BR112016023086B1 - COMPOUND, COMPOSITION, AND, USE OF A COMPOUND - Google Patents

Abstract

COMPOUND, COMPOSITION, AND USE THEREOF. The present invention provides novel cell-permeable succinates and cell-permeable succinate precursors intended to increase ATP production in mitochondria. The main part of ATP produced and used in the eukaryotic cell originates from mitochondrial oxidative phosphorylation, a process for which high-energy electrons are provided by the Krebs cycle. Not all Krebs cycle intermediates are readily permeable to the cell membrane, one of them being succinate. The provision of the new cell-permeable succinates is considered to allow passage across the cell membrane and thus the cell-permeable succinates can be used to improve mitochondrial ATP output.

Description

Field of Invention

[001] The present invention provides novel cell-permeable succinates and cell-permeable succinate precursors intended to increase ATP production in mitochondria. The main part of the ATP produced and used in the eukaryotic cell originates mitochondrial oxidative phosphorylation, a process to which high-energy electrons are supplied by the Krebs cycle. Not all Krebs cycle intermediates are readily permeable to the cell membrane, one of them being succinate. The provision of the new cell-permeable succinates is predicted to allow passage across the cell membrane, and therefore, the cell-permeable succinates can be used to increase mitochondrial ATP production.

[002] Furthermore, the present invention provides cell-permeable succinates or succinate equivalents that, in addition to being cell-permeable and releasing the succinate into the cytosol, are also potentially capable of providing additional energy to the organism through the hydrolytic products resulting from chemical hydrolysis. or enzymatic of succinate derivatives.

[003] The present invention also provides methods for preparing compounds of the invention that have improved properties for use in the areas of medicine and/or cosmetics. Notably, the compounds of the invention are useful in preventing or treating mitochondria-related disorders, maintaining normal mitochondrial function, improving mitochondrial function, i.e., producing more ATP than normal, or restoring defects in mitochondrial respiratory chain system.

Fundamentals of Invention

[004] Mitochondria are organelles in eukaryotic cells. They generate most of the cellular source of adenosine triphosphate (ATP), which is used as an energy source. Thus, mitochondria are essential for the production of energy, for the survival of eukaryotic cells and for correct cellular function. In addition to providing energy, mitochondria are involved in several other processes, such as cell signaling, cell differentiation, cell death, and control of the cell cycle and cell growth. In particular, mitochondria are crucial regulators of cellular apoptosis and they also play an important role in multiple forms of apoptotic cell death, such as necrosis.

[005] In recent years, many works have been published describing mitochondrial contributions to various diseases. Some diseases may be caused by mutations or deletions in the mitochondrial or nuclear genome, while others may be caused by primary or secondary impairment of the mitochondrial respiratory chain system or other mechanisms related to mitochondrial dysfunction. At this time, there is no treatment available that can cure mitochondrial diseases.

[006] In view of the recognized importance of preserving or reestablishing normal mitochondrial function, or of increasing cellular energy (ATP) production, there is a need to develop compounds that have the following properties: cellular permeability of the original, the ability to releasing intracellular succinate or a succinate precursor, low toxicity of the parent compound and released products, and physicochemical properties consistent with administration to a patient.

[007] Succinate compounds have been prepared as prodrugs of other active agents, for example, document WO 2002/28345 describes the bis(2,2-dimethylpropionyloxymethyl) ester of succinic acid, the dibutyryloxymethyl ester of succinic acid and the ester bis-(1-butyryloxyethyl) succinic acid. These compounds are prepared as agents for releasing formaldehyde, and are intended for different medical uses than current compounds.

[008] Prior art compounds include those of document WO9747584, which describes a range of polyolsuccinates.

[009] In the example given therein, Y is an H group or an alkyl group. Each succinate compound contains several succinate moieties, linked by a C(Y)-C(Q) backbone group, and each ester acid is therefore directly linked to a moiety containing at least two carbon atoms in the form of a ethyl group, O-C-C. Each described compound contains more than one succinate moiety, and the succinate moiety is not protected by an O-C-X moiety, where X is a heteroatom.

[0010] Various succinate ester compounds are known in the art. Diethyl succinate, monomethyl succinate and dimethyl succinate are shown to be inactive in the assays exemplified below, and are outside the scope of the invention.

[0011] Furthermore, U.S. 5,871,755 refers to dehydroalanine derivatives of succinamides for use as agents against oxidative stress and for cosmetic purposes.

Description of the Invention

[0012] A compound according to the invention is given by formula (I) or a pharmaceutically acceptable salt thereof, wherein the dotted line between A and B denotes an optional bond so as to form a closed ring structure, and wherein Z is selected from -CH2-CH2- or >CH(CH3) , A is selected from -SR, -OR and NHR, and R is

[0013] B is selected from -O-R', -NHR'', -SR''' or -OH; and R' is selected from formula (II) to (IX) below:

[0014] R', R'' and R''' are independently identical or different, and are selected from the formulas (IV to VIII) below: R1 and R3 are independently identical or different and are selected from H, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, O-acyl, O-alkyl, N-acyl, N-alkyl, X-acyl, CH2X-alkyl, CH2X-acyl, F, CH2COOH and CH2CO2-alkyl, C(O)CH3, C(O)CH2C(O)CH3, C(O)CH2CH(OH)CH3, p is an integer and is 1 or 2 R6 is selected from H, Me, Et, propyl, i- propyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl or formula (II) or formula (VIII) t-butyl, -COOH, -C(=O)XR6, CONR1R3 or is the formula X7 is selected from R1, -NR1R3, R9 is selected from H, Me, Et or O2CCH2CH2COXR8 and R8 are independently identical or different and are/are selected from H, alkyl, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl or formula (II), or the formula (VIII), R11 and R12 are independently identical or different and are selected from H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, propionyl, benzoyl, -CH2-X-aquil, -CH2-X-acyl, where X is O, NR6 or S, Rc and Rd are independently identical or different and are selected from CH2-X-alkyl and CH2-X-acyl, where X = O, NR6 or S, R13, R14 and R15 are independently identical or different and are selected from H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, -COOH, O-acyl, O-alkyl, N-acyl, N -alkyl, X-acyl and CH2X-alkyl;

[0015] The substituents on R13 and R14 or on R13 and R15 can bond to form a cyclic system to form cycloalkyl, heterocycloalkyl, lactone or lactams. Rf, Rg and Rh are independently identical or different and are selected from X-acyl, -CH2-X-alkyl, -CH2-X-acyl and R9, alkyl is selected from Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acyl is selected from formyl, acetyl, propionyl, isopropionyl, butyryl, tert-butyryl, pentanoyl, benzoyl and succinyl. acyl and/or alkyl may be optionally substituted, and when the dotted bond between A and B is present, the compound according to formula (I) is where X4 is selected from -COOH, -C(=O)XR6,

[0016] The compounds of formula (I) (and any of their pharmaceutically acceptable salts) are hereinafter referred to as “compound of the invention”, “compounds of the invention” or as “compounds of the invention”.

[0017] The compounds of the invention of particular interest are the compounds in which Z is -CH2CH2- and A is -SR.

[0018] Compounds of the invention of particular interest are compounds in which Z is -CH2CH2-, A is SR, and B is OH or B is SR’’’.

[0019] The compounds of the invention of particular interest are the compounds in which Z is -CH2CH2-, A is SR, and B is OH or B is SR''', where R''' is

[0020] The compounds of the invention of particular interest are the compounds in which Z is -CH2CH2-, A is SR and B is OH.

[0021] The compounds of the invention of particular interest are the compounds in which Z is -CH2CH2-, A is SR B is OH or B is SR, where R is

[0022] The compounds of the invention of particular interest are the compounds in which Z is -CH2CH2-, A is NR, B is OH and R is

[0023] Preferably, and in relation to formula (II), at least one of R1 and R3 is -H, so that formula II is:

[0024] Preferably, and in relation to formula (VII), p = 1 and X5 is -H, so that formula (VII) is

[0025] Preferably, and in relation to formula (VII), p = 1 and X5 is COXR6, so that formula (VII) is

[0026] Preferably, and in relation to formula (VII), p = 1 and X5 is CONR1R3, so that formula (VII) is

[0027] A compound according to formula (I) can be where X4 is selected from -COOH, -C(=O)XR6,

[0028] Notably, a compound according to the invention is given by the formula (IA) or a pharmaceutically acceptable salt thereof, wherein Z is -CH2-CH2-, A is selected from -SR, -OR and NHR, and R is B is selected from -O-R', -NHR'', -SR''' or -OH; and R', R'' and R''' are independently identical or different, and are selected from one of the formulas below: R1 and R3 are independently identical or different and are selected from H, Me, Et, propyl, O-Me, O-Et, O-propyl, X is selected from O, NH, S, p is an integer and is 1 R6 is selected from H, Me, Et, X5 is selected from -H, Me, Et, -COOH, -C(=O)XR6, CONR1R3 or different and are selected from H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, -COOH, O-acyl, O-alkyl, N-acyl, N-alkyl, X-acyl and CH2 -X-alkyl, where alkyl and acyl are as defined in this document above.

[0029] A compound of particular interest is given by the formula (IA) or a pharmaceutically acceptable salt thereof, wherein Z is -CH2-CH2-, A is selected from -SR, -OR and NHR, and R is B is selected from -O-R', -NHR'', -SR''' or -OH; and R', R'' and R''' are independently identical or different, and are selected from one of the formulas below: R1 and R3 are independently identical or different and are selected from H, Me, Et, propyl, O-Me, O-Et, O-propyl, X is selected from O, NH, S, p is an integer and is 1 R6 is selected from H, Me, Et, X5 is selected from -H, Me, Et, -COOH, -C(=O)OR6, CONR1R3, identical or different and are selected from H, Me, Et and -COOH.

[0030] The following compound is known in Moore et al. J. Biol. Chem., 1982, 257, pp.10882-10892

[0031] However, the invention may or may not include these compounds for use in the treatment of mitochondria-related diseases, as discussed herein, or for the manufacture of a medicament for/in the treatment of mitochondria-related diseases, as discussed in the present invention.

[0032] The following are specific compounds, according to the invention:

General Chemistry Methods

[0033] The person skilled in the art will recognize that the compounds of the invention can be prepared, in known ways, in various ways. The routes below are merely illustrative of some methods that can be used for the synthesis of compounds of formula (I).

[0034] The compounds of the invention can be made starting with succinic acid, a monoprotected succinic acid, a monoactivated methylmalonic acid and a monoprotected methylmalonic acid, or a monoactivated methylmalonic acid.

[0035] Protective groups include, but are not limited to, benzyl and tert-butyl Other protective groups for carbonyl and their removal are detailed in “Greene’s Protective Groups in Organic Synthesis” (Wuts and Greene, Wiley, 2006). Protecting groups may be removed by methods known to a person skilled in the art, including hydrogenation in the presence of a heterogeneous catalyst for benzyl esters and treatment with organic or mineral acids, preferably trifluoroacetic acid or dilute HCl, for esters. tert-butyl.

[0036] Activating groups include, but are not limited to, mixed anhydrides and acyl chlorides.

[0037] Thus, in order for the compounds of formula (I) to be symmetric, a symmetric starting material is selected. A symmetric dicarboxylic acid is selected or a diaactivated carboxylic acid is selected. Preferably, the compound selected is succinic acid or succinyl chloride.

[0038] When the compound of formula (I) is asymmetric, then the selected starting material is asymmetric. These include “acid-protected”, “acid-activated”, and “acid-protected-activated”. Preferably, this includes succinic acid monobenzyl ester, succinic acid monotert-butyl ester and 4-chloro-4-oxobutyric acid.

[0039] Alternatively, for an asymmetric compound of formula (I), a symmetric starting material is selected, preferably succinic acid, and a less derivative starting material is used.

[0040] The following general methods are not exhaustive and it will be clear to a person skilled in the art that other methods can be used to generate the compounds of the invention. The methods can be used together or separately.

[0041] Compounds of formula (I) containing formula (II) can be made by reacting a carboxylic acid with a suitable alkyl halide (formula (X)). For example, where Hal represents a halogen (e.g. F, Cl, Br or I) and R1, R2 and R3 are as defined in formula (II). The reaction may conveniently be carried out in a solvent, such as dichloromethane, acetone, acetonitrile or N,N-dimethylformamide, with a suitable base, such as triethylamine, diisopropylethylamine or cesium carbonate at a temperature, for example, in the range of -10 °C to 80°C, and particularly at room temperature. The reaction can be carried out with optional additives, such as with sodium iodide or tetralkylammonium halides (e.g., tetrabutylammonium iodide).

[0042] Compounds of formula X are commercially available or can be conveniently prepared by literature methods, such as those described in the Journal of the American Chemical Society, 43, 660-7; 1921 or in the Journal of medicinal chemistry (1992), 35(4), 687-94.

[0043] Compounds of formula (I) containing formula (VII) can be made by reacting an activated carboxylic acid with a compound of formula XIV, optionally, in the presence of an activation species. wherein X5 and R1 are as defined in formula (VII) and X7 is Hal (Cl, F, Br) or mixed anhydride. Preferably, X7 = Cl. The reaction may conveniently be carried out in a solvent, such as dichloromethane, acetone, THF, acetonitrile or N,N-dimethylformamide, with a suitable base, such as triethylamine, diisopropylethylamine or cesium carbonate at a temperature, for example, in the range -10°C to 80°C, and particularly at room temperature.

[0044] Compounds of formula (I) containing formula (VII) can be made by reacting an activated carboxylic acid with a compound of formula XIV, optionally, in the presence of an activating species where Hal represents a halogen (e.g. F, Cl, Br or I) and R11, R12 and Rc and Rd are as defined in formula (VIII). The reaction may conveniently be carried out in a solvent, such as dichloromethane, acetone, acetonitrile or N,N-dimethylformamide, with a suitable base, such as triethylamine, diisopropylethylamine or cesium carbonate at a temperature, for example, in the range of -10 °C to 80°C, and particularly to 80°C. The reaction can be carried out with optional additives, such as with sodium iodide or tetralkylammonium halides (e.g., tetrabutylammonium iodide).

[0045] Compounds of formula X are commercially available or can be conveniently prepared by literature methods, whereby an amine reacts with an acyl chloride.

[0046] Compounds of formula (I) containing formula (IX) can be made by combining the methods described above and by other methods known to the person skilled in the art.

General use of the compounds of the invention

[0047] The compounds, as described in the present invention, can be used in the areas of medicine and cosmetics, or in the manufacture of a composition for such use. The medicine can be used in any situation where increased or restored energy (ATP) production is desired, such as the treatment of metabolic diseases, or in the treatment of diseases or conditions of mitochondrial dysfunction, treatment or suppression of mitochondrial diseases. The compounds can be used in stimulating mitochondrial energy production and restoring drug-induced mitochondrial dysfunction, for example, in sensory hearing loss or tinnitus (side effect of certain antibiotics due to mitochondrial toxicity) or lactic acidosis. The compounds can be used in the treatment of cancer, diabetes, acute starvation, endotoxemia, sepsis, systemic inflammatory response syndrome, multiple organ dysfunction syndrome and after hypoxia, ischemia, stroke, myocardial infarction, acute angina, renal failure acute, coronary occlusion and atrial fibrillation, or to prevent or counteract reperfusion injury. Furthermore, it is anticipated that the compounds of the invention may be beneficial in the treatment of male infertility.

[0048] It is anticipated that the compounds of the invention will provide cell-permeable precursors of components of the Krebs cycle and, optionally, glycolytic pathways. It is anticipated that upon entry into the cell, enzymatic or chemical hydrolysis will release succinate or methylmalonate, optionally together with other energy-providing materials such as acetate and glucose.

[0049] The compounds of the invention can be used to improve or restore energy production in mitochondria. Notably, the compounds can be used in the fields of medicine or cosmetics. The compounds can be used in the prevention or treatment of disorders or diseases, having a component related to mitochondrial dysfunction and/or an energy deficiency (ATP) component.

[0050] Increased energy production, for example, is relevant in individuals suffering from a mitochondrial defect, disorder or disease. Mitochondrial diseases result from dysfunction of mitochondria, which are specialized compartments present in all cells in the body except red blood cells. When mitochondrial function decreases, the energy generated within the cell decreases and then cell injury or cell death occurs. If this process is repeated throughout the body, the individual's life is severely compromised.

[0051] Diseases of mitochondria appear most frequently in organs that demand a lot of energy, such as the retina, cochlea, brain, heart, skeletal muscles, liver, kidney and the endocrine system and respiratory system.

[0052] Symptoms of a mitochondrial disease may include loss of motor coordination, muscle weakness and pain, epilepsy attacks, hearing/visual problems, heart disease, liver disease, gastrointestinal disorders, swallowing difficulties and others.

[0053] A mitochondrial disease can be inherited or can be caused by spontaneous mutations, which lead to altered functions of proteins or RNA molecules, normally resident in mitochondria.

[0054] It has been found that many diseases involve a mitochondrial deficiency, such as a deficiency of complex I, II, III or IV or an enzyme deficiency such as, for example, pyruvate dehydrogenase deficiency. However, the picture is complex and many factors can be involved in the diseases.

[0055] To date, there are no curative treatments available. The only treatments available are those that can alleviate symptoms and slow the progression of the disease.

[0056] Therefore, the conclusions of the present inventors and described here are very important, as they demonstrate the beneficial effect of the cell-permeable compounds of succinic acid on energy production in mitochondria.

[0057] Furthermore, compared to known succinate prodrugs (such as, for example, those mentioned in WO 97/47584), they show improved properties for the treatment of the same and related diseases, including better permeability cellular, longer plasma half-life, reduced toxicity, increased energy release to mitochondria and improved formulation (due to improved properties including increased solubility). In some cases, the compounds are also bioavailable orally, allowing for easier administration.

[0058] Thus, the advantageous properties of the compound of the invention may include one or more of the following: - Increased cellular permeability - Longer half-life in plasma - Reduced toxicity - Greater energy release to mitochondria - Improved formulation - Increased solubility - Increased oral bioavailability

[0059] The present invention provides the compound of the invention for use as a medicine, in particular in the treatment of cellular energy (ATP) deficiency.

[0060] A compound of the invention can be used in the treatment of complex I impairment, whether dysfunction of the complex itself or any condition or disease that limits the supply of NADH to complex I, for example, Krebs cycle dysfunction, glycolysis, beta-oxidation, pyruvate metabolism and even transport of glucose or other substrates related to complex I).

[0061] The present invention also provides a method for treating disorders related to complex I, such as, but not limited to, Leigh syndrome, Leber's hereditary optic neuropathy (LHON), MELAS (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) and MERRF (myoclonic epilepsy with red ruptured fibers), which comprises administering, to an individual in need thereof, an effective amount of the compound of the invention.

[0062] The present invention also provides the use of the compound of the invention for the manufacture of a medicament for the treatment of drug-induced lactic acidosis.

[0063] A compound of the invention may also be useful in any condition where extra energy production would be potentially beneficial such as, but not limited to, prolonged surgery and intensive care.

Mitochondria

[0064] Mitochondria are organelles in eukaryotic cells, popularly known as the “energy center” of the cell. One of its main functions is oxidative phosphorylation. The adenosine triphosphate (ATP) molecule functions as an energy “currency” or energy transporter in the cell, and eukaryotic cells derive most of their ATP from biochemical processes carried out by mitochondria. These biochemical processes include the citric acid cycle (the tricarboxylic acid cycle or Krebs cycle), which generates the reduced nicotinamide adenine dinucleotide (NADH) form of oxidized nicotinamide adenine dinucleotide (NAD+) and reduced flavin adenine dinucleotide (FADH2) of oxidized flavin adenine dinucleotide (FAD), as well as oxidative phosphorylation, during which NADH and FADH2 are oxidized back to NAD<+> and FAD.

[0065] The electrons released by the oxidation of NADH are transported to a series of protein complexes (complex I, complex II, complex III and complex IV) known as the respiratory chain. Succinate oxidation occurs in complex II (succinate dehydrogenase complex) and FAD is a prosthetic group in the succinate dehydrogenase enzyme complex (complex II). Respiratory complexes are incorporated into the inner membrane of mitochondria. Complex IV, at the end of the chain, transfers electrons to oxygen, which is reduced to water. The energy released as these electrons pass through the complexes is used to generate a proton gradient across the inner membrane of the mitochondria, which creates an electrochemical potential across the inner membrane. Another protein complex, complex V (which is not directly associated with complexes I, II, III and IV) uses the energy stored by the electrochemical gradient to convert ADP into ATP.

[0066] The citric acid cycle and oxidative phosphorylation are preceded by glycolysis, in which a glucose molecule is split into two pyruvate molecules, with the net generation of two ATP molecules per glucose molecule. The pyruvate molecules then enter the mitochondria, where they are completely oxidized to CO2 and H2O via oxidative phosphorylation (the entire process is known as aerobic respiration). The complete oxidation of the two pyruvate molecules to carbon dioxide and water produces approximately at least 28 to 29 ATP molecules, in addition to the 2 ATP molecules generated through the transformation of glucose into two pyruvate molecules. If there is no oxygen, the pyruvate molecule does not enter the mitochondria and is converted into lactate, in the process of anaerobic respiration.

[0067] The overall net yield per glucose molecule is therefore about at least 30 to 31 ATP molecules. ATP is used to power, directly or indirectly, almost all other biochemical reactions in the cell. Thus, the (approximately) at least 28 or 29 extra ATP molecules provided by oxidative phosphorylation during aerobic respiration are essential for the proper functioning of the cell. Lack of oxygen prevents aerobic respiration and will result in the eventual death of almost all aerobic organisms; Some organisms, such as yeast, are able to survive using aerobic or anaerobic respiration.

[0068] When cells in an organism are temporarily deprived of oxygen, anaerobic respiration is used until oxygen again becomes available, or until the cell dies. Pyruvate generated during glycolysis is converted to lactate during anaerobic respiration. The buildup of lactic acid is believed to be responsible for muscle fatigue during periods of intense activity when oxygen cannot be delivered to muscle cells. When oxygen becomes available again, lactate is converted back to pyruvate for use in oxidative phosphorylation.

[0069] Mitochondrial dysfunction contributes to several disease states. Some mitochondrial diseases are due to mutations or deletions in the mitochondrial or nuclear genome. If a limiting proportion of the mitochondria in the cell are defective, and if a limiting proportion of such cells in a tissue have defective mitochondria, symptoms of organ or tissue dysfunction may occur. Virtually any tissue can be affected and a wide variety of symptoms can be present depending on the extent to which different tissues are involved.

Use of the compounds of the invention

[0070] The compounds of the invention can be used in any situation where increased or restored production of energy (ATP) is desired. Examples are, for example, in all clinical conditions where there is a potential benefit of increased mitochondrial ATP production or restoration of mitochondrial function, such as in the restoration of drug-induced mitochondrial dysfunction or lactic acidosis and in the treatment of cancer, diabetes, starvation acute, endotoxemia, sepsis, reduced auditory and visual acuity, systemic inflammatory response syndrome and multiple organ dysfunction syndrome. The compounds may also be useful following hypoxia, ischemia, stroke, myocardial infarction, acute angina, acute renal failure, coronary occlusion, atrial fibrillation and in preventing or limiting reperfusion injury.

[0071] In particular, the compounds of the invention can be used in medicine, notably in the treatment or prevention of a condition, disease or disorder related to mitochondria, or in cosmetics.

[0072] Mitochondrial dysfunction is also described in relation to renal tubular acidosis; motor neuron diseases; other neurological diseases; epilepsy; genetic diseases; Huntington's disease; mood disorders; schizophrenia; bipolar disorder; diseases associated with age; strokes, macular degeneration; diabetes; and cancer. Compounds of the invention for use in disorders or diseases related to mitochondria.

[0073] The compounds according to the invention can be used in the prevention or treatment of a disease related to mitochondria, selected from the following: • Alpers' disease (progressive infantile poliodystrophy) • Amyotrophic lateral sclerosis (ALS) • Autism • Barth syndrome (lethal infantile cardiomyopathy) • Beta-oxidation defects • Deficiency of bioenergetic metabolism • Carnitine-acyl-carnitine deficiency • Carnitine deficiency • Creatine deficiency syndromes (cerebral creatine deficiency syndromes (CCDS) includes: deficiency of guanidinoacetate methyltransferase (GAMT deficiency), L-arginine:glycine amidinotransferase deficiency (AGAT deficiency) and SLC6A8-related creatine transporter deficiency (SLC6A8 deficiency).

[0074] • Coenzyme Q10 deficiency • Complex I deficiency (NADH dehydrogenase (NADH-CoQ reductase) deficiency) • Complex II deficiency (Succinate dehydrogenase deficiency) • Complex III deficiency (ubiquinone-cytochrome c oxidoreductase deficiency) • Complex IV Deficiency/COX Deficiency (cytochrome c oxidase deficiency is caused by a defect in complex IV of the respiratory chain) • Complex V Deficiency (ATP synthase deficiency) • COX Deficiency • CPEO (External Ophthalmoplegia Syndrome Progressive) • CPT I Deficiency • CPT II Deficiency • Friedreich's Ataxia (FRDA or FA) • Glutaric Aciduria Type II • KSS (Kearns-Sayre Syndrome) • Lactic Acidosis • LCAD (Long Chain Acyl-CoA Dehydrogenase Deficiency ) • LCHAD • Leigh's disease or syndrome (Subacute Necrotizing Encephalomyelopathy) • LHON (Leber's hereditary optic neuropathy) • Luft's disease • MCAD (Medium-chain acyl-CoA dehydrogenase deficiency) • MELAS (Lactic acidosis and similar episodes mitochondrial encephalomyopathy stroke) • MERRF (myoclonic epilepsy disease with red ruptured fibers) • MIRAS (Mitochondrial recessive ataxia syndrome) • Mitochondrial cytopathy • Mitochondrial DNA depletion • Mitochondrial encephalopathy includes: encephalomyopathy, encephalomyelopathy • Mitochondrial myopathy • MNGIE (Disorder Myoneurogastrointestinal and Encephalopathy) • NARP (Neuropathy, Ataxia and Retinitis Pigmentosa) • Neurodegenerative disorders associated with Parkinson's disease, Alzheimer's disease or Huntington's disease • Pearson's syndrome • Pyruvate carboxylase deficiency • Pyruvate dehydrogenase deficiency • POLG mutations • Respiratory chain deficiencies • SCAD (Short-chain acyl-CoA dehydrogenase deficiency) • SCHAD (Short-chain L-3-hydroxyacyl-CoA dehydrogenase deficiency (SCHAD), also known as HADH 3-hydroxyacyl-CoA dehydrogenase deficiency • VLCAD (Very Long Chain Acyl-CoA Dehydrogenase Deficiency) • Diabetes • Acute Starvation • Endotoxemia • Sepsis • Systemic Inflammatory Response Syndrome (SIRS) • Multiple Organ Failure

[0075] With reference to information from the United Mitochondrial Disease Foundation web page (www.umdf.org), some of the aforementioned diseases are discussed in more detail below: Complex I Deficiency: Within the mitochondria there is a group of proteins that transport electrons through four chain reactions (Complexes I to IV), resulting in the production of energy. This chain is known as the electron transport chain. A fifth group (Complex V) produces ATP. Together, the electron transport chain and ATP synthase form the respiratory chain and the entire process is known as oxidative phosphorylation or OXPHOS.

[0076] Complex I, the first step in this chain, is the most common site for mitochondrial abnormalities, accounting for up to a third of respiratory chain deficiencies. Often manifested at birth or infancy, complex I deficiency is generally a progressive neurodegenerative disease and is responsible for several clinical symptoms, particularly in organs and tissues that require high levels of energy, such as the brain, heart, liver and muscles. skeletal. Several specific mitochondrial disorders have been associated with complex I deficiency, including: Leber hereditary optic neuropathy (LHON), MELAS, MERRF, and Leigh syndrome (LS). MELAS stands for (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) and MERRF stands for myoclonic epilepsy with red ruptured fibers.

[0077] LHON is characterized by blindness, which occurs on average between 27 and 34 years of age; blindness can develop in both eyes simultaneously, or sequentially (one eye will develop blindness, followed by the other eye two months later, on average). Other symptoms may also occur, such as cardiac abnormalities and neurological complications.

[0078] There are three main forms of complex I deficiency: i) Fatal childhood multisystem disorder - characterized by poor muscle tone, developmental delay, heart disease, lactic acidosis and respiratory failure.

[0079] II) Myopathy (muscle disease) - beginning in childhood or adulthood and characterized by weakness or exercise intolerance.

[0080] III) Mitochondrial encephalomyopathy (brain and muscle disease) - starting in childhood or adulthood and involving combinations of variable symptoms, which may include: eye muscle paralysis, pigmentary retinopathy (retinal color changes with loss of vision), hearing loss, sensory neuropathy (damage to the nerve surrounding the sensory organs), epilepsy attacks, dementia, ataxia (abnormal muscle coordination), and involuntary movements. This form of complex I deficiency can cause Leigh Syndrome and MELAS.

[0081] Most cases of complex I deficiency result from autosomal recessive inheritance (combination of defective nuclear genes from the mother and father). Less frequently, the disorder is maternally inherited or sporadic and the genetic defect is in the mitochondrial DNA.

[0082] Treatment: As with all mitochondrial diseases, there is currently no cure for complex I deficiency. A variety of treatments, which may or may not be effective, may include such metabolic therapies as: thiamine, riboflavin, biotin, coenzyme Q10 , carnitine and ketogenic diet. Therapies for the multisystemic infantile form have not been successful.

[0083] The clinical course and prognosis for Complex I patients are highly variable and may depend on the specific genetic defect, the age of onset, the organs involved and other factors.

[0084] Complex III Deficiency: Symptoms include four main forms: i) Fatal infantile encephalomyopathy, congenital lactic acidosis, hypotonia, dystrophic posture, epilepsy attacks and coma. Red ruptured fibers in muscle tissue are common.

[0085] II) Late-onset encephalomyopathies (from childhood to adulthood): various combinations of weakness, short stature, ataxia, dementia, hearing loss, sensory neuropathy, pigmentary retinopathy and pyramidal signs. Red ruptured fibers are common. Possible lactic acidosis.

[0086] III) Myopathy, with exercise intolerance progressing to fixed weakness. Red ruptured fibers are common. Possible lactic acidosis.

[0087] IV) Infantile histiocytoid cardiomyopathy. Complex IV deficiency/COX deficiency: symptoms include the two main forms: 1. Encephalomyopathy: generally normal for the first 6 to 12 months of life and then presents developmental regression, ataxia, lactic acidosis, optic atrophy, ophthalmoplegia, nystagmus, dystonia, pyramidal signs and respiratory problems. Frequent epilepsy attacks. Can cause Leigh syndrome 2. Myopathy: Two main variants: 1. Fatal infantile myopathy: can begin soon after birth and be accompanied by hypotonia, weakness, lactic acidosis, red ruptured fibers, respiratory failure and kidney problems.

[0088] 2. Benign infantile myopathy: it can begin soon after birth and be accompanied by hypotonia, weakness, lactic acidosis, red ruptured fibers and respiratory problems, however (if the child survives) followed by spontaneous improvement.

[0080] KSS (Kearns-Sayre Syndrome): KSS is a multisystemic and slowly progressive mitochondrial disease that often begins with drooping of the eyelids (ptosis). Other eye muscles eventually become involved, resulting in paralysis of eye movement. Retinal degeneration generally causes difficulty seeing in poorly lit environments.

[0081] KSS is characterized by three main features: • typical onset before age 20, although it can occur in childhood or adulthood • paralysis of specific eye muscles (called chronic progressive external ophthalmoplegia - CPEO) • degeneration of the retina, causing abnormal accumulation of pigmented (colored) material (pigmentary retinopathy).

[0082] In addition, one or more of the following conditions is present: • blockage of electrical signals in the heart (cardiac conduction defects) • elevated protein levels in the cerebrospinal fluid.

[0089] • lack of coordination of movements (ataxia).

[0083] Patients with KSS may also have problems such as deafness, dementia, kidney dysfunction and muscle weakness. Endocrine abnormalities, including growth retardation, short stature, or diabetes, may also be evident.

[0084] KSS is a rare disease. It is usually caused by a single large deletion (loss) of genetic material in mitochondrial DNA (mtDNA), rather than in the DNA of the cell nucleus. These deletions, of which there are more than 150 species, typically arise spontaneously. Less frequently, the mutation is transmitted from the mother.

[0085] As with all mitochondrial diseases, there is no cure for KSS.

[0086] Treatments are based on the types of symptoms and organs involved, and may include: coenzyme Q10, insulin for diabetes, heart drugs and a heart pacemaker, which can save lives. Surgical intervention for droopy eyelids may be considered, but must be performed by specialists in ophthalmic surgical centers.

[0087] KSS is slowly progressive and the prognosis varies depending on the severity. Death is common in the third or fourth decade and may be due to organ failure.

[0088] Leigh's Disease or Syndrome (Subacute Necrotizing Encephalomyelopathy): Symptoms: epilepsy attacks, hypotonia, fatigue, nystagmus, poor reflexes, difficulties eating and swallowing, breathing problems, poor motor function and ataxia.

[0089] Causes: Pyruvate dehydrogenase deficiency, complex I deficiency, complex II deficiency, complex IV/COX and NARP deficiency.

[0090] Leigh's disease is a progressive neurometabolic disorder with a general onset in childhood or childhood, generally following a viral infection, but which can also occur in adolescents and adults. It is characterized by magnetic resonance imaging by visible necrotizing lesions (dead or dying tissue) in the brain, particularly in the midbrain and brainstem.

[0091] The child often appears normal at birth, but typically begins to exhibit symptoms within a few months to two years of age, although the timing may be much earlier or later. Initial symptoms may include loss of basic skills such as sucking, head control, walking and talking. These may be accompanied by other problems such as irritability, loss of appetite, vomiting and seizures. There may be periods of sharp decline or temporary restoration of some functions. Eventually, the child may also have heart, kidney, vision and breathing complications.

[0092] There is more than one defect that causes Leigh's disease. These include pyruvate dehydrogenase (PDHC) deficiency and respiratory chain enzyme defects - complexes I, II, IV and V. Depending on the defect, the mode of inheritance may be dominant and related to the X chromosome (X chromosome defect and disease generally occurring only in males), autosomal recessive (inherited from genes from the mother and father) and maternal (only from the mother). There may also be spontaneous cases that are not inherited.

[0093] There is currently no cure for Leigh's disease. Treatments generally involve variations of vitamin therapies and supplements, often in a “cocktail” combination, and are only partially effective. Various resource locations include possible use of: thiamine, coenzyme Q10, riboflavin, biotin, creatine, succinic acid, and idebenone. Experimental drugs such as dichloroacetate (DCA) are also being tested in some clinics. In some cases, a special diet may be requested and should be monitored by a nutritionist experienced in metabolic disorders.

[0094] The prognosis for Leigh disease is poor. Depending on the defect, individuals typically live anywhere from a few years to mid-adolescence. People diagnosed with Leigh syndrome or who do not exhibit symptoms until adulthood tend to live longer.

[0095] MELAS (Mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes): Symptoms: short stature, seizures, stroke-like episodes with focal neurological deficits, recurrent headaches, cognitive regression, disease progression and red ruptured fibers.

[0096] Cause: Point mutations in mitochondrial DNA: A3243G (most common)

[0097] MELAS - mitochondrial myopathy (muscle weakness), encephalopathy (disease of the brain and central nervous system), lactic acidosis (accumulation of a product of anaerobic respiration) and stroke-like episodes (partial paralysis, partial loss of vision or other neurological abnormalities ).

[0098] MELAS is a progressive neurodegenerative disorder with typical onset between the ages of 2 and 15 years, although it can occur in childhood or later in adulthood. Initial symptoms may include stroke-like episodes, seizures, migraines, and recurrent vomiting.

[0099] Generally, the patient appears normal during childhood, although short stature is common. Less common are symptoms in early childhood, which may include developmental delay, learning difficulties, or attention deficit disorder. Exercise intolerance, limb weakness, hearing loss, and diabetes may also precede the occurrence of stroke-like episodes.

[00100] Stroke-like episodes, often accompanied by seizures, are the characteristic symptom of MELAS and cause partial paralysis, vision loss and focal neurological defects. The gradual cumulative effects of these episodes often result in varying combinations of loss of motor skills (speech, movement, and eating), impaired sensitivity (loss of vision and loss of bodily sensations), and mental impairment (dementia). Patients with MELAS may also suffer additional symptoms, including: muscle weakness, peripheral nerve dysfunction, diabetes, hearing loss, heart and kidney problems, and digestive abnormalities. Lactic acid generally accumulates to high levels in the blood, cerebrospinal fluid, or both.

[00101] MELAS is inherited from the mother due to a defect in mitochondrial DNA. There are at least 17 different mutations that can cause MELAS. By far the most prevalent is the A3243G mutation, which accounts for about 80% of cases.

[00102] There is no cure or specific treatment for MELAS. Although clinical trials have not proven their effectiveness, general treatments may include such metabolic therapies as: CoQ10, creatine, phylloquinone and other vitamins and supplements. Drugs such as seizure medications and insulin may be necessary to control additional symptoms. Some patients with muscle dysfunction may benefit from supervised moderate exercise. In selected cases, other therapies that may be prescribed include dichloroacetate (DCA) and menadione, although these are not routinely used due to their potential for harmful side effects.

[00103] The prognosis for MELAS is poor. Typically, the age of death is between 10 to 35 years, although some patients may live longer. Death may arise as a result of general bodily loss due to progressive dementia and muscle weakness, or complications from other affected organs such as the heart or kidneys.

[00104] MERRF is a progressive multisystem syndrome usually beginning in childhood, but onset can occur in adulthood. The rate of progression varies greatly. The onset and extent of symptoms may differ between affected siblings.

[00105] Classic features of MERRF include: • Myoclonus (brief, sudden, twitching muscle spasms) - the most characteristic symptom • Epilepsy attacks • Ataxia (impaired coordination) • Red torn fibers (a characteristic microscopic abnormality seen on muscle biopsy of patients with MERRF and other mitochondrial disorders). Additional symptoms may include: hearing loss, lactic acidosis (high level of lactic acid in the blood), short stature, exercise intolerance, dementia, heart defects, eye abnormalities and speech impairment.

[0080] Although some cases of MERRF are sporadic, most cases are inherited from the mother, due to a mutation in the mitochondria. The most common MERRF mutation is A8344G, which represents more than 80% of cases. Four other mitochondrial DNA mutations have been reported to cause MERRF. Although a mother will pass on her MERRF mutation to all of her offspring, some of them may never show symptoms.

[0081] As with all mitochondrial disorders, there is no cure for MERRF. Therapies may include coenzyme Q10, L-carnitine, and various vitamins, often in a “cocktail” combination. Controlling epilepsy seizures often requires anticonvulsant drugs. Medications to control other symptoms may also be needed.

[0082] The prognosis for MERRF varies greatly, depending on the age of onset, the type and severity of symptoms, the organs involved and other factors.

[0083] Depletion of mitochondrial DNA: Symptoms include three main forms:1. Congenital myopathy: neonatal weakness, hypotonia requiring assisted ventilation, and possible renal dysfunction. Severe lactic acidosis. Prominent red torn fibers. Death due to respiratory failure usually occurs before one year of age.

[0090] 2. Infantile myopathy: After the start of normal development up to one year of age, weakness manifests and worsens rapidly, causing respiratory failure and death usually within a few years.

[0091] 3. Liver disease: Enlargement of the liver and intractable liver failure, myopathy. Severe lactic acidosis. Death is characteristic in the first year.

Friedreich's ataxia

[0084] Friedreich's ataxia (FRDA or FA) is an autosomal recessive neurodegenerative and cardiodegenerative disorder caused by lower levels of the protein frataxin. Frataxin is important for the assembly of iron-sulfur clusters in mitochondrial respiratory chain complexes. Estimates of the prevalence of FRDA in the United States range from 1 in 22,000 to 29,000 people (see www.nlm.nih.gov/medlineplus/ency/article/001411.htm) to 1 in 50,000 people. The disease causes progressive loss of voluntary motor coordination (ataxia) and cardiac complications. Symptoms generally begin in childhood and the disease progressively worsens as the patient grows; Patients eventually become wheelchair users due to motor disabilities.

[0085] In addition to congenital disorders involving inherited defective mitochondria, acquired mitochondrial dysfunction has been suggested to contribute to diseases, particularly neurodegenerative diseases associated with aging, such as Parkinson's, Alzheimer's and Huntington's diseases. The incidence of somatic mutations in mitochondrial DNA increases exponentially with age; decreased activity of the respiratory chain is universally seen in older people. Mitochondrial dysfunction is also implicated in excitotoxicity, neuronal injury, and strokes, such as those associated with epilepsy attacks, stroke, and ischemia.

Pharmaceutical compositions comprising a compound of the invention

[0086] The present invention also provides a pharmaceutical composition comprising the compound of the invention, together with one or more pharmaceutically acceptable diluents or carriers.

[0087] The compound of the invention or a formulation thereof can be administered by any conventional method, for example, but without limitation, it can be administered parenterally, orally, topically (including buccal, sublingual or transdermal), through a medical device (e.g. an expandable stent graft), by inhalation or by injection (subcutaneous or intramuscular). Treatment may consist of a single dose or a plurality of doses over a period of time.

[0088] Treatment can be by administration once a day, twice a day, three times a day, four times a day, etc. Treatment may also be by continuous administration, such as, for example, by intravenous drip administration.

[0089] Although it is possible for the compound of the invention to be administered alone, it is preferable to present it as a pharmaceutical formulation, together with one or more acceptable carriers. The carrier(s) must be acceptable in the sense of being compatible with the compound of the invention and not harmful to its receptors. Examples of suitable carriers are described in more detail below.

[0090] The formulations can be conveniently presented in unit dosage form and can be prepared by any of the methods well known in the pharmaceutical art. Such methods include the step of associating the active ingredient (the compound of the invention) with the carrier that constitutes one or more supporting ingredients. In general, formulations are prepared by uniformly and thoroughly associating the active ingredient with liquid carriers, or finely divided solid carriers, or both, and then, if necessary, shaping the product.

[0091] The compound of the invention will normally be administered intravenously, orally or by any parenteral route, in the form of a pharmaceutical formulation comprising the active ingredient, optionally, in the form of a non-toxic organic, inorganic, acidic salt or base, in a pharmaceutically acceptable dosage form. Depending on the disorder and the patient being treated, as well as the route of administration, the compositions can be administered in different doses. [0092] Pharmaceutical compositions must be stable under manufacturing and storage conditions; therefore, they must be preferably protected against the contaminating action of microorganisms, such as bacteria and fungi. The carrier may be a solvent or dispersion medium containing, for example, water, ethanol, polyol (e.g. glycerol, propylene glycol and liquid polyethylene glycol), vegetable oils and suitable mixtures thereof.

[0093] For example, the compound of the invention can also be administered orally, buccally or sublingually in the form of tablets, capsules, ovules, elixirs, solutions or suspensions, which may contain flavoring or coloring agents, for immediate or delayed applications. or controlled release.

[0094] Formulations according to the present invention suitable for oral administration may be presented as discrete units, such as capsules, wafers or tablets, each containing a predetermined amount of the active ingredient; as a powder or granules; as a solution or suspension in an aqueous liquid or in a non-aqueous liquid; or as a liquid oil-in-water emulsion or a liquid water-in-oil emulsion. The active ingredient may also be presented as a large pill, electuary or paste.

[0095] Solutions or suspensions of the compound of the invention suitable for oral administration may also contain excipients, for example, N,N-dimethylacetamide, dispersants, for example, polysorbate 80, surfactants and solubilizers, for example, polyethylene glycol, Phosal 50 PG ( which consists of phosphatidylcholine, soybean fatty acids, ethanol, mono/diglycerides, propylene glycol and ascorbyl palmitate). The formulations according to the present invention can also be in the form of emulsions, wherein a compound according to formula (I) can be present in an aqueous oil emulsion. The oil can be any oily substance, such as soybean oil or safflower oil, medium chain triglyceride (MCT oil) such as coconut oil, palm oil, etc. or combinations thereof.

[0096] Tablets may contain excipients such as microcrystalline cellulose, lactose (e.g., lactose monohydrate or anhydrous lactose), sodium citrate, calcium carbonate, dibasic calcium phosphate and glycine, butylated hydroxytoluene (E321), crospovidone, hypromellose, disintegrants such as starch (preferably corn, potato or tapioca starch), sodium starch glycolate, croscarmellose sodium and certain complex silicates, and granulation binders such as polyvinylpyrrolidone, hydroxypropyl methyl cellulose (HPMC), hydroxypropyl cellulose (HPC) , macrogol 8000, sucrose, gelatin and acacia. Additionally, lubricating agents such as magnesium stearate, stearic acid, glyceryl benate and talc may be included.

[0097] A tablet can be made by compression or molding, optionally, with one or more supporting ingredients. Compressed tablets may be prepared by compressing, in a suitable machine, the active ingredient into a free-flowing form, such as powder or granules, optionally mixed with a binder (e.g., povidone, gelatin, hydroxypropylmethylcellulose), lubricant, inert diluent, preservative, disintegrant (e.g. sodium starch glycolate, cross-linked povidone, cross-linked sodium carboxymethyl cellulose), surfactant or dispersant. Molded tablets can be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent. The tablets may optionally be coated or scored and may be formulated to provide a slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethylcellulose in varying proportions to provide the desired release profile.

[0098] Similar solid compositions can also be used as fillers in gelatin capsules. Preferred excipients in this regard include lactose, starch, cellulose, milk sugar or high molecular weight polyethylene glycols. For aqueous suspensions and/or elixirs, the compounds of the invention can be combined with various sweeteners or flavoring agents, dyes or dyes, with emulsifying and/or suspending agents and with diluents such as water, ethanol, propylene glycol and glycerin, and combinations thereof. .

[0099] Formulations suitable for topical administration in the mouth include troches, comprising the active ingredient in a flavored base, generally sucrose and acacia or tragacanth; pastilles, comprising the active ingredient in an inert base, such as gelatin and glycerin, or sucrose and acacia; and mouth rinses comprising the active ingredient in a suitable liquid carrier.

[00100] Pharmaceutical compositions adapted for topical administration can be formulated as ointments, creams, suspensions, lotions, powders, solutions, pastes, gels, impregnated dressings, sprays, aerosols or oils, transdermal devices, dusting powders and the like. These compositions can be prepared by conventional methods, containing the active agent. Thus, they may also comprise compatible conventional vehicles and additives, such as preservatives, solvents to aid drug penetration, emollient in creams or ointments, and ethanol or oleyl alcohol for lotions. Such carriers may be present from about 1% to about 98% of the composition. More generally, they will form up to about 80% of the composition. Just as an illustration, a cream or ointment is prepared by mixing sufficient quantities of hydrophilic material and water, containing about 5 to 10% by weight of the compound, in quantities sufficient to produce a cream or ointment of the desired consistency.

[00101] Pharmaceutical compositions adapted for transdermal administration can be presented as discreet patches intended to remain in intimate contact with the recipient's epidermis for an extended period of time. For example, the active agent can be administered from the patch by iontophoresis.

[00102] For applications to external tissues, for example, the mouth and skin, the compositions are preferably applied as a topical ointment or cream. When formulated into an ointment, the active agent can be used with a paraffinic or water-miscible ointment base.

[00103] Alternatively, the active ingredient can be formulated to produce a cream with an oil-in-water cream base or water-in-oil base.

[00104] For parenteral administration, fluid unit dosage forms are prepared using the active ingredient and a sterile vehicle, for example, but without limitation, water, alcohols, polyols, glycerin and vegetable oils, preferably water. The active ingredient, depending on the vehicle and concentration used, can be colloidal, suspended or dissolved in the vehicle. When preparing solutions, the active ingredient can be dissolved in water for injection and sterile filtered before filling into a suitable, sealed vial or ampoule.

[00105] Advantageously, agents such as local anesthetics, preservative agents and buffering agents can be dissolved in the vehicle. To increase stability, the composition may be frozen after filling the vial and removing the water under vacuum. The dried lyophilized powder is then sealed in the vial and an additional vial of water for injection may be provided to reconstitute the liquid before use.

[00106] The pharmaceutical compositions of the present invention suitable for injectable use include sterile aqueous solutions or dispersions. Furthermore, the compositions may be in the form of sterile powders for the extemporaneous preparation of such sterile injectable solutions or dispersions. In all cases, the final injectable form must be sterile and must be effectively fluid for easy syringability.

[00107] Parenteral suspensions are prepared in substantially the same way as solutions, except that the active ingredient is suspended in the vehicle instead of being dissolved, and sterilization cannot be carried out by filtration. The active ingredient can be sterilized by exposure to ethylene oxide before suspending it in the sterile vehicle. Advantageously, a surfactant or wetting agent is included in the composition to facilitate uniform distribution of the active ingredient.

[00108] It should be understood that in addition to the ingredients particularly mentioned above, the formulations of this invention may include other agents conventional in the art in relation to the type of formulation in question, for example, those suitable for oral administration may include flavoring agents. A person skilled in the art will know how to choose a suitable formulation and how to prepare it (see, for example, Remington's Pharmaceutical Sciences 18th edition or later). A person skilled in the art will also know how to choose a suitable route of administration and dosage.

[00109] It will be recognized by one skilled in the art that the optimal amount and spacing of individual dosages of a compound of the invention will be determined by the nature and extent of the condition being treated, the manner, route and site of administration, and the age and condition of the specific individual being treated, and that a physician will ultimately determine the appropriate dosages to use. This dosage may be repeated as frequently as appropriate. If side effects arise, the dosage amount and/or frequency may be changed or reduced in accordance with normal clinical practice.

[00110] All % values mentioned in the present invention are in % w/w, unless otherwise indicated.

[00111] All compounds of the invention can be transformed into a biological matrix to release succinic acid, succinyl coenzyme A or canonical forms thereof. They can also do this in the following way.

[00112] Where R', R'' or R''' is a compound of formula (II), the acyl group including R2 can be cleaved by an appropriate enzyme, preferably by an esterase. This releases a hydroxymethyl ester, an aminomethyl ester, or a thiolmethyl ester that could be spontaneously converted to a carbonyl, imine, or thiocarbonyl group and a free carboxylic acid. By way of example, in formula (I), where A is OR' with R' being formula (II) and B being H and Z being -CH2CH2-.

[00113] When B is -SR’’, a thiol group is released. This is considered to be especially advantageous, since the thiol group has reducing properties. Many diseases have an unwanted oxidative stress component, which can damage cellular structure and cellular function. Therefore, release of a component that can act as an antioxidant and scavenge free radicals or reduce reactive oxygen species is expected to further benefit medical or cosmetic use.

[00114] Where R', R'' or R''' is a compound of formula (V), the substituent in group R10 can be removed by the action of a suitable enzyme, or by means of chemical hydrolysis in vivo. By way of example, in formula (I), where A is OR' with R' being formula (V) and B being H, and Z being -CH2CH2-, X is O and R8 is H, R9 is Me and R10 is O-acetyl.

[00115] Where R', R'' or R''' is a compound of formula (VII), the group can be removed by the action of a suitable enzyme, or by means of chemical hydrolysis in vivo, to release succinic acid. By way of example, in formula (I), where A is SR with R being formula (VII) and B is OH and Z is - CH2CH2-, X5 is CO2H and R1 is Et:

[00116] Alternatively, for compounds of formula VII, the entity itself can be inserted directly into the Krebs cycle, in place of succinyl-CoA.

[00117] Where formula (I) is the compound can hydrolyze to produce a compound according to the scheme below and when X4 is -COOH.

Other aspects of the invention

[00118] The present invention also provides a combination (for example, for the treatment of mitochondrial dysfunction) of a compound of formula (I) or a pharmaceutically acceptable form thereof, as defined above, and one or more independently selected agents selected from: • Quinone derivatives, e.g. ubiquinone, idebenone, MitoQ • Vitamins, e.g. tocopherols, tocotrienols and Trolox (vitamin E), ascorbate (C), thiamine (B1), riboflavin (B2), nicotinamide (B3 ) and menadione (K3), • Antioxidants in addition to vitamins, e.g. TPP compounds (MitoQ), Sk compounds, epicatechin, catechin, lipoic acid, uric acid and melatonin • Dichloroacetate • Methylene blue • l-arginine • Szeto Peptides -Schiller • Creatine • Benzodiazepines • PGC-1α modulators • Ketogenic diet

[00119] Another aspect of the invention is that any of the compounds as described in the present invention can be administered together with any other compounds such as, for example, sodium bicarbonate (as a bolus (e.g., 1 mEq/Kg ) followed by a continuous infusion), as a concomitant medication for the compounds as described in the present invention. Lactic acidosis or drug-induced side effects due to Complex I-related impairment of mitochondrial oxidative phosphorylation

[00120] The present invention also relates to the prevention or treatment of lactic acidosis and drug-induced side effects related to mitochondria. In particular, the compounds according to the invention are used in the prevention or treatment of drug-induced side effects related to mitochondria in or upstream of Complex I, or otherwise expressed, the invention provides, according to the invention , the prevention or treatment of direct drug-induced inhibition of complex I or any drug-induced effect that limits the supply of NADH to complex I (such as, but not limited to, effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and even drugs that influence the transport of glucose levels or other substrates related to complex I).

[00121] Drug-induced mitochondrial toxicity may be a part of the desired therapeutic effect (for example, cancer drug-induced mitochondrial toxicity), but in most cases, drug-induced mitochondrial toxicity is an undesired effect. Mitochondrial toxicity can markedly increase glycolysis to compensate for the cellular loss of mitochondrial ATP formation through oxidative phosphorylation. This can result in higher plasma lactate levels, which if excessive, results in lactic acidosis, which can be lethal. Type A lactic acidosis is primarily associated with tissue hypoxia, whereas type B aerobic lactic acidosis is associated with drugs, toxins, or systemic disorders such as liver disease, diabetes, cancer, and inborn errors of metabolism (e.g., liver defects). mitochondrial genetics).

[00122] Many known drug substances negatively influence mitochondrial respiration (e.g., antipsychotics, local anesthetics, and antidiabetics) and it is therefore necessary to identify or develop means that can be used to circumvent or mitigate the negative mitochondrial effects induced by use. of such medicinal substance.

[00123] The present invention provides compounds for use in preventing or treating lactic acidosis and drug-induced side effects related to mitochondria. In particular succinate prodrugs are used in the prevention or treatment of drug-induced side effects related to mitochondria in or upstream of complex I, or otherwise expressed, the invention provides succinate prodrugs for the prevention or the treatment of direct drug-induced inhibition of complex I or any drug-induced effect that limits the supply of NADH to complex I (such as, but not limited to, effects on the Krebs cycle, glycolysis, beta-oxidation , pyruvate metabolism and even drugs that affect the transport or levels of glucose or other substrates related to complex I).

[00124] As mentioned above, increased plasma lactate levels are often observed in patients treated with drugs that may have mitochondria-related side effects. The present invention is based on experimental results showing that metformin (the first-line treatment for type 2 diabetes and which has been associated with lactic acidosis as a rare side effect) inhibits the mitochondrial function of peripheral blood cells. in complex I in a time- and dose-dependent manner at concentrations relevant for intoxication caused by metformin. Metformin also causes a significant increase in lactate production by intact platelets over time. The use of the compounds according to the invention significantly reduced lactate production in intact platelets exposed to metformin. Exogenously applied succinate, the substrate itself, does not reduce metformin-induced lactate production.

[00125] In another study, lactate production was observed for several hours in rotenone-inhibited platelets (i.e., a condition where complex I function is impaired). The use of the compounds according to the invention (but not the succinate) attenuated the rotenone-induced lactate production of intact human platelets. Respirometric experiments were repeated on human fibroblasts and human heart muscle fibers, and confirmed the findings observed in blood cells.

[00126] Therefore, the invention provides compounds according to formula (I) for use in preventing the treatment of lactic acidosis. However, as the results indicated herein are based on lactic acidosis related to direct inhibition of complex I, or are associated with a defect in or upstream of complex I, it is anticipated that the compounds according to the invention are suitable for use in preventing or treating drug-induced side effects related to mitochondria in or upstream of complex I. Compounds according to the invention could also neutralize drug effects that impair metabolism upstream of complex I (indirect inhibition of complex I, which could encompass any drug effect that limits the supply of NADH to complex I, for example, that affects the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and even drugs that affect the levels of glucose or other substrates related to complex I).

[00127] It is contemplated that the compounds according to the invention may also be used in industrial applications, for example, in vitro to reduce or inhibit the formation of lactate or to increase the availability of ATP from commercial or industrial cell lines. Examples include use in cell culture, organ preservation, etc.

[00128] The compounds according to the invention are used in the treatment or prevention of drug-induced mitochondria-related side effects or to increase or restore cellular energy (ATP) levels in treatment. Especially, they are used in the treatment or prevention of direct or indirect drug-induced complex I mitochondria-related side effects. In particular, they are used in the treatment or prevention of lactic acidosis, such as lactic acidosis induced by a medicinal substance.

[00129] The invention also relates to a combination of a compound of formula (I) and a medicinal substance that can induce a mitochondrial side effect, in particular, a side effect that is caused by direct or indirect impairment of the complex I for the medicinal substance. Such a combination can be used as prophylactic prevention of a mitochondrial side effect or, in case the side effect appears, in the relief and/or treatment of the mitochondrial side effect.

[00130] It is contemplated that the compounds, as described below, will be effective in treating or preventing drug-induced side effects, in particular, side effects related to direct or indirect inhibition of complex I.

[00131] Medicinal substances that are known to cause defects, malfunction and/or impairment in Complex I and/or that are known to have lactic acidosis as a side effect are: Analgesics, including paracetamol and capsaicin Antianginals, including amiodarone and perhexiline Antibiotics, including linezolid, trovafloxacin, and gentamicin Cancer drugs, including quinones, including mitomycin C and adriamycin Anticonvulsant drugs, including valproic acid Antidiabetics, including metformin, phenformin, butylbiguanide, troglitazone, rosiglitazone, and pioglitazone Antihepatitis B drugs, including fialuridine Antihistamines Anti-Parkinson's drugs, including tolcapone Antipsychotics, such as risperidone, Antischizophrenics, such as zotepine and clozapine Antiseptics, quaternary ammonium compounds (QAC) Antituberculosis drugs, including isoniazid Fibrates, including clofibrate, ciprofibrate, and simvastatin Hypnotics, including propofol Modified antirheumatic drug r of immunosuppressive disease (DMARD), leflunomide Local anesthetics, including bupivacaine, diclofenac, indomethacin, and lidocaine Muscle relaxant, including dantrolene Neuroleptics, including antipsychotic neuroleptics, such as chlorpromazine, fluphenazine, and haloperidol NRTI (nucleotide analogue reverse transcriptase inhibitors) including efavirenz , tenofovir, emtricitabine, zidovudine, lamivudine, rilpivirine, abacavir and didanosine NSAIDs, including nimesulide, mefenamic acid and sulindac Barbituric acids.

[00132] Other medicinal substances that are known to have lactic acidosis as a side effect include beta2-agonists, adrenaline, theophylline or other herbicides. Alcohols and cocaine can also result in lactic acidosis.

[00133] Furthermore, it is contemplated that the compounds of the invention may also be effective in treating or preventing lactic acidosis, even if it is not related to a complex I defect.

Combination of drugs and compounds of the invention

[00134] The present invention also relates to a combination of a medicinal substance and a compound of the invention for use in the treatment and/or prevention of a drug-induced side effect selected from lactic acidosis and side effects related to a defect of the complex I, inhibition or malfunction, wherein i) the medicinal substance is used for the treatment of a disease for which the medicinal substance is indicated, and ii) the compound of the invention is used for the prevention or alleviation of side effects induced or inducible by the medicinal substance, wherein the side effects are selected from lactic acidosis and side effects related to a defect, inhibition or malfunction of complex I.

[00135] Any combination of such a medicinal substance with any compound of the invention is within the scope of the present invention. In this sense, based on the description of the present invention, a person skilled in the art will understand that the essence of the invention is the investigation of the valuable properties of the compounds of the invention to avoid or reduce the side effects described in the present invention. Thus, the potential use of compounds of the invention capable of entering cells and delivering succinate and, possibly, other active moieties, together with any medicinal substance that has or potentially has the side effects described herein is evident from the present description.

[00136] The invention further relates to i) a composition comprising a medicinal substance and a compound of the invention, wherein the medicinal substance has a potential drug-induced side effect selected from lactic acidosis and side effects related to a defect, inhibition or complex I malfunction.

[0092] ii) a composition, as described above in i), wherein the compound of the invention is used for the prevention or relief of side effects induced or inducible by the medicinal substance, wherein the side effects are selected from lactic acidosis and side effects related to a defect, inhibition or malfunction of complex I.

[00137] The composition may be in the form of two separate packages: A first package, containing the medicinal substance or a composition comprising the medicinal substance and a second package containing the compound of the invention or a composition comprising the compound of the invention. The composition may also be a single composition, comprising both the medicinal substance and the compound of the invention.

[00138] In the case where the composition comprises two separate packages, the medicinal substance and the compound of the invention can be administered by different routes of administration (for example, the medicinal substance via oral administration and the compound of the invention via parenteral administration or by mucosa) and/or they can be administered essentially at the same time, or the medicinal substance can be administered before the compound of the invention, or vice versa.

Kits

[00139] The invention also provides a kit comprising i) a first container comprising a medicinal substance, which has a potential drug-induced side effect selected from lactic acidosis and side effects related to a defect, inhibition or malfunction of complex I , and ii) a second container comprising a compound of the invention, which has the potential to prevent or alleviate side effects induced or inducible by the medicinal substance, wherein the side effects are selected from lactic acidosis and side effects related to a defect , inhibition or malfunction of complex I.

Method for treating/preventing side effects

[00140] The invention also relates to a method for treating an individual suffering from a drug-induced side effect selected from lactic acidosis and a side effect related to a defect, inhibition or malfunction of complex I, the method comprising administering an amount effectiveness of a compound of the invention to the individual, and to a method for preventing or alleviating a drug-induced side effect selected from lactic acidosis and side effects related to a defect, inhibition or malfunction of complex I in an individual, who is suffering of a disease that is treated with a medicinal substance that potentially induces a selected side effect of lactic acidosis and a side effect related to a defect, inhibition or malfunction of complex I, the method comprising administering an effective amount of a compound of the invention to the individual before, during or after treatment with said medicinal substance.

Metformin

[00141] Metformin is an antidiabetic drug belonging to the biguanide class. It is the first line of treatment for type 2 diabetes, which accounts for about 90% of diabetes cases in the United States. The antidiabetic effect has been attributed to the decrease in hepatic glucose production, increasing the biological effect of insulin through increased glucose absorption in peripheral tissues and decreased glucose absorption in the intestine, but the exact mechanisms of action have not been completely elucidated. Despite its advantages over other antidiabetics, it has been linked to rare cases of lactic acidosis (LA) as a side effect). LA is defined as an increased anion gap, an arterial blood lactate level above 5 mM, and a pH < 7.35. Although the precise pathogenesis of metformin-associated LA is not completely described, an inhibition of gluconeogenesis and the resulting accumulation of gluconeogenic precursors such as alanine, pyruvate and lactate has been suggested. Others, however, propose the drug's interference with mitochondrial function as the key factor in primary therapy, for the glucose-lowering effect and for the development of metformin-associated AT). As a consequence of mitochondrial inhibition, the cell could partially shift from aerobic to anaerobic metabolism, promoting glycolysis with resulting high lactate levels. Phenformin, another antidiabetic agent in the same drug class as metformin, has been withdrawn from the market in most countries due to a high incidence of LA (4 cases per 10000 treatment-years). In comparison, the incidence of LA for metformin is about one-tenth that for phenformin and is therefore considered a fairly safe therapeutic agent. LA associated with metformin is primarily seen in patients who have additional predisposing conditions affecting the cardiovascular system, liver, or kidneys. Under these conditions, clearance of the drug from the body is impaired, which, if not detected in time, results in increasing blood concentrations of metformin. As the use of metformin is expected to rise due to the increasing prevalence of type 2 diabetes, the investigation of metformin-induced mitochondrial toxicity and LA becomes a current and urgent issue. Research on the mitochondrial toxicity of metformin reports inconsistent results. Kane et al. (2010) did not detect the inhibition of basal breathing and maximal respiratory capacities by metformin in vivo in the skeletal muscle of rats, nor did they perform muscle biopsies in patients with type 2 diabetes treated with metformin. On the contrary, other reports have described the toxic effects of metformin and phenformin on mitochondria and their association with LA in animal tissues. Data on human tissue are scarce, especially ex vivo or in vivo. Most human data on metformin and LA are based on retrospective studies due to the difficulty of obtaining human tissue samples. Protti et al. (2010), however, reported decreased systemic oxygen consumption in patients with biguanide-associated LA, and both Protti et al. (2012b) like Larsen et al. (2012) described in vitro mitochondrial dysfunction in response to metformin exposure at <10 mM in human skeletal muscle and platelets, respectively. Protti et al. (2012b) further reported increased lactate release in human platelets in response to exposure to 1 mM metformin. Although metformin is not found at this concentration under therapeutic conditions, it has been shown to approach these levels in the blood during intoxication and is known to accumulate 7- to 10-fold in the gastrointestinal tract, kidney, liver, salivary glands, lung , in the spleen and muscle, compared to plasma.

[00142] In the study reported in the present invention, the objective was to evaluate the mitochondrial toxicity of metformin and phenformin in human blood cells using high-resolution respirometry. Phenformin was included to compare the activity of the two similarly structured drugs and to study the relationship between mitochondrial toxicity and the incidence of AL described in human patients. In order to investigate the membrane permeability and specific target toxicity of these biguanides, a model to test drug toxicity was applied using intact and permeabilized blood cells with sequential additions of respiratory complex-specific substrates and inhibitors.

[00143] Other aspects appear from the attached claims. All details and particulars apply, mutatis mutandis, to these aspects.

Definitions

[00144] The articles “a” and “an” are used here to refer to one or more than one (that is, at least one) of the grammatical objects of the article. By way of example, “an analogue” means one analogue or more than one analogue.

[00145] As used in the present invention, the terms “cell-permeable succinates”, “compounds of the invention”, “cell-permeable succinate derivatives” and “cell-permeable succinate precursors” are used interchangeably and refer to compounds of formula (I).

[00146] As used in the present invention, the term “bioavailability” refers to the degree to which or the rate at which a drug or other substance is absorbed or becomes available at the site of biological activity after administration. This property depends on a number of factors, including the solubility of the compound, the rate of absorption in the intestine, the degree of binding to proteins and metabolism, etc. Various tests for bioavailability that would be familiar to a person skilled in the art are described in the present invention (see also Trepanier et al, 1998, Gallant-Haidner et al, 2000).

[00147] As used in the present invention, the terms “impairment”, “inhibition”, “defect” used in relation to complex I of the respiratory chain are intended to denote that a certain medicinal substance has a negative effect on complex I or on mitochondrial metabolism upstream of complex I, which could encompass any effect and drug that limits the supply of NADH to complex I, e.g., effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and even even drugs that affect the levels of glucose or other substrates related to complex I). As described in the present invention, an excess of lactate in an individual is often an indication of a negative effect on aerobic respiration, including complex I.

[00148] As used in the present invention, the term “side effect” used in relation to the function of complex I of the respiratory chain, may be a side effect relating to lactic acidosis or it may be a side effect relating to organ toxicity to the drug. idiosyncratic, for example, hepatotoxicity, neurotoxicity, cardiotoxicity, renal toxicity and muscle toxicity, including but not limited to, for example, ophthalmoplegia, myopathy, sensorineural hearing impairment, epilepsy attacks, stroke, stroke-like events, ataxia, ptosis, cognitive impairment, altered states of consciousness, neuropathic pain, polyneuropathy, neuropathic gastrointestinal problems (gastroesophageal reflux, constipation, intestinal pseudo-obstruction), proximal renal tubular dysfunction, cardiac conduction defects (heart blocks), cardiomyopathy, hypoglycemia, gluconeogenic defects, insufficiency non-alcoholic liver disease, optic neuropathy, visual loss, diabetes and exocrine pancreatic insufficiency, fatigue, respiratory problems including intermittent shortness of breath.

[00149] As used in the present invention, the term “drug-induced” in relation to the term “side effect” should be understood in a broad sense. Thus, it not only includes drug substances, but also other substances that can lead to the unwanted presence of lactate. Examples are herbicides, toxic mushrooms, berries, etc.

[00150] Pharmaceutically acceptable salts of the compound of the invention include conventional salts formed from pharmaceutically acceptable organic or inorganic acids or bases, as well as quaternary ammonium acid addition salts. More specific examples of suitable acid salts include hydrochloric, hydrobromic, sulfuric, phosphoric, nitric, perchloric, fumaric, acetic, propionic, succinic, glycolic, formic, lactic, maleic, tartaric, citric, palmoic, malonic, hydroxymalic, phenylacetic acids. , glutamic, benzoic, salicylic, fumaric, toluenesulfonic, methanesulfonic, naphthalene-2-sulfonic, hydroxynaphthoic benzenesulfonic, iodide, malic, steroic, tannic and similar. Other acids, such as oxalic acid, although not in themselves pharmaceutically acceptable, may be useful in the preparation of salts useful as intermediates in obtaining the compounds of the invention and their pharmaceutically acceptable salts. More specific examples of suitable basic salts include sodium, lithium, potassium, magnesium, aluminum, calcium, zinc, N,N'-dibenzylethylenediamine, chloroprocaine, choline, diethanolamine, ethylenediamine, N-methylglucamine and procaine salts.

[00151] As used in the present invention, the term “alkyl” refers to any linear or branched chain composed of only sp3 carbon atoms, fully saturated with hydrogen atoms such as, for example, -CnHn+i, for chain alkyls linear, where n can be in the range of 1 and 10, such as, for example, methyl, ethyl, propyl, isopropyl, n-butyl, isobutyl, sec-butyl, tert-butyl, n-pentyl, neopentyl, isopentyl, hexyl , isohexyl, heptyl, octyl, nonyl or decyl. The alkyl, as used in the present invention, may be further substituted.

[00152] As used in the present invention, the term “cycloalkyl” refers to carbon chains structured as a cycle/ring with the general formula -CnHn-i, where n is between 3 and 10, such as, for example, cyclopropyl, cyclobutyl, cyclopentyl , cyclohexyl, cycloheptyl or cyclooctyl, bicyclo[3,2,1]octyl, spiro[4,5]decyl, norpinyl, norbonyl, norcapryl, adamantyl and the like.

[00153] As used in the present invention, the term “alkene” refers to a linear or branched chain composed of carbon and hydrogen, in which at least two carbon atoms are linked by a double bond, such as a chain C2-10 alkenyl unsaturated hydrocarbon with two to ten carbon atoms and at least one double bond. C2-6 alkenyl groups include, but are not limited to, vinyl, 1-propenyl, allyl, isopropenyl, n-butenyl, n-pentenyl, n-hexenyl and the like.

[00154] The term “C1-10 alkoxy”, in the present context, designates a -O-C1-6 alkyl group used alone or in combination, where C1-10 alkyl is as defined above. Examples of linear alkoxy groups are methoxy, ethoxy, propoxy, butoxy, pentoxy and hexoxy; Examples of branched-chain alkoxy groups are isopropoxy, sec-butoxy, tert-butoxy, isopentoxy, and isohexoxy. Examples of cyclic alkoxy groups are cyclopropyloxy, cyclobutyloxy, cyclopentyloxy and cyclohexyloxy.

[00155] The term “C3-7 heterocycloalkyl”, as used in the present invention, denotes a radical of a fully saturated heterocycle, such as a cyclic hydrocarbon containing one or more heteroatoms selected from nitrogen, oxygen and sulfur, independently in the cycle. Examples of heterocycles include, but are not limited to, pyrrolidine (1-pyrrolidine, 2-pyrrolidine, 3-pyrrolidine, 4-pyrrolidine, 5-pyrrolidine), pyrazolidine (1-pyrazolidine, 2-pyrazolidine, 3-pyrazolidine, 4- pyrazolidine, 5- pyrazolidine), imidazolidine (1-imidazolidine, 2-imidazolidine, 3- imidazolidine, 4-imidazolidine, 5-imidazolidine), thiazolidine (2-thiazolidine, 3- thiazolidine, 4-thiazolidine, 5-thiazolidine), piperidine (1-piperidine, 2-piperidine, 3-piperidine, 4-piperidine, 5-piperidine, 6-piperidine), piperazine (1-piperazine, 2-piperazine, 3-piperazine, 4-piperazine, 5-piperazine, 6- piperazine), morpholine (2-morpholine, 3-morpholine, 4-morpholine, 5-morpholine, 6-morpholine), thiomorpholine (2-thiomorpholine, 3-thiomorpholine, 4-thiomorpholine, 5-thiomorpholine, 6-thiomorpholine), 1 ,2-oxathiolane (3-(1,2-oxathiolane), 4-(1,2-oxathiolane), 5-(1,2-oxathiolane)), 1,3-dioxolane (2-(1,3-dioxolane ), 3-(1,3-dioxolane), 4-(1,3-dioxolane)), tetrahydropyran (2-tetrahydropyran, 3-tetrahydropyran, 4-tetrahydropyran, 5-tetrahydropyran , 6-tetrahydropyran), hexahydropyradizine, (1-(hexahydropyradizine), 2-(hexahydropyradizine), 3-(hexahydropyradizine), 4-(hexahydropyradizine), 5-(hexa- hydropyradizine) and 6-(hexahydropyradizine)).

[00156] The term “alkyl-C1-10-C3-10 cycloalkyl”, as used in the present invention, refers to a cycloalkyl group, as defined above, linked through an alkyl group, as defined above, having the indicated number of carbon atoms.

[00157] The term “C1-10-alkyl-C3-7 heterocycloalkyl”, as used in the present invention, refers to a heterocycloalkyl group, as defined above, linked through an alkyl group, as defined above, having the indicated number of carbon atoms.

[00158] The term “aryl”, as used in the present invention, is intended to include aromatic carbocyclic ring systems. Aryl is also intended to include the partially hydrogenated derivatives of the carbocyclic systems listed below.

[00159] The term “heteroaryl”, as used in the present invention, includes unsaturated heterocyclic ring systems containing one or more heteroatoms selected from nitrogen, oxygen and sulfur, such as furyl, thienyl and pyrrolyl, and is also intended to include the partially hydrogenated derivatives of the heterocyclic systems listed below.

[00160] The terms “aryl” and “heteroaryl”, as used in the present invention, refer to an aryl, which may be optionally unsubstituted or mono-, di- or trisubstituted, or a heteroaryl, which may be optionally unsubstituted or mono, di or trisubstituted. Examples of "aryl" and "heteroaryl" include, but are not limited to, phenyl, biphenyl, indenyl, naphthyl (1-naphthyl, 2-naphthyl), N-hydroxytetrazolyl, N-hydroxytriazolyl, N-hydroxyimidazolyl, anthracenyl ( 1-anthracenyl, 2-anthracenyl, 3-anthracenyl), phenanthrenyl, fluorenyl, pentalenyl, azulenyl, biphenylenyl, thiophenyl (1-thienyl, 2-thienyl), furyl (1-furyl, 2-furyl), furanyl, thiophenyl, isoxazolyl , isothiazolyl, 1,2,3-triazolyl, 1,2,4-triazolyl, pyranyl, pyridazinyl, pyrazinyl, 1,2,3-triazinyl, 1,2,4-triazinyl, 1,3,5-triazinyl, 1 ,2,3-oxadiazolyl, 1,2,4-oxadiazolyl, 1,2,5-oxadiazolyl, 1,3,4-oxadiazolyl, 1,2,3-thiadiazolyl, 1,2,4-thiadiazolyl, 1,2 ,5-thiadiazolyl, 1,3,4-thiadiazolyl, tetrazolyl, thiadiazinyl, indolyl, isoindolyl, benzofuranyl, benzothiophenyl (tianaphthenyl), indolyl, oxadiazolyl, isoxazolyl, quinazolinyl, fluorenyl, xanthenyl, isoindanyl, benzhydryl, acridinyl, benzisoxazolyl, purinyl, quinazolinyl, quinolizinyl, quinolinyl, isoquinolinyl, quinoxalinyl, naphthyridinyl, phteridinyl, azepinyl, diazepinyl, pyrrolyl (2-pyrrolyl), pyrazolyl (3-pyrazolyl), 5-thiophene-2-yl-2H- pyrazol-3-yl, imidazolyl ( 1-imidazolyl, 2-imidazolyl, 4-imidazolyl, 5-imidazolyl), triazolyl (1,2,3-triazol-1-yl, 1,2,3-triazol-2-yl, 1,2,3-triazole -4-yl, 1,2,4-triazol-3-yl), oxazolyl (2-oxazolyl, 4-oxazolyl, 5-oxazolyl), thiazolyl (2-thiazolyl, 4-thiazolyl, 5-thiazolyl), pyridyl ( 2-pyridyl, 3-pyridyl, 4- pyridyl), pyrimidinyl (2-pyrimidinyl, 4-pyrimidinyl, 5-pyrimidinyl, 6- pyrimidinyl), pyrazinyl, pyridazinyl (3-pyridazinyl, 4-pyridazinyl, 5- pyridazinyl), isoquinolyl (1-isoquinolyl, 3-isoquinolyl, 4-isoquinolyl, 5-isoquinolyl, 6-isoquinolyl, 7-isoquinolyl, 8-isoquinolyl), quinolyl (2-quinolyl, 3-quinolyl, 4-quinolyl, 5-quinolyl, 6- quinolyl, 7-quinolyl, 8- quinolyl), benzo[b]furanyl (2-benzo[b]furanyl, 3-benzo[b]furanyl, 4-benzo[b]furanyl, 5-benzo[b]furanyl, 6 -benzo[b]furanyl, 7-benzo[b]furanyl), 2,3-dihydro-benzo[b]furanyl (2-(2,3-dihydro-benzo[b]furanyl), 3- (2,3-dihydro-benzo[b]furanyl), 4-(2,3-dihydro-benzo[b]furanyl), 5-(2,3-dihydro-benzo[b]furanyl ), 6-(2,3-dihydro-benzo[b]furanyl), 7-(2,3-dihydro-benzo[b]furanyl)), benzo[b]thiophenyl(2-benzo[b ]thiophenyl, 3-benzo[b]thiophenyl,5-benzo[b]thiophenyl, 6-benzo[b]thiophenyl, 7- 2,3-dihydro-benzo[b]thiophenyl (2-(2,3- dihydro-3-(2,3-dihydro-benzo[b]thiophenyl), 4-(2,3-dihydro-5-(2,3-dihydro-benzo[b]thiophenyl) , 6-(2,3-dihydro-benzo[b]thiophenyl), 7-(2,3-dihydro-benzo[b]thiophenyl)), indolyl (1-indolyl, 2-indolyl, 3- indolyl, 4-indolyl, 5-indolyl, 6-indolyl, 7-indolyl), indazolyl (1- indazolyl, 2-indazolyl, 3-indazolyl, 4-indazolyl, 5-indazolyl, 6-indazolyl, 7-indazolyl), benzimidazolyl, (1-benzimidazolyl, 2-benzimidazolyl, 4- benzimidazolyl, 5-benzimidazolyl, 6-benzimidazolyl, 7-benzimidazolyl, 8- benzimidazolyl), benzoxazolyl (1-benzoxazolyl, 2-benzoxazolyl), benzothiazolyl (1-benzothiazolyl, 2 -benzothiazolyl, 4-benzothiazolyl, 5-benzothiazolyl, 6-benzothiazolyl, 7-benzothiazolyl) and carbazolyl (1-carbazolyl, 2-carbazolyl, 3-carbazolyl, 4-carbazolyl). Non-limiting examples of partially hydrogenated derivatives are 1,2,3,4-tetrahydronaphthyl, 1,4-dihydronaphthyl, pyrrolinyl, pyrazolinyl, indolinyl, oxazolidinyl, oxazolinyl, oxazepinyl and the like.

[00161] As used in the present invention, the term “acyl” refers to a carbonyl group -C(=O)R, wherein the R group is any of the groups defined above. Specific examples are formyl, acetyl, propionyl, butyryl, pentanoyl, hexanoyl, heptanoyl, octanoyl, nonanoyl, decanoyl, benzoyl and the like.

[00162] “Optionally substituted”, as applied to any group, means that said group may, if desired, be substituted with one or more substituents, which may be the same or different. “Optionally substituted alkyl” includes both “alkyl” and “substituted alkyl”.

[00163] Examples of suitable substituents for “substituted” and “optionally substituted” moieties include halogen (fluorine, chlorine, bromine or iodine), C1-6 alkyl, C3-6 cycloalkyl, hydroxyl, C1-6 alkoxy, cyano, amino nitro , C1-6 alkylamino, C2-6 alkenylamino, C1-6 dialkylamino, C1-6 acylamino, C1-6 diacylamino, C1-6 aryl, C1-6 arylamino, C1-6 aroylamino, benzylamino, C1-6 arylamido, carboxyl, C1-6 alkoxycarbonyl, or (C1-6 aryl)(C1-10 alkoxy)carbonyl, carbamoyl, C1-6 monocarbamoyl, C1-6 dicarbamoyl or any of the foregoing, wherein a hydrocarbyl moiety is itself substituted in si by halogen, cyano, hydroxyl, C1-2 alkoxy, amino, nitro, carbamoyl, carboxyl or C1-2 alkoxycarbonyl. In groups containing an oxygen atom, such as hydroxyl and alkoxy, the oxygen atom can be replaced with sulfur to form groups such as thio (SH) and thioalkyl (S-alkyl). Optional substituents therefore include groups such as S-methyl. In thioalkyl groups, the sulfur atom can be further oxidized to make a sulfoxide or sulfone, and thus optional substituents therefore include groups such as S(O)-alkyl and S(O)2-alkyl.

[00164] The substitution may take the form of double bonds, and may include heteroatoms. Thus, an alkyl group with a carbonyl (C=O) instead of a CH2 can be considered a substituted alkyl group.

[00165] Substituted groups therefore include, for example, CFH2, CF2H, CF3, CH2NH2, CH2OH, CH2CN, CH2SCH3, CH2OCH3, OMe, OEt, Me, Et, -OCH2O-, CO2Me, C(O)Me, i -Pr, SCF3, SO2Me, NMe2, CONH2, CONMe2, etc. In the case of aryl groups, substitutions may be in the form of rings of adjacent carbon atoms on the aryl ring, for example cyclic acetals such as O-CH2-O.

[00166] The invention is illustrated in the following figures: Figure 1. Schematic figure of the evaluation test for improving mitochondrial energy production function in cells with inhibited complex I. Protocol for evaluating compounds according to the invention. In the assay, mitochondrial function in intact cells is repressed with the respiratory complex I inhibitor rotenone. Candidate drugs are compared with endogenous (non-cell permeable) substrates before and after plasma membrane permeabilization to assess bioenergetic enhancement or inhibition.

[00167] Figure 2. Schematic figure of the assay for the improvement and inhibition of mitochondrial energy production function in intact cells. Protocol for evaluating the potency of compounds according to the invention. In the assay, mitochondrial activity is stimulated by the uncoupling of mitochondria with the FCCP protonphore. Candidate drugs are titrated to obtain the level of maximum convergent respiration (derived from complex I and complex II). Upon addition of rotenone, complex II-dependent stimulation is obtained. The complex III inhibitor antimycin is added to assess non-mitochondrial oxygen consumption.

[00168] Figure 3. Schematic figure of the assay for the prevention of lactate accumulation in cells exposed to a mitochondrial complex I inhibitor. Protocol for evaluating the potency of compounds according to the invention. In the assay, mitochondrial function in intact cells is repressed with the respiratory complex I inhibitor rotenone. As cells switch to glycolysis, lactate accumulates in the medium. The drug candidates are compared to endogenous (non-cell permeable) substrates and the reduced rate of lactate accumulation indicates restoration of mitochondrial ATP production.

[00169] Figure 4. Figure of lactate accumulation in an acute metabolic crisis model in pigs.

[00170] Lactate accumulation in an acute metabolic crisis model in pigs. In the animal model, mitochondrial function is repressed by infusion of the respiratory complex I inhibitor rotenone. As cells switch to glycolysis, lactate builds up in the body. Mean arterial lactate concentrations are demonstrated for animals treated with rotenone and vehicle at the indicated infusion rates. The drug candidates are evaluated in rotenone-treated animals and the decreased rate of accumulation indicates restoration of mitochondrial ATP production.

[00171] Figure 5 Effect of metformin on mitochondrial respiration in peripheral blood mononuclear cells (PBMCs) and human platelets. (a) Representative traces of O2 consumption measured simultaneously from PBMCs permeabilized and treated with metformin (1 mM, black trace) or with vehicle (H2O, gray trace) evaluated by applying sequential additions of respiratory complex-specific substrates and inhibitors. The trace stabilization phase, perturbations due to chamber reoxygenation, and complex IV substrate administration have been omitted (dashed lines). The boxes below the dashes define the respiratory complexes used for respiration during the oxidation of said substrates, complex I (CI), complex II (CII) or both (CI + II), as well as the respiratory states in the indicated parts of the protocol. Respiratory rates in the three different respiratory states and substrate combinations are illustrated by PBMCs (b) and platelets (c) for control (H2O) and the indicated concentrations of metformin: oxidative phosphorylation capacity supported by complex I substrates (OXPHOSCI) , maximum complex II-dependent flux through the electron transport system (ETSCII) followed by FCCP protonophore titration, and complex IV capacity (CIV). Values are represented as mean ± SEM. * = P < 0.05, ** = P < 0.01, and *** = P < 0.001 using one-way ANOVA with the Holm-Sidak multiple comparison method, n = 5. OXPHOS = oxidative phosphorylation. ETS = electron transport system. ROX = residual oxygen concentration.

[00172] Figure 6 Dose response comparison of toxicity exhibited by metformin and phenformin on mitochondrial respiratory capacity during oxidative phosphorylation, supported by substrates linked to complex I (OXPHOSCI) in permeabilized human platelets. Respiration rates are presented as the mean ± SEM and standard nonlinear curve fitting was applied to obtain half-maximal inhibitory concentration (IC50) values for metformin and phenformin. * = P < 0.05, ** = P < 0.01, and *** = P < 0.001 compared to control using one-way ANOVA with the Holm-Sidak multiple comparison method, n = 5.

[00173] Figure 7 Time- and dose-dependent effects of metformin on mitochondrial respiration in intact human platelets. (a) Routine platelet respiration, i.e., cell respiration with their endogenous substrate sources and ATP demand were monitored during 60 min incubation of the indicated concentrations of metformin or vehicle (H2O), which was followed by (b) Maximum respiratory capacity induced by titrating the FCCP protonophore to determine the maximum flux through the electron transport system (ETS) of intact cells. Data are expressed as the mean ± SEM, n = 5. * = P < 0.05, ** = P < 0.01, and *** = P < 0.001 using one-tailed ANOVA (b) and two-tailed ANOVA (a) with the Holm-Sidak post-hoc test.

[00174] Figure 8 Effect of metformin and phenformin on lactate production and pH in intact human platelet suspensions. Platelets were incubated in phosphate-buffered saline containing glucose (10 mM) for 8 h with metformin (10 mM, 1 mM), phenformin (0.5 mM), the complex I inhibitor rotenone (2 μM), or vehicle ( DMSO, control). (a) Lactate levels were determined every 2 h (n = 5), and (b) pH was measured every 4 h (n = 4). Data are expressed as the mean ± SEM. * = P < 0.05, ** = P < 0.01, and *** = P < 0.001 using two-tailed ANOVA with the Holm-Sidak post-hoc test.

[00175] Figure 9 Human intact thrombocytes (200 • 106/mL) incubated in PBS containing 10 mM glucose. (A) Cells incubated with 10 mM metformin were treated with succinate or NV118 in consecutive additions of 250 μM every 30 minutes. Before addition of NV118 at time 0 h, cells were incubated with metformin or vehicle for 1 h to establish equal initial lactate levels (data not shown). Lactate concentrations were sampled every 30 minutes. (B) Lactate production was calculated with a nonlinear fit regression and 95% confidence intervals for the time point at which the lactate curves were calculated. Cells incubated with metformin had significantly higher lactate production than the control, and succinate additions did not change this. Lactate production was significantly decreased when NV118 was added to cells incubated with metformin. (C) Rotenone-induced lactate production could similarly be attenuated by repeated additions of NV118.

[00176] Figure 10 Human intact thrombocytes (200 • 106/mL) incubated in PBS containing 10 mM glucose. (A) Cells incubated with 10 mM metformin were treated with succinate or NV189 in consecutive additions of 250 μM every 30 min. Before addition of NV189 at time 0 h, cells were incubated with metformin or vehicle for 1 h to establish equal initial lactate levels (data not shown). Lactate concentrations were sampled every 30 minutes. (B) Lactate production was calculated with a nonlinear fit regression and 95% confidence intervals for the time point at which the lactate curves were calculated. Cells incubated with metformin had significantly higher lactate production than the control, and succinate additions did not change this. Lactate production was significantly decreased when NV189 was added to cells incubated with metformin. (C) Rotenone-induced lactate production could similarly be attenuated by repeated additions of NV189. When antimycin was also added, the effect of NV189 on complex 2 was abolished by the inhibitory effect of antimycin on complex III.

[00177] Figure 11 Human intact thrombocytes (200 • 106/mL) incubated in PBS containing 10 mM glucose. (A) Cells incubated with 10 mM metformin were treated with succinate or NV241 in consecutive additions of 250 μM every 30 min. Before addition of NV241 at time 0 h, cells were incubated with metformin or vehicle for 1 h to establish equal initial lactate levels (data not shown). Lactate concentrations were sampled every 30 minutes. (B) Lactate production was calculated with a nonlinear fit regression and 95% confidence intervals for the time point at which the lactate curves were calculated. Cells incubated with metformin had significantly higher lactate production than the control, and succinate additions did not change this. Lactate production was significantly decreased when NV241 was added to cells incubated with metformin. (C) Rotenone-induced lactate production could similarly be attenuated by repeated additions of NV241.

[00178] Figure 12 Thrombocytes (200 • 106/mL), incubated in PBS containing 10 mM glucose with sampling of lactate concentrations every 30 minutes. (A) During 3 hours of incubation, cells treated with rotenone (2 μM) or its vehicle are monitored for changes in lactate concentration in the medium over time. Furthermore, cells were incubated with rotenone along with NV189 and cells with rotenone, NV189, and the complex III inhibitor antimycin (1 μg/mL) were monitored. Before addition of NV189 at time 0 h, cells were incubated with rotenone alone or vehicle for 1 h to establish equal initial lactate levels (data not shown). Rotenone increased the cells' lactate production, but it returned to normal (same slope of the curve) by co-incubation with NV189 (in consecutive additions of 250 μM every 30 minutes). When antimycin is also present, NV189 cannot function at the complex II level, and lactate production is again increased to the same level with only rotenone present. (B) A similar rate of lactate production as with rotenone can be induced by incubation with metformin at a concentration of 10 mM.

Experimental part General Biology Methods

[00179] A person skilled in the art will be able to determine the pharmacokinetics and bioavailability of the compound of the invention using in vivo and in vitro methods known to a person skilled in the art, including, but not limited to, those described below and in Gallant - Haidner et al, 2000 and Trepanier et al, 1998, and references therein. The bioavailability of a compound is determined by a number of factors, (e.g., water solubility, cell membrane permeability, the degree of protein binding and metabolism, and stability), each of which can be determined by in vitro testing, as described in the examples in the present invention, and it will be appreciated by a person skilled in the art that an improvement in one or more of these factors will lead to an improvement in the bioavailability of a compound. Alternatively, the bioavailability of the compound of the invention can be measured using in vivo methods, as described in more detail below, or in the examples in the present invention.

[00180] To measure in vivo bioavailability, a compound can be administered to a test animal (e.g., to a mouse or rat) either intraperitoneally (i.p.) or intravenously (i.v.) and orally (p.o.), and are Blood samples were taken at regular intervals to examine how the plasma concentration of the drug varies over time. The time course of plasma concentration over time can be used to calculate the absolute bioavailability of the compound as a percentage using standard models. An example of a typical protocol is described below.

[00181] For example, mice or rats are dosed with 1 or 3 mg/kg of the compound of the invention i.v., or 1, 5 or 10 mg/kg of the compound of the invention p.o. Blood samples are collected at intervals of 5 min, 15 min, 1 h, 4 h and 24 h, and the concentration of the compound of the invention in the sample is determined by LCMS-MS. The time course of plasma or whole blood concentrations can then be used to derive key parameters such as the area under the plasma or blood concentration curve over time (AUC - which is directly proportional to the total amount of drug unchanged drug reaching the systemic circulation), the maximum plasma or blood drug concentration (peak), the time at which the maximum plasma or blood drug concentration occurs (time of peak), additional factors that are used in accurately determining the Bioavailability include: terminal half-life of the compound, total body clearance, steady-state volume distribution and F%. These parameters are then analyzed by compartmental or non-compartmental methods to provide a calculated percent bioavailability, for an example of this type of method see Gallant-Haidner et al, 2000 and Trepanier et al, 1998, and references therein.

[00182] The effectiveness of the compound of the invention can be tested using one or more of the methods described below:

I. Assays to Assess Enhancement and Inhibition of Mitochondrial Energy Production Function in Intact Cells High resolution respirometry - A - General method

[00183] Mitochondrial respiration measurement is performed on a high-resolution oxygraph (Oxygraph - 2k, Oroboros Instruments, Innsbruck, Austria) at a constant temperature of 37°C. Isolated human platelets, leukocytes, fibroblasts, human heart muscle fibers, or other cell types containing live mitochondria are suspended in a 2 mL glass chamber at a concentration sufficient to generate an oxygen consumption in the medium > 10 pmol O2 s-1 mL-1.

High-resolution respirometry - B (used in lactate studies)

[00184] Real-time respirometric measurements were performed using high-resolution oxygraphs (Oxygraph - 2k, Oroboros Instruments, Innsbruck, Austria). The experimental conditions during measurements were as follows: 37°C, active chamber volume of 2 mL, and stirring speed of 750 rpm. O2 concentrations in the chamber were maintained between 200 and 50 μM with reoxygenation of the chamber during experiments as appropriate (Sjõvall et al., 2013a). To record data, DatLab software, versions 4 and 5, was used (Oroboros Instruments, Innsbruck, Austria). Settings, daily calibration, and instrumental baseline corrections were performed according to the manufacturer's instructions. Respiratory measurements were performed in any buffer containing 0.5 mM EGTA, 3 mM MgCl2, 60 mM K-lactobionate, 20 mM taurine, 10 mM KH2PO4, 20 mM HEPES, 110 mM sucrose and 1 g/L bovine serum albumin (MiR05 ) or phosphate-buffered saline (PBS) with glucose (5 mM) and EGTA (5 mM) as indicated in the corresponding sections. Respiratory values were corrected for the oxygen solubility factor of both media (0.92) (Pesta and Gnaiger, 2012). Lactate production of intact human platelets was determined in PBS containing 10 mM glucose. All measurements were performed at a platelet concentration of 200 x 10 cells per mL or at a PBMC concentration of 5 x 10 cells per mL.

Evaluation of compounds

[00185] Four typical evaluation protocols are used in intact cells. (1) Test to improve mitochondrial energy production function in cells with inhibited respiratory complex I.

[00186] The cells are placed in a buffer containing 110 mM sucrose, 20 mM HEPES, 20 mM taurine, 60 mM K-lactobionate, 3 mM MgCl2, 10 mM KH2PO4, 0.5 mM EGTA and 1 g/L BSA, in pH 7.1. After establishing the basal level of respiration with endogenous substrates, complex I is inhibited with 2 μM rotenone. Compounds dissolved in DMSO are titrated over a final concentration range of 10 μM to 10 mM. Subsequently, cell membranes are permeabilized with digitonin (1mg/1*106 plt) to allow entry of extracellularly released energy substrate or cell-impermeable energy substrates. After respiration stabilizes, 10 mM succinate is added as a reference to allow respiration downstream of complex I. After respiration stabilizes, the experiment is terminated by addition of antimycin at the final concentration of 1 μg/mL and any consumption of residual non-mitochondrial oxygen is measured. An increase in respiration rate in the described protocol is tightly coupled to ATP synthesis by oxidative phosphorylation, unless the cells are uncoupled (i.e., proton leak without ATP production). Uncoupling is tested by adding the ATP synthase inhibitor oligomycin (1 to 2 μg mL-1) in protocol 3, where the degree of uncoupling corresponds to the respiratory rate after addition of oligomycin.

(2) Assay for the enhancement and inhibition of mitochondrial energy production function in intact cells

[00187] In the second protocol, the same buffer is used as described above. Once basal respiration is established, the mitochondrial uncoupler FCCP is added at a concentration of 2 nM to increase metabolic demand. Compounds dissolved in DMSO are titrated in several steps from 10 μM to a final concentration of 10 mM in order to evaluate the concentration range of improvement and/or inhibition of respiration. The experiment is terminated by the addition of 2 μM rotenone to inhibit complex I, describing the use of the remaining substrate downstream of this respiratory complex, and 1 μg/mL of the complex III inhibitor antimycin to measure non-mitochondrial oxygen consumption.

(3) Assay to assess uncoupling in intact cells

[00188] In the third protocol, the same buffer as described above is used. After basal respiration is established, 1 mM of compound dissolved in DMSO is added. Subsequently, the ATP synthase inhibitor oligomycin is added. A reduction in respiration is a measure of how much of the oxygen consumption is coupled to ATP synthesis. Nothing, or only a slight reduction, indicates that the compound is inducing a proton leak across the inner mitochondrial membrane. The FCCP decoupler is then titrated to induce maximum uncoupled breathing. Rotenone (2 μM) is then added to inhibit complex I, describing the use of the remaining substrate downstream of this respiratory complex. The experiment is terminated by the addition of 1 μg/mL of the complex III inhibitor antimycin to measure non-mitochondrial oxygen consumption.

(4) Assay for improvement of mitochondrial energy production function in cells with respiratory complex I inhibited in human plasma

[00189] Intact human blood cells are incubated in plasma from the same donor. After establishing the basal level of respiration with endogenous substrates, complex I is inhibited with 2 μM rotenone. Compounds dissolved in DMSO are titrated over a final concentration range of 10 μM to 10 mM. The experiment is terminated by addition of antimycin at a final concentration of 1 μg/mL and any residual non-mitochondrial oxygen consumption is measured.

Properties of the desired compound in breathing assays

[00190] The ideal compound stimulates respiration in the protocols described in intact cells at low concentration without the inhibitory effect on succinate-stimulated respiration after permeabilization in protocol 1 or endogenous respiration in protocol 2. The concentration interval between the stimulatory effect maximum and inhibition should be as great as possible. After inhibition of respiration with mitochondrial toxins in or downstream of complex III, respiration must be stopped. See figure 1 and the listing below.

[00191] Desired properties of compounds:• maximum value reached at low drug concentration.

[0093] • a substantially greater than a' • a approaches b' • c approaches c' • d approaches d'

[0080] Compounds impermeable to the cell membrane are identified in the test as: • a approaches a'

[0081] Non-mitochondrial oxygen consumption induced by the candidate drug is identified when • d is greater than d'

II. Assay for the Prevention of Lactate Accumulation in Cells Exposed to a Mitochondrial Complex I Inhibitor

[0082] Intact human platelets, leukocytes, fibroblasts or other cell types containing live mitochondria are incubated in phosphate-buffered saline containing 10 mM glucose for 8 h with any of the complex I inhibitor drugs metformin (10 mM), phenformin (0.5 mM) or rotenone (2 μM). Inhibition of mitochondrial ATP production through oxidative phosphorylation by these compounds increases lactate accumulation through glycolysis. Lactate levels are determined every 2 h (or more frequently, e.g. every 30 min) using the Lactate Pro™ 2 blood lactate test meter (Arkray, Alere AB, Lidingo, Sweden) or similar types of measurements. Incubation is carried out at 37°C. pH is measured at the beginning and after 4 and then 8 h (or more frequently) of incubation using a standard pH meter, e.g. PHM210 (Radiometer, Copenhagen, Denmark). Candidate drugs are added to the assay from the beginning or after 30 to 60 minutes at concentrations within the range of 10 μM to 5 mM. Prevention of lactate accumulation is compared with parallel experiments with the carrier compound alone, typically DMSO. To evaluate the specificity of the candidate drug, it is also tested in combination with a downstream inhibitor of respiration, such as antimycin complex III inhibitor at 1 μg/mL, which should abolish the effect of the candidate drug and restore lactate production. The use of antimycin, therefore, is also a control for excessive effects of the candidate drugs on the lactate production capacity of the cells used in the assay. See, for example, figures 9, 10 and 11).

Data analysis

[0083] Statistical analysis was performed using Graph Pad PRISM software (GraphPad Software version 6.03, La Jolla, California, USA). All respiration, lactate, and pH data are expressed as the mean ± SEM. The ratios are graphed individually and as averages. One-way ANOVA was used for one-way comparison of three or more groups (drug concentration) and two-way mixed model ANOVA was used for two-way comparison (time and drug/treatment concentration) of three or more groups. Post-hoc tests to compensate for multiple comparisons were performed according to Holm-Sidak. Correlations were expressed as P and r2 values. Standard nonlinear curve fitting was applied to calculate half-maximal inhibitory concentration (IC50) values. The results were considered statistically significant at P < 0.05.

Properties of the desired compound in the cellular lactate accumulation assay

[0094] (1) The ideal compound prevents the accumulation of lactate induced by the inhibition of complex I, that is, the accumulation of lactate approaches a rate similar to that in cells with uninhibited complex I. (2) The prevention of lactate accumulation is abolished by a downstream respiratory inhibitor such as antimycin.

III. Trial for the prevention of lactate accumulation and energetic inhibition in a pig model of acute metabolic crisis

[0084] The exemplary drug candidates will be tested in a proof-of-concept in vivo model of metabolic crisis due to mitochondrial dysfunction in complex I. The model mimics severe conditions that can arise in children with genetic mutations in mitochondrial complex I or in treated patients and overdoses with clinically used medications such as metformin, which inhibits complex I when it accumulates in cells and tissues.

[0085] Landrace sows are used in the study. They are anesthetized and taken to surgery where catheters are placed for infusions and monitoring activities. A metabolic crisis is induced by infusion of the mitochondrial complex I inhibitor rotenone at a rate of 0.25 mg/kg/h for 3 h, followed by 0.5 mg/kg/h infused for one hour (vehicle consisting of NMP 25 %/Polysorbate 80 4%/water 71%). Cardiovascular parameters, such as arterial blood pressure, are measured continuously through a catheter placed in the femoral artery. Cardiac output (CO) is measured and recorded every 15 minutes by thermodilution, and pulmonary arterial pressure (BP, systolic and diastolic), central venous pressure (CVP) and SvO2 are recorded every 15 min, and blood pressure. Pulmonary incarceration (PECP) is recorded every 30 min from a Swan-Ganz catheter. Indirect calorimetry is performed, for example, using a Quark RMR ICU equipment (Cosmed, Rome, Italy). Blood gases and electrolytes are determined in arterial blood and venous blood collected from the femoral artery and Swan-Ganz catheters, and analyzed using an ABL725 blood gas analyzer (Radiometer Medical Aps, Br0nsh0j, Denmark). Analyzes include pH, BE, hemoglobin, HCO3, pO2, pCO2, K+, Na+, glucose and lactate.

Properties of the desired compound in an in vivo proof-of-concept model of metabolic crisis

[0086] The ideal compound should reduce lactate accumulation and reduce pH in pigs with metabolic crisis induced by complex I inhibition. The decrease in energy expenditure after complex I inhibition should be attenuated. The compound should not induce any overt negative effects as measured by blood tests and hemodynamics.

Metabolomics Method

[0087] Leukocytes and platelets are collected by standard methods and suspended in MiR05, a buffer containing 110 mM sucrose, 20 mM HEPES, 20 mM taurine, 60 mM K-lactobionate, 3 mM MgCl2, 10 mM KH2PO4, 0 EGTA, 5 mM and 1 g/L BSA, with or without 5 mM glucose, at pH 7.1. The sample is incubated with agitation in a high-resolution oxygraph (Oxygraph - 2k, Oroboros Instruments, Austria) at a constant temperature of 37°C.

[0088] After 10 minutes, rotenone in DMSO is added (2 μM) and the incubation continues. After another 5 minutes, the test compound in DMSO is added, optionally with more test compounds later and an additional incubation period. During incubation, O2 consumption is measured in real time.

[0089] At the end of incubation, the cells are collected by centrifugation and washed with 5% mannitol solution and extracted in methanol. An aqueous solution containing internal standard is added and the resulting solution treated by centrifugation in a suitable microcentrifuge tube with a filter.

[0090] The resulting filtrate is dried under vacuum before CE-MS analysis to quantify various primary metabolites by the method of Ooga et al (2011) and Ohashi et al (2008).

[0091] In particular, metabolite levels in the TCA cycle and glycolysis are evaluated for the impact of the compounds of the invention.

[0092] Ooga et al, Metabolomic anatomy of an animal model revealing homeostatic imbalances in dyslipidaemia, Molecular Biosystems, 2011, 7, 1217-1223 [0093] Ohashi et al, Molecular Biosystems, 2008, 4, 135-147

Materials

[0094] Unless otherwise indicated, all reagents used in the examples below are obtained from commercial sources. Examples Example 1

[0095] Succinyl chloride (0.1 mol) and triethylamine (0.4 mol) are dissolved in DCM and cysteine is added. The reaction is stirred at room temperature. The reaction is added to aqueous dilute hydrochloric acid, and then it is washed with water and brine. The organic layers are dried over magnesium sulfate and reduced under vacuum. The target compound is that purified by silica gel chromatography. Example 2 - Synthesis of (NV038, 01-038)

[0096] To a solution of cysteamine hydrochloride (5.0 g, 44 mmol) in CH3OH (50 mL) was added Et3N (4.4 g, 44 mmol), followed by (Boc)2O (10.5 g, 48.4 mmol) and the mixture was stirred at room temperature for 1 h. The reaction mixture was concentrated in vacuo. The residue obtained was dissolved in CH2Cl2, washed with 2 M aqueous HCl solution and brine, dried over Na2SO4, filtered and evaporated to yield tert-butyl 2-mercaptoethylcarbamate as a colorless oil, which was used in the next step without further purification.

[0097] Tert-butyl 2-mercaptoethylcarbamate (9.8 g, 55.0 mmol) and Et3N (5.6 g, 55.0 mmol) were dissolved in CH2Cl2 (100 mL), the mixture was cooled to 0° C and succinyl chloride (2.1 g, 13.8 mmol) was dropped. Then, the mixture was stirred at room temperature for 2 h. The reaction mixture was concentrated and the residue was purified by column chromatography (petroleum ether/EtOAc = 1/10 to 1/1). S,S-bis(2-(tert-butoxycarbonylamino)ethyl) butanobis(thioate) was obtained as a white solid.

[0098] A mixture of S,S-bis(2-(tertbutoxycarbonylamino)ethyl) butanobis(thioate) (2.0 g, 4.58 mmol) and TFA (10 mL) in CH2Cl2 (10 mL) was stirred in room temperature for 4 hours. The reaction mixture was concentrated to produce S,S-bis(2-aminoethyl) butanobis(thioate) as a yellow oil which was used in the next step without further purification.

[0099] S,S-bis(2-aminoethyl) butanobis(thioate) (1.1 g, 4.58 mmol) and Et3N (1.4 g, 13.74 mmol) were dissolved in CH2Cl2 (15 mL) , the mixture was cooled to 0°C and propionyl chloride (0.9 g, 10.07 mmol) was added dropwise. Then, the mixture was stirred at room temperature for 3 hours. The reaction mixture was concentrated and the residue was purified by preparative TLC (CH2Cl2/MeOH = 15/1). S,S-bis(2-propionamidoethyl) butanobis(thioate) was obtained as a white solid.Example 3 - Synthesis of (R)-4-(2-carboxy-2-propionamidoethylthio)-4-oxobutanoic acid (NV- 041, 01-041)

[00100] To a mixture of L-cysteine (2.00 g, 16.5 mmol) in THF/H2O (8 mL/2ml) was added NaOAc (2.70 g, 33.0 mmol). The mixture was stirred at room temperature for 20 min. The reaction was cooled to 5°C before propionic anhydride (2.30 g, 17.6 mmol) was dropped. The reaction mixture was stirred at room temperature overnight and then heated to reflux for 4 hours. The reaction mixture was cooled and acidified to pH 5 by adding 4N HCl. The resulting solution was evaporated under reduced pressure to remove THF. The residue was purified by HPLC-prep (elution with H2O (TFA 0.05%) and CH3CN) to yield 1.00 g of (R)-3-mercapto-2-propionamidopropanoic acid as a colorless oil.

[00101] A solution of (R)-3-mercapto-2-propionamidopropanoic acid (1.00 g, 5.65 mmol), succinic anhydride (565 mg, 5.65 mmol) and Et3N (572 mg, 5.65 mmol) in 10 mL of THF was heated under reflux overnight. The reaction mixture was concentrated and the residue was purified by preparative HPLC (eluting with H2O (TFA 0.05%) and CH3CN) to yield (R)-4-(2-carboxy-2-propionamidoethylthio)-4-oxobutanoic acid as a colorless oil. Example 4 Step 1

[00102] Triethylamine (0.24 mol) is added to a solution of N-acetylcysteamine (0.2 mol) in DCM. 4-Chloro-4-oxobutanoic acid (0.1 mol) is dropped and the reaction mixture is stirred at room temperature. The mixture is added to aqueous dilute hydrochloric acid and extracted with ethyl acetate, and then it is washed with water and brine. The organic layers are dried over magnesium sulfate and reduced under vacuum.Step 2

[00103] The product from step 3 (0.1 mol), acetic acid 1-bromoethyl ester (0.1 mol) and cesium carbonate (0.12 mol) is suspended in DMF and stirred at 60°C under inert atmosphere. The suspension is allowed to cool to room temperature, ethyl acetate is added and washed successively with dilute aqueous hydrochloric acid and water. The organic material is dried over magnesium sulfate and reduced under vacuum. The residue is purified by column chromatography.Example 5 Step 1

[00104] Triethylamine (0.24 mol) is added to a solution of N-acetylcysteamine (0.2 mol) in DCM. 4-Chloro-4-oxobutanoic acid (0.1 mol) is dropped and the reaction mixture is stirred at room temperature. The mixture is added to aqueous dilute hydrochloric acid and extracted with ethyl acetate, and then it is washed with water and brine. The organic layers are dried over magnesium sulfate and reduced under vacuum.Step 2

[00105] Dimethylamine (0.1 mol) and triethylamine (0.1 mol) are diluted in dichloromethane, the solution is cooled to 0°C and 2-chloroprpionyl chloride (0.1 mol) in DCM is added, and the solution is allowed to warm to room temperature and is allowed to stir under an inert atmosphere. The solution is washed with water. Organic materials are combined and volatile compounds are removed under vacuum. The residue is purified by silica gel chromatography. Step 3

[00106] 2-chloro-N,N-dimethylpropionamide (0.1 mol), the product of step 1 (0.1 mol), cesium carbonate (0.1 mol) and sodium iodide (0.01 mol) are suspended in DMF and the suspension is stirred at 80°C under an inert atmosphere. The suspension is cooled to room temperature, diluted with ethyl acetate and washed with water. Organic material is reduced under vacuum. The residue is purified by silica gel chromatography to produce the target compound.Example 6 - Synthesis of 4-oxo-4-(2-propionamidoethylthio)butanoic acid (NV114, 01-114)

[00107] Propionic anhydride (11.7 g, 89.7 mmol) and aqueous KOH (8 M, to maintain pH = 8) were dropped into a stirred solution of cysteamine hydrochloride (3.40 g, 30.0 mmol ) in 24 mL of water. The mixture was neutralized by the addition of 2N HCl and stirred for 1 hour at room temperature. The solution was cooled in an ice bath and solid KOH (6.00 g, 105 mmol) was added slowly. The mixture was stirred at room temperature for 50 minutes. After saturated with NaCl and neutralized with 6N HCl, the mixture was extracted with CH2Cl2 (4 x 30 mL). The combined CH2Cl2 extracts were dried (Na2SO4) and concentrated under vacuum to yield N-(2-mercaptoethyl)propionamide as a colorless oil, which was used in the next step without further purification.

[00108] A solution of N-(2-mercaptoethyl)propionamide (2.00 g, 15.0 mmol), succinic anhydride (1.50 g, 15.0 mmol) and Et3N (1.50 g, 15.0 mmol) in 20 mL of THF was heated under reflux overnight. The reaction mixture was concentrated and the residue was purified by preparative HPLC (elution with H2O (TFA 0.05%) and CH3CN) to yield 4-oxo-4-(2-propionamidoethylthio)butanoic acid as a colorless oil.Example 7 – Synthesis of 4-(2-acetamidoethylthio)-4-oxobutanoic acid (NV108, 01-108)

[00109] Acetic anhydride (8.48 mL, 90.0 mmol) and aqueous KOH (8 M, to maintain pH = 8) were dropped into a stirred solution of cysteamine hydrochloride (3.40 g, 30.0 mmol ) in 24 mL of water. The pH was then adjusted to 7 with the addition of 2N HCl. The mixture was stirred for 1 hour at room temperature and then the solution was cooled in an ice bath. To the above solution, solid KOH (6.0 g, 105 mmol) was added slowly, and the resulting mixture was stirred for 50 minutes at room temperature. After saturated with NaCl and neutralized with 6N HCl, the mixture was extracted with CH2Cl2 (4 x 30 mL). The combined CH2Cl2 extracts were dried (Na2SO4) and concentrated under vacuum to yield N-(2-mercaptoethyl)propionamide as a colorless oil, which was used in the next step without further purification.

[00110] A solution of N-(2-mercaptoethyl)acetamide (1.50 g, 12.7 mmol), succinic anhydride (1.3 g, 12.7 mmol) and Et3N (1.3 g, 12.7 mmol) in 20 mL of THF was heated under reflux overnight. The reaction mixture was concentrated and the residue was purified by preparative HPLC (elution with H2O (TFA 0.05%) and CH3CN) to yield 4-(2-acetamidoethylthio)-4-oxobutanoic acid as a colorless oil. Example 8 - Synthesis of (R)-3-(4-((R)-2-carboxy-2-propionamidoethylthio)-4-oxobutanoylthio)-2-propionamidopropanoic acid (NV099, 01-099)

[00111] The mixture of N-hydroxysuccinimide (3.00 g, 26.1 mmol) and Et3N (3.20 g, 31.3 mmol) in CH2Cl2 (60 mL) was dripped with succinyl chloride (2.00 g, 13.0 mmol). The mixture was stirred at room temperature for 3 hours before being diluted with water (60 ml). The resulting suspension was filtered and washed with water and CH2Cl2. The mass was collected and dried to yield bis(2,5-dioxopyrrolidin-1-yl) succinate as a gray solid.

[00112] A mixture of N-(2-mercaptoethyl)propionamide (400 mg, 2.26 mmol), bis(2,5-dioxopyrrolidin-1-yl) succinate (353 mg, 1.13 mmol) and TEA (286 mg, 2.83 mmol) in 3.0 mL of CH3CN was stirred at room temperature for 2 hours. The clear reaction solution was purified by preparative HPLC (elution with H2O (TFA 0.05%) and CH3CN) directly to yield the acid (R)-3-(4-((R)-2-carboxy-2-propionamidoethylthio) -4-oxobutanoylthio)-2-propionamidopropanoic acid as a colorless oil. Example 9 - Synthesis of (R)-4-(1-carboxy-2-(propionylthio)ethylamino)-4-oxobutanoic acid (NV122, 01-122)

[00113] To a mixture of (R)-3-mercapto-2-propionamidopropanoic acid (1.00 g, 8.25 mmol) and propionic acid (1.0 mL) in CHCl3 (10 mL) propionic anhydride was dripped (1.13 g, 8.67 mmol). The reaction mixture was heated to reflux overnight. The reaction mixture was cooled and succinic anhydride (1.00 g, 9.99 mmol) was added. The mixture was refluxed overnight before being concentrated under reduced pressure. The residue was purified by HPLC-prep (eluting with H2O (TFA 0.05%) and CH3CN) to yield (R)-4-(1-carboxy-2-(propionylthio)ethylamino)-4-oxobutanoic acid as a off-white solid.Example 10 - Synthesis of 4-(1-acetamido-2-methylpropan-2-ylthio)-4-oxobutanoic acid (NV188, 01-188)

[00114] To a stirred solution of cysteamine hydrochloride (2.00 g, 14.1 mmol) in 15 mL of water was added acetic anhydride (4.30 g, 42.4 mmol) and aqueous KOH (8 M, for maintain pH = 8) drop by drop. The mixture was then neutralized by the addition of 2N HCl and stirred for 1 hour at room temperature. To the solution cooled in an ice bath, solid KOH (2.80 g, 49.4 mmol) was slowly added and the mixture was stirred for 50 minutes at room temperature. After being saturated with NaCl and neutralized with 6N HCl, the mixture was extracted with CH2Cl2 twice. The combined CH2Cl2 extracts were dried (Na2SO4) and concentrated under vacuum to yield N-(2-mercapto-2-methylpropyl)acetamide as a white solid, which was used in the next step without further purification.

[00115] A solution of N-(2-mercapto-2-methylpropyl)acetamide (400 mg, 2.72 mmol), succinic anhydride (326 mg, 3.26 mmol) and Et3N (330 mg, 3.26 mmol) in 6 mL of THF was heated overnight. The reaction mixture was concentrated and the residue was purified by preparative HPLC (eluting with H2O (0.05% TFA) and CH3CN) to yield 4-(1-acetamido-2-methylpropan-2-ylthio)-4-oxobutanoic acid as a yellow oil.Example 11 - Synthesis of S,S-bis((R)-3-(diethylamino)-3-oxo-2-propionamidopropyl) butanobis(thioate) (NV185, 01-185)

[00116] To a solution of (R)-3-mercapto-2-propionamidopropanoic acid (5.00 g, 28.0 mmol) in DMF (50 mL) was added triphenylmethyl chloride (8.70 g, 31.0 mmol) at 0°C. The mixture was stirred at 0°C for 30 minutes and then it was warmed to room temperature overnight. The mixture was treated with water and extracted with EtOAc twice. The combined organic layers were washed with brine, dried over Na2SO4 and concentrated under reduced pressure. The residue was purified by silica gel column chromatography (CH2Cl2/MeOH = 80/1 ~ 50/1) to yield (R)-2-propionamido-3-(tritylthio)propanoic acid as a white solid.

[00117] To a stirred solution of (R)-2-propionamido-3-(tritylthio)propanoic acid (1.7 g, 4.0 mmol) in CH2Cl2 (50 mL) was added DCC (1.7 g, 8 .0 mmol) and HOBT (0.50 g, 4.0 mmol) at room temperature. The mixture was stirred at room temperature for 1 h, then diethylamine (0.80 g, 8.0 mmol) was added. The mixture was stirred at room temperature overnight. The mixture was washed with water, dried over Na2SO4 and concentrated under reduced pressure to give the crude product which was purified by silica gel column chromatography (EtOAc/petroleum ether = 1/6 ~ 1/1) to give (R) -N,N-diethyl-3-mercapto-2-propionamidopropanamide as a yellow oil.

[00118] To a solution of (R)-N,N-diethyl-3-mercapto-2-propionamidopropanamide (400 mg, 0.800 mmol) in CH2Cl2 (10 mL) at 0°C was added TFA (1 mL) and i -Pr3SiH (253 mg, 1.60 mmol). The mixture was warmed to room temperature and stirred for 2 hours. The solution evaporated under reduced pressure. The residue was purified by preparative HPLC (elution with H2O (TFA 0.5%) and CH3CN) to yield (R)-N,N-diethyl-3-mercapto-2-propionamidopropanamide as a yellow oil.

[00119] A mixture of (R)-N,N-diethyl-3-mercapto-2-propionamidopropanamide (150 mg, 0.600 mmol), Et3N (242 mg, 2.40 mmol) and bis(2,5-dioxopyrrolidin- 1-yl) succinate (94 mg, 0.30 mmol) in CH3CN (100 mL) was stirred at room temperature overnight. The mixture was evaporated under reduced pressure. The residue was purified by preparative HPLC (elution with H2O (TFA 0.5%) and CH3CN) to yield S,S-bis((R)-3-(diethylamino)-3-oxo-2-propionamidopropyl)butanobis(thioate ) (36% yield) as a yellow solid.Example 12 - Synthesis of 4-(2-(2-(diethylamino)-2-oxoethoxy)ethylthio)-4-oxobutanoic acid (NV193, 01-193).

[00120] To a solution of 2-bromoacetyl bromide (4.00 g, 20.0 mmol) and DIPEA (2.60 g, 20 mmol) in CH2Cl2 (50 mL) was dropped diethylamine (1.60 g, 20 .0 mmol) at 0°C. The mixture was stirred at 0°C for 30 min. The solution was evaporated under reduced pressure to remove CH2Cl2. The residue was purified by silica gel column chromatography (EtOAc/petroleum ether = 1/5 ~ 1/2) to yield 2-bromo-N,N-diethylacetamide as a yellow oil.

[00121] A solution of 2-mercaptoethanol (2.50 g, 32.0 mmol), triphenylmethyl chloride (10.7 g, 38.4 mmol) in 100 mL of THF was heated under reflux overnight . The reaction mixture was concentrated and the residue was purified by silica gel column chromatography (EtOAc/petroleum ether = 1/5 ~ 1/1) to yield 2-(2,2,2-triphenylethylthio)ethanol as a white solid .

[00122] To a solution of 2-(2,2,2-triphenylethylthio)ethanol (3.50 g, 10.9 mmol) in THF (30 mL) was added NaH (0.500 g, 13.0 mmol, 60% in oil) in portions at 0°C. The reaction mixture was stirred at 0°C for 1 hour. Then, a solution of 2-bromo-N,N-diethylacetamide (2.1 g, 10.9 mmol) in THF (5 mL) was dropped. The resulting mixture was warmed to room temperature for 2 hours. The mixture was quenched with water and extracted with EtOAc. The combined organic layers were washed with brine, dried over Na2SO4 and concentrated under reduced pressure. The residue was purified by silica gel column chromatography (EtOAc/petroleum ether = 1/5 ~ 1/2) to yield N,N-diethyl-2-(2-(tritylthio)ethoxy)acetamide as a white solid.

[00123] To a solution of N,N-diethyl-2-(2-(tritylthio)ethoxy)acetamide (2.70 g, 6.30 mmol) in CH2Cl2 (20 mL) was added TFA (2 mL) and i - Pr3SiH (2.00 g, 12.6 mmol) at 0°C. The mixture was warmed to room temperature and stirred for 2 hours. The solution was evaporated under reduced pressure to remove CH2Cl2. The residue was purified by silica gel column chromatography (EtOAc/petroleum ether = 1/5 ~ 1/1) to yield N,N-diethyl-2-(2-mercaptoethoxy)acetamide as a colorless oil.

[00124] A solution of N,N-diethyl-2-(2-mercaptoethoxy)acetamide (356 mg, 1.90 mmol), succinic anhydride (200 mg, 2.10 mmol) and Et3N (300 mg, 2.90 mmol) in 10 mL of THF was stirred under reflux overnight. The reaction mixture was concentrated in vacuo and the residue was purified by preparative HPLC (elution with H2O (0.5% TFA) and CH3CN) to yield 4-(2-(2-(diethylamino)-2-oxoethoxy)ethylthio acid )-4-oxobutanoic acid as a colorless oil.Example 13 - Synthesis of 3-(4-((R)-3-methoxy-3-oxo-2-propionamidopropylthio)-4-oxobutanoylthio)-2-propionamidopropanoate from (R) -methyl (NV205, 01-205)

[00125] propionamidoethylthio)-4-oxobutanoylthio)-2-propionamidopropanoic acid (300 mg, 0.69 mmol), CH3I (293 mg, 2.06 mmol) and K2CO3 (475 mg, 3.44 mmol) in 4.0 mL of DMF was stirred at room temperature overnight. The reaction mixture was filtered and the filtrate was purified by preparative HPLC (elution with H2O (TFA 0.05%) and CH3CN) directly to yield 3-(4-((R)-3-methoxy-3-oxo-2- (R)-methylpropionamidopropylthio)-4-oxobutanoylthio)-2-propionamidopropanoate as an off-white solid.Example 14 - Synthesis of NV189

[00126] A mixture of N-(2-mercapto-2-methylpropyl)acetamide (400 mg, 2.72 mmol), bis(2,5-dioxopyrrolidin-1-yl) succinate (339 mg, 1.09 mmol) and Et3N (550 mg, 5.44 mmol) in 6 mL of CH3CN was stirred at room temperature overnight. The reaction mixture was concentrated and the residue was purified by preparative HPLC (elution with H2O (TFA 0.05%) and CH3CN) to yield NV189 as an off-white solid. Example 15 - Synthesis of S,S-bis(2-(2-(diethylamino)-2-oxoethoxy)ethyl)butanobis(thioate) (NV195, 01-195)

[00127] To a solution of N,N-diethyl-2-(2-mercaptoethoxy)acetamide (438 mg, 2.3 mmol) in CH3CN (10 mL) was added bis(2,5-dioxopyrrolidin-1-yl) succinate (374 mg, 1.2 mmol) and Et3N (232 mg, 2.3 mmol). The mixture was stirred at room temperature overnight. The reaction mixture was concentrated under vacuum and the residue was purified by preparative HPLC (elution with H2O (TFA 0.5%) and CH3CN) to yield S,S-bis(2-(2-(diethylamino)-2-oxoethoxy )ethyl) butanobis(thioate) as a colorless oil. Example 16 - Synthesis of NV206

[00128] A mixture of (R)-3-(4-((R)-2-carboxy-2-propionamidoethylthio)-4-oxobutanoylthio)-2-propionamidopropanoic acid (400 mg, 0.916 mmol), CH3I (156 mg , 1.1 mmol) and K2CO3 (190 mg, 1.37 mmol) in 4 mL of DMF was stirred at room temperature for 6 hours. The reaction mixture was filtered and the filtrate was purified by HPLC-prep (elution with H2O (TFA 0.05%) and CH3CN) directly to produce NV206 as a colorless gum.Example 17 Results of biological experiments

[00129] The compounds presented in the following table were subjected to tests (1) to (4) mentioned under title I. Test to evaluate the improvement and inhibition of mitochondrial energy production function in intact cells. In the following table, the results are shown, which indicate that all tested compounds have suitable properties. Importantly, all compounds show specific effects on CII-related respiration, as can be seen from screening protocols 1 and 4, as well as a convergent effect, with available CI substrates, as seen in assay 2. Results of screening protocols 1 to 4

[00130] The compound numbers are as set out in examples 1 to 16. Legend: Convergent (routine) - increase in mitochondrial oxygen consumption induced by the compound under the conditions described in screening assay 3; Convergent (FCCP) - increase in mitochondrial oxygen consumption induced by the compound under the conditions described in screening assay 2 (uncoupled conditions); Convergent (plasma) - compound-induced increase in mitochondrial oxygen consumption in complex I-inhibited cells incubated in human plasma, as described in screening assay 4; CII - increase in mitochondrial oxygen consumption induced by the compound in cells with inhibited complex I, as described in screening assay 1; Uncoupling - level of oxygen consumption after addition of oligomycin as described in screening assay 3. The response of each parameter is classified as +, ++ or +++ in order of increasing potency. The parentheses [()] indicate an intermediate effect, that is, (+++) is between ++ and +++. Toxicity - the lowest concentration during compound titration at which a decrease in oxygen consumption is seen as described in screening assay 2. Examples 18 to 20 Metformin Studies

[00131] In the metformin study, the following compounds were used (and which are referred to in the figures). The compounds are described in WO 2014/053857. Sample preparation and acquisition

[00132] The study was carried out with the approval of the Regional Ethical Review Board of Lund University, Sweden (ethical review board authorization No. 2013/181). Venous blood from 18 healthy adults (11 men and 7 women) was collected into K2EDTA tubes (BD Vacutainer® brand, with dipotassium EDTA, BD, Plymouth, UK) according to standard clinical procedure after obtaining informed consent. in writing. For platelet isolation, whole blood was centrifuged (Multifuge 1 S-R Heraeus, Thermo Fisher Scientifics, Waltham, USA) at 500 g at room temperature (RT) for 10 min. Platelet-rich plasma was collected in 15 mL Falcon tubes and was centrifuged at 4600 g at room temperature for 8 min. The resulting pellet was resuspended in 1 to 2 mL of the donor's own plasma. PBMC were isolated using Ficol gradient centrifugation (Boyum, 1968). Blood remaining after platelet isolation was washed with an equal volume of saline and layered in 3 mL of Lymphoprep™. After centrifugation at 800 g at room temperature for 30 min, the PBMC layer was collected and washed with saline. After centrifugation at 250 g at room temperature for 10 minutes, the PBMC pellet was resuspended in two parts of saline and one part of the donor's own plasma. Cell counting for PBMCs and platelets was performed using an automated hemocytometer (Swelab Alfa, Boule Medical AB, Stockholm, Sweden).

Objective of the study reported in examples 18 and 19

[00133] Metformin induces lactate production in peripheral blood mononuclear cells and platelets through inhibition of mitochondrial complex I

[00134] Metformin is a widely used antidiabetic drug associated with the rare side effect of lactic acidosis, which has been proposed to be related to drug-induced mitochondrial dysfunction. Using respirometry, the aim of the study reported in examples 1 and 2 below was to evaluate the mitochondrial toxicity of metformin to human blood cells relative to phenformin, a biguanide analogue banned in most countries due to a high incidence of lactic acidosis. . Objective of the study reported in example 20

[00135] The objective is to investigate the ability of succinate prodrugs to alleviate or circumvent the undesirable effects of metformin and phenformin. Example 18A Effects of metformin and phenformin on mitochondrial respiration in permeabilized human platelets

[00136] In order to investigate the specific target of biguanide toxicity, a protocol was applied using digitonin permeabilization of blood cells and sequential additions of respiratory complex-specific substrates and inhibitors into the MiR05 medium. After stabilization of routine respiration, that is, the respiration of cells with their endogenous substrate supplies and ATP demand, metformin, phenformin or their vehicle (doubly deionized water) were added. A wide range of drug concentrations was applied: metformin 0.1, 0.5, 1 and 10 mM and phenformin 25, 100 and 500 μM. After incubation with the drugs for 10 min at 37°C, platelets were permeabilized with digitonin at a previously determined optimal digitonin concentration (1 μg 10-6 platelets) to induce maximal permeabilization of the cell membrane without interruption of function. mitochondrial and enabling measurements of maximal respiratory capacity (Sjovall et al. (2013a). To assess the capacity for complex I-dependent oxidative phosphorylation (OXPHOSCI) first, the NADH-bound substrates pyruvate and malate (5 mM), then ADP (1 mM) and lastly the additional complex I substrate glutamate (5 mM) were added sequentially. Subsequently, the FADH2-bound substrate succinate (10 mM) was provided to determine the convergent complex I and II-dependent OXPHOS capacity. (OXPHOSCI+II).The LEAKI+II state, a respiratory state where oxygen consumption is compensating for the reflux of protons across the mitochondrial membrane (Gnaiger, 2008), was assessed by the addition of the ATP synthase inhibitor oligomycin (1 μg .mL-1). The capacity of the maximum uncoupled respiratory electron transport system supported by insertion by complex I and II (ETSCI+II) was evaluated by subsequent titration with the protonophore carbonyl cyanide p-(trifluoromethoxy)phenylhydrazone (FCCP). Addition of the complex I inhibitor rotenone (2 μM) revealed complex II-dependent maximal uncoupled respiration (ETSCII). The complex III inhibitor antimycin (1 μg.mL-1) was then given to describe residual oxygen consumption (ROX). Finally, the artificial complex IV substrate N,N,N',N'-tetramethyl-p-phenylenediamine dihydrochloride (TMPD, 0.5 mM) was added, and the complex IV inhibitor sodium azide (10 mM) was added. was provided to measure complex IV activity and basal chemical level, respectively. Complex IV activity was calculated by subtracting the sodium azide value from the TMPD value. With the exception of complex IV activity, all respiratory states were measured at steady state and corrected for ROX. Complex IV activity was measured after ROX determination and not at steady state. The integrity of the mitochondrial outer membrane was examined by the addition of cytochrome c (8 μM) during OXPHOSCI+II in the presence of vehicle, 100 mM metformin, or 500 μM phenformin. Example 18B Effect of metformin on mitochondrial respiration in permeabilized human peripheral blood mononuclear cells and on mitochondrial respiration in intact human platelets

[00137] To analyze the respiration of permeabilized PBMCs in response to metformin (0.1, 1 and 10 mM), the same as that used for permeabilized platelets was used, except that the digitonin concentration was adjusted to 6 μg 10-6 PBMCs (Sjovall et al., 2013b).Results

[00138] Respiration using complex I substrates was dose-dependently inhibited by metformin in both permeabilized human PBMCs and platelets (figure 1). OXPHOSCI capacity was decreased with increasing concentrations of metformin compared to controls with almost complete inhibition at 10 mM (-81.47%, P < 0.001 in PBMCs and -92.04%, P < 0.001 in platelets), resulting in an IC50 of 0.45 mM for PBMCs and 1.2 mM for platelets. Respiratory capacities using both complex I and complex II bound substrates, OXPHOSCI+II and ETSCI+II, were decreased in the same way as OXPHOSCI by metformin, as illustrated by representative traces of simultaneously measured O2 consumption of permeabilized PBMCs. treated with vehicle and treated with 1 mM metformin (Figure 5a). In contrast, ETSCII capacity and complex IV activity did not change significantly in the presence of metformin compared to controls in any cell type (Figure 5b, c) and neither did LEAKI+II respiration (the respiratory state where consumption of oxygen is compensating for proton reflux across the mitochondrial membrane, traditionally denoted as state 4 in isolated mitochondria, data not shown). The mitochondrial inhibition of complex I induced by metformin did not appear to be reversible through extracellular and intracellular removal of the drug by washing and cell permeabilization, respectively. Although the severity of injury from complex I inhibition was attenuated by removal (likely attributed to a shorter drug exposure time), platelets did not recover routine and maximal mitochondrial function compared to control (data not shown). Phenformin, likewise, inhibited OXPHOSCI (figure 6), OXPHOSCI+II and ETSCI+II, but not ETSCII or complex IV-specific respiration (data not shown). Phenformin demonstrated a 20-fold more potent inhibition of OXPHOSCI in permeabilized platelets than metformin (IC50 0.058 mM and 1.2 mM, respectively) (figure 2). Metformin and phenformin did not induce increased respiration following cytochrome c administration and therefore did not disrupt the integrity of the outer mitochondrial membrane.

[00139] After stabilization of routine respiration in the MiR05 medium, the vehicle (double deionized water) or metformin 1, 10 and 100 mM metformin was added. Routine respiration was monitored for 60 min at 37°C before the ATP synthase inhibitor oligomycin (1 μg mL-1) was added to assess LEAK respiration. The maximum capacity of the uncoupled respiratory electron transport system supported by endogenous substrates (ETS) was achieved by FCCP titration. Respiration was then blocked by the complex I inhibitor rotenone (2 μM), the complex III inhibitor antimycin (1 μg mL-1) and the complex IV inhibitor sodium azide (10 mM) to evaluate ROX, in that all respiration values have been corrected. In an additional experiment, whole blood was incubated in K2EDTA tubes with different concentrations of metformin (0.1, 0.5 and 1 mM) for a period of 18 h before platelet isolation and breath analysis.Results

[00140] In intact human platelets, metformin decreased routine breathing in a dose- and time-dependent manner (figure 7a). When exposed to metformin or vehicle, platelets showed a continued decrease in routine breathing over time. After 60 min, routine breathing was reduced by - 14.1% in control (P < 0.05), by - 17.27% at 1 mM (P < 0.01), by -28.61% at 10 mM (P < 0.001) and by -81.78% at 100 mM metformin (P < 0.001) compared to the first measurement after addition. Metformin at 100 mM decreased routine breathing significantly compared to control already after 15 min of exposure (-39.77%, P < 0.01). The maximum uncoupled respiration of platelets (the capacity of ETS titrated with protonophore) after 60 min of incubation, was significantly inhibited by 10 mM (-23.86%, P < 0.05) and 100 mM (-56.86%, P < 0.001) of metformin (figure 3b). LEAK respiration in intact cells was not significantly altered by metformin incubation (data not shown). When whole blood was incubated at metformin concentrations of 1 mM for 18, routine respiration of intact human platelets was reduced by 30.49% (P < 0.05). Example 19 Effect of metformin and phenformin on lactate production and pH of intact human platelets.

[00141] Platelets were incubated for 8 h with metformin (1 mM, 10 mM), phenformin (0.5 mM), rotenone (2 μM) or the vehicle for rotenone (DMSO). Lactate levels were determined every 2 h (n = 5) using the Lactate Pro™ 2 blood lactate test meter (Arkray, Alere AB, Lidingo, Sweden)(Tanner et al, 2010). Incubation was carried out at 37°C, at a shaker speed of 750 rpm, and pH was measured at the beginning, after 4 and after 8 h of incubation (n = 4) using a standard pH meter PHM210 (Radiometer , Copenhagen, Denmark).Results

[00142] Lactate production increased in a time- and dose-dependent manner in response to incubation with metformin and phenformin in human platelets (figure 8a). Compared to the control, platelets treated with metformin (1 and 10 mM), phenformin (0.5 mM), and rotenone (2 μM) produced significantly more lactate over 8 h of treatment. At 1 mM metformin concentration, lactate increased from 0.30 ± 0.1 to 3.34 ± 0.2 over 8 h, and at 10 mM metformin concentration, lactate increased from 0.22 ± 0. 1 to 5.76 ± 0.7 mM. The corresponding pH decreased from 7.4 ± 0.01 in both groups to 7.16 ± 0.03 and 7.00 ± 0.04 for metformin at 1 mM and 10 mM concentration, respectively. Platelets treated with phenformin (0.5 mM) produced similar levels of lactate as samples treated with 10 mM metformin. The lactate level increase correlated with the decrease in pH for all treatment groups. Increased lactate levels in metformin-treated intact platelets were also correlated with decreased absolute respiratory OXPHOSCI values observed in metformin-treated permeabilized platelets (r2 = 0.60, P < 0.001). A limited set of experiments further demonstrated that intact PBMCs also show increased lactate release following exposure to 10 mM metformin (data not shown). Discussion of results from Examples 18 and 19

[00143] This study demonstrates a non-reversible toxic effect of metformin on mitochondria specific to complex I in human platelets and PBMCs at concentrations relevant to the clinical picture of intoxication caused by metformin. In platelets, a correlation between decreased complex I respiration and increased lactate production has been additionally demonstrated. The mitochondrial toxicity we observed for metformin developed over time, in intact cells. Phenformin, a structurally related compound currently banned in most countries due to a high incidence of LA, induced lactate release and pH reduction in platelets through a specific effect of complex I at a substantially lower concentration.

[00144] In the present study, using a high-resolution respirometry application model to evaluate the integrated mitochondrial function of human platelets, it was demonstrated that the mitochondrial toxicity of metformin and phenformin is specific to respiratory complex I and that a specific inhibition similar also occurs in PBMC. Complex I respiration of permeabilized PBMC was 2 times more sensitive to metformin than that of permeabilized platelets. However, due to the time-dependent toxicity of metformin (see below), the IC50 is possibly an underestimate and could be lower if determined after a longer exposure time. These findings further reinforce that the mitochondrial toxicity of metformin is not limited to specific tissues, as previously shown by others, but rather is a generalized effect at the subcellular level. The inhibition of metformin-induced complex IV in platelets reported by (Protti et al, 2012a, Protti et al, 2012b) was not confirmed in this study or in a previous study by Dykens et al._(2008) using isolated bovine mitochondria. Furthermore, metformin and phenformin did not induce respiratory inhibition through any nonspecific permeability changes of the inner or outer mitochondrial membranes, as there was no evidence of uncoupled or stimulatory response following addition of cytochrome c addition in the presence of the drugs. . High-resolution respirometry is a highly sensitive method and allows O2 measurements to be performed in the picomolar range. When applied to human blood cells ex vivo, it enables assessment of respiration in the fully integrated state in intact cells and allows exogenous delivery and control of substrates to intact mitochondria in permeabilized cells. This is in contrast to the enzymatic spectrophotometric assays predominantly used in research into the mitochondrial toxicity of metformin, for example by Dykens et al. (2008) and Owen et al. (2000). These assays measure the independent and non-integrated function of individual complexes and are therefore less physiological, potentially contributing to the differences in results between our studies.

[00145] The results of the study demonstrated significant respiratory inhibition, increased lactate and decreased pH in intact platelet suspensions caused by metformin at concentrations relevant for intoxication already after 8 to 18 h. Time-dependent inhibition of mitochondrial respiration coupled with lack of reversal following extracellular buffer exchange and dilution of intracellular content of soluble metformin by permeabilization of the cell's point for intramitochondrial accumulation being a key factor in the development of drug-induced mitochondrial dysfunction related by LA, and was proposed by third parties (Chan et al, 2005, Lalau, 2010).

[00146] The mitochondrial toxicity of phenformin has previously been demonstrated, for example, in HepG2 cells, a liver carcinoma cell line, and in isolated rat and cow mitochondria. Here, we demonstrate mitochondrial-specific toxicity also using human blood cells. Compared to metformin, phenformin had a stronger mitochondrial toxic potency in human platelets (IC50 1.2 mM and 0.058 mM, respectively). Phenformin and metformin show a 10- to 15-fold difference in clinical dosage and a 3- to 10-fold difference in therapeutic plasma concentration. In this study, we observed a 20-fold difference between phenformin and metformin in the potential to inhibit complex I. If translated to patients, this difference in mitochondrial toxicity relative to clinical dosing could potentially explain the higher incidence of LA associated with phenformin documented for phenformin.

[00147] Standard therapeutic plasma concentrations of metformin are in the range of 0.6 and 6.0 μM and toxic concentrations are between 60 μM and 1 mM. In a case report of involuntary poisoning caused by metformin, before hemodialysis, a serum metformin level greater than 2 mM was reported (Al-Abri et al., 2013). Tissue distribution studies have additionally demonstrated that the steady-state concentration of metformin is lower in plasma/serum than in other organs. It has been shown to accumulate in 7- to 10-fold higher concentrations in the gastrointestinal tract, with fewer but significantly higher amounts in the kidney, liver, salivary glands, lung, spleen, and muscles compared to plasma levels. In circumstances where metformin clearance is impaired, such as predisposing conditions affecting the cardiovascular system, liver or kidneys, toxic levels may eventually be reached. The toxic concentration of metformin observed in the present study (1 mM) is, therefore, comparable to that found in the blood of patients intoxicated with metformin. Although metformin is toxic to blood cells, as shown in this study, platelets and PBMCs are unlikely to be major contributors to the development of LA. As metformin accumulates in other organs and, additionally, these organs become more metabolically active, increased lactate production is likely to be observed first in other tissues. Our results therefore reinforce what has been suggested by others (Brunmair et al, 2004, Protti et al, 2012b, Dykens et al, 2008), that systemic mitochondrial inhibition is the cause of metformin-induced LA.

[00148] Based on previous studies and the present findings, it is intriguing to speculate on the possibility that the antidiabetic effect of metformin may be related to the inhibition of aerobic respiration. The reduced glucose levels in the liver and the reduced uptake of glucose into the blood from the small intestine in diabetic patients treated with metformin could be due to partial inhibition of complex I. Inhibition of complex I causes reduced production of ATP, greater amounts of AMP, the activation of the enzyme AMP-activated protein kinase (AMPK) and the accelerated replacement of glucose by the higher level of glycolysis activity, trying to compensate for the reduced production of ATP.

[00149] So far, treatment measures for metformin-associated LA consist of hemodialysis and hemofiltration to remove the toxin, correct acidosis, and increase renal blood flow. Example 20 Intervention in metformin-induced increase in lactate production with cell-permeable succinate prodrugs

[00150] Intervention of the metformin-induced increase in lactate production in intact human platelets with newly developed and synthesized cell-permeable succinate prodrugs was done in PBS containing 10 mM glucose. Platelets were exposed only to rotenone (2 μM), rotenone (2 μM) and antimycin (1 μg/mL, only for cells treated with NV 189) or 10 mM metformin and after 60 min vehicle (DMSO, control), or the cell-permeable succinate prodrugs (NV118, NV189, and NV241) or succinate were added at a concentration of 250 μM every 30 minutes. Lactate levels were measured at 30 min intervals at the beginning of the experiment. Furthermore, pH was measured before the first addition of vehicle (DMSO, control), the different cell-permeable succinate prodrugs (NV118, NV189, NV241) or succinate and at the end of the experiment. The lactate production rate was calculated with a non-linear adjustment with a 95% confidence interval (CI) of slope of the lactate x time curve (figures 9, 10, 11 and 12).

[00151] The results relating to example 20 are based on the tests described in the present invention. Lactate production due to incubation with rotenone and metformin in thrombocytes is attenuated by addition of the cell-permeable succinate prodrugs

[00152] The rate of lactate production in thrombocytes incubated with 2 μM rotenone was 0.86 mmol lactate (200406 trc^h)-1 (95% confidence interval [CI] 0.76 to 0.96) which was attenuated by NV118 (0.25 mmol [95% CI 0.18 to 0.33]), NV189 (0.42 mmol [95% CI 0.34 to 0.51]) and NV241 (0.34 mmol [95% CI 0.17 to 0.52]), which was not significantly different from cells that did not receive rotenone (0.35 [95% CI 0.14 to 0.55]) (Figures 9,10 and 11) . Cells incubated with antimycin in addition to rotenone and NV189 had lactate production comparable to the rotenone-treated cell (0.89 mmol [0.81 to 0.97]), demonstrating the specific mitochondrial effect of succinate prodrugs. permeable to cells (Figure 10).

[00153] Cells incubated with 10 mM metformin produce lactate at a rate of 0.86 mmol lactate (200409 trc^h)-1 (95% CI 0.69 to 1.04) compared to 0.22 mmol ( 95% CI 0.14 to 0.30) in cells treated with vehicle (water) (figure 12). Co-incubation with any of the three succinate prodrugs attenuates the effect of metformin, resulting in the production of 0.43 mmol (95% CI 0.33 to 0.54) for NV118 (Figure 9), 0.55 mmol ( 95% CI 0.44 to 0.65) for NV189 (figure 10) and 0.43 mmol (95% CI 0.31 to 0.54) for NV241 (figure 11).

[00154] All references cited in this application, including patents and patent applications, are incorporated into the present invention by reference, to the maximum extent possible.

[00155] Throughout the specification and the following claims, unless the context indicates otherwise, the word “comprise”, and variations such as “comprise” and “comprising” will be understood as implying the inclusion of an integer, step , group of integers, or group of steps, but not to the exclusion of any other integer, step, group of integers, or group of steps.

[00156] The application of which this description and claims form a part may be used as a basis for priority over any subsequent application. The claims of such subsequent application may be directed to any feature or combination of features described in the present invention. They may take the form of product, composition, process or use claims, and may include, by way of example and without limitation, the following claims:

[00157] All references cited in this application, including patents and patent applications, are incorporated into the present invention by reference, to the maximum extent possible.

[00158] Throughout the specification and the following claims, unless the context indicates otherwise, the word “comprise”, and variations such as “comprise” and “comprising” will be understood as implying the inclusion of an integer, step , group of integers, or group of steps, but not to the exclusion of any other integer, step, group of integers, or group of steps. The word “comprises” includes “contains” and “consisting of.”

General description of the class of compounds to which the compounds according to the invention belong and specific embodiments

[00159] The class of compounds can be defined by the formula (IB) below, or a pharmaceutically acceptable salt thereof. Where the dotted line between A and B denotes an optional bond in order to form a closed ring structure, where Z is selected from -CH2-CH2- or >CH(CH3), -O, S, A and B are independently identical or different and are selected from -O-R', -NHR'', -SR''' or -OH, with the proviso that both A and B cannot be H, R', R'' and R''' are independently identical or different, and are selected from the formulas (IIB) to (IXB) below: R1 = H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, O-acyl, O-alkyl, N-acyl, N-alkyl, X-acyl, CH2-X-alkyl, CH2- X-acyl, F, CH2COOH, CH2CO2-alkyl or any of the formulas below (a) to (f)

[00160] In preferred structures, R1 = H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, O-acyl, O-alkyl, N-acyl, N-alkyl, X-acyl, CH2 - X-alkyl, CH2-X-acyl, F or CH2COOH. X = O, NH, NR6, S R2 = ME, ET, PROPILA, I -PROPILHA, Butyl, Isobutyl, T -Butyl, -C (O) CH3, -C (O) CH2C (O) CH3, -C ( O)CH2CH(OH)CH3, R3 = R1, that is, it is the same or different group, as mentioned in R1 X1 = CR'3R'3, NR4 n = 1 to 4, p = 1 to 2 X2 = OR5, NR1R'2 R'3 = H, Me, Et, F R4 = H, Me, Et, i-Pr R5 = acetyl, propionyl, benzoyl, benzylcarbonyl R'2 = H.HX3, acyl, acetyl, propionyl, benzoyl, X3 = F, Cl, BR and I R6 = H or alkyl such as me, et, n-propilla, ipopilla, butyl, isobutil, t-butyl or acetila, such as acyl, propionilla, benzoil or the formula (IIB), formula (IIBI) or formula (VIIIB) X5 = -H, -COOH, -C(=O)XR6, x , X5 can also be CONR1R3. R9 = H, Me, Et or O2CCH2CH2COXR8 R10 = O-acyl, NH-alkyl, NH-acyl or O2CCH2CH2COX6R8 - butyl, acetyl, acyl, propionyl, benzoyl or the formula (IIB), R11 and R12 are independently H, alkyl, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl, acyl, -CH2-X-acyl, -CH2-X-acyl, where X = O, NR6 or S, Rc and Rd are independently CH2-X-alkyl, CH2-X-acyl, where X = O, NR6 or S, Rf, Rg and Rh are independently selected from -butyl, isobutyl, sec-butyl, tert-butyl, n-pentyl, neopentyl, isopentyl, hexyl, isohexyl, heptyl, octyl, nonyl or decyl, and acyl is, for example, formyl, acetyl, propionyl, butyryl, pentanoyl, benzoyl and the like, and in which acyls and alkyls can be optionally substituted,

[00161] The dotted bond between A and B denotes an optional bond to form a cyclic structure of formula (I) and with the proviso that when a cyclic bond is present, the compound according to formula (I) is selected in where X4 is selected from -COOH, -C(=O)XR6, and wherein Rx and Ry are selected independently of R1, R2, R6 or R', R'' or R''', with the proviso that Rx and Ry cannot both be -H.

[00162] In a preferred aspect, R', R'' and R''' are independently identical or different and selected from the formula (IIB), (VB), (VII) or (VIIIB) below:

[00163] Preferably, and in relation to formula (IIB), at least one of R1 and R3 is -H, so that formula II is:

[00164] Preferably, and in relation to formula (VII), p is 1 or 2, preferably p is 1 and X5 is -H, so that formula (VIIB) is

[00165] Preferably, and in relation to formula (IXB), at least one of Rf, Rg and Rh is - H or alkyl, with alkyl being as defined herein. Furthermore, it is also preferred, with respect to formula (IX), that at least one of Rf, Rg and Rh is -CH2-X-acyl, with acyl being as defined herein.

[00166] An interesting subclass of the aforementioned class refers to compounds of formula (I) or a pharmaceutically acceptable salt thereof. The dotted line between A and B denotes an optional bond in order to form a closed ring structure.

[00167] In formula (IC) Z is selected from -CH2-CH2- or >CH(CH3), A is selected from -SR, -OR and NHR, and where R is

[00168] B is selected from -O-R', -NHR'', -SR''' or -OH; R' is selected from the formula (IIC) to (IXC) below:

[00169] Preferably, R' is selected from the formula (IIC), (VC) to (IXC) below: R', R'' and R''' are independently identical or different, and are selected from the formulas (IVC to VIIIC) below: R1 = H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, O-acyl, O-alkyl, N-acyl, N-alkyl, X-acyl, CH2-X-alkyl, CH2- X-acyl, F, CH2COOH, CH2CO2-alkyl or any of formulas (a) to (f)

[00170] Preferably, R1 = H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, O-acyl, O-alkyl, N-acyl, N-alkyl, X-acyl, CH2-Xalkyl , CH2-X-acyl, F, CH2COOH, CH2CO2-alkyl, X = O, NH, NR6, S R2 = Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, C(O)CH3, C(O)CH2C(O)CH3, C(O)CH2CH(OH)CH3, R3 = R1, that is, it can be the same or different group, as defined for R1,X1 = CR'3R'3, NR4 n = 1 to 4, p = 1 to 2 2 = H.HX3, acyl, acetyl, propionyl, benzoyl, benzylcarbonyl, , propionyl, benzoyl or the formula (IIC), formula (IIIC) or the formula (VIIIC) X5 can also be CONR1R3 R9 = H, Me, Et or O2CCH2CH2COXR8 R10 = O-acyl, NH-alkyl, NH-acyl or O2CCH2CH2COX6R8 butyl, isobutyl, tbutyl, acetyl, acyl, propionyl, benzoyl or the formula (IIC), formula (IIIC) or formula (VIIIC) R11 and R12 are independently H, alkyl, Me, Et, propyl, ipropyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl, acyl, -CH2-X-acyl, -CH2-X-acyl, where X = O, NR6 or S Rc and Rd are independently CH2-X-alkyl, CH2-X -acyl, where X = O, NR6 or S, Rf, Rg and Rh are independently selected from propyl, i-propyl, butyl, isobutyl, t-butyl and acyl is, for example, formyl, acetyl, propionyl, isopropionyl, butyryl, tert-butyryl, pentanoyl, benzoyl and the like, and in which acyls and alkyls may optionally be substituted, and when the dotted bond between A and B is present, the compound according to formula (I) is where X4 is selected from -COOH, -C(=O)XR6,

[00171] Preferably, and in relation to formula (IIC), at least one of Ri and R3 is -H, so that formula II is:

[00172] Preferably, and in relation to the formula (VIIC), p is 1 or 2, preferably p is 1 and X5 is -H, so that the formula (VIIC) is

[00173] Preferably, and in relation to formula (IXC), at least one of Rf, Rg and Rh is - H or alkyl, with alkyl being as defined herein. Furthermore, it is also preferred, with respect to formula (IXC), that at least one of Rf, Rg and Rh is -CH2-X-acyl, with acyl being as defined herein.

[00174] Interesting compounds according to formula (IC) are: where X4 is selected from -COOH, -C(=O)XR6, where R1 and X5 are as defined in this document. Preferably, X5 is -H. where R6, X5 and R1 are as defined herein. Preferably, X5 is -H. where X5 and R1 are as defined in this document. Preferably, X5 is -H.

Specific modalities:

[0095] 1. a compound according to Formula (I) or a pharmaceutically acceptable salt thereof, wherein the dotted bond between A and B indicates an optional bond so as to form a closed ring structure, and wherein Z is selected from -CH2-CH2- or >CH(CH3) , A is selected from -SR, -OR and NHR, and NHR and R is B is selected from --O-R', -NHR'', -SR''' or -OH; and R' is selected from formula (II) to (IX) below: R', R'' and R''' are independently different or identical and are selected from the formulas (IV-VIII) below: R1 = H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, O-acyl, O-alkyl, N-acyl, N-alkyl, Xacyl, CH2Xalkyl, CH2X-acyl, F, CH2COOH, CH2CO2alkyl or any of the below formulas (a)-(f) R2 = Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, C(O)CH3, C(O)CH2C(O)CH3, C(O)CH2CH(OH)CH3, R3 = R1, i.e. different or identical to the groups mentioned in R1, X1 = CR'3R'3, NR4 n = 1-4, p = 1-2 R4 = H, Me, Et, i-Pr R5 = acetyl, propionyl, benzoyl, benzylcarbonyl R'2 = H.HX3, acyl, acetyl, propionyl, benzoyl, benzylcarbonyl X3 = F, Cl, Br and I R6 = H, alkyl, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl or formula (II), formula (III) or formula (VIII) -C(=O)XR6, R9 = H, Me, Et or O2CCH2CH2COXR8 R10 = Oacyl, NHalkyl, NHacyl or O2CCH2CH2CO acyl, propionyl, benzoyl or formula (II), formula (III) or formula (VIII) R11 and R12 are independently H, alkyl, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, acyl , propionyl, benzoyl, acyl, -CH2Xalkyl, -CH2Xacyl, where X = O, NR6 or S Rc and Rd are independently CH2Xalkyl, CH2Xacyl, where -CH2Xalkyl, -CH2X-acyl and R9 alkyl is, for example, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl and acyl is, for example, formyl, acetyl, propionyl, isopropionyl, bituryl, tert -butyryl, pentanoyl, benzoyl and the like, and in which acyls or alkyls may be optionally substituted, and when the dotted bond between A and B is present, the compound according to formula (I) is where X4 is selected from -COOH, -C(=O)XR6, and with the additional condition that the compound is not any of the compounds below

[0096] 2. A compound according to embodiment 1, wherein formula (II) is such that at least one of R1 and R3 is -H such that formula II is:

[0097] 3. A compound according to embodiment 1, wherein formula (III) is such that R4 is –H and formula (III) is

[0098] 4. A compound according to modality 1, wherein formula (VII) is such that , p=2 and X5 is –H and formula (VII) is

[0099] 5. A compound according to embodiment 1, wherein formula (IX) is such that at least one of Rf, Rg, Rh is -H or alkyl, with alkyl as defined herein.

[00100] 6. A compound according to modality 1 or 5, wherein formula (IX) is such that at least one of Rf, Rg, Rh is -CH2Xacyl, with the acyl as defined herein.

[00101] 7. A compound according to any one of embodiments 1 to 6, wherein Formula (I) is where X4 is selected from -COOH, -C(=O)XR6,

[00102] 8. A compound according to any one of embodiments 1 to 6, wherein Formula (I) is wherein X5 and R1 is as defined in embodiment 1, and wherein X5 is preferably -H.

[00103] 9. A compound according to any one of embodiments 1 to 6, wherein Formula (I) is wherein X5 and R1 is as defined in embodiment 1, and wherein X5 is preferably -H.

[00104] 10. A compound according to any one of embodiments 1 to 6, wherein Formula (I) is wherein X5, R1 and R6 is as defined in embodiment 1, and wherein X5 is preferably -H.

[00105] 11. A compound according to any one of embodiments 1-10 for use in medicines.

[00106] 12. A compound according to any one of embodiments 1 to 10, for use in cosmetics.

[00107] 13. A compound, according to any one of embodiments 1 to 10, for use in the treatment or prevention of metabolic diseases, or in the treatment of diseases of mitochondrial dysfunction or diseases related to mitochondrial dysfunction, treatment or suppression of mitochondrial disorders , stimulation of mitochondrial energy production, treatment of cancer and subsequent hypoxia, ischemia, stroke, myocardial infarction, acute angina, acute kidney injury, coronary occlusion and atrial fibrillation, or to prevent or neutralize reperfusion injury.

[00108] 14. A compound according to the use according to embodiment 11, wherein the medical use is the prevention or treatment of drug-induced mitochondrial side effects.

[00109] 15. A compound for use according to embodiment 14, wherein the prevention or drug-induced mitochondrial side effects refer to drug interaction with Complex I, such as, for example, interaction with Complex I of metformin.

[00110] 16. A compound according to embodiment 13, wherein diseases of mitochondrial dysfunction involve, for example, mitochondrial deficiency, such as a deficiency of Complex I, II, III or IV or an enzyme deficiency, such as , for example, pyruvate dehydrogenase deficiency.

[00111] 17. A compound for use according to any of modalities 13 to 16, in which diseases of mitochondrial dysfunction or diseases related to mitochondrial dysfunction are selected from Alpers Syndrome (Progressive Infantile Polyodystrophy, Amyotrophic Lateral Sclerosis (ALS) , Autism, Barth Syndrome (Lethal Infantile Cardiomyopathy), Beta-oxidation Insufficiency, Bioenergetic Metabolism Deficiency, Carnitine-acylcarnitine Deficiency, Carnitine Deficiency, Creatinine Deficiency Syndromes (Brain Creatinine Deficiency Syndromes (CCDS) include: Guanidinoacetate Methyltransferase Deficiency (GAMT Deficiency), L-Arginine: Glycine Amidinotransferase Deficiency (AGAT Deficiency) and Related Creatine Transporter SLC6A8 Deficiency (SLC6A8 Deficiency), Complex I Deficiency Coenzyme Q10 Deficiency (NADH Dehydrogenase ( NADH-CoQ reductase deficiency), Complex II Deficiency (Succinate dehydrogenase deficiency), Complex III deficiency (Ubiquinone-cytochrome c oxidoreductase deficiency), Complex IV deficiency/COX deficiency (cytochrome c oxidase deficiency is caused due to an insufficiency in Complex IV of the respiratory chain), Complex V Deficiency (ATP synthase deficiency), COX Deficiency, CPEO (Chronic Progressive External Ophthalmoplegia Syndrome), CPT I Deficiency, CPT II Deficiency, Friedreich's Ataxia ( FRDA or FA), Glutaric Aciduria Type II, SKS (Kearns-Sayre Syndrome), Lactic Acidosis, LCAD (Long Chain Acyl-CoA Dehydrogenase Deficiency), LCHAD, Leigh Syndrome or Disease (Subacute Necrotizing Encephalomyelopathy), LHON (Leber's Hereditary Optic Neuropathy), Luft's Disease, MCAD (Medium Chain Acyl-CoA Dehydrogenase Deficiency), MELAS (Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-Like Episodes), MERRF (Myoclonic Epilepsy and Red Stabbed Fiber Disease) , MIRAS (Mitochondrial Recessive Ataxia Syndrome), Mitochondrial Cytopathy, Mitochondrial DNA Depletion, Mitochondrial Encephalopathy, including: Encephalomyopathy and Encephalomyelopathy, Mitochondrial Myopathy, MNGIE (Myoneurogastrointestinal Disorder and Encephalopathy, NARP (Neuropathy, Ataxia and Retinitis pigmentosa), Associated Neurodegenerative Disorders with Parkinson's, Alzheimer's or Huntington's disease, Pearson Syndrome, Pyruvate Carboxylase Deficiency, Pyruvate Dehydrogenase Deficiency, POLG Mutations, Respiratory Chain Deficiencies, SCAD (Short Chain Acyl-CoA Dehydrogenase Deficiency), SCHAD, VLCAD (Short Chain Acyl-CoA Dehydrogenase Deficiency), SCHAD, VLCAD of Very Long Chain Acyl-CoA Dehydrogenase).

[00112] 18. A compound for use according to modality 17, in which mitochondrial dysfunction or disease related to mitochondrial dysfunction is attributed to complex I dysfunction and selected from Leigh Syndrome, Leber Hereditary Optic Neuropathy (LHON ), MELAS (Mitochondrial Encephalopathy, Lactic Acidosis and stroke-like episodes) and MERRF (Myoclonic Epilepsy with Red Split Fibers).

[00113] 19. A composition comprising a compound of Formula (I) as defined according to any one of embodiments 1 to 10 and one or more pharmaceutically or cosmetically acceptable excipients.

[00114] 20. A method of treating an individual suffering from diseases of mitochondrial dysfunction or diseases related to mitochondrial dysfunction as defined in any one of embodiments 16 to 18, the method comprising administering to the individual an effective amount of a composition as defined in modality 19.

[00115] 21. A method according to embodiment 20, wherein the composition is administered parenterally, orally, topically (including buccal, sublingual or transdermal), via a medical device (e.g., a stent), by inhalation or by injection (subcutaneous or intramuscular)

[00116] 22. A method according to any one of embodiments 20 to 21, wherein the composition is administered as a single dose or a plurality of doses over a period of time, such as, for example, once a day, twice a day, or 3 to 5 times a day as needed.

[00117] 23. A compound according to any one of embodiments 1 to 10 for use in the treatment or prevention of lactic acidosis.

[00118] 24. A compound according to any one of embodiments 1 to 10, for use in the treatment or prevention of a selected drug-induced side effect of lactic acidosis and side effects related to insufficiency, inhibition or malfunction of Complex I.

[00119] 25. A compound according to any one of embodiments 1 to 10, for use in the treatment or prevention of a selected drug-induced side effect of lactic acidosis and side effects related to insufficiency, inhibition or malfunction in aerobic metabolism a upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect that limits the supply of NADH to Complex I, e.g., effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism, and drug that affect glucose levels or other substrates related to Complex I).

[00120] 26. A combination of a drug substance and a compound according to any one of embodiments 1 to 10 for use in treating and/or preventing a drug-induced side effect selected from i) lactic acidosis, ii) and side effects related to insufficiency, inhibition or malfunction of Complex I, and iii) side effects related to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect which limits the supply of NADH to Complex I, e.g., effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism, and drugs that affect glucose levels or other substrates related to Complex I), where i ) the drug substance is used for the treatment of a disease for which the drug substance is indicated, and ii) the succinate prodrug is used for the prevention or relief of side effects induced or inducible by the drug substance, wherein side effects are selected from lactic acidosis and side effects related to insufficiency, inhibition or malfunction of Complex I.

[00121] 27. A composition comprising a drug substance and a compound according to any one of embodiments 1 to 10, wherein the drug substance has a drug-induced side effect potential selected from i) lactic acidosis, ii) side effects related to insufficiency, inhibition or malfunction of Complex I, and iii) side effects related to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect which limits the supply of NADH to Complex I, e.g. effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and even drugs that affect glucose levels or other substrates related to Complex I).

[00122] 28. A kit comprising i) a first container comprising a drug substance, which has a potential drug-induced side effect selected from i) lactic acidosis, ii) and side effects related to an insufficiency, inhibition or malfunction of the Complex I, and iii) side effects related to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect that limits the supply of NADH to Complex I, e.g. example, effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and drugs that affect glucose levels or other substrates), and ii) a second container comprising a compound as defined in any of embodiments 1 to 10 , which has the potential for prevention or alleviation of side effects induced or inducible by the drug substance, wherein the side effects are selected from i) lactic acidosis, ii) side effects related to an insufficiency, inhibition or malfunction of Complex I, and iii) side effects related to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect that limits the supply of NADH to Complex I, e.g. about the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and even drugs that affect glucose levels or other substrates).

[00123] 29. A method for treating an individual suffering from a drug-induced side effect selected from i) lactic acidosis, ii) side effect related to insufficiency, inhibition or malfunction of Complex I, and iii) related side effects to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect that limits the supply of NADH to Complex I, e.g. effects on the Krebs cycle, glycolysis, beta-oxidation, pyruvate metabolism and even drugs that affect glucose levels or other substrates, the method comprises administering an effective amount of a compound as defined in any one of embodiments 1 to 10 to the individual

[00124] 30. A method for preventing or alleviating a drug-induced side effect selected from i) lactic acidosis, ii) side effect related to insufficiency, inhibition or malfunction of Complex I, and iii) side effects related to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I (indirect inhibition of Complex I, which may involve any drug effect that limits the supply of NADH to Complex I, e.g., effects on the Krebs cycle, glycolysis, beta -oxidation, pyruvate metabolism and drugs that affect glucose levels or other substrates) in an individual, who suffers from a disease that is treated with a drug substance, which potentially induces a selected side effect of i) lactic acidosis , ii) side effect related to insufficiency, inhibition or malfunction of Complex I, and iii) side effects related to insufficiency, inhibition or malfunction in aerobic metabolism upstream of Complex I, such as Krebs cycle dehydrogenase, pyruvate dehydrogenase and fatty acid metabolism, the method comprises administering an effective amount of a compound as defined in any one of embodiments 1 to 10 to the subject.

[00125] 31. A method according to any one of embodiments 29 to 30, wherein the drug substance is an antidiabetic substance.

[00126] 32. A method according to any one of embodiments 29 to 31, wherein the drug substance is an antidiabetic substance, which is metformin.

[00127] 33. A compound according to any one of embodiments 1 to 10, for use in treating absolute or relative cellular energy deficiency.

Claims (13)

1. Compound according to Formula (IA) pharmaceutically acceptable thereof, characterized by the fact that Z is -CH2-CH2- A is -SR, and R is B is selected from the group consisting of -O-R', -SR''' and -OH; and R' is selected from the group consisting of: R''' is selected from the group consisting of: R1 and R3 are independently different or identical and are selected from the group consisting of H, Me, Et, propyl, i-propyl, butyl, isobutyl, O-acyl, O-alkyl, N-acyl, N-alkyl, Xacyl, CH2Xalkyl, CH2X-acyl, F, CH2COOH, and CH2CO2alkyl, , t-butyl, C(O)CH3, C(O)CH2C(O)CH3, and C(O)CH2CH(OH)CH3, R6 is selected from the group consisting of H, Me, Et, propyl, i- propyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl, formula (II) and formula (VIII), X5 is selected from the group consisting of Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, -COOH, -C(=O)XR6, CONR1R3, X7 is R1, or -NR1R3, R9 is selected from the group consisting of H, Me, Et and O2CCH2CH2COXR8, group consisting of O, NR8, and NR6R8, wherein R6 and R8 are independently different or identical and are selected from the group consisting of H, alkyl, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, acyl, propionyl, benzoyl, formula (II) and formula (VIII), R11 and R12 are independently different or identical and are selected from the group consisting of H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, acetyl, propionyl, benzoyl, -CH2Xalkyl, and -CH2Xacyl, where X is O, NR6 or S, Rc and Rd are independently different or identical and are CH2Xalkyl or CH2Xacyl, where X = O, NR6 or S, R13 , R14 and R15 are independently different or identical and are selected from H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, -COOH, O-acyl, O-alkyl, N-acyl, N- alkyl, Xacyl and CH2Xalkyl; substituents on R13 and R14 or R13 and R15 can bridge to form a cyclic system, Rf, Rg and Rh are independently different or identical and are selected from the group consisting of Xacyl, -CH2Xalkyl, -CH2X-acyl and R9, alkyl is selected from the group consisting of Me, Et, propyl, i-propyl, butyl and isobutyl, acyl is selected from the group consisting of formyl, acetyl, propionyl, isopropionyl, butyryl, tert-butyryl, pentanoyl and benzoyl, acyl and /or alkyl may be optionally substituted with the proviso that the compound is not 2. Compound according to claim 1 having Formula (IA) or a pharmaceutically acceptable salt thereof, characterized in that Z is -CH2-CH2-, A is -SR, and R is B is selected from the group consisting of -O-R', -SR''' and -OH; and R' and R''' are independently different or identical and are: R1 and R3 are independently different or identical and are selected from the group consisting of H, Me, Et, propyl, O-Me, O-Et, and O-propyl, S, R6 is selected from the group consisting of H, Me, and Et, X5 is selected from the group consisting of -H, Me, Et, -COOH, -C(=O)XR6, CONR1R3, X7 is R1, or -NR1R3, and R13, R14 and R15 are independently different or identical and are selected from the group consisting of H, Me, Et, propyl, i-propyl, butyl, isobutyl, t-butyl, -COOH, O-acyl, O -alkyl, N-acyl, N-alkyl, Xacyl, and CH2Xalkyl. 3. Compound according to claim 1 or 2, which has Formula (IA) or a pharmaceutically acceptable salt thereof, characterized in that Z is -CH2-CH2-, A is -SR, and R is B is selected from the group consisting of -O-R', -SR''' and -OH; and R', and R''' are independently different or identical and are: R1 and R3 are independently different or identical and are selected from the group consisting of H, Me, Et, propyl, O-Me, O-Et, and O-propyl, X is selected from the group consisting of O, NH, and S , R6 is selected from the group consisting of H, Me, Et, X5 is selected from the group consisting of Me, Et, -COOH, -C(=O)OR6, and CONR1R3, X7 is R1, or -NR1R3, and R13, R14 and R15 are independently different or identical and are selected from the group consisting of H, Me, Et, -COOH. 4. Compound according to any one of claims 1 to 3, characterized by the fact that Z is -CH2CH2-, A is -SR, and B is OH or SR’’’. 5. Compound according to any one of claims 1 to 4, characterized by the fact that Z is -CH2CH2-, A is -SR, B is OH or SR''', where R''' is 6. Compound according to any one of claims 1 to 5, characterized by the fact that Z is -CH2CH2- and A is SR and B is OH. 7. Compound according to any one of claims 1 to 3, characterized by the fact that Z is -CH2CH2-, A is NR, B is OH and R is 8. Compound according to any one of claims 1 to 7, characterized by the fact that R and/or R''' is 9. Compound according to any one of claims 1 to 8, characterized by the fact that R and/or R''' is 10. Compound according to any one of claims 1 to 7, characterized by the fact that R and/or R''' is and X5 is CONR1R3. 11. Compound according to any one of claims 1 to 10, characterized in that the compound is selected from: 12. Use of a compound as defined in any one of claims 1 to 11, characterized in that it is for the preparation of a medicament for the treatment or prevention of lactic acidosis. 13. Composition, characterized by the fact that it comprises a compound of Formula (I) as defined in any one of claims 1 to 11, and one or more pharmaceutically acceptable excipients.