide effective and safe management of HH, which can improve patient compliance, reduce procedural burden, and decrease the frequency of venotomy.

[0015] Within the major type 1 HH patient groups described above, approximately 10% of subgroups are completely unsuitable for conventional treatment, namely venotomy, for various reasons. In particular, these specific patient groups require novel HH treatments that can completely avoid or replace venotomy.

[0016] Furthermore, venotomy only provides symptomatic relief and cannot target the underlying pathophysiology of hematopoietic hypertension (HH).

[0017] Conventional drugs for treating iron overload are iron chelating compounds aimed at removing a certain amount of excess iron. Established drugs commonly used in chelation therapy include deferoxamine (also known as desferrioxamine B or Desferal®), deferasirox (also known as Exjade®), and deferipron (also known as Ferriprox®). However, in hematopoietic hypertension (HH), iron chelation is only a treatment option when patients are intolerant to or refractory to venotomy. Venotomy is the first-line treatment option for HH. When iron chelation is considered in the treatment of patients with HH, Desferal® is the only approved drug, and it is approved in only a limited number of countries. In any case, established drugs for iron chelation therapy are known to exhibit potential toxicity, which is potentially problematic with long-term administration due to the need for long-term treatment. Desferal®, the only approved drug for HH, cannot be administered orally.

[0018] Orally administered drugs are a preferred option compared to parenteral administration, for example, in order to improve patient compliance and provide novel treatment methods that are more comfortable and easier to implement in patients' daily lives. Oral administration offers advantages over parenteral administration, such as ease of administration for patients, especially elderly patients, a high degree of flexibility in dosage and formulation, cost-effectiveness, reduced sterility constraints, and a reduced risk of infection, injection site reactions, and anti-drug antibody formation.

[0019] A novel class of low molecular weight compounds having activity as ferroportin inhibitors is described in International Applications and Publications 2017 / 068089 and 2017 / 068090. Furthermore, International Application and Publication 2018 / 192973 relates to specific salts of selected ferroportin inhibitors described in International Publications 2017 / 068089 and 2017 / 068090. International Application and Publication 2021 / 191202 further describes manufacturing routes for preparing selected ferroportin inhibitors as well as specific salt forms and polymorphs thereof. In this, reference to the potential treatment of hemochromatosis is merely mentioned in general terms in the list of possible indications without providing data.

[0020] The novel ferroportin inhibitors described in the above international applications have been successfully tested in methods for treating transfusion-dependent thalassemia (TDT), as described in international application publication 2021 / 013771; methods for treating renal ischemia-reperfusion injury (IRI) or ischemic injury and acute kidney injury (AKI), as described in international application publication 2021 / 013772; methods for treating sickle cell disease (SCD), as described in international application publication 2021 / 078889; or methods for treating myelodysplastic syndrome (MDS), as described in international application publication 2022 / 157185. The use of the small molecule ferroportin inhibitor compound vamifeport (formerly known as VIT-2763) for the treatment of β-thalassemia and sickle cell disease has been further described in several scientific papers: [V, Nyffenegger N, Flace A, et al. Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of β-thalassemia. J Clin Invest. 2019;130:491-506; Porter J, Taher A, Viprakasit V, et al. Oral ferroportin inhibitor vamifeport for improving iron homeostasis and erythropoiesis in β-thalassemia: current evidence and future clinical development. Expert Rev Hematol. 2021;14:633-644; Nyffenegger N, Flace A, Doucerain C, Durrenberger F, Manolova V. The oral ferroportin inhibitor] VIT-2763 improves erythropoiesis without interfering with iron chelation therapy in a mouse model of β-thalassemia.Int J Mol Sci.2021;22:873;Nyffenegger N, Zennadi R, Kalleda N, et al. The oral ferroportin inhibitor vamifeport improves hemodynamics in a mouse model of sickle cell disease. Blood. 2022;140:769 - 781; Kalleda N, Flace A, Altermatt P, et al. The ferroportin inhibitor vamifeport ameliorates ineffective erythropoiesis in a mouse model of beta - thalassemia with blood transfusions. Haematologica. 2023]. Furthermore, the first - in - human trial of vamifeport in a phase 1 study using healthy volunteers is described [F. Richard et al. Oral ferroportin inhibitor RIB - 2763: First - in - human, phase 1 study in healthy volunteers, American Journal of Hematoloty, Vol. 95, No. 1, pages 68 - 77; 2019].

[0021] The inventors of the present invention have now found that the ferroportin inhibitor compound vamifeport (previously called VIT - 2763) has been found to be a promising drug compound for treating HH. In particular, the inventors of the present invention have shown the effectiveness of vamifeport in reducing serum iron levels and / or preventing liver iron deposition in the Hfe C282Y mouse model of HH, both alone and in combination with phlebotomy, in experimental tests.

Prior Art Documents

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Non-licensed literature

[0023] [Non-licensed document 1] A.Katsarou and K.Pantopoulos,Hepcidin Therapeutics,Pharmaceuticals,Vol.11,No.4,page 127;2018 [Non-licensed document 2] Kowdley KV et al.,ACG clinical guideline:hereditary hemochromatosis.Am J Gastroenterol.2019;114:1202-1218 [Non-licensed document 3] Brissot P.et al.,Haemochromatosis.Nat Rev Dis Primers.2018;4:18016

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[0024] The object of the present invention is to provide novel methods for treating hereditary hemochromatosis (HH) and related symptoms and pathological conditions. A particular object of the present invention can be seen as providing novel drug compounds for effectively treating HH and related symptoms and pathological conditions, which enable improvement of the burden associated with conventional HH treatment methods such as frequent venotomy. Further objects to be addressed in further embodiments of the present invention include providing novel therapeutic options that provide one or more combinations of the following aspects: providing effective and safe treatment for HH, providing improved patient compliance, being comfortable and easy to implement in the patient's daily life, being orally administered, and enabling reduction of the treatment burden. In further embodiments, the present invention should provide novel treatments that enable or completely replace venotomy in order to enable complete avoidance or replacement of venotomy, particularly for HH patients who are not eligible for conventional treatment, i.e., venotomy. A further object of the present invention is to provide novel therapeutic options for HH that not only can provide symptomatic treatment but also target the underlying pathophysiology of HH. A further object of the present invention is to provide a novel combination therapy option that can be used in combination with conventional venotomy without interfering with the iron removal process of venotomy. [Means for solving the problem]

[0025] The inventors of this invention have identified a compound having the following formula (I): bamifeport [ka]

[0026] Alternatively, it could be shown that a pharmaceutically acceptable salt, solvate, hydrate, or polymorph thereof can be used in novel methods for the treatment of hereditary hemochromatosis.

[0027] In a preferred embodiment of the present invention, the compound of formula (I) is used in the form of an HCl salt, and more preferably, the compound (i) is used in the form of a 3HCl salt having the following formula (I-3HCl). [ka]

[0028] Hereinafter, the bamifeport compounds (I), each described in any of these specifications, including their salts, solvates, hydrates, and polymorphs, are also collectively referred to as "bamifeport."

[0029] The experimental tests conducted by the inventors and presented in the following experimental section provide a preclinical proof of concept regarding the efficacy of bamifeport in HH with or without venotomy. In particular, the inventors were able to demonstrate that a single oral administration of bamifeport could reduce serum iron levels in Hfe C282Y mice, with a later onset and shorter duration than observed in wild-type mice. Bamifeport induced transient hypotrinemia by inhibiting ferroportin, resulting in feedback modulation of hepatic Hamp in wild-type mice, which was absent in Hfe C282Y mice, reflecting dysregulated systemic iron sensing in this HH model. Chronic administration of bamifeport resulted in a sustained decrease in serum and hepatic iron in Hfe C282Y mice and a significant reduction in hepatic Hamp expression in Hfe C282Y mice, suggesting clear modulation of hepatic Hamp expression after acute or continuous iron restriction by bamifeport. Importantly, the bamife port retained its activity when combined with venotomy and did not interfere with hepatic iron removal by venotomy in Hfe C282Y mice. Experimental data demonstrated that chronic bamife port treatment significantly reduced serum iron levels and prevented hepatic iron overload in the HH Hfe C282Y mouse model, thus supporting the invention as further described herein.

[0030] patient group In particular, the inventors have found that bamifeport can be used to treat patients suffering from type 1 hemochromatosis and related symptoms and pathological conditions.

[0031] In one embodiment, the present invention relates to a compound of formula (I), or a salt, solvate, hydrate, and polymorph thereof, for the treatment of patients suffering from HH caused by a homozygous C282Y or H63D mutation of the HFE gene, or a compound heterozygous C282Y / H63D mutation, preferably patients suffering from HH caused by a homozygous C282Y mutation of the HFE gene.

[0032] In principle, the subjects treated in the use of the present invention may be any mammal, such as rodents and primates, and in a preferred embodiment, the medical use relates to the treatment of humans. Subjects suffering from HH and treated by the method of the present invention are also referred to as “patients” or “individuals.”

[0033] The subjects treated may be of any age. Preferred embodiments of the present invention relate to the treatment of adults and elderly individuals. In preferred embodiments of the present invention, subjects treated by the novel method described herein are over 20 years of age. In further embodiments of the present invention, subjects treated by the novel method described herein are over 30 years of age, preferably over 40 years of age, more preferably over 50 years of age and over 50 years of age, or over 60 years of age. In preferred cases of treating elderly patients, subjects treated by the novel method described herein are 50 years of age or older, mainly due to the fact that typically type 1 HH patients develop iron overload considerably later, i.e., after the age of 50.

[0034] Treatment of elderly patients is particularly preferred due to the significant advantages provided by the treatment according to the present invention. Bamifeport and its salts, solvates, hydrates, or polymorphs can be administered orally, which is advantageous over parenteral administration. Furthermore, the orally bioavailable ferroportin inhibitor bamifeport has been found to have moderate bioavailability and half-life in the body and is therefore washed out relatively quickly. This results in fewer adverse effects and faster reversibility of the drug, which is particularly important in the treatment of elderly patients.

[0035] A group of patients or patient populations suffering from HH and treated by the method according to the present invention are selected from subjects (patients) characterized as defined above. In a further aspect of the present invention, a group of patients or patient populations suffering from HH and treated by the method according to the present invention are selected from subjects (patients) having one or more of the above-described pathological parameters.

[0036] In a further aspect of the present invention, the group or population of patients suffering from HH and treated by the method according to the present invention requires frequent / regular venotomy. However, further clinical symptoms and parameters also play an important role in determining HH.

[0037] Regular venotomy further means repeating the venotomy procedure (setting) two or more times within a predetermined time interval. During the induction phase, a weekly time interval is determined, and during the maintenance phase, a time interval of monthly, quarterly, or semi-annual may be determined. The intervals between repeating venotomy sessions may be of equal length or may vary depending on the individual patient, the course of the disease, its severity, and the treatment response. In particular, the interval is extended after the induction phase when entering the maintenance phase.

[0038] In a further aspect of the present invention, regular / frequent venotomy means a period of 6 months or less, preferably 4 months or less without venotomy.

[0039] Indications and treatment parameters In the context of use of the present invention, the terms “to treat,” “to treat,” or “to treat” include the prevention and improvement of at least one symptom or pathological condition related to HH, for example, the symptoms and pathological conditions described in any of the herein and the following examples.

[0040] In the context of the present invention, the terms “to treat,” “treatment,” or “to treat” further include, for example, prevention or remedy by administration of the compounds of the present invention prior to or associated with venotomy in HH patients.

[0041] Non-limiting examples of symptoms or pathological conditions associated with HH include, for example, elevated systemic iron levels, elevated hepatic iron levels, iron accumulation in organs such as the liver, pancreas and heart, elevated hemoglobin levels, and venotomy burden, as well as fatigue or weakness (including extreme tiredness (fatigue)), joint pain, especially in the knees and hands, abdominal pain over the liver, weight loss, loss of sexual interest or erectile dysfunction, arthritis, liver disease (cirrhosis) or liver cancer, diabetes, cardiac abnormalities and / or the onset of skin discoloration (including darkening of the skin color, which may appear gray, metallic, or bronze), and combinations of these symptoms or conditions.

[0042] The efficacy of the compounds of the present invention in medical use to treat HH can be evaluated by determining the following parameters: serum iron, NTBI level, LPI (unstable plasma iron) level, erythropoietin, TSAT (transferrin saturation), Hb (hemoglobin), Hct (hematocrit), MCV (mean cell volume), MCH (mean cellular hemoglobin), RDW (red blood cell distribution width), and reticulocyte count, whole blood count, and iron content of the liver, spleen, and kidneys. The determination can be made using conventional methods of the art, particularly by the methods described in more detail below. Compound (I) of the present invention is suitable for improving at least one of these parameters.

[0043] In certain embodiments, HH treatment according to the present invention results in a reduction of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% in the patient's serum iron level compared to the patient's serum iron level determined at any point in time within a period of up to 72 hours, up to 60 hours, up to 48 hours, up to 36 hours, up to 24 hours, up to 12, 8, 6, 5, 4, 3, 2, 1, and 0.5 hours after administration, and at any point in time within a period of up to 0.5, 1, 2, 3, 4, 5, 6, 8, 12, 24, 36, or 48 hours, or up to 1 week prior to the commencement of treatment according to the present invention. Serum iron levels may be determined according to the assays described in the following examples.

[0044] In further embodiments, HH treatment according to the present invention may result in a reduction of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% of the liver iron concentration in the patient compared to the level of liver iron concentration in the patient determined at any point within a period of up to 1 week, 2 weeks, 3 weeks, or 3 months after the first administration, and at any point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment according to the present invention. The liver iron concentration may be determined according to the assay described in the following examples.

[0045] Accordingly, in further embodiments, HH treatment according to the present invention may result in a reduction of pancreatic iron concentration in a patient of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% compared to the level of pancreatic iron concentration in the patient determined at any point within a period of up to 1 week, 2 weeks, 3 weeks, or 3 months after the first administration, and at any point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment according to the present invention. Pancreatic iron concentration may be determined according to the assay described in the following examples.

[0046] In a further embodiment, HH treatment according to the present invention may result in a reduction of at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% of the cardiac iron concentration in a patient, compared to the cardiac iron concentration in a subject determined at any point within a period of up to 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment according to the present invention. The cardiac iron concentration may be determined according to the assay described in the following examples.

[0047] In a further embodiment, HH treatment according to the present invention may result in a reduction of serum ferritin levels in a patient by at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% compared to serum ferritin levels in the patient determined at any point within a period of up to 1 week, 2 weeks, 3 weeks, or 3 months after the first administration, and at any point within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment according to the present invention. Serum ferritin levels may be determined according to conventional assays.

[0048] In a further embodiment, HH treatment according to the present invention may result in an improvement of at least one of the parameters Hb, Hct, RBC count, MCV, MCH, RDW, and reticulocyte count in a patient by at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100% compared to the respective parameters in the subject determined at any point within a period of up to 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the commencement of treatment according to the present invention. The parameters may be determined according to conventional methods.

[0049] A further aspect of the present invention relates to the use of bamifeport and its salts, solvates, hydrates or polymorphs in the treatment of HH as described herein, wherein the treatment is controlled to reduce serum iron content and / or organ iron content and / or prevent iron accumulation in organs compared to HH patients who are untreated or treated only by conventional venotomy.

[0050] In a further, more specific embodiment, the treatment is controlled to reduce the hepatic iron content and / or prevent the accumulation of iron in the liver, pancreas and / or heart, preferably the liver.

[0051] In a further embodiment, the HH treatment according to the present invention may result in an increase in the time interval between one venotomy setting and subsequent venotomy settings over the entire treatment time.

[0052] In a further embodiment, the treatment of HH according to the present invention can achieve that an HH patient treated according to the method of the present invention will not require venotomy for at least 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 13 weeks, 14 weeks, 15 weeks, 16 weeks, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 18 months, 24 months, or even longer, until the HH patient treated according to the method of the present invention is independent of venotomy during or after the treatment.

[0053] In further embodiments, treatment of HH according to the present invention may result in the relief of symptoms associated with one or more clinical HH and / or venotomy complications. Non-limiting examples are described above.

[0054] In a further embodiment, HH treatment according to the present invention may result in an improvement in the patient's quality of life compared to the patient's quality of life determined within 1, 2, 3, or 4 weeks prior to the initiation of the treatment according to the present invention. The improvement in quality of life is determined within 3, 6, 9, 12, 15, 18, 21, or 24 months after the initiation of the treatment. The quality of life may be determined according to the assay described in the following examples.

[0055] One or more of the above-mentioned improvements can be achieved by the HH treatment according to the present invention.

[0056] Administration regimen Compounds of formula (I) (including their salts, solvates, hydrates, and polymorphs) may be used in any of the treatments described herein, which are characterized by one of the following administration regimens:

[0057] In a preferred embodiment, the Vamifeport according to the present invention is administered to HH patients in need as a chronic, i.e., repeated dose, over a selected treatment period that may be limited depending on the patient's condition or may last a lifetime.

[0058] Chronic administration involves repeated administration of bamifeport over periods of at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks and / or up to at least 8 weeks. The number of repeated doses during such time intervals may vary depending on age, weight, patient condition, disease severity or type of administration and the course of disease development under treatment.

[0059] The Vamifeport according to the present invention can be administered in doses of 0.001 to 500 mg, for example, 1 to 4 times a day, according to the method of the present invention. However, the dose may be increased or decreased depending on age, weight, patient condition, severity of the disease or type of administration and the course of the disease development under treatment.

[0060] In a further embodiment of the present invention, Bamifeport is available in doses of 0.1 mg, 0.2 mg, 0.3 mg, 0.4 mg, 0.5 mg, 0.6 mg, 0.7 mg, 0.8 mg, 0.9 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg, 3 mg, 3.5 mg, 4 mg, 4.5 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 45 mg, 50 mg, 55 mg, 60 mg, 65 mg, 70 mg, 75 mg, 80 mg, 85 mg, 90 mg, 95 mg, 100 mg, 105 mg, 110 mg, 1 It can be administered in doses of 15mg, 120mg, 125mg, 130mg, 135mg, 140mg, 145mg, 150mg, 155mg, 160mg, 165mg, 170mg, 175mg, 180mg, 185mg, 190mg, 195mg, 200mg, 205mg, 210mg, 215mg, 220mg, 225mg, 230mg, 235mg, 240mg, 245mg, 250mg, 255mg, 260mg, 265mg, 270mg, 275mg, 280mg, 285mg, 290mg, 295mg, 300mg, 325mg, 350mg, 375mg, 400mg, 425mg, 450mg, 475mg, and 500mg.

[0061] Preferably, the dose is 0.5 to 500 mg, more preferably 5 to 400 mg. Most preferably, the dose is 5 mg, 15 mg, 30 mg, 60 mg, 120 mg, 180 mg, 240 mg, or 360 mg.

[0062] The dosages defined above refer to the total dose administered in humans, preferably as a single dose or divided into two or three doses per day.

[0063] Preferably, Vamifeport is administered daily at the dose defined above.

[0064] Preferably, the treatment according to the present invention includes administration of Vamifeport in a daily dose of 40 to 360 mg, including a single dose or a daily dose of 40, 60, 120 mg, 180 mg, 240 mg, or 360 mg administered two or three times a day.

[0065] The dosage defined above can be administered as a single dose once daily, or divided into subdoses for administration two, three, or more times daily.

[0066] In further embodiments, doses of 0.001–35 mg / kg body weight, 0.01–35 mg / kg body weight, 0.1–25 mg / kg body weight, or 0.5, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10–20 mg / kg body weight may be administered. Particularly preferred doses are 120 mg for patients weighing more than 50 kg and 60 mg for patients weighing less than 50 kg, in both cases once or twice daily.

[0067] In a further embodiment, one of the doses defined above may be selected as the initial dose, followed by the administration of the same or a variety of doses defined above at repeated intervals of 1 to 7 days, 1 to 5 days, preferably 1 to 3 days, or every 2 days.

[0068] The initial dose and subsequent doses may be selected from the dosages defined above and may be adjusted / modified within the provided range according to the needs of the HH patient.

[0069] In particular, the amount of subsequent doses can be appropriately selected according to the individual patient, the course of the disease, and the response to treatment. It is possible to administer subsequent doses of 1, 2, 3, 4, 5, 6, 7, and above.

[0070] The initial dose may be equal to or different from one or more subsequent doses. Subsequent doses may, furthermore, be equal to or different from the initial dose.

[0071] The repetition interval may be the same length or may be modified depending on the individual patient, the course of the disease, and the treatment response.

[0072] Preferably, the subsequent dose is an amount that decreases as the number of subsequent administrations increases.

[0073] Preferably, doses of 3 mg to 360 mg, more preferably 5 mg to 360 mg, most preferably 5 mg, 15 mg, 30 mg, 60 mg, 120 mg, 180 mg, 240 mg, or 360 mg are administered once, twice, or three times daily over a treatment period of at least 3, at least 5, or at least 7 days. In a more preferred embodiment, a dose of 60 mg or 120 mg is administered once daily. In a more preferred embodiment, a total daily dose of 120 mg is administered by administering a dose of 60 mg twice daily, or a total daily dose of 240 mg is administered by administering 120 mg twice daily or 60 mg three times daily. A more preferred administration regimen includes the administration of a total daily dose of 240 or 360 mg, either as a single dose or divided into two or three subsets, for example, 240 mg / day in two 120 mg subsets, or 360 mg / day in two 180 mg subsets or three 120 mg subsets.

[0074] In a more preferred embodiment, a total daily dose of 240 mg is administered by administering a dose of 120 mg twice daily, or a total daily dose of 360 mg is administered by administering a dose of 120 mg three times daily. These doses have been found to be safe and well-tolerated.

[0075] The preferred dosing regimen also showed rapid oral absorption, with detectable levels as early as 15–30 minutes after administration. Absorption levels could be maintained stably even with repeated administration, and no significant accumulation was observed.

[0076] The preferred dosing regimen was further found to efficiently reduce mean serum iron levels and mean calculated transferrin saturation, and to shift the mean serum hepcidin peak, demonstrating its efficiency in treating HH.

[0077] In a further aspect of the present invention, the initial dose and one or more subsequent doses are adjusted according to the hemoglobin concentration of the patient being treated. The hemoglobin concentration is determined by conventional methods.

[0078] Combination therapy A further object of the present invention relates to the treatment of HH using a bamife port (including its salts, solvates, hydrates, and polymorphs) in combination with conventional venotomy therapy.

[0079] In this context, drug administration may be performed before or simultaneously with venotomy.

[0080] A preferred embodiment of the present invention relates to the treatment of HH as described herein in the form of a combination therapy including chronic administration of bamifeport as described above and frequent venotomy.

[0081] Such combination therapies include, in particular, chronic administration of vamifeport (at the same or different doses and / or dosing intervals) as described above, and increasing the time interval between one venotomy setting and subsequent venotomy settings over the entire treatment period.

[0082] In a further embodiment, such combination therapy includes chronic administration of Vamifeport as described above (at the same or different doses and / or dosing intervals) and increasing the time interval between one venotomy setting and subsequent venotomy settings over the entire treatment period until the venotomy procedure is completely discontinued and replaced by Vamifeport administration.

[0083] A further aspect of the present invention is that a pharmaceutical, pharmaceutical composition, or dosage form comprising bamifeport as defined herein may exist as a combination formulation containing one or more additional pharmaceutically active compounds ("combination therapy compounds" / "co-drugs") in addition to bamifeport. Such additional active compounds are preferably selected from those useful for the treatment of HH patients. Preferred combination therapy compounds are, in particular, compounds selected from pharmaceuticals for treating iron overload and related symptoms, or co-drugs useful for treating the above-mentioned pathological conditions and disorders associated with HH.

[0084] Combination therapy with one or more of the combination therapy compounds (co-drugs) defined above may be carried out using fixed-dose or free-dose combinations for sequential use. Such combination therapy may include the co-administration of vamifeport as defined in the present invention with at least one additional pharmaceutically active compound (drug / combination therapy compound).

[0085] In fixed-dose combination therapy, the combination therapy includes the co-administration of vamifeport as defined herein with at least one additional pharmaceutically active compound in the fixed-dose formulation.

[0086] In free-dose combination therapy, the combination therapy includes the co-administration of vamifeport as defined herein and at least one additional pharmaceutically active compound, each compound at a free dose, either by simultaneous administration of the individual compounds or by sequential use of the individual compounds divided over a period of time.

[0087] Bamifeport salts, solvates, hydrates, and polymorphs This invention relates to a novel medical use of the compound bamifeport having the structure of formula (I). [ka]

[0088] In further embodiments, the present invention relates to the use and methods of treatment as defined herein, wherein the compound according to formula (I) is used in the form of its pharmaceutically acceptable salt, or solvates, hydrates, and polymorphs.

[0089] Examples of suitable pharmaceutically acceptable salts are described in International Applications Publication Nos. 2017 / 068089, 2017 / 068090, and 2018 / 192973. Further examples of suitable salt forms and polymorphs are described in International Application Publication No. 2021 / 191202, which is incorporated herein by reference in this regard.

[0090] In a preferred embodiment, the treatment method described in any of the foregoing uses a HCl salt of bamifeport, and more preferably a triHCl salt of bamifeport.

[0091] Other suitable pharmaceutically acceptable salts include salts with acids from the group consisting of benzoic acid, citric acid, fumaric acid, lactic acid, malic acid, maleic acid, methanesulfonic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid, and toluenesulfonic acid, preferably salts with acids from the group consisting of citric acid, maleic acid, phosphoric acid, and sulfuric acid.

[0092] Generally, pharmaceutically acceptable salts of bamifeport can be selected from monosalts (1:1 salts), trisalts (1:3 salts), and salts characterized by a bamifeport-to-acid ratio of 1-2:1-3, including their solvates, hydrates, and polymorphs.

[0093] In this context, Bamifeport salts can be characterized by a base:acid ratio in the range of 1.0–2.0 (molar base):1.0–3.0 (molar acid), i.e., a selected ratio of Bamifeport:acid as defined above. In certain embodiments, the selected base:acid ratio is 1.0–2.0 (molar base):1.0–2.0 (molar acid).

[0094] Specific examples include the following base:acid ratios, i.e., bamifeport:acid ratios as defined above: 1.0 (molar base): 1.0 (molar acid), 1.0 (molar base): 1.25 (molar acid), 1.0 (molar base): 1.35 (molar acid), 1.0 (molar base): 1.5 (molar acid), 1.0 (molar base): 1.75 (molar acid), 1.0 (molar base): 2.0 (molar acid), 1.0 (molar base):3.0 (molar acid), and 2.0 (molar base): 1.0 (molar acid).

[0095] Among these, salts with a base-to-acid ratio of 1:1 are also called "(one or more) monosalts" or "(one or more) 1:1 salts." For example, monoHCl salts are also called 1HCl or 1HCl salts.

[0096] Among these, salts with a base:acid ratio of 1:2 are also called "(one or more) di-salts" or "(one or more) 1:2 salts." For example, di-HCl salts are also called 2HCl or 2HCl salts.

[0097] Among these, salts with a base-to-acid ratio of 1:3 are also called "(one or more) tri salts," "(one or more) tri salts," or "(one or more) 1:3 salts." For example, triHCl salt is also called 3HCl or 3HCl salt.

[0098] A salt with a base-to-acid ratio of 1:1.25 is also called a "(one or more) 1:1.25 salt".

[0099] A salt with a base-to-acid ratio of 1:1.35 is also called a "(one or more) 1:1.35 salt".

[0100] A salt with a base-to-acid ratio of 1:1.5 is also called a "(one or more) 1:1.5 salt."

[0101] A salt with a base-to-acid ratio of 1:1.75 is also called a "(one or more) 1:1.75 salt".

[0102] Salts with a base-to-acid ratio of 2:1 are also called "(one or more) hemi salts" or "(one or more) 2:1 salts."

[0103] Salts of bamifeport can exist in amorphous, polymorphic, crystalline and / or semi-crystalline (partially crystalline) forms, as well as in the form of solvates of the salts. Preferably, salts of bamifeport exist in crystalline and / or semi-crystalline (partially crystalline) forms and / or in the form of solvates thereof.

[0104] The preferred degree of crystallinity of a salt or salt solvate can be determined by conventional analytical methods, such as various X-ray methods that enable clear and simple analysis of salt compounds in particular. Specifically, the grade of crystallinity can be determined or confirmed by powder X-ray diffraction (reflection) or powder X-ray diffraction (transmission) (PXRD). For crystalline solids having the same chemical composition, different resulting crystal lattices are summarized in the term polymorphism. For solvates, hydrates, and polymorphs, as well as salts having specific degrees of crystallinity, see International Application Publication 2018 / 192973 and International Publication 2021 / 191202, which are incorporated herein by reference in this regard.

[0105] In a further aspect of the present invention, bamifeport compound (I) is comprised of the following salts: 1:1 sulfate having the following formula [ka]

[0106] 1:1 phosphate with the following formula [ka]

[0107] 2:1 phosphate (hemilate) [ka]

[0108] A selection is made from its polymorphs.

[0109] As described in International Publication Nos. 2017 / 068089, 2017 / 068090, and 2018 / 192973, the bamifeport compound (I) acts as a ferroportin inhibitor. Therefore, with respect to the ferroportin inhibitory activity of bamifeport, reference is made to the aforementioned international applications.

[0110] Dosage Form In a further aspect of the present invention, HH treatment involves oral administration of bamifeport, its salts, solvates, hydrates, or polymorphs as described herein to a patient in need thereof.

[0111] For this purpose, bamifeport (including its salts, solvates, hydrates, or polymorphs) is preferably provided in pharmaceuticals or pharmaceutical compositions in the form of oral administration forms, such as pills, tablets, such as enteric-coated tablets, film tablets, and layered tablets, sustained-release formulations for oral administration, depot formulations, sugar-coated tablets, granules, emulsions, dispersions, microcapsules, micro formulations, nano formulations, liposome formulations, capsules, such as enteric-coated capsules, powders, microcrystalline formulations, patches, drops, ampoules, solutions, and suspensions for oral administration.

[0112] In preferred embodiments of the present invention, bamifeport (including its salts, solvates, hydrates, or polymorphs) is administered in the form of tablets or capsules as defined above. These may exist, for example, as an acid-resistant form or with a pH-dependent coating.

[0113] Therefore, further aspects of the present invention relate to the compound bamifeport (including its salts, solvates, hydrates, or polymorphs) for use in the treatment of HH in an orally administered form, as well as pharmaceuticals, compositions, and combination formulations containing the same.

[0114] A pharmaceutical product, pharmaceutical composition, or dosage form containing bamifeport, its salts, solvates, hydrates, or polymorphs may further contain one or more compounds selected from the group comprising pharmaceutical carriers, auxiliaries, solvents, and excipients.

[0115] Preferably, the pharmaceutical carrier, auxiliaries, solvents, and excipients are selected from compounds suitable for preparing oral dosage forms.

[0116] The pharmaceutical product, pharmaceutical composition, or dosage form may contain, for example, up to 99% by weight, up to 90% by weight, up to 80% by weight, or up to 70% by weight of bamifeport (including its salts, solvates, hydrates, or polymorphs), with the remainder being formed by a pharmaceutical carrier, an adjuvant, a solvent, and an excipient, and in the case of the combination therapy dosage forms described below, further pharmaceutically active compounds may be included.

[0117] Among these, pharmaceutically acceptable carriers, auxiliary substances, or solvents are common pharmaceutical carriers, auxiliary substances, excipients, or solvents, and include various organic or inorganic carriers and / or auxiliary materials conventionally used for pharmaceutical purposes, particularly in solid pharmaceutical formulations. Examples include excipients, e.g., sucrose, starch, mannitol, sorbitol, lactose, glucose, cellulose, talcum, calcium phosphate, calcium carbonate; binders, e.g., cellulose, methylcellulose, hydroxypropylcellulose, polypropylpyrrolidone, gelatin, gum arabic, polyethylene glycol, sucrose, starch; disintegrants, e.g., starch, hydrolyzed starch, carboxymethylcellulose, calcium salts of carboxymethylcellulose, hydroxypropyl starch, sodium glycol starch, sodium bicarbonate, calcium phosphate, calcium citrate; and lubricants, e.g., magnesium stearate. Examples include talcum, sodium lauryl sulfate, flavorings such as citric acid, menthol, glycine, orange powder, preservatives such as sodium benzoate, sodium bisulfite, parabens (e.g., methylparaben, ethylparaben, propylparaben, butylparaben), stabilizers such as citric acid, sodium citrate, acetic acid and citriplex series multicarboxylic acids such as diethylenetriaminepentaacetic acid (DTPA), suspending agents such as methylcellulose, polyvinylpyrrolidone, aluminum stearate, dispersants, diluents such as water, organic solvents, waxes, oils and fats such as beeswax, cocoa butter, polyethylene glycol, and white petrolatum.

[0118] Liquid pharmaceutical formulations, such as solutions, suspensions, and gels, typically contain a liquid carrier such as water and / or a pharmaceutically acceptable organic solvent. Furthermore, such liquid formulations may also contain pH adjusters, emulsifiers or dispersants, buffers, preservatives, wetting agents, gelling agents (e.g., methylcellulose), dyes, and / or flavoring agents, as defined above. The composition may be isotonic, i.e., it may have the same osmotic pressure as blood. The isotonicity of the composition can be adjusted by using sodium chloride and other pharmaceutically acceptable agents, such as dextrose, maltose, boric acid, sodium tartrate, propylene glycol, and other inorganic or organic soluble substances. The viscosity of the liquid composition can be adjusted by a pharmaceutically acceptable thickener such as methylcellulose. Other suitable thickeners include, for example, xanthan gum, carboxymethylcellulose, hydroxypropylcellulose, and carbomer. The preferred concentration of the thickener depends on the agent selected.

[0119] To extend the shelf life of liquid compositions, pharmaceutically acceptable preservatives may be used. For example, several preservatives including parabens, thimerosal, chlorobutanol, and benzalkonium chloride may be used, but benzyl alcohol may be preferred. [Brief explanation of the drawing]

[0120] [Figure 1] Dynamics of pharmacodynamic changes after a single oral administration of bamifeport in Hfe C282Y mouse models and 129S2 wild-type mice with hereditary hemochromatosis. Experimental design (A), serum iron concentration (B), and hepatic Hamp expression in Hfe C282Y (left) and 129S2 wild-type (right) mice after treatment with vehicle or bamifeport (C). For all scatter plots, data are shown as individual values ​​with the mean (n=6-10 mice / time point / treatment). Significant differences compared to the vehicle-treated group are shown as follows: *p<0.05, **p<0.01, and ***p<0.001. [Figure 2]Pharmacodynamics of pharmacodynamic effects after chronic oral administration of bamifeport in an Hfe C282Y mouse model of hereditary hemochromatosis. Experimental design (A), serum iron concentration and hepatic Hamp expression (B), hemoglobin levels over time (C), total hepatic iron and 58Fe hepatic iron concentrations (D). Total splenic iron concentration and representative images from DAB-enhanced Perls staining of duodenal sections from vehicle-treated or bamifeport-treated Hfe C282Y mice (E). Hemoglobin data are shown as mean values ​​with standard deviation. For all scatter plots, data are shown as individual values ​​with mean (n=5-6 mice / time point / treatment). Significant differences compared to the vehicle-treated group are shown in black as follows: *p<0.05, **p<0.01, and ***p<0.001. Significant intratreatment differences in the vehicle group are shown in gray as follows: †p<0.01 week 1 vs week 7, ‡p<0.01 week 1 vs week 8, §p<0.05 week 7 vs week 8. Significant intratreatment differences in the Bamifeport group are shown in blue as follows: †p<0.05 week 3 vs week 7, ‡p<0.05 week 4 vs week 7, §p<0.05 week 7 vs week 8 [LID, low iron diet]. [Figure 3] Dynamics of hematological effects after chronic oral administration of bamifeport in an Hfe C282Y mouse model of hereditary hemochromatosis. Red blood cell (RBC) count (A), reticulocyte count (B), white blood cell count (C), platelet count (D), hematocrit level (E), mean corpuscular hemoglobin (MCH) concentration (F), mean corpuscular volume (MCV) (G), reticulocyte hemoglobin (Hb) concentration (H). For all scatter plots, data are shown as individual values ​​along with the mean (n=5-6 mice / time point / treatment). Significant differences compared to the vehicle treatment group are shown as follows: *p<0.05, **p<0.01, and ***p<0.001. [Figure 4]Bamifeport does not interfere with venotomy-mediated hepatic iron removal in the Hfe C282Y mouse model of hereditary hemochromatosis. Experimental design (A), serum iron concentration and hepatic Hamp expression (B), total hepatic iron and 58Fe hepatic iron concentration (C), total splenic iron concentration (D). For all scatter plots, data are shown as individual values ​​with the mean (n=6-9 mice / time point / treatment). Significant differences between treatment groups are shown as follows: *p<0.05, **p<0.01, and ***p<0.001.

[0121] [LID, low iron diet, SD, standard diet, WT, wild type]. [Figure 5] Dynamics of hematological effects after chronic oral administration of bamifeport and venotomy in an Hfe C282Y mouse model of hereditary hemochromatosis. Hemoglobin (A) and erythropoietin (B) levels. Hemoglobin data are shown as mean values ​​with standard deviation. For scatter plots, data are shown as individual values ​​with mean values ​​(n=5-6 mice / time point / treatment). Significant differences compared to the vehicle-treated group are shown as follows: *p<0.05, **p<0.01, and ***p<0.001 [OD, optical density, WT, wild-type]. [Modes for carrying out the invention]

[0122] [Examples] The present invention will be described in more detail by the following examples. The examples are for illustrative purposes only, and those skilled in the art can extend specific examples to further ferroportin inhibitor compounds according to the present invention.

[0123] I. Bamifeport and its salts, solvates, hydrates or polymorphs For the preparation of the compound bamifeport used in the method of the present invention, and for the preparation of its pharmaceutically acceptable salts, solvates, hydrates or polymorphs, see International Publication Nos. 2017 / 068089, 2017 / 068090, 2018 / 192973, and 2021 / 191202.

[0124] II. Evaluation of the ferroportin inhibitor compound bamifeport in a preclinical mouse model of hemochromatosis pharmacological assays. II.1 Materials and Methods Test compound In the experiments described below, bamifeport was administered in the form of its 3HCl salt.

[0125] Animal models Mice were housed under pathogen-free conditions. Mice were housed in a facility and acclimatized for at least 5 days before the start of the experiment. Animals were housed in groups (2-5 mice per cage) under a 12-hour reverse dark / light cycle, with free access to nesting material, enrichment materials, and water / food. Both acute and chronic studies were conducted in the laboratory, and animals were placed in a holding room after each step of the chronic study. There was no blinding of treatments in these studies.

[0126] A) Acute pharmacodynamic effects of single oral administration of vamifeport in HH Hfe C282Y mouse models and 129S2 wild-type mice. To test the acute effects of bamifeport, cages of 8-9 week old female (n=42) and male (n=39) Hfe C282Y mice [Levy JE, et al., The C282Y mutation causing hereditary hemochromatosis does not produce a null allele. Blood. 1999;94:9-11] (JAX stock number 005063, Jackson Laboratory, Bar Harbor, Maine) and strain and age-matched wild-type female (n=45) and male (n=45) 129S2 / SvPasCRL mice (Charles River Laboratories, Sulzfeld, Germany) were randomly assigned to the relevant treatment group and time point. Mice were administered a single dose of either vehicle (0.5% methylcellulose) or bamifeport 60 mg / kg (10 mL / kg) by forced oral administration. Following administration, the animals were given free access to a low-iron diet (LID, #2039, Fe=13.4 mg / kg, Granovit SA, Kaiseraukscht, Switzerland) and drinking water. The animal groups were euthanized by complete hemorrhage after terminal anesthesia with isoflurane at 0.5, 1, 3, 6, and 16 hours post-administration. Blood and liver samples were collected for analysis of serum iron and hepatic hepcidin (Hamp) expression.

[0127] B) Chronic pharmacodynamic effects of vamifeport administered in drinking water in the HH Hfe C282Y mouse model. To test the chronic effects of bamifeport, Hfe C282Y mice were distributed into cages at weaning (3 weeks of age), and each cage was assigned to a treatment group / time point according to stratified randomization. Mice were given LID (#2039, Fe=10.4 mg / kg, Granovit SA, Kaiserauchst, Switzerland) and given free access to drinking water. Since the primary objective was to evaluate the treatment effect of bamifeport compared to vehicles in a chronic study, wild-type mice were not used in accordance with the 3R principle. Bamifeport was administered in drinking water rather than by forced oral administration as in an acute study to avoid potential stress associated with animal handling and prolonged forced oral administration twice daily (i.e., treatment over several weeks). Four-week-old female (n=15) and male (n=26) Hfe C282Y mice (129-Hfetm1.1Nca / J) were given free access to autoclaved mineral water containing either vehicle or bamifeport 1.0 mg / mL (base weight of bamifeport equivalent to a daily oral dose of approximately 110 mg / kg) for up to eight weeks. Fresh bamifeport formulations were prepared weekly in the drinking water, and water intake per cage was measured at 3- or 4-day intervals by weighing the water bottles. The average daily water intake was 2.7 ± 0.3 mL / mouse. 58The mice were supplemented with 0.5 mM Fe(II)SO4 containing Fe (12% of total iron content, Vifor Pharma, batch number ROR3171), 1% glucose, and 10 mM ascorbic acid. The bamifeport dose was selected based on oral doses that have been shown to be effective in other mouse models of chronic bamifeport treatment (120 mg / kg, 60 mg / kg twice daily forced oral administration) [Manolova V, et al. Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of β-thalassemia. J Clin Invest. 2019;130:491-506.]. Small blood samples were collected weekly by tail vein dissection for analysis of hemoglobin levels. At predetermined time points (weeks 2, 4, 6, and 8), the animals were euthanized by complete hemorrhage after cervical dislocation following terminal anesthesia with isoflurane. Blood and liver samples were collected, and the effects of bamifeport on serum and organ iron levels and hepatic hepcidin (Hamp) expression were analyzed.

[0128] C) Chronic effect of vamifeport administered in drinking water on the hepatic iron loss effect of venotomy in the Hfe C282Y mouse model of HH. To investigate the potential of combining bamife port with venotomy, a pilot study was conducted. As described above, 9-10 week old female (n=7) and male (n=6) Hfe C282Y mice were given 0.3 mg / mL (approximately 40 mg / kg) or 1 mg / mL (approximately 110 mg / kg) of bamife port in vehicle or drinking water. The mice were given a standard diet freely (#3432, Fe=170 mg / kg, Granovit SA, Kaiseraugst, Switzerland) for 9-10 weeks (iron loading), then switched to LID (Fe=13.4 mg / kg) in week 0 of the study. The mice were anesthetized with isoflurane and venotomy was performed every two weeks by sublingual hemorrhage (removing approximately 20% of their total blood volume). Vehicle-treated, unvenous Hfe C282Y mice (4 males / 4 females) and wild-type 129S2 mice (4 males / 5 females) were used as controls. At the end of the study (week 4), the mice were pre-anesthetized with isoflurane, and blood was collected by post-orbital hemorrhage. The mice were then sacrificed by cervical dislocation, and their livers were collected and used to analyze the effect of bamife port in combination with venotomy on organ iron accumulation.

[0129] Analysis of iron-related parameters Serum iron levels were determined using triple replicates of the Multigent Iron Assay (Abbott Diagnostics, Barr, Switzerland) at 0.5, 1, 3, 6, and 16 hours in the acute trial, and at 2, 4, 6, and 8 weeks in the chronic trial.

[0130] Relative hepatic hepcidin (Hamp) expression was analyzed by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) using TaqMan Gene Expression Assays (#Mm04231240_s1, Thermo Fisher Scientific, Waltham, Massachusetts) on a LightCycler 480 II instrument (Roche Diagnostics, Rothkreuz, Switzerland) according to the manufacturer's instructions. Hamp transcript levels were calculated by comparison with the reference gene Gusb (TaqMan:#Mm01197698_m1, Thermo Scientific, Waltham, Massachusetts). Hamp expression levels were analyzed at 0.5, 1, 3, 6, and 16 hours in the acute study and at 2, 4, 6, and 8 weeks in the chronic study.

[0131] In chronic and venotomy studies, hemoglobin levels in tail vein blood were determined weekly (HemoCue AB, Engelholm, Sweden).

[0132] The total blood count was measured using a veterinary ProCyte blood analyzer (Idexx Bioresearch, Westbrook, Maine).

[0133] The organs were rapidly frozen in liquid nitrogen, and total iron and / or were measured using inductively coupled plasma emission spectroscopy and inductively coupled plasma mass spectrometry, respectively. 58 The Fe concentration was determined. Organ iron levels (total and 58 Fe) was analyzed at 4 weeks in the venotomy study and at 2, 4, 6, and 8 weeks in the chronic study.

[0134] The duodenum was fixed with 10% buffered formalin and embedded in paraffin. Deparaffinized tissue sections were stained for non-heme trivalent iron deposition using diaminobenzidine (DAB) enhanced Perls staining. Serial sections were stained with hematoxylin and eosin (HE). Images were acquired using an Olympus VS120 Virtual Slide Microscope with a 40x objective lens (NA 0.95).

[0135] statistical analysis As part of the animal licensing application for chronic studies (ZH108 / 2017), pre-sample size calculations were performed with estimated effect sizes for several parameters, a target power of 0.8, and α=0.05. Hemoglobin data were analyzed using two-way ANOVA with repeated measures for time-course effects. Bonferroni multiple comparison tests were performed where statistically significant effects were observed. Analysis of serum iron, Hamp gene expression, and organ iron concentrations utilized one-way ANOVA with Dunnett's multiple comparison test. Statistical analysis was performed using Prism software (GraphPad Prism version 9.4.1, San Diego, California).

[0136] result A) Effect of a single dose of bamifeport on attenuated serum iron and hepatic Hamp expression in the HH Hfe C282Y mouse model compared to 129S2 wild-type mice. Homozygous mice with the C282Y mutation (Hfe C282Y mice) have restricted Hfe expression, and HFE deficiency (Hfe - / - They exhibit iron metabolism-related parameters similar to those seen in mice. Both mouse models develop iron overload due to a deficiency in iron-regulating Hamp expression, and adequately reproduce the pathology observed in human HH [Levy JE, et al., The C282Y mutation causing hereditary hemochromatosis does not produce a null allele. Blood. 1999; 94: 9-11; Zhou XY, et al., HFE gene knockout produces mouse model of hereditary hemochromatosis. Proc Natl Acad Sci US A. 1998; 95: 2492-2497].

[0137] To evaluate the pharmacodynamic effects of bamifeport on systemic iron levels in the HH model, a single oral dose of bamifeport (60 mg / kg) was administered to Hfe C282Y mice and corresponding wild-type controls (129S2 mice), and the dynamics of changes in serum iron and hepatic Hamp expression were assessed. A schematic diagram outlining the experimental design of the study evaluating the acute effects of bamifeport treatment is shown in Figure 1A.

[0138] Consistent with data published by HH Levy JE, et al., Blood. 1999;94:9-11, vehicle-treated Hfe C282Y mice had slightly higher steady-state serum iron levels at all time points than their wild-type 129S2 counterparts (51±4 μM vs. 45±5 μM, respectively) (Figure 1B). In both Hfe C282Y mice and 129S2 wild-type mice, serum iron levels began to decrease 30 minutes after a single oral administration of bamife port (60 mg / kg). However, the response to bamife port was delayed, less pronounced, and shorter-lasting in Hfe C282Y mice compared to the wild-type counterpart. In Bamifeport-treated Hfe C282Y mice, serum iron levels were significantly lower at 1 and 3 hours post-administration than in the vehicle-treated group. However, in 129S2 wild-type mice, serum iron levels were significantly reduced after Bamifeport-treated mice at 30 minutes, 1, 3, and 6 hours post-administration compared to the vehicle-treated group. At 16 hours post-administration, there was no difference in serum iron levels between the Bamifeport-treated and vehicle-treated groups in either Hfe C282Y or 129S2 mice.

[0139] Vehicle-treated Hfe C282Y mice showed lower hepatic Hamp expression than wild-type counterparts at all time points (expressed as mean ΔCt Gusb-Hamp 6.6±0.1 vs. 8±0.5) (Figure 1C).

[0140] Interestingly, in Hfe C282Y mice, there was no significant change in hepatic Hamp expression after a single oral administration of bamifeport (60 mg / kg), while in 129S2 wild-type mice, a significant decrease was observed at 3 and 6 hours after bamifeport treatment. This clearly demonstrates that iron restriction-induced hepatic Hamp expression is differentially regulated in Hfe C282Y mice and 129S2 wild-type mice.

[0141] B) Chronic iron restriction with bamifeport results in a sustained decrease in serum and hepatic iron in the HH Hfe C282Y mouse model. To investigate the long-term effects of chronic bamifeport treatment on serum iron, hepatic Hamp, hemoglobin, and organ iron concentrations, a cohort of Hfe C282Y mice was administered 1.0 mg / mL of bamifeport in drinking water (equivalent to a daily dose of 110 mg / kg) for up to 8 weeks. The experimental design of this study is shown in Figure 2A.

[0142] Serum iron levels began to decrease in Hfe C282Y mice at week 2 of bamifeport administration, but were not significantly different from those observed in vehicle-treated mice at this point (Figure 2B). Chronic bamifeport intake resulted in a sustained decrease in serum iron levels in Hfe C282Y mice. Serum iron concentrations continued to decrease at weeks 4, 6, and 8 of bamifeport administration, and were significantly lower at all of these time points than those observed in vehicle-treated mice.

[0143] In contrast to observations in acute studies (Hamp expression was measured up to 16 hours after a single dose of bamifeport), hepatic Hamp expression was significantly lower in Hfe C282Y mice at weeks 2, 4, 6, and 8 of chronic bamifeport administration compared to the vehicle-treated group (Figure 2B). These data suggest that sustained iron restriction due to chronic bamifeport treatment modulates Hamp expression in a way that differs from that resulting from acute bamifeport treatment.

[0144] With the exception of week 7, hemoglobin levels observed in vehicle-treated Hfe C282Y mice during chronic bamifeport administration were significantly lower from week 1 to the end of the study (week 8) (Figure 2C), reflecting bamifeport-induced iron-restricted erythropoiesis.

[0145] Mutations present in Hfe C282Y mice result in inappropriate Hamp expression, leading to low hepcidin levels and excessive iron absorption and storage. Total liver iron concentration (reflecting liver iron accumulated before and during the study) remained significantly lower in Hfe C282Y mice treated with chronic bamife port than in those treated with vehicle. The difference in total liver iron concentration was observed from week 2 and remained lower in bamife port-treated animals throughout the study period, reaching statistical significance from week 4 (Figure 2D).

[0146] Chronic bamifeport intake via drinking water was observed in the liver of Hfe C282Y mice after vehicle administration. 58 Fe accumulation was prevented. At weeks 2, 4, 6, and 8, 58 Fe liver iron concentration was significantly lower in Bamife port-treated mice than in vehicle-treated mice (Figure 2D), demonstrating that iron restriction with Bamife port effectively prevented de novo iron accumulation.

[0147] Total splenic iron concentration increased over time in both the vehicle-treated and bamifeport-treated groups, but the level at week 6 was significantly higher in chronic bamifeport-treated mice than in vehicle-treated mice, reflecting iron retention in splenic cells as a result of ferroportin inhibition (Figure 2E). DAB-enhanced Perls staining of duodenal sections from Hfe C282Y mice showed iron accumulation in duodenal intestinal cells after 8 weeks of bamifeport treatment. Duodenal staining was not evident in vehicle-treated mice (Figure 2E). These data demonstrate that bamifeport inhibits iron transport from splenic cells and dietary iron absorption.

[0148] Compared to the vehicle-treated Hfe C282Y mice, those treated with the Bamife port showed a significant increase in red blood cell count at 6 weeks and a significant increase in reticulocytes at 2 and 4 weeks (Figures 3A and 3B). White blood cell and platelet levels were similar in these treatment groups (Figures 3C and 3D). Hematocrit, mean corpuscular hemoglobin, mean corpuscular volume, and reticulocyte hemoglobin levels were significantly higher at all time points in the vehicle-treated Hfe C282Y mice due to the induction of iron-restricted erythropoiesis during Bamife port treatment (Figures 3E to 3H).

[0149] C) Combination therapy of Vamifeport with venotomy and hepatic iron removal in the Hfe C282Y mouse model of HH Venotomy is the current standard of care for the clinical management of HH patients, typically performed weekly during the induction phase and reduced to 3-4 times per year during the maintenance phase. To investigate the potential of combining venotomy with vamife porting in HH, a pilot study was conducted to evaluate the effect of bi-weekly venotomy combined with vamife porting compared to venotomy alone (i.e., in combination with vehicle treatment) in Hfe C282Y mice. The experimental design of this pilot study is shown in Figure 4A.

[0150] Bamifeport was provided in drinking water at concentrations of 0.3 mg / mL and 1.0 mg / mL, which should correspond to daily doses of approximately 40 mg / kg and 110 mg / kg of bamifeport, respectively. The intake of water containing 0.3 mg / mL of bamifeport was similar to the intake of vehicle-containing water in venotomed Hfe C282Y mice (Table 1). [Table 1]

[0151] However, venotomy-treated Hfe C282Y mice drank 56% less water containing higher concentrations of bamifeport (compared to the vehicle-treated group). Surprisingly, control, non-venotomy-treated Hfe C282Y mice treated with 1 mg / mL bamifeport consumed approximately 20% less water than the non-venotomy-treated vehicle-treated group, suggesting that the intake of water containing 1 mg / mL bamifeport is reduced in sublingually venotomy-treated animals. Based on the measured intake of bamifeport-containing water, the daily dose of bamifeport in this study was approximately 40 mg / kg for 0.3 mg / mL and approximately 60 mg / kg for 1 mg / mL. Since the intake of bamifeport was disproportionately reduced in the 1 mg / mL dose group, only the data obtained for the 0.3 mg / mL group was considered reliable. Therefore, we report results only for the 0.3 mg / mL bamifeport dose.

[0152] Serum iron concentration and hepatic Hamp expression did not change with venotomy alone. Both parameters showed a non-significant decrease with the addition of a bamife port and venotomy (Figure 4B).

[0153] Veniotomy alone significantly reduced total hepatic iron concentration in the HH Hfe C282Y mouse model, but not compared to vehicle-treated, non-veniotomy mice. 58 Fe did not affect hepatic iron concentration (Figure 4C). Importantly, the bamife port did not hinder the hepatic iron removal effect of venotomy more effectively in Hfe C282Y mice that received venotomy + bamife port than in Hfe C282Y mice that received venotomy alone (total hepatic iron levels were lower, but not statistically significant). Furthermore, the decrease in total iron levels observed in venotomy + bamife port compared to no venotomy (p<0.001) was statistically significant at a higher level than that observed in venotomy alone compared to no venotomy (p<0.05). 58There was no significant difference in hepatic iron levels. Combining phlebotomy with bamiferoport significantly decreased hepatic iron concentration in Hfe C282Y mice compared to phlebotomy alone, indicating that bamiferoport prevented iron absorption from drinking water and thereby prevented iron accumulation in the liver. Similar hemoglobin, spleen iron, and erythropoietin levels were observed between phlebotomy + bamiferoport treatment and phlebotomy alone (Figure 5). 58 prevented iron absorption from drinking water and thereby prevented iron accumulation in the liver. Similar hemoglobin, spleen iron, and erythropoietin levels were observed between phlebotomy + bamiferoport treatment and phlebotomy alone (Figure 5). 58 prevented iron absorption from drinking water and thereby prevented iron accumulation in the liver. Similar hemoglobin, spleen iron, and erythropoietin levels were observed between phlebotomy + bamiferoport treatment and phlebotomy alone (Figure 5).

[0154] Discussion The preclinical trials presented herein evaluated the efficacy of the oral ferroportin inhibitor bamiferoport in reducing serum iron levels and preventing hepatic iron deposition in the Hfe C282Y mouse model of HH, both alone and in combination with phlebotomy. In these trials, Hfe C282Y mice showed elevated serum iron levels compared to control 129S2 wild-type mice, which is consistent with lower hepatic expression of the iron regulatory peptide hepcidin in the former group. Both acute and chronic oral bamiferoport treatment significantly decreased serum iron levels in this mouse model, demonstrating the potential of ferroportin inhibition by bamiferoport to correct the elevated systemic iron levels in HH, despite chronically decreased hepcidin levels.

[0155] In the chronic trial, the decrease in serum iron levels due to bamiferoport treatment attenuated iron accumulation in the liver.

[0156] In 129S2 wild-type mice, Hamp expression was downregulated in response to acute hypotyremia 3 and 6 hours after bamife port administration, but liver Hamp expression levels did not change significantly in Hfe C282Y mice in the acute test. These findings are consistent with the presence of non-functional HFE in Hfe C282Y mice, which prevents proper endogenous regulation of hepcidin levels in the presence of acute hypotyremia, leading to progressive organ iron overload. Another possible explanation for the lack of hepcidin downregulation in the acute test is that serum iron levels may still be above the threshold at which hepcidin is inhibited after acute bamife port treatment in Hfe C282Y mice. Acute bamife port treatment did not significantly affect liver Hamp levels in Hfe C282Y mice, but chronic treatment significantly reduced Hamp expression. The differential modulation of Hamp observed during acute (decreased serum iron and persistent hepatic iron excess) and chronic (decreased serum and hepatic iron concentrations) vamifeport treatment may reflect two hypothetical mechanisms of hepcidin regulation. Detection of changes in hepatic iron storage is primarily mediated by hepatic BMP6, which interacts with BMPRI / II and a multiprotein complex on the hepatocyte membrane to regulate hepcidin expression. In contrast, changes in serum iron (bound to transferrin) regulate hepcidin expression via HFE and TFR2 signaling.

[0157] Hemoglobin levels during chronic bamife port treatment were significantly lower than those observed in vehicle-treated Hfe C282Y mice, suggesting that iron restriction in this HH model normalizes hemoglobin levels to levels similar to those observed in healthy mice in a shorter 3-week trial (160 g / L, n=5 males / 5 females). Bamife port also induced iron-restricted erythropoiesis in Hfe C282Y mice (presumably as a function of the decrease in mean corpuscular volume), as evidenced by the decrease in mean corpuscular hemoglobin content, mean corpuscular volume, and hematocrit levels. Bamife port-treated mice had lower total blood hemoglobin levels, but their red blood cell count was unaffected. Chronic oral administration of bamife port also affected total liver iron concentration and 58 Both Fe hepatic iron concentrations were significantly reduced, suggesting that bamife porting prevents hepatic iron overload in Hfe C282Y mice. Furthermore, bamife porting resulted in increased iron capture in iron transport organs such as the spleen and duodenum.

[0158] Importantly, bamifeport did not interfere with the venotomy iron removal process in pilot preclinical studies. However, the dose of bamifeport used (approximately 40 mg / kg) was lower than the dose (120 mg / kg) that had been shown to be optimally effective in other rodent studies. While a dose of approximately 40 mg / kg of bamifeport did not significantly improve hepatic iron removal in the livers of venotomy-treated Hfe C282Y mice. 58 The potential of the bamife port to prevent Fe uptake and improve the effectiveness of venotomy in HH patients was demonstrated.

[0159] Accordingly, the Bamifeport offers a new therapeutic approach that targets HH based on the underlying pathophysiology, as an alternative to the merely symptomatic approach currently applied with venotomy.

[0160] The data presented herein support, for example, the use of vamifeport in combination therapy with venotomy during the induction phase, and the use of vamifeport in the maintenance phase of treatment or as a potential alternative to venotomy in patients who are not eligible for venotomy.

[0161] Approaches explored in the literature to date include the restoration of hepcidin levels by administering hepcidin mimetics (e.g., rusfertide [PTG-300] and rusfertide analog PN23114), synthetic hepcidin (e.g., LJPC-401), and minihepcidin (e.g., PR65 and oral minihepcidin PN20076). Agents targeting TMPRSS6, a protein that inhibits hepcidin transcription, have also been evaluated (e.g., lipid nanoparticle-containing small interfering RNA [siRNA], GalNAc-siRNA conjugate SLN124, and antisense oligonucleotides [e.g., IONIS-TMPRSS6-LRx / sapabrucen], all of which target Tmprss6 expression). Most of the available data are related to HH's Hfe - / - The results originate from preclinical trials of subcutaneously administered drugs in knockout mouse models. In such models, almost all of the drugs tested resulted in a decrease in serum iron levels and / or TSAT, as well as a decrease in hepatic iron accumulation. However, therapeutic approaches requiring an injection route for drug administration are less advantageous than orally administered drugs for the reasons mentioned above.

[0162] Oral-available minihepcidin PN20076 is Hfe2 - / - Mouse (Hemomoduvelin knockout [Hjv - / - It has also been reported that it significantly reduces hepatic iron accumulation in hepcidin knockouts (Hamp) with iron overload. - / -Subcutaneous administration of PR65 in mice was reported to significantly reduce hepatic iron concentration, but not serum iron levels. However, there was also a significant decrease in hemoglobin levels, suggesting that there may have been a transient decrease in serum iron concentration that was not captured in this study. Interestingly, the rusfertide analog PN23114 is HH's Hjv - / - In a mouse model, combining venotomy improved iron parameters.

[0163] As observed in the Vamife report of this study, none of the evaluated treatment strategies (PN23114 or venotomy alone or in combination) resulted in a significant reduction in total hepatic iron content, although all three treatments reduced further hepatic iron deposition. In a recent 6-month trial, subcutaneously administered rusfertide reduced serum iron levels and hepatic iron concentrations in 16 HH patients with a stable venotomy regimen. Furthermore, the venotomy rate significantly improved from a mean of 0.27 per month at baseline to 0.03 per month during rusfertide treatment. Positive results were also reported in an interim analysis of a Phase 2 trial of subcutaneous LJPC-401 compared to placebo in 26 HH patients. After 16 weeks of treatment, patients receiving LJPC-401 had a significantly reduced TSAT compared to placebo, and similarly, the need for venotomy was reduced (0.06 vs. 0.41 per month, respectively).

[0164] However, as mentioned above, subcutaneous (parenteral) administration is disadvantageous compared to oral administration methods such as vamifeport. Exemplary advantages include improved convenience and ease of administration for patients, cost savings due to reduced need for hospital visits, dosage / formulation flexibility, avoidance of the risk of injection site reactions / infections, and generally easier storage and supply chain management compared to injectable drugs. With oral medications, absorption and onset of action are generally slow, but vamifeport is absorbed relatively quickly, with detectable levels 15-30 minutes after administration and serum iron levels decreasing to trough levels 4-8 hours after administration in healthy volunteers.

[0165] In summary, these preclinical proof-of-concept trials demonstrate that the ferroportin inhibitor bamifeport significantly reduces serum iron levels and prevents hepatic iron overload after chronic administration in an Hfe C282Y mouse model of HH, thus supporting future clinical development in this indication. Bamifeport has potential in combination therapy with venotomy in induction-stage HH patients and has even been shown to potentially replace venotomy in HH patients in the long term.

[0166] III. Veniotomy Loading The venotomy load in subjects treated according to the method of the present invention can be assessed, for example, by determining the patient's venotomy requirements through conventional clinically recognized assessments of required volume and / or frequency of phlebotomy sessions.

[0167] IV. Organ Iron Levels Iron levels, such as those in the liver, kidneys, spleen, duodenum, or myocardium, can be determined using one or more conventional assays. For example, iron levels (e.g., liver iron concentration, pancreatic iron concentration, kidney iron concentration, spleen iron concentration, duodenal iron concentration, or myocardium iron concentration) can be determined by inductively coupled emission spectroscopy (ICP-OES) and inductively coupled plasma mass spectrometry (ICP-MS).

[0168] V. Determination of serum ferritin levels Serum ferritin levels can be determined using one or more conventional assays.

[0169] VI. Determining Hemoglobin Hemoglobin levels can be determined using one or more conventional assays.

[0170] VII. Quality of Life The quality of life can be assessed using the Short Form(36) Health Survey(SF-26), as described, for example, in International Publication No. 2016 / 183280.

Claims

1. Compounds according to the following formula (I) for use in the treatment of hereditary hemochromatosis 【Chemistry 1】 or a pharmaceutically acceptable salt, solvate, hydrate, or polymorph thereof.

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

3. The compound for use according to claim 1 or 2 is a 3HCl salt having the following formula (I-3HCl). 【Chemistry 2】

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

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

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

7. The compound for use according to claim 6, wherein the chronic administration comprises administering the compound (I), or a pharmaceutically acceptable salt, solvate, hydrate, or polymorph thereof, daily for a period of at least one week, at least two weeks, at least three weeks, at least four weeks, at least five weeks, at least six weeks, at least seven weeks, at least eight weeks, and / or up to at least eight weeks.

8. The compound for use according to any one of claims 1 to 7, wherein the treatment is a combination therapy comprising chronic administration of the compound of formula (I) and frequent venotomy.

9. The compound for use according to claim 8, wherein the combination therapy comprises chronic administration of the compound of formula (I) and increasing the time interval between one venotomy setting and subsequent venotomy settings over the entire treatment period.

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

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

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

13. Acids from the group consisting of benzoic acid, citric acid, fumaric acid, lactic acid, malic acid, maleic acid, methanesulfonic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid, and toluenesulfonic acid, Preferably, an acid from the group consisting of citric acid, maleic acid, phosphoric acid, and sulfuric acid. This is a pharmaceutically acceptable form of salt, More preferably, the compound is a salt from the following group: 1:1 sulfate having the following formula 【Transformation 3】 1:1 phosphate having the following formula 【Chemistry 4】 2:1 phosphate (hemilate) 【Transformation 5】 and selected from its polymorphs, A compound for use according to any one of claims 1 or 4 to 12.

14. The compound for use according to any one of claims 1 to 13, wherein the treatment comprises treating and / or improving associated symptoms, including fatigue or weakness, fatigue, pain in the joints, especially the knees and hands, abdominal pain over the liver, weight loss, and loss of interest in sex or erectile dysfunction, arthritis, liver disease including cirrhosis and liver cancer, diabetes, heart abnormalities, and skin discoloration (including darkening of the skin color which may appear gray, metallic, or bronze).

15. A compound for use according to any one of claims 1 to 14, formulated into a pharmaceutical dosage form further comprising one or more selected from the group of pharmaceutical carriers, adjuvants, solvents, and / or excipients, and / or one or more additional pharmaceutically active compounds.

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