WO2019099651A1

WO2019099651A1 - Methods of using deuterated pyruvate kinase activators

Info

Publication number: WO2019099651A1
Application number: PCT/US2018/061255
Authority: WO
Inventors: Tao Liu; Zhihau Sui; Robert Zahler
Original assignee: Agios Pharmaceuticals, Inc.
Priority date: 2017-11-16
Filing date: 2018-11-15
Publication date: 2019-05-23

Abstract

Described herein are deuterated compounds and methods for using compounds that activate pyruvate kinase.

Description

METHODS OF USING DEUTERATED PYRUVATE KINASE ACTIVATORS

CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of ET.S. Provisional Patent Application No. 62/587,133, filed November 16, 2017, the entire contents of which are hereby incorporated herein by reference.

BACKGROUND

Pyruvate kinase deficiency (PKD) is one of the most common enzyme defects in erythrocytes in humans due to autosomal recessive mutations of the PKLR gene (Zanella, A., et al., Br J Haematol 2005, 130 (1), 11-25). It is also the most frequent enzyme mutation in the central glycolytic pathway and only second to glucose-6 phosphate dehydrogenase (G6PD) deficiency (Kedar, P., et al., Clin Genet 2009, 75 (2), 157-62) of the hexose monophosphate shunt.

Human erythrocytes are unique in that they anucleate when mature. Immature erythrocytes have nuclei but during early erythropoiesis prior to becoming circulating reticulocytes they extrude nuclei as well as other organelles such as mitochondria, endoplasmic reticulum, and Golgi apparatus, in order to make room for oxygen carrying hemoglobin. As a result of lacking mitochondria, mature red blood cells do not utilize any of the oxygen they transport to economically synthesize adenosine triphosphate (ATP) as other normal differentiated cells do. Instead, red blood cells depend entirely on anaerobic glycolysis to cycle nicotinamide adenine dinucleotide (NAD⁺) and to make ATP, an essential energy source largely used to drive ATPase- dependent K⁺/Na⁺ and Ca²⁺ pumps, in order to maintain cell membrane integrity and pliability as they navigate through blood vessels. In PKD disorder, two major distinctive metabolic abnormalities are ATP depletion and concomitant increase of 2,3-diphosphoglycerate consistent with accumulation of upper glycolytic

intermediates. Moreover, one of the consequences of decreased ATP and pyruvate levels is lowered lactate level leading to inability to regenerate NAD⁺ through lactate dehydrogenase for further use in glycolysis. The lack of ATP disturbs the cation gradient across the red cell membrane, causing the loss of potassium and water, which causes cell dehydration, contraction, and crenation, and leads to premature destruction and diminished lifetime of the red blood cells (RBCs). Such defective RBCs are destroyed in the spleen, and excessive hemolysis rate in the spleen leads to the manifestation of hemolytic anemia. The exact mechanism by which PKD sequesters newly matured RBCs in the spleen to effectively shorten overall half-lives of circulating RBCs is not yet clear, but recent studies suggest that metabolic

dysregulation affects not only cell survival but also the maturation process resulting in ineffective erythropoiesis (Aizawa, S. et al., Exp Hematol 2005, 33 (11), 1292-8).

Pyruvate kinase catalyzes the transfer of a phosphoryl group from

phosphoenolpyruvate (PEP) to ADP, yielding one molecule of pyruvate and one molecule of ATP. The enzyme has an absolute requirement for Mg²⁺ and K⁺ cations to drive catalysis. PK functions as the last critical step in glycolysis because it is an essentially irreversible reaction under physiological conditions. In addition to its role of synthesizing one of the two ATP molecules from the metabolism of glucose to pyruvate, pyruvate kinase is also an important cellular metabolism regulator. It controls the carbon flux in lower-glycolysis to provide key metabolite intermediates to feed biosynthetic processes, such as pentose-phosphate pathway among others, in maintaining healthy cellular metabolism. Because of these critical functions, pyruvate kinase is tightly controlled at both gene expression and enzymatic allostere levels. In mammals, fully activated pyruvate kinase exists as a tetrameric enzyme. Four different isozymes (Ml, M2, L and R) are expressed from two separate genes.

Erythrocyte-specific isozyme PKR is expressed from the PKLR gene (“L gene”) located on chromosome lq2l. This same gene also encodes the PKL isozyme, which is predominately expressed in the liver. PKLR consists of 12 exons with exon 1 is erythroid-specific whereas exon 2 is liver-specific. The two other mammalian isozymes PKM1 and PKM2 are produced from the PKM gene (“M gene”) by alternative splicing events controlled by hnRNP proteins. The PKM2 isozyme is expressed in fetal tissues and in adult proliferating cells such as cancer cells. Both PKR and PKM2 are in fact expressed in proerythroblasts. However, upon erythroid differentiation and maturation, PKM2 gradually is decreased in expression and progressively replaced by PKR in mature erythrocytes.

Clinically, hereditary PKR deficiency disorder manifests as non-spherocytic hemolytic anemia. The clinical severity of this disorder ranges from no observable symptoms in fully-compensated hemolysis to potentially fatal severe anemia requiring chronic transfusions and/or splenectomy at early development or during physiological stress or serious infections. Most affected individuals, who are asymptomatic, paradoxically due to enhanced oxygen-transfer capacity, do not require any treatment. However, for some of the most severe cases, while extremely rare population-wise with estimated prevalence of 51 per million (Beutler, E. Blood 2000, 95 (11), 3585-8), there is no disease-modifying treatment available for these patients other than palliative care (Tavazzi, D. et al., Pediatr Ann 2008, 37 (5), 303-10). These hereditary non-spherocytic hemolytic anemia (HNSHA) patients present a clear unmet medical need.

Heterogenous genetic mutations in PKR lead to dysregulation of its catalytic activity. Since the initial cloning of PKR and report of a single point mutation Thr³⁸⁴>Met associated with a HNSHA patient (Kanno, H. et al., Proc Natl Acad Sci U SA 1991, 88 (18), 8218-21), there are now nearly 200 different reported mutations associated with this disease reported worldwide (Zanella, A. et al., Br J Haematol 2005, 130 (1), 11-25; Kedar, P., et al., Clin Genet 2009, 75 (2), 157-62; Fermo, E. et al., Br J Haematol 2005, 129 (6), 839-46; Pissard, S. et al., Br J Haematol 2006, 133 (6), 683-9). Although these mutations represent wide range genetic lesions that include deletional and transcriptional or translational abnormalities, by far the most common type is missense mutation in the coding region that one way or another affects conserved residues within domains that are structurally important for optimal catalytic function of PKR. The pattern of mutation prevalence seems to be unevenly distributed toward specific ethnic backgrounds. For instance, the most frequent codon substitutions reported for North American and European patients appear to be

Arg⁴⁸⁶>Trp and Arg⁵¹⁰>Gln, while mutations Arg⁴⁷⁹>His, Arg⁴⁹⁰>Trp and Asp³³¹>Gly were more frequently found in Asian patients (Kedar, P., et al., Clin Genet 2009, 75 (2), 157-62).

Given that the effect of deuteration is unpredictable, variability in deuterium effects has also led experts to question or dismiss deuterium modification as a viable drug design strategy for inhibiting adverse metabolism (see Foster, A B, Adv Drug Res 1985, 14: 1-40 and Fisher, M B et al, Curr Opin Drug Discov Devel, 2006, 9: 101- 09). However, a potentially attractive strategy for improving a drug's metabolic properties is deuterium modification, especially at the metabolic sites of the drug. In this approach, one attempts to slow the CYP-mediated metabolism of a drug or to reduce the formation of undesirable metabolites by replacing one or more hydrogen atoms with deuterium atoms at the metabolic site of the drug. Deuterium is a safe, stable, non-radioactive isotope of hydrogen. Compared to hydrogen, deuterium forms slightly stronger bonds with carbon, which may impact pharmacokinetics of a drug with the potential for improved drug efficacy, safety, and/or tolerability, without affecting the biochemical potency and selectivity of the drug as compared to non- deuterated analog. This application provides for compounds that should have enhanced drug efficacy, safety, and/or tolerability in which deuterium atoms are introduced at various carbon atoms. SUMMARY OF THE INVENTION

In one aspect, provided is a compound or a pharmaceutically acceptable salt of formula (I):

wherein each of Ri and R₂ is independently hydrogen (H) or deuterium (D); m is 0, 1, 2, 3, 4, or 5; n is 0 or an integer from 1 to 8 inclusive; o is 0, 1, 2, 3, or 4; p is 0, 1, 2, or 3; and q is 0, 1, 2, or 3; provided that at least one of Ri and R₂ is D or at least one of m, n, o, p, and q is not zero.

In another aspect, provided is a pharmaceutical composition comprising a compound of formula (I) or a pharmaceutically acceptable salt thereof.

In yet another aspect, the present invention provides a method of evaluating a subject, the method comprising: administering to the subject a compound of formula (I); and acquiring a value for the level of the compound of formula (I), the level of 2,3-diphosphoglycerate (2,3-DPG), the level of adenosine triphosphate (ATP), or the activity of PKR in the subject, to thereby evaluate the subject.

In a further aspect, the present invention provides a method of treating a subject, the method comprising: administering to the subject a therapeutically effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier; and acquiring a value for the level of the compound of formula (I), the level of 2,3-diphosphoglycerate (2,3-DPG), the level of adenosine triphosphate (ATP), or the activity of PKR in the subject, to thereby treat the subject.

In another aspect, the present invention provides a method for treating pyruvate kinase deficiency (PKD) in a subject in need thereof, comprising

administering to the subject a therapeutically effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a

pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, to thereby treat PKD in the subject. DETAILED DESCRIPTION OF THE INVENTION

The details of construction and the arrangement of components set forth in the following description or illustrated in the drawings are not meant to be limiting.

Embodiments can be practiced or carried out in various ways. The skilled artisan would understand that the compounds of formula (I) is made of the following four fragments that are interconnected through direct bonds or linkers:

Therefore, the compound of formula (I) can be written as W-C(R_IR₂)-X-Y-S0₂-Z, wherein the points of attachment are: a is attached to -C(R_IR₂)-; b is attached to - C(R_IR₂)-; C is attached to d ; e is attached to -S0₂-; and /is attached to -S0₂-.

Further, the skilled artisan would understand that the orientation of the fragments match that of the structure of compound (I) such that, for example, the NH group of Fragment Y is connected to Fragment Z (via an S0₂ linker). Similarly, the artisan would understand that Fragment W is connected to N of Fragment X, which is also connected to Fragment Y via the carbonyl group.

In some embodiments, each of Ri and R₂ is H. In other embodiments, each of

Ri and R₂ is D. In a further embodiment, one of Ri and R₂ is D and the other is H.

In some embodiments, m is 0. In some embodiments, m is 1. In some embodiments, m is 2. In some embodiments, m is 4. In some embodiments, m is 5.

In other embodiments, n is 0 or an integer from 1 to 8 inclusive. In further embodiments, n is 0. In further embodiments, n is 2, 4, or 8.

In some embodiments, o is 0, 1, 2, 3, or 4. In further embodiments, o is 0, 2, or 4.

In some embodiments, each of p and q is independently 0, 1, 2, or 3. In further embodiments, p and q are the same and are 0, 1, 2, or 3. In further

embodiments, both p and q are 0. In further embodiments, both p and q are 1. In further embodiments, both p and q are 3. In further embodiments, one of p and q is 1 and the other is 0, 1, 2, or 3. In further embodiments, one of p and q is 3 and the other is 0, 1, 2, or 3. In further embodiments, one of p and q is 0 and the other is 0, 1, 2, or 3.

In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of formula:

or a pharmaceutically acceptable salt thereof, wherein m, n, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0,

4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is

0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is

0, 4 or 8; o is 0, 2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, n, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4; p is 0, 1,

2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0,

2, or 4; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0,

2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, n, o, p, and q are as defined herein, and wherein at least one of m, n, o, p, and q is not zero. In some

embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0,

1, or 3, and wherein at least one of m, n, o, p, and q is not zero. In further

embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3, and wherein at least one of m, n, o, p, and q is not zero. In further

embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3, and wherein at least one of m, n, o, p, and q is not zero. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; wherein at least one of m, n, o, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; wherein at least one of m, n, o, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4; p is 0, 1, 2, or

3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; wherein at least one of m, n, o, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is

0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0; wherein at least one of m, n, and o is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1.

In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 1; q is 0.

In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; p is 3; q is 3.

In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of one of the following formulae:

or a pharmaceutically acceptable salt thereof, wherein n, o, p, and q are as defined herein. In some embodiments, n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, n is 0, 4 or 8; o is 0,

2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein n, o, p, and q are as defined herein. In some embodiments, n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or

3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is

0, 1, 2, or 3. In further embodiments, n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, n is

0, 4 or 8; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, n is 0, 4 or 8; o is 0,

2, or 4; p is 3; q is 3.

2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein n, o, p, and q are as defined herein. In some embodiments, n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

0, 1, 2, or 3. In further embodiments, n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3. In further embodiments, n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, n is 0, 4 or 8; o is 0,

2, or 4; p is 3; q is 3.

2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein n, o, p, and q are as defined herein, and at least one of n, o, p, and q is not zero. In some embodiments, n is 0; 4, or 8; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3, and at least one of n, o, p, and q is not zero. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3, and at least one of n, o, p, and q is not zero. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of n, o, p, and q is not zero. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of n, o, p, and q is not zero. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of n, o, p, and q is not zero. In further embodiments, n is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of o, p, and q is not zero. In further embodiments, n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of n, p, and q is not zero. In further embodiments, n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of n, o, p, and q is not zero. In further embodiments, n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0; and at least one of n and o is not zero. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, n is 0, 4 or 8; o is 0,

2, or 4; p is 1; q is 0. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 3; q is

3.

In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of any one of the following formulae:

2, or 3. In further embodiments, n is 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3 In further embodiments, n is 8; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, n is 0, 4 or 8; o is 0, 2, or 4; p is 3; q is 3. In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of formula:

or a pharmaceutically acceptable salt thereof, wherein m, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

1, 2, or 3. In further embodiments, m is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3 In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3 In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3. In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

or a pharmaceutically acceptable salt thereof, wherein m, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3

In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3

or a pharmaceutically acceptable salt thereof, wherein m, o, p, and q are as defined herein; and at least one of m, o, p, and q is not zero. In some embodiments, m is 0, 1, 2, 4, or 5; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3; and at least one of m, o, p, and q is not zero. In further embodiments, m is 0, 1, or 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0,

1, 2, or 3; and at least one of o, p, and q is not zero. In further embodiments, m is 1; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; o is 0,

2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, o, p, and q is not zero.

In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, o, p, and q is not zero. In further embodiments, m is 0, 1,

2 or 4; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, o, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, o, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1,

2 or 4; o is 0, 2, or 4; p is 0; q is 0; and at least one of m and o, p is not zero. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 3; q is 3.

3 In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

or a pharmaceutically acceptable salt thereof, wherein m, o, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; o is 0, 2, or 4; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 0 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; o is 2 or 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; o is 0, 2, or 4; p is 3; q is 3. In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of formula:

or a pharmaceutically acceptable salt thereof, wherein m, n, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; p is 0, 1, or 3; q is

0, 1, or 3. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, m is 1; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3. In further embodiments, m is 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3. In further

embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or

4; n is 0, 4 or 8; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, n, p, and q are as defined herein; and at least one of m, n, p, and q is not zero. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; p is 0, 1, or 3; q is 0, 1, or 3; and at least one of m, n, p, and q is not zero. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, n, p, and q is not zero. In further embodiments, m is 0; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of n, p, and q is not zero. In further embodiments, m is 1; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1,

2, or 3. In further embodiments, m is 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3; and at least one of m, n, and q is not zero. In further

embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3; and at least one of m, n, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, n, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3; and at least one of m, n, p, and q is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 0; and at least one of m and n is not zero. In further

embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, n, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1,

embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or

3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 3; q is 3.

or a pharmaceutically acceptable salt thereof, wherein m, n, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is

0, 1, 2, or 3. In further embodiments, m is 0; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or

or a pharmaceutically acceptable salt thereof, wherein m, n, p, and q are as defined herein. In some embodiments, m is 0, 1, 2, 3, 4, or 5, n is 0 or an integer of 1-8 inclusive; p is 0, 2, or 3; and q is 0, 1, 2, or 3. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; p is 0, 1, or 3; q is 0, 1, or 3. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 1; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; n is 0, 4 or

8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; p is

0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 4; p is 0,

1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 8; p is 0, 1,

2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3.

In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 0; q is 1. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 1; q is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; p is 3; q is 3.

2, or 3. In further embodiments, m is 1; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 2; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 5; n is 0, 4 or 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 4; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 8; p is 0, 1, 2, or 3; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; q is 0, 1, 2, or 3. In further

or a pharmaceutically acceptable salt thereof, wherein m, n, and o are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4. In further

embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4.

embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4.

or a pharmaceutically acceptable salt thereof, wherein m, n, and o are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0; 4, or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4.

embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is

0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4.

or a pharmaceutically acceptable salt thereof, wherein m, n, and o are as defined herein. In some embodiments, m is 0, 1, 2, 4, or 5; n is 0, 4, or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4. In further

or a pharmaceutically acceptable salt thereof, wherein m, n, and o are as defined herein; wherein at least one of m, n, and o is not zero. In some embodiments, m is 0,

1, 2, 4, or 5; n is 0; 4, or 8; o is 0, 2, or 4; wherein at least one of m, n, and o is not zero. In further embodiments, m is 0, 1, or 2; n is 0, 4 or 8; o is 0, 2, or 4; wherein at least one of m, n, and o is not zero. In further embodiments, m is 0; n is 0, 4 or 8; o is 0, 2, or 4; wherein at least one of m, n, and o is not zero. In further embodiments, m is 1; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 2; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 5; n is 0, 4 or 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0; o is 0, 2, or 4; wherein at least one of m and o is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 4; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 8; o is 0, 2, or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0; wherein at least one of m and n is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0 or 4; wherein at least one of m, n, and o is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 2 or 4. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; wherein at least one of m, n, and o is not zero. In further embodiments, m is 0, 1, 2 or 4; n is 0, 4 or 8; o is 0, 2, or 4; wherein at least one of m, n, and o is not zero.

or a pharmaceutically acceptable salt thereof, wherein o is 0, 1, 2, 3, or 4. In some embodiments, o is 0, 2, or 4. In further embodiments, o is 2 or 4. In further embodiments, o is 0 or 2. In further embodiments, o is 0 or 4. In further

embodiments, o is 0. In further embodiments, o is 2. In further embodiments, o is 4.

In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of one of the following formula:

embodiments, o is 0. In further embodiments, o is 2. In further embodiments, o is 4. In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of formula:

embodiments, o is 0. In further embodiments, o is 2. In further embodiments, o is 4. In another embodiment, provided is a compound (or a pharmaceutical composition comprising the compound) of one of the following formulae

In certain embodiment, a preferred compounds include compound of formula

A or a pharmaceutically acceptable salt thereof:

In certain embodiment, a particularly preferred compounds include a compound of formula B or a pharmaceutically acceptable salt thereof:

In certain embodiment, a particularly preferred compound include compound of formula C or a pharmaceutically acceptable salt thereof:

In certain embodiment, a preferred compound include compound of formula D or a pharmaceutically acceptable salt thereof:

In certain embodiment, a preferred compounds include a compound of formula

E or a pharmaceutically acceptable salt thereof:

The phraseology and terminology used herein is for the purpose of description and should not be regarded as limiting. The use of“including,”“comprising,” or “having,”“containing”,“involving”, and variations thereof herein, is meant to encompass the items listed thereafter and equivalents thereof as well as additional items.

As used herein, the term“treat” means decrease, suppress, attenuate, diminish, arrest, or stabilize the development or progression of a disease/disorder ( e.g .., hereditary non-spherocytic hemolytic anemia; sickle cell anemia; thalassemia, e.g. beta-thalassemia; hereditary spherocytosis; hereditary elliptocytosis;

sbetalipoproteinemia; Bassen-Kornzweig syndrome; or paroxysmal nocturnal hemoglobinuria), lessen the severity of the disease/disorder (e.g, hereditary non- spherocytic hemolytic anemia; sickle cell anemia; thalassemia, e.g. beta-thalassemia; hereditary spherocytosis; hereditary elliptocytosis; sbetalipoproteinemia; Bassen- Kornzweig syndrome; or paroxysmal nocturnal hemoglobinuria) or improve the symptoms associated with the disease/disorder (e.g, e.g, hereditary non-spherocytic hemolytic anemia; sickle cell anemia; thalassemia, e.g. beta-thalassemia; hereditary spherocytosis; hereditary elliptocytosis; sbetalipoproteinemia; Bassen-Kornzweig syndrome; or paroxysmal nocturnal hemoglobinuria).

As used herein, an amount of a compound of formula (I) effective to treat a disorder, or a“therapeutically effective amount” refers to an amount of the compound which is effective, upon single or multiple dose administration to a subject, in treating a cell, or in curing, alleviating, relieving or improving a subject with a disorder beyond that expected in the absence of such treatment.

As used herein, the term“subject” is intended to mean human. Exemplary human subjects include a human patient (referred to as a patient) having a disorder, e.g. , a disorder described herein or a normal subject.

As used herein, the term“pharmaceutically acceptable salt” refers to those salts which are, within the scope of sound medical judgement, suitable for use in contact with the tissues of humans and lower animals without undue toxicity, irritation, allergic response and the like, and are commensurate with a reasonable benefit/risk ratio. A“pharmaceutically acceptable salt” means any non-toxic salt of a compound of this invention that, upon administration to a recipient, is capable of providing, either directly or indirectly, a compound of this invention.

Pharmaceutically acceptable salts are well known in the art. For example, S.

M. Berge, et al. describe pharmaceutically acceptable salts in detail in J.

Pharmaceutical Sciences , 1977, 66, 1-19, incorporated herein by reference.

Pharmaceutically acceptable salts of the compound of this invention include those derived from suitable inorganic and organic acids. Examples of pharmaceutically acceptable, nontoxic acid addition salts are salts of an amino group formed with inorganic acids such as hydrochloric acid, hydrobromic acid, phosphoric acid, sulfuric acid and perchloric acid or with organic acids such as acetic acid, oxalic acid, maleic acid, tartaric acid, citric acid, succinic acid or malonic acid or by using other methods used in the art such as ion exchange. Other pharmaceutically acceptable salts include adipate, alginate, ascorbate, aspartate, benzenesulfonate, benzoate, bisulfate, borate, butyrate, camphorate, camphorsulfonate, citrate, cyclopentanepropionate, digluconate, dodecyl sulfate, ethanesulfonate, formate, fumarate, glucoheptonate,

glycerophosphate, gluconate, hemisulfate, heptanoate, hexanoate, hydroiodide, 2- hydroxy-ethanesulfonate, lactobionate, lactate, laurate, lauryl sulfate, malate, maleate, malonate, methanesulfonate, 2-naphthalenesulfonate, nicotinate, nitrate, oleate, oxalate, palmitate, pamoate, pectinate, persulfate, 3-phenylpropionate, phosphate, picrate, pivalate, propionate, stearate, succinate, sulfate, tartrate, thiocyanate, p- toluenesulfonate, undecanoate, valerate salts, and the like.

As described herein, the pharmaceutically acceptable compositions of the invention additionally comprise a pharmaceutically acceptable carrier, adjuvant, or vehicle, which, as used herein, includes any and all solvents, diluents, or other liquid vehicle, dispersion or suspension aids, surface active agents, isotonic agents, thickening or emulsifying agents, preservatives, solid binders, lubricants and the like, as suited to the particular dosage form desired. Remington’s Pharmaceutical

Sciences, Sixteenth Edition, E. W. Martin (Mack Publishing Co., Easton, Pa., 1980) discloses various carriers used in formulating pharmaceutically acceptable compositions and known techniques for the preparation thereof. Except insofar as any conventional carrier medium is incompatible with the compound of the invention, such as by producing any undesirable biological effect or otherwise interacting in a deleterious manner with any other component(s) of the pharmaceutically acceptable composition, its use is contemplated to be within the scope of this invention. Some examples of materials which can serve as pharmaceutically acceptable carriers include, but are not limited to, ion exchangers, alumina, aluminum stearate, lecithin, serum proteins, such as human serum albumin, buffer substances such as phosphates, glycine, sorbic acid, or potassium sorbate, partial glyceride mixtures of saturated vegetable fatty acids, water, salts or electrolytes, such as protamine sulfate, disodium hydrogen phosphate, potassium hydrogen phosphate, sodium chloride, zinc salts, colloidal silica, magnesium trisilicate, polyvinyl pyrrolidone, polyacrylates, waxes, polyethylene-polyoxypropylene-block polymers, wool fat, sugars such as lactose, glucose and sucrose; starches such as corn starch and potato starch; cellulose and its derivatives such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; powdered tragacanth; malt; gelatin; talc; excipients such as cocoa butter and suppository waxes; oils such as peanut oil, cottonseed oil; safflower oil; sesame oil; olive oil; corn oil and soybean oil; glycols; such a propylene glycol or polyethylene glycol; esters such as ethyl oleate and ethyl laurate; agar; buffering agents such as magnesium hydroxide and aluminum hydroxide; alginic acid; pyrogen-free water; isotonic saline; Ringer’s solution; ethyl alcohol, and phosphate buffer solutions, as well as other non-toxic compatible lubricants such as sodium lauryl sulfate and magnesium stearate, as well as coloring agents, releasing agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the composition, according to the judgment of the formulator.

In another aspect, the invention features a pharmaceutical composition comprising the compound of the invention, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

The present invention further provides a method for increasing the lifetime of red blood cells (RBCs) in need thereof comprising contacting blood with an effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

In another aspect, the present invention provides a method of treating a subject, the method comprising: administering to the subject a therapeutically effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier; and acquiring a value for the level of the compound of formula (I), the level of 2,3-diphosphoglycerate (2,3-DPG), the level of adenosine triphosphate (ATP), or the activity of PKR in the subject, to thereby treat the subject.

In another aspect, the invention provides a method of treating a subject for a disorder, e.g ., hereditary non- spherocytic hemolytic anemia; sickle cell anemia;

thalassemia, e.g. beta-thalassemia; hereditary spherocytosis; hereditary elliptocytosis; sbetalipoproteinemia; Bassen-Kornzweig syndrome; or paroxysmal nocturnal hemoglobinuria, comprising administering to the subject an amount of the compound of formula (I) sufficient to provide a blood concentration of 2,3-DPG reduced by at least 15% relative to the reference standard (e.g, from about 15% to about 60%). In some embodiments, the blood concentration of 2,3-DPG is reduced by at least about 15%, by at least about 20%, by at least about 25%, by at least about 30%, by at least about 35%, by at least about 40%, by at least about 45%, by at least about 50%, by at least about 55%, by at least about 60%. In some embodiments, the method comprising orally administering to the subject a dose of about 10 mg to about 3000 mg, e.g ., about 10 mg to about 60 mg, about 60 mg to about 200 mg, about 200 mg to about 500 mg, about 500 mg to about 1200 mg, about 1200 mg to about 2000 mg, or about 2000 mg to about 3000 mg, e.g. , about 30 mg, about 120 mg, about 360 mg, about 700 mg, about 1400 mg, about 2500 mg, of the compound of formula (I). In some embodiments, the disorder is hereditary non-spherocytic hemolytic anemia. In some embodiments, the disorder is sickle cell anemia. In some embodiments, the disorder is thalassemia, e.g. , beta-thalassemia. In some embodiments, the disorder is hereditary spherocytosis. In some embodiments, the disorder is hereditary

elliptocytosis. In some embodiments, the disorder is abetalipoproteinemia. In some embodiments, the disorder is Bassen-Komzweig syndrome. In some embodiments, the disorder is paroxysmal nocturnal hemoglobinuria.

The present invention further provides a method for regulating 2,3- diphosphoglycerate levels, e.g. , reducing 2,3 -diphosphogly cerate levels, in blood in need thereof comprising contacting blood with an effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, to thereby treat PKD in the subject.

In another aspect, the present invention provides a method of activating pyruvate kinase in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of (1) the compound of formula (I) or a

pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, to thereby activate pyruvate kinase in the subject.

The present invention further provides a method for treating hereditary non- spherocytic hemolytic anemia comprising administering to a subject in need thereof a therapeutically effective amount of (1) the compound of formula (I) or a

pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

The present invention further provides a method for treating sickle cell anemia comprising administering to a subject in need thereof a therapeutically effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

The present invention further provides a method for treating diseases or conditions that are associated with increased 2,3 -diphosphogly cerate levels ( e.g ., liver diseases (Am J Gastroenterol, 1987;82(12): 1283) and Parkinson’s (J. Neurol,

Neurosurg, and Psychiatry 1976,39:952) comprising administering to a subject in need thereof a therapeutically effective amount of (1) the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

The present invention further provides a method for treating hemolytic anemia (e.g., chronic hemolytic anemia caused by phosphogly cerate kinase deficiency, Blood Cells Mol Dis, 2011; 46(3):206) comprising administering to a subject in need thereof a therapeutically effective amount of (1) the compound of formula (I) or a

The present invention further provides a method for treating thalassemia ( e.g ., beta-thalassemia), hereditary spherocytosis, hereditary elliptocytosis,

abetalipoproteinemia (or Bassen-Kornzweig syndrome), paroxysmal nocturnal hemoglobinuria, acquired hemolytic anemia (e.g., congenital anemias (e.g, enzymopathies)), or anemia of chronic diseases comprising administering to a subject in need thereof a therapeutically effective amount of the compound of formula (I) or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of formula (I) or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of formula (I) or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier.

The dosages and regimens suitable for using the compound of formula (I), which are described in U.S. Patent No. 8,785,450, are incorporated herein by reference in its entirety.

In some embodiments, the subject is administered the compound of formula (I) within a preselected period of less than 7 days, less than 6 days, less than 5 days, less than 4 days, less than 3 days, or less than 72 hours prior to the evaluation, e.g, less than 48 hours, less than 24 hours, less than 12 hours, less than 10 hours, less than 8 hours, less than 6 hours, less than 4 hours, less than 3 hours, less than 2 hours, less than 1.5 hours, less than 1 hour, less than 45 minutes, less than 30 minutes, or less than 15 minutes.

In some embodiments, the subject is administered the compound of formula (I), e.g, orally, a dose of about 10 mg to about 3000 mg, e.g, about 10 mg to about 60 mg, about 50 mg to about 300 mg, about 60 mg to about 200 mg, about 200 mg to about 500 mg, about 500 mg to about 1200 mg, about 1200 mg to about 2000 mg, or about 2000 mg to about 3000 mg, e.g, about 30 mg, about 120 mg, about 360 mg, about 700 mg, about 1400 mg, about 2500 mg, of the compound of formula (I).

In some embodiments, the subject is administered, e.g, orally, the compound of formula (I) once or twice daily. In some embodiments, the subject is administered the compound of formula (I), e.g, orally, twice daily, e.g, about every 12 hours. In some embodiments, the compound of formula (I) is administered to the subject at about 10 mg to about 1000 mg about every 12 hours, e.g, about 10 mg to about 60 mg about every 12 hours, about 60 mg to about 200 mg about every 12 hours, about 200 mg to about 500 mg about every 12 hours, about 500 mg to about 1000 mg about every 12 hours.

In some embodiments, the subject is administered the compound of formula (I), e.g ., orally, once daily, e.g. , about every 24 hours. In some embodiments, the compound of formula (I) is administered, e.g. , orally, to the subject at about 60 mg to about 200 mg about every 24 hours, e.g. , about 90 mg about every 24 hours, about 120 mg about every 24 hours, about 150 mg about every 24 hours, about 180 mg about every 24 hours, or about 200 mg about every 24 hours.

In some embodiments, the activity of PKR is acquired by analyzing the blood concentration of ¹³C-label in the blood. For example, ¹³C-labeled glucose is administered to a subject, and incorporated into certain glycolytic intermediates in the blood.

In some embodiments, the value for the level of the compound of formula (I) is acquired by analyzing the plasma concentration of the compound of formula (I).

In some embodiments, the method comprises activating one or more isozymes of pyruvate kinase, e.g. , one or more of pyruvate kinase R (PKR), pyruvate kinase M2 (PKM2) and/or pyruvate kinase L (PKL) isozymes.

In some embodiments, the method comprises activating wild type PKR isozyme and/or a mutant PKR isozyme.

In an embodiment, to increase the lifetime of the red blood cells, the compound of formula (I), composition or pharmaceutical composition described herein is added directly to whole blood or packed cells extracorporeally or be provided to the subject (e.g, the patient) directly (e.g, by i.p., i.v., i.m., oral, inhalation (aerosolized delivery), transdermal, sublingual and other delivery routes). Without being bound by theory, the compound of formula (I) increases the lifetime of the RBCs, thus counteract aging of stored blood, by impacting the rate of release of 2,3-DPG from the blood. A decrease in the level of 2,3-DPG concentration induces a leftward shift of the oxygen-hemoglobin dissociation curve and shifts the allosteric equilibrium to the R, or oxygenated state, thus producing a therapeutic inhibition of the intracellular polymerization that underlies sickling by increasing oxygen affinity due to the 2,3-DPG depletion, thereby stabilizing the more soluble oxy-hemoglobin. Accordingly, in one embodiment, the compound of formula (I) is useful as an antisickling agent. In another embodiment, to regulate 2,3 -diphosphogly cerate, e.g. reduce 2,3 -diphosphogly cerate levels, the compound of formula (I) is added directly to whole blood or packed cells extracorporeally or be provided to the subject (e.g, the patient) directly (e.g, by i.p., i.v., i.m., oral, inhalation (aerosolized delivery), transdermal, sublingual and other delivery routes).

When the compositions provided herewith comprise a combination of the compound of formula (I) and one or more additional therapeutic or prophylactic agents, both the compound and the additional agent should be present at dosage levels of between about 1 to 100%, and more preferably between about 5 to 95% of the dosage normally administered in a monotherapy regimen. The additional agents may be administered separately, as part of a multiple dose regimen, from the compounds provided herewith. Alternatively, those agents may be part of a single dosage form, mixed together with the compound of formula (I) in a single composition.

Lower or higher doses than those recited above may be required. Specific dosage and treatment regimens for any particular patient will depend upon a variety of factors, including the activity of the specific compound employed, the age, body weight, general health status, sex, diet, time of administration, rate of excretion, drug combination, the severity and course of the disease, condition or symptoms, the patient’s disposition to the disease, condition or symptoms, and the judgment of the treating physician.

Upon improvement of a patient’s condition, a maintenance dose of a compound, composition or combination provided herewith may be administered, if necessary. Subsequently, the dosage or frequency of administration, or both, may be reduced, as a function of the symptoms, to a level at which the improved condition is retained when the symptoms have been alleviated to the desired level. Patients may, however, require intermittent treatment on a long-term basis upon any recurrence of disease symptoms.

Patient Selection and Monitoring

The compound of formula (I) can activate wild type PKR and/or mutant PKRs. Some examples of the mutants that are activated by the compounds described herein include G332S, G364D, T384M, G37E, R479H, R479K, R486W, R532W, R510Q, I90N, and R490W. Accordingly, a patient and/or subject can be selected for treatment using the compound of formula (I) by first evaluating the patient and/or subject to determine whether the subject carries a mutation in PKR (for examples, one of the mutations as described herein), and if the subject is determined to be carrying a mutation in PKR thus is in need of activation of the activity of the mutant PKR, then optionally administering to the subject the compound of formula (I). A subject can be evaluated as carrying a mutation in PKR using methods known in the art. The subject can also be monitored, for example, subsequent to administration of the compound of formula (I). In embodiments, the subject can be monitored for evaluation of certain PK/PD parameters of the compound of formula (I) such as levels of the compound of formula (I), levels of 2,3-DPG, or levels of ATP.

EXAMPLES

The compound of formula (I) is prepared in accordance with any of Schemes 1-4, or combinations thereof.

Scheme 1 :

Scheme 2:

Scheme 2 illustrates various examples of the reaction between reagents of the formula W-C(L)R_IR₂ (described below in detail) and compound 8 to prepare a compound of formula (I), wherein L is a leaving group. The term“leaving group” is given its ordinary meaning in the art of synthetic organic chemistry and refers to an atom or a group capable of being displaced by a nucleophile. Examples of suitable leaving groups include, but are not limited to, halogen (such as F, Cl, Br, or I (iodine)), alkoxycarbonyloxy, aryloxycarbonyloxy, alkanesulfonyloxy, arenesulfonyloxy, alkyl- carbonyloxy ( e.g ., acetoxy), arylcarbonyloxy, aryloxy, methoxy, N,O- dimethylhydroxylamino, pixyl, and haloformates. In certain embodiments, the leaving group is halogen, alkanesulfonyloxy, arenesulfonyloxy, diazonium, alkyl diazenes, aryl diazenes, alkyl triazenes, aryl triazenes, nitro, alkyl nitrate, aryl nitrate, alkyl phosphate, aryl phosphate, alkyl carbonyl oxy, aryl carbonyl oxy, alkoxcarbonyl oxy, aryoxcarbonyl oxy ammonia, alkyl amines, aryl amines, hydroxyl group, alkyloxy group, or aryloxy. In some cases, the leaving group is a sulfonic acid ester, such as toluenesulfonate (tosylate, -OTs), methanesulfonate (mesylate, -OMs), p- bromobenzenesulfonyloxy (brosylate, -OBs), -0S(=0)₂(CF₂)₃CF₃ (nonaflate, -ONf), or trifluoromethanesulfonate (triflate, -OTf). In some cases, the leaving group is a brosylate, such as / bromobenzenesulfonyloxy. In some cases, the leaving group is a nosylate, such as 2-nitrobenzenesulfonyloxy. In some embodiments, the leaving group is a sulfonate-containing group. In some embodiments, the leaving group is a tosylate group. In some embodiments, the leaving group is halogen. In some embodiments, the leaving group is bromide (see J. Med. Chem., 2005, 48(26), 8261-8265). In some embodiments, the leaving group is iodide. A variety of W-C(L)R_IR₂ compounds can be prepared from any of the undeuterated and partially or fully deuterated

cyclopropane carboxylic acids and aldehydes that are known in the art.

Scheme 3 :

Many deuterated and un-deuterated intermediate compounds for preparing the compound of formula (I) are known in the art. The skilled artisan can prepare any desired deuterated starting material that is not available commercially or not described in scientific literature.

Fragment Z

Table 1 provides exemplified starting materials for introducing Fragment Z:

Table 1.

Partially or fully deuterated and undeuterated quinolines may be converted to partially or fully deuterated or undeuterated quinoline-8-sulfonyl chloride in accordance with Scheme 5:

Scheme 5:

Fragment Y

Table 2 provides exemplified starting materials for introducing Fragment Y:

via an ester of 4-aminobenzoic acid, or a partially or fully deuterated form thereof. The esters can be prepared from the corresponding 4-aminobenzoic acid as below.

Table 2.

Additionally, undeuterated, partially deuterated or fully deuterated 4- aminobenzoic acid ethyl esters can be prepared from reducing the corresponding 4- nitrobenzoic acid ethyl esters as in the following scheme (see JP 2012046513 and WO 2010090299 where o is 4):

Fragment X

Table 3 provides exemplified starting materials for introducing Fragment X:

via a protected piperazine or its partially or fully deuterated form. The skilled artisan can design a protection scheme for introducing piperazine into the compound of formula (I) in accordance with Scheme 1 or an alternative scheme thereof. For example, Boc-protected and benzyl protected piperazines may be suitable. Boc protecting group may be introduced into piperazine in accordance with the reaction below (as disclosed in US 20160151362): Boc

Some Boc or benzyl protected piperazines are commercially available. The following undeuterated, partially deuterated, or fully deuterated piperazine compounds are commercially available or are known in the literature (Table 3). Table 3.

Fragment W

Fragment W may be introduced into the compound of formula (I) via undeuterated, partially deuterated or fully deuterated cyclopropane carbaldehyde.

(Fragment W)

Undeuterated, partially deuterated and fully deuterated cyclopropanecarboxylic acid are commercially available or are known in the art. For example, Fragment W may be introduced into the compound of formula (I) via a reaction between

(W-C(L)R_IR₂),

wherein L is a leaving group as defined herein (such as a halogen), and the amino group from Fragment X. For example,

to obtain a compound of formula (I). In some embodiments, L may be a halogen (e.g. Br or I). For example, using a commercially available bromomethyl cyclopropane (from Sigma Aldrich) or deuterated bromomethyl cyclopropane (from Alfa Chemistry Product List or Aurora Screening Library), the following compound may be prepared.

Si Ald i h

Commerically available from

Alfa Chemistry Product List

Commerically available from

Aurora Screening Library

Other W-C(L)R_IR₂ compounds suitable to introduce Fragment W in the compound of formula (I) (wherein L is a leaving group) are known in the literature, are commercially available, or may be prepared in accordance with the following schemes. For example, as described in Heterocycles, 27(7), 1595-8; 1988, cyclopropane carboxylic acid may be reduced to its corresponding aldehyde using a conventional reducing reagent:

Boranes, such as 9-BBN (i.e., 9-borabicyclo(3.3. l)nonane), are prepared by hydroboration of an alkene (such as l,5-cyclooctadiene in the case of 9-BBN) in an ether solvent. Use of deuteroborane (i.e., BD₃, known from US20070197695 and commercially available from Katchem) instead of borane (i.e., B¾) should produce deuteriated 9-BBN. Use of deuterated 9-BBN in the reduction of cyclopropane carboxylic acid can be expected to introduce a deuterium atom on the aldehyde carbon:

deutrated

The aldehyde can then be reduced to a corresponding alcohol (with or without an additional deuteration) in accordance with Journal of the American Chemical Society, 112(8), 3156-62; 1990. The hydroxyl group of the OH group of the so- obtained alcohol can then be converted to a leaving group. For example, the OH group may be converted to a perfluoroalkyl sulfonate (i.e., triflate), halide (such as iodide, bromide or chloride), tosylate, or mesylate (or methanesulfonate or methanesulfonyl ester) using standard methods. For example, the alcohol may be reacted with methanesulfonyl chloride (MsCl) in accordance with:

UAID₄ (D)m OH (D)m OMS

E _H MsCl, pyridine D _H

Et₂0

D or

^^(D)m LiAID₄ (D)m OH MsCl, pyridine (^D)m OMS

P>— CDO

Et₂0 C^c ₂ C^cb₂

The resultant methanesulfonyl ester contains one or two deuterium atoms at the hydrogen/deuterium that would correspond to Ri and R₂ of the compounds of formula (I):

(D)m OMs

Alternatively, a cyclopropane carboxylic acid may be directly reduced to an alcohol followed by conversion of the alcohol to a W-C(L)R_IR₂ compound. For example, the alcohol may be converted to the corresponding methane sulfonyl ester as described in Journal of the American Chemical Society, 112(8), 3156-62; 1990:

(D)_mOMs

>~CH₂

If a deuterated reducing agent (such as LiAlD₄) is used, both hydrogens connected to the alcohol carbon may be deuterium atoms.

, , LiAID₄ /(D)m MsCI, pyridine /(^)m l^^c°^2H _Et2Q - [ -C(D)₂OH - - -► D>-C(D)₂OMS

The skilled artisan can also convert undeuterated, partially deuterated and fully deuterated cyclopropanecarboxylic acid to the corresponding aldehyde or deutero aldehyde (i.e., a compound in which a deuterium atom is bonded to the aldehyde carbonyl) using Rosenmund’s method in which an acyl halide of the

cyclopropanecarboxylic acid is subjected to hydrogenolysis reaction with palladium- on-barium sulfate catalyst. To prepare deutero aldehyde from

cyclopropanecarboxylic acid, deuterium gas may be used in the hydrogenolysis reaction. In the event that the reaction goes through a mechanism that involved Pd-H bond formation, use of deuterated solvent and hydrogen gas may be sufficient to produce deutero aldehyde.

The Rosenmund reduction ordinarily uses hydrogen (or deuterium) in the presence of a supported Pd catalyst. Although alcohol is produced as a by-product (as the result of the subsequent reduction of the aldehyde), the skilled artisan would understand that the reduction of the desired aldehyde to the alcohol by-product can be minimized by using a catalyst poison or regulator, which deactivates the catalyst for the desired reaction and renders the repeated use of the catalyst difficult. It may be possible to obtain very high selectivities to the aldehyde even in the absence of a regulator, provided that the temperature employed is about 30-40 °C and the reduction is carried out at atmospheric pressure, at which the rate of hydrogenolysis is acceptable. The use of deuterium as the reducing gas or judicial choice of solvent will allow the artisan to introduce hydrogen or deuterium on the aldehyde carbon. The coupling reaction of the cyclopropane carbaldehyde with the free amine on the piperizine group as shown in Scheme 1 introduces a hydrogen/deuterium to the carbon connected to the cyclopropane of Fragment W (i.e., the carbonyl carbon in the aldehyde which eventually become the -CR_IR₂- group of the compound of formula (I)). The skilled artisan would know how to choose proper deuterating reagents (instead of hydrogenating reagents) to introduce deuterium to the carbon connected to the cyclopropane of Fragment W. For example, using sodium acetoxy borodeuteride and deuterated acetic acid will introduce a deuterium to the carbon connected to the cyclopropane of Fragment W.

Therefore, the skilled artisan would know how to prepare the compound

in which m is 0, 1, 2, 3, 4, or 5, Ri and R₂ are independently H or D; and L is a leaving group such as mesylate, halogen, tosylate, triflate, etc. Table 4 lists commercially available undeuterated, partially deuterated and fully deuterated cyclopropanecarboxylic acids and the fragment on the compound of formula (I) to which they can be converted.

Table 4.

The exemplary schemes above depict a representative syntheses of certain compounds described herein. In Scheme 1, sulfonyl chloride 1 is reacted with amine 2 under standard coupling conditions to produce ester 3. Hydrolysis of 3 using lithium hydroxide generates carboxylic acid 4. Piperazine (5) is reacted with 4 in the presence of a coupling reagent to provide 7. Piperazine derivative 7 is deprotected to produce piperazine derivative 8. Cyclopropane carbaldehyde 9 is then treated with piperazine derivative 8 to produce final compound, which is the compound of formula

(I)·

Scheme 2 depicts how various W-C(L)R_IR₂ compounds are reacted with compound 8 to produce a compound of formula (I).

In Scheme 4, the compound of formula (I) is prepared by reacting carboxylic acid 4 with compound 13. In accordance with Scheme 3, compound 13 is prepared by reacting cyclopropane carbaldehyde 11 with Boc-protected piperazine 5.

Cyclopropane carbaldehyde 11 is in turn prepared by reducing cyclopropane carboxylic acid 10. Regardless of which scheme is followed, the skilled artisan would appreciate that the degree of deuteration and where any deuterium atom present in the compound of formula (I) may be located depends on the choice of starting materials (sulfonyl chloride 1, amine 2, piperizine 5, and carboxylic acid 10) and the reaction conditions for reducing cyclopropane carboxylic acid 10 to cyclopropane carbaldehyde 9 or cyclopropylmethanol 11 and the reaction between carbaldehyde 9 or

cyclopropylmethanol 11 (or its derivative) with piperazine 5 or piperazine derivative 8.

Exemplary starting materials (sulfonyl chloride 1, amine 2, piperizine 5, and carboxylic acid 10) are described in Tables 1-4. For example, Table 1 lists a number of quinolines with various degrees of deuteration and how the compounds may be obtained. Each of the quinoline described in Table 1 may be coupled with any of the other starting materials described in Tables 2-4 to prepare a compound of formula (I). Similarly, Table 2 provides details of some of the aminobenzoic acids with various degrees of deuteration and how the compounds may be obtained. Any of the aminobenzoic acids described in Table 2 may be used to prepare a compound of formula (I) using any of the other starting materials described in Tables 1, 3, and 4. Further, Table 3 provides details of some of the piperazines suitable for the preparation of the compound of formula (I), with various degrees of deuteration and how the compounds may be obtained. Any of the piperazines described in Table 3 and any of the other starting materials described in Tables 1, 2, and 4 may be used to prepare a compound of formula (I) with the desired deuteration. Additionally, Table 4 provides details of some of the cyclopropane carboxylic acids suitable for the preparation of the compound of formula (I), with various degrees of deuteration and how the compounds may be obtained. Any of the cyclopropanecarboxylic acids described in Table 4 and any of the other starting materials described in Tables 1-3 may be used to prepare a compound of formula (I) with the desired deuteration.

With regard to the reaction conditions that may introduce one or more deuterium atoms, the skilled artisan would appreciate that cyclopropane carboxylic acid 10 may be reduced to the corresponding carbaldehyde 9 in which the aldehyde carbon is hydrogenated (or deuterated) as described by Thompson A.F. and Cromwell N.H.“The Preparation and Properties of Aldehydes containing Deuterium in the Functional Group,” J Am. Chem. Soc., 1939, 61 (6), pp 1374-1376. Thus, in accordance with the method by Thompson and Cromwell, the skilled artisan may convert a cyclopropane carboxylic acid (with any level of deuteration) to the corresponding aldehyde in which the aldehyde carbonyl is hydrogenated or deuterated.

The reaction of carbaldehyde 9 with piperazine 5 or piperazine derivative 8 involves use of a reducing agent such as sodium tri-acetoxy borohydride in the presence of acetic acid (see Schemes 1 and 3). The skilled artisan would understand that use of sodium tri-acetoxy borodeutride and deuterated acetic acid would introduce a deuterium atom in a position corresponding to Ri or R₂ of the compound of formula (I). The skilled artisan would appreciate that sodium tri-acetoxy borodeutride may be prepared similar to how sodium tri-acetoxy borohydride is commonly prepared— i.e., reacting NaBD₄ with acetic acid.

As can be appreciated by the skilled artisan, methods of synthesizing the compounds of the formulae herein will be evident to those of ordinary skill in the art. Additionally, the various synthetic steps may be performed in an alternate sequence or order to give the desired compounds. Synthetic chemistry transformations and protecting group methodologies (protection and deprotection) useful in synthesizing the compounds described herein are known in the art and include, for example, those such as described in R. Larock, Comprehensive Organic Transformations , VCH Publishers (1989); T.W. Greene and P.G.M. Wuts, Protective Groups in Organic Synthesis , 2d. Ed., John Wiley and Sons (1991); L. Fieser and M. Fieser, Fieser and Fieser's Reagents for Organic Synthesis , John Wiley and Sons (1994); and L.

Paquette, ed., Encyclopedia of Reagents for Organic Synthesis , John Wiley and Sons (1995), and subsequent editions thereof.

The skilled artisan will recognize that some variation of natural isotopic abundance occurs in a synthesized compound depending upon the origin of chemical materials used in the synthesis. Thus, a preparation of undeuterated compound of formula (I) contains deuterium atoms at the natural abundance. The skilled artisan would consider that the concentration of naturally abundant stable hydrogen to be small and immaterial as compared to the degree of stable isotopic substitution of compounds of this invention. See, for instance, Wada, E et ak, Seikagaku, 1994,

66: 15; Gannes, L Z et ak, Comp Biochem Physiol Mol Integr Physiol, 1998, 119:725. In the compounds of this invention any atom not specifically designated as a particular isotope is meant to represent any stable isotope of that atom. Unless otherwise stated, when a position is designated specifically as "H" or "hydrogen", the position is understood to have hydrogen at its natural abundance isotopic composition. As used herein,“D” refers to deuterium (²H). In the compound of the invention, the positions designated specifically as“D” or“deuterium” shall be understood to have an isotopic enrichment factor for each designated deuterium atom of at least 3000.

Based on the natural abundance of deuterium (about 0.015%), an isotopic enrichment factor of at least 3000 corresponds to at least 45% deuterium incorporation.

As used herein, the term“isotopic enrichment factor” refers to the ratio between the isotopic abundance of a given isotope at a designated position of a compound and the natural abundance of that isotope. The skilled artisan would understand how to prepare compounds with varying degrees of isotopic enrichment at a particular hydrogen atom. For example, the artisan could use various ratios of mixtures of compounds in which, at the hydrogen of interest, one compound is fully deuterated and the other compound fully hydrogenated (of course, with deuterium being present at its natural abundance). Therefore, any level of desired enrichment can be prepared by the skilled artisans.

In some embodiments, the positions designated specifically as“D” or “deuterium” in the compound of the invention shall be understood to have an isotopic enrichment factor for each designated deuterium atom of at least 3500 (52.5% deuterium incorporation), at least 4000 (60% deuterium incorporation), at least 4500 (67.5% deuterium incorporation), at least 5000 (75% deuterium incorporation), at least 5500 (82.5% deuterium incorporation), at least 6000 (90% deuterium

incorporation), at least 6333 (95% deuterium incorporation), or at least 6600 (99% deuterium incorporation.

The compound of formula (I) contains carbon atom that may be asymmetric, depending on substitution on the cyclopropyl ring. Deuteration of the compound may introduce additional asymmetric carbon atoms. As such, the present invention contemplates that compounds of this invention can exist as either individual enantiomers and diastereomers, or mixtures thereof. Accordingly, a compound of the present invention may exist as either a racemic mixture or a scalemic mixture, or as individual respective stereoisomers that are substantially free from another possible stereoisomer. The term "substantially free of other stereoisomers" as used herein means less than 25% of other stereoisomers, preferably less than 10% of other stereoisomers, more preferably less than 5% of other stereoisomers and most preferably less than 2% of other stereoisomers are present. Methods of obtaining or synthesizing an individual enantiomer or diastereomer for a given compound are known in the art and may be applied as practicable to final compounds or to starting material or intermediates.

Example 1. Synthesis of undeuterated compound of Formula (I)

The synthesis of an undeuterated compound of formula (I) is carried out following the procedure described in U.S. Patent No. 8,785,450, which is

incorporated herein by reference in its entirety.

General procedure for Compound 1: Undeuterated, partially deuterated or fully deuterated quinolines may be converted to undeuterated, partially deuterated, or fully deuterated quinoline-8-sulfonyl chloride in accordance with Scheme 5:

Scheme 5:

As described in JP2005139149, quinoline-8-sulfonyl chloride is obtained in high purity by reacting quinoline with chlorosulfonic acid until quinoline substantially disappears to afford a mixture of a sulfonated material of quinoline with a

chlorosulfonated material of quinoline. Reacting the mixture of sulfonated material of quinoline and chlorosulfonated material of quinoline with thionyl chloride in the presence or absence of dimethylformamide affords the desired quinoline-8-sulfonyl chloride. The skilled artisan would expect that partially and fully deuterated quinolines would behave similar to undeuterated quinoline and the procedure above would produce the corresponding partially or fully deuterated quinoline-8-sulfonyl chloride (Compound 1).

General procedure for Compound 3: Compound 1 may be reacted with Compound 2 in the presence of a non-nucleophilic base (such as pyridine) in a moderately polar solvent (such as DCM) at room temperature. The reaction between sulfonyl chlorides (such Compound 1) and amines (such Compound 2) are well known in the art and the skilled artisan would be able to prepare Compound 3. It is noted that Scheme 1 does not specify the level of deuteration and that the skilled artisan would understand that both Compound 1 and 2 may be undeuterated, partially deuterated or fully deuterated, producing undeuterated, partially deuterated or fully deuterated Compound 3.

General procedure for Compound 4: Undeuterated, partially deuterated or fully deuterated ethyl 4-(quinoline-8-sulfonamido)benzoate (Compound 3) may be converted to Compound 4 by hydrolyzing the ester functionality in the presence of a base or an acid. For example, reacting Compound 3 (0.0014 moles, 1 eq) in THF- H₂0 (1 : 1, 30 mL/30 mL) with LiOH.H₂0 (0.293 g, 0.007 moles, 5 eq) should produce Compound 4. The reaction may require stirring at reflux for overnight. The skilled artisan would understand how to isolate Compound 4 from the reaction mixture. For example, after completion of the starting material, the solvent may be removed under reduced pressure to obtain the crude product. The crude product may be washed with ethyl acetate. The aqueous layer may be acidified with citric acid (pH = 4) and extracted again with ethyl acetate (2 ^c 25 mL). The combined organic layer may be dried over Na₂S0₄ and concentrated under reduced pressure. The resultant acid may further be washed with hexane to get substantially pure compound 4.

General procedure for Compound 7: The skilled artisan would understand how to convert undeuterated, partially deuterated or fully deuterated Compound 4 to an undeuterated, partially deuterated or fully deuterated Compound 7. For example, a solution of Compound 4, (0.00074 moles, 1 eq) in DMF (25 mL), 1.1 eq of a coupling agent (such as EDCI , HOBt or PyBop), and DIPEA (0.48 mL, 0.0026 moles, 3.5 eq) are added at 0°C and stirred for 15 minutes. A solution of Boc- protected piperizine (Compound 5, 0.00074 moles, 1 eq) is then added at 0°C and then the resulting mixture is allowed to stir at room temperature for overnight. After completion of the reaction, water (30 mL) is added and extracted with ethyl acetate (2x30 mL). The combined organic layer is dried over anhydrous Na₂S0₄ and concentrated under reduced pressure. The crude product is dissolved in EtOAc and to this pentane is added to yield compound 7.

General procedure for Compound 8: In a two neck RB flask, Compound 7

(0.00205 moles, 1 eq) is treated with methanolic-HCl at between 0°C and RT. The resulting mixture is stirred for overnight. After completion of the starting material as indicated by TLC, solvent is removed under reduced pressure and a solid material is obtained. The solid material is washed with ethyl acetate and dried to obtain the amine compound 8 .

General procedure for the synthesis of Compound of formula (I):

To a solution of amine Compound 8 (0.25 mmoles) and aldehyde 9 (0.27 mmol) in DCM, acetic acid (0.2 mL) is added at room temperature and the resulting mixture is allowed to stir for 30 min. Then sodium tri-acetoxy borohydride (STAB) (0.26 gm, 1.26 mmol) is added to reaction mixture and the resulting mixture is allowed to stir at 50 °C for 1 hr. After completion of reaction, the crude mixture is diluted with DCM, washed with water, dried over Na₂S0₄ and concentrated under reduced pressure. The residue is purified by column chromatography to afford compound of formula (I). General procedure for the synthesis of Compound 11

A pressure vessel is charged with 60 mL dry toluene, 0.030 mole of anhydrous sodium acetate, 0.3 g. of dry, 10% palladium-on-carbon catalyst, 0.010 moles of cyclopropane carboxylic acid chloride (prepared from Compound 10 in a method known to the skilled artisans), and 0.1 mL of Quinoline S. The pressure vessel is flushed with nitrogen, sealed, evacuated briefly, and pressured to 50 p.s.i. with hydrogen (or deuterium). The mixture is shaken with 50 p.s.i. of hydrogen (or deuterium) for 1 hour at room temperature, then heated at 35-40° for 2 hours.

Agitation is continued overnight while the reaction mixture cools to room

temperature. The pressure on the vessel is released, the vessel is opened, and the mixture is filtered through 10 g. of Celite filter aid, and the insoluble material is washed with 2.5 ml. of toluene. The combined filtrates are washed successively with 2.5 ml. of 5% sodium carbonate solution and 2.5 ml. of water. The toluene solution is dried over 0.5 g. of anhydrous sodium sulfate and filtered. The filtrate is concentrated by distillation at reduced pressure using a water aspirator. The residue is distilled through a lO-cm. Vigreux column with warm water circulating through the condenser, to prevent crystallization of the distillate, obtaining Compound 10.

General procedure for Compound 12: The skilled artisan would understand how to convert undeuterated, partially deuterated or fully deuterated Compound 11 to an undeuterated, partially deuterated or fully deuterated Compound 12. For example, a solution of Compound 11, (0.00074 moles, 1 eq) in DMF (25 mL), 1.1 eq of a coupling agent (such as EDCI , HOBt or PyBop), and DIPEA (0.48 mL, 0.0026 moles, 3.5 eq) are added at 0°C and stirred for 15 minutes. A solution of Boc- protected piperizine (Compound 5, 0.00074 moles, 1 eq) is then added at 0°C and then the resulting mixture is allowed to stir at room temperature for overnight. After completion of the reaction, water (30 mL) is added and extracted with ethyl acetate (2x30 mL). The combined organic layer is dried over anhydrous Na₂S0₄ and concentrated under reduced pressure. The crude product is dissolved in EtOAc and to this pentane is added to yield compound 11.

General procedure for Compound 13: In a two neck RB flask, Compound 12

(0.00205 moles, 1 eq) is treated with methanolic-HCl at between 0°C and RT. The resulting mixture is stirred for overnight. After completion of the starting material as indicated by TLC, solvent is removed under reduced pressure and a solid material is obtained. The solid material is washed with ethyl acetate and dried to obtain the amine compound 13 .

General procedure for the compound of formula (I): The skilled artisan would understand how to convert undeuterated, partially deuterated or fully deuterated Compound 4 to an undeuterated, partially deuterated or fully deuterated compound of formula (I). For example, a solution of Compound 4, (0.00074 moles, 1 eq) in DMF (25 mL), 1.1 eq of a coupling agent (such as EDCI , HOBt or PyBop), and DIPEA (0.48 mL, 0.0026 moles, 3.5 eq) are added at 0°C and stirred for 15 minutes. A solution of Compound 13 (0.00074 moles, 1 eq) is then added at 0°C and then the resulting mixture is allowed to stir at room temperature for overnight. After completion of the reaction, water (30 mL) is added and extracted with ethyl acetate (2x30 mL). The combined organic layer is dried over anhydrous Na₂S0₄ and concentrated under reduced pressure. The crude product is dissolved in EtOAc and to this pentane is added to yield the compound of formula (I).

General procedure for the compound of formula (I): The skilled artisan would understand how to convert undeuterated, partially deuterated or fully deuterated Compound 8 to an undeuterated, partially deuterated or fully deuterated compound of formula (I). For example, Compound 8 may be reacted with compound W-C(L)R_IR₂ (such as compound 9a, 9b, 9c, 9d, 9e, 9f, and 9g) under conditions that would allow substitution of the leaving group on W-C(L)R_IR₂ by the nitrogen of the piperizine group of compound 8. After completion of the reaction, water (30 mL) is added and extracted with ethyl acetate (2x30 mL). The combined organic layer is dried over anhydrous Na₂S0₄ and concentrated under reduced pressure. The crude product is dissolved in EtOAc and to this pentane is added to yield the compound of formula

(I)·

Table 5 lists compounds that may be prepared in accordance with the schemes and examples discussed above. When a number in Table 5 is defined as being equal to D (e.g., l2,l4=D in compound 33) , the number corresponds to a D on carbon atoms 12 and 13 as numbered in the generic compound drawn below:

For example, compound 33 requires that in fragment W, m is 4 and that carbon atoms 12 and 13 are substituted with D. Similarly, compound 72 requires that, in Fragment Y, o is 2 and that carbon atoms 7 and 10 are substituted with D. Compound 72 also requires that, in Fragment Z, q is 1 and that D is substituted on carbon number 3. Compound 72 also requires that, in fragment W, m is 4 and that carbon atoms 12 and 13 are substituted with D. W, X, Y, and Z refer to fragments as drawn in the compound above and as used throughout this application.

Table 5:

Example 2. PKR Mutant Assay

Procedure :

• PKR or PKR mutant enzyme solution is diluted in assay buffer.

• 2 pL of test compound is added into wells first, and then 180 pL reaction mix is added.

• Reactions mixture with test compound is assembled except for ADP, and plates are stored for 60 minutes at room temperature.

• 20 uL ADP is added to start reaction at room temperature and reaction

progress is measured as changes in absorbance at 340nm wavelength at room temperature.

Test compound preparation.

• Test compound stock is made at lOOx concentration in 100% DMSO (lOmM)

• 1 to 3 dilutions are made for 11 points (i.e. 50pl of first concentration is added to lOOpl 100% DMSO to yield 3.33mM, 50pl of this is added to lOOpl DMSO to yield 1.1 lmM, and so forth)

• 1 to 100 dilution into assay (2pl in 200pl) yields starting concentration of lOOpM, decreasing 3 fold for 11 points.

Assay Buffer: 100 mM KC1, 50 mM Tris 7.5, 5 mM MgCl2, 1 mM DTT, 0.03% BSA

Reaction Mixture : PKR mutant enzyme: 80-400 ng/well; ADP: 0.22-1.65 mM; PEP:

0.1-0.5 mM; NADH: l80 uM; LDH: 0.5 units (Sigma# 59023); DTT: 1 mM; BSA:

0.03%.

Example 3. PKR WT Single Point Percent Activation Assay

A compound described herein is diluted with DMSO and tested at 1 mM concentration. The enzyme is diluted in IX Buffer: (100 mM KC1, 50 mM Tris 7.5, 5 mM MgCl₂, 1 mM DTT, 0.03% BSA). 2 pL of compound solution is first added into wells, and then 180 pL of enzyme solution is added. Assays are assembled except for ADP, and plates are stored for 60 minutes at RT. 20 pL ADP is added to start the assay and assay output is evaluated using OD340 at SpectraMax. The assay is run at room temperature. Final concentration: PKR wt (100 ng/well), Tris pH 7.5 (50 mM), KC1 (100 mM), MgCl₂ (5 mM), ADP (0.48 mM), PEP (0.15 mM), NADH (180 mM), LDH (0.5 units, Sigma 59023), DTT (1 mM) and BSA (0.03%).

Example 4. PKR R510Q Single Point Percent Activation Assay

A compound described herein is diluted with DMSO and tested at ImM concentration. The enzyme is diluted in IX Buffer: (100 mM KC1, 50 mM Tris 7.5, 5 mM MgCl₂, 1 mM DTT, 0.03% BSA). 2 pL of compound solution is first added into wells, and then 180 pL of enzyme solution is added. Assays are assembled except for ADP, and plates are stored for 60 minutes at RT. 20 pL ADP is added to start the assay and assay output is evaluated using OD340 at SpectraMax. The assay is run at room temperature.

Final concentration: PKR R510Q (40 ng/well), Tris pH 7.5 (50 mM), KC1 (100 mM), MgCl₂ (5 mM), ADP (0.2 mM), PEP (0.11 mM), NADH (180 mM), LDH (0.5 units, Sigma 59023), DTT (1 mM) and BSA (0.03%).

Example 5. PKR R532W Single Point Percent Activation Assay

A compound described herein is diluted with DMSO and tested at lpM concentration. The enzyme is diluted in IX Buffer: (100 mM KC1, 50 mM Tris 7.5, 5 mM MgCl₂, 1 mM DTT, 0.03% BSA). 2 pL of compound solution is first added into wells, and then 180 pL of enzyme solution is added. Assays are assembled except for ADP, and plates are stored for 60 minutes at RT. 20 pL ADP is added to start the assay and assay output is evaluated using OD340 at SpectraMax. The assay is run at room temperature.

Final concentration: PKR R532W (100 ng/well), Tris pH 7.5 (50 mM), KC1 (100 mM), MgCl2 (5 mM), ADP (0.36 mM), PEP (0.1 mM), NADH (180 mM), LDH (0.5 units, Sigma 59023), DTT (1 mM) and BSA (0.03%).

Example 6. PKR T384W Single Point Percent Activation Assay

A compound described herein is diluted with DMSO and tested at lpM concentration. The enzyme is diluted in IX Buffer: (100 mM KC1, 50 mM Tris 7.5, 5 mM MgCl₂, 1 mM DTT, 0.03% BSA). 2 pL of compound solution is first added into wells, and then 180 pL enzyme solution is added. Assays are assembled except for ADP, and plates are stored for 60 minutes at RT. 20 pL ADP is added to start the assay and assay output is evaluated using OD340 at SpectraMax. The assay is run at room temperature.

Final concentration: PKR T384W soluble (300 ng/well), Tris pH 7.5 (50 mM), KC1 (100 mM), MgCl2 (5 mM), ADP (0.08 mM), PEP (0.23 mM), NADH (180 mM),

LDH (0.5 units, Sigma 59023), DTT (1 mM) and BSA (0.03%).

Example 7. Activation of Pyruvate Kinase In Vivo Enhances Red Cell

Glycolysis in Mice

Pyruvate kinase deficiency (PKD) is an autosomal recessive enzymopathy that is the most common cause of hereditary nonspherocytic hemolytic anemia (HNSHA). PKD is a rare disease characterized by a life-long chronic hemolysis with severe co- morbidities. It is hypothesized that insufficient energy production to maintain red cell membrane homeostasis promotes the chronic hemolysis. Treatment is generally palliative, focusing on the resultant anemia, and there are no approved drugs that directly target mutated pyruvate kinase.

The compound of formula (I) is an allosteric activator of the red cell isoform of pyruvate kinase (PKR) that may enter Phase I clinical trials in normal healthy volunteers. The compound of formula (I) increases the catalytic efficiency and enhances the protein stability of a spectrum of recombinantly expressed PKR mutant proteins that have been associated with PKD. PKD red cells are characterized by changes in metabolism associated with defective glycolysis, including a build-up of the upstream glycolytic intermediate 2,3-DPG and deficiency in the PKR product adenosine triphosphate (ATP). PKR flux, e.g. the rate of carbon flow through the PKR enzyme reaction, is examined in PKD patient or WT donor blood samples by incubation of whole blood with a stable isotope tracer, [U-¹³C₆]-glucose. At various time points after the addition of [U-¹³C₆]-glucose, metabolism is quenched and metabolites should be extracted. Metabolite pool sizes and ¹³C label incorporation into glycolytic intermediates should be monitored by LC/MS. The rate of label incorporation is found to be significantly slower in PKD patient red cells, consistent with decreased glycolytic activity. Treatment of PKD red cells with the compound of formula (I) ex-vivo induces changes in metabolism consistent with increased glycolytic activity including reduced 2,3-DPG levels, increased ATP levels, and increased PKR enzyme activity levels.

The effect of the compound of formula (I) on red cell metabolism in vivo is evaluated in mice. C57/BL6 mice should be dosed by oral gavage either with a single dose, or with multiple doses (13 doses, BID) of the compound of formula (I) for 7 days. Dose levels tested should be 1 mpk, 10 mpk, 50 mpk, and 150 mpk. Following the last dose, mice should be bled to evaluate drug exposure and pharmacodynamic markers including 2,3-DPG and ATP levels, and PKR activity. The compound of formula (I) is expected to be a well-behaved compound, with dose-proportional increase in exposure, both in the single dose and multiple dose studies. A single dose of the compound of formula (I) is expected to result in a dose-dependent increase in PKR activity levels, concomitant with reduction in 2,3-DPG levels. There should be no significant changes in ATP levels after a single administration of the compound of formula (I). In the multiple dose studies, similar changes in PKR activity and 2,3- DPG levels should be observed. In contrast to the single-dose study, ATP levels in the multiple dose study should be observed to be robustly increased in a dose- dependent manner. The resulting pharmacokinetic/pharmacodynamic correlations between the compound of formula (I) exposure in plasma and each pharmacodynamic marker (PKR activity as well as ATP and 2,3-DPG levels) for both the single dose and multiple dose studies further highlights these observations.

The effect of the compound of formula (I) on PKR flux is assessed in whole blood from mice treated with the compound of formula (I). C57BL/6 mice should be dosed by oral gavage with the compound of formula (I) at 100 mpk BID for 13 total doses. Whole blood is incubated with [U-¹³C₆]-glucose at 37 °C and the metabolite pool sizes and rate of ¹³C label incorporation into glycolytic intermediates should be assessed. The data should be subsequently analyzed using a mathematical kinetic flux model to quantify the overall change in carbon flow through the PKR reaction. Using this model, it should be confirmed that the compound of formula (I) treatment significantly increased glycolytic flux through the PKR reaction.

Claims

We claim:

1. A compound or a pharmaceutically acceptable salt of formula (I):

wherein each of Ri and R₂ is independently hydrogen or deuterium; m is 0, 1, 2, 3, 4, or 5; n is 0 or an integer from 1 to 8 inclusive; o is 0, 1, 2, 3, or 4; p is 0, 1, 2, or 3; and q is 0, 1, 2, or 3; provided that at least one of Ri and R₂ is D or at least one of m, n, o, p, and q is not zero.

2. The compound of claim 1 having formula:

or a pharmaceutically acceptable salt thereof, wherein m is 0, 1, 2, 3, 4, or 5, o is 0, 1,

2, 3, or 4; p is 0, 1, 2, or 3; and q is 0, 1, 2, or 3.

3. The compound of claim 2 having formula

or a pharmaceutically acceptable salt thereof, wherein o is 0, 1, 2, 3, or 4.

4. The compound of claim 3, wherein the compound is compound A:

Ill

5. The compound of claim 2 having formula:

or a pharmaceutically acceptable salt thereof, wherein o is 0, 1, 2, 3, or 4.

6. The compound of claim 5, wherein the compound is compound C:

7. The compound of claim 2 having formula:

or a pharmaceutically acceptable salt thereof, wherein o is 0, 1, 2, 3, or 4.

8. The compound of claim 7, wherein the compound is selected from the groups consisting of:

9. The compound of claim 2 having formula:

or a pharmaceutically acceptable salt thereof, wherein o is 0, 1, 2, 3, or 4.

10. The compound of claim 9, wherein the compound is compound E:

11. A method for treating pyruvate kinase deficiency (PKD) in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of (1) a compound of claim 1, or a pharmaceutically acceptable salt thereof; (2) a composition comprising the compound of claim 1 or a salt thereof and a carrier; or (3) a pharmaceutical composition comprising the compound of claim 1 or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier, to thereby treat PKD in the subject.

12. The method of claim 11, wherein the compound is

13. The method of claim 11, wherein the compound is

14. The method of claim 11, wherein the compound is

15. The method of claim 11, wherein the compound is

16. The method of claim 11, wherein the compound is