WO2024011188A1 - Combination therapy for treatment of iron overload diseases - Google Patents

Combination therapy for treatment of iron overload diseases Download PDF

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Publication number
WO2024011188A1
WO2024011188A1 PCT/US2023/069727 US2023069727W WO2024011188A1 WO 2024011188 A1 WO2024011188 A1 WO 2024011188A1 US 2023069727 W US2023069727 W US 2023069727W WO 2024011188 A1 WO2024011188 A1 WO 2024011188A1
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seq
compound
peptide
isovaleric acid
palm
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PCT/US2023/069727
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French (fr)
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Roopa TARANATH
David Y. Liu
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Protagonist Therapeutics, Inc.
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Publication of WO2024011188A1 publication Critical patent/WO2024011188A1/en

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P3/00—Drugs for disorders of the metabolism
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/22—Hormones

Definitions

  • the present disclosure relates, inter alia, to methods for the treatment and/or prevention of iron overload diseases, such as hereditary hemochromatosis.
  • Iron plays an important role in many cellular and organismal activities, from cell division to oxygen transport (see, e.g., Casu, C. et al., Blood 2018; 131(16): 1790-1794).
  • ROS toxic reactive oxygen species
  • humans and other vertebrates have evolved regulatory systems to optimize the absorption and organ distribution of iron.
  • ROS toxic reactive oxygen species
  • iron homeostasis dysregulate iron absorption or distribution, causing organ damage and creating conditions for overwhelming infections or inflammation, with associated morbidity and mortality.
  • Hepcidin is a 25 amino acid peptide hormone produced primarily in the liver in proportion to plasma iron concentration and iron stores. Hepcidin is a key regulator of iron homeostasis, since it binds and degrades the only known iron exporter, ferroportin-1, which is expressed on the surfaces of cells involved in iron absorption, recycling, and storage.
  • the present disclosure provides combination therapies for treating iron overload disorders, such as hereditary hemochromatosis, with a hepcidin mimetic and therapeutic phlebotomy.
  • the disclosure provides methods and dosing regimens of hepcidin mimetics and therapeutic phlebotomy that restore iron homeostasis in human, e.g., humans with hereditary hemochromatosis, methods, clinically effective dosages, and dosing regimens of hepcidin mimetics that restore iron homeostasis in human, e.g., humans with hereditary hemochromatosis.
  • the methods modulate pharmacodynamic markers associated with efficacy in the treatment of disease and disorders associated with dysregulation of iron homeostasis, such as iron overload diseases and disorders, including, e.g., hereditary hemochromatosis (HH).
  • HH hereditary hemochromatosis
  • dosages, dosage regimens, and methods disclosed herein are used to treat hereditary hemochromatosis, hereditary hemochromatosis arthropathy, or joint pain associated with hereditary hemochromatosis arthropathy.
  • the methods are used to treat hereditary hemochromatosis patients during the phlebotomy induction phase.
  • the disclosure provides a method for treating an iron overload disease, e.g., HH, in a human subject, comprising providing to the subject an effective amount of a hepcidin mimetic, such as, e.g., Compound 25 or Compound 46, in combination with therapeutic phlebotomy.
  • a hepcidin mimetic such as, e.g., Compound 25 or Compound 46
  • the subject has been diagnosed with hereditary hemochromatosis.
  • the subject has not previously received therapeutic phlebotomy for the condition being treated.
  • the combination therapy is performed during the induction phase of phlebotomy treatment.
  • the subject is administered a first effective amount of the hepcidin mimetic for a first time period, and a second effective amount of the hepcidin mimetic for a second time period.
  • the subject is administered a third or more effective amounts of the hepcidin mimetic for a third or more time periods.
  • the frequency of administration during the first and second time periods are the same or different.
  • the frequency of administration during the third or more time periods are each the same or different from that of the first and second time period and each other.
  • each time period independently comprises about one week, about two weeks, about four weeks, about one month, about two months, about four months, about six months, or about one year.
  • the dosage and or frequency of administration is altered following testing of the subject’s serum iron and/or TSAT saturation levels after a time period of treatment, so as to achieve parameters disclosed herein.
  • the effective amount of the hepcidin mimetic comprises a dose in the range of about 5 mg to about 40 mg, and optionally the subject is administered different doses dining different time periods over a course of treatment.
  • the hepcidin mimetic is Compound 25 or Compound 46.
  • an effective dose is a dose that results in the treated patient’ s TS AT % to be reduced to ⁇ 45% or ⁇ 40%.
  • the effective amount of the hepcidin mimetic is about 10 mg to about 40 mg for at least some time period during the course of treatment.
  • the effective amount of the hepcidin mimetic is administered to the subject about once a week, about twice a week, or about three times a week, for at least some time period during the course of treatment.
  • the subject is administered about 10 mg to about 15 mg, about 15 mg to about 20 mg, or about 10 mg to about 20 mg of the hepcidin mimetic about twice a week or about three times a week for at least some time period during the course of treatment, and in another embodiments, the subject is administered about 20 mg to about 30 mg, about 20 mg to about 40 mg, or about 30 mg to about 40 mg of the hepcidin mimetic about once a week for at least some time period during the course of treatment.
  • the subject is administered about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, or about 25 mg of the hepcidin mimetic about twice a week or about three times a week for at least some time period during the course of treatment.
  • the subject is administered about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, about 25 mg, about 26 mg, about 27 mg, about 28 mg, about 29 mg, about 30 mg, about 31 mg, about 32 mg, about 33 mg, about 34 mg, about 35 mg, about 36 mg, about 37 mg, about 38 mg, about 39 mg, about 40 mg, about 41 mg, about 42 mg, about 43 mg, about 44 mg, or about 45 mg of the hepcidin mimetic about twice a week or about three times a week for at least some time period during the course of treatment.
  • the hepcidin mimetic is administered subcutaneously.
  • one or more therapeutic phlebotomy is performed about once per month, about once every two weeks, about once per week, or about twice per week over a course of treatment.
  • the therapeutic phlebotomy is performed at different frequency during the course of treatment.
  • phlebotomy is performed about once per week for at least or about 8 weeks, e.g., about once per week for about 8 weeks to about 12 or 16 weeks.
  • each phlebotomy comprises removing about 250 cc - about 1000 cc of blood from the subject.
  • each phlebotomy comprises removing about 500 cc of blood from the subject.
  • the method results in the subject’s TSAT level being decreased to less than about 50% TSAT (%) or less than about 45% TSAT (%) or less than about 40% TSAT (%), or less than 35% TSAT or less than 30% TSAT.
  • the method results in the subject’s serum iron level being decreased to less than about 150 ug/dL.
  • the method results in the subject’s liver iron concentration being substantially maintained, e.g., not significantly changed.
  • the method results in the subject’s serum ferritin and serum transferrin levels or concentrations being substantially maintained, e.g., not significantly changed.
  • the method results in the subject having improved emotional and/or physical outcomes.
  • the subject following the combination treatment, the subject requires reduced or no phlebotomy treatment.
  • a subject undergoing a course of treatment disclosed herein may require no phlebotomies per month, or one or less phlebotomies per month following the course of treatment disclosed herein.
  • a course of a combination treatment disclosed herein may be for at least or about four weeks, at least or about six weeks, at least or about eight weeks, at least or about 10 weeks, at least or about 12 weeks, at least or about four months, or longer.
  • the combination therapy lasts for about eight weeks to about 16 weeks.
  • the hepcidin mimetic comprises a peptide of any one of Formulas I- VIII as disclosed herein.
  • the peptide comprises or consists of one of the following sequences or structures: Isovaleric acid-DTHFPICIFGPRSKGWVC-NH 2 (Compound 1; SEQ ID NO: 1);
  • Isovaleric acid-DTHFPCIlFGPRSKGWVCK-NH 2 Compound 2; SEQ ID NO: 2
  • Isovaleric acid-DTHFPCHFEPRSKGWVCK-NH 2 Compound 3; SEQ ID NO: 3
  • Isovaleric acid-DTHFPCIlFGPRSKGWACK-NH 2 Compound 4; SEQ ID NO: 4
  • Isovaleric acid-DTHFPCIlFGPRSKGWVCKK-NH 2 Compound 5; SEQ ID NO: 5
  • Isovaleric acid-DTHFPCIlFVCHRPKGCYRRVCR-NH 2 Compound 6; SEQ ID NO: 6
  • Isovaleric acid-DTHFPCI(K(PEG8))FGPRSKGWVCK-NH 2 Compound 7; SEQ ID NO: 7);
  • Isovaleric acid-DTHFPCIKF(K(PEG8))PRSKGWVCK-NH 2 Compound 8; SEQ ID NO: 8;
  • Isovaleric acid-DTHFPICIFGPRS(K(PEG8))GWVC-NH 2 Compound 9; SEQ ID NO: 9;
  • Isovaleric acid-DTHFPICIFGPRS(K(PEG4))GWVC-NH 2 Compound 10; SEQ ID NO: 10;
  • Isovaleric acid-DTHFPCIIFGPRSRGWVC(K(PEG4))-NH 2 Compound 12; SEQ ID NO: 12;
  • Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG2))-NH 2 Compound 13; SEQ ID NO: 13;
  • Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH 2 (Compound 20; SEQ ID NO: 20);
  • Isovaleric acid-DTHFPCIKFGPRS(K(PEG3-Palm))GWVCK-NH 2 (Compound 22; SEQ ID NO: 22);
  • Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGWECK-NH 2 (Compound 28; SEQ ID NO: 28) ;
  • Isovaleric acid-DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH 2 Compound 29; SEQ ID NO: 29
  • Isovaleric acid-DTHFPCIKFEPRSK(K(isoGlu-Palm))CK-NH 2 Compound 30; SEQ ID NO: 30);
  • the reduction in the TSAT% level and/or serum iron level is the maximum reduction following treatment with the agent, while in other embodiments, the reduction in the TSAT% level and/or serum iron level is the reduction observed at trough level of the agent following administration to a subject.
  • TSAT% is reduced to less than or equal to about 45%, less than or equal to about 40%, less than or equal to about 30%, less than or equal to about 20%, less than or equal to about 15%, less than or equal to about 10%, between about 10% and about 40%, between about 5% and about 20%, or between about 10% and about 20% at the time tested.
  • the serum iron is reduced to less than or equal to about 150 micrograms/dL, less than or equal to about 100 micrograms/dL, less than or equal to about 75 micrograms/dL, or less than or equal to about 600 micrograms/dL at the time tested.
  • TSAT% level and/or serum iron level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers.
  • the agent e.g., hepcidin mimetic peptide, such as Compound 25 or Compound 46
  • the agent is provided to the subject as a salt form and/or in a pharmaceutical composition, and in certain embodiments, it is provided parenterally, e.g., subcutaneously.
  • FIG. 1 provides a schematic diagram of the design and timeline of an animal study of the effect of hepcidin mimetics on treatment of iron overload diseases.
  • Animals at 8-12 wks (first set) and 12-16wks (second set) were maintained under 35ppm iron diet since weaning. Mice were acclimatized for 1 week under 35ppm iron diet prior to study.
  • FIG. 2 is a graph showing serum iron (uM) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • the graph shows that Compound 46 treatment was better able to control serum iron.
  • Serum iron reflects TSAT%, and it wwaass previously demonstrated that Transferrin does not vary with age/treatment.
  • FIG. 3 is a graph showing serum Ferritin (ng/mL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was better able to lower serum Ferritin. Serum Ferritin was lowest for the group that received Compound 46 and phlebotomy treatments. Treatment with Compound 46 alone or in combination with phlebotomy, controlled serum ferritin significantly better as compared to weekly phlebotomy therapy. Reduction in Ferritin with Compound 46 treatment was better after 44-day treatment as compared to 23-day treatment.
  • FIG. 4 is a graph showing liver iron (uh/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • the graph shows that Compound 46 treatment was equally effective at preventing liver iron deposition as compared to phlebotomy therapy.
  • the apparent benefit of treatment with peptide, phlebotomy or combination was entirely due to prevention of iron deposition in the liver.
  • There was no evidence of reversal of liver iron deposited at the start of the study (compare treatment groups with baseline group). For animal treated over longer duration, all three treatment arms showed equivalent effectiveness in preventing liver iron deposition.
  • Vehicle treated group showed significant iron deposition after 46days in the study compared to baseline at study start.
  • FIG. 5 is a graph showing heart iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • the graph shows that Compound 46 treatment was effective at reducing heart iron concentration compared to baseline, while Phleb was effective only in prevention.
  • Animals that received Phleb+Compound 46 cotreatment for either longer duration or shorter duration clearly showed significant reduction in heart iron concentration.
  • FIG. 6 is a graph showing kidney iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • the graph shows that Compound 46 treatment was effective at reducing kidney iron concentration compared to baseline.
  • Animals that received Phleb+Compound 46 co-treatment also showed significant reduction in kidney iron concentration (true for both treatment durations). Animals that received only Phleb also show reductions in kidney iron concentration.
  • FIG. 7 is a graph showing pancreas iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • the graph shows that Compound 46 treatment was effective preventing increase in Pancreatic iron concentration compared to baseline.
  • Compound 46 was able to prevent iron deposition in pancreas.
  • Phlebotomy treatment was not able to prevent iron deposition in the pancreas.
  • Compound 46+Phleb cotreatment was not able to prevent iron deposition in the pancreas.
  • FIG. 8 is a graph showing spleen iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 redistributed excess iron into spleen. Treatment with Compound 46 alone redistributed the excess iron into spleen, thereby significantly elevating spleen iron concentration, while co-treatment with phlebotomy lowered this iron sequestration in spleen.
  • FIG. 9 is a graph showing duodenum iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • the graph shows that Compound 46 treatment increase duodenum iron concentration. There was a trend towards increased duodenum iron concentration in Compound 46 and Compound 46+Phleb treated groups, but it was not statistically significant. There was no change in duodenum iron with phlebotomy treatment alone.
  • FIG. 10 is a graph showing hemoglobin (g/dL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • FIG. 11 is a graph showing red blood cells (REC) (xlO 6 cells/uL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • FIG. 12 is a graph showing MCV (fL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • FIG. 13 is a graph showing MCH (pg) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • FIG. 14 is a graph showing MCHC (g/dL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
  • FIG. 15 is a table of the indicated values determined at baseline and following the indicated treatments post-last dose on Day 46 or Day 25.
  • the present disclosure identifies a therapeutically effective combination therapy useful for treating diseases and disorders associated with iron dysregulation, such as hereditary hemochromatosis (HH), which includes treatment with a combination of a hepcidin mimetic and therapeutic phlebotomy.
  • HH hereditary hemochromatosis
  • the method may be practiced during the induction phase of phlebotomy.
  • the methods disclosed herein are practiced using Compound 25 or Compound 46 in combination with phlebotomy to treat hereditary hemochromatosis.
  • patient may be used interchangeably and refer to either a human or a non-human animal. These terms include mammals such as humans, primates, livestock animals (e.g., bovines, porcines), companion animals (e.g., canines, felines) and rodents (e.g., mice and rats).
  • livestock animals e.g., bovines, porcines
  • companion animals e.g., canines, felines
  • rodents e.g., mice and rats.
  • rodents e.g., mice and rats.
  • mamammal refers to any mammalian species such as a human, mouse, rat, dog, cat, hamster, guinea pig, rabbit, livestock, and the like.
  • peptide refers broadly to a sequence of two or more amino acids j oined together by peptide bonds. It should be understood that this term does not connote a specific length of a polymer of amino acids, nor is it intended to imply or distinguish whether the polypeptide is produced using recombinant techniques, chemical or enzymatic synthesis, or is naturally occurring.
  • hepcidin mimetic refers broadly to peptide monomers and peptide dimers comprising one or more structural features and/or functional activities in common with hepcidin, or a functional region thereof.
  • a hepcidin mimetic includes peptides sharing substantial amino acid sequence identity with hepcidin, e.g., peptides that comprise one or more amino acid insertions, deletions, or substitutions as compared to a wild-type hepcidin, e.g., human hepcidin, amino acid sequence.
  • a hepcidin mimetic comprises one or more additional modification, such as, e.g., conjugation to another compound.
  • hepcidin mimetic is any peptide monomer or peptide dimer disclosed herein.
  • a hepcidin mimetic has one or more functional activities of hepcidin.
  • amino acid or “any amino acid” as used here refers to any and all amino acids, including naturally occurring amino acids (e.g., a-amino acids), unnatural amino acids, modified amino adds, and non-natural amino acids. It includes both D- and L-amino acids. Natural amino acids include those found in nature, such as, e.g., the 23 amino acids that combine into peptide chains to form the building-blocks of a vast array of protdns. These are primarily L stereoisomers, although a few D-amino acids occur in bacterial envelopes and some antibiotics.
  • non-standard natural amino adds are pyrrolysine (found in methanogenic organisms and other eukaryotes), selenocystdne (present in many noneukaryotes as well as most eukaryotes), and N-formylmethionine (encoded by the start codon AUG in bacteria, mitochondria and chloroplasts).
  • “Unnatural” or “non-natural” amino acids are non- proteinogenic amino acids (i.e., those not naturally encoded or found in the genetic code) that dther occur naturally or are chemically synthesized. Over 140 natural amino adds are known and thousands of more combinations are possible.
  • “unnatural” amino adds include P-amino acids ( ⁇ 3 and ⁇ 2 ), homo-amino acids, proline and pyruvic acid derivatives, 3- substituted alanine derivatives, glycine derivatives, ring-substituted phenylalanine and tyrosine derivatives, linear core amino acids, diamino acids, D-amino adds, andN-methyl amino acids.
  • Unnatural or non-natural amino adds also include modified amino acids.
  • “Modified” amino acids include amino acids (e.g., natural amino acids) that have been chemically modified to include a group, groups, or chemical moiety not naturally present on the amino acid.
  • sequences disclosed herein are shown proceeding from left to right, with the left end of the sequence being the N-terminus of the peptide and the right end of the sequence being the C-terminus of the peptide.
  • sequences disclosed herein are sequences incorporating a “Hy-” moiety at the amino terminus (N-terminus) of the sequence, and either an “-OH” moiety or an “-NH 2 ” moiety at the carboxy terminus (C-terminus) of the sequence.
  • a “Hy- ” moiety at the N-terminus of the sequence in question indicates a hydrogen atom, corresponding to the presence of a free primary or secondary amino group at the N-terminus, while an “-OH” or an “-NHz” moiety at the C-terminus of the sequence indicates a hydroxy group or an amino group, corresponding to the presence of an amido (CONHz) group at the C- terminus, respectively.
  • a C-terminal “-OH” moiety may be substituted for a C-terminal “-NH 2 ” moiety, and vice-versa.
  • the moiety at the amino terminus or carboxy terminus may be a bond, e.g., a covalent bond, particularly in situations where the amino terminus or carboxy terminus is bound to a linker or to another chemical moiety, e.g., a PEG moiety.
  • NH 2 refers to the free amino group present at the amino terminus of a polypeptide.
  • OH refers to the free carboxy group present at the carboxy terminus of a peptide.
  • Ac refers to Acetyl protection through acylation of the C- or N-terminus of a polypeptide.
  • amino acids are referred to by their full name (e.g., alanine, arginine, etc.), they are designated by their conventional three-letter or single-letter abbreviations (e.g., Ala or A for alanine, Arg or R for arginine, etc.).
  • amino acids are referred to by their full name (e.g., alanine, arginine, etc.)
  • they are designated by their conventional three-letter or single-letter abbreviations e.g., Ala or A for alanine, Arg or R for arginine, etc.
  • sarcosine, ornithine, etc. frequently employed three- or four-character codes are employed for residues thereof, including, Sar or Sarc (sarcosine, i.e., N-methylglycine), Aib (a-aminoisobutyric acid), Daba (2,4-diaminobutanoic acid), Dapa (2,3- diaminopropanoic acid), y-Glu (y-glutamic acid), pGlu (pyroglutantic acid), Gaba (y- aminobutanoic acid), ⁇ -Pro (pyrrolidine-3 -carboxylic acid), 8 Ado (8-amino-3,6-dioxaoctanoic acid), Abu (4-aminobutyric acid), bhPro (P-homo-proline), bhPhe (P-homo-L-phenylalanine), bhAsp (P-homo-aspartic acid]), Dpa ( ⁇ , ⁇ dipheny
  • R1 can in all sequences be substituted with isovaleric acids or equivalent.
  • a peptide of the present invention is conjugated to an acidic compound such as, e.g., isovaleric acid, isobutyric acid, valeric acid, and the like
  • an acidic compound such as, e.g., isovaleric acid, isobutyric acid, valeric acid, and the like
  • the presence of such a conjugation is referenced in the add form. So, for example, but not to be limited in any way, instead of indicating a conjugation of isovaleric add to a peptide by referencing isovaleroyl, in some embodiments, the present application may reference such a conjugation as isovaleric acid.
  • L-amino acid refers to the “L” isomeric form of a peptide
  • D-amino acid refers to the “D” isomeric form of a peptide
  • the amino acid residues described herein are in the “L” isomeric form, however, residues in the “D” isomeric form can be substituted for any L-amino acid residue, as long as the desired functional is retained by the peptide.
  • dimer refers broadly to a peptide comprising two or more monomer subunits. Certain dimers comprise two DRPs. Dimers of the present invention include homodimers and heterodimers. A monomer subunit of a dimer may be linked at its C- or N-terminus, or it may be linked via internal amino acid residues. Each monomer subunit of a dimer may be linked through the same site, or each may be linked through a different site (e.g., C-terminus, N-terminus, or internal site).
  • parentheticals e.g., ( ) represent side chain conjugations and brackets, e.g., [ ], represent unnatural amino acid substitutions or amino adds and conjugated side chains.
  • brackets e.g., [ ]
  • linker is shown at the C-terminus of a peptide sequence or structure, it indicates that the peptide is dimerized with another peptide, wherein the linker is attached to the C-terminus of the two peptides.
  • cyclized refers to a reaction in which one part of a polypeptide molecule becomes linked to another part of the polypeptide molecule to form a closed ring, such as by forming a disulfide bridge or other similar bond.
  • subunit refers to one of a pair of polypeptide monomers that are joined to form a dimer peptide composition.
  • linker moiety refers broadly to a chemical structure that is capable of linking or joining together two peptide monomer subunits to form a dimer.
  • solvate in the context of the present invention refers to a complex of defined stoichiometry formed between a solute (e.g., a hepcidin analogue or pharmaceutically acceptable salt thereof according to the invention) and a solvent.
  • the solvent in this connection may, for example, be water, ethanol or another pharmaceutically acceptable, typically small- molecular organic species, such as, but not limited to, acetic acid or lactic acid.
  • a solvate is normally referred to as a hydrate.
  • salts or zwitterionic forms of the peptides or compounds of the present invention which are water or oil-soluble or dispersible, which are suitable for treatment of diseases without undue toxicity, irritation, and allergic response; which are commensurate with a reasonable benefit/risk ratio, and which are effective for their intended use.
  • the salts can be prepared during the final isolation and purification of the compounds or separately by reacting an amino group with a suitable acid.
  • Representative acid addition salts include acetate, adipate, alginate, citrate, aspartate, benzoate, benzenesulfonate, bisulfate, butyrate, camphorate, camphorsulfonate, digluconate, glycerophosphate, hemisulfate, heptanoate, hexanoate, formate, fumarate, hydrochloride, hydrobromide, hydroiodide, 2-hydroxyethansulfonate (isethionate), lactate, maleate, mesitylenesulfonate, methanesulfonate, naphthylenesulfonate, nicotinate, 2- naphthalenesulfonate, oxalate, pamoate, pectinate, persulfate, 3-phenylproprionate, picrate, pivalate, propionate, succinate, tartrate, trichloroacetate, trifluoroacetate, phosphate
  • amino groups in the compounds of the present invention can be quatemized with methyl, ethyl, propyl, and butyl chlorides, bromides, and iodides; dimethyl, diethyl, dibutyl, and diamyl sulfates; decyl, lauryl, myristyl, and steryl chlorides, bromides, and iodides; and benzyl and phenethyl bromides.
  • acids which can be employed to form therapeutically acceptable addition salts include inorganic acids such as hydrochloric, hydrobromic, sulfuric, and phosphoric, and organic acids such as oxalic, maleic, succinic, and citric.
  • a pharmaceutically acceptable salt may suitably be a salt chosen, e.g., among acid addition salts and basic salts.
  • acid addition salts include chloride salts, citrate salts and acetate salts.
  • basic salts include salts where the cation is selected among alkali metal cations, such as sodium or potassium ions, alkaline earth metal cations, such as calcium or magnesium ions, as well as substituted ammonium ions, such as ions of the type N(R1)(R2)(R3)(R4)+, where Rl, R2, R3 and R4 independently will typically designate hydrogen, optionally substituted Cl-6-alkyl or optionally substituted C2-6-alkenyL Examples of relevant Cl-6-alkyl groups include methyl, ethyl, 1 -propyl and 2-propyl groups.
  • C2-6-alkenyl groups of possible relevance include ethenyl, 1 -propenyl and 2-propenyl.
  • Other examples of pharmaceutically acceptable salts are described in “Remington’s Pharmaceutical Sciences”, 17th edition, Alfonso R. Gennaro (Ed.), Mark Publishing Company, Easton, PA, USA, 1985 (and more recent editions thereof), in the “Encyclopaedia of Pharmaceutical Technology”, 3rd edition, James Swarbrick (Ed ), Informa Healthcare USA (Inc.), NY, USA, 2007, and in J. Pharm. Sci. 66: 2 (1977).
  • suitable base salts are formed from bases which form non-toxic salts.
  • bases include the aluminum, arginine, benzathine, calcium, choline, diethylamine, diolamine, glycine, lysine, magnesium, meglumine, olamine, potassium, sodium, tromethamine, and zinc salts.
  • Hemisalts of acids and bases may also be formed, e.g., hemisulphate and hemicalcium salts.
  • alkyl includes a straight chain or branched, noncyclic or cyclic, saturated aliphatic hydrocarbon containing from 1 to 24 carbon atoms.
  • Representative saturated straight chain alkyls include, but are not limited to, methyl, ethyl, n-propyl, n-butyl, n-pentyl, n-hexyl, and the like, while saturated branched alkyls include, without limitation, isopropyl, sec-butyl, isobutyl, tert-butyl, isopentyl, and the like.
  • saturated cyclic alkyls include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and the like, while unsaturated cyclic alkyls include, without limitation, cyclopentenyl, cyclohexenyl, and the like.
  • a “therapeutically effective amount” of the peptide agonists of the invention is meant to describe a sufficient amount of the peptide agonist to treat an hepcidin- related disease, including but not limited to any of the diseases and disorders described herein (for example, a disease of iron metabolism). In particular embodiments, the therapeutically effective amount will achieve a desired benefit/risk ratio applicable to any medical treatment.
  • Hepcidin targets the maj or iron transporter ferroportin and causes its internalization and subsequent degradation. Hepcidin regulation is crucial for providing adequate iron needed for cellular functions while also preventing iron toxicity.
  • Hereditary Hemochromatosis HH
  • hyperabsorption of dietary iron leads to primary iron overload.
  • transferrin is saturated (e.g., Transferrin SATuration (TSAT) % > 80%)
  • TSAT Transferrin SATuration
  • excess iron deposition can lead to organ damage.
  • the presence of labile iron increases overall systemic iron toxicity.
  • the present disclosure identifies methods of dosing and using hepcidin mimetics with a therapeutic effect for the treatment of diseases and disorders associated with iron overload, such as hereditary hemochromatosis.
  • methods disclosed herein are applied for the prevention, inhibition, or treatment of a disease or disorder associated with dysregulated iron levels (e.g., diseases or disorders of iron metabolism; diseases or disorders related to iron overload; and diseases or disorders related to abnormal hepcidin activity or expression).
  • the disease or disorder is a disease of iron metabolism, such as, e.g., an iron overload disease or another disorder of iron metabolism.
  • the disease of iron metabolism is a hemochromatosis, such as, e.g., hereditary hemochromatosis, HFE mutation hemochromatosis, ferroportin mutation hemochromatosis, transferrin receptor 2 mutation hemochromatosis, hemojuvelin mutation hemochromatosis, hepcidin mutation hemochromatosis, juvenile hemochromatosis, or neonatal hemochromatosis.
  • the disease is hereditary hemochromatosis (HH).
  • the disease is phlebotomy-requiring HH or HH in the induction phase.
  • the disease or disorder is HH associated with arthropathy, or HH-associated arthropathy.
  • Chronic arthropathy occurs in 37-80% of HH patients.
  • joint pain may be an early manifestation of the disease and in many cases is the cause for first diagnosis of HH. This may be done by X-ray and/or MRI imaging, often combined with validated joint pain and/or results of function scoring instruments.
  • the arthropathy may be associated with elevated age, ferritin, and TSAT levels.
  • the iron accumulation of HH may be associated with increased oxidative stress, disrupted matrix metabolism, and cartilage degeneration, which can contribute to the development of arthropathy similar to osteoarthritis.
  • Persistent arthropathy can diminish quality of life and yield high healthcare utilization and associated costs, particularly since up to 16% of HH patients undergo joint replacement surgery. See, e.g., Whalen, N. “Association of Transferrin Saturation with the Arthropathy of Hereditary Hemochromatosis” 2017; Nguyen, C. “Bone and joint complications in patients with hereditary hemochromatosis: a cross-sectional study of 93 patients” 2020; Carroll, GJ. “Hereditary Hemochromatosis is characterized by a clinically definable arthropathy that correlates with iron load” 2011; Karim, A.
  • the disclosure provides a method for treating an iron overload disease, e.g., HH, HH associated with arthropathy, or HH-associated arthropathy, in a human subject, comprising providing to the subject an effective amount of a hepcidin mimetic, including but not limited to those disclosed herein, such as Compound 25, in combination with therapeutic phlebotomy.
  • an iron overload disease e.g., HH, HH associated with arthropathy, or HH-associated arthropathy
  • the hepcidin mimetic is provided subcutaneously.
  • the subject has been diagnosed with hereditary hemochromatosis.
  • the subject has not received phlebotomy treatment prior to the treatment disclosed herein.
  • the subject’s HH is in the induction phase, and the combination therapy disclosed herein is the first phlebotomy treatment the subject receives for treatment of the iron overload disease, e.g., HH
  • the subject is administered the combination therapy comprising a hepcidin mimetic and therapeutic phlebotomy over a period of time, e.g., during the induction phase.
  • the period of time comprises at least or about four weeks, at least or about six weeks, at least or about 8 weeks, at least or about 10 weeks, at least or about 12 weeks, at least or about four months, or at least or about six months, which time period begins at the time the subject is administered the first dose of hepcidin mimetic or the first phlebotomy as part of the combination treatment.
  • the time period, or induction phase lasts for about 10 weeks, and the subject may have about four therapeutic phlebotomies per week (or one therapeutic phlebotomy per week). In particular embodiments, the period of time is sufficient to achieve complete blood volume replacement of the subject. E.g., about ten therapeutic phlebotomies, where each removes about 0.5 L of blood.
  • the combination therapy may continue into transition phase. In certain embodiments, the combination therapy is stopped once the subject reaches transition phase or maintenance phase, after which time the subject may be treated with a hepcidin mimetic alone, or in certain embodiments, therapeutic phlebotomy alone.
  • the subject may first be administered the hepcidin mimetic, or may first be administered a therapeutic phlebotomy.
  • Administration of the hepcidin mimetic and therapeutic phlebotomies may occur on the same or different days, which will depend in part on the frequency with each is performed over the course of treatment.
  • the dosing regimen for a subject may change throughout the course of treatment, but in particular embodiments, administration of the hepcidin mimetic (e.g., Compound 25) occurs about once a week, about twice a week, or about three times a week, over the course of treatment, and the dosage is about 5 mg to about 80 mg, or about 10 mg to about 40 mg, e.g., about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 60 mg, or about 80 mg per administration.
  • the hepcidin mimetic e.g., Compound 25
  • administration of the hepcidin mimetic occurs about once a week, about twice a week, or about three times a week, over the course of treatment, and the dosage is about 5 mg to about 80 mg, or about 10 mg to about 40 mg, e.g., about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 60 mg, or about 80 mg per administration.
  • the subject is administered different dosages (at the same or different frequency), or the same dosage at different frequency, during different time periods of the course of treatment, but in particular embodiments, the frequency throughout the course of treatment is about once a week, about twice a week, or about three times a week, and each dosage administered is in the range of about 5 mg to about 40 mg.
  • the agent is a hepcidin mimetic peptide disclosed herein, e.g., a peptide of any one of Formula I-VHI or any of Compounds 1-34, such as Compound 25.
  • the decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level is at least 60% for at least one day.
  • the subject is administered about 5 to about 40 mg (e.g., about 5 mg, about 10 mg, about 15 mg, about 20 mg or about 40 mg) of the hepcidin mimetic about twice a week or three times a week, and/or is administered about 5 to about 80 mg (e.g., about 5 mg, about 10 mg, 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg, about 40 mg, or about 80 mg) of the hepcidin mimetic about once a week.
  • the subject is administered different dosages at different frequency during different time periods.
  • the subject is administered the hepcidin mimetic for at least one month, at least two months, or at least four months.
  • the subject also receives therapeutic phlebotomy, e.g., about 0.5 L blood withdrawal, about once per week for at least one month, at least two months, or at least four months, e.g., during the induction phase.
  • therapeutic phlebotomy e.g., about 0.5 L blood withdrawal, about once per week for at least one month, at least two months, or at least four months, e.g., during the induction phase.
  • the method further comprises determining a TSAT level and/or serum iron level and/or MCHC level in the subject before and/or after treatment with the hepcidin mimetic and therapeutic phlebotomy.
  • the subject has a reduction in TSAT and/or serum iron and/or MCHC of at least 20%, at least 30%, at least 40%, at least 50%, at least 60% or at least 80%, and is provided with further combination therapy.
  • the method comprises measuring a TSAT% level in the subject before and/or after providing the subject with the combination therapy, and in some embodiments, the method comprises providing additional hepcidin mimetic to the subject to achieve or maintain the reduced TSAT% level, e.g., ⁇ 45% TSAT or ⁇ 40% TSAT.
  • the agent is any of those disclosed herein, e.g., a hepcidin mimetic peptide, such as a peptide of any one of Formula I-VHI or any of Compounds 1-46, e.g., Compound 25 or Compound 46.
  • the method comprises determining TSAT% and/or serum iron levels and/or MCHC levels in a subject before and after administering the combination therapy to the subject, and then determining whether the subject’s TSAT% and/or serum iron levels and/or MCHC levels were reduced to the desired level after administration of the combination therapy.
  • the subject is given increasing amounts of the hepcidin mimetic until TSAT% and/or serum iron levels and/or MCHC levels are reduced to the desired level.
  • the subject is given therapeutic phlebotomy at an increased frequency until TSAT% and/or serum iron levels and/or MCHC levels are reduced to the desired level.
  • the subject is given multiple different doses of the hepcidin mimetic over a course of treatment (and potentially at different frequencies, such as once a week and/or twice a week and/or three times a week), and the subject’s TSAT% and/or serum iron levels and/or MCHC levels are monitored at various times during a course of treatment to identify the minimal or appropriate dose and/or concentration required to reduce TSAT% and/or serum iron levels to the desired level, and/or to identify how frequently the subject should be treated to maintain the subject’s TSAT% and/or serum iron levels and/or MCHC levels at the desired level.
  • the method comprises measuring a TSAT% level in the subject before and/or after administering the combination therapy to the subject, and in some embodiments, the method comprises providing additional hepcidin mimetic and/or therapeutic phlebotomy to the subject to achieve or maintain the reduced TSAT% level, e.g., a level at or below 45% TSAT.
  • the hepcidin mimetic is a peptide of any one of Formula I-VHI or any of Compounds 1-46, e.g., Compound 25 or Compound 46.
  • the disclosure provides a method for treating HH, HH associated with arthropathy, or HH-associated arthropathy, e.g., during the induction phase, comprising: a) subcutaneously administering to a subject diagnosed with HH, e.g., induction-phase HH, HH associated with arthropathy, or HH-associated arthropathy, about 5 to about 25 mg (optionally 10 mg or 20 mg) of a hepcidin mimetic disclosed herein, e.g., Compound 25 and performing therapeutic phlebotomy on the subject; b) determining the subject’s TSAT % following step a), optionally at trough drug level, e.g., about 7 days following step a); and c) if the subject’s TSAT % is greater than about 40% or greater than about 45%, (i) subcutaneously administering to the subject an increased amount of the hepcidin mimetic, e.g., about
  • the method comprises monitoring the subject’s TSAT % levels, e.g., about 7 days after the first weekly dose, and adjusting the dosing by increasing the dose or increasing the frequency of dosing, if the TSAT% is greater than 40% or greater than 45%.
  • the method may further include determining and/or monitoring the subject’s serum iron level and/or MCHC level, and adjusting the dosage amount or frequency based on either or both.
  • the TSAT% level and/or serum iron level and/or MCHC levels is reduced by a percentage, or it is reduced to or below a particular TSAT% level or serum iron level and/or MCHC levels, e.g., in order to be associated with a therapeutically effective agent or dosing regimen.
  • the reduction in the TSAT% level and/or serum iron level and/or MCHC levels is maintained for a duration of time, e.g., 12 hours, one day, two days, three days, four days, five days, six days, or one week.
  • a percentage reduction in any of these levels could be the percentage reduction in a particular patient, for example, when monitoring TS AT% level and/or serum iron level and/or MCHC levels to determine dosing or dosing regimen for the patient, or a percentage reduction in TSAT% level and/or serum iron level and/or MCHC levels could be a reduction as compared to a predetermined value, e.g., the average or mean TSAT% level, or serum iron level, or MCHC level associated with a particular patient population.
  • the reduction in TSAT% is a reduction as compared to a normal, healthy volunteer.
  • Serum iron can be measured by various methods including colorimetrically.
  • TSAT represents the percentage of the transferrin iron-binding capacity actually occupied by iron in the serum. It is calculated as the serum iron multiplied by 100 and divided by the total iron- binding capacity (Coyne. Kidney International 69:54-58).
  • the subj ect is administered an effective amount of a hepcidin mimetic one or more times.
  • the hepcidin mimetic is administered about twice per week, about once per week, or about every two weeks.
  • the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46 is about 1 mg to about 100 mg, or about 10 mg to about 80 mg.
  • the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46 is about 5 mg to about 80 mg, or about 10 mg to about 80 mg.
  • the effective amount of the hepcidin mimetic is about 10 mg to about 40 mg, or about 5 mg to about 50 mg. In certain embodiments, the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46, is about 10 mg to about 40 mg, or about 5 mg to about 50 mg. In particular embodiments, the effective amount of the hepcidin mimetic is administered to the subject about once a week, about twice a week, or about three times a week.
  • the subject is administered about 10 mg to about 20 mg, about 10 mg to about 15 mg, or about 15 mg to about 20 mg, of the hepcidin mimetic about twice a week or about three times a week, and in another embodiments, the subject is administered about 10 mg to about 80 mg, about 10 mg to about 40 mg, about 20 mg to about 30 mg, about 20 mg to about 40 mg, or about 30 mg to about 40 mg of the hepcidin mimetic about once a week.
  • the subject is administered about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, or about 25 mg of the hepcidin mimetic about twice a week.
  • the subject is administered about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, about 25 mg, about 26 mg, about 27 mg, about 28 mg, about 29 mg, about 30 mg, about 31 mg, about 32 mg, about 33 mg, about 34 mg, about 35 mg, about 36 mg, about 37 mg, about 38 mg, about 39 mg, about 40 mg, about 41 mg, about 42 mg, about 43 mg, about 44 mg, or about 45 mg of the hepcidin mimetic about twice a week or about three times a week.
  • the hepcidin mimetic is administered subcutaneously.
  • the hepcidin mimetic is Compound 25.
  • the hepcidin mimetic is Compound 46.
  • the amount administered to the subject may vary over the course of treatment.
  • the agent modulates serum iron levels, e.g., by temporarily sequestering or redistributing iron in various tissues and/or preventing further absorption of iron from food.
  • an iron sequestration compound prevents export of iron.
  • the agent effects serum iron levels and/or iron load or distribution in various tissues/organs. It is understood that the disclosure further relates to pharmaceutically acceptable salts and solvates on any of the agents disclosed herein.
  • the hepcidin mimetic is described in any of the following: US patents, US 9,822,157 and US 10,030,061, which describe hepcidin analogs and their use to treat iron overload diseases, which include hereditary hemochromatosis and iron-loading anemias; PCT application publication, WO 15200916, which describes additional hepcidin analogs and their use to treat iron overload diseases; PCT application publication, WO17117411, which describes additional hepcidin analogs with improved in vivo half-lives and their use to treat iron overload diseases; PCT application publication, WO 18048944, which describes additional hepcidin analogs and their use to treat prevention of iron overload in a subject and/or reducing serum iron levels in a subject; PCT application publication, WO18128828, which describes additional hepcidin analogs and their use to treat hepcidin- associated disorders, including prophylaxis and treatment of iron overload diseases such as hemochromatosis, iron-
  • the hepcidin mimetic is a peptide comprising or consisting of Formula I:
  • R1 is hydrogen, a C1-C6 alkyl, a C6-C12 aryl, a C1-C20 alkanoyl, or pGlu;
  • R2 is NH 2 or OH;
  • X is an amino acid sequence of Formula II: X1-X2-X3-X4-X5-X6-X7-X8-X9-X10 (II) wherein
  • XI is Asp, Ala, Ida, pGlu, bhAsp, Leu, D-Asp, or absent;
  • X2 is Thr, Ala, or D-Thr
  • X3 is His, Lys, D-His, or Lys
  • X4 is Phe, Ala, Dpa, or D-Phe
  • X5 is Pro, Gy, Arg, Lys, Ala, D-Pro, or bhPro;
  • X6 is Ile, Cys, Arg, Lys, D-Ile, or D-Cys;
  • X7 is Cys, De, Leu, Vai, Phe, D-Ile, or D-Cys;
  • X8 is De, Arg, Phe, Gn, Lys, Gu, Vai, Leu, or D-Ile;
  • X9 is Phe or bhPhe
  • X10 is Lys, Phe, or absent; wherein if Y is absent, X7 is Ile; and
  • Y is an amino acid sequence of Formula III:
  • Y1 is Gy, Cys, Ala, Phe, Pro, Gu, Lys, D-Pro, Vai, Ser, or absent;
  • Y2 is Pro, Ala, Cys, Gly, or absent;
  • Y3 is Arg, Lys, Pro, Gy, His, Ala, Trp, or absent;
  • Y4 is Ser, Arg, Gy, Trp, Ala, His, Tyr, or absent;
  • Y5 is Lys, Met, Arg, Ala, or absent;
  • Y6 is Gy, Ser, Lys, Ile, Ala, Pro, Vai, or absent;
  • Y7 is Trp, Lys, Gy, Ala, Ile, Vai, or absent;
  • Y8 is Vai, Thr, Gy, Cys, Met, Tyr, Ala, Gu, Lys, Asp, Arg, or absent;
  • Y9 is Cys, Tyr, or absent
  • Y10 is Met, Lys, Arg, Tyr, or absent;
  • Y11 is Arg, Met, Cys, Lys, or absent
  • Y12 is Arg, Lys, Ala or absent
  • Y13 is Arg, Cys, Lys, Vai or absent
  • Y14 is Arg, Lys, Pro, Cys, Thr or absent
  • Y15 is Thr, Arg or absent; wherein the peptide comprising Formula I is optionally PEGylated on Rl, X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherein Ida is iminodiacetic acid, pGu is pyroglutamic acid, bhAsp is p-homoaspartic acid, and bhPro is P-homoproline.
  • any of the peptides disclosed herein comprise a disulfide bond between two Cys amino acid residues present in the peptide, e.g., wherein the thiol groups of two cysteine residues in the peptide form a disulfide bond.
  • R1 is hydrogen, isovaleric acid, isobutyric acid or acetyl.
  • X is an amino acid sequence of Formula IV: Xl-Thr-His-X4-X5-X6-X7-X8-Phe-X10 (IV) wherein
  • XI is Asp, Ida, pGlu, bhAsp or absent;
  • X4 is Phe or Dpa
  • X5 is Pro or bhPro
  • X6 is De, Cys, or Arg
  • X7 is Cys, De, Leu, or Vai
  • X8 is Ile, Lys, Glu, Phe, Gin, or Arg;
  • X10 is Lys or absent.
  • X is an amino acid sequence of Formula V:
  • XI is Asp, Ida, pGlu, bhAsp, or absent;
  • X4 is Phe or Dpa
  • X5 is Pro or bhPro
  • X8 is De, Lys, Glu, Phe, Gin or Arg;
  • X10 is Lys or absent.
  • the peptide comprises Formula VI:
  • R 1 is hydrogen, isovaleric acid, isobutyric acid, or acetyl
  • R 2 isNH2 or OH
  • X is an amino acid sequence of Formula VII: Xl-Thr-His-X4-X5-Cys-Ile-X8-Phe-X10 (VII) wherein
  • XI is Asp, Ida, pGlu, bhAsp, or absent;
  • X4 is Phe or Dpa;
  • X5 is Pro or bhPro;
  • X8 is He, Lys, Glu, Phe, Gin, or Arg;
  • X10 is Lys or absent; wherein Y is an amino add sequence of Formula VUI:
  • VUI Yl-Pro-Y3-Ser-Y5-Y6-Y7-Y8-Cys-Y10
  • Y1 is Gly, Glu, Vai, or Lys
  • Y3 is Arg or Lys
  • Y5 is Arg or Lys
  • Y6 is Gly, Ser, Lys, Ile, or Arg
  • Y7 is Tip or absent
  • Y8 is Vai, Thr, Asp, Glu, or absent
  • Y10 is Lys or absent; wherein the peptide comprises a disulfide bond between the two Cys; wherein the peptide is optionally PEGylated on R 1 , X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherein Ida is iminodiacetic acid; pGhi is pyroglutamic acid; bhAsp is P-homoaspartic acid; and bhPro is P-homoproline.
  • the peptide comprises or consists of one of the following sequences:
  • DTHFPICIFGPRSKGWVC (SEQ ID NO: 46);
  • DTHFPCIIFEPRSKGWVCK (SEQ ID NO: 48);
  • DTHFPCIKFGPRSKGWVCK (SEQ ID NO: 52);
  • DTHFPCIKFKPRSKGWVCK (SEQ ID NO: 53);
  • DTHFPCIIFGPRSRGWVCK (SEQ ID NO: 54);
  • DTHFPCIKFEPKSKGWECK SEQ ID NO: 57
  • DTHFPCIKFEPRSKKCK SEQ ID NO: 58
  • DTHFPCIKFEPRSKGCKK (SEQ ID NO: 59);
  • DTHFPCIKFEPKSKGCK (SEQ ID NO: 61);
  • DTHFPCIKF (SEQ ID NO: 62);
  • DTKFPCIIF (SEQ ID NO: 64), wherein said peptide is optionally PEGylated on Rl, X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherein the peptide optionally comprises a disulfide bond between two Cys amino add residues of the peptide.
  • the peptide comprises or consists of one of the following sequences:
  • Isovaleric acid-DTHFPICIFGPRSKGWVC-NH 2 (SEQ IDNO:1);
  • Isovaleric acid-DTHFPCIlFEPRSKGWVCK-NH 2 (SEQ ID NO:3 ⁇ Isovaleric acid-DTHFPCIlFGPRSKGWACK-NH 2 (SEQ ID NO:4 ⁇ Isovaleric acid-DTHFPCIlFGPRSKGWVCKK-NH 2 (SEQ ID NO:5 ⁇ Isovaleric acid-DTHFPCIlFVCHRPKGCYRRVCR-NIh (SEQ ID NO:6 ⁇ Isovaleric acid-DTHFPCI(K(PEG8))FGPRSKGWVCK-NH 2 (SEQ ID NO:7 ⁇ Isovaleric acid-DTHFPCIKF(K(PEG8))PRSKGWVCK-NH 2 (SEQ ID NO:8 ⁇
  • Isovaleric acid-DTHFPICIFGPRS(K(PEG8))GWVC-NH 2 SEQ ID NO:9 ⁇ Isovaleric acid-DTHFPICIFGPRS(K(PEG4))GWVC-NH 2 (SEQ ID NO: 10)
  • Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG8))-NH 2 SEQ ID NO: 11 ⁇ Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG4))-NH 2
  • SEQ ID NO: 12 ⁇ Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG2))-NH 2 SEQ ID NO: 13 ⁇ Isovaleric acid-DTHFPCI(K(Palm))FGPRSKGWVCK-NH 2 (SEQ ID NO: 14 ⁇
  • Isovaleric acid-DTHFPCIKF)K(Palm))PRSKGWVCK-NH 2 SEQ ID NO: 15 ⁇ Isovaleric acid-DTHFPCIKFGP(K(Palm))SKGWVCK-NH 2
  • SEQ ID NO: 18 ⁇ Isovaleric acid-DTHFPCI(K(PEG3-Palm))FGPRSKGWVCK-NH 2 SEQ ID NO: 19 ⁇ Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH 2 (SEQ ID NO:20) ;
  • Isovaleric acid-DTHFPCIKFGP(K(PEG3-Palm))SKGWVCK-NH 2 (SEQ ID NO:21) ;
  • Isovaleric acid-DTHFPCIKFEPRSK(K(isoGlu-Palm))CK-NH 2 (SEQ ID NO:30);
  • Hy-DTHFPCIKF-NH 2 (SEQ ID NO:41);
  • Hy-DTHFPCIIKF-NH 2 (SEQ ID NO:43);
  • Hy-DTKFPCIIF-NH 2 (SEQ ID NO:45); or
  • the peptide is selected from the group consisting of:
  • Peptides disclosed herein may be produced using methods known in the art including chemical synthesis, biosynthesis or in vitro synthesis using recombinant DNA methods, and solid phase synthesis. See e.g., PCT Application Publication Nos. WO 2014/145561 and WO 2015/200916; Kelly & Winkler (1990) Genetic Engineering Principles and Methods, vol. 12, J. K. Setlow ed., Plenum Press, NY, pp. 1-19; Merrifield (1964) J Amer Chem Soc 85:2149; Houghten (1985) PNAS USA 82:5131-5135; and Stewart & Young (1984) Solid Phase Peptide Synthesis, 2ed.
  • the peptides disclosed herein may be purified using protein purification techniques known in the art such as reverse phase high-performance liquid chromatography (HPLC), ion-exchange or immunoaffinity chromatography, filtration or size exclusion, or electrophoresis. See Olsnes, S. and A. Pihl (1973) Biochem. 12(16):3121-3126; and Scopes (1982) Protein Purification, Springer- Veriag, NY, which are herein incorporated by reference.
  • the peptides may be made by recombinant DNA techniques known in the art.
  • peptides disclosed herein may be PEGylated.
  • Polyethylene glycol or “PEG” is a polyether compound of general Formula H- (O-CH2-CH2)n-OH.
  • PEGs are also known as polyethylene oxides (PEOs) or polyoxyethylenes (POEs), depending on their molecular weight.
  • PEG, PEG, or POE refers to an oligomer or polymer of ethylene oxide.
  • PEG has tended to refer to oligomers and polymers with a molecular mass below 20,000 Da
  • PEO polymers with a molecular mass above 20,000 Da
  • POE polymer of any molecular mass.
  • PEG and PEO are liquids or low-melting solids, depending on their molecular weights. Throughout this disclosure, the three names are used indistinguishably.
  • PEGs are prepared by polymerization of ethylene oxide and are commercially available over a wide range of molecular weights from 300 Da to 10,000,000 Da.
  • PEG moi eties include polyethylene glycols (PEG), homo- or co-polymers of PEG, a monomethyl-substituted polymer of PEG (mPEG), or polyoxyethylene glycerol (POG). See, for example, Int. J. Hematology 68:1 (1998); Bioconjugate Chem. 6:150 (1995); and Grit. Rev. Therap. Drug Carrier Sys. 9:249 (1992).
  • PEGs that are prepared for purpose of half life extension, for example, mono-activated, alkoxy-terminated polyalkylene oxides (POAs) such as mono- methoxy-terminated polyethyelene glycols (mPEGs); bis activated polyethylene oxides (glycols) or other PEG derivatives are also contemplated.
  • POAs mono-activated, alkoxy-terminated polyalkylene oxides
  • mPEGs mono- methoxy-terminated polyethyelene glycols
  • Glycols bis activated polyethylene oxides
  • Suitable PEGs will vary substantially by weights, e.g., ranging from about 200 Da to about 40,000 Da or from about 200 Da to about 60,000 Da, any of which may used for the purposes of the present disclosure. In certain embodiments, PEGs having molecular weights from 200 Da to 2,000 Da or from 200 Da to 500 Da are used.
  • PEG poly(ethylene glycol)
  • a common initiator is a monofunctional methyl ether PEG, or methoxypoly(ethylene glycol), abbreviated mPEG.
  • Lower- molecular-weight PEGs are also available as pure oligomers, referred to as monodisperse, uniform, or discrete. These are used in certain embodiments of the present disclosure.
  • PEGs are also available with different geometries: branched PEGs have three to ten PEG chains emanating from a central core group; star PEGs have 10 to 100 PEG chains emanating from a central core group; and comb PEGs have multiple PEG chains normally grafted onto a polymer backbone.
  • PEGs can also be linear.
  • PEGylation is the act of covalently coupling a PEG structure to the peptide inhibitor of the invention, which is then referred to as a “PEGylated peptide inhibitor”.
  • the PEG of the PEGylated side chain is a PEG with a molecular weight from about 200 Da to about 40,000 Da.
  • the agents are present in a pharmaceutical composition
  • a pharmaceutical composition comprising one or more pharmaceutically acceptable diluents, carriers, or excipients.
  • a pharmaceutically acceptable carrier, diluent or excipient refers to a non-toxic solid, semi -solid or liquid filler, diluent, encapsulating material or formulation auxiliary of any type.
  • pharmaceutically acceptable carrier includes any of the standard pharmaceutical carriers. Pharmaceutically acceptable carriers for therapeutic use are well known in the pharmaceutical art and are described, for example, in “Remington's Pharmaceutical Sciences”, 17th edition, Alfonso R. Gennaro (Ed.), Mark Publishing Company, Easton, PA, USA, 1985.
  • Suitable pH-buffering agents mmaayy e.g., be phosphate, citrate, acetate, tris(hydroxymethyl)aminomethane (TRIS), N-tris(hydroxymethyl)methyl-3- aminopropanesulfonic acid (TAPS), ammonium bicarbonate, diethanolamine, histidine, arginine, lysine or acetate (e.g., as sodium acetate), or mixtures thereof.
  • TIS tris(hydroxymethyl)aminomethane
  • TAPS N-tris(hydroxymethyl)methyl-3- aminopropanesulfonic acid
  • ammonium bicarbonate diethanolamine
  • histidine arginine
  • lysine or acetate e.g., as sodium acetate
  • the term further encompasses any carrier agents listed in the US Pharmacopeia for use in animals, including humans.
  • Therapeutic phlebotomy for iron overload diseases is performed to reduce iron levels in the patient.
  • Therapeutic phlebotomy includes three phases: induction phase, transition phase, and maintenance phase.
  • Induction is when therapy is initiated.
  • Transition is the phase in which iron reduction is taking place to return iron levels to a normal healthy range. Once iron levels reach satisfactory and healthy levels, a patient enters the maintenance phase.
  • Induction phase it is important to achieve iron reduction without generating symptoms or accelerating disease, which depends on several factors. These include how the phlebotomy is performed (e.g., amount and frequency), patient, diet and behavior modifications, and continued education.
  • iron levels may be erratic or fall predictably.
  • the frequency of phlebotomies may change from twice weekly, to weekly or monthly.
  • serum ferritin is less than 500ng/mL
  • the frequency of phlebotomy can be slowed to once a month.
  • a subject’s response may depend on age, the extent of iron saturation, serum ferritin levels, hemoglobin response, physical condition including symptoms, and the speed with which an individual unloads iron.
  • compliance with therapy schedules and care with diet will impact this phase.
  • the goal of the transition period is to transition the patient from therapeutic phase into the maintenance phase. During this period, if iron levels are allowed to fall steadily, over time and not too rapidly, the body can reach healthy iron levels and possibly without canpetition from the genes that are programmed to load iron.
  • Maintenance phase patients are those who have reached healthy iron ranges and who can remain within those healthy ranges, typically by donating blood periodically.
  • a healthy range for ferritin is 25-150ng/mL. But patients in therapy for iron reduction should achieve a serum ferritin below 50ng/mL on at least one occasion. Thereafter, the ferritin is preferably maintained within the range of 25-75ng/mL.
  • the patient may donate blood routinely as defined by attending physician for optimum quality of health or may have periodic therapeutic phlebotomy by doctor’s order. Frequency of donation or therapeutic phlebotomy will depend upon patient’s Personal Health Profile as observed by patient and attending physician: age, weight, response to treatment, symptoms, rate of iron unloading and general physical condition.
  • the amount of time required to reach the maintenance phase of treatment will vary. Thereafter, how often that person must have a phlebotomy to keep iron levels in a normal range will depend on compliance. Many hemochromatosis patients abandon therapy once they achieve normal iron levels. This sets them up fa irreversible organ damage and the need for repeat series of therapeutic phlebotomies. [0095] In certain embodiment, once in maintenance phase, the patient may be treated with a hepcidin mimetic alone, phlebotomy alone, or a combination thereof.
  • the phlebotomy schedule according to the present methods is based on serum iron, TSAT, and or serum ferritin levels.
  • serum ferritin will drop by about 30-50ng/mL with each full unit of blood removed. This helps the physician to form an estimate of when the serum ferritin is will be below l,000ng/mL.
  • phlebotomies can be as frequent as twice a week.
  • the SF may be evaluated, e.g., every 1-6 weeks, until it is lowered below 750 ng/mL.
  • SF above 750 but below 1,000 is still a very high and may require continued weekly phlebotomies.
  • Iron Disorders Institute Advisory Board recommends against phlebotomy (with few exceptions) for patients whose hemoglobin is lower than 12.5g/dL.
  • a patient prior to treatment, a patient will have a serum ferritin greater than 200ng/mL (females) or 300ng/mL (males) with an accompanying transferrin-iron saturation percentage greater than 45%.
  • ferritin is above lOOOng/mL
  • phlebotomy treatments may be as frequent as once or twice weekly, while tolerable and until ferritin drops below lOOOng/mL.
  • the frequency of treatment may slow down from once or twice weekly to once a week or even to every other week depending upon the patient’s condition, behavior (eating habits) and ability to unload iron.
  • the methods disclosed herein reduce transferrin saturation (TSAT) level and/or serum iron level and/or mean corpuscular hemoglobin concentration (MCHC) level in the subject by at least 30%, at least 40%, or at least 60%.
  • the effective amount causes a decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron of at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90%.
  • the TSAT% and/or serum iron level and/or MCHC level is reduced between about 40% and about 90%, between about 50% and about 90%, or between 50% and 75%.
  • TSAT% level and/or serum iron level and/or MCHC level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type.
  • the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the maximum reduction observed in the subject following treatment with the agent, while in other embodiments, the reduction in the TSAT% level and/or serum iron level is the reduction observed at trough level of the agent following administration to a subject.
  • the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the average reduction observed, e.g., in a plurality of subjects.
  • the subject’s TSAT level is reduced to ⁇ 60% TSAT, ⁇ 50% TS AT, ⁇ 45% TSAT, ⁇ 40% TSAT, ⁇ 30% TSAT, ⁇ 20% TSAT, or ⁇ 10% TSAT.
  • the subject’s TSAT level is reduced to ⁇ 45% TSAT, or ⁇ 40% TSAT.
  • the subject’s TSAT level is reduced to ⁇ 40% TSAT, or ⁇ 35% TSAT.
  • the TSAT level is reduced to between about 20% TSAT and about 50% TSAT, e.g., between about 25% TSAT to about 40% TSAT.
  • the TSAT% and/or serum iron level is reduced by at least 10%, at least 20%, at least 40%, at least 40%, at least 50%, at least 60%, at least 70%, or at least 90%.
  • the TSAT% value is reduced to about 0% to about 60%, about 0% to about 40%, about 10% to about 40%, about 10% to about 30%, about 10% to about 20%, about 20% to about 60%, about 20% to about 40%, or about 20% to about 30%.
  • TSAT% is reduced to less than or equal to 50% TSAT, less than or equal to 45% TSAT, less than or equal to 40% TSAT, less than or equal to 35% TSAT, less than or equal to 30% TSAT, less than or equal to 20% TSAT, less than or equal to 15% TSAT, less than or equal to 10% TSAT, between about 10% TSAT and about 45% TSAT, between about 5% TSAT and about 20% TSAT, or between about 10% TSAT and about 20% TSAT at the time tested.
  • TSAT% level and/or serum iron level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type.
  • the serum iron level is reduced to about 0 uM to about 30 uM, about 0 uM to about 5 uM, about 0 uM to about 20 uM, about 0 uM to about 15 uM, about 0 uM to about 10 uM, or about 0 uM to about 5 uM.
  • the subject’s serum iron level is reduced to ⁇ 20 umol/L, ⁇ 18 umol/L, ⁇ 16 umol/L, ⁇ 14 umol/L, ⁇ 12 umol/L, ⁇ 10 umol/L, ⁇ 8 umol/L, ⁇ 6 umol/L, or ⁇ 4 umol/L.
  • the subject’s serum iron level is reduced to between about 2 umol/L and about 100 umol/L, e.g., between 2 and about 10 umol/L, or between about 10 umol/L and about 50 umol/L, or between about 10 umol/L and 30 about umol/L. In some embodiments, the subject’s serum iron level is reduced to between about 2 umol/L and about 100 umol/L, e.g., between 2 and about 10 umol/L, or between about 10 umol/L and about 50 umol/L, or between about 10 umol/L and 30 about umol/L.
  • the subject’s serum iron level is reduced to between about 50 mcg/dL to about 200 mcg/dL, or about 60 mcg/dL to about 170 mcg/dL. In certain embodiments, the serum iron level is reduced to less than about 150 ug/dL, less than about 100 ug/dL, or less than about 75 ug/dL.
  • the subject’s MCHC level is reduced by at least 5%, at least 10%, at least 20%, at least 40%, at least 40%, at least 50%, at least 60%, at least 70%, or at least 90%.
  • the MCHC value (g/dL) is reduced to less than about 35, less than or about 34, less than or about 33, less than or about 32, less than or about 31, less than or about 30, or less than or about 29.
  • the methods reduce transferrin saturation (TSAT) level and/or serum iron and/or MCHC level in the subject by at least 10%, at least 20%, at least 30%, at least 40%, or at least 60%.
  • the effective amount causes a decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron and/or MCHC level of at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90%.
  • the TSAT% and/or serum iron level and/or MCHC level is reduced between about 40% and about 90%, between about 50% and about 90%, or between 50% and 75%.
  • TSAT% level and/or serum iron level and/or MCHC level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type.
  • the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the maximum reduction observed in the subject following treatment with the agent, while in other embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the reduction observed at trough level of the agent following administration to a subject.
  • the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the average reduction observed, e.g., in a plurality of subjects.
  • TSAT% level and/or serum iron level and/or MCHC level is reduced to a level less than 200%, less than 150%, less than 100T, less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type.
  • an HH patient following treatment with the combination therapy disclosed herein, e.g., Compound 25 or Compound 46, an HH patient exhibits: TSAT levels of ⁇ 45% or ⁇ 40%, serum iron levels of ⁇ 150 ug/dL, ⁇ 100 ug/dL, or ⁇ 75 ug/dL; and/or MCHC levels of ⁇ 35 g/dL or ⁇ 30 g/dL. In particular embodiments, these levels occur at trough concentration of the hepcidin mimetic, e.g., about 7 days following the last dosing.
  • the decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level and/or MCHC level occurs for at least one day, at least two days, at least three days, at least four days, at least five days, at least six days, or at least one week following administration of the hepcidin mimetic.
  • the subject is provided with the hepcidin mimetic about three times a week, about twice a week, or about once a week, e.g., as a single dose or over a period of time, and with therapeutic phlebotomy about once per week or once every two weeks.
  • the decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level and/or MCHC level is at least 50%, or at least 60% or at least 80% for at least one day, at least two days, at least 3 days, or at least 4 days following a dose.
  • TSAT transferrin saturation
  • the decrease in TSAT and/or serum iron level and/or MCHC is maintained over the course of treatment, wherein the course of treatment may be, e.g., once a week or twice a week for at least two months, at least four months, at least six months, at least one year, at least two years, at least three years or longer.
  • the combination therapy disclosed herein results in a reduction in one or more of: serum iron, liver iron, heart iron, kidney iron, and/or pancreas iron of at 40%, at least 50%, at least 60%, at least 70%, or at least 80%, e.g., when measured at the end of a course of treatment of about 8 weeks, ten weeks, 12 weeks, or four months.
  • the combination therapy disclosed herein results in an increase in spleen iron, e.g., when measured at the end of a course of treatment of about 8 weeks, ten weeks, 12 weeks, or four months.
  • the decrease or increase associated with the combination therapy is greater than with treatment with the hepcidin mimetic alone or therapeutic phlebotomy alone, and in certain embodiments, treatment with the combination of hepcidin mimetic and therapeutic phlebotomy acts synergistically.
  • the subject needs fewer phlebotomies following treatment with a hepcidin mimetic, e.g., Compounds 25, according to the disclosed methods. In some embodiments, the subject needs less than 0.1 phlebotomy per month, or less than 0.05 phlebotomy per month during treatment according to the disclosure.
  • the subject has improved arthropathy following treatment, e.g., as determined by methods available in the art, e.g., X-ray, MRI, joint pain, and/or use of functional scoring instruments.
  • the subject has reduced oxidative stress, reduced disrupted matrix metabolism, and/or reduced cartilage degeneration following treatment.
  • the methods disclosed herein result in the subject having decreased circulating transferrin saturation (TSAT) and/or decreased toxic non-transferrin bound iron (NTBI), and/or decreased iron accumulation in organs, e.g., such as the liver, pancreas, heart, and bone.
  • TSAT circulating transferrin saturation
  • NTBI toxic non-transferrin bound iron
  • iron overload can cause hepatomegaly, diabetes mellitus, skin hyperpigmentation, cardiomyopathy, diastolic dysfunction, heart failure, cirrhosis, etc.
  • methods of treatment disclosed herein reduce, alleviate, or improve any of these symptoms or pathologies associated with iron overload, such as HH.
  • HBTU O-(Benzotriazol-l-yl)-N,N,N , ,N’-tetramethyluronium hexafluorophosphate
  • HATH 2-(7 -aza- lH-benzotriazole- 1 -yl)- 1 , 1 ,3,3 -tetramethyluronium hexafluorophosphate
  • DCC Dicyclohexylcarbodiimide
  • TIS triisopropylsilane
  • HPLC high performance liquid chromatography
  • ESI-MS electron spray ionization mass spectrometry
  • PBS phosphate-buffered saline
  • IVA Isovaleric acid (or Isovaleryl)
  • K( ) In the peptide sequences provided herein, wherein a compound or chemical group is presented in parentheses directly after a Lysine residue, it is to be understood that the compound or chemical group in the parentheses is a side chain conjugated to the Lysine residue. So, e.g., but not to be limited in any way, K-[(PEG8)]- indicates that a PEGS moiety is conjugated to a side chain of this Lysine.
  • Palm Indicates conjugation of a palmitic add (palmitoyl).
  • C( ) refers to a cysteine residue involved in a particular disulfide bridge.
  • disulfide bridges there are four disulfide bridges: the first between the two C(l) residues; the second between the two C(2) residues; the third between the two C(3) residues; and the fourth between the two C(4) residues. Accordingly, in some embodiments, the sequence for Hepcidin is written as follows:
  • Hy-DTHFPIC(1)IFC(2)C(3)GC(2)C(4)HRSKC(3)GMC(4)C(1)KT-OH SEQ ID NO: 65
  • sequence for other peptides may also optionally be written in the same manner.
  • Peptide analogues of the invention were chemically synthesized using optimized 9- fluorenylmethoxy carbonyl (Fmoc) solid phase peptide synthesis protocols.
  • Fmoc 9- fluorenylmethoxy carbonyl
  • rink-amide resin was used, although wang and trityl resins were also used to produce C-terminal acids.
  • the side chain protecting groups were as follows: Glu, Thr and Tyr: O- tButyl; Trp and Lys: t-Boc (t-butyloxycarbonyl); Arg: N-gamma-2,2,4,6,7- pentamethyldihydrobenzofuran-5-sulfonyl; His, Gin, Asn, Cys: Trityl.
  • HATU O-(7-azabenzotriazol-l-yl)-l,l,3,3,-tetramethyluronium hexafluorophosphate
  • Fmoc protecting group removal was achieved by treatment with a DMF, piperidine (2:1) solution.
  • Method B Selective oxidation of two disulfides. When more than one disulfide was present, selective oxidation was often performed. Oxidation of the free cysteines was achieved at pH 7.6 NH4CO3 solution at Img /10 mL of peptide. After 24 h stirring and prior to purification the solution was acidified to pH 3 with TEA followed by lyophilization. The resulting single oxidized peptides (with ACM protected cysteines) were then oxidized / selective deprotection using iodine solution.
  • the peptide (1 mg per 2 mL) was dissolved in MeOH/H 2 O, 80:20 iodine dissolved in the reaction solvent was added to the reaction (final concentration: 5 mg/mL) at room temperature. The solution was stirred for 7 minutes before ascorbic acid was added portion wise until the solution is clear. The solution was then loaded directly onto the HPLC.
  • Oxidation of the unprotected peptides of the invention was achieved by adding drop-wise iodine in MeOH (1 mg per 1 mL) to the peptide in a solution (ACN: H2O, 7: 3, 0.5% TFA). After stirring for 2 min, ascorbic add portion wise was added until the solution was clear and the sample was immediately loaded onto the HPLC for purification.
  • Glyoxylic acid (DIG), IDA, or Fmoc- ⁇ -Ala-IDA was pre-activated as the N- hydoxysucdnimide ester by treating 1 equivalent (abbreviated “eq”) of the acid with 2.2 eq of both N-hydoxysuccinimide (NHS) and dicyclohexyl carbodiimide (DCC) in NMP (N-methyl pyrolidone) at a 0.1 M final concentration.
  • NMS N-hydoxysuccinimide
  • DCC dicyclohexyl carbodiimide
  • NMP N-methyl pyrolidone
  • the activated ester - 0.4 eq was added slowly to the peptide in NMP (Img/mL) portionwise. The solution was left stirring for 10 min before 2-3 additional aliquots of the linker -0.05 eq were slowly added. The solution was left stirring for a further 3 h before the solvent was removed under vaccuo and the residue was purified by reverse phase HPLC. An additional step of stirring the peptide in 20% piperidine in DMF (2 x 10 min) before an additional reverse phase HPLC purification was performed.
  • Dimerization Procedure 2mL of anhydrous DMF was added to a vial containing peptide monomer (0.1 mmol). The pH of the peptide was the adjusted to 8 ⁇ 9 with DIEA. Activated linker (IDA or PEG13, PEG 25) (0.48eq relative to monomer, 0.048 mmol) was then added to the monomer solution. The reaction mixture was stirred at room temperature for one hour. Completion of the dimerization reaction was monitored using analytical HPLC. The time for completion of dimerization reaction varied depending upon the linker. After completion of reaction, the peptide was precipitated in cold ether and centrifuged. The supernatant ether layer was discarded. The precipitation step was repeated twice.
  • Activated linker IDA or PEG13, PEG 25
  • the crude dimer was then purified using reverse phase HPLC (Luna Cl 8 support, lOu, 100 A, Mobile phase A: water containing 0.1% TFA, mobile phase B: Acetonitrile (ACN) containing 0.1% TFA, gradient of 15%B and change to 45%B over 60min, flow rate 15ml/min). Fractions containing pure product were then freeze-dried on a lyophilizer.
  • Hepcidin deficiency in hereditary hemochromatosis leads to hyperabsorption of dietary iron and primary iron overload. Persistent high transferrin-saturation (TSAT%) results in the occurrence of labile iron that can be toxic. Deposition of excess iron in organs, e.g., liver iron overload, contributes to tissue damage and potential organ dysfunction.
  • Hepcidin mimetic peptide therapy mini-hepddin was demonstrated to be beneficial in preventing iron overload in a hepcidin knockout mouse model (Hamp -/- ) (Ramos E, Blood (2012) 120 (18):3829-36).
  • Rusfertide is a hepcidin mimetic peptide designed for superior drug like properties compared to the endogenous protein, which has demonstrated potential benefit in reducing the need for therapeutic maintenance phlebotomy in hemochromatosis subjects who have previously required chronic phlebotomies to reduce and maintain ferritin and liver iron values within normal range (Kowdley KV, AASLD Hepatology (2021) 74: Issue SI).
  • This study evaluated the potential synergistic/additive effects of co-treatment with Compound 46 (a rusfertide analog peptide with identical pharmacokinetic and pharmacodynamic characteristics) in the induction phlebotomy phase by using the HJV -/- mouse model.
  • Male HJV -/- mice were recruited into the study at 8-12 weeks of age and given 35 ppm iron diet from weaning. One basline group was terminated at Day 0, and another baseline group was terminated at the end of the study.
  • mice were treated with vehicle, either Compound 46 (7.5 mg/kg, TIW, SubQ), phlebotomy ( ⁇ 0.3mL blood drawn retroorbitally, QW), or combination of both for a total of 46 days (baseline group was terminated at study start), outlined in FIG. 1. Clinical observation was performed daily, and body weights taken every two weeks. Following termination, serum was analyzed for iron and ferritin. Liver, spleen, pancreas, heart, kidneys, and duodenum were collected and frozen prior to determination of tissue iron content by ICP-MS.
  • Compound 46 7.5 mg/kg, TIW, SubQ
  • phlebotomy ⁇ 0.3mL blood drawn retroorbitally, QW
  • combination of both for a total of 46 days (baseline group was terminated at study start), outlined in FIG. 1. Clinical observation was performed daily, and body weights taken every two weeks. Following termination, serum was analyzed for iron and ferritin. Liver, spleen, pancreas, heart
  • Vehicle group showed elevated total iron concentrations in liver, heart, pancreas and kidney compared to baseline group and were all much higher than wild type values (FIGs. 4- 7). All three treatment strategies were able to prevent liver iron accumulation, however, none were able to lower the liver iron concentration as compared to respective baseline groups for either treatment length (FIG. 4). A longer length of treatment may result in effects on liver iron concentration. Significant reductions in iron concentrations were observed in heart and kidney for all the treatment strategies, but more statistically significant for the groups treated with Compound 46 alone or Compound 46 in combination with phlebotomy (FIGs. 5 and 6).
  • Hemoglobin levels were lowered with Compound 46 treatment alone, and lowered to an even greater extent with Compound 46 treatment in combination with phlebotomy (FIG. 10).
  • Red blood cell levels were lowered with Compound 46 treatment alone, and lowered to an even greater extent with Compound 46 treatment in combination with phlebotomy (FIG. 11).
  • MCV levels increased with phlebotomy treatment alone (FIG. 12).
  • MCH was reduced by treatment with Compound 46, alone or in combination with phlebotomy (FIG. 13).
  • MCHC was slightly reduced by treatment with Compound 46, alone or in combination with phlebotomy (FIG. 13).
  • Data is summarized in FIG. 14.

Abstract

The disclosure provides methods for the treatment and/or prevention of iron overload diseases such as hereditary hemochromatosis.

Description

COMBINATION THERAPY FOR TREATMENT OF IRON OVERLOAD DISEASES
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This application claims priority to U.S. Provisional Application No. 63/359,042 filed on July 7, 2022, which is incorporated by reference herein in its entirety.
SEQUENCE LISTING
[0002] The Sequence Listing XML associated with this application is provided in XML file format and is hereby incorporated by reference into the specification. The name of the XML file containing the Sequence Listing XML is PRTH_081_01WO_ST26.xml. The XML file is 114,323 bytes, and created on July 6, 2023, and is being submitted electronically via USPTO Patent Center.
FIELD OF THE INVENTION
[0003] The present disclosure relates, inter alia, to methods for the treatment and/or prevention of iron overload diseases, such as hereditary hemochromatosis.
BACKGROUND
[0004] Iron plays an important role in many cellular and organismal activities, from cell division to oxygen transport (see, e.g., Casu, C. et al., Blood 2018; 131(16): 1790-1794). However, excess iron promotes the formation of toxic reactive oxygen species (ROS), which can damage DNA, proteins, and lipid membranes, and lead to organ dysfunction or failure, and humans and other vertebrates have evolved regulatory systems to optimize the absorption and organ distribution of iron. Unfortunately, however, several genetic or acquired disorders of iron homeostasis dysregulate iron absorption or distribution, causing organ damage and creating conditions for overwhelming infections or inflammation, with associated morbidity and mortality.
[0005] Hepcidin is a 25 amino acid peptide hormone produced primarily in the liver in proportion to plasma iron concentration and iron stores. Hepcidin is a key regulator of iron homeostasis, since it binds and degrades the only known iron exporter, ferroportin-1, which is expressed on the surfaces of cells involved in iron absorption, recycling, and storage.
[0006] Given the central role of iron homeostasis in a variety of diseases and disorders, agents capable of modulating iron levels, e.g., in erythrocytes and organs, are being developed as therapeutic agents. However, there remains a need for methods for using iron modulating agents to restore iron homeostasis, e.g., for the treatment of hereditary hemochromatosis. The present invention addresses this need.
SUMMARY OF THE INVENTION
[0007] The present disclosure provides combination therapies for treating iron overload disorders, such as hereditary hemochromatosis, with a hepcidin mimetic and therapeutic phlebotomy. In particular, the disclosure provides methods and dosing regimens of hepcidin mimetics and therapeutic phlebotomy that restore iron homeostasis in human, e.g., humans with hereditary hemochromatosis, methods, clinically effective dosages, and dosing regimens of hepcidin mimetics that restore iron homeostasis in human, e.g., humans with hereditary hemochromatosis. In certain embodiments, the methods modulate pharmacodynamic markers associated with efficacy in the treatment of disease and disorders associated with dysregulation of iron homeostasis, such as iron overload diseases and disorders, including, e.g., hereditary hemochromatosis (HH). In certain embodiments, dosages, dosage regimens, and methods disclosed herein are used to treat hereditary hemochromatosis, hereditary hemochromatosis arthropathy, or joint pain associated with hereditary hemochromatosis arthropathy. In particular embodiments, the methods are used to treat hereditary hemochromatosis patients during the phlebotomy induction phase.
[0008] In one aspect, the disclosure provides a method for treating an iron overload disease, e.g., HH, in a human subject, comprising providing to the subject an effective amount of a hepcidin mimetic, such as, e.g., Compound 25 or Compound 46, in combination with therapeutic phlebotomy. In certain embodiments, the subject has been diagnosed with hereditary hemochromatosis. In certain embodiments, the subject has not previously received therapeutic phlebotomy for the condition being treated. In particular embodiments, the combination therapy is performed during the induction phase of phlebotomy treatment.
[0009] In particular embodiments, the subject is administered a first effective amount of the hepcidin mimetic for a first time period, and a second effective amount of the hepcidin mimetic for a second time period. In certain embodiments, the subject is administered a third or more effective amounts of the hepcidin mimetic for a third or more time periods. In certain embodiments, the frequency of administration during the first and second time periods are the same or different. In certain embodiments, the frequency of administration during the third or more time periods are each the same or different from that of the first and second time period and each other. In particular embodiments, each time period independently comprises about one week, about two weeks, about four weeks, about one month, about two months, about four months, about six months, or about one year. In certain embodiments, the dosage and or frequency of administration is altered following testing of the subject’s serum iron and/or TSAT saturation levels after a time period of treatment, so as to achieve parameters disclosed herein.
[0010] In particular embodiments, the effective amount of the hepcidin mimetic comprises a dose in the range of about 5 mg to about 40 mg, and optionally the subject is administered different doses dining different time periods over a course of treatment. In some embodiments, the hepcidin mimetic is Compound 25 or Compound 46. In certain embodiments, an effective dose is a dose that results in the treated patient’ s TS AT % to be reduced to <45% or <40%.
[0011] In certain embodiments of the methods disclosed herein, the effective amount of the hepcidin mimetic is about 10 mg to about 40 mg for at least some time period during the course of treatment. In particular embodiments, the effective amount of the hepcidin mimetic is administered to the subject about once a week, about twice a week, or about three times a week, for at least some time period during the course of treatment. In some embodiments, the subject is administered about 10 mg to about 15 mg, about 15 mg to about 20 mg, or about 10 mg to about 20 mg of the hepcidin mimetic about twice a week or about three times a week for at least some time period during the course of treatment, and in another embodiments, the subject is administered about 20 mg to about 30 mg, about 20 mg to about 40 mg, or about 30 mg to about 40 mg of the hepcidin mimetic about once a week for at least some time period during the course of treatment. In certain embodiments, the subject is administered about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, or about 25 mg of the hepcidin mimetic about twice a week or about three times a week for at least some time period during the course of treatment. In certain embodiments, the subject is administered about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, about 25 mg, about 26 mg, about 27 mg, about 28 mg, about 29 mg, about 30 mg, about 31 mg, about 32 mg, about 33 mg, about 34 mg, about 35 mg, about 36 mg, about 37 mg, about 38 mg, about 39 mg, about 40 mg, about 41 mg, about 42 mg, about 43 mg, about 44 mg, or about 45 mg of the hepcidin mimetic about twice a week or about three times a week for at least some time period during the course of treatment. In particular embodiments, the hepcidin mimetic is administered subcutaneously. [0012] In particular embodiments, one or more therapeutic phlebotomy is performed about once per month, about once every two weeks, about once per week, or about twice per week over a course of treatment. Optionally, the therapeutic phlebotomy is performed at different frequency during the course of treatment. In certain embodiments, phlebotomy is performed about once per week for at least or about 8 weeks, e.g., about once per week for about 8 weeks to about 12 or 16 weeks. In certain embodiments, each phlebotomy comprises removing about 250 cc - about 1000 cc of blood from the subject. In certain embodiments, each phlebotomy comprises removing about 500 cc of blood from the subject.
[0013] In some embodiments of any of the methods disclosed herein, the method results in the subject’s TSAT level being decreased to less than about 50% TSAT (%) or less than about 45% TSAT (%) or less than about 40% TSAT (%), or less than 35% TSAT or less than 30% TSAT. In some embodiments, the method results in the subject’s serum iron level being decreased to less than about 150 ug/dL. In some embodiments, the method results in the subject’s liver iron concentration being substantially maintained, e.g., not significantly changed. In some embodiments, the method results in the subject’s serum ferritin and serum transferrin levels or concentrations being substantially maintained, e.g., not significantly changed. In some embodiments, the method results in the subject having improved emotional and/or physical outcomes. In certain embodiments of the disclosed methods, following the combination treatment, the subject requires reduced or no phlebotomy treatment. For example, a subject undergoing a course of treatment disclosed herein may require no phlebotomies per month, or one or less phlebotomies per month following the course of treatment disclosed herein.
[0014] In particular embodiments, a course of a combination treatment disclosed herein may be for at least or about four weeks, at least or about six weeks, at least or about eight weeks, at least or about 10 weeks, at least or about 12 weeks, at least or about four months, or longer. In certain embodiments, the combination therapy lasts for about eight weeks to about 16 weeks. [0015] In some embodiments of any of the methods disclosed herein, the hepcidin mimetic comprises a peptide of any one of Formulas I- VIII as disclosed herein. In certain embodiments, the peptide comprises or consists of one of the following sequences or structures: Isovaleric acid-DTHFPICIFGPRSKGWVC-NH2 (Compound 1; SEQ ID NO: 1);
Isovaleric acid-DTHFPCIlFGPRSKGWVCK-NH2 (Compound 2; SEQ ID NO: 2); Isovaleric acid-DTHFPCHFEPRSKGWVCK-NH2 (Compound 3; SEQ ID NO: 3); Isovaleric acid-DTHFPCIlFGPRSKGWACK-NH2 (Compound 4; SEQ ID NO: 4); Isovaleric acid-DTHFPCIlFGPRSKGWVCKK-NH2 (Compound 5; SEQ ID NO: 5); Isovaleric acid-DTHFPCIlFVCHRPKGCYRRVCR-NH2 (Compound 6; SEQ ID NO: 6); Isovaleric acid-DTHFPCI(K(PEG8))FGPRSKGWVCK-NH2 (Compound 7; SEQ ID NO: 7);
Isovaleric acid-DTHFPCIKF(K(PEG8))PRSKGWVCK-NH2 (Compound 8; SEQ ID NO: 8);
Isovaleric acid-DTHFPICIFGPRS(K(PEG8))GWVC-NH2 (Compound 9; SEQ ID NO: 9);
Isovaleric acid-DTHFPICIFGPRS(K(PEG4))GWVC-NH2 (Compound 10; SEQ ID NO: 10);
Isovaleric acid-DTHFPCIIFGPRSRGWVC(K(PEG8))-NH2 (Compound 11; SEQ ID NO: 11);
Isovaleric acid-DTHFPCIIFGPRSRGWVC(K(PEG4))-NH2(Compound 12; SEQ ID NO: 12);
Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG2))-NH2 (Compound 13; SEQ ID NO: 13);
Isovaleric acid-DTHFPCI(K(Palm))FGPRSKGWVCK-NH2 (Compound 14; SEQ ID NO: 14);
Isovaleric acid-DTHFPCIKF)K(Palm))PRSKGWVCK-NH2(Compound 15; SEQ ID NO: 15);
Isovaleric acid-DTHFPCIKFGP(K(Palm))SKGWVCK-NH2(Compound 16; SEQ ID NO: 16);
Isovaleric acid-DTHFPCIKFGPRS(K(Palm))GWVCK-NH2 (Compound 17; SEQ ID NO: 17);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(Palm))NH2 (Compound 18; SEQ ID NO: 18);
Isovaleric acid-DTHFPCI(K(PEG3-Palm))FGPRSKGWVCK-NH2 (Compound 19; SEQ ID NO: 19);
Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH2 (Compound 20; SEQ ID NO: 20);
Isovaleric acid-DTHFPCIKFGP(K(PEG3-Palm))SKGWVCK-NH2 (Compound 21; SEQ ID NO: 21);
Isovaleric acid-DTHFPCIKFGPRS(K(PEG3-Palm))GWVCK-NH2 (Compound 22; SEQ ID NO: 22);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(PEG3-Palm))-NH2 (Compound 23; SEQ ID NO: 23);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(PEG8))-NH2 (Compound 24; SEQ ID NO:
24);
Isovaleric acid-DTHFPCI(K(isoGlu-Palm))FEPRSKGCK-NH2 (Compound 25; SEQ ID NO:
25);
Isovaleric acid-DTHFPCIKF(K(isoGlu-Palm))PRSKGCK-NH2 (Compound 26; SEQ ID NO:
26);
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGCK-NH2 (Compound 27; SEQ ID NO:
27);
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGWECK-NH2 (Compound 28; SEQ ID NO: 28);
Isovaleric acid-DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH2 (Compound 29; SEQ ID NO: 29); Isovaleric acid-DTHFPCIKFEPRSK(K(isoGlu-Palm))CK-NH2 (Compound 30; SEQ ID NO: 30);
Isovaleric acid-DTHFPCIKFEPRSKGCK(K(isoGlu-Palm))-NH2 (Compound 31; SEQ ID NO: 31);
Isovaleric acid-DTHFPCI(K(Dapa-Palm))FEPRSKGCK-NH2 (Compound 32; SEQ ID NO: 32);
Isovaleric acid-DTHFPCIK(F(Dapa-Palm))PRSKGCK-NH2 (Compound 33; SEQ ID NO: 33); Isovaleric acid-DTHFPCIKFEP(K(Dapa-Palm))SKGCK-NH2 (Compound 34; SEQ ID NO:
34);
Isovaleric acid-DTHFPCIKFEPRS(K(Dapa-Palm))GCK-NH2 (Compound 35; SEQ ID NO:
35);
Isovaleric acid-DTHFPCIKFEPRSK(K(Dapa-Palm))CK-NH2 (Compound 36; SEQ ID NO:
36);
Isovaleric acid-DTHFPCIKFEPRSKGC(K(Dapa-Palm))K-NH2 (Compound 37; SEQ ID NO:
37);
Isovaleric acid-DTHFPCIKFEPRSKGC(K(Dapa-Palm))-NH2 (Compound 38; SEQ ID NO:
38);
Isovaleric acid-DTHFPCIKF(K(PEGll-Palm))PRSK[Sar]CK-NH2 (Compound 39; SEQ ID NO: 39);
Isolvaleric acid-DTHFPCIKF-NH2 (Compound 40; SEQ ID NO: 40); Hy-DTHFPCIKF-NH2 (Compound 41; SEQ ID NO: 41);
Isolvaleric acid-DTHFPCIIF-NH2 (Compound 42; SEQ ID NO: 42); Hy-DTHFPCIIKF-NH2 (Compound 43; SEQ ID NO: 43);
Isovaleric acid-DTKFPCIIF-NH2 (Compound 44; SEQ ID NO: 44); Hy-DTKFPCIIF-NH2 (Compound 45; SEQ ID NO: 45); or
Isovaleric acid-ETHFPCI(k(IsoGlu-Palm))FEPRSKGCK-NH2 (Compound 46; SEQ ID NO: 66).
[0016] In particular embodiments of any of the methods disclosed herein, the reduction in the TSAT% level and/or serum iron level is the maximum reduction following treatment with the agent, while in other embodiments, the reduction in the TSAT% level and/or serum iron level is the reduction observed at trough level of the agent following administration to a subject. In some embodiments, TSAT% is reduced to less than or equal to about 45%, less than or equal to about 40%, less than or equal to about 30%, less than or equal to about 20%, less than or equal to about 15%, less than or equal to about 10%, between about 10% and about 40%, between about 5% and about 20%, or between about 10% and about 20% at the time tested. In some embodiments, the serum iron is reduced to less than or equal to about 150 micrograms/dL, less than or equal to about 100 micrograms/dL, less than or equal to about 75 micrograms/dL, or less than or equal to about 600 micrograms/dL at the time tested. In some embodiments, TSAT% level and/or serum iron level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers. [0017] In various embodiments of any ofthe methods disclosed herein, the agent, e.g., hepcidin mimetic peptide, such as Compound 25 or Compound 46, is provided to the subject as a salt form and/or in a pharmaceutical composition, and in certain embodiments, it is provided parenterally, e.g., subcutaneously.
BRIEF DESCRIPTION OF THE DRAWINGS
[0018] FIG. 1 provides a schematic diagram of the design and timeline of an animal study of the effect of hepcidin mimetics on treatment of iron overload diseases. Animals at 8-12 wks (first set) and 12-16wks (second set) were maintained under 35ppm iron diet since weaning. Mice were acclimatized for 1 week under 35ppm iron diet prior to study.
[0019] FIG. 2 is a graph showing serum iron (uM) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was better able to control serum iron. Serum iron reflects TSAT%, and it wwaass previously demonstrated that Transferrin does not vary with age/treatment. Treatment with Compound 46 alone or in combination with phlebotomy, controlled serum iron significantly better as compared to weekly phlebotomy therapy. There was also a trend towards higher serum iron in the phlebotomy only group as compared to vehicle group, but it was not statistically significant.
[0020] FIG. 3 is a graph showing serum Ferritin (ng/mL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was better able to lower serum Ferritin. Serum Ferritin was lowest for the group that received Compound 46 and phlebotomy treatments. Treatment with Compound 46 alone or in combination with phlebotomy, controlled serum ferritin significantly better as compared to weekly phlebotomy therapy. Reduction in Ferritin with Compound 46 treatment was better after 44-day treatment as compared to 23-day treatment.
[0021] FIG. 4 is a graph showing liver iron (uh/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was equally effective at preventing liver iron deposition as compared to phlebotomy therapy. The apparent benefit of treatment with peptide, phlebotomy or combination was entirely due to prevention of iron deposition in the liver. There was no evidence of reversal of liver iron deposited at the start of the study (compare treatment groups with baseline group). For animal treated over longer duration, all three treatment arms showed equivalent effectiveness in preventing liver iron deposition. Vehicle treated group showed significant iron deposition after 46days in the study compared to baseline at study start.
[0022] FIG. 5 is a graph showing heart iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was effective at reducing heart iron concentration compared to baseline, while Phleb was effective only in prevention. There was a clear significant reduction in the heart iron concentration for animals treated with Compound 46 for longer duration as compared to baseline group. Animals that received Phleb+Compound 46 cotreatment for either longer duration or shorter duration clearly showed significant reduction in heart iron concentration. There was no reduction in heart iron for the group treated with phlebotomy only as compared to baseline, but phlebotomy treatment was successful in preventing further iron deposition in the heart.
[0023] FIG. 6 is a graph showing kidney iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was effective at reducing kidney iron concentration compared to baseline. There was a clear significant reduction in the kidney iron concentration for animals treated with Compound 46 as compared to baseline group (true for both treatment durations). Animals that received Phleb+Compound 46 co-treatment also showed significant reduction in kidney iron concentration (true for both treatment durations). Animals that received only Phleb also show reductions in kidney iron concentration.
[0024] FIG. 7 is a graph showing pancreas iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment was effective preventing increase in Pancreatic iron concentration compared to baseline. Compound 46 was able to prevent iron deposition in pancreas. Phlebotomy treatment was not able to prevent iron deposition in the pancreas. Surprisingly, Compound 46+Phleb cotreatment was not able to prevent iron deposition in the pancreas.
[0025] FIG. 8 is a graph showing spleen iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 redistributed excess iron into spleen. Treatment with Compound 46 alone redistributed the excess iron into spleen, thereby significantly elevating spleen iron concentration, while co-treatment with phlebotomy lowered this iron sequestration in spleen. [0026] FIG. 9 is a graph showing duodenum iron (ug/g wet tissue) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). The graph shows that Compound 46 treatment increase duodenum iron concentration. There was a trend towards increased duodenum iron concentration in Compound 46 and Compound 46+Phleb treated groups, but it was not statistically significant. There was no change in duodenum iron with phlebotomy treatment alone.
[0027] FIG. 10 is a graph showing hemoglobin (g/dL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
[0028] FIG. 11 is a graph showing red blood cells (REC) (xlO6 cells/uL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side). [0029] FIG. 12 is a graph showing MCV (fL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
[0030] FIG. 13 is a graph showing MCH (pg) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
[0031] FIG. 14 is a graph showing MCHC (g/dL) at baseline and following the indicated treatments post-last dose on Day 46 (left side) or Day 25 (right side).
[0032] FIG. 15 is a table of the indicated values determined at baseline and following the indicated treatments post-last dose on Day 46 or Day 25.
DETAILED DESCRIPTION
[0033] The present disclosure identifies a therapeutically effective combination therapy useful for treating diseases and disorders associated with iron dysregulation, such as hereditary hemochromatosis (HH), which includes treatment with a combination of a hepcidin mimetic and therapeutic phlebotomy. The method may be practiced during the induction phase of phlebotomy. In particular embodiments, the methods disclosed herein are practiced using Compound 25 or Compound 46 in combination with phlebotomy to treat hereditary hemochromatosis.
Definitions and Nomenclature
[0034] Unless otherwise defined herein, scientific and technical terms used in this application shall have the meanings that are commonly understood by those of ordinary skill in the art. Generally, nomenclature used in connection with, and techniques of, chemistry, molecular biology, cell and cancer biology, immunology, microbiology, pharmacology, and protein and nucleic acid chemistry, described herein, are those well-known and commonly used in the art.
[0035] As used herein, the following terms have the meanings ascribed to them unless specified otherwise.
[0036] Throughout this specification, the word “comprise” or variations such as “comprises” or “comprising” will be understood to imply the inclusion of a stated integer (or components) or group of integers (or components), but not the exclusion of any other integer (or components) or group of integers (or components).
[0037] The singular forms “a,” “an,” and “the” include the plurals unless the context clearly dictates otherwise.
[0038] The term “including” is used to mean “including but not limited to.” “Including” and “including but not limited to” are used interchangeably.
[0039] The terms “patient,” “subject,” and “individual” may be used interchangeably and refer to either a human or a non-human animal. These terms include mammals such as humans, primates, livestock animals (e.g., bovines, porcines), companion animals (e.g., canines, felines) and rodents (e.g., mice and rats). The term “mammal” refers to any mammalian species such as a human, mouse, rat, dog, cat, hamster, guinea pig, rabbit, livestock, and the like.
[0040] The term “peptide,” as used herein, refers broadly to a sequence of two or more amino acids j oined together by peptide bonds. It should be understood that this term does not connote a specific length of a polymer of amino acids, nor is it intended to imply or distinguish whether the polypeptide is produced using recombinant techniques, chemical or enzymatic synthesis, or is naturally occurring.
[0041] The term “hepcidin mimetic,” as used herein, refers broadly to peptide monomers and peptide dimers comprising one or more structural features and/or functional activities in common with hepcidin, or a functional region thereof. In certain embodiments, a hepcidin mimetic includes peptides sharing substantial amino acid sequence identity with hepcidin, e.g., peptides that comprise one or more amino acid insertions, deletions, or substitutions as compared to a wild-type hepcidin, e.g., human hepcidin, amino acid sequence. In certain embodiments, a hepcidin mimetic comprises one or more additional modification, such as, e.g., conjugation to another compound. Encompassed by the term “hepcidin mimetic” is any peptide monomer or peptide dimer disclosed herein. In some embodiments, a hepcidin mimetic has one or more functional activities of hepcidin.
[0042] The term “amino acid” or “any amino acid” as used here refers to any and all amino acids, including naturally occurring amino acids (e.g., a-amino acids), unnatural amino acids, modified amino adds, and non-natural amino acids. It includes both D- and L-amino acids. Natural amino acids include those found in nature, such as, e.g., the 23 amino acids that combine into peptide chains to form the building-blocks of a vast array of protdns. These are primarily L stereoisomers, although a few D-amino acids occur in bacterial envelopes and some antibiotics. The “non-standard,” natural amino adds are pyrrolysine (found in methanogenic organisms and other eukaryotes), selenocystdne (present in many noneukaryotes as well as most eukaryotes), and N-formylmethionine (encoded by the start codon AUG in bacteria, mitochondria and chloroplasts). “Unnatural” or “non-natural” amino acids are non- proteinogenic amino acids (i.e., those not naturally encoded or found in the genetic code) that dther occur naturally or are chemically synthesized. Over 140 natural amino adds are known and thousands of more combinations are possible. Examples of “unnatural” amino adds include P-amino acids (β3 and β2), homo-amino acids, proline and pyruvic acid derivatives, 3- substituted alanine derivatives, glycine derivatives, ring-substituted phenylalanine and tyrosine derivatives, linear core amino acids, diamino acids, D-amino adds, andN-methyl amino acids. Unnatural or non-natural amino adds also include modified amino acids. “Modified” amino acids include amino acids (e.g., natural amino acids) that have been chemically modified to include a group, groups, or chemical moiety not naturally present on the amino acid.
[0043] As is clear to the skilled artisan, the peptide sequences disclosed herein are shown proceeding from left to right, with the left end of the sequence being the N-terminus of the peptide and the right end of the sequence being the C-terminus of the peptide. Among sequences disclosed herein are sequences incorporating a “Hy-” moiety at the amino terminus (N-terminus) of the sequence, and either an “-OH” moiety or an “-NH2” moiety at the carboxy terminus (C-terminus) of the sequence. In such cases, and unless otherwise indicated, a “Hy- ” moiety at the N-terminus of the sequence in question indicates a hydrogen atom, corresponding to the presence of a free primary or secondary amino group at the N-terminus, while an “-OH” or an “-NHz” moiety at the C-terminus of the sequence indicates a hydroxy group or an amino group, corresponding to the presence of an amido (CONHz) group at the C- terminus, respectively. In each sequence of the invention, a C-terminal “-OH” moiety may be substituted for a C-terminal “-NH2” moiety, and vice-versa. It is further understood that the moiety at the amino terminus or carboxy terminus may be a bond, e.g., a covalent bond, particularly in situations where the amino terminus or carboxy terminus is bound to a linker or to another chemical moiety, e.g., a PEG moiety.
[0044] The term “NH2,” as used herein, refers to the free amino group present at the amino terminus of a polypeptide. The term “OH,” as used herein, refers to the free carboxy group present at the carboxy terminus of a peptide. Further, the term “Ac,” as used herein, refers to Acetyl protection through acylation of the C- or N-terminus of a polypeptide.
[0045] The term “carboxy,” as used herein, refers to -CO2H.
[0046] For the most part, the names of naturally occurring and non-naturally occurring aminoacyl residues used herein follow the naming conventions suggested by the IUPAC Commission on the Nomenclature of Organic Chemistry and the IUPAC-IUB Commission on Biochemical Nomenclature as set out in “Nomenclature of a- Amino Acids (Recommendations, 1974)” Biochemistry, 14(2), (1975). To the extent that the names and abbreviations of amino acids and aminoacyl residues employed in this specification and appended claims differ from those suggestions, they will be made clear to the reader. Some abbreviations useful in describing the invention are defined below in the following Table 1.
Table 1 Abbreviations of Non-Natural Amino Adds and Chemical Mdeties
Figure imgf000014_0001
Figure imgf000015_0001
Figure imgf000016_0001
Figure imgf000017_0001
Figure imgf000018_0001
[0047] Throughout the present specification, unless naturally occurring amino acids are referred to by their full name (e.g., alanine, arginine, etc.), they are designated by their conventional three-letter or single-letter abbreviations (e.g., Ala or A for alanine, Arg or R for arginine, etc.). In the case of less common or non-naturally occurring amino acids, unless they are referred to by their full name (e.g. sarcosine, ornithine, etc.), frequently employed three- or four-character codes are employed for residues thereof, including, Sar or Sarc (sarcosine, i.e., N-methylglycine), Aib (a-aminoisobutyric acid), Daba (2,4-diaminobutanoic acid), Dapa (2,3- diaminopropanoic acid), y-Glu (y-glutamic acid), pGlu (pyroglutantic acid), Gaba (y- aminobutanoic acid), β-Pro (pyrrolidine-3 -carboxylic acid), 8 Ado (8-amino-3,6-dioxaoctanoic acid), Abu (4-aminobutyric acid), bhPro (P-homo-proline), bhPhe (P-homo-L-phenylalanine), bhAsp (P-homo-aspartic acid]), Dpa (β,β diphenylalanine), Ida (Iminodiacetic acid), hCys (homocysteine), and bhDpa (P-homo-p,p -diphenylalanine).
[0048] Furthermore, R1 can in all sequences be substituted with isovaleric acids or equivalent. In some embodiments, wherein a peptide of the present invention is conjugated to an acidic compound such as, e.g., isovaleric acid, isobutyric acid, valeric acid, and the like, the presence of such a conjugation is referenced in the add form. So, for example, but not to be limited in any way, instead of indicating a conjugation of isovaleric add to a peptide by referencing isovaleroyl, in some embodiments, the present application may reference such a conjugation as isovaleric acid.
[0049] The term “L-amino acid,” as used herein, refers to the “L” isomeric form of a peptide, and conversely the term “D-amino acid” refers to the “D” isomeric form of a peptide. In certain embodiments, the amino acid residues described herein are in the “L” isomeric form, however, residues in the “D” isomeric form can be substituted for any L-amino acid residue, as long as the desired functional is retained by the peptide.
[0050] Unless otherwise indicated, reference is made to the L-isomeric forms of the natural and unnatural amino adds in question possessing a chiral center. Where appropriate, the D- isomeric form of an amino add is indicated in the conventional manner by the prefix “D” before the conventional three-letter code (e.g., Dasp, (D)Asp or D-Asp; Dphe, (D)Phe or D- Phe).
[0051] The term “dimer,” as used herein, refers broadly to a peptide comprising two or more monomer subunits. Certain dimers comprise two DRPs. Dimers of the present invention include homodimers and heterodimers. A monomer subunit of a dimer may be linked at its C- or N-terminus, or it may be linked via internal amino acid residues. Each monomer subunit of a dimer may be linked through the same site, or each may be linked through a different site (e.g., C-terminus, N-terminus, or internal site).
[0052] As used herein, in the context of certain peptide sequences disclosed herein, parentheticals, e.g., ( ), represent side chain conjugations and brackets, e.g., [ ], represent unnatural amino acid substitutions or amino adds and conjugated side chains. Generally, where a linker is shown at the N-terminus of a peptide sequence, it indicates that the peptide is dimerized with another peptide, wherein the linker is attached to the N-terminus of the two peptides. Generally, where a linker is shown at the C-terminus of a peptide sequence or structure, it indicates that the peptide is dimerized with another peptide, wherein the linker is attached to the C-terminus of the two peptides.
[0053] The term “cyclized,” as used herein, refers to a reaction in which one part of a polypeptide molecule becomes linked to another part of the polypeptide molecule to form a closed ring, such as by forming a disulfide bridge or other similar bond.
[0054] The term “subunit,” as used herein, refers to one of a pair of polypeptide monomers that are joined to form a dimer peptide composition.
[0055] The term “linker moiety,” as used herein, refers broadly to a chemical structure that is capable of linking or joining together two peptide monomer subunits to form a dimer.
[0056] The term “solvate” in the context of the present invention refers to a complex of defined stoichiometry formed between a solute (e.g., a hepcidin analogue or pharmaceutically acceptable salt thereof according to the invention) and a solvent. The solvent in this connection may, for example, be water, ethanol or another pharmaceutically acceptable, typically small- molecular organic species, such as, but not limited to, acetic acid or lactic acid. When the solvent in question is water, such a solvate is normally referred to as a hydrate.
[0057] The term “pharmaceutically acceptable salt,” as used herein, represents salts or zwitterionic forms of the peptides or compounds of the present invention which are water or oil-soluble or dispersible, which are suitable for treatment of diseases without undue toxicity, irritation, and allergic response; which are commensurate with a reasonable benefit/risk ratio, and which are effective for their intended use. The salts can be prepared during the final isolation and purification of the compounds or separately by reacting an amino group with a suitable acid. Representative acid addition salts include acetate, adipate, alginate, citrate, aspartate, benzoate, benzenesulfonate, bisulfate, butyrate, camphorate, camphorsulfonate, digluconate, glycerophosphate, hemisulfate, heptanoate, hexanoate, formate, fumarate, hydrochloride, hydrobromide, hydroiodide, 2-hydroxyethansulfonate (isethionate), lactate, maleate, mesitylenesulfonate, methanesulfonate, naphthylenesulfonate, nicotinate, 2- naphthalenesulfonate, oxalate, pamoate, pectinate, persulfate, 3-phenylproprionate, picrate, pivalate, propionate, succinate, tartrate, trichloroacetate, trifluoroacetate, phosphate, glutamate, bicarbonate, para-toluenesulfonate, and undecanoate. Also, amino groups in the compounds of the present invention can be quatemized with methyl, ethyl, propyl, and butyl chlorides, bromides, and iodides; dimethyl, diethyl, dibutyl, and diamyl sulfates; decyl, lauryl, myristyl, and steryl chlorides, bromides, and iodides; and benzyl and phenethyl bromides. Examples of acids which can be employed to form therapeutically acceptable addition salts include inorganic acids such as hydrochloric, hydrobromic, sulfuric, and phosphoric, and organic acids such as oxalic, maleic, succinic, and citric. A pharmaceutically acceptable salt may suitably be a salt chosen, e.g., among acid addition salts and basic salts. Examples of acid addition salts include chloride salts, citrate salts and acetate salts. Examples of basic salts include salts where the cation is selected among alkali metal cations, such as sodium or potassium ions, alkaline earth metal cations, such as calcium or magnesium ions, as well as substituted ammonium ions, such as ions of the type N(R1)(R2)(R3)(R4)+, where Rl, R2, R3 and R4 independently will typically designate hydrogen, optionally substituted Cl-6-alkyl or optionally substituted C2-6-alkenyL Examples of relevant Cl-6-alkyl groups include methyl, ethyl, 1 -propyl and 2-propyl groups. Examples of C2-6-alkenyl groups of possible relevance include ethenyl, 1 -propenyl and 2-propenyl. Other examples of pharmaceutically acceptable salts are described in “Remington’s Pharmaceutical Sciences”, 17th edition, Alfonso R. Gennaro (Ed.), Mark Publishing Company, Easton, PA, USA, 1985 (and more recent editions thereof), in the “Encyclopaedia of Pharmaceutical Technology”, 3rd edition, James Swarbrick (Ed ), Informa Healthcare USA (Inc.), NY, USA, 2007, and in J. Pharm. Sci. 66: 2 (1977). Also, for a review on suitable salts, see Handbook of Pharmaceutical Salts: Properties, Selection, and Use by Stahl and Wermuth (Wiley-VCH, 2002). Other suitable base salts are formed from bases which form non-toxic salts. Representative examples include the aluminum, arginine, benzathine, calcium, choline, diethylamine, diolamine, glycine, lysine, magnesium, meglumine, olamine, potassium, sodium, tromethamine, and zinc salts. Hemisalts of acids and bases may also be formed, e.g., hemisulphate and hemicalcium salts.
[0058] The term “alkyl” includes a straight chain or branched, noncyclic or cyclic, saturated aliphatic hydrocarbon containing from 1 to 24 carbon atoms. Representative saturated straight chain alkyls include, but are not limited to, methyl, ethyl, n-propyl, n-butyl, n-pentyl, n-hexyl, and the like, while saturated branched alkyls include, without limitation, isopropyl, sec-butyl, isobutyl, tert-butyl, isopentyl, and the like. Representative saturated cyclic alkyls include, but are not limited to, cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, and the like, while unsaturated cyclic alkyls include, without limitation, cyclopentenyl, cyclohexenyl, and the like. [0059] As used herein, a “therapeutically effective amount” of the peptide agonists of the invention is meant to describe a sufficient amount of the peptide agonist to treat an hepcidin- related disease, including but not limited to any of the diseases and disorders described herein (for example, a disease of iron metabolism). In particular embodiments, the therapeutically effective amount will achieve a desired benefit/risk ratio applicable to any medical treatment.
Combination Therapy with Hepcidin Mimetics and Phlebotomy
[0060] Hepcidin targets the maj or iron transporter ferroportin and causes its internalization and subsequent degradation. Hepcidin regulation is crucial for providing adequate iron needed for cellular functions while also preventing iron toxicity. In Hereditary Hemochromatosis (HH), hyperabsorption of dietary iron leads to primary iron overload. Under these iron overload conditions, where transferrin is saturated (e.g., Transferrin SATuration (TSAT) % > 80%), excess iron deposition can lead to organ damage. In addition, the presence of labile iron increases overall systemic iron toxicity. The present disclosure identifies methods of dosing and using hepcidin mimetics with a therapeutic effect for the treatment of diseases and disorders associated with iron overload, such as hereditary hemochromatosis. [0061] In some embodiments, methods disclosed herein are applied for the prevention, inhibition, or treatment of a disease or disorder associated with dysregulated iron levels (e.g., diseases or disorders of iron metabolism; diseases or disorders related to iron overload; and diseases or disorders related to abnormal hepcidin activity or expression). In certain embodiments, the disease or disorder is a disease of iron metabolism, such as, e.g., an iron overload disease or another disorder of iron metabolism.
[0062] In particular embodiments, the disease of iron metabolism is a hemochromatosis, such as, e.g., hereditary hemochromatosis, HFE mutation hemochromatosis, ferroportin mutation hemochromatosis, transferrin receptor 2 mutation hemochromatosis, hemojuvelin mutation hemochromatosis, hepcidin mutation hemochromatosis, juvenile hemochromatosis, or neonatal hemochromatosis. In certain embodiments, the disease is hereditary hemochromatosis (HH). In certain embodiments, the disease is phlebotomy-requiring HH or HH in the induction phase.
[0063] In certain embodiments, the disease or disorder is HH associated with arthropathy, or HH-associated arthropathy. Chronic arthropathy occurs in 37-80% of HH patients. In these cases, joint pain may be an early manifestation of the disease and in many cases is the cause for first diagnosis of HH. This may be done by X-ray and/or MRI imaging, often combined with validated joint pain and/or results of function scoring instruments. In certain embodiments, the arthropathy may be associated with elevated age, ferritin, and TSAT levels. The iron accumulation of HH may be associated with increased oxidative stress, disrupted matrix metabolism, and cartilage degeneration, which can contribute to the development of arthropathy similar to osteoarthritis. Persistent arthropathy can diminish quality of life and yield high healthcare utilization and associated costs, particularly since up to 16% of HH patients undergo joint replacement surgery. See, e.g., Whalen, N. “Association of Transferrin Saturation with the Arthropathy of Hereditary Hemochromatosis” 2017; Nguyen, C. “Bone and joint complications in patients with hereditary hemochromatosis: a cross-sectional study of 93 patients” 2020; Carroll, GJ. “Hereditary Hemochromatosis is characterized by a clinically definable arthropathy that correlates with iron load” 2011; Karim, A. “The role of disrupted iron homeostasis in the development and progression of arthropathy” 2022; and Burton, LH. “Systemic administration of a pharmacologic iron chelator reduces cartilage lesion development in the Dunkin-Hartley model of primary osteoarthritis” 2022. [0064] In one aspect, the disclosure provides a method for treating an iron overload disease, e.g., HH, HH associated with arthropathy, or HH-associated arthropathy, in a human subject, comprising providing to the subject an effective amount of a hepcidin mimetic, including but not limited to those disclosed herein, such as Compound 25, in combination with therapeutic phlebotomy. In certain embodiments, the hepcidin mimetic is provided subcutaneously. In certain embodiments, the subject has been diagnosed with hereditary hemochromatosis. In certain embodiments, the subject has not received phlebotomy treatment prior to the treatment disclosed herein. In particular embodiments, the subject’s HH is in the induction phase, and the combination therapy disclosed herein is the first phlebotomy treatment the subject receives for treatment of the iron overload disease, e.g., HH
[0065] In particular embodiments, the subject is administered the combination therapy comprising a hepcidin mimetic and therapeutic phlebotomy over a period of time, e.g., during the induction phase. In certain embodiments, the period of time comprises at least or about four weeks, at least or about six weeks, at least or about 8 weeks, at least or about 10 weeks, at least or about 12 weeks, at least or about four months, or at least or about six months, which time period begins at the time the subject is administered the first dose of hepcidin mimetic or the first phlebotomy as part of the combination treatment. In certain embodiments, the time period, or induction phase, lasts for about 10 weeks, and the subject may have about four therapeutic phlebotomies per week (or one therapeutic phlebotomy per week). In particular embodiments, the period of time is sufficient to achieve complete blood volume replacement of the subject. E.g., about ten therapeutic phlebotomies, where each removes about 0.5 L of blood. In certain embodiments, the combination therapy may continue into transition phase. In certain embodiments, the combination therapy is stopped once the subject reaches transition phase or maintenance phase, after which time the subject may be treated with a hepcidin mimetic alone, or in certain embodiments, therapeutic phlebotomy alone. In various embodiments of the combination therapy, the subject may first be administered the hepcidin mimetic, or may first be administered a therapeutic phlebotomy. Administration of the hepcidin mimetic and therapeutic phlebotomies may occur on the same or different days, which will depend in part on the frequency with each is performed over the course of treatment.
[0066] In certain embodiments, the dosing regimen for a subject may change throughout the course of treatment, but in particular embodiments, administration of the hepcidin mimetic (e.g., Compound 25) occurs about once a week, about twice a week, or about three times a week, over the course of treatment, and the dosage is about 5 mg to about 80 mg, or about 10 mg to about 40 mg, e.g., about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 60 mg, or about 80 mg per administration. In particular embodiments, the subject is administered different dosages (at the same or different frequency), or the same dosage at different frequency, during different time periods of the course of treatment, but in particular embodiments, the frequency throughout the course of treatment is about once a week, about twice a week, or about three times a week, and each dosage administered is in the range of about 5 mg to about 40 mg. In some embodiments, the agent is a hepcidin mimetic peptide disclosed herein, e.g., a peptide of any one of Formula I-VHI or any of Compounds 1-34, such as Compound 25. In certain embodiments, the decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level is at least 60% for at least one day.
[0067] In particular embodiments, the subject is administered about 5 to about 40 mg (e.g., about 5 mg, about 10 mg, about 15 mg, about 20 mg or about 40 mg) of the hepcidin mimetic about twice a week or three times a week, and/or is administered about 5 to about 80 mg (e.g., about 5 mg, about 10 mg, 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg, about 40 mg, or about 80 mg) of the hepcidin mimetic about once a week. In particular embodiments, the subject is administered different dosages at different frequency during different time periods. In particular embodiments, the subject is administered the hepcidin mimetic for at least one month, at least two months, or at least four months. In particular embodiments, the subject also receives therapeutic phlebotomy, e.g., about 0.5 L blood withdrawal, about once per week for at least one month, at least two months, or at least four months, e.g., during the induction phase.
[0068] In certain embodiments, the method further comprises determining a TSAT level and/or serum iron level and/or MCHC level in the subject before and/or after treatment with the hepcidin mimetic and therapeutic phlebotomy. In particular embodiments, the subject has a reduction in TSAT and/or serum iron and/or MCHC of at least 20%, at least 30%, at least 40%, at least 50%, at least 60% or at least 80%, and is provided with further combination therapy. In certain embodiments, the method comprises measuring a TSAT% level in the subject before and/or after providing the subject with the combination therapy, and in some embodiments, the method comprises providing additional hepcidin mimetic to the subject to achieve or maintain the reduced TSAT% level, e.g., < 45% TSAT or < 40% TSAT. In particular embodiments, the agent is any of those disclosed herein, e.g., a hepcidin mimetic peptide, such as a peptide of any one of Formula I-VHI or any of Compounds 1-46, e.g., Compound 25 or Compound 46. [0069] In some embodiments, the method comprises determining TSAT% and/or serum iron levels and/or MCHC levels in a subject before and after administering the combination therapy to the subject, and then determining whether the subject’s TSAT% and/or serum iron levels and/or MCHC levels were reduced to the desired level after administration of the combination therapy. In some embodiments, the subject is given increasing amounts of the hepcidin mimetic until TSAT% and/or serum iron levels and/or MCHC levels are reduced to the desired level.
In some embodiments, the subject is given therapeutic phlebotomy at an increased frequency until TSAT% and/or serum iron levels and/or MCHC levels are reduced to the desired level.
In some embodiments, the subject is given multiple different doses of the hepcidin mimetic over a course of treatment (and potentially at different frequencies, such as once a week and/or twice a week and/or three times a week), and the subject’s TSAT% and/or serum iron levels and/or MCHC levels are monitored at various times during a course of treatment to identify the minimal or appropriate dose and/or concentration required to reduce TSAT% and/or serum iron levels to the desired level, and/or to identify how frequently the subject should be treated to maintain the subject’s TSAT% and/or serum iron levels and/or MCHC levels at the desired level. In certain embodiments, the method comprises measuring a TSAT% level in the subject before and/or after administering the combination therapy to the subject, and in some embodiments, the method comprises providing additional hepcidin mimetic and/or therapeutic phlebotomy to the subject to achieve or maintain the reduced TSAT% level, e.g., a level at or below 45% TSAT. In particular embodiments, the hepcidin mimetic is a peptide of any one of Formula I-VHI or any of Compounds 1-46, e.g., Compound 25 or Compound 46.
[0070] In certain embodiments, the disclosure provides a method for treating HH, HH associated with arthropathy, or HH-associated arthropathy, e.g., during the induction phase, comprising: a) subcutaneously administering to a subject diagnosed with HH, e.g., induction-phase HH, HH associated with arthropathy, or HH-associated arthropathy, about 5 to about 25 mg (optionally 10 mg or 20 mg) of a hepcidin mimetic disclosed herein, e.g., Compound 25 and performing therapeutic phlebotomy on the subject; b) determining the subject’s TSAT % following step a), optionally at trough drug level, e.g., about 7 days following step a); and c) if the subject’s TSAT % is greater than about 40% or greater than about 45%, (i) subcutaneously administering to the subject an increased amount of the hepcidin mimetic, e.g., about 20 mg to about 80 mg, optionally about 20 mg or about 40 mg, on an about weekly or about twice weekly schedule;
(ii) subcutaneously administering to the subject the same or an increased amount of the hepcidin mimetic, e.g., about 10 mg or about 20 mg or about 40 mg, on an increased dosing schedule, e.g., about twice weekly; and/or
(iii) administering more frequent therapeutic phlebotomy to the subject.
In particular embodiments, the method comprises monitoring the subject’s TSAT % levels, e.g., about 7 days after the first weekly dose, and adjusting the dosing by increasing the dose or increasing the frequency of dosing, if the TSAT% is greater than 40% or greater than 45%. The method may further include determining and/or monitoring the subject’s serum iron level and/or MCHC level, and adjusting the dosage amount or frequency based on either or both.
[0071] In various embodiments of any of the methods disclosed herein, the TSAT% level and/or serum iron level and/or MCHC levels is reduced by a percentage, or it is reduced to or below a particular TSAT% level or serum iron level and/or MCHC levels, e.g., in order to be associated with a therapeutically effective agent or dosing regimen. In particular embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC levels is maintained for a duration of time, e.g., 12 hours, one day, two days, three days, four days, five days, six days, or one week. As would be understood, a percentage reduction in any of these levels could be the percentage reduction in a particular patient, for example, when monitoring TS AT% level and/or serum iron level and/or MCHC levels to determine dosing or dosing regimen for the patient, or a percentage reduction in TSAT% level and/or serum iron level and/or MCHC levels could be a reduction as compared to a predetermined value, e.g., the average or mean TSAT% level, or serum iron level, or MCHC level associated with a particular patient population. In certain embodiments, the reduction in TSAT% is a reduction as compared to a normal, healthy volunteer.
[0072] Serum iron can be measured by various methods including colorimetrically. TSAT represents the percentage of the transferrin iron-binding capacity actually occupied by iron in the serum. It is calculated as the serum iron multiplied by 100 and divided by the total iron- binding capacity (Coyne. Kidney International 69:54-58).
Hepcidin Mimetics
[0073] Over the course of the combination therapy disclosed herein, the subj ect is administered an effective amount of a hepcidin mimetic one or more times. In particular embodiments, the hepcidin mimetic is administered about twice per week, about once per week, or about every two weeks. In certain embodiments, the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46, is about 1 mg to about 100 mg, or about 10 mg to about 80 mg. In certain embodiments, the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46, is about 5 mg to about 80 mg, or about 10 mg to about 80 mg. In certain embodiments, the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46, is about 10 mg to about 40 mg, or about 5 mg to about 50 mg. In certain embodiments, the effective amount of the hepcidin mimetic, e.g., Compound 25 or Compound 46, is about 10 mg to about 40 mg, or about 5 mg to about 50 mg. In particular embodiments, the effective amount of the hepcidin mimetic is administered to the subject about once a week, about twice a week, or about three times a week. In some embodiments, the subject is administered about 10 mg to about 20 mg, about 10 mg to about 15 mg, or about 15 mg to about 20 mg, of the hepcidin mimetic about twice a week or about three times a week, and in another embodiments, the subject is administered about 10 mg to about 80 mg, about 10 mg to about 40 mg, about 20 mg to about 30 mg, about 20 mg to about 40 mg, or about 30 mg to about 40 mg of the hepcidin mimetic about once a week. In certain embodiments, the subject is administered about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, or about 25 mg of the hepcidin mimetic about twice a week. In certain embodiments, the subject is administered about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, about 20 mg, about 21 mg, about 22 mg, about 23 mg, about 24 mg, about 25 mg, about 26 mg, about 27 mg, about 28 mg, about 29 mg, about 30 mg, about 31 mg, about 32 mg, about 33 mg, about 34 mg, about 35 mg, about 36 mg, about 37 mg, about 38 mg, about 39 mg, about 40 mg, about 41 mg, about 42 mg, about 43 mg, about 44 mg, or about 45 mg of the hepcidin mimetic about twice a week or about three times a week. In particular embodiments, the hepcidin mimetic is administered subcutaneously. In particular embodiments, the hepcidin mimetic is Compound 25. In particular embodiments, the hepcidin mimetic is Compound 46. In certain embodiments, the amount administered to the subject may vary over the course of treatment.
[0074] Methods disclosed herein may be practiced various hepcidin mimetics, including but not limited to those described herein, such as Compound 25. In certain embodiments, the agent modulates serum iron levels, e.g., by temporarily sequestering or redistributing iron in various tissues and/or preventing further absorption of iron from food. In some embodiments, an iron sequestration compound prevents export of iron. In various embodiments, the agent effects serum iron levels and/or iron load or distribution in various tissues/organs. It is understood that the disclosure further relates to pharmaceutically acceptable salts and solvates on any of the agents disclosed herein.
[0075] In particular embodiments, the hepcidin mimetic is described in any of the following: US patents, US 9,822,157 and US 10,030,061, which describe hepcidin analogs and their use to treat iron overload diseases, which include hereditary hemochromatosis and iron-loading anemias; PCT application publication, WO 15200916, which describes additional hepcidin analogs and their use to treat iron overload diseases; PCT application publication, WO17117411, which describes additional hepcidin analogs with improved in vivo half-lives and their use to treat iron overload diseases; PCT application publication, WO 18048944, which describes additional hepcidin analogs and their use to treat prevention of iron overload in a subject and/or reducing serum iron levels in a subject; PCT application publication, WO18128828, which describes additional hepcidin analogs and their use to treat hepcidin- associated disorders, including prophylaxis and treatment of iron overload diseases such as hemochromatosis, iron-loading anemias such as thalassemia, and diseases being associated with ineffective or augmented erythropoiesis; PCT application publication, WO 17068089, which describes additional hepcidin analogs (ferroportin inhibitors) and their use to treat thalassemia and hemochromatosis; or US Patent, US9315545, which describe additional novel analogs and their use to treat diseases of iron metabolism, beta thalassemia, hemochromatosis, iron-loading anemias, alcoholic liver disease, or chronic hepatitis C.
[0076] In certain embodiments, the hepcidin mimetic is a peptide comprising or consisting of Formula I:
R1-X-Y-R2 (I) or a pharmaceutically acceptable salt or solvate thereof, wherein
R1 is hydrogen, a C1-C6 alkyl, a C6-C12 aryl, a C1-C20 alkanoyl, or pGlu; R2 is NH2 or OH;
X is an amino acid sequence of Formula II: X1-X2-X3-X4-X5-X6-X7-X8-X9-X10 (II) wherein
XI is Asp, Ala, Ida, pGlu, bhAsp, Leu, D-Asp, or absent;
X2 is Thr, Ala, or D-Thr; X3 is His, Lys, D-His, or Lys;
X4 is Phe, Ala, Dpa, or D-Phe;
X5 is Pro, Gy, Arg, Lys, Ala, D-Pro, or bhPro;
X6 is Ile, Cys, Arg, Lys, D-Ile, or D-Cys;
X7 is Cys, De, Leu, Vai, Phe, D-Ile, or D-Cys;
X8 is De, Arg, Phe, Gn, Lys, Gu, Vai, Leu, or D-Ile;
X9 is Phe or bhPhe; and
X10 is Lys, Phe, or absent; wherein if Y is absent, X7 is Ile; and
Y is an amino acid sequence of Formula III:
Y1-Y2-Y3-Y4-Y5-Y6-Y7-Y8-Y9-Y10-Y11-Y12-Y13-Y14-Y15 (HI) wherein
Y1 is Gy, Cys, Ala, Phe, Pro, Gu, Lys, D-Pro, Vai, Ser, or absent;
Y2 is Pro, Ala, Cys, Gly, or absent;
Y3 is Arg, Lys, Pro, Gy, His, Ala, Trp, or absent;
Y4 is Ser, Arg, Gy, Trp, Ala, His, Tyr, or absent;
Y5 is Lys, Met, Arg, Ala, or absent;
Y6 is Gy, Ser, Lys, Ile, Ala, Pro, Vai, or absent;
Y7 is Trp, Lys, Gy, Ala, Ile, Vai, or absent;
Y8 is Vai, Thr, Gy, Cys, Met, Tyr, Ala, Gu, Lys, Asp, Arg, or absent;
Y9 is Cys, Tyr, or absent;
Y10 is Met, Lys, Arg, Tyr, or absent;
Y11 is Arg, Met, Cys, Lys, or absent;
Y12 is Arg, Lys, Ala or absent;
Y13 is Arg, Cys, Lys, Vai or absent;
Y14 is Arg, Lys, Pro, Cys, Thr or absent; and
Y15 is Thr, Arg or absent; wherein the peptide comprising Formula I is optionally PEGylated on Rl, X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherein Ida is iminodiacetic acid, pGu is pyroglutamic acid, bhAsp is p-homoaspartic acid, and bhPro is P-homoproline. [0077] In certain embodiments, any of the peptides disclosed herein comprise a disulfide bond between two Cys amino acid residues present in the peptide, e.g., wherein the thiol groups of two cysteine residues in the peptide form a disulfide bond.
[0078] In certain embodiments, R1 is hydrogen, isovaleric acid, isobutyric acid or acetyl.
[0079] In certain embodiments, X is an amino acid sequence of Formula IV: Xl-Thr-His-X4-X5-X6-X7-X8-Phe-X10 (IV) wherein
XI is Asp, Ida, pGlu, bhAsp or absent;
X4 is Phe or Dpa;
X5 is Pro or bhPro;
X6 is De, Cys, or Arg;
X7 is Cys, De, Leu, or Vai;
X8 is Ile, Lys, Glu, Phe, Gin, or Arg; and
X10 is Lys or absent.
[0080] In certain embodiments, X is an amino acid sequence of Formula V:
Xl-Thr-His-X4-X5-Cys-He-X8-Phe-X10 (V) wherein
XI is Asp, Ida, pGlu, bhAsp, or absent;
X4 is Phe or Dpa;
X5 is Pro or bhPro;
X8 is De, Lys, Glu, Phe, Gin or Arg; and
X10 is Lys or absent.
[0081] In certain embodiments, the peptide comprises Formula VI:
RLX-Y-R2 (VI) or a pharmaceutically acceptable salt thereof, wherein:
R1 is hydrogen, isovaleric acid, isobutyric acid, or acetyl; R2 isNH2 or OH;
X is an amino acid sequence of Formula VII: Xl-Thr-His-X4-X5-Cys-Ile-X8-Phe-X10 (VII) wherein
XI is Asp, Ida, pGlu, bhAsp, or absent;
X4 is Phe or Dpa; X5 is Pro or bhPro;
X8 is He, Lys, Glu, Phe, Gin, or Arg; and
X10 is Lys or absent; wherein Y is an amino add sequence of Formula VUI:
Yl-Pro-Y3-Ser-Y5-Y6-Y7-Y8-Cys-Y10 (VUI) wherein
Y1 is Gly, Glu, Vai, or Lys;
Y3 is Arg or Lys;
Y5 is Arg or Lys;
Y6 is Gly, Ser, Lys, Ile, or Arg;
Y7 is Tip or absent;
Y8 is Vai, Thr, Asp, Glu, or absent; and
Y10 is Lys or absent; wherein the peptide comprises a disulfide bond between the two Cys; wherein the peptide is optionally PEGylated on R1, X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherein Ida is iminodiacetic acid; pGhi is pyroglutamic acid; bhAsp is P-homoaspartic acid; and bhPro is P-homoproline.
[0082] In certain embodiments, the peptide comprises or consists of one of the following sequences:
DTHFPICIFGPRSKGWVC (SEQ ID NO: 46);
DTHFPCIlFGPRSKGWVCK (SEQ ID NO: 47);
DTHFPCIIFEPRSKGWVCK (SEQ ID NO: 48);
DTHFPCIlFGPRSKGWACK (SEQ ID NO: 49);
DTHFPCIIFGPRSKGWVCKK (SEQ ID NO:50);
DTHFPCIIFVCHRPKGCYRRVCR (SEQ ID NO: 51);
DTHFPCIKFGPRSKGWVCK (SEQ ID NO: 52);
DTHFPCIKFKPRSKGWVCK (SEQ ID NO: 53);
DTHFPCIIFGPRSRGWVCK (SEQ ID NO: 54);
DTHFPCIKFGPKSKGWVCK (SEQ ID NO: 55);
DTHFPCIKFEPRSKGCK (SEQ ID NO: 56);
DTHFPCIKFEPKSKGWECK (SEQ ID NO: 57); DTHFPCIKFEPRSKKCK (SEQ ID NO: 58);
DTHFPCIKFEPRSKGCKK (SEQ ID NO: 59);
DTHFPCIKFKPRSKGCK (SEQ ID NO: 60);
DTHFPCIKFEPKSKGCK (SEQ ID NO: 61);
DTHFPCIKF (SEQ ID NO: 62);
DTHFPCIIF (SEQ ID NO: 63); or
DTKFPCIIF (SEQ ID NO: 64), wherein said peptide is optionally PEGylated on Rl, X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherein the peptide optionally comprises a disulfide bond between two Cys amino add residues of the peptide.
[0083] In certain embodiments, the peptide comprises or consists of one of the following sequences:
Isovaleric acid-DTHFPICIFGPRSKGWVC-NH2 (SEQ IDNO:1);
Isovaleric acid-DTHFPCIlFGPRSKGWVCK-NH2 (SEQ ID NO:2}
Isovaleric acid-DTHFPCIlFEPRSKGWVCK-NH2 (SEQ ID NO:3} Isovaleric acid-DTHFPCIlFGPRSKGWACK-NH2 (SEQ ID NO:4} Isovaleric acid-DTHFPCIlFGPRSKGWVCKK-NH2 (SEQ ID NO:5} Isovaleric acid-DTHFPCIlFVCHRPKGCYRRVCR-NIh (SEQ ID NO:6} Isovaleric acid-DTHFPCI(K(PEG8))FGPRSKGWVCK-NH2 (SEQ ID NO:7} Isovaleric acid-DTHFPCIKF(K(PEG8))PRSKGWVCK-NH2 (SEQ ID NO:8}
Isovaleric acid-DTHFPICIFGPRS(K(PEG8))GWVC-NH2 (SEQ ID NO:9} Isovaleric acid-DTHFPICIFGPRS(K(PEG4))GWVC-NH2 (SEQ ID NO: 10), Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG8))-NH2 (SEQ ID NO: 11} Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG4))-NH2 (SEQ ID NO: 12} Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG2))-NH2 (SEQ ID NO: 13} Isovaleric acid-DTHFPCI(K(Palm))FGPRSKGWVCK-NH2 (SEQ ID NO: 14}
Isovaleric acid-DTHFPCIKF)K(Palm))PRSKGWVCK-NH2 (SEQ ID NO: 15} Isovaleric acid-DTHFPCIKFGP(K(Palm))SKGWVCK-NH2 (SEQ ID NO: 16} Isovaleric acid-DTHFPCIKFGPRS(K(Palm))GWVCK-NH2 (SEQ ID NO: 17} Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(Palm))NH2 (SEQ ID NO: 18} Isovaleric acid-DTHFPCI(K(PEG3-Palm))FGPRSKGWVCK-NH2 (SEQ ID NO: 19} Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH2 (SEQ ID NO:20);
Isovaleric acid-DTHFPCIKFGP(K(PEG3-Palm))SKGWVCK-NH2 (SEQ ID NO:21);
Isovaleric acid-DTHFPCIKFGPRS(K(PEG3-Palm))GWVCK-NH2 (SEQ ID NO:22);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(PEG3-Palm))-NH2 (SEQ ID NO:23);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(PEG8))-NH2 (SEQ ID NO:24);
Isovaleric acid-DTHFPCI(K(isoGlu-Palm))FEPRSKGCK-NH2 (SEQ ID NO:25);
Isovaleric acid-DTHFPCIKF-K(isoGlu-Palm)-PRSKGCK-NH2 (SEQ ID NO:26);
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGCK-NH2(SEQ ID NO:27>,
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGWECK-NH2 (SEQ ID NO:28>,
Isovaleric acid-DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH2 (SEQ ID NO:29),
Isovaleric acid-DTHFPCIKFEPRSK(K(isoGlu-Palm))CK-NH2 (SEQ ID NO:30);
Isovaleric acid-DTHFPCIKFEPRSKGCK(K(isoGlu-Palm))-NH2 (SEQ ID NO:31), Isovaleric acid-DTHFPCI-K(Dapa-Pahn)-FEPRSKGCK-NH2(SEQ ID NO:32);
Isovaleric acid-DTHFPCIK(F(Dapa-Palm))PRSKGCK-NH2 (SEQ ID NO:33);
Isovaleric acid-DTHFPCIKFEP(K(Dapa-Palm))SKGCK-NH2 (SEQ ID NO:34);
Isovaleric acid-DTHFPCIKFEPRS(K(Dapa-Palm))GCK-NH2(SEQ ID NO:35);
Isovaleric acid-DTHFPCIKFEPRSK(K(Dapa-Palm))CK-NH2(SEQ ID NO:36);
Isovaleric acid-DTHFPCIKFEPRSKGC(K(Dapa-Palm))K-NH2 (SEQ ID NO:37);
Isovaleric acid-DTHFPCIKFEPRSKGC(K(Dapa-Palm))-NH2(SEQ ID NO:38);
Isovaleric acid-DTHFPCIKF(K(PEGl l-Palm))PRSK[Sar]CK-NH2 (SEQ ID NO:39);
Isolvaleric acid-DTHFPCIKF-NH2(SEQ ID NO:40);
Hy-DTHFPCIKF-NH2 (SEQ ID NO:41);
Isolvaleric acid-DTHFPCIIF-NIh (SEQ ID NO:42);
Hy-DTHFPCIIKF-NH2 (SEQ ID NO:43);
Isovaleric acid-DTKFPCIIF-NH2 (SEQ ID NO:44);
Hy-DTKFPCIIF-NH2 (SEQ ID NO:45); or
Isovaleric acid-ETHFPCI(k(IsoGlu-Palm))FEPRSKGCK-NH2 (SEQ ID NO:66), optionally wherein the peptide comprises a disulfide bond between two Cys amino acid residues of the peptide.
[0084] In certain embodiments, the peptide is selected from the group consisting of:
Figure imgf000034_0001
Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH2 (SEQ ID NO: 20);
Figure imgf000034_0002
Isovaleric acid-DTHFPCI(K(isoGlu-Palm))FEPRSKGCK-NH2 (SEQ ID NO: 25);
Figure imgf000035_0001
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGCK-NH2 (SEQ ID NO: 27);
Figure imgf000036_0001
Isovaleric acid-DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH2 (SEQ ID NO: 29); and (f)
Figure imgf000037_0001
Isovaleric acid-ETHFPCI(k(IsoGlu-Palm))FEPRSKGCK-NH2 (SEQ ID NO: 66), wherein the amino acids are L-amino acids.
[0085] Peptides disclosed herein, including hepcidin mimetics, may be produced using methods known in the art including chemical synthesis, biosynthesis or in vitro synthesis using recombinant DNA methods, and solid phase synthesis. See e.g., PCT Application Publication Nos. WO 2014/145561 and WO 2015/200916; Kelly & Winkler (1990) Genetic Engineering Principles and Methods, vol. 12, J. K. Setlow ed., Plenum Press, NY, pp. 1-19; Merrifield (1964) J Amer Chem Soc 85:2149; Houghten (1985) PNAS USA 82:5131-5135; and Stewart & Young (1984) Solid Phase Peptide Synthesis, 2ed. Pierce, Rockford, IL, which are herein incorporated by reference. The peptides disclosed herein may be purified using protein purification techniques known in the art such as reverse phase high-performance liquid chromatography (HPLC), ion-exchange or immunoaffinity chromatography, filtration or size exclusion, or electrophoresis. See Olsnes, S. and A. Pihl (1973) Biochem. 12(16):3121-3126; and Scopes (1982) Protein Purification, Springer- Veriag, NY, which are herein incorporated by reference. Alternatively, the peptides may be made by recombinant DNA techniques known in the art.
[0086] In certain embodiments, peptides disclosed herein may be PEGylated. As used herein, “Polyethylene glycol” or “PEG” is a polyether compound of general Formula H- (O-CH2-CH2)n-OH. PEGs are also known as polyethylene oxides (PEOs) or polyoxyethylenes (POEs), depending on their molecular weight. PEG, PEG, or POE, as used herein, refers to an oligomer or polymer of ethylene oxide. The three names are chemically synonymous, but PEG has tended to refer to oligomers and polymers with a molecular mass below 20,000 Da, PEO to polymers with a molecular mass above 20,000 Da, and POE to a polymer of any molecular mass. PEG and PEO are liquids or low-melting solids, depending on their molecular weights. Throughout this disclosure, the three names are used indistinguishably. PEGs are prepared by polymerization of ethylene oxide and are commercially available over a wide range of molecular weights from 300 Da to 10,000,000 Da. While PEG and PEO with different molecular weights find use in different applications, and have different physical properties (e.g., viscosity) due to chain length effects, their chemical properties are nearly identical. PEG moi eties include polyethylene glycols (PEG), homo- or co-polymers of PEG, a monomethyl-substituted polymer of PEG (mPEG), or polyoxyethylene glycerol (POG). See, for example, Int. J. Hematology 68:1 (1998); Bioconjugate Chem. 6:150 (1995); and Grit. Rev. Therap. Drug Carrier Sys. 9:249 (1992). Also encompassed are PEGs that are prepared for purpose of half life extension, for example, mono-activated, alkoxy-terminated polyalkylene oxides (POAs) such as mono- methoxy-terminated polyethyelene glycols (mPEGs); bis activated polyethylene oxides (glycols) or other PEG derivatives are also contemplated. Suitable PEGs will vary substantially by weights, e.g., ranging from about 200 Da to about 40,000 Da or from about 200 Da to about 60,000 Da, any of which may used for the purposes of the present disclosure. In certain embodiments, PEGs having molecular weights from 200 Da to 2,000 Da or from 200 Da to 500 Da are used. Different forms of PEG may also be used, depending on the initiator used for the polymerization process; a common initiator is a monofunctional methyl ether PEG, or methoxypoly(ethylene glycol), abbreviated mPEG. Lower- molecular-weight PEGs are also available as pure oligomers, referred to as monodisperse, uniform, or discrete. These are used in certain embodiments of the present disclosure. [0087] PEGs are also available with different geometries: branched PEGs have three to ten PEG chains emanating from a central core group; star PEGs have 10 to 100 PEG chains emanating from a central core group; and comb PEGs have multiple PEG chains normally grafted onto a polymer backbone. PEGs can also be linear. The numbers that are often included in the names of PEGs indicate their average molecular weights (e.g., a PEG with n = 9) would have an average molecular weight of approximately 400 daltons, and would be labeled PEG 400.
[0088] As used herein, “PEGylation” is the act of covalently coupling a PEG structure to the peptide inhibitor of the invention, which is then referred to as a “PEGylated peptide inhibitor”. In certain embodiments, the PEG of the PEGylated side chain is a PEG with a molecular weight from about 200 Da to about 40,000 Da.
[0089] In various embodiments, the agents are present in a pharmaceutical composition comprising one or more pharmaceutically acceptable diluents, carriers, or excipients. A pharmaceutically acceptable carrier, diluent or excipient refers to a non-toxic solid, semi -solid or liquid filler, diluent, encapsulating material or formulation auxiliary of any type. The term “pharmaceutically acceptable carrier” includes any of the standard pharmaceutical carriers. Pharmaceutically acceptable carriers for therapeutic use are well known in the pharmaceutical art and are described, for example, in “Remington's Pharmaceutical Sciences”, 17th edition, Alfonso R. Gennaro (Ed.), Mark Publishing Company, Easton, PA, USA, 1985. For example, sterile saline and phosphate-buffered saline at slightly acidic or physiological pH may be used. Suitable pH-buffering agents mmaayy,, e.g., be phosphate, citrate, acetate, tris(hydroxymethyl)aminomethane (TRIS), N-tris(hydroxymethyl)methyl-3- aminopropanesulfonic acid (TAPS), ammonium bicarbonate, diethanolamine, histidine, arginine, lysine or acetate (e.g., as sodium acetate), or mixtures thereof. The term further encompasses any carrier agents listed in the US Pharmacopeia for use in animals, including humans.
Therapeutic Phlebotomy
[0090] Therapeutic phlebotomy for iron overload diseases is performed to reduce iron levels in the patient. Therapeutic phlebotomy includes three phases: induction phase, transition phase, and maintenance phase. Induction is when therapy is initiated. Transition is the phase in which iron reduction is taking place to return iron levels to a normal healthy range. Once iron levels reach satisfactory and healthy levels, a patient enters the maintenance phase. [0091] During the induction phase, it is important to achieve iron reduction without generating symptoms or accelerating disease, which depends on several factors. These include how the phlebotomy is performed (e.g., amount and frequency), patient, diet and behavior modifications, and continued education. With few exceptions, the Iron Disorders Institute Advisory Board recommends a pre-treatment hemoglobin of 12.5g/dL. Exceptions will include some females or patients with liver or blood diseases. For most hemochromatosis patients, an order might be written as follows: “Phlebotomize 500 cc once a week** if Hgb=or >12.5g/dL” (38% hematocrit)(** period of time should reflect frequency desired).
[0092] During the transition phase, iron levels may be erratic or fall predictably. The frequency of phlebotomies may change from twice weekly, to weekly or monthly. Generally, when a patient’s serum ferritin is less than 500ng/mL, the frequency of phlebotomy can be slowed to once a month. A subject’s response may depend on age, the extent of iron saturation, serum ferritin levels, hemoglobin response, physical condition including symptoms, and the speed with which an individual unloads iron. Also, compliance with therapy schedules and care with diet will impact this phase. The goal of the transition period is to transition the patient from therapeutic phase into the maintenance phase. During this period, if iron levels are allowed to fall steadily, over time and not too rapidly, the body can reach healthy iron levels and possibly without canpetition from the genes that are programmed to load iron.
[0093] Maintenance phase patients are those who have reached healthy iron ranges and who can remain within those healthy ranges, typically by donating blood periodically. A healthy range for ferritin is 25-150ng/mL. But patients in therapy for iron reduction should achieve a serum ferritin below 50ng/mL on at least one occasion. Thereafter, the ferritin is preferably maintained within the range of 25-75ng/mL. The patient may donate blood routinely as defined by attending physician for optimum quality of health or may have periodic therapeutic phlebotomy by doctor’s order. Frequency of donation or therapeutic phlebotomy will depend upon patient’s Personal Health Profile as observed by patient and attending physician: age, weight, response to treatment, symptoms, rate of iron unloading and general physical condition. [0094] The amount of time required to reach the maintenance phase of treatment will vary. Thereafter, how often that person must have a phlebotomy to keep iron levels in a normal range will depend on compliance. Many hemochromatosis patients abandon therapy once they achieve normal iron levels. This sets them up fa irreversible organ damage and the need for repeat series of therapeutic phlebotomies. [0095] In certain embodiment, once in maintenance phase, the patient may be treated with a hepcidin mimetic alone, phlebotomy alone, or a combination thereof.
[0096] In particular embodiments, the phlebotomy schedule according to the present methods is based on serum iron, TSAT, and or serum ferritin levels. In most cases, the serum ferritin will drop by about 30-50ng/mL with each full unit of blood removed. This helps the physician to form an estimate of when the serum ferritin is will be below l,000ng/mL.
[0097] For patients whose initial serum ferritin (SF) is greater than 1,000 ng/mL, phlebotomies can be as frequent as twice a week. The SF may be evaluated, e.g., every 1-6 weeks, until it is lowered below 750 ng/mL. SF above 750 but below 1,000 is still a very high and may require continued weekly phlebotomies. Iron Disorders Institute Advisory Board recommends against phlebotomy (with few exceptions) for patients whose hemoglobin is lower than 12.5g/dL.
[0098] In certain embodiments, prior to treatment, a patient will have a serum ferritin greater than 200ng/mL (females) or 300ng/mL (males) with an accompanying transferrin-iron saturation percentage greater than 45%. When ferritin is above lOOOng/mL phlebotomy treatments may be as frequent as once or twice weekly, while tolerable and until ferritin drops below lOOOng/mL. Once serum ferritin is below 500ng/mL, the frequency of treatment may slow down from once or twice weekly to once a week or even to every other week depending upon the patient’s condition, behavior (eating habits) and ability to unload iron.
[0099] In embodiments, the methods disclosed herein reduce transferrin saturation (TSAT) level and/or serum iron level and/or mean corpuscular hemoglobin concentration (MCHC) level in the subject by at least 30%, at least 40%, or at least 60%. In some embodiments, the effective amount causes a decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron of at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90%. In certain embodiments, the TSAT% and/or serum iron level and/or MCHC level is reduced between about 40% and about 90%, between about 50% and about 90%, or between 50% and 75%. In some embodiments, TSAT% level and/or serum iron level and/or MCHC level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type. In particular embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the maximum reduction observed in the subject following treatment with the agent, while in other embodiments, the reduction in the TSAT% level and/or serum iron level is the reduction observed at trough level of the agent following administration to a subject. In some embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the average reduction observed, e.g., in a plurality of subjects.
[00100] In some embodiments, the subject’s TSAT level is reduced to < 60% TSAT, < 50% TS AT, < 45% TSAT, < 40% TSAT, < 30% TSAT, < 20% TSAT, or < 10% TSAT. In particular embodiments, the subject’s TSAT level is reduced to < 45% TSAT, or < 40% TSAT. In particular embodiments, the subject’s TSAT level is reduced to < 40% TSAT, or < 35% TSAT. In certain embodiments, the TSAT level is reduced to between about 20% TSAT and about 50% TSAT, e.g., between about 25% TSAT to about 40% TSAT. In particular embodiments, the TSAT% and/or serum iron level is reduced by at least 10%, at least 20%, at least 40%, at least 40%, at least 50%, at least 60%, at least 70%, or at least 90%. In certain embodiments, the TSAT% value is reduced to about 0% to about 60%, about 0% to about 40%, about 10% to about 40%, about 10% to about 30%, about 10% to about 20%, about 20% to about 60%, about 20% to about 40%, or about 20% to about 30%. In some embodiments, TSAT% is reduced to less than or equal to 50% TSAT, less than or equal to 45% TSAT, less than or equal to 40% TSAT, less than or equal to 35% TSAT, less than or equal to 30% TSAT, less than or equal to 20% TSAT, less than or equal to 15% TSAT, less than or equal to 10% TSAT, between about 10% TSAT and about 45% TSAT, between about 5% TSAT and about 20% TSAT, or between about 10% TSAT and about 20% TSAT at the time tested. In some embodiments, TSAT% level and/or serum iron level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type.
[00101] In certain embodiments, the serum iron level is reduced to about 0 uM to about 30 uM, about 0 uM to about 5 uM, about 0 uM to about 20 uM, about 0 uM to about 15 uM, about 0 uM to about 10 uM, or about 0 uM to about 5 uM. In certain embodiments, the subject’s serum iron level is reduced to < 20 umol/L, < 18 umol/L, < 16 umol/L, < 14 umol/L, < 12 umol/L, < 10 umol/L, < 8 umol/L, < 6 umol/L, or < 4 umol/L. In some embodiments, the subject’s serum iron level is reduced to between about 2 umol/L and about 100 umol/L, e.g., between 2 and about 10 umol/L, or between about 10 umol/L and about 50 umol/L, or between about 10 umol/L and 30 about umol/L. In some embodiments, the subject’s serum iron level is reduced to between about 2 umol/L and about 100 umol/L, e.g., between 2 and about 10 umol/L, or between about 10 umol/L and about 50 umol/L, or between about 10 umol/L and 30 about umol/L. In some embodiments, the subject’s serum iron level is reduced to between about 50 mcg/dL to about 200 mcg/dL, or about 60 mcg/dL to about 170 mcg/dL. In certain embodiments, the serum iron level is reduced to less than about 150 ug/dL, less than about 100 ug/dL, or less than about 75 ug/dL.
[00102] In some embodiments, the subject’s MCHC level is reduced by at least 5%, at least 10%, at least 20%, at least 40%, at least 40%, at least 50%, at least 60%, at least 70%, or at least 90%. In certain embodiments, the MCHC value (g/dL) is reduced to less than about 35, less than or about 34, less than or about 33, less than or about 32, less than or about 31, less than or about 30, or less than or about 29.
[00103] In embodiments, the methods reduce transferrin saturation (TSAT) level and/or serum iron and/or MCHC level in the subject by at least 10%, at least 20%, at least 30%, at least 40%, or at least 60%. In some embodiments, the effective amount causes a decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron and/or MCHC level of at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, or at least 90%. In certain embodiments, the TSAT% and/or serum iron level and/or MCHC level is reduced between about 40% and about 90%, between about 50% and about 90%, or between 50% and 75%. In some embodiments, TSAT% level and/or serum iron level and/or MCHC level is reduced to a level less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type. In particular embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the maximum reduction observed in the subject following treatment with the agent, while in other embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the reduction observed at trough level of the agent following administration to a subject. In some embodiments, the reduction in the TSAT% level and/or serum iron level and/or MCHC level is the average reduction observed, e.g., in a plurality of subjects.
[00104] In some embodiments, TSAT% level and/or serum iron level and/or MCHC level is reduced to a level less than 200%, less than 150%, less than 100T, less than 90%, less than 80%, less than 70%, less than 60%, or less than 50% of the level observed in normal, healthy volunteers of the same mammal type.
[00105] In certain embodiments, following treatment with the combination therapy disclosed herein, e.g., Compound 25 or Compound 46, an HH patient exhibits: TSAT levels of < 45% or < 40%, serum iron levels of < 150 ug/dL, < 100 ug/dL, or < 75 ug/dL; and/or MCHC levels of < 35 g/dL or < 30 g/dL. In particular embodiments, these levels occur at trough concentration of the hepcidin mimetic, e.g., about 7 days following the last dosing. [00106] In certain embodiments, the decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level and/or MCHC level occurs for at least one day, at least two days, at least three days, at least four days, at least five days, at least six days, or at least one week following administration of the hepcidin mimetic. In particular embodiments, the subject is provided with the hepcidin mimetic about three times a week, about twice a week, or about once a week, e.g., as a single dose or over a period of time, and with therapeutic phlebotomy about once per week or once every two weeks. In certain embodiments, the decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level and/or MCHC level is at least 50%, or at least 60% or at least 80% for at least one day, at least two days, at least 3 days, or at least 4 days following a dose. In particular embodiments, the decrease in TSAT and/or serum iron level and/or MCHC is maintained over the course of treatment, wherein the course of treatment may be, e.g., once a week or twice a week for at least two months, at least four months, at least six months, at least one year, at least two years, at least three years or longer.
[00107] In certain embodiments, the combination therapy disclosed herein results in a reduction in one or more of: serum iron, liver iron, heart iron, kidney iron, and/or pancreas iron of at 40%, at least 50%, at least 60%, at least 70%, or at least 80%, e.g., when measured at the end of a course of treatment of about 8 weeks, ten weeks, 12 weeks, or four months. In certain embodiments, the combination therapy disclosed herein results in an increase in spleen iron, e.g., when measured at the end of a course of treatment of about 8 weeks, ten weeks, 12 weeks, or four months. In particular embodiments, the decrease or increase associated with the combination therapy is greater than with treatment with the hepcidin mimetic alone or therapeutic phlebotomy alone, and in certain embodiments, treatment with the combination of hepcidin mimetic and therapeutic phlebotomy acts synergistically.
[00108] In certain embodiments, the subject needs fewer phlebotomies following treatment with a hepcidin mimetic, e.g., Compounds 25, according to the disclosed methods. In some embodiments, the subject needs less than 0.1 phlebotomy per month, or less than 0.05 phlebotomy per month during treatment according to the disclosure.
[00109] In certain embodiments, the subject has improved arthropathy following treatment, e.g., as determined by methods available in the art, e.g., X-ray, MRI, joint pain, and/or use of functional scoring instruments.
[00110] In certain embodiments, the subject has reduced oxidative stress, reduced disrupted matrix metabolism, and/or reduced cartilage degeneration following treatment. [00111] In certain embodiments, the methods disclosed herein result in the subject having decreased circulating transferrin saturation (TSAT) and/or decreased toxic non-transferrin bound iron (NTBI), and/or decreased iron accumulation in organs, e.g., such as the liver, pancreas, heart, and bone.
[00112] If untreated, iron overload can cause hepatomegaly, diabetes mellitus, skin hyperpigmentation, cardiomyopathy, diastolic dysfunction, heart failure, cirrhosis, etc. In particular embodiments, methods of treatment disclosed herein reduce, alleviate, or improve any of these symptoms or pathologies associated with iron overload, such as HH.
EXAMPLES
[00113] The following examples demonstrate certain specific embodiments of the present invention. The following examples were carried out using standard techniques that are well known and routine to those of skill in the art, except where otherwise described in detail. It is to be understood that these examples are for illustrative purposes only and do not purport to be wholly definitive as to conditions or scope of the invention. As such, they should not be construed in any way as limiting the scope of the present invention.
ABBREVIATIONS:
DCM: di chloromethane
DMF: N,N-dimethylformamide
NMP: N-methylpyrolidone
HBTU: O-(Benzotriazol-l-yl)-N,N,N,,N’-tetramethyluronium hexafluorophosphate
HATH: 2-(7 -aza- lH-benzotriazole- 1 -yl)- 1 , 1 ,3,3 -tetramethyluronium hexafluorophosphate DCC: Dicyclohexylcarbodiimide
NHS: N-hydoxy succinimide DIPEA: diisopropylethylamine EtOH: ethanol
Et20: diethyl ether
Hy: hydrogen
TFA: trifluoroacetic acid
TIS: triisopropylsilane
ACN: acetonitrile
HPLC: high performance liquid chromatography ESI-MS: electron spray ionization mass spectrometry
PBS: phosphate-buffered saline
Boc: t-butoxycarbonyl
Fmoc: Fluorenylmethyloxycarbonyl
Acm: acetamidomethyl
IVA: Isovaleric acid (or Isovaleryl)
[00114] K( ): In the peptide sequences provided herein, wherein a compound or chemical group is presented in parentheses directly after a Lysine residue, it is to be understood that the compound or chemical group in the parentheses is a side chain conjugated to the Lysine residue. So, e.g., but not to be limited in any way, K-[(PEG8)]- indicates that a PEGS moiety is conjugated to a side chain of this Lysine.
[00115] Palm: Indicates conjugation of a palmitic add (palmitoyl).
[00116] As used herein “C( )” refers to a cysteine residue involved in a particular disulfide bridge. For example, in Hepcidin, there are four disulfide bridges: the first between the two C(l) residues; the second between the two C(2) residues; the third between the two C(3) residues; and the fourth between the two C(4) residues. Accordingly, in some embodiments, the sequence for Hepcidin is written as follows:
Hy-DTHFPIC(1)IFC(2)C(3)GC(2)C(4)HRSKC(3)GMC(4)C(1)KT-OH (SEQ ID NO: 65); and the sequence for other peptides may also optionally be written in the same manner.
EXAMPLE 1
SYNTHESIS OF PEPTIDE ANALOGUES
[00117] Unless otherwise specified, reagents and solvents employed in the following were available commercially in standard laboratory reagent or analytical grade, and were used without further purification.
Procedure for solid-phase synthesis of peptides
[00118] Peptide analogues of the invention were chemically synthesized using optimized 9- fluorenylmethoxy carbonyl (Fmoc) solid phase peptide synthesis protocols. For C-terminal amides, rink-amide resin was used, although wang and trityl resins were also used to produce C-terminal acids. The side chain protecting groups were as follows: Glu, Thr and Tyr: O- tButyl; Trp and Lys: t-Boc (t-butyloxycarbonyl); Arg: N-gamma-2,2,4,6,7- pentamethyldihydrobenzofuran-5-sulfonyl; His, Gin, Asn, Cys: Trityl. For selective disulfide bridge formation, Acm (acetamidomethyl) was also used as a Cys protecting group. For coupling, a four to ten-fold excess of a solution containing Fmoc amino acid, HBTU and DIPEA (1:1:1.1) in DMF was added to swelled resin [HBTU: O-(Benzotriazol-l-yl)- N,N,N',N'-tetramethyluroiiium hexafluorophosphate; DIPEA: diisopropylethylamine; DMF: dimethylformamide]. HATU (O-(7-azabenzotriazol-l-yl)-l,l,3,3,-tetramethyluronium hexafluorophosphate) was used instead of HBTU to improve coupling efficiency in difficult regions. Fmoc protecting group removal was achieved by treatment with a DMF, piperidine (2:1) solution.
Procedure for cleavage of peptides off resin
[00119] Side chain deprotection and cleavage of the peptide analogues of the invention (e.g., Compound No. 2) was achieved by stirring dry resin in a solution containing trifluoroacetic acid, water, ethanedithiol and tri-isopropylsilane (90:5:2.5:2.5) for 2 to 4 hours. Following TFA removal, peptide was precipitated using ice-cold diethyl ether. The solution was centrifuged and the ether was decanted, followed by a second diethyl ether wash. The peptide was dissolved in an acetonitrile, water solution (1:1) containing 0.1% TFA (trifluoroacetic acid) and the resulting solution was filtered. The linear peptide quality was assessed using electrospray ionization mass spectrometry (ESI-MS).
Procedure for purification of neotides
[00120] Purification of the peptides of the invention (e.g., Compound No. 2) was achieved using reverse-phase high performance liquid chromatography (RP-HPLC). Analysis was performed using a Cl 8 column (3 μm, 50 x 2mm) with a flow rate of 1 mL/min. Purification of the linear peptides was achieved using preparative RP-HPLC with a Cl 8 column (5μm, 250 x 21.2 mm) with a flow rate of 20 mL/min. Separation was achieved using linear gradients of buffer B in A (Buffer A: Aqueous 0.05% TFA; Buffer B: 0.043% TFA, 90% acetonitrile in water). Procedure for oxidation of peptides.
[00121] Method A (Single disulfide oxidation). Oxidation of the unprotected peptides of the invention was achieved by adding drop-wise iodine in MeOH (1 mg per 1 mL) to the peptide in a solution (ACN: HzO, 7: 3, 0.5% TFA). After stirring for 2 min, ascorbic acid portion wise was added until the solution was clear and the sample was immediately loaded onto the HPLC for purification.
[00122]Method B (Selective oxidation of two disulfides). When more than one disulfide was present, selective oxidation was often performed. Oxidation of the free cysteines was achieved at pH 7.6 NH4CO3 solution at Img /10 mL of peptide. After 24 h stirring and prior to purification the solution was acidified to pH 3 with TEA followed by lyophilization. The resulting single oxidized peptides (with ACM protected cysteines) were then oxidized / selective deprotection using iodine solution. The peptide (1 mg per 2 mL) was dissolved in MeOH/H2O, 80:20 iodine dissolved in the reaction solvent was added to the reaction (final concentration: 5 mg/mL) at room temperature. The solution was stirred for 7 minutes before ascorbic acid was added portion wise until the solution is clear. The solution was then loaded directly onto the HPLC.
[00123]Method C (Native oxidation). When more than one disulfide was present and when not performing selective oxidations, native oxidation was performed. Native oxidation was achieved with 100 mM NH4CO3 (pH7.4) solution in the presence of oxidized and reduced glutathione (peptide/GSH/GSSG, 1:100:10 molar ratio) of (peptide: GSSG: GSH, 1:10, 100). After 24 h stirring and prior to RP-HPLC purification the solution was acidified to pH 3 with TFA followed by lyophilization.
Procedure of cysteine oxidation to produce dimers. Oxidation of the unprotected peptides of the invention was achieved by adding drop-wise iodine in MeOH (1 mg per 1 mL) to the peptide in a solution (ACN: H2O, 7: 3, 0.5% TFA). After stirring for 2 min, ascorbic add portion wise was added until the solution was clear and the sample was immediately loaded onto the HPLC for purification.
Procedure for dimerization.
[00124] Glyoxylic acid (DIG), IDA, or Fmoc-β-Ala-IDA was pre-activated as the N- hydoxysucdnimide ester by treating 1 equivalent (abbreviated “eq”) of the acid with 2.2 eq of both N-hydoxysuccinimide (NHS) and dicyclohexyl carbodiimide (DCC) in NMP (N-methyl pyrolidone) at a 0.1 M final concentration. For the PEG13 and PEG25 linkers, these chemical entities were purchased pre-formed as the activated succinimide ester. The activated ester - 0.4 eq was added slowly to the peptide in NMP (Img/mL) portionwise. The solution was left stirring for 10 min before 2-3 additional aliquots of the linker -0.05 eq were slowly added. The solution was left stirring for a further 3 h before the solvent was removed under vaccuo and the residue was purified by reverse phase HPLC. An additional step of stirring the peptide in 20% piperidine in DMF (2 x 10 min) before an additional reverse phase HPLC purification was performed.
[00125] One of skill in the art will appreciate that standard methods of peptide synthesis may be used to generate the compounds of the invention.
Linker activation and dimerization [00126] Peptide monomer subunits were linked to form hepcidin analogue peptide dimers as described below.
Small Scale DIG Linker Activation Procedure: 5mL of NMP was added to a glass vial containing IDA diacid (304.2 mg, 1 mmol), N-hydroxysuccinimide (NHS, 253.2 mg, 2.2 eq. 2.2mmol) and a stirring bar. The mixture was stirred at room temperature to completely dissolve the solid starting materials. N, N’-Dicyclohexylcarbodiimide (DCC, 453.9mg, 2.2 eq., 2.2 mmol) was then added to the mixture. Precipitation appeared within 10 min and the reaction mixture was further stirred at room temperature overnight. The reaction mixture was then filtered to remove the precipitated dicyclohexylurea (DCU). The activated linker was kept in a closed vial prior to use for dimerization. The nominal concentration of the activated linker was approximately 0.20 M.
[00127] For dimerization using PEG linkers, there was no pre-activation step involved. Commercially available pre-activated bi-functional PEG linkers were used.
Dimerization Procedure: 2mL of anhydrous DMF was added to a vial containing peptide monomer (0.1 mmol). The pH of the peptide was the adjusted to 8~9 with DIEA. Activated linker (IDA or PEG13, PEG 25) (0.48eq relative to monomer, 0.048 mmol) was then added to the monomer solution. The reaction mixture was stirred at room temperature for one hour. Completion of the dimerization reaction was monitored using analytical HPLC. The time for completion of dimerization reaction varied depending upon the linker. After completion of reaction, the peptide was precipitated in cold ether and centrifuged. The supernatant ether layer was discarded. The precipitation step was repeated twice. The crude dimer was then purified using reverse phase HPLC (Luna Cl 8 support, lOu, 100 A, Mobile phase A: water containing 0.1% TFA, mobile phase B: Acetonitrile (ACN) containing 0.1% TFA, gradient of 15%B and change to 45%B over 60min, flow rate 15ml/min). Fractions containing pure product were then freeze-dried on a lyophilizer.
Conjugation of Half-Life Extension Moieties
[00128] Conjugation of peptides were performed on resin. Lys(ivDde) was used as the key amino acid. After assembly of the peptide on resin, selective deprotection of the ivDde group occurred using 3 x 5 min 2% hydrazine in DMF for 5 min. Activation and acylation of the linker using HBTU, DIEA 1-2 equivalents for 3 h, and Fmoc removal followed by a second acylation with the lipidic acid gave the conjugated peptide.
EXAMPLE 2 TREATMENT OF HEREDITARY HEMOCHROMATOSIS WITH A COMBINATION OF A HEPCIDIN
MIMETIC PEPTIDE AND THERAPEUTIC PHLEBOTOMY
[00129] Hepcidin deficiency in hereditary hemochromatosis (HH) leads to hyperabsorption of dietary iron and primary iron overload. Persistent high transferrin-saturation (TSAT%) results in the occurrence of labile iron that can be toxic. Deposition of excess iron in organs, e.g., liver iron overload, contributes to tissue damage and potential organ dysfunction. Hepcidin mimetic peptide therapy (mini-hepddin) was demonstrated to be beneficial in preventing iron overload in a hepcidin knockout mouse model (Hamp-/-) (Ramos E, Blood (2012) 120 (18):3829-36). [00130] Rusfertide is a hepcidin mimetic peptide designed for superior drug like properties compared to the endogenous protein, which has demonstrated potential benefit in reducing the need for therapeutic maintenance phlebotomy in hemochromatosis subjects who have previously required chronic phlebotomies to reduce and maintain ferritin and liver iron values within normal range (Kowdley KV, AASLD Hepatology (2021) 74: Issue SI). This has confirmed and is consistent with the benefit of rusfertide therapy in preventing iron overload in a mouse model for hemochromatosis that was generated by homozygous deletion of hemojuvelin protein which is an essential positive regulator of hepcidin expression (HJV-/- or HFE2-/- mice) (Taranath R, Blood (2019) 134 (Supplement_1): 3540). Rusfertide treatment in HJV-/- mice over 24 days (2.5 mg/kg, Q2D, subcutaneous injections) was efficacious in maintaining TSAT% within normal range, and prevention of iron deposition in liver, kidneys, and pancreas. However, newly diagnosed patients most likely present with severe iron overload therefore requiring frequent phlebotomies during the induction phase of therapy that can last for many months because of TSAT levels continuing to be high.
[00131] This study evaluated the potential synergistic/additive effects of co-treatment with Compound 46 (a rusfertide analog peptide with identical pharmacokinetic and pharmacodynamic characteristics) in the induction phlebotomy phase by using the HJV-/- mouse model. Male HJV-/- mice were recruited into the study at 8-12 weeks of age and given 35 ppm iron diet from weaning. One basline group was terminated at Day 0, and another baseline group was terminated at the end of the study. Mice were treated with vehicle, either Compound 46 (7.5 mg/kg, TIW, SubQ), phlebotomy (~0.3mL blood drawn retroorbitally, QW), or combination of both for a total of 46 days (baseline group was terminated at study start), outlined in FIG. 1. Clinical observation was performed daily, and body weights taken every two weeks. Following termination, serum was analyzed for iron and ferritin. Liver, spleen, pancreas, heart, kidneys, and duodenum were collected and frozen prior to determination of tissue iron content by ICP-MS.
[00132] Vehicle group showed elevated total iron concentrations in liver, heart, pancreas and kidney compared to baseline group and were all much higher than wild type values (FIGs. 4- 7). All three treatment strategies were able to prevent liver iron accumulation, however, none were able to lower the liver iron concentration as compared to respective baseline groups for either treatment length (FIG. 4). A longer length of treatment may result in effects on liver iron concentration. Significant reductions in iron concentrations were observed in heart and kidney for all the treatment strategies, but more statistically significant for the groups treated with Compound 46 alone or Compound 46 in combination with phlebotomy (FIGs. 5 and 6). Treatment with Compound 46 alone had redistributed the excess iron into spleen and duodenum, thereby significantly elevating spleen iron concentration, while co-treatment with phlebotomy lowered this iron sequestration in spleen FIGs. 8 and 9). Serum ferritin was lowered with phlebotomy or Compound 46 treatment, while normalization of serum iron required Compound 46 (FIGs. 2 and 3). Hemoglobin levels were lowered with Compound 46 treatment alone, and lowered to an even greater extent with Compound 46 treatment in combination with phlebotomy (FIG. 10). Red blood cell levels were lowered with Compound 46 treatment alone, and lowered to an even greater extent with Compound 46 treatment in combination with phlebotomy (FIG. 11). MCV levels increased with phlebotomy treatment alone (FIG. 12). MCH was reduced by treatment with Compound 46, alone or in combination with phlebotomy (FIG. 13). MCHC was slightly reduced by treatment with Compound 46, alone or in combination with phlebotomy (FIG. 13). Data is summarized in FIG. 14.
[00133] The overall data indicated that combining hepcidin mimetic treatment along with phlebotomy, may be more effective in lowering TSAT% towards normal values and thereby also more quickly reverse tissue iron deposition in specific organs compared to others. Titration of rusfertide (or a rusfertide peptide analog) to the desired clinical effect may be effective in combination with phlebotomy during the induction phase of clinical management to reduce the frequency and duration of phlebotomy treatment as well as lingering high TSAT levels.
[00134] All of the above U.S. patents, U.S. patent application publications, U.S. patent applications, foreign patents, foreign patent applications and non-patent publications referred to in this specification and/or listed in the Application Data Sheet, are incorporated herein by reference, in their entirety. [00135] From the foregoing it will be appreciated that, although specific embodiments of the invention have been described herein for purposes of illustration, various modifications may be made without deviating from the spirit and scope of the invention.

Claims

Claims
1. A method for treating hereditary hemochromatosis, hereditary hemochromatosis arthropathy, or joint pain associated with hereditary hemochromatosis arthropathy, in a subject, comprising administering to the subject one or more doses of a hepcidin mimetic in combination with one or more therapeutic phlebotomies.
2. The method of claim 1, wherein the subject has not previously received a therapeutic phlebotomy for treatment of hereditary hemochromatosis, hereditary hemochromatosis arthropathy, or joint pain associated with hereditary hemochromatosis arthropathy.
3. The method of claim 1 or claim 2, wherein the subject is treated during the induction phase of therapeutic phlebotomy.
4. The method of any one of claims 1-3, wherein the subject is treated with the hepcidin mimetic and/or therapeutic phlebotomy for at least the four weeks, six week, eight weeks, 10 weeks, 12 weeks, four months, or six months following a first phlebotomy.
5. The method of any one of claims 1-4, wherein each dose is about 5 mg to about 40 mg, and optionally wherein the subject is administered different doses during different time periods of treatment.
6. The method of any one of claims 1-5, wherein the subject is administered the hepcidin mimetic about once a week, about twice a week, or about three times a week during treatment.
7. The method of claim 6, wherein the subject is administered about 5 mg to about 20 mg of the hepcidin mimetic about three times a week for at least some time period during the course of treatment.
8. The method of claim 6, wherein the subject is administered about 10 mg to about 40 mg of the hepcidin mimetic about once a week, about twice a week, or about three times a week for at least some time period during the course of treatment.
9. The method of any one of claims 1-8, wherein the one or more therapeutic phlebotomy is performed about once per month, about once every two weeks, about once per week, or about twice per week, and optionally wherein the therapeutic phlebotomy is performed at different frequency during treatment.
10. The method of claim 9, wherein a phlebotomy is performed about once per week for about 8 weeks.
11. The method of any one of claims 1-10, wherein each phlebotomy comprises removing about 500 cc of blood from the subject.
12. The method of any one of claims 1-11, wherein the method causes a decrease in the subject’s transferrin saturation (TSAT) level and/or serum iron level.
13. The method of claim 12, wherein the subject’s TSAT level is decreased to less than 45%.
14. The method of claim 12, wherein the subject’s TSAT level is decreased to less than 40%.
15. The method of claim 13 or claim 14, wherein the subject’s TSAT level is maintained at less than 45% over the course of treatment, optionally wherein the course of treatment comprises at least 8 weeks.
16. The method of any one of claims 1-15, wherein hepcidin mimetic is a peptide having Formula I:
R1-X-Y-R2 (I) or a pharmaceutically acceptable salt or solvate thereof, wherein
R1 is hydrogen, a C1-C6 alkyl, a C6-C12 aryl, a C1-C20 alkanoyl, or pGlu;
R2 is NH2 or OH;
X is an amino acid sequence of Formula II:
X1-X2-X3-X4-X5-X6-X7-X8-X9-X10 (II) wherein XI is Asp, Ala, Ida, pGlu, bhAsp, Leu, D-Asp, or absent;
X2 is Thr, Ala, or D-Thr;
X3 is His, Lys, D-His, or Lys;
X4 is Phe, Ala, Dpa, or D-Phe;
X5 is Pro, Gly, Arg, Lys, Ala, D-Pro, or bhPro;
X6 is De, Cys, Arg, Lys, D-De, or D-Cys;
X7 is Cys, De, Leu, Vai, Phe, D-De, or D-Cys;
X8 is De, Arg, Phe, Gin, Lys, Glu, Vai, Leu, or D-De;
X9 is Phe or bhPhe; and
X10 is Lys, Phe, or absent; wherein if Y is absent, X7 is De; and
Y is an amino acid sequence of Formula III:
Y1-Y2-Y3-Y4-Y5-Y6-Y7-Y8-Y9-Y10-Y11-Y12-Y13-Y14-Y15 (III) wherein
Y1 is Gly, Cys, Ala, Phe, Pro, Glu, Lys, D-Pro, Vai, Ser, or absent;
Y2 is Pro, Ala, Cys, Gly, or absent;
Y3 is Arg, Lys, Pro, Gly, His, Ala, Trp, or absent;
Y4 is Ser, Arg, Gly, Trp, Ala, His, Tyr, or absent;
Y5 is Lys, Met, Arg, Ala, or absent;
Y6 is Gly, Ser, Lys, Ile, Ala, Pro, Vai, or absent;
Y7 is Trp, Lys, Gly, Ala, Ile, Vai, or absent;
Y8 is Vai, Thr, Gly, Cys, Met, Tyr, Ala, Glu, Lys, Asp, Arg, or absent;
Y9 is Cys, Tyr, or absent;
Y10 is Met, Lys, Arg, Tyr, or absent;
Y11 is Arg, Met, Cys, Lys, or absent;
Y12 is Arg, Lys, Ala or absent;
Y13 is Arg, Cys, Lys, Vai or absent;
Y14 is Arg, Lys, Pro, Cys, Thr or absent; and
Y15 is Thr, Arg or absent; wherein the peptide of Formula I is optionally PEGylated on Rl, X, or Y; wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; wherein the peptide of Formula I optionally has a disulfide bond formed between the thiol groups of two cysteine residues; and wherein Ida is iminodiacetic acid, pGlu is pyroglutamic acid, bhAsp is P-homoaspartic acid, and bhPro is β-homoproline.
17. The method of claim 16, wherein R1 is hydrogen, isovaleric acid, isobutyric acid or acetyl.
18. The method of claim 16 or claim 17, wherein X is an amino acid sequence of Formula IV: Xl-Thr-His-X4-X5-X6-X7-X8-Phe-X10 (IV) wherein
XI is Asp, Ida, pGlu, bhAsp or absent;
X4 is Phe or Dpa;
X5 is Pro or bhPro;
X6 is Ile, Cys, or Arg;
X7 is Cys, Ile, Leu, or Vai;
X8 is Ile, Lys, Glu, Phe, Gin, or Arg; and X10 is Lys or absent.
19. The method of claim 17 or claim 18, wherein X is an amino acid sequence of Formula V: Xl-Thr-His-X4-X5-Cys-Ile-X8-Phe-X10 (V) wherein
XI is Asp, Ida, pGlu, bhAsp, or absent;
X4 is Phe or Dpa;
X5 is Pro or bhPro;
X8 is Ile, Lys, Glu, Phe, Gin or Arg; and X10 is Lys or absent.
20. The method of claim 16, wherein the peptide has Formula VI: R1-X-Y-R2 (VI) or a pharmaceutically acceptable salt thereof, wherein: R1 is hydrogen, isovaleric acid, isobutyric acid, or acetyl; R2 isNH2 or OH; X is an amino acid sequence of Formula VII:
Xl-Thr-His-X4-X5-Cys-Ile-X8-Phe-X10 (VII) wherdn
XI is Asp, Ida, pGlu, bhAsp, or absent;
X4 is Phe or Dpa;
X5 is Pro or bhPro;
X8 is De, Lys, Glu, Phe, Gin, or Arg; and
X10 is Lys or absent; wherein Y is an amino add sequence of Formula VIII:
Yl-Pro-Y3-Ser-Y5-Y6-Y7-Y8-Cys-Y10 (VIII) wherein
Y1 is Gly, Glu, Vai, or Lys;
Y3 is Arg or Lys;
Y5 is Arg or Lys;
Y6 is Gly, Ser, Lys, Ile, or Arg;
Y7 is Tip or absent;
Y8 is Vai, Thr, Asp, Glu, or absent; and
Y10 is Lys or absent; wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues; wherdn the peptide is optionally PEGylated on R1, X, or Y; wherein a side chain of an amino acid of die peptide is optionally conjugated to a lipophilic substituent or polymeric moiety; and wherdn Ida is iminodiacetic acid; pGlu is pyroglutamic add; bhAsp is β-homoaspartic acid; and bhPro is P-homoproline.
21. The method of any one of claims 16-20, wherein the peptide has one of the following sequences:
DTHFPICIFGPRSKGWVC (SEQ ID NO:46); DTHFPCIIFGPRSKGWVCK (SEQ ID NO:47); DTHFPCIIFEPRSKGWVCK (SEQ ID NO:48); DTHFPCIIFGPRSKGWACK (SEQ ID NO:49); DTHFPCIIFGPRSKGWVCKK (SEQ ID NO:50); DTHFPCIIFVCHRPKGCYRRVCR (SEQ ID N0:51); DTHFPCIKFGPRSKGWVCK (SEQ ID NO:52); DTHFPCIKFKPRSKGWVCK (SEQ ID NO:53); DTHFPCIlFGPRSRGWVCK (SEQ ID NO:54); DTHFPCIKFGPKSKGWVCK (SEQ ID NO:55); DTHFPCIKFEPRSKGCK (SEQ ID NO:56); DTHFPCIKFEPKSKGWECK (SEQ ID NO:57); DTHFPCIKFEPRSKKCK (SEQ ID NO:58); DTHFPCIKFEPRSKGCKK (SEQ ID NO:59); DTHFPCIKFKPRSKGCK (SEQ ID NO:60); DTHFPCIKFEPKSKGCK (SEQ ID N0:61);
DTHFPCIKF (SEQ ID NO:62);
DTHFPCIlF (SEQ ID NO:63); or DTKFPCHF (SEQ ID NO:64), wherein said peptide is optionally PEGylated on Rl, X, or Y; and wherein a side chain of an amino acid of the peptide is optionally conjugated to a lipophilic substituent or polymeric moiety.
22. The method of any one of claims 1-20, wherein the peptide has one of the following sequences or structures:
Isovaleric acid-DTHFPICIFGPRSKGWVC-NH2 (Compound 1; SEQ ID NO: 1);
Isovaleric acid-DTHFPCIlFGPRSKGWVCK-NH2 (Compound 2; SEQ ID NO:2);
Isovaleric acid-DTHFPCIlFEPRSKGWVCK-NH2 (Compound 3; SEQ ID NO:3);
Isovaleric acid-DTHFPCIlFGPRSKGWACK-NIh (Compound 4; SEQ ID NO:4);
Isovaleric acid-DTHFPCIlFGPRSKGWVCKK-NH2 (Compound 5; SEQ ID NO:5);
Isovaleric acid-DTHFPCIlFVCHRPKGCYRRVCR-NIh (Compound 6; SEQ ID NO:6>,
Isovaleric acid-DTHFPCI(K(PEG8))FGPRSKGWVCK-NH2 (Compound 7; SEQ ID NO:7>,
Isovaleric acid-DTHFPCIKF(K(PEG8))PRSKGWVCK-NH2 (Compound 8; SEQ ID NO: 8),
Isovaleric acid-DTHFPICIFGPRS(K(PEG8))GWVC-NH2 (Compound 9; SEQ ID NO:9); Isovaleric acid-DTHFPICIFGPRS(K(PEG4))GWVC-NH2 (Compound 10; SEQ ID NO:10);
Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG8))-NH2 (Compound 11 ; SEQ ID NO: 11>, Isovaleric acid-DTHFPCIIFGPRSRGWVC(K(PEG4))-NH2(Compound 12; SEQ ID NO: 12); Isovaleric acid-DTHFPCIlFGPRSRGWVC(K(PEG2))-NH2 (Compound 13: SEQ ID NO: 13) ; Isovaleric acid-DTHFPCI(K(Palm))FGPRSKGWVCK-NH2 (Compound 14; SEQ ID NO: 14)
Isovaleric acid-DTHFPCIKF)K(Palm))PRSKGWVCK-NH2(Compound 15; SEQ ID NO: 15);
Isovaleric acid-DTHFPCIKFGP(K(Palm))SKGWVCK-NH2(Compound 16; SEQ ID NO: 16) ;
Isovaleric acid-DTHFPCIKFGPRS(K(Palm))GWVCK-NH2 (Compound 17; SEQ ID NO: 17)
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(Palm))NH2 (Compound 18; SEQ ID NO:18);
Isovaleric acid-DTHFPCI(K(PEG3-Palm))FGPRSKGWVCK-NH2 (Compound 19; SEQ ID NO: 19);
Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH2 (Compound 20; SEQ ID
NO:20);
Isovaleric acid-DTHFPCIKFGP(K(PEG3-Palm))SKGWVCK-NH2 (Compound 21; SEQ ID
NO:21);
Isovaleric acid-DTHFPCIKFGPRS(K(PEG3-Palm))GWVCK-NH2 (Compound 22; SEQ ID
NO:22);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(PEG3-Palm))-NH2 (Compound 23; SEQ ID
NO:23);
Isovaleric acid-DTHFPCIKFGPRSKGWVC(K(PEG8))-NH2 (Compound 24; SEQ ID
NO:24);
Isovaleric acid-DTHFPCI(K(isoGlu-Palm))FEPRSKGCK-NH2 (Compound 25; SEQ ID
NO:25);
Isovaleric acid-DTHFPCIKF-K(isoGlu-Palm)-PRSKGCK-NH2 (Compound 26; SEQ ID
NO:26);
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGCK-NH2 (Compound 27; SEQ ID
NO:27);
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGWECK-NH2 (Compound 28; SEQ ID
NO:28);
Isovaleric acid-DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH2 (Compound 29; SEQ ID
NO:29);
Isovaleric acid-DTHFPCIKFEPRSK(K(isoGlu-Palm))CK-NH2 (Compound 30; SEQ ID
NO:30);
Isovaleric acid-DTHFPCIKFEPRSKGCK(K(isoGlu-Palm))-NH2 (Compound 31; SEQ ID NO:31); Isovaleric acid-DTHFPCI(K(Dapa-Palm))FEPRSKGCK-NH2 (Compound 32; SEQ ID NO:32);
Isovaleric acid-DTHFPCIK(F(Dapa-Palm))PRSKGCK-NH2 (Compound 33; SEQ ID
NO:33);
Isovaleric acid-DTHFPCIKFEP(K(Dapa-Palm))SKGCK-NH2 (Compound 34; SEQ ID
NO:34);
Isovaleric acid-DTHFPCIKFEPRS(K(Dapa-Palm))GCK-NH2 (Compound 35; SEQ ID
NO:35);
Isovaleric acid-DTHFPCIKFEPRSK(K(Dapa-Palm))CK-NH2 (Compound 36; SEQ ID
NO:36);
Isovaleric acid-DTHFPCIKFEPRSKGC(K(Dapa-Palm))K-NH2(Compoimd 37; SEQ ID
NO:37);
Isovaleric acid-DTHFPCIKFEPRSKGC(K(Dapa-Palm))-NH2 (Compound 38; SEQ ID
NO:38);
Isovaleric acid-DTHFPCIKF(K(PEGll-Palm))PRSK[Sar]CK-NH2 (Compound 39; SEQ ID
NO:39);
Isolvaleric acid-DTHFPCIKF-NH2 (Compound 40; SEQ ID NO:40);
Hy-DTHFPCIKF-NH2 (Compound 41; SEQ ID NO:41);
Isolvaleric acid-DTHFPCIIF-NH2 (Compound 42; SEQ ID NO:42);
Hy-DTHFPCIIKF-NH2 (Compound 43; SEQ ID NO:43);
Isovaleric acid-DTKFPCIIF-NH2 (Compound 44; SEQ ID NO:44);
Hy-DTKFPCIIF-NH2 (Compound 45; SEQ ID NO:45); or
Isovaleric acid-ETHFPCI(K(IsoGlu-Palm))FEPRSKGCK-NH2 (Compound 46; SEQ ID NO: 66), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
23. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIIFGPRSKGWVCK-NH2 (Compound 2; SEQ ID NO:2), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
24. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIIFEPRSKGWVCK-NH2 (Compound 3; SEQ ID NO:3), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
25. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCI(K(PEG8))FGPRSKGWVCK-NH2 (Compound 7; SEQ ID NO:7), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
26. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKF(K(PEG8))PRSKGWVCK-NH2 (Compound 8; SEQ ID NO:8), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
27. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIIFGPRSRGWVC(K(PEG8))-NH2 (Compound 11; SEQ ID NO: 11), optionally wherein the peptide has a disulfide bond famed between the thiol groups of two cysteine residues.
28. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCI(K(Palm))FGPRSKGWVCK-NH2 (Compound 14; SEQ ID NO: 14), optionally wherein the peptide has a disulfide bond famed between the thiol groups of two cysteine residues.
29. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKF(K(Palm))PRSKGWVCK-NH2 (Compound 15; SEQ ID NO: 15), optionally wherein the peptide has a disulfide bond famed between the thiol groups of two cysteine residues.
30. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKFGP(K(Palm))SKGWVCK-NH2 (Compound 16; SEQ ID NO: 16), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
31. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKFGPRSKGWVC(K(Palm))-NH2 (Compound 18; SEQ ID NO: 18), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
32. The method of claim 22, wherein the peptide is: Isovaleric add-DTHFPCI(K(PEG3- Palm))FGPRSKGWVCK-NH2 (Compound 19; SEQ ID NO: 19), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
33. The method of claim 22, wherein the peptide is: Isovaleric add-DTHFPCIKF(K(PEG3- Palm))PRSKGWVCK-NH2 (Compound 20; SEQ ID NO:20), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
34. The method of claim 22, wherein the peptide is: Isovaleric add- DTHFPCIKFGP(K(PEG3-Palm))SKGWVCK-NH2 (Compound 21; SEQ ID NO:21), optionally wherein the peptide has a disulfide bond famed between the thiol groups of two cysteine residues.
35. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKFGPRS(K(PEG3-Palm))GWVCK-NH2 (Compound 22; SEQ ID NO:22), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
36. The method of claim 22, wherein the peptide is: Isovaleric add- DTHFPCIKFGPRSKGWVC(K(PEG3-Palm))-NH2 (Compound 23; SEQ ID NO:23), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
37. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKFGPRSKGWVC(K(PEG8))-NH2 (Compound 24; SEQ ID NO:24), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
38. The method of claim 22, wherein the peptide is: Isovaleric acid-DTHFPCI(K(isoGlu- Palm))FEPRSKGCK-NH2 (Compound 25; SEQ ID NO:25), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
39. The method of claim 22, wherein the peptide is: Isovaleric acid-DTHFPCIKF(K(isoGlu- Palm))PRSKGCK-NH2 (Compound 26; SEQ ID NO:26), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
40. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKFEP(K(isoGlu-Palm))SKGCK-NH2 (Compound 27; SEQ ID NO:27), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
41. The method of claim 22, wherein the peptide is: Isovaleric acid- DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH2 (Compound 28; SEQ ID NO:28), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
42. The method of claim 22, wherein the peptide is: Isovaleric acid-DTHFPCI(K(Dapa- Palm))FEPRSKGCK-NH2 (Compound 32; SEQ ID NO:32), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
43. The method of claim 22, wherein the peptide is: Isovaleric acid-DTHFPCIKFEP(K(Dapa- Palm))SKGCK-NH2 (Compound 34; SEQ ID NO:34), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
44. The method of claim 22, wherein the peptide is: Isovaleric acid-ETHFPCI(K(IsoGlu- Palm))FEPRSKGCK-NH2 (Compound 46; SEQ ID NO: 66), optionally wherein the peptide has a disulfide bond formed between the thiol groups of two cysteine residues.
45. The method of claim 22, wherein the peptide is selected from the group consisting of: (a)
Figure imgf000064_0001
Isovaleric acid-DTHFPCIKF(K(PEG3-Palm))PRSKGWVCK-NH2 (Compound 20; SEQ ID NO:20);
(b)
Figure imgf000065_0001
Isovaleric acid-DTHFPCI(K(isoGlu-Palm))FEPRSKGCK-NH2 (Compound 25; SEQ ID NO:25);
(c)
Figure imgf000065_0002
Isovaleric acid-DTHFPCIKF(K(isoGlu-Palm))PRSKGCK-NH2 (Compound 26; SEQ ID NO:26);
(d)
Figure imgf000066_0001
Isovaleric acid-DTHFPCIKFEP(K(isoGlu-Palm))SKGCK-NH2 (Compound 27; SEQ ID NO:27);
(e)
Figure imgf000066_0002
Isovaleric acid-DTHFPCIKFEPRS(K(isoGlu-Palm))GCK-NH2 (Compound 28; SEQ ID
NO:28); and
Figure imgf000067_0001
ETHFPCI(k(IsoGlu-Palm))FEPRSKGCK-NH2 (Compound 46; SEQ ID NO:66), wherein the amino acids are L-amino acids.
46. The method of any one of claims 1-45, wherein the method comprises measuring TSAT and/or serum iron level in the subject before and after the hepcidin mimetic is administered to the subject, optionally wherein the TSAT level is measured at trough level of the hepcidin mimetic following administration to the subject.
47. The method of any one of claims 1-46, wherein the hepcidin mimetic is administered to the subject subcutaneously.
48. The method of any one of claims 1-47, wherein following the treatment, the subject requires substantially fewer or no phlebotomies, optionally with a phlebotomy frequency of less than 0.1, less than 0.05, or no phlebotomies per month.
PCT/US2023/069727 2022-07-07 2023-07-06 Combination therapy for treatment of iron overload diseases WO2024011188A1 (en)

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Citations (3)

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Publication number Priority date Publication date Assignee Title
US20110294861A1 (en) * 2006-05-23 2011-12-01 Novartis Ag Method of treatment of hereditary hemochromatosis
US20170362292A1 (en) * 2014-12-29 2017-12-21 The Regents Of The University Of California S-Alkylated Hepcidin Peptides and Methods of Making and Using Thereof
US20210061872A1 (en) * 2019-09-03 2021-03-04 Protagonist Therapeutics, Inc. Conjugated hepcidin mimetics

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Publication number Priority date Publication date Assignee Title
US20110294861A1 (en) * 2006-05-23 2011-12-01 Novartis Ag Method of treatment of hereditary hemochromatosis
US20170362292A1 (en) * 2014-12-29 2017-12-21 The Regents Of The University Of California S-Alkylated Hepcidin Peptides and Methods of Making and Using Thereof
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