CN116710091A

CN116710091A - Membrane iron transporter inhibitors for the treatment of myelodysplastic syndrome (MDS)

Info

Publication number: CN116710091A
Application number: CN202280011066.3A
Authority: CN
Inventors: 弗朗西斯卡·文奇; 瓦尼亚·麦诺洛娃; 弗朗茨·杜尔伦贝格尔
Original assignee: Vifor International AG
Current assignee: Vifor International AG
Priority date: 2021-01-20
Filing date: 2022-01-19
Publication date: 2023-09-05

Abstract

The present invention relates to the use of membrane iron transporter inhibitor compounds of formula (I) for the treatment of myelodysplastic syndrome (MDS).

Description

Membrane iron transporter inhibitors for the treatment of myelodysplastic syndrome (MDS)

Technical Field

The present invention relates to the use of compounds of formula (I) as inhibitors of membrane-iron transporters for the treatment of myelodysplastic syndrome (MDS) and the symptoms and pathological conditions associated therewith.

Background

Iron is an essential element of almost all organisms, and its relevance is in its critical role in erythropoiesis and oxygen transport. Balance of iron metabolism is primarily regulated from hemoglobin of aging red blood cells, iron storage from the liver, and iron recovery levels in dietary iron absorption from the duodenum. Elemental iron is taken up by duodenal cells via a specific transport system (DMT-1, membrane iron transporter), transferred into the blood circulation, and thus delivered to the appropriate tissues and organs to which its carrier transferrin is bound. In humans, iron is very important, especially for oxygen transport, oxygen uptake, cellular functions such as mitochondrial electron transport, cognitive functions, etc., and ultimately for the whole energy metabolism. Mammalian organisms are unable to remove or secrete iron from the body through the active system. Iron homeostasis is controlled by the hepcidin hormone hepcidin, which regulates the activity of the only known iron exporter membrane iron transporter and thus regulates iron release by macrophages, hepatocytes and intestinal cells. Hepcidin controls the absorption of iron through the intestines and placenta and the recirculation of iron from the reticuloendothelial system. The production of hepcidin is regulated directly by the molten iron, i.e. if sufficient or excess iron and oxygen are supplied to the organism, more hepcidin is produced; less hepcidin is produced if iron and oxygen levels are low, or in the case of increased erythropoiesis. In small intestine mucosal cells and macrophages, hepcidin binds to membrane iron transporters, blocking their export function and promoting their internalization and degradation. By this mechanism, hepcidin reduces the outflow of iron from cells to the blood stream. Transport protein membrane iron transport proteins are transmembrane proteins consisting of 571 amino acids, which are expressed in the liver, spleen, kidneys, heart, intestines and placenta. In particular, membrane iron transporters are located in the basolateral membrane of intestinal epithelial cells. Thus, membrane iron transporters act to export dietary iron into the blood. If hepcidin binds to the membrane iron transporter, the membrane iron transporter is transported into the cell where dissociation of the membrane iron transporter occurs, thereby blocking release of iron from the cell. If the membrane iron transporter is inactivated or inhibited by hepcidin such that it cannot export iron stored in mucosal cells, the absorption of iron in the intestine is blocked. The reduction of hepcidin results in an increase in active membrane iron transporters, allowing an increase in the release of iron for dietary iron absorption and storage, and an increase in serum iron levels.

In pathological conditions, increased iron levels lead to iron overload. For example, excessive iron uptake in organs such as the liver and heart leads to iron accumulation. Furthermore, iron accumulation in the brain has been observed in patients suffering from neurodegenerative diseases such as alzheimer's disease and parkinson's disease. The major part of circulating iron is associated with transferrin, a classical iron transport molecule that prevents the formation of free reactive iron. The iron fraction that is not bound to transferrin (or to other conventional iron binding molecules such as heme, deferiprone, heme, etc.) is collectively referred to as non-transferrin bound iron (NTBI). In another aspect of iron overload conditions and diseases, many problems and pathological conditions result from excessive levels of free iron in the circulation, NTBI.

A key detrimental aspect of such excess free iron is the undesirable formation of free radicals. In particular, iron (II) ions catalyze the formation of Reactive Oxygen Species (ROS), especially by the Fenton reaction. ROS cause damage to DNA, lipids, proteins and carbohydrates, thereby profoundly affecting cells, tissues and organs. The formation of ROS is well known and described in the literature as causing so-called oxidative stress. NTBI is widely described as exhibiting a high propensity to induce ROS, with potential toxicity to cells and major organs, including heart, liver, pancreas, kidney, and bone marrow. Thus, iron overload is known to cause tissue and organ damage, such as heart, liver and endocrine damage (Vinchi, hell, platzbecker, "Controversies on the consequences of iron overload and chelation in MDS", hemaschere, volume 27, 4 (3), 2020; patel m. et al, "Non Transferrin Bound Iron: nature, manifestations and Analytical Approaches for Estimation", ind.j. Clin. Biochem.,2012, volume 27, volume 4: pages 322-332 and Brissot p. Et al review, "Non-transferrin bound iron: A key role in iron overload and iron toxicity", biochimica et Biophysica Acta,2012, volume 1820, pages 403-410).

Myelodysplastic syndrome (MDS) is a heterogeneous group of clonal myelodisorders characterized by ineffective hematopoiesis leading to peripheral cytopenias and risk of leukemia transformation. MDS is one of the most commonly encountered acquired bone marrow failure syndromes in adults. Genetic and epigenetic changes affecting Hematopoietic Stem Cells (HSCs) and hematopoietic niche changes leading to degeneration and apoptosis of Hematopoietic Stem and Progenitor Cells (HSPCs) result primarily in ineffective hematopoiesis.

MDS refers to a group of cancers in which HSPCs in bone marrow are immature and therefore cannot become healthy blood cells. Typically, there are no symptoms in the early stages, but later stages may include feeling tired, shortness of breath, bleeding disorders, anemia, and frequent infections. Some types of MDS can develop into acute myelogenous leukemia. In MDS, the production of blood cells is ineffective, resulting in insufficient numbers of erythrocytes, platelets and leukocytes. Some MDS types are characterized by an increase in immature blood cells called myeloblasts in bone marrow and/or blood. The type of MDS is based on specific changes in blood cells and bone marrow.

The International Prognostic Scoring System (IPSS) and revised IPSS (IPSS-R) characterize different kinds of MDSs. The lower risk MDS is defined as low or medium 1 risk according to IPSS, or very low, low or medium risk according to revised IPSS [ IPSS-R ].

According to IPSS or IPSS-R, lower risk myelodysplastic syndromes are most commonly manifested as symptomatic anemia. In particular in the elderly, chronic anaemia is associated with a number of complications including increased risk of cardiovascular complications, falls and fractures and reduced survival time. A high proportion of patients with lower risk myelodysplastic syndromes eventually rely on erythrocyte infusion (transfusion dependency), which is associated with reduced quality of life and overall survival.

With the increasing availability of sequencing and identification of somatic gene mutations in clinical practice, other MDS subtypes defined by genetic abnormalities can be identified. Such subtypes are MDS with an isolated del (5 q) or MDS with an SF3B1 mutation and are further described in the specific report paper by L.Malcovati et al: "SF3B1-mutant MDS as a distinct disease subtype: a proposal from the International Working Group for the Prognosis of MDS"; blood, volume 136, phase 2, pages 157-170, 2020.

Common biological features of low risk MDS include defects in hematopoietic stem and progenitor cell self-renewal and differentiation, leading to cytopenia. About 60% to 80% of MDS patients suffer from symptomatic anemia, and 80% to 90% of anemic MDS patients require Red Blood Cell (RBC) infusion as a supportive therapy.

Iron overload is common in MDS, as intestinal iron absorption increases to support erythropoiesis expansion and long-term RBC infusion, which are often necessary to correct anemia in this patient population.

The primary driver of iron overload in MDS patients is ineffective erythropoiesis and transfusion therapy. Patients with MDS begin to develop iron overload prior to transfusion dependence. This means that MDS patients may develop iron overload due to their potentially ineffective erythropoiesis even before receiving transfusion, which triggers an increase in iron uptake to support erythrocyte expansion in an attempt to restore anemia. Amelioration of anemia by RBC infusion is the central point of support care for MDS, and blood transfusion is still often the primary cause of iron overload in this patient population. Ineffective erythropoiesis results in the inhibition of the iron hormone hepcidin, which in turn triggers unrestricted absorption of iron by duodenal intestinal cells. This mechanism increases iron influx into the circulation to support neonatal erythropoiesis in the bone marrow, thereby establishing iron overload in MDS. Thus, correction of unbalanced iron absorption by induction of hepcidin synthesis or supplementation with hepcidin mimics is assessed as an attractive therapeutic approach to normalize deregulated iron metabolism in MDS.

Patients with MDS require long-term transfusion therapy, which often results in secondary iron overload, ultimately producing life-threatening consequences in the patient population. Although transfusion dependence itself is a negative prognostic factor reflecting poor bone marrow function, subsequent transfusion iron overload has an additional dose-dependent negative impact on survival in patients at low risk for MDS. Recent data indicate that markers of iron overload in fact are predictive of relatively poor prognosis, and retrospective analysis demonstrates that iron chelation therapy is associated with increased survival in transfusion-dependent MDS patients.

Diagnosis of suspected MDS is based on clinical and hematological analysis, aided by genetic analysis of possible genetic abnormalities. To date, treatments for MDS include supportive care, drug therapy, and hematopoietic stem cell transplantation. Supportive care can include intermittent or periodic blood transfusions, drugs that increase erythropoiesis (including erythropoietin stimulators), and antibiotics. Drugs known to be useful in the treatment of MDS include lenalidomide, anti-thymocyte globulin, and azacitidine. Donor stem cell transplantation following chemotherapy is another treatment option for patients with MDS.

Since iron accumulation is an early event in a subset of patients with MDS that has potentially deleterious effects, and iron chelators often exhibit undesirable side effects, including gastrointestinal symptoms, new methods are needed to address the iron overload conditions associated with MDS and to implement currently available therapeutic strategies with the aim of improving the quality of life and prognosis of the patient population and delaying the progression of leukemia of the disease. Since MDS affects primarily the elderly population, most patients are not able to withstand intensive therapeutic methods such as allogeneic hematopoietic stem cell transplantation. In addition, the burden of regular blood transfusion is also difficult for elderly patients. There is therefore a need for new treatments that avoid the drawbacks of the existing treatments.

In the new therapeutic approach, the recombinant engineered fusion protein Luspatercept, which binds to transforming growth factor β superfamily ligands to reduce SMAD2 and SMAD3 signaling, showed promising results in phase 2 studies (P.Fenaux et al, "Luspatercept in Patients with Lower-Risk Myelodysplastic Syndromes", N Engl J Med, volume 382: pages 140-151, 2020).

Luspatercept is administered parenterally. Lusparcept and its use in the treatment of symptoms of beta-thalassemia, including defective erythropoiesis and ineffective erythropoiesis in bone marrow, is described, for example, in WO 2016183280.

Parenteral administration of drugs often requires medical care, which can increase treatment costs and can affect patient compliance, thereby placing additional burden on the patient. Oral administration provides advantages over parenteral administration such as ease of administration for patients, particularly elderly patients, high flexibility of dosage and formulation, cost effectiveness, fewer sterile restrictions and risk of infection, injection site reactions, and anti-drug antibody production.

In view of the severely life-threatening conditions of patients with MDS, there is clearly a need for new and improved treatment options to improve survival in patients with MDS and improve quality of life.

In addition to the treatment described with lusparcept, MDS has so far generally been treated with periodic blood transfusion (RBC infusion) while periodic combination therapy with iron chelating compounds is aimed at constantly removing excess iron from secondary iron overload caused by periodic blood transfusion.

Established drugs for chelation therapy include deferoxamine (also known as deferoxamine B; or). Two newer drugs for iron chelation therapy are deferasirox (also known as +.>) And deferiprone (also known as +.>) Patients who are experiencing iron overload on regular transfusion to treat thalassemia have been approved for use.

WO2013/086312A1 describes oral formulations comprising desazadesferrithiocin polyether (DADFT-PE) analogues for the treatment of iron overload, such as transfusion dependent hereditary and acquired anaemia, by chelating iron as a potential mechanism of action.

A disadvantage of treating MDS with regular blood transfusions is the need to continue regular blood transfusions to patients and regular removal of excess iron by chelation therapy. Furthermore, given drugs for iron chelation therapy are known to exhibit potential toxicity, which is a potential problem in long-term administration due to the long-term need for transfusion therapy.

Low molecular weight compounds having activity as inhibitors of membrane iron transporters are described in international applications WO2017/068089 and WO 2017/068090. Furthermore, international application WO2018/192973 relates to specific salts of selected membrane iron transporter inhibitors described in WO2017/068089 and WO 2017/068090. The membrane iron transporter inhibitors described in the three international applications overlap with the compounds according to formula (I) used in the present application. Wherein the potential treatment of MDS is generally mentioned only in the list of possible indications, without providing any data. The unpublished international application PCT/EP2020/070391 describes the use of a panel of selected membrane iron transporter inhibitors in the treatment of transfusion dependent thalassemia.

Manolova Vania et al, "Oral ferroportin inhibitor ameliorates ineffective erythropoiesis in a model of [ beta ] -thaasasemia", the Journal of Clinical Investigation, volume 130, stage 1, month 1, day 2 of 2020, pages 491-506, XP055844753 describes experimental studies with selected oral membrane iron transporter inhibitor compounds (VIT-2763, corresponding to example compound 127 of the present application), showing that VIT-2763 improves ineffective erythropoiesis and reduces anemia, and prevents hepatic iron burden in a mouse model of beta-thalassemia. The paper speculates that the potential (expected) effectiveness of VIT-2763 in correcting ineffective erythropoiesis and iron overload in a range of diseases, including the potential effectiveness in alleviating myeloproliferative/myelodysplastic disorders such as MDS.

Frank Richard et al: "Oral ferroportin inhibitor VIT-2763: first-in-human, phase1study in healthy volunteers", american Journal Of Hematology, volume 95, stage 1, 11/19/2019, pages 68-77, XP055657378 gave the results of a first human phase1study evaluating the safety, tolerability, pharmacokinetics, etc. of the oral film iron transporter inhibitor compound VIT-2763 in healthy volunteers. Similar to the article by Manolova et al (2020) cited above, the potential of VIT-2763 to improve erythropoiesis and anemia in patients with ineffective erythropoiesis, such as MDS patients, is speculated in the discussion section herein as well, due to its ability to limit iron absorption.

The underlying pathogenesis of MDS and beta-thalassemia (bthal) is significantly different. There are significant differences in the ineffective erythropoiesis mechanisms of bthal and MDS, several of which are unique to MDS and not present in bthal.

Ineffective erythropoiesis in MDS and beta-thalassemia:

ineffective erythropoiesis is a hallmark of other diseases such as thalassemia. Ineffective erythropoiesis occurs under conditions where erythroid progenitor precursors fail to mature, die during the process of becoming red blood cells, or develop into abnormal red blood cells and die prematurely. Although thalassemia and MDS both exhibit ineffective erythropoiesis, their underlying molecular mechanisms differ.

In beta-thalassemia, ineffective erythropoiesis is characterized by expansion of erythrocyte precursors, limited differentiation, and premature death, a process mediated by factors involved in cell cycle, iron intake, and heme synthesis. Specifically, imbalance in the production of alpha-globin chains and beta-globin chains results in the accumulation of excess heme and alpha-globin elements in the form of ferriprotons. High iron blood chromogens are toxic aggregates that increase oxidative stress and cause cell death due to the presence of active iron moieties. Ferric hemoglobin precipitates on the Red Blood Cell (RBC) membrane, causing changes in membrane structure, inducing lipid peroxidation, and resulting in exposure of anionic phospholipids, which together result in premature RBC clearance from the circulation. In beta-thalassemia, iron limitation in the erythrocyte precursor acts as a compensatory mechanism whereby cellular iron reduction results in reduced heme synthesis and reduced ferric hemoglobin. Delivering smaller amounts of iron to more red blood cell precursors results in a decrease in Mean Cell Hemoglobin (MCH) and a decrease in ferrihemoglobin. Because high iron chromogens and ROS cause ineffective erythropoiesis in beta-thalassemia, iron limitation and reduced iron intake by erythrocytes result in more efficient erythropoiesis, normalize RBC structure and life, increase circulating Hb, and reverse splenomegaly. Thus, the use of drugs that reduce iron intake in the diet improves erythropoiesis in β -thalassemia.

Although ineffective erythropoiesis is characterized by the expansion of early erythropoietin-driven erythrocyte precursors, which is associated with β -thalassemia and apoptosis of erythrocyte precursors in MDS, erythrocyte expansion is more severe in β -thalassemia, and the cellular and molecular mechanisms of ineffective erythropoiesis and its iron-excess-induced exacerbation are different in β -thalassemia and MDS. In contrast to beta-thalassemia (where iron is the center of disease pathogenesis through ferric hemochromatosis), MDS is a HSC disease that may be exacerbated by iron (although not directly driven) and characterized by both ineffective erythropoiesis and hematopoiesis. Although in beta-thalassemia ineffective erythropoiesis is premature death of erythrocyte precursors due to the formation of ferric hemochromagen, in MDS it is due to the arrest of differentiation and increased apoptosis of erythrocyte precursors induced by genetic lesions derived from HSPCs, as well as excessive amounts of pro-inflammatory cytokines and immune disorders in the bone marrow niche, and is not associated with ferric hemochromagen not produced in MDS.

Thus, iron excess may exacerbate these mechanisms, limiting the improvement of which is described below:

(1) Effect of iron on ineffective erythropoiesis in MDS:

Iron causes ineffective erythropoiesis in MDS in a different manner than beta thalassemia due to the lack of high iron chromogen formation.

● Iron directly affects HSPCMay contribute to HSPC depletion and thus ineffective erythropoiesis. ROS are closely related to hematopoiesis: while a certain amount of ROS is critical for the coordinated proliferation and differentiation of HSPCs, excessive ROS lead to higher stem cell turnover and ultimately to HSC depletion. Thus, exposure of HSCs to excess iron in the bone marrow niche promotes ROS formation in HSCs, induces apoptosis of hematopoietic precursor cells and contributes to ineffective erythropoiesis.

● Iron directly affects erythrocyte lineages. Exposure of erythrocyte precursors to elevated levels of molten iron induces dysplastic changes and significantly impairs erythroblast differentiation and RBC maturation, resulting in an overall reduction in burst colony forming unit colony formation and erythroblast apoptosis.These events are reversed by chelation and antioxidants. Consistent with these observations, HSCs from iron-treated MDS animals and from MDS patients with moderately elevated serum ferritin (> 250 μg/l) showed impaired proliferation-only in the erythrocyte lineage. Recent findings indicate that intracellular oxidative stress impairs erythrocyte development, which can be positively ameliorated by modulating membrane iron transporter expression on these cells. The increased sensitivity of erythrocyte precursors to iron toxicity may be due to the direct effects of unstable iron exposure and/or mitochondrial iron retention, particularly in MDS-RS (MDS with cyclic iron granulocytes). In MDS-RS, erythrocyte precursors accumulate iron in mitochondria (represented as cyclic iron granulocytes). As mitochondrial iron remains, iron incorporation into heme is reduced, which contributes to oxidative stress and hypoxia, further promoting expanded but ineffective erythropoiesis in MDS. Iron in the young cyclic iron granulocytes appears to be deposited in mitochondrial ferritin, levels of which are associated with early apoptosis of MDS-RS erythroblasts. Taken together, this suggests that iron overload exacerbates ineffective erythropoiesis by exacerbating the differentiation defects and the propensity of MDS erythrocyte precursors to apoptosis.

(2) Effect of iron on leukemia progression:

in addition to ineffective erythropoiesis, in MDS, the presence of unstable plasma iron and the associated increase in unstable cellular iron, as well as ROS production, have been postulated to play a role in disease pathogenesis by increasing the rate of apoptosis and genomic instability of HSPCs, alterations in bone marrow microenvironment, and disease progression toward Acute Myelogenous Leukemia (AML) with MDS-related features. Markers of ROS formation and oxidative DNA damage are elevated and further exacerbated by transfusion iron overload in bone marrow of MDS patients and corrected by iron chelation therapy. Iron excess is also associated with epigenetic abnormalities and induction of telomere erosion. Overall, iron-induced oxidative stress, DNA damage, and telomere shortening may lead to myelomutagenesis, emphasizing that iron is a potential additional driver of genomic instability and malignant transformation in MDS. Although iron overload by itself cannot trigger stem cell leukemic transformation, it may accelerate leukemic progression by mediating genotoxic stress in highly proliferative HSPCs. Furthermore, depletion of normal HSCs may aid in the selective expansion of MDS clones due to the iron-driven ROS elevation-induced withdrawal of normal HSCs from quiescent phase. This suggests that iron may play a role in clonal expansion and progression of myeloid leukemia by promoting malignant transformation and normal HSC depletion.

(3) Influence of iron on the disturbed bone marrow microenvironment:

abnormal myeloid microenvironments play a critical role in the pathogenesis of MDS and the evolution of low risk MDS into more aggressive diseases. Due to its critical functions in the maintenance, self-renewal and differentiation of HSCs, bone marrow microenvironment, its changes are associated with hematopoietic dysfunction and progenitor apoptosis and dysplasia. Iron may lead to decreased viability and functional impairment of a variety of cell types within the bone marrow microenvironment, including Mesenchymal Stromal Cells (MSCs), bone cells, immune cells, and vascular endothelial cells. Changes in iron-driven mesenchymal cell compartments affect their support for hematopoiesis. In fact, under iron overload conditions, the expression of several adhesion molecules and the secretion of cytokines in bone marrow stromal cells are altered, compromising their ability to support hematopoietic cell growth. Furthermore, iron and blood transfusion may play a role in bone marrow niche dysfunction and disturbed hematopoiesis in MDS patients with frequent occurrence of a pro-inflammatory niche by inducing altered cellular functions in immune cells and immunomodulation by cytokine production.

(4) Effect of iron overload on organ toxicity:

in addition to bone marrow, alterations in iron metabolism can also affect other organs. Similar to beta thalassemia, in MDS, iron overload caused by multiple transfusions has been shown to be toxic to various organs such as liver, heart, pancreas, thyroid and pituitary glands, leading to increased morbidity and mortality.

The inventors of the present application surprisingly found that the ferroportin inhibitor compounds as defined herein not only act to block ferroportin, but even further improve the following aspects in steady state MDS:

● Ineffective erythropoiesis

● Survival of HSC

● Medullary sample expansion

● Inflammation in bone marrow microenvironment

● Structural iron overload

While in beta-thalassemia and MDS, iron limitation mediated by membrane iron transporter inhibitors improves ineffective erythropoiesis, the underlying mechanism focuses on the reduction of ferriferrous chromogen formation in erythrocyte precursors in beta-thalassemia, whereas in MDS, it focuses on the multifactorial improvement in HSC and erythroid progenitor cell quality and number (e.g., reduction of apoptosis, improvement of maturation) due to ROS reduction upon reduced iron availability.

Improvements in unique aspects of MDS, including limited depletion of HSC pools, myeloid expansion and reduced leukemia progression, and reduced inflammation in the myeloid microenvironment, surprisingly also show efficacy in MDS, based on additional and different modes of action compared to β -thalassemia.

Importantly, the findings of the inventors of the present application demonstrate that increased iron uptake is pathologically relevant and that inhibition of iron uptake by the membrane iron transporter inhibitors described herein has therapeutic benefit in steady state MDS by modulating underlying pathophysiological mechanisms, including ineffective erythropoiesis, HSC depletion, and bone marrow clonal expansion.

Object of the Invention

The object of the present invention is to provide a novel method for the treatment of myelodysplastic syndrome (MDS). A particular object of the present invention can be seen in providing novel pharmaceutical compounds that are effective in treating MDS and symptoms and pathological conditions associated therewith or alleviating the burden associated with conventional methods of treating MDS. In particular, novel pharmaceutical compounds should be provided for the treatment of MDS, and symptoms and pathological conditions associated therewith, or for alleviating the burden associated with conventional methods of MDS treatment employing modified routes of administration, such as, in particular, oral administration, to simplify administration, reduce side effects caused by parenteral administration, increase patient compliance, save safety treatment costs, and alleviate the patient's treatment burden. In another aspect, the object of the present invention can be seen in providing compounds useful for the treatment of MDS, and symptoms and pathological conditions associated therewith, which are easier and cheaper to prepare than medicaments based on recombinant engineered proteins or genetically engineered pharmaceutical compounds.

Detailed Description

The inventors of the present invention have surprisingly found that compounds of formula (I) as defined herein, which are inhibitors of membrane iron transporters (fpnl), are useful in the treatment of MDS and symptoms and pathological conditions associated therewith, such as in particular defects in erythropoiesis in bone marrow, ineffective hematopoiesis such as in particular ineffective erythropoiesis, low hemoglobin levels/anemia, iron overload and multiple organ dysfunction, liver and kidney iron overload and cardiac iron overload. In another aspect, the ferroportin inhibitor compounds as defined herein may be used to reduce myeloimmature cells and myeloblasts, and thus to reduce myeloid expansion, in a subject with MDS, thereby potentially preventing or delaying leukemia development in a subject with MDS, for reducing macrophage production of inflammatory cytokines such as tnfα and IL-1 β, and/or improving the bone marrow microenvironment. In particular, the novel and surprising results that show a delay in leukemia evolution provide a novel method of treating leukemia with a ferroportin inhibitor compound as defined herein.

Accordingly, a first aspect of the invention relates to a compound according to formula (I) for use in the treatment of myelodysplastic syndrome (MDS):

wherein,,

X ¹ is N or O; and

X ² n, S or O;

provided that X ¹ And X ² Different;

R ¹ selected from the group consisting of

-hydrogen, and

-optionally substituted alkyl;

n is an integer from 1 to 3;

A ¹ and A ² Independently selected from alkanediyl groups

R ² Is that

Hydrogen, or

-optionally substituted alkyl;

or (b)

A ¹ And R is ² Together with the nitrogen atom to which they are bonded form an optionally substituted 4-to 6-membered ring;

R ³ represents 1, 2 or 3 optional substituents which may be independently selected from

Halogen(s),

-cyano group,

Optionally substituted alkyl,

-optionally substituted alkoxy, and

-a carboxyl group;

R ⁴ selected from the group consisting of

Hydrogen, hydrogen,

Halogen(s),

-C ₁ -C ₃ Alkyl group, and

-halogen substituted alkyl;

also included are their pharmaceutically acceptable salts, solvates, hydrates and polymorphs.

Indication of disease

The present invention relates to selected medical uses of compounds of formula (I) as described herein, and salts, solvates, hydrates, and polymorphs thereof, in the treatment of MDS.

Treatment of myelodysplastic syndrome (MDS) and/or symptoms associated therewith includes treatment of ineffective hematopoiesis, particularly ineffective erythropoiesis.

Treatment of MDS and/or symptoms associated therewith also includes ameliorating, preventing, or delaying the progression of leukemia, reducing myeloimmature cells and myeloid expansion, reducing macrophage production of inflammatory cytokines such as TNF alpha and IL-1 beta, and/or ameliorating the bone marrow microenvironment.

As described above, several subtypes of MDS are classified into International Prognostic Scoring System (IPSS) and revised IPSS (IPSS-R). The lower risk MDS is defined as low or medium 1 risk according to IPSS, or very low, low or medium risk according to revised IPSS [ IPSS-R ].

In another aspect, the invention relates to compounds of formula (I), or salts, solvates, hydrates, and polymorphs thereof, for use in treating MDS, wherein a subject with MDS is selected from individuals suffering from an extremely low risk, or medium risk myelodysplastic syndrome according to the IPSS/IPSS-R scoring system. Preferably lower risk MDS (IPSS) is treated.

In addition, genetic MDS subtypes are defined, such as MDS with isolated del (5 q) or MDS with SF3B1 mutations. The report paper by Malcovati et al (2020), as described above, further defines diagnostic criteria for subtypes of MDS and MDS entities, as set forth in Table 1 below:

BM, bone marrow; MDS-EB, MDS with excess primordial cells; MDS-U, MDS, unclassifiable; PB, peripheral blood.

* RS is the percentage of bone marrow erythrocyte component.

Cytogenetics using conventional karyotyping.

If SF3B1 mutation is present.

One percent of PB original signal must be recorded on ≡2 separate occasions.

According to definition, more than or equal to 15% of cases with RS have significant erythrodysplasia, classified as MDS-RS-SLD.

Another aspect of the invention relates to compounds of formula (I), or salts, solvates, hydrates, and polymorphs thereof, for use in the treatment of MDS selected from one of the MDS entities defined in table 1 above.

In another aspect of the invention, the subject with MDS to be treated is selected from one or more of the following patient groups, wherein the subject is characterized by one or more of the following:

-according to the world health organization standard, with myelodysplastic syndrome accompanied by cyclic iron granulomatous cells (RS), characterized by more than 15% of cyclic iron granulomatous cells, or more than 5% of cyclic iron granulomatous cells if SF3B1 mutations are present, or less than 5% of myeloblasts;

-myelodysplastic syndrome with erythropoietin levels above 200U/L;

-having erythrocyte dysplasia;

-suffering from cytopenia, in particular peripheral cytopenia;

-myeloblasts < 5%;

-peripheral blood blast < 1%;

-a reduced or absent response to erythropoiesis stimulating agents in the patient with myelodysplastic syndrome;

-myelodysplastic syndrome with concomitant chromosome 5q deletion (del [5q ]);

-SF3B1 mutant patient;

-a patient with significantly down-regulated PPOX and/or ABCB7 genes compared to a healthy individual;

dependent on transfusion or receiving regular red blood cell infusions of > 2 units every 8 weeks.

In one aspect, the invention relates to compounds of formula (I) or salts, solvates, hydrates, and polymorphs thereof for use in the treatment of non-transfusion dependent MDS.

In another aspect, the invention relates to compounds of formula (I) or salts, solvates, hydrates, and polymorphs thereof, for use in the treatment of transfusion dependent MDS, i.e., to the treatment of MDS according to the invention, wherein the selected patient group is characterized by the need for periodic transfusion or is a transfusion dependent patient. Such regular blood transfusion or infusion dependence is characterized by

a) Repeating the infusion of blood of equal Red Blood Cell (RBC) units at different subsequent time intervals; or (b)

b) Repeatedly infusing equal RBC units of blood over equal subsequent time intervals; or (b)

c) Repeatedly infusing blood of different RBC units at equal subsequent time intervals; or (b)

d) The infusion of blood of different RBC units was repeated at different subsequent time intervals.

In the context of the use of the present invention, the term "treating" includes ameliorating at least one symptom or pathological condition associated with MDS. Non-limiting examples of symptoms or pathological conditions associated with MDS include defective erythropoiesis in bone marrow, ineffective hematopoiesis such as, inter alia, ineffective erythropoiesis, insufficient hemoglobin levels, multiple organ dysfunction, iron overload, anemia, hepatic iron overload, and cardiac iron overload, as well as the symptoms described above and in the examples below.

The term "treatment" in the context of the present invention also includes prophylaxis, for example by administering a compound of the present invention prior to or simultaneously with transfusion in a patient with transfusion dependent MDS, to prevent or at least reduce the occurrence of a pathological condition caused by transfusion.

Patients with MDS may develop severe iron overload due to regular Blood Transfusions (BT). The primary purpose of transfusion therapy in MDS treatment is to correct anemic conditions and inhibit erythropoiesis. This is believed to be accomplished at Hb levels of > 9 g/dL. Thus, in another aspect of the treatment of a subject with MDS, administration of a membrane iron transporter inhibitor compound of formula (I) of the present invention helps prevent intestinal iron absorption during the transfusion interval, which helps further reduce the iron load of the subject with MDS.

Elevated levels of non-transferrin-bound iron (NTBI) have been observed in MDS patients. NTBI is released by macrophage recirculation of damaged RBCs caused by immature RBC formation in bone marrow and/or contained in infused RBC units and triggers oxidative stress, vascular injury, and organ iron overload (Baek j.h. et al, "Iron accelerates hemoglobin oxidation increasing mortality in vascular diseased guinea pigs following transfusion of stored blood." JCI Insight,2017, volume 2, 9).

The inventors of the present invention have found that the compounds of formula (I) of the present invention are particularly useful in the treatment of MDS by ameliorating ineffective erythropoiesis by limiting iron excess mediated by the compounds of formula (I). It is further assumed that the compounds of formula (I) of the present invention are particularly useful for treating MDS by limiting Reactive Oxygen Species (ROS) in erythrocyte precursors and thereby improving erythropoiesis in patients with MDS. Thus, more life-prolonging RBCs improve anemia and improve tissue oxygenation in MDS patients. In MDS, compounds of formula (I) are further effective in reducing elevated NTBI levels, which helps prevent the resulting pathological conditions, such as liver, kidney and heart iron overload, and thus prevent the occurrence of organ dysfunction and other diseases.

NTBI, which contains all forms of serum iron that are not closely related to transferrin or other molecules, is chemically and functionally heterogeneous. LPI (unstable plasma iron) represents a component of NTBI, which has both redox activity and chelating properties, and is capable of penetrating into organs and inducing tissue iron overload. The compounds of formula (I) have the potential to effectively reduce elevated NTBI levels in MDS and thus LPI levels.

The following parameters can be determined to assess the efficacy of the compounds of the invention in the treatment of MDS for medical use: serum iron, NTBI levels, LPI (unstable plasma iron) levels, erythropoietin, TSAT (transferrin saturation), hb (hemoglobin), hct (hematocrit), MCV (mean cell volume), MCH (mean cell hemoglobin), RDW (red cell distribution width) and reticulocyte numbers, whole blood count, myeloblasts in bone marrow and peripheral blood, spleen weight, erythropoiesis in bone marrow and spleen, liver, spleen and kidney iron content. The determination may be carried out using methods conventional in the art, in particular by the methods described in more detail below. The compounds (I) according to the invention are suitable for improving at least one of these parameters.

As explained by Patel et al (2012; cited above), under normal physiological conditions, transferrin levels are sufficient to completely scavenge absorbed and recycled iron, thereby ensuring that no NTBI is present and thus that NTBI levels in normal healthy individuals do not exceed 0.1 μmol/L and are mostly undetectable by most commonly used methods. It was reported that NTBI levels were as high as 20. Mu. Mol/L in the absence of transferrin, and that NTBI levels were found to be as high as 10. Mu. Mol/L in the absence or high saturation of transferrin. However, as described by Patel et al (2012) and Brissot et al (2012), the assay is largely dependent on the application method and assay used, and the technical difficulties arising from assaying heterogeneous chemical forms of circulating NTBI must be considered. For example, hider et al (2010), cited by Brissot et al (2012), have described fluorescence measurements with reproducible accuracy as low as 0.1. Mu.M/L. According to Patel et al (2012; table 1), the elevation of NTBI levels in clinical iron overload conditions ranged between 0.25. Mu. Mol/L and 4.0. Mu. Mol/L (with different accuracies and different assay methods). In view of this, in the sense of the present invention, the NTBI level is considered to be elevated, preferably exceeding 0.1 μm/L, if detectable with known methods, such as the methods described in Patel et al (2012) or Brissot et al (2012).

In a particular aspect, the MDS treatment according to the invention results in a decrease in the subject's NTBI level 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%, as measured at any time point within a time period of at most 72 hours, at most 60 hours, at most 48 hours, at most 36 hours, at most 24 hours, or at most 12 hours, 8 hours, 6 hours, 5 hours, 4 hours, 3 hours, 2 hours, 1 hour, and 0.5 hours, and as compared to the subject's NTBI level measured at any time point within at most < 1 week, at most 72 hours, at most 60 hours, at most 36 hours, at most 24 hours, or at most 24 hours, at least 1 hour, prior to the initiation of the treatment of the invention. NTBI can be determined according to the assay described in the examples below.

In a particular aspect, the MDS treatment according to the invention results in a decrease in the LPI level of the patient by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or at least 100% as measured at any time point within a time period of at most 72 hours, at most 60 hours, at most 48 hours, at most 36 hours, at most 24 hours or at most 12 hours, 8 hours, 6 hours, 5 hours, 4 hours, 3 hours, 2 hours, 1 hour and 0.5 hours prior to the initiation of the treatment of the invention, and as compared to the total LPI level of the patient measured at any time point within at most less than 1 week, 0.5 hours, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 8 hours, 12 hours, 24 hours, 36 hours or 48 hours. LPI can be determined according to the assay described in the examples below.

Reactive Oxygen Species (ROS) cause shortened RBC life, anemia, and tissue hypoxia. The effect of the compounds of the present invention on ROS levels in RBCs can be monitored by commercially available ROS-sensitive sensors that emit far infrared or green light, for example, as described in the examples below.

In another aspect, MDS treatment according to the invention results in a reduction in ROS levels in RBCs of 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%, as measured at any time point within a time period of at most 5 days, at most 6 days, at most 7 days, at most 8 days, at most 9 days, at most 10 days, at most 11 days, at most 12 days, at most 13 days, at most 14 days, at most 15 days, at most 16 days, at most 17 days, at most 18 days, at most 19 days, at most 20 days, at most 21 days, and at most 1 month, after the first administration and/or after an ischemic event, as compared to levels in RBCs of a patient measured at any time point within 12 hours, 24 hours, 36 hours, 48 hours, 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the initiation of treatment of the invention. ROS levels in RBCs can be determined according to the assay described in the examples below.

As described above, decreasing elevated NTBI and LPI levels helps to reduce liver, kidney and myocardial iron concentrations.

Thus, in another aspect, a treatment of MDS according to the invention may result in a decrease in the liver iron concentration of a patient by at least 1%, 2%, 3%, 4%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or at least 100%, as measured at any point in time over a period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months after the first administration, as compared to the level of liver iron concentration of a patient measured at any point in time over 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the initiation of the treatment of the invention. The liver iron concentration can be determined according to the assay described in the examples below.

Thus, in another aspect, a treatment of MDS according to the invention may result in a decrease in the patient's renal iron concentration 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%, as measured at any point in time over a period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months after the first administration, as compared to the level of the patient's renal iron concentration measured at any point in time over 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the initiation of the treatment of the invention. The renal iron concentration may be determined according to the assays described in the examples below.

In another aspect, a treatment of MDS according to the invention may result in a decrease in myocardial 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%, as measured at any point in time over a period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months after the first administration, as compared to the level of myocardial iron concentration in the subject measured at any point in time over 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the initiation of the treatment of the invention. Myocardial iron concentrations can be determined according to the assays described in the examples below.

In another aspect, a MDS treatment according to the invention can result in an increase in at least one of the patient's parameters Hb, hct, RBC count, MCV, MCH, RDW, and reticulocyte number 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%, as measured at any point in time over a period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months after the first administration, and as compared to the corresponding parameters of the subject measured at any point in time over 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the initiation of the treatment of the invention. The parameters may be determined according to conventional methods.

In another aspect, the treatment of MDS according to the invention may result in a red blood cell response, which may include at least a 33%, preferably at least a 50% reduction in the transfusion burden of the patient. In principle, the red blood cell response may comprise reducing the transfusion burden of the patient by at least 10%, 15%, 20%, 25%, 30%, 33%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 98% or 100%. In another aspect, treatment of MDS according to the invention may result in an erythrocyte response, which may include reducing the transfusion burden of the patient by at least 10%, 15%, 20%, 25%, 30%, 33%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 98% or 100% 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, up to 18 months, up to 24 months or until independent of transfusion. In another aspect, treatment of MDS according to the invention may result in a red blood cell response, which may include reducing the infusion of red blood cells into a patient by at least 1, 2, 3, 4, or more red blood cell units. In another aspect, treatment of MDS according to the invention may result in an erythrocyte response, which may include reducing erythrocyte infusion by a patient by at least 1, 2, 3, 4, or more erythrocyte units 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, up to 18 months, up to 24 months, or until independent of erythrocyte unit infusion. The erythrocyte response may also comprise one or more of the improvements described above. The erythrocyte response can be determined as described in the examples below.

Wherein a unit of red blood cells refers to an amount of hematocrit derived from about 200mL to 500mL of donated blood. Typically, transfusion will be regulated according to age, severity of the disease and initial blood parameters of the patient. Guidelines for selecting transfusion volumes suggest, for example:

the individual transfusion capacity can be further calculated by the following formula:

(desired Hb-actual Hb) ×body weight [ kg ] ×3/hematocrit of infused unit = ml to be infused

According to the recommended MDS transfusion protocol, each kilogram of body weight is infused with equivalent to 100 ml to 200ml of pure red blood cells per year.

In another aspect, the MDS treatment according to the invention may reduce the transfusion burden on the patient compared to the transfusion burden on the patient within 1 week, 2 weeks, 3 weeks, or 4 weeks, 2 months, 3 months, 4 months, 6 months, 8 months, 9 months, 12 months, 24 months prior to initiation of the treatment according to the invention.

In another aspect, treatment of MDS according to the invention may be effected, with MDS patients treated according to the methods of the invention not requiring erythrocyte infusion until independent of erythrocyte infusion 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 following treatment.

In another aspect, treatment of MDS according to the invention may result in a reduction in daily iron-chelating treatment of a subject with transfused MDS, e.g., a reduction in the dosage of one or more iron-chelating therapeutic agents administered to the subject or a reduction in the frequency of administration. Non-limiting examples of iron chelating therapeutic agents include those described above.

In another aspect, treatment of MDS according to the invention may reduce treatment with an erythropoietin-stimulating agent, such as Erythropoietin (EPO), such as reducing the dose of the erythropoietin-stimulating agent administered to a patient with MDS or reducing the frequency of administration.

In another aspect, a treatment of MDS according to the invention may result in a decrease in serum ferritin levels in a patient of at least 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or at least 100% as measured at any point in time over a period of up to one week, up to 2 weeks, up to 3 weeks, up to 4 weeks, up to 3 months after the first administration, and as compared to serum ferritin levels in a patient measured at any point in time over 1 week, 2 weeks, 3 weeks, or 4 weeks prior to the initiation of the treatment of the invention. Serum ferritin levels may be determined according to conventional assays.

In another aspect, the MDS treatment according to the invention may reduce symptoms associated with one or more clinical MDS complications. Non-limiting examples of symptoms of MDS include pallor, jaundice, fatigue, and clinical complications of chronic erythrocyte infusion, such as hepatitis B virus infection, hepatitis C virus infection, and human immunodeficiency virus infection, alloimmunity, and organ damage due to iron overload, such as liver damage, heart damage, and endocrine gland damage.

In another aspect, the MDS treatment according to the invention may improve the quality of life of a patient compared to the quality of life of the patient measured within 1 week, 2 weeks, 3 weeks, or 4 weeks prior to initiation of the treatment of the invention. Improvement in quality of life was measured within 3 months, 6 months, 9 months, 12 months, 15 months, 18 months, 21 months or 24 months after initiation of treatment. Quality of life can be determined according to the assay described in the examples below.

With the methods of treating MDS according to the present invention, one or more of the above improvements may be achieved.

Patient group

The present invention relates to the medical use of compounds of formula (I) as described herein, and salts, solvates, hydrates, and polymorphs thereof, for the treatment of MDS, particularly one or more of the above-defined entities/subtypes of MDS.

In principle, the subject to be treated in the use according to the invention may be any mammal, such as rodents and primates, and in a preferred aspect, the medical use relates to the treatment of humans. Subjects suffering from MDS and treated with the methods of the invention are also referred to as "patients" or "individuals.

In particular, patients with MDS to be treated in accordance with the present invention are characterized by underlying pathophysiological mechanisms, including those with ineffective erythropoiesis, HSC depletion, and myeloclonal expansion, as explained in detail above.

The subject to be treated may be of any age. A preferred aspect of the invention relates to the treatment of elderly people. Thus, in a preferred aspect of the invention, the subject to be treated with the novel methods described herein is greater than 25 years old. In another aspect of the invention, the subject to be treated with the novel methods described herein is 25 to 30 years old, or greater than 30 years old, such as preferably 25 to 30 years old, 30 to 35 years old, 35 to 40 years old, 40 to 45 years old, 45 to 50 years old, 50 to 55 years old, 55 to 60 years old, or greater than 60 years old. In the preferred case of treating elderly patients, the subject to be treated with the novel methods described herein is 60 to 65 years old, 65 to 70 years old, 70 to 75 years old, 75 to 80 years old, or more than 80 years old.

Treatment of elderly patients is particularly preferred due to the significant advantages afforded by treatment with the membrane iron transporter inhibitor compounds of formula (I) of the present invention. The compounds may be administered orally, which is superior to parenteral administration of currently available drugs (e.g., lusputtercept). Furthermore, the orally bioavailable inhibitors of membrane iron transport proteins of the present invention have been demonstrated to have moderate bioavailability and half-life in vivo and therefore to be washed away relatively quickly. This results in fewer side effects and faster drug reversibility, which is particularly important in the treatment of elderly people.

The group or population of patients suffering from MDS and to be treated with a method according to the invention is selected from the subjects (patients) characterized as defined above. In another aspect of the invention, the group or population of patients suffering from MDS and to be treated according to the methods of the invention is selected from subjects (patients) having elevated levels of NTBI. If detectable using the known methods described above, the NTBI level is considered to be elevated. Preferably, NTBI levels ∈0.1. Mu. Mol/L are considered to be elevated in MDS patients. More preferably, elevated levels of NTBI in a subject with MDS according to the invention are those where the value of NTBI exceeds that determined for healthy individuals using corresponding assays described in de Swart et al, "Second international round robin for the quantification of serum non-transferring rin-bound iron and labile plasma iron in patients with iron-overload disorders", haemato logica,2016, volume 101, phase 1, pages 38-45.

In another aspect of the invention, the group or population of patients suffering from MDS and to be treated according to the methods of the invention is selected from subjects (patients) having elevated LPI levels. LPI levels are considered to be elevated if detectable using the known methods described above. Preferably, elevated LPI levels in patients with MDS according to the present invention are those where LPI values exceed those determined for healthy individuals using corresponding assays described in de Swart et al, "Second international round robin for the quantification of serum non-transferring rin-bound iron and labile plasma iron in patients with iron-overload disorders", haemato logica,2016, volume 101, phase 1, pages 38-45.

In another aspect of the invention, the group or population of patients suffering from MDS and to be treated according to the methods of the invention is selected from subjects (patients) having elevated levels of TSAT. Preferably, an elevated level of TSAT in a subject with MDS in accordance with the present invention is one in which the level of TSAT exceeds the average "normal" TSAT level measured by a corresponding assay in a healthy subject. About 25% of TSATs are considered to be averages. However, the reference range depends on various factors such as age, sex, race and test device. Most laboratories define "normal" as 30% for female and 45% for male. Above 50%, the risk of toxic non-transferrin binding iron (NTBI) increases exponentially, possibly causing organ damage. TSAT levels may further be used to indirectly reflect NTBI and thus may be used as a translation marker.

In another aspect of the invention, the group or population of patients suffering from MDS and to be treated according to the methods of the invention is selected from subjects (patients) having dysfunctions and pro-apoptotic Hematopoietic Stem and Progenitor Cells (HSPCs) bearing mutations in MDS.

Typically, one or more of the following MDS diagnostic criteria are applied:

(1) Cytopenia as defined by standard hematological values;

(2) Genetic analysis of somatic SF3B1 mutations;

(3) Morphological dysplasia (with or without RS);

(4) Bone marrow blast < 5% and peripheral blood blast < 1%;

(5) Leukemia progression, AML progression.

One of the most important hematological values is the hemoglobin level (Hb). Hb levels in patients with MDS are maintained at 5g/dl to 10g/dl. Patients with MDS are typically classified as anemic by Hb levels < 9g/dL or < 8 g/dL. Hb levels in patients with MDS can be as low as 4g/dl to 5g/dl. Although international guidelines suggest that the hemoglobin range of a transfusional patient reaches 9g/dL to 10g/dL and the optimal post-transfusion range is 13g/dL to 14g/dL, in clinical practice Hb levels > 7g/dL are generally considered sufficient without regular transfusion, and then the usual purpose of transfusion is to maintain the patient's hemoglobin level between 9.5g/dL and 10g/dL. However, depending on the particular situation, patients with hemoglobin levels between 7g/dL and 8g/dL may require transfusion. Achieving the recommended higher Hb levels of 13g/dL to 14g/dL requires an excessive increase in transfusion burden. However, the amount of blood required varies greatly from patient to patient and is greatly affected by the patient's weight and the target hemoglobin level.

With this in mind, in another aspect of the invention, a patient group or population having MDS and to be treated according to a method of the invention may be selected from subjects (patients) having a hemoglobin (Hb) level of less than 8 g/dL.

In another aspect of the invention, a patient group or population having MDS and to be treated according to a method of the invention may be selected from subjects (patients) having an MCV between 50fL and 70 fL.

In another aspect of the invention, a group or population of patients suffering from MDS and to be treated according to a method of the invention may be selected from subjects (patients) having MCH between 12pg and 20 pg.

In another aspect, a patient group or population suffering from MDS and to be treated according to the methods of the invention may be selected from subjects (patients) having one or more of the following characteristics, including a) Hb levels below 8g/dL; b) MCV is between 50fL and 70 fL; and c) MCH is between 12pg and 20 pg.

In another aspect of the invention, a patient group or population having MDS and to be treated according to the methods of the invention receives periodic blood transfusions. However, other clinical symptoms and parameters also play an important role in the determination of MDS, as discussed in detail above.

Regular blood transfusion also means that the infusion of Red Blood Cell (RBC) units is repeated more than once for a time interval of at least up to two months or for a shorter time interval. The intervals may be of equal length or may vary depending on the individual patient, the course of the disease, its severity and the response to the treatment. Periodic transfusions may also include repeated infusions of the same or different transfusion units at subsequent transfusion time points. Periodic blood transfusions may include

-repeatedly infusing equal RBC units of blood at varying subsequent time intervals; or (b)

-repeatedly infusing equal RBC units of blood at equal subsequent time intervals; or (b)

-repeated infusions of blood of different RBC units at equal subsequent time intervals; or (b)

Repeated infusions of blood of different RBC units at different subsequent time intervals.

In another aspect of the invention, regular transfusion refers to a transfusion-free period of no more than 3 months, preferably no more than 2 months.

In another aspect of the invention, the group or population of patients suffering from MDS and to be treated according to the methods of the invention is selected from subjects (patients) in need of periodic iron chelation therapy. Such patient groups or populations requiring periodic iron chelation treatment may be further characterized by one or more of the features defined above.

Form of administration

In another aspect of the invention, the treatment of MDS may comprise orally administering to a patient in need thereof one or more of the compounds of formula (I), salts, solvates, hydrates, or polymorphs thereof, each as described herein.

For this purpose, the compounds of formula (I) according to the invention are preferably provided in the form of medicaments or pharmaceutical compositions for oral administration, including, for example, pills, tablets (such as enteric tablets, film tablets and lamellar tablets), slow-release formulations for oral administration, depot formulations, dragees, granules, emulsions, dispersions, microcapsules, micro-formulations, nano-formulations, liposome formulations, capsules (such as enteric-coated capsules), powders, microcrystalline formulations, sprinkles, drops, ampoules, solutions and suspensions for oral administration.

In a preferred embodiment of the invention, the compounds of formula (I) according to the invention are administered in the form of tablets or capsules as defined above. These may be present, for example, as acid-resistant forms or with pH-dependent coatings.

Thus, another aspect of the invention relates to the use of compounds of formula (I), including pharmaceutically acceptable salts, solvates, hydrates and polymorphs thereof, and medicaments, compositions and combined preparations comprising them, according to the invention in the treatment of MDS in the form of oral administration.

Dosing regimen

Another aspect of the invention relates to a compound of formula (I) according to the invention for use according to the invention, wherein the treatment is characterized by one of the following dosing regimens:

in one aspect, the compounds of formula (I) according to the invention may be administered to a patient in need thereof in a dose of 0.001mg to 500mg, for example 1 to 4 times per day. However, the dosage may be increased or decreased depending on the age, weight, condition, severity of the disease or type of administration of the patient. In another aspect of the present invention, the compound of formula (I) may be used in an amount of 0.1mg, 0.2mg, 0.3mg, 0.4mg, 0.5mg, 0.6mg, 0.7mg, 0.8mg, 0.9mg, 1mg, 1.5mg, 2mg, 2.5mg, 3mg, 3.5mg, 4mg, 4.5mg, 5mg, 6mg, 7mg, 8mg, 9mg, 10mg, 11mg, 12mg, 13mg, 14mg, 15mg, 16mg, 17mg, 18mg, 19mg, 20mg, 25mg, 30mg, 35mg, 40mg, 45mg, 50mg, 55mg, 60mg, 65mg, 70mg, 75mg, 80mg, 85mg, 90mg, 95mg, 100mg, 105mg, 15mg 110mg, 115mg, 120mg, 125mg, 130mg, 135mg, 140mg, 145mg, 150mg, 155mg, 160mg, 165mg, 170mg, 175mg, 180mg, 185mg, 190mg, 195mg, 200mg, 205mg, 210mg, 215mg, 220mg, 225mg, 230mg, 235mg, 240mg, 245mg, 250mg, 255mg, 260mg, 265mg, 270mg, 275mg, 280mg, 285mg, 290mg, 295mg, 300mg, 325mg, 350mg, 375mg, 400mg, 425mg, 450mg, 475mg, 500 mg.

Preferred dosages are between 0.5mg and 500mg, more preferably between 1mg and 300mg or 3mg and 300mg, more preferably between 1mg and 250mg or 5mg and 250 mg.

The most preferred dosage is 5mg, 15mg, 60mg, 120mg or 240mg.

The above-mentioned dosages may be administered in the form of a single daily dose or a total daily dose divided into sub-doses administered twice daily or more.

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

In another aspect, one of the dosages as defined above may be selected as the initial dosage and the same or different dosages as defined above may be subsequently administered 1 or more times at a repeating interval of 1 to 7 days, 1 to 5 days, preferably 1 to 3 days or every two days.

The initial dose and subsequent doses may be selected from the doses defined above, and adjusted/varied within the ranges provided according to the needs of the MDS patient.

In particular, the amount of the subsequent dose may be appropriately selected according to the individual patient, the course of the disease and the therapeutic response. Subsequent doses may be administered 1, 2, 3, 4, 5, 6, 7 and more times.

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

The repetition interval may be of the same length or may vary depending on the individual patient, the course of the disease and the response to the treatment.

Preferably, the amount of subsequent doses decreases with increasing number of subsequent administrations.

Preferably, a dose of 3mg to 300mg, more preferably 5mg to 250mg, most preferably 5mg, 15mg, 60mg, 120mg or 240mg is administered once daily over a treatment period of at least 3 days, at least 5 days, at least 7 days. In a further preferred aspect, a dose of 60mg or 120mg is administered once daily. In a further preferred aspect, a total daily dose of 120mg is administered by administering a dose of 60mg twice daily.

In a further preferred aspect, the total daily dose of 240mg is administered by administering a dose of 120mg twice daily. The doses proved to be safe and well tolerated.

The preferred dosing regimen also shows rapid oral absorption, where levels can be detected as early as 15 minutes to 30 minutes after dosing. The absorption level remained stable even upon repeated dosing, and no severe deposition was observed.

The preferred dosing regimen further demonstrates an effective reduction in average serum iron levels and average calculated transferrin saturation and shifts the average serum hepcidin peak, indicating its efficacy in treating MDS.

In another aspect of the invention, the initial and one or more subsequent administrations are adjusted in accordance with the hemoglobin concentration of the patient being treated. Hemoglobin concentration was measured by conventional methods.

Membrane iron transporter (Fpn) inhibitor compounds

The present invention relates to a novel medical use of a compound of formula (I) as defined herein:

wherein and throughout the invention, substituent groups have the meaning as defined in detail anywhere herein:

optionally substituted alkyl groups preferably include: preferably a linear or branched alkyl group containing 1 to 8, more preferably 1 to 6, particularly preferably 1 to 4, even more preferably 1, 2 or 3 carbon atoms, also denoted C ₁ -C ₄ Alkyl or C ₁ -C ₃ An alkyl group.

Optionally substituted alkyl also includes cycloalkyl groups preferably containing 3 to 8, more preferably 5 or 6 carbon atoms.

Examples of alkyl residues containing 1 to 8 carbon atoms include: methyl group, ethyl group, n-propyl group, isopropyl group, n-butyl group, isobutyl group, sec-butyl group, tert-butyl group, n-pentyl group, isopentyl group, sec-pentyl group, tert-pentyl group, 2-methylbutyl group, n-hexyl group, 1-methylpentyl group, 2-methylpentyl group, 3-methylpentyl group, 4-methylpentyl group, 1-ethylbutyl group, 2-ethylbutyl group, 3-ethylbutyl group, 1-dimethylbutyl group, 2-dimethylbutyl group, 3-dimethylbutyl group, 1-ethyl-1-methylpropyl group, n-heptyl group, 1-methylhexyl group, 2-methylpropyl group 3-methylhexyl group, 4-methylhexyl group, 5-methylhexyl group, 1-ethylpentyl group, 2-ethylpentyl group, 3-ethylpentyl group, 4-ethylpentyl group, 1-dimethylpentyl group, 2-dimethylpentyl group, 3-dimethylpentyl group, 4-dimethylpentyl group, 1-propylbutyl group, n-octyl group, 1-methylheptyl group, 2-methylheptyl group, 3-methylheptyl group, 4-methylheptyl group, 5-methylheptyl group, 6-methylheptyl group, 1-ethylhexyl group, 2-ethylhexyl group, 3-ethylhexyl group, 4-ethylhexyl group, 5-ethylhexyl group, 1-dimethylhexyl group, 2, 2-dimethylhexyl radical, 3-dimethylhexyl radical, 4-dimethylhexyl radical, 5-dimethylhexyl radical, 1-propylpentyl group, 2-propylpentyl group, and the like. Those having 1 to 4 carbon atoms (C ₁ -C ₄ Alkyl) such as, in particular, methyl, ethyl, n-propyl, isopropyl, n-butyl, isobutyl, sec-butyl and tert-butyl are preferred. C (C) ₁ -C ₃ Alkyl groups, particularly methyl, ethyl, propyl and isopropyl groups, are more preferred. Most preferred is C ₁ And C ₂ Alkyl groups such as methyl and ethyl.

Cycloalkyl residues containing 3 to 8 carbon atoms preferably include: cyclopropyl groups, cyclobutyl groups, cyclopentyl groups, cyclohexyl groups, cycloheptyl groups and cyclooctyl groups. Cyclopropyl groups, cyclobutyl groups, cyclopentyl groups and cyclohexyl groups are preferred. Cyclopropyl groups are particularly preferred.

The substituents of the optionally substituted alkyl groups defined above preferably comprise 1, 2 or 3 identical or different substituents selected from, for example: halogen as defined below, such as preferred F, cycloalkyl as defined above, such as preferred cyclopropyl, optionally substituted heteroaryl as defined below, such as preferred benzimidazolyl group, optionally substituted amino as defined below, such as preferred amino group or benzyloxycarbonylamino, carboxyl group, aminocarbonyl group as defined below, and alkylene group such as especially methylene group to form, for example, methylene substituted ethyl group (CH ₃ -(C＝CH ₂ ) -orWherein represents the bonding site).

Within the meaning of the present invention, halogen includes fluorine, chlorine, bromine and iodine, preferably fluorine or chlorine, most preferably fluorine.

Examples of the straight or branched alkyl residues substituted with halogen and having 1 to 8 carbon atoms include:

fluoromethyl group, difluoromethyl group, trifluoromethyl group, chloromethyl group, dichloromethyl group, trichloromethyl group, bromomethyl group, dibromomethyl group tribromomethyl group, 1-fluoroethyl group, 1-chloroethyl group, 1-bromoethyl group, 2-fluoroethyl group, 2-chloroethyl group, 2-bromoethyl group difluoroethyl groups such as 1, 2-difluoroethyl group, 1, 2-dichloroethyl group, 1, 2-dibromoethyl group, 2-difluoroethyl group, 2-dichloroethyl group, 2-dibromoethyl group, 2-trifluoroethyl group, heptafluoroethyl group, 1-fluoropropyl group, 1-chloropropyl group, 1-bromopropyl group, 2-fluoropropyl group 2-chloropropyl group, 2-bromopropyl group, 3-fluoropropyl group, 3-chloropropyl group, 3-bromopropyl group, 1, 2-difluoropropyl group, 1, 2-dichloropropyl group, 1, 2-dibromopropyl group, 2, 3-difluoropropyl group, 2, 3-dichloropropyl group, 2, 3-dibromopropyl group, 3-trifluoropropyl group, 2, 3-pentafluoropropyl group 2-fluorobutyl group, 2-chlorobutyl group, 2-bromobutyl group, 4-fluorobutyl group, 4-chlorobutyl group, 4-bromobutyl group, 4-trifluorobutyl group 2,3, 4-heptafluorobutyl group, perfluorobutyl group, 2-fluoropentyl group, 2-chloropentyl group, 2-bromopentyl group, 5-fluoropentyl group, 5-chloropentyl group, 5-bromopentyl group, perfluoropentyl group, 2-fluorohexyl group, 2-chlorohexyl group, 2-bromohexyl group, 6-fluorohexyl group, 6-chlorohexyl group, 6-bromohexyl group, perfluorohexyl group, 2-fluoroheptyl group, 2-chloroheptyl group, 2-bromoheptyl group, 7-fluoroheptyl group, 7-chloroheptyl group, 7-bromoheptyl group, perfluoroheptyl group and the like. Fluoroalkyl, difluoroalkyl and trifluoroalkyl groups, and trifluoromethyl and mono-and difluoroethyl groups are particularly mentioned. Particularly preferred is trifluoromethyl.

Examples of cycloalkyl substituted alkyl groups include the above alkyl residues containing 1 to 3, preferably 1 cycloalkyl groups, for example: cyclopropylmethyl, cyclobutylmethyl, cyclopentylmethyl, cyclohexylmethyl, 2-cyclopropylethyl, 2-cyclobutylethyl, 2-cyclopentylethyl, 2-cyclohexylethyl, 2-cyclopropylpropyl or 3-cyclopropylpropyl, 2-cyclobutylpropyl or 3-cyclobutylpropyl, 2-cyclopentylpropyl or 3-cyclohexylpropyl, 2-cyclohexylpropyl or 3-cyclohexylpropyl and the like. Preferred is cyclopropylmethyl.

Examples of heteroaryl-substituted alkyl groups include the above-mentioned alkyl residues containing 1 to 3, preferably 1 (optionally substituted) heteroaryl group, e.g. pyridyl, pyridazinyl, pyrimidinyl, pyrazinyl, pyrazolyl, imidazolyl, benzimidazolyl, thienyl or oxazolyl groups, such as pyridin-2-yl-methyl, pyridin-3-yl-methyl, pyridin-4-yl-methyl, 2-pyridin-2-yl-ethyl, 2-pyridin-1-yl-ethyl, 2-pyridin-3-yl-ethyl, pyridazin-3-yl-methyl, pyrimidin-2-yl-methyl, pyrimidin-4-yl-methyl, pyrazin-2-yl-methyl, pyrazol-3-yl-methyl, pyrazol-4-yl-methyl, pyrazol-5-yl-methyl, imidazol-2-yl-methyl, imidazol-5-yl-methyl, benzimidazol-2-yl-methyl, thiophen-3-yl-methyl, 1, 3-oxazol-2-yl-methyl.

Preferred are alkyl groups substituted with benzimidazolyl groups, such as benzimidazol-2-yl-methyl and benzimidazol-2-yl-ethyl.

Examples of amino-substituted alkyl residues include the above-mentioned alkyl residues containing 1 to 3, preferably 1 (optionally substituted) amino groups as defined below, such as aminoalkyl (NH) ₂ -alkyl) or mono-or dialkylamino-alkyl, such as aminomethyl, 2-aminoethyl, 2-aminopropyl or 3-aminopropyl, methylaminomethyl, methylaminoethyl, methylaminopropyl, 2-ethylaminomethyl, 3-ethylaminomethyl, 2-ethylaminoethyl, 3-ethylaminoethyl, etc. Preferably 3-aminopropyl, or an alkyl group which may be substituted by an optionally substituted alkoxycarbonylamino group, such as a group according to the formula

Wherein R defines a phenyl group, thereby forming a benzyloxycarbonylaminopropyl group. />

The optionally substituted amino groups according to the invention preferably comprise: amino (-NH) ₂ ) Optionally substituted mono-or dialkylamino (alkyl-NH-, (alkyl) ₂ N-), wherein reference is made to the definition of optionally substituted alkyl as described above for "alkyl". Preferred are mono-or dimethylamino, mono-or diethylamino, and monopropylamino. Most preferred are amino groups NH ₂ ) And monopropylamino.

Further, in the sense of the present invention, a carboxyl group denotes a group [ - (c=o) -OH]And aminocarbonyl groups represent a group [ NH ] ₂ -(C＝O)-]。

Optionally substituted alkoxy includes optionally substituted alkyl-O-groups, wherein reference may be made to the foregoing definition of alkyl groups. Preferred alkoxy groups are straight-chain or branched alkoxy groups having up to 6 carbon atoms, such as methoxy groups, ethoxy groups, n-propoxy groups, isopropoxy groups, n-butoxy groups, isobutoxy groups, sec-butoxy groups, tert-butoxy groups, n-pentoxy groups, isopentoxy groups, sec-pentoxy groups, tert-pentoxy groups, 2-methylbutoxy groups, n-hexoxy groups, isohexoxy groups, tert-hexoxy groups, sec-hexoxy groups, 2-methylpentoxy groups, 3-methylpentoxy groups, 1-ethylbutoxy groups, 2-ethylbutoxy groups, 1-dimethylboxy groups, 2-dimethylboxy groups, 3-dimethylboxy groups, 1-ethyl-1-methylpropoxy groups, and cycloalkoxy groups, such as cyclopentoxy groups or cyclohexyloxy groups. Methoxy groups, ethoxy groups, n-propoxy groups and isopropoxy groups are preferred. Methoxy and ethoxy groups are more preferred. Particularly preferred are methoxy groups.

In the present invention, the optionally substituted alkanediyl is preferably a divalent linear or branched alkanediyl radical having from 1 to 6, preferably from 1 to 4, more preferably from 1,2 or 3 carbon atoms, which alkanediyl radical optionally carries from 1 to 3, preferably 1 or 2 substituents selected from halogen, hydroxy (-OH), oxo (c=o; forming carbonyl or acyl groups [ - (c=o) - ]) and alkyl groups as defined above, such as preferably methyl. The following may be mentioned as preferred examples: methylene, ethane-1, 2-diyl, ethane-1, 1-diyl, propane-1, 3-diyl, propane-1, 1-diyl, propane-1, 2-diyl, propane-2, 2-diyl, butane-1, 4-diyl, butane-1, 2-diyl, butane-1, 3-diyl, butane-2, 3-diyl, butane-1, 1-diyl, butane-2, 2-diyl, butane-3, 3-diyl, pentane-1, 5-diyl, and the like. Particularly preferred are methylene, ethane-1, 2-diyl, ethane-1, 1-diyl, propane-1, 3-diyl, propane-2, 2-diyl and butane-2, 2-diyl. Most preferred are methylene, ethane-1, 2-diyl and propane-1, 3-diyl.

Preferably the substituted alkanediyl radical is a hydroxy-substituted alkanediyl radical such as hydroxy-substituted ethanediyl, an oxo-substituted alkanediyl radical such as oxo-substituted methylene or ethanediyl radical thereby forming a carbonyl or acyl (acetyl) group, a halogen-substituted alkanediyl radical such as an alkanediyl radical substituted by one or two halogen atoms selected from F and Cl, preferably a 2, 2-difluoroethanediyl radical, or an alkanediyl radical substituted by a methyl group.

According to the invention, it is further possible that A has the meaning of a linear or branched alkanediyl group as defined above ¹ And R has the meaning of an optionally substituted alkyl group as defined above ² Together with the nitrogen atom to which they are bonded, form an optionally substituted 4-to 6-membered ring which may be substituted with 1 to 3 substituents as defined above. Thus, A ¹ And R is ² May together be derived from a group according to one of the following formulas

Wherein (substituted or unsubstituted) 4-membered ring formation is preferred, such as very particularly the group +.>Wherein the left-hand bonding site represents the position X in formula (I) according to the invention ¹ And X ² A direct bonding site of a heterocyclic 5-membered ring. The right-hand bonding site represents a group A having the meaning of an alkanediyl group as defined herein ² Is a binding site of (a).

In formula (I) as defined herein any where n has the meaning of an integer from 1 to 3, including 1,2 or 3, thus representing a methylene group, an ethane-1, 2-diyl group or a propane-1, 3-diyl group. More preferably n is 1 or 2, and even more preferably n is 1, representing a methylene group.

In the present invention, each substituent of the above formula (I) may have the following meanings:

A)X ¹ is N or O; and

X ² n, S or O;

provided that X ¹ And X ² Different;

thereby forming a 5-membered heterocyclic ring according to the formula,

wherein represents a bonding site to an aminocarbonyl group, and a represents a bonding site to a ¹ Bonding sites of the groups.

B) n is an integer of 1, 2 or 3; preferably n is 1 or 2, more preferably n is 1.

C)R ¹ Selected from the group consisting of

-hydrogen, and

-optionally substituted alkyl (as defined above);

preferably R ¹ Is hydrogen or methyl, more preferably R ¹ Is hydrogen.

D)R ² Selected from the group consisting of

-hydrogen, and

-optionally substituted alkyl (as defined above);

preferably R ² Is hydrogen or C ₁ -C ₄ Alkyl, more preferably R ² Is hydrogen or methyl, even more preferably R ² Is hydrogen.

E)R ³ Represents 1, 2 or 3 optional substituents which may be independently selected from

Halogen (as defined above),

-cyano group,

Optionally substituted alkyl (as defined above),

-optionally substituted alkoxy (as defined above), and

-a carboxyl group (as defined above);

preferably, R ³ Represents 1 or 2 optional substituents which may be independently selected from

Halogen(s),

-cyano group,

Alkyl (as defined above), which may be substituted by 1, 2 or 3 halogen atoms (as defined above),

optionally substituted alkoxy (as defined above), and

a carboxyl group (as defined above);

more preferably R ³ Represents 1 or 2 optional substituents which may be independently selected from

F and Cl,

-cyano group,

-trifluoromethyl,

-methoxy and

-a carboxyl group;

even more preferably R ³ Is hydrogen, thereby representing an unsubstituted terminal benzimidazolyl ring of formula (I).

F)R ⁴ Selected from the group consisting of

Hydrogen, hydrogen,

Halogen (as defined above),

-C ₁ -C ₃ Alkyl group, and

-halogen substituted alkyl (as defined above);

preferably R ⁴ Selected from the group consisting of

Hydrogen, hydrogen,

-Cl、

-methyl, ethyl, isopropyl and

-trifluoromethyl;

more preferably R ⁴ Selected from the group consisting of

Hydrogen, hydrogen,

-Cl、

-methyl and

-trifluoromethyl;

more preferably R ⁴ Selected from the group consisting of

Hydrogen, hydrogen,

-Cl and

-methyl;

even more preferably R ⁴ Is hydrogen.

G)A ¹ Is an alkanediyl group;

preferably A ¹ Is methylene or ethane-1, 2-diyl, more preferably A ¹ Is ethane-1, 2-diyl.

H)A ² Is an alkanediyl group;

preferably A ² Is methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

more preferably A ² Is methylene or ethane-1, 2-diyl;

even more preferably A ² Is ethane-1, 2-diyl.

I) Or A ¹ And R is ² Together with the nitrogen atom to which they are bonded form an optionally substituted 4-to 6-membered ring as defined above;

wherein A is ¹ And R is ² Together with the nitrogen atom to which they are bonded preferably form an optionally substituted 4-membered ring as defined above;

Wherein A is ¹ And R is ² More preferably form an unsubstituted 4-membered ring (azetidinyl ring) together with the nitrogen atom to which they are bonded.

The substituents of the following compounds of formula (I) may in particular have the following meanings:

n has any of the meanings according to B) above, and the remaining substituents may have any of the meanings defined in a) and C) to I).

R ¹ Having any of the meanings defined in accordance with C) above, and the remaining substituents may have any of the meanings defined in A) and B) and D) to I).

R ² Having any of the meanings defined in accordance with D) above, and the remaining substituents may have any of the meanings defined in A) to C) and E) to H) or I).

R ³ Having any of the meanings according to E) above, and the remaining substituents may have any of the meanings defined in A) to D) and F) to I).

R ⁴ Having any of the meanings defined in accordance with F) above, and the remaining substituents may have any of the meanings defined in A) to E) and G) to I).

A ¹ Having any of the meanings according to G) above, and the remaining substituents may have any of the meanings defined in a) to F) and H) or I).

A ² Having any of the meanings according to H) above, and the remaining substituents may have any of the meanings defined in a) to G) and I).

R ² And A ¹ Having any of the meanings as defined in I), and the remaining substituents may have any of the meanings as defined in a) to C), E), F) and H).

In a preferred embodiment of the invention, the compounds of the general formula (I) are defined as

X ¹ Is N or O; and

X ² n, S or O;

provided that X ¹ And X ² Different;

R ¹ is hydrogen;

n is 1,2 or 3;

A ¹ is methylene or ethane-1, 2-diyl;

A ² is methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

R ² is hydrogen or C ₁ -C ₄ An alkyl group;

or (b)

A ¹ And R is ² Together with the nitrogen atom to which they are bonded form an optionally substituted 4-membered ring;

R ³ represents 1 or 2 optional substituents which may be independently selected from

Halogen(s),

-cyano group,

Alkyl (which may be substituted by 1,2 or 3 halogen atoms),

-optionally substituted alkoxy, and

-a carboxyl group;

R ⁴ selected from the group consisting of

Hydrogen, hydrogen,

-Cl、

-methyl, ethyl, isopropyl, and

-trifluoromethyl.

In a further preferred embodiment of the present invention, the compounds of the general formula (I) are defined as X ¹ Is N or O; and

X ² n, S or O;

provided that X ¹ And X ² Different;

R ¹ is hydrogen;

n is 1 or 2;

A ¹ is methylene or ethane-1, 2-diyl;

A ² is methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

R ² is hydrogen or methyl;

Or A ¹ And R is ² Together with the nitrogen atom to which they are bonded, form an unsubstituted 4 membered ring;

R ³ represents 1 or 2 optional substituents which may be independently selected from-F and Cl,

-cyano group,

-trifluoromethyl,

-methoxy, and

-a carboxyl group;

R ⁴ selected from the group consisting of

Hydrogen, hydrogen,

-Cl、

-methyl, and

-trifluoromethyl.

X ² n, S or O;

provided that X ¹ And X ² Different;

R ¹ is hydrogen;

n is 1;

A ¹ is methylene or ethane-1, 2-diyl;

A ² is methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

R ² is hydrogen;

R ³ represents hydrogen, thereby forming an unsubstituted terminal benzimidazolyl ring;

R ⁴ selected from the group consisting of

Hydrogen, hydrogen,

-Cl, and

-methyl.

In a further preferred embodiment of the present invention, the compounds of the general formula (I) are defined as

X ¹ Is N or O; and

X ² n, S or O;

provided that X ¹ And X ² Different;

R ¹ is hydrogen;

n is 1;

A ¹ is methylene or ethane-1, 2-diyl;

A ² is methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

R ² is hydrogen;

R ³ Represents hydrogen, thereby forming an unsubstituted terminal benzimidazolyl ring; and

R ⁴ is hydrogen.

In a further aspect, the present invention relates to a novel use and a method of treatment as defined herein, wherein the compound according to formula (I) or a salt, solvate, hydrate and polymorph thereof is selected from the group of compounds of formula (I) as shown above, wherein

n＝1；

R ³ =hydrogen;

R ⁴ =hydrogen;

A ¹ methylene or ethane-1, 2-A diradical;

A ² =methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

or A ¹ And R is ² Together with the nitrogen atom to which they are bonded form an optionally substituted 4-membered ring,

thereby forming a compound according to formula (II) or (III):

wherein in formulae (II) and/or (III)

l is 0 or 1;

m is an integer of 1,2 or 3, and

X ¹ 、X ² 、R ¹ and R is ² Has the meaning defined anywhere herein for the compounds of formula (I).

Preferably, in formulae (II) and (III), X ¹ And X ² Has the meaning as defined under A).

In formula (II), R ¹ And R is ² Preferably hydrogen.

In formula (III), R ¹ Preferably hydrogen and m is preferably 2.

In a further preferred embodiment of the present invention, the compounds of the general formula (II) are defined as

X ¹ And X ² Selected from N and O and are different;

R ¹ =hydrogen;

R ² =hydrogen;

l=1; and

m＝2。

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

For suitable pharmaceutically acceptable salts of the compounds of formulae (I), (II) and (III) as defined herein any of the text, reference is made to international applications WO2017/068089, WO2017/068090, and in particular WO2018/192973. The definition of pharmaceutically acceptable salts disclosed therein is incorporated herein by reference.

Other compounds that act as inhibitors of membrane iron transporters and are suitable for the treatment of MDS as defined herein are those described in WO2020/123850A1, which is incorporated herein by reference in its entirety. Those specific compounds described in WO2020/123850A1 that are suitable for the treatment of MDS as defined herein may be selected from:

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in a further preferred aspect, the present invention relates to the use and method of treatment as defined herein, wherein the pharmaceutically acceptable salt of the compound of formula (I), (II) or (III) or the compound according to WO2020/123850A1 is selected from salts formed with acids selected from benzoic acid, citric acid, fumaric acid, hydrochloric acid, lactic acid, malic acid, maleic acid, methanesulfonic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid and toluenesulfonic acid. Preferably an acid selected from the group consisting of citric acid, hydrochloric acid, maleic acid, phosphoric acid and sulfuric acid is selected.

In a further preferred aspect, the present invention relates to a novel use and a method of treatment as defined herein, wherein the pharmaceutically acceptable salt of the compound of formula (I), (II) or (III) is selected from the group consisting of mono-salts (1:1 salts), tri-salts (1:3 salts) and salts characterized by a ratio of compound (I), (II) or (III) to acid of 1-2:1-3; including solvates, hydrates and polymorphs thereof.

Wherein the salt of the compound (I), (II) or (III) is characterized by the ratio of base to acid selected, i.e. the acid of the compound (I), (II) or (III) as defined above is in the range of 1.0 to 2.0 (mole base) 1.0 to 3.0 (mole acid). In a specific embodiment, the base acid is selected to be 1.0 to 2.0 (mole base) 1.0 to 2.0 (mole acid).

Specific examples include the following base to acid ratios, i.e. compounds (I), (II) or (III), acids as defined above:

1.0 1.0 (mole acid);

1.0 1.25 (moles of acid);

1.0 1.35 (moles of acid);

1.0 1.5 (moles of acid);

1.0 1.75 (moles of acid);

1.0 (molar base) 2.0 (molar acid);

1.0 (mol base) 3.0 (mol acid); and

2.0 1.0 (mole acid).

Wherein salts having a ratio of base to acid of 1:1 are also referred to as "mono-salts" or "1:1 salts". For example, the mono HCl salt is also known as 1HCl or 1HCl salt.

Wherein salts having a ratio of base to acid of 1:2 are also referred to as "di-salts" or "1:2 salts". For example, the di-HCl salt is also known as 2HCl or 2HCl salt.

Wherein salts having a ratio of base to acid of 1:3 are also referred to as "trisalts", "trisalts" or "1:3 salts". For example, the trichci salt is also known as 3HCl or 3HCl salt.

Salts having a ratio of base to acid of 1:1.25 are also referred to as "1:1.25 salts".

Salts having a ratio of base to acid of 1:1.35 are also referred to as "1:1.35 salts".

Salts having a ratio of base to acid of 1:1.5 are also referred to as "1:1.5 salts".

Salts having a ratio of base to acid of 1:1.75 are also referred to as "1:1.75 salts".

Salts having a ratio of base to acid of 2:1 are also referred to as "hemi-salts" or "2:1 salts".

Salts of the compounds of formula (I), (II) or (III) according to the invention may exist in amorphous, polymorphic, crystalline and/or semi-crystalline (partially crystalline) form as well as in the form of solvates of the salts. Preferably, the salts of the compounds of formula (I), (II) or (III) according to the invention are present in crystalline and/or semi-crystalline (partially crystalline) form and/or in the form of solvates thereof.

The crystallinity of a preferred salt or salt solvate can be determined by using conventional analytical methods such as, inter alia, by using various X-ray methods, which allows for a clear and simple analysis of salt compounds. In particular, the level of crystallinity can be determined or confirmed by using a powder X-ray diffraction (reflection) method or by using a powder X-ray diffraction (transmission) method (PXRD). For crystalline solids having the same chemical composition, the different resulting crystal gratings are summarized by the term "polymorphism". Reference is made to international application WO2018/192973 for solvates, hydrates and polymorphs and salts having a specific crystallinity, which is included herein by reference.

In a further preferred aspect, the present invention relates to the use and method of treatment as defined herein, wherein the compound of formula (I), (II) or (III) is selected from:

and pharmaceutically acceptable salts, solvates, hydrates, and polymorphs thereof.

In a further preferred aspect, the present invention relates to a novel use and a method of treatment as defined herein, wherein the compound of formula (I), (II) or (III) is selected from:

/>

In an even more preferred aspect of the invention, the compound of formula (I), (II) or (III) is selected from:

In a further preferred aspect of the invention, the compound of formula (I), (II) or (III) is selected from the following salts:

A 1:1 sulfate salt having the formula

A 1:1 phosphate having the formula

2:1 phosphate (half phosphate)

A 1:3hcl salt having the formula

And polymorphs thereof.

As described in WO2017/068089, WO2017/068090 and WO2018/192973, the compounds of formula (I) act as membrane iron transporter inhibitors. Thus, reference is made to the international application for compound's membrane iron transporter inhibitor activity.

Pharmaceutical comprising a ferroportin inhibitor compound

Another aspect of the invention relates to a medicament or pharmaceutical composition comprising one or more of the compounds of formula (I), (II) or (III) as defined herein in any of the following, for use in a novel method of treatment of MDS as defined herein.

Such medicaments may further comprise one or more pharmaceutically acceptable carriers and/or one or more adjuvants and/or one or more solvents.

Preferably, the medicament is in the form of an oral dosage form, such as defined above, for example.

Preferably, the pharmaceutically acceptable carrier and/or adjuvant and/or solvent is selected from the group of suitable compounds for use in the preparation of oral dosage forms.

The pharmaceutical composition comprises, for example, up to 99% by weight or up to 90% by weight or up to 80% by weight or up to 70% by weight of the inventive ferroportin inhibitor compound, the remainder being formed from a pharmacologically acceptable carrier and/or adjuvant and/or solvent and/or optionally other pharmaceutically active compound.

Among them, pharmaceutically acceptable carriers, auxiliary substances or solvents are common pharmaceutical carriers, auxiliary substances or solvents, including various organic or inorganic carriers and/or auxiliary materials, as they are commonly used for pharmaceutical purposes, in particular for solid pharmaceutical formulations. Examples include: excipients such as sucrose, starch, mannitol, sorbitol, lactose, glucose, cellulose, talc, calcium phosphate, calcium carbonate; binders such as cellulose, methylcellulose, hydroxypropyl cellulose, polypropylene pyrrolidone, gelatin, acacia, polyethylene glycol, sucrose, starch; disintegrants, such as starch, hydrolyzed starch, carboxymethyl cellulose calcium salt, hydroxypropyl starch, sodium starch glycolate, sodium bicarbonate, calcium phosphate, calcium citrate; lubricants such as magnesium stearate, talc, sodium lauryl sulfate; flavorants such as citric acid, menthol, glycine, orange powder; preservatives such as sodium benzoate, sodium bisulphite, parabens (e.g. methyl parahydroxybenzoate, ethyl parahydroxybenzoate, propyl parahydroxybenzoate, butyl parahydroxybenzoate); stabilizers such as citric acid, sodium citrate, acetic acid and polycarboxylic acids from the titrilex series, for example diethylenetriamine pentaacetic acid (DTPA); suspending agents such as methylcellulose, polyvinylpyrrolidone, aluminum stearate; a dispersing agent; diluents such as water, organic solvents; waxes, fats and oils such as beeswax, cocoa butter; polyethylene glycol; white vaseline, etc.

Liquid pharmaceutical formulations, such as solutions, suspensions and gels, typically contain a liquid carrier, such as water and/or a pharmaceutically acceptable organic solvent. In addition, such liquid formulations may also contain pH adjusting agents, emulsifying or dispersing agents, buffering agents, preservatives, wetting agents, gelling agents (e.g., methylcellulose), dyes, and/or flavoring agents, such as defined above. The compositions may be isotonic, i.e., they may have the same osmotic pressure as blood. The isotonicity of the composition can be adjusted by using sodium chloride and other pharmaceutically acceptable agents such as dextrose, maltose, boric acid, sodium tartrate, propylene glycol and other inorganic or organic soluble materials. The viscosity of the liquid composition may be adjusted by a pharmaceutically acceptable thickener such as methyl cellulose. Other suitable thickening agents include, for example, xanthan gum, carboxymethyl cellulose, hydroxypropyl cellulose, carbomers, and the like. The preferred concentration of thickener will depend on the agent selected.

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

Combination therapy

A further object of the present invention relates to a medicament or a combination formulation comprising one or more of the membrane iron transporter inhibitor compounds defined herein anywhere and at least one further pharmaceutically active compound ("combination therapy compound"), preferably a further active compound, for use in the treatment of MDS as defined herein. Preferred combination therapy compounds are particularly those useful in the prevention and treatment of ineffective erythropoiesis, including erythropoietin stimulators, erythropoietin (EPO) and antibiotics and immunosuppressants. Drugs known to be useful in the treatment of MDS include lenalidomide, anti-thymocyte globulin, and azacitidine. Donor stem cell transplantation following chemotherapy is another treatment option for patients with MDS. Further preferred combination therapy compounds are selected from the group of drugs for the treatment of iron overload and related symptoms. The most preferred combination therapy compounds are iron chelating compounds, or compounds useful for the prevention and treatment of any condition, disorder or disease associated with or caused by iron overload and MDS. Suitable combination therapy pharmaceutical compounds (combination) may be selected from pharmaceutically active compounds useful for the prevention and treatment of MDS and associated symptoms. In particular, combinations for the treatment of ineffective hematopoiesis, in particular ineffective erythropoiesis, such as erythropoietin stimulators or erythropoietin, are preferred. In a further embodiment, the at least one additional pharmaceutically active combination therapy compound is selected from the group consisting of drugs for reducing iron overload (e.g. Tmprss 6-ASO) and iron chelators, in particular curcumin, SSP-004184, difirine, deferasirox, deferoxamine and deferiprone and hydroxyurea or JAK2 inhibitors.

Further preferred combination therapy compounds may be selected from drugs for the treatment of MDS, such as lenalidomide, anti-thymocyte globulin, and azacytidine or antibiotics, and immunosuppressants.

Additional possible combinations include erythrocyte maturation agents (such as Luspatercept), or other erythrocyte maturation/erythrocyte stimulators (e.g. EPO, epoetin or darbepetin), or synthetic human hepcidin (LJPC-401), hepcidin mimetic peptide PTG-300 and antisense oligonucleotides targeting Tmprss6 (IONIS-Tmprss 6-L RX).

In another aspect, the invention relates to the use and medical treatment of MDS as defined herein, wherein a combination therapy, in which a ferroportin inhibitor compound as defined herein is combined with one or more of the combination therapy compounds (combination drugs) as defined above, in a fixed dose or free dose, is administered to a patient in need thereof, for sequential use. Such combination therapies include co-administration of a ferroportin inhibitor compound as defined herein with the at least one additional pharmaceutically active compound (drug/combination therapy compound).

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

Combination therapies in free dose combination therapies include co-administration of a ferroportin inhibitor compound as defined herein and the at least one additional pharmaceutically active compound at free doses of the respective compounds by simultaneous administration of the individual compounds or by sequential use of the distributed individual compounds over a period of time.

In a preferred embodiment, the combination therapy comprises simultaneous administration of an oral membrane iron transporter inhibitor according to example compound number 127 described herein and erythropoietin.

In a further embodiment, the combination therapy comprises the simultaneous administration of an oral membrane iron transporter inhibitor according to example compound number 127 described herein and lusputtercept.

In a further embodiment, the combination therapy comprises simultaneous administration of an oral membrane iron transporter inhibitor according to example compound number 127 described herein and the iron chelator deferasirox.

Another embodiment of the invention relates to a combination therapy as described herein, wherein the membrane iron transporter inhibitor compound is selected from those described in WO2020/123850A1, in particular one of its specific example compounds as described above. Preferably, such combination therapy comprises the simultaneous administration of the membrane iron transporter inhibitor compound and the iron chelator deferasirox.

Drawings

Fig. 1: anemia in 3 month-old MDS mice. Blood parameters (hemoglobin, number of red blood cells, hematocrit, mean cell volume and white blood cell count) of 3 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice.

Fig. 2: MDS mice show very mild, mild and moderate anemia at 3 months of age. Based on the level of anemia (no/very mild anemia: hb > 13g/dl; mild anemia: 10g/dl < Hb < 13g/dl; moderate anemia: 8g/dl < Hb < 10g/dl; severe anemia: hb < 8 g/dl), the blood parameters (hemoglobin, number of erythrocytes, hematocrit and white blood cell count) of 3 month old wild-type (WT) control mice and Myelodysplastic (MDS) mice.

Fig. 3: fpn127 treatment reduces serum iron levels and reduces NTBI formation in MDS mice. Total iron (SFBC) and non-transferrin-bound iron (NTBI) measurements in serum of 6 month old wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (MDS+VIT) for 3 months.

Fig. 4: fpn127 treatment prevents iron burden in MDS mice. Liver, kidney and spleen iron content of 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (mds+vit) for 3 months.

Fig. 5: fpn127 treatment improves anemia in MDS mice. Erythrocyte parameters (hemoglobin, number of erythrocytes, hematocrit, mean cell volume, mean cellular hemoglobin, and reticulocyte count) of 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (mds+vit) for 3 months.

Fig. 6: fpn127 treatment showed a trend to reduce leukemia progression in MDS mice. White blood cell parameters (white blood cell, platelet, neutrophil, lymphocyte and monocyte counts) of 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (mds+vit) for 3 months.

Fig. 7: fpn127 treatment improves bone marrow erythrocyte maturation in MDS mice. Immature to mature red blood cell populations were monitored by progressive loss of CD71 expression on myeloid Ter119+ erythroid cells in 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (MDS+VIT) for 3 months.

Fig. 8: fpn127 treatment improves bone marrow erythrocyte maturation in MDS mice. Erythrocyte maturation was assessed by assessing erythrocyte populations I through V (I: pre-erythroblasts; II: basophilic erythroblasts; III: multi-stained erythroblasts; IV: orthochromatic erythroblasts/reticulocytes; V: erythrocytes) by progressive loss of CD44 expression on bone marrow Ter119+ erythrocytes of untreated or 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice treated with 0.5mg/ml Fpn127 (MDS+VIT) for 3 months.

Fig. 9: fpn127 treatment improves spleen red blood cell maturation in MDS mice. Immature to mature red blood cell populations were monitored by progressive loss of CD71 expression on spleen Ter119+ erythroid cells in 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (MDS+VIT) for 3 months.

Fig. 10: fpn127 treatment improves spleen red blood cell maturation in MDS mice. Erythrocyte maturation was assessed by assessing erythrocyte populations I through V (I: pre-erythroblasts; II: basophilic erythroblasts; III: multi-stained erythroblasts; IV: orthochromatic erythroblasts/reticulocytes; V: erythrocytes) by progressive loss of CD44 expression on splenic Ter119+ erythrocytes of untreated or 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice treated with 0.5mg/ml Fpn127 (MDS+VIT) for 3 months.

Fig. 11: fpn127 treatment improves erythrocyte maturation in MDS mice. Improvement of red cell maturation by Fpn127 was confirmed by monitoring loss of CD71 expression on bone marrow and spleen ter119+ erythroid cells of 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (mds+vit) for 3 months.

Fig. 12: fpn127 treatment ameliorates anemia by reducing oxidative stress and apoptosis of erythrocyte precursors in MDS mice. Iron accumulation (labile iron), oxidative stress (ROS), and apoptosis (annexin V) in bone marrow and spleen ter119+ erythroid cells of 6 month old wild-type (WT) control mice and Myelodysplastic (MDS) mice, untreated or treated with 0.5mg/ml Fpn127 (mds+vit), were monitored by flow cytometry.

Fig. 13: fpn127 treatment improves the overall status of hematopoietic LSK cells in MDS mice. The cell percentage of myelohematopoietic Lin-Sca-1+ckit+ (LSK) cells, iron accumulation (labile iron), oxidative stress (ROS), apoptosis (annexin V) and double strand breaks (γh2ax) of 6 month old Wild Type (WT) control mice and Myelodysplastic (MDS) mice, untreated or treated with 0.5mg/ml Fpn127 (mds+vit), were monitored by flow cytometry.

Fig. 14: fpn127 treatment improves anemia in aged MDS mice. Erythrocyte parameters (hemoglobin, erythrocyte number, hematocrit) of Wild Type (WT) control mice of 8 months to 10 months of age and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml Fpn127 (MDS+VIT) for 3 months to 5 months

Fig. 15: fpn127 treatment reduces leukemia-related death in older MDS mice. WBC counts of wild-type (WT) control mice and Myelodysplastic (MDS) mice of 8 to 10 months of age for 3 to 5 months of treatment with 0.5mg/ml Fpn127 (mds+vit). As shown, 2 untreated MDS mice died from leukemia, while 2 Fpn127 treated MDS mice died from MDS, as also indicated by low WBC counts.

Fig. 16: treatment with VIT-2763 ameliorates anemia in MDS mice. From 3 months of age, blood parameters (hemoglobin-Hb, hematocrit-HCT, red blood cell-RBC) of wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) were monitored longitudinally.

Fig. 17: treatment with VIT-2763 ameliorates anemia in MDS mice. From 3 months of age, hb, HCT and RBC were improved (delta) in Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT). Shown at 2 months, 3 months and 4 months (5 months of age, 6 months of age and 7 months of age) after treatment.

Fig. 18: VIT-2763 treatment delays leukemia progression in MDS mice. Starting at 3 months of age, total leukocytes, monocytes and neutrophils were monitored longitudinally in wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT).

Fig. 19: VIT-2763 treatment increased survival in MDS mice. Kaplan-Meier curves for wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) starting at 3 months of age.

Fig. 20: treatment with VIT-2763 reduces bone marrow immature cells in MDS mice. In-bone marrow cKit from wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) starting at 3 months to 6 months of age ⁺ And Lin ⁺ cKit ⁺ Percentage of cells. Immature primitive cells in Lin ⁺ cKit ⁺ In the population.

Fig. 21: VIT-2763 treatment reduced myeloid expansion in the bone marrow of MDS mice. CD45+ immune cells, CD11b, in bone marrow of wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) starting from 3 months to 6 months of age ⁺ Myeloid cells and CD3 ⁺ CD19 ⁺ Percentage of lymphoid cells.

Fig. 22: VIT-2763 treatment reduced myeloid expansion in the bone marrow of MDS mice. Total CD11b+Ly6C+Ly6G+ Myeloid Derived Suppressor Cells (MDSC), CD11b in bone marrow of Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) starting from 3 months to 6 months of age ⁺ Ly6C ⁺ Monocytes and CD11b ⁺ Ly6G ⁺ Percentage of granulocyte MDSC.

Fig. 23: VIT-2763 treatment increased macrophage numbers in the bone marrow of MDS mice. Percentage of total macrophages, erythroblast islands and HSC macrophages in bone marrow of Wild Type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (mds+vit) starting from 3 months to 6 months of age.

Fig. 24: VIT-2763 treatment limited bone marrow macrophage-mediated inflammation in MDS mice. Production of TNFα and IL-1b in total bone marrow macrophages of untreated or wild-type (WT) control mice and Myelodysplastic (MDS) mice treated with 0.5mg/ml VIT-2763 (MDS+VIT) starting from 3 months of age to 6 months of age.

Fig. 25: treatment with VIT-2763 ameliorates anemia in MDS mice. From 5 months of age, blood parameters (hemoglobin-Hb, hematocrit-HCT, red blood cell-RBC) of wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) were monitored longitudinally.

Fig. 26: VIT-2763 treatment delays leukemia progression in MDS mice. White blood cells from wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) were monitored longitudinally starting at 5 months of age.

Fig. 27: VIT-2763 treatment increased survival in MDS mice. Kaplan-Meier curves for wild-type (WT) control mice and Myelodysplastic (MDS) mice untreated or treated with 0.5mg/ml VIT-2763 (MDS+VIT) starting at 5 months of age.

In the drawings, "VIT-2763" or "VIT" means test compound Fpn127 (example compound number 127).

Examples

The invention is illustrated in more detail by the following examples. These examples are merely illustrative and one skilled in the art can extend the specific examples to other membrane iron transporter inhibitor compounds according to the present invention.

I. Exemplary compounds of Membrane iron Transporter inhibitors

For the preparation of specific membrane iron transporter inhibitors described herein exemplary compound numbers 1, 2, 4, 40, 94, 118, 126, 127, 193, 206, 208 and 233 and their pharmaceutically acceptable salts, reference is made to international applications WO2017/068089, WO2017/068090 and WO2018/192973.

For the preparation of specific membrane iron transporter inhibitor compounds as described in WO2020/123850A1 reference is made to the preparation method as described in said International application WO2020/123850A 1.

Pharmacological assay

II.1 preamble

Oral bioavailable inhibitors of membrane iron transporters, such as clinical stage compounds according to example compound No. 127 (Fpn 127), have been shown to improve ineffective erythropoiesis, improve anemia, and prevent NTBI formation and hepatic iron burden in a mouse model of MDS. Membrane iron transporter inhibitors, such as clinical stage example compound number 127, further limit iron availability and Reactive Oxygen Species (ROS) in erythrocyte precursors, thereby preventing their apoptosis and improving ineffective erythropoiesis. Thus, more life-prolonging RBCs improve anemia and improve tissue oxygenation.

Based on this, the inventors of the present invention have found that the described inhibitors of membrane iron transporters are particularly effective in the treatment of MDS, particularly ineffective erythropoiesis. Patients with MDS with ineffective erythropoiesis have reduced Hb levels, usually treated by Blood Transfusion (BT), resulting in severe iron overload. In another aspect, prevention of intestinal iron absorption by membrane iron transporter inhibitors during the transfusion interval helps to further reduce iron load in MDS patients. In addition, non-transferrin-bound iron (NTBI) is released by macrophages recycling damaged RBCs and induces oxidative stress and vascular damage. Elevated levels of NTBI have been found in patients with MDS, which is suitable for both transfusional and non-transfusional MDS patients.

It has now been found that oral ferroportin inhibitors according to the invention, such as ferroportin inhibitor example compound number 127, have the potential to prevent these deleterious effects by sequestering iron in macrophages. Because the membrane iron transporter inhibition therapy will achieve beneficial effects on hemoglobin levels, NTBI levels, and LPI levels in a subject with MDS, the membrane iron transporter inhibitor compounds of the present invention have the potential to improve the hematologic value in a subject with MDS, and on the other hand, a reduction in infused RBC units can be achieved, thereby alleviating the transfusion burden in a subject with MDS.

II.2 evaluation background overview of Membrane iron Transporter inhibitor Compound Fpn127 in preclinical MDS mouse model

Patients with myelodysplastic syndrome (MDS) are prone to iron overload due to ineffective erythropoiesis and long-term transfusion that promote increased iron absorption, which is often necessary to restore anemia in the patient population. The role of the membrane iron transporter inhibitor compounds according to the invention in non-transfusion dependent and transfusion dependent MDS was evaluated with example compound Fpn in order to demonstrate that iron restriction can reduce iron absorption, mitigate non-transferrin binding iron (NTBI) formation and tissue iron deposition and mediate its redistribution, and to show whether the membrane iron transporter inhibitors of the invention are beneficial in reducing total iron load by reducing body iron influx caused by erythropoiesis driven hepcidin inhibition in non-transfusion dependent MDS. Reduction of iron levels and NTBI are thought to have an impact on MDS by alleviating iron-driven cytotoxicity (cell death, ROS production) and organ damage, improving bone marrow functionality to have a positive effect on microenvironment and erythropoiesis, limiting oxidative damage to Hematopoietic Stem Cells (HSCs). In transfusion dependent MDS, in addition to reducing iron absorption, FPN inhibition is believed to provide a strategy to limit RBC-derived iron, resulting in its redistribution from iron-sensitive tissues to recycle macrophages. This is believed to reduce NTBI levels and thus exert beneficial effects in transfusion dependent MDS, particularly by reducing bone marrow exposure of NTBI. Furthermore, the combination of a membrane iron transporter inhibitor according to the present invention with iron chelation administered in combination therapy is believed to provide a novel and more effective strategy for removing iron in vivo in transfusion dependent MDS conditions.

Determination of administration Fpn 127-induced iron limitation in a steady-state MDS mouse model

Membrane iron transporter inhibitor compound Fpn127 was tested in NUP98-HOXD13MDS mice. Fpn127 is administered in drinking water containing 1% glucose at a concentration of 0.5 mg/ml.

Prevention effect:

to investigate the protective effect of the membrane iron transporter inhibitors according to the invention on the progressive development of iron overload and related toxicity, a total of 15 3 month old MDS mice were treated with example compound Fpn127 and compared to 15 untreated MDS mice matched to age and sex and wild type controls (total of 3 replicates). Treatment was performed for a period of 3 months, i.e. 3 to 6 months of age. During the treatment period, 2 untreated and 1 treated MDS mice died.

3 month old MDS mice have shown some degree of anemia, which supports the use of membrane iron transporter inhibitors in therapy to improve erythropoiesis and anemia from 3 months (fig. 1).

About 60% to 70% of MDS mice show mild to moderate anemia at 3 months of age. Based on Hb levels, 3 month-old MDS mice can be divided into 3 groups, exhibiting very mild, light and moderate anemias (no/very mild anemia: hb > 13g/dl; mild anemia: 10g/dl < Hb < 13g/dl; moderate anemia: 8g/dl < Hb < 10 g/dl) (FIG. 2). MDS mice rarely develop severe anemia at 3 months of age (severe anemia: hb < 8 g/dl). This reflects the occurrence of anemia of varying severity in 70% to 80% of patients with MDS at diagnosis.

In 3-to 6-month-old MDS mice treated with Fpn127 for 3 months, the following parameters were monitored:

serum iron levels and NTBI;

liver iron accumulation;

anemia and blood parameters;

erythropoiesis-including RBC maturation, erythrocyte precursor apoptosis and ROS;

hematopoietic stem cells-including apoptosis, ROS, and DNA damage;

bone marrow macrophages and bone marrow derived suppressor cells (not shown).

Fig. 3 to 15 show the average results of 3 independent experiments.

Serum iron levels and NTBI:

serum iron and NTBI levels were elevated in MDS mice compared to control mice and significantly reduced by Fpn127 treatment (fig. 3).

Liver iron accumulation:

liver and kidney iron levels were elevated in MDS mice compared to control group and significantly reduced (male and female) by Fpn127 treatment (fig. 4). In contrast, spleen iron in MDS mice was slightly but not significantly elevated due to increased iron uptake and moderate erythrocyte expansion, with further elevation via VIT treatment consistent with VIT-mediated FPN inhibition and spleen macrophage iron accumulation (fig. 4).

Anemia and blood parameters:

hb, RBC, and HCT were all reduced in MDS mice compared to control animals, and significantly improved by Fpn127 treatment. Reticulocytes showed a trend toward improvement after Fpn127 treatment. MCV and MCH remained unchanged (fig. 5).

White blood cell parameters:

WBC counts were decreased in MDS mice. Only MDS mice that develop forms of leukemia show a significant increase in WBC counts of lymphoid or myeloid lineage. Although 3 mice showed an elevated WBC count in the untreated group (one developed leukemia), only one mouse showed a trend of elevated WBC count in the Fpn127 treated group. Reticulocytes showed a trend toward improvement after Fpn127 treatment. Platelet counts of MDS mice decreased and remained unchanged after Fpn127 treatment (fig. 6).

Erythropoiesis:

erythropoiesis was significantly impaired in bone marrow and spleen of MDS mice compared to control group, and significantly improved by Fpn127 treatment. According to the assessment of CD71 loss and CD44 loss on ter119+ cells, red blood cell maturation was improved by iron restriction, resulting in a decrease in the percentage of cells in the immature population and an increase in the percentage of cells in the mature population (fig. 7-10). Taken together, this suggests improved RBC maturation, reduced ineffective erythropoiesis (in bone marrow and spleen). This was confirmed by a significant decrease in CD71 expression on ter119+ erythrocyte precursors, especially in bone marrow (fig. 11).

Erythropoiesis:

improvement of anemia following Fpn treatment was associated with reduction of ROS formation and apoptosis in ter119+ erythrocyte precursors, suggesting that limited oxidative stress and increased cell survival are mechanistically conducive to improvement of erythropoiesis (fig. 12).

Hematopoietic stem cells:

fpn127 treated iron limitation was associated with overall improvement in hematopoietic LSK stem cell status (fig. 13). LSK cell banks were reduced in MDS mice and could be preserved by Fpn127 treatment. LSK cells of Fpn127 treated MDS mice showed reduced iron accumulation, reduced ROS production and increased cell survival (reduced apoptosis), indicating that changes in these events better preserved HSC pool. Furthermore, LSK cells showed reduced double strand breaks (DSB; γh2ax lower) in Fpn127 treated MDS mice compared to untreated animals. DSBs may promote leukemia progression through accumulation of mutations in HSPCs, where proliferation and clonality tend to increase.

Rescue effect:

to investigate the rescue effect of the membrane iron transporter inhibitors according to the invention on established iron overload and associated toxicity in MDS, 8 5 month old MDS mice were treated with a total of example compound Fpn127 and compared to 8 age and sex matched non-MDS treated mice and wild type controls (1 experiment). Mice received treatment starting at 5 months of age. During the treatment period, 3 untreated and 3 treated MDS mice died. In the mice in this cohort, no improvement in anemia was observed after 3 months of treatment (5 months to 8 months of age). However, the results for the 9 and 10 month old mice indicate that a subset of mice can benefit from Fpn treatment with partially improved anaemia (fig. 14). Mice died for different reasons-2 untreated MDS mice died from AML and TLL;2 MDS mice treated with Fpn127 died from MDS with no apparent leukemia progression (fig. 15). Another 2 mice died, and there was no opportunity to monitor the parameters. As this cohort was reserved for further observation and monitoring, molecular analysis of treated 5 month old mice could not be obtained. To better track individual blood parameter adjustments, two groups of mice beginning treatment at 3 and 5 months of age, respectively, were analyzed longitudinally once a month during the course of treatment.

Additional results:

similar to the above mouse model of MDS, the kinetic effect of administering VIT-2763 in drinking water (0.5 mg/ml) was studied in the NUP98-HOXD13 model of MDS.

Preventive effect-additional results:

to investigate the protective effect of compounds on the progressive development of iron overload and related toxicity, 3 month old MDS mice were treated and compared to age and sex matched untreated MDS mice and wild type controls. Mice were treated with VIT-2763 starting at 3 months of age to track blood parameters and survival longitudinally (fig. 16-19), or 3 months starting at 3 months to 6 months of age for cellular and biochemical analysis (fig. 20-24).

Anemia and blood parameters-additional results:

hb, HCT and RBC were reduced in MDS mice compared to control animals, and significantly improved by VIT-2763 treatment starting from 5 months of age to 7 months of age (fig. 16). VIT treatment increased Hb levels in MDS mice by about 2g/dl (figure 17).

Leukocyte parameters-additional results:

WBC counts in MDS mice were initially reduced. Only MDS mice with leukemia showed a significant increase in WBC counts. Interestingly, several MDS mice in the untreated group showed elevated WBC counts and developed into leukemia, whereas such WBC increases in peripheral blood were not observed or delayed in the VIT-2763 treated group (fig. 18).

Consistent with the reduction/delay in the progression of leukemia, MDS mice contain myeloblasts in immature Lin ⁺ cKit ⁺ Cells increased and decreased after 3 months of VIT treatment (figure 20).

As indicated by the decreased percentage of myeloid cd11b+ myeloid cells and monocyte and granulocyte Myeloid Derived Suppressor Cells (MDSCs), MDS mice had decreased myeloid expansion following VIT treatment (fig. 21 and 22).

Bone marrow macrophages in MDS mice were significantly reduced. This may be the result of a myeloid terminal differentiation failure and lead to ineffective erythropoiesis and HSC loss. VIT treatment increased macrophage numbers in bone marrow of MDS mice (fig. 23). At the same time, inflammatory cytokines such as tnfα and IL-1β produced by macrophages were reduced by VIT treatment (fig. 24), with potentially beneficial effects on erythropoiesis, HSPCs and bone marrow microenvironment.

Rescue effect-additional outcome:

to investigate the rescue effect of compounds on established iron overload and associated toxicity in MDS, 5 month old MDS mice were treated and compared to age and sex matched untreated MDS mice and wild type controls. Mice received treatment starting at 5 months of age. In mice in this cohort, an improvement in anemia was observed 5 months (10 months of age) after treatment. Anemia in MDS mice tends to worsen from 5 months of age. The results indicate that while mice hardly benefited from treatment at the beginning, a subset of mice could benefit at about 10 months of age with partial improvement in anemia (fig. 25).

Interestingly, MDS mice treated with VIT showed a delay in leukemia development (fig. 26), similar to that observed in 3 month old mice.

Although most MDS mice died at about 12/13 months of age, two MDS mice treated with VIT (10 total) survived at 15 months of age with stable blood parameters (Hb of about 9 g/dl), one reaching 20 months of age (fig. 25).

In summary, VIT treatment of older MDS mice resulted in a modest prolongation of median survival for about 16 days compared to untreated mice (fig. 27). However, this clearly shows that a subset of mice can benefit particularly from VIT treatment, untreated MDS animals all die within 400 days, while MDS mice that benefit from VIT treatment can survive up to 600 days.

Blood transfusion burden

The transfusion burden of a subject treated according to the methods of the invention can be assessed by determining the transfusion requirement of the patient, for example by routine and clinically accepted assessment of the required amount and/or frequency of erythrocyte infusion.

IV level of iron

Iron levels, such as liver, kidney or myocardial iron levels, may be determined using conventional assays. For example, iron levels (e.g., liver iron concentration, kidney iron concentration, or myocardial iron concentration) may be determined by magnetic resonance imaging.

V. serum ferritin level determination

Serum ferritin levels may be determined using conventional assays.

VI erythrocyte response

The duration of the erythrocyte response of a subject who achieves the response can be calculated using the following algorithm:

first day of response = first day of display first 12 week interval of response.

Last day of response = last day of last consecutive 129 week interval showing response.

Date of last evaluation = last visit date of subject still taking drug or stop date of subject stopping treatment.

The duration of the erythrocyte response can be calculated as follows, depending on whether the response ended before the last evaluation date:

1. for subjects whose responses did not last to the end of the treatment period, the duration of the responses was not examined and calculated as follows:

duration of response = last day of response-first day of response +1;

2. for subjects who continue to exhibit a red blood cell response at the end of the treatment period, the end date of the response was reviewed and the duration of the response calculated as follows:

response duration = date of last response evaluation-first day of response +1.

The time to first erythrocyte response can be calculated as follows:

The number of days of the first day from the first dose of study drug to the response will be calculated using the following formula:

response time = first day of response-date of first dose study drug +1.

Hemoglobin determination

Hemoglobin levels can be measured using conventional assays.

Quality of life

Quality of life assessment may be performed using a simple format (36) health survey (SF-26) and/or functional assessment of cancer therapy-anemia (FACT-An) as described in, for example, WO 2016/183280.

IX. Membrane iron Transporter inhibitor VIT-2653 (example Compound No. 40) reduces erythrocyte infusion in guinea pigs Therapeutic effects of post-plasma iron, oxidant stress and renal injury

The efficacy of the membrane iron transporter inhibitor compounds of the present invention in the treatment of MDS is supported by the following literature results: h. baek et al, "Ferroportin inhibition attenuates plasma iron, oxydan stress, and renal injury following red blood cell Transfusion in guinea pigs", transfusions, month 3 of 2020, volume 60, phase 3: pages 513-523.

The experiments described herein were performed by intravenous administration of the small molecule membrane iron transporter inhibitor VIT-2653 corresponding to example compound No. 40 of the present invention, and some findings of the present invention were further confirmed.

By administering the membrane iron transporter inhibitors, NTBI and Hb levels after a change of blood are significantly improved.

Furthermore, total iron in the kidney after transfusion can be reduced by administration of membrane iron transporter inhibitors. The contribution of circulating Hb to renal iron load and subsequent effects on oxidative stress and cellular injury were evaluated, revealing that administration of a transfusion-fed guinea pig membrane iron transporter inhibitor significantly reduced the occurrence of changes in plasma creatinine > 0.3mg/dL, which were used as indicators of early Acute Kidney Injury (AKI).

Experimental details and conditions of investigation and specific results can be derived from the above papers.

Claims

1. Compounds according to formula (I) and pharmaceutically acceptable salts, solvates, hydrates and polymorphs thereof, for use in the prevention or treatment of myelodysplastic syndrome (MDS) and/or symptoms associated therewith,

wherein,,

X ¹ is N or O; and

X ² n, S or O;

provided that X ¹ And X ² Different;

R ¹ selected from the group consisting of

-hydrogen, and

-optionally substituted alkyl;

n is an integer from 1 to 3;

A ¹ and A ² Independently selected from alkanediyl groups

R ² Is that

Hydrogen, or

-optionally substituted alkyl;

or (b)

Halogen(s),

-cyano group,

Optionally substituted alkyl,

-optionally substituted alkoxy, and

-a carboxyl group;

R ⁴ selected from the group consisting of

Hydrogen, hydrogen,

Halogen(s),

-C ₁ -C ₃ Alkyl group, and

-halogen substituted alkyl.

2. The compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to claim 1, wherein treating myelodysplastic syndrome (MDS) and/or symptoms associated therewith comprises treating ineffective hematopoiesis, in particular ineffective erythropoiesis.

3. The compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to claim 1, wherein treating myelodysplastic syndrome (MDS) and/or symptoms associated therewith comprises ameliorating, preventing or delaying leukemia evolution, reducing bone marrow immature cells, reducing myeloid expansion, reducing inflammatory cytokines such as tnfa and IL-1 β produced by macrophages and/or ameliorating bone marrow microenvironment.

4. Compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to any one of the preceding claims, wherein the patient to be treated is selected from individuals suffering from an extremely low risk, low risk or medium risk myelodysplastic syndrome according to the IPSS scoring system.

5. The compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to any one of the preceding claims, wherein the patient to be treated is selected from individuals characterized by one or more of the following:

-according to the world health organization standard, with myelodysplastic syndrome accompanied by cyclic iron granulomatous cells, characterized in that cyclic iron granulomatous cells are not less than 15%, or if SF3B1 mutation is present, cyclic iron granulomatous cells are not less than 5%, or are accompanied by myeloblasts < 5%;

-myelodysplastic syndrome with erythropoietin levels above 200U/L;

-having erythrocyte dysplasia;

-suffering from cytopenia, in particular peripheral cytopenia;

-myeloblasts < 5%;

-peripheral blood blast < 1%;

-myelodysplastic syndrome with concomitant chromosome 5q deletion (del [5q ]);

-SF3B1 mutant patient;

6. A compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to any one of the preceding claims, wherein the patient is characterized by

a) Showing detectable NTBI levels; and/or

b) Hb levels below 8g/dL; and/or

c) MCV is between 50 and 70 10 fl; and/or

d) MCH is between 12pg and 20 pg; and/or

e) TSAT levels > 45%.

7. The compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to any one of the preceding claims, wherein the patient to be treated is selected from transfusion dependent patients characterized by receiving regular transfusions comprising

8. The compound of formula (I) or a salt, solvate, hydrate, and polymorph thereof for use according to any one of the preceding claims, wherein the treatment comprises orally administering one or more of the compound of formula (I), a salt, solvate, hydrate, or polymorph thereof to a patient in need thereof.

9. The compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to any one of the preceding claims, wherein the treatment comprises administering to a patient in need thereof a dose of 5mg, 15mg, 60mg, 120mg or 240 mg; preferably, a dose of 120mg is administered to patients weighing > 50kg, and a dose of 60mg is administered to patients weighing < 50kg, once or twice a day.

10. A compound of formula (I) or a salt, solvate, hydrate and polymorph thereof for use according to any one of the preceding claims, wherein in formula (I)

n＝1；

R ³ =hydrogen;

R ⁴ =hydrogen;

A ¹ =methylene or ethane-1, 2-diyl;

A ² =methylene, ethane-1, 2-diyl or propane-1, 3-diyl;

or A ¹ And R is ² Together with the nitrogen atom to which they are bound, form an optionally substituted 4-membered ring, thereby forming a compound according to formula (II) or (III):

wherein in formulae (II) and (III)

l is 0 or 1;

m is an integer of 1,2 or 3, and

X ¹ 、X ² and R is ¹ Has the meaning as defined in claim 1.

11. The compound for use according to any one of the preceding claims, in the form of a pharmaceutically acceptable salt with an acid from the group consisting of benzoic acid, citric acid, fumaric acid, hydrochloric acid, lactic acid, malic acid, maleic acid, methanesulfonic acid, phosphoric acid, succinic acid, sulfuric acid, tartaric acid and toluenesulfonic acid,

Preferably in the form of salts with acids from citric acid, hydrochloric acid, maleic acid, phosphoric acid and sulfuric acid;

and their solvates, hydrates and polymorphs.

12. The compound for use according to any one of the preceding claims, wherein the compound of formula (I) is selected from:

preferably, the compound of formula (I) is selected from:

13. The compound for use according to any one of the preceding claims, and pharmaceutically acceptable salts, solvates, hydrates and polymorphs thereof, wherein the compound of formula (I) is selected from:

or a salt selected from the group consisting of:

a 1:1 sulfate salt having the formula

A 1:1 phosphate having the formula

A 1:3hcl salt having the formula

And polymorphs thereof.

14. A medicament comprising one or more of the compounds for use according to any one of the preceding claims 1 and 9 to 13, wherein the medicament further comprises one or more pharmaceutically carrier and/or adjuvant and/or solvent, and/or one or more additional pharmaceutically active compounds.

15. The compound of formula (I), or a salt, solvate, hydrate and polymorph thereof, as defined in any one of the preceding claims, for use in a combination therapy for the treatment of myelodysplastic syndrome, wherein the combination therapy comprises co-administration of a compound, including a salt, solvate, hydrate and polymorph thereof, as defined in any one of the preceding claims, with one or more other additional pharmaceutically active compounds,

Wherein co-administration of the combination therapy can be carried out as a fixed dose combination therapy by co-administration of a compound as defined in any one of the preceding claims, including salts, solvates, hydrates and polymorphs thereof, with one or more other additional pharmaceutically active compounds in a fixed dose formulation, or

Wherein co-administration of the combination therapy can be carried out in free dose combination therapy by co-administration of the individual compounds, including salts, solvates, hydrates and polymorphs thereof, and the one or more other additional pharmaceutically active compounds in free doses of the respective compounds, either simultaneously or by sequential use of the individual compounds administered over a period of time.